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Healthcare looms large for left-wing leadership hopefuls

These days, political reporters in Ottawa are spending most of their column inches and airtime on the three federal by-elections recently announced for September 8.

Liberal ridings in Westmount-Ville Marie, Quebec, and Guelph, Ontario, are being challenged by the New Democrats and the Conservatives; and a Bloc Québécois riding in St Lambert, Quebec, is also slated to vote.

That's not the big political story of this summer, however. After all, with a federal general election rumoured for the fall or winter, the new MPs from those three Quebec and Ontario ridings may only end up sitting a few days in their hard-earned seats before they're sent back out on the campaign trail, knocking on doors and kissing babies all over again.

No -- the big story, which has been quietly but steadily gaining steam, is the prospect of major changes in the left-wing opposition parties in Ontario and Alberta, provinces that together comprise more than half of the nation's gross domestic product. With the Ontario NDP's Howard Hampton and the Alberta Liberals' Kevin Taft both ousted after poor showings in the provinces' elections in the past year, the implications of the two leadership campaigns are far-reaching -- especially in terms of health policy.

In last October's election, the NDP actually gained several seats under the leadership of Howard Hampton, but that wasn't enough to lift them anywhere near the prominence the party enjoyed (and squandered) in the 90s under former Premier Bob Rae.

The leadership campaign will last an interminable eight months for some reason, and so far has attracted interest from nearly half of the party's 10-member caucus, .

Ontario's Liberal government has managed to avoid allowing healthcare to become a central political issue, thanks in part to Deputy Premier George Smitherman's deft (and occasionally daft, but not altogether unsuccessful) maneuvering in the health portfolio for the last five years.

Nevertheless, healthcare remains a potential cause célèbre simmering on the back burner.

After the election results came in last October, I spoke to Dr Michael Rachlis, a physician and health policy analyst in Toronto. He told me, "Next time I think that the election result could be very different, because if the government's plans from their first term don't go so smoothly in the second term, they'll be vulnerable." As I wrote in on the expected effects of the election results on the health sector, a number of major issues are still of concern to Ontarians: the government's reluctance to implement a comprehensive electronic health records initiative, the health tax (which the NDP proposed to do away with), and the risky decision to delegate many administrative and budgeting responsibilities to Local Health Integration Networks. Longtime health policy expert Michael Decter enumerated what he saw as the province's top five healthcare problems in December:

  • chronic disease
  • integrating health services
  • making smart systems smarter
  • "We want more doctors but we are getting family health teams"
  • extending wait times reductions
The NDP's most obvious opportunity to challenge the Liberals and Tories on healthcare is the hospital funding question. The New Democrats are to the expansion of public-private partnerships, or P3s, which have emerged as a major element of the government's healthcare funding plan, especially in light of the June that saw Infrastructure Minister David Caplan ("the minister of P3s and privatization," according to Natalie Mehra of the Ontario Health Coalition) appointed to the Ministry of Health.

The next election, though it may be some time off still, promises to provide fertile ground for the NDP to take on the government on healthcare. Perhaps, if the right leader says the right things at the right times, the New Democrats may begin a return from the third-place doldrums they've been caught in for the last decade.

The prognosis for the Alberta Liberals can only be described -- if we're being generous -- as a mixed bag. The Kevin Taft-led party tanked in the March election, losing nearly half its seats and leaving the Tories with 72 of the legislature's 83 total seats. But on the bright side, things can't get any worse, can they?

In all seriousness, though, the headline of my April article about the Tories' huge victory should give you a hint about the current state of affairs: "."

Given the ongoing healthcare problems in Alberta -- overcrowding in Calgary, administrative strife, two recent infection control scandals, and growing discontent on physicians' behalf -- it's particularly imperative that the opposition gets organized, and quickly.

Rumours have been bandied about since March of a , perhaps led by , a Calgary physician who's now the Alberta Liberals' environment critic (before he went into politics, he was fired as a public health officer for speaking out against the provincial government's refusal to endorse the Kyoto Accord). In March, the NDP sunk to a paltry two seats and the Greens failed to get a candidate elected to office; the thinking is that a rebranding and a reorientation might revitalize voters' interest in an alternative to Ed Stelmach's Progressive Conservative government.

Meanwhile, the Liberals have already begun the process of replacing Mr Taft. The party's deputy leader and health critic, Dave Taylor, has already . Dr Swann is thought to be interested in running; the same goes for Laurie Blakeman, who was health critic before Mr Taylor. MLA Hugh MacDonald may also join the race, . Edmonton-based ex-MLA Mo Elsalhy, a very young pharmacist, already he will compete with Mr Taylor.

There seems to be an unusual preponderance of health experience in the Alberta Liberal leadership race. That may simply be a coincidence, or it may be a sign that opposition politicians have finally recognized the opportunity to address the provincial government's checkered healthcare record.

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Extra! Extra! Doctors heeded rosiglitazone news

In heartening news for health journalists everywhere, an Ontario in the July issue of found that physicians stood up and took notice when news that rosiglitazone increased MI risk in diabetics was emblazoned across every newspaper in the country - including our own .

(Read our coverage of Steve Nissen's controversial meta-analysis and the fallout .)

Looking at records of new prescriptions for Ontario residents, the researchers found that just after the meta-analysis started making headlines, new scripts abruptly declined.

"This is the first time we’ve seen a prescribing change so quickly following this type of study, and it shows that media exposure can influence health care,”
notes lead author Dr Baiju Shah.

He adds, "All of this attention benefits the patient and helps them make an informed medical decision and sometimes, it just may save their life.”

Did I read that right? Praise for the media? Wow.

Interestingly, the study also noted a short-lived spike in scripts for the rival glucose-lowering med pioglitazone, which like rosiglitazone is in the thiazolidinedione class. "The decision to switch between thiazolidinediones may have been prompted by a large randomized trial of pioglitazone that showed favourable cardiovascular outcomes, leading physicians to believe that the purported ischaemic effects of rosiglitazone were not a class effect," they write. They go on to say that subsequent negative studies resulted in an overall decline in new prescriptions for the class.

Editorial cartoon from NRM June 15 2007

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Should doctors ask “Does he hit you?” Hospitals can’t decide

Whether patients in the emergency department should be screened for domestic violence as a matter of course is a question that remains unresolved in many Canadian hospitals.

To say the issue is unresolved is to understate the situation. According to a published this month in the Canadian Journal of Emergency Medicine, the debate itself seems to have reached an impasse.

The new study -- a survey of Canadian emergency departments (EDs) by three McMaster University physicians -- reveals that there was no change in the number of EDs providing universal domestic-violence screening between 1994 and 2004, nor in the number of EDs with established guidelines on how to deal with domestic abuse.

A 1994 survey found:

  • 39.4% of Canadian EDs had domestic-violence policies and procedures
  • 13.1% had universal screening policies
And the new McMaster survey found that the numbers in 2004 had not risen at all:
  • 31.9% have domestic-violence policies and procedures
  • 13.6% have universal screening policies
Why was there no increase in those figures?

In an accompanying editorial, "," Kathleen Mackay, a social worker and the clinical coordinator of Vancouver General Hospital's Domestic Violence Program, posits that the long delay is rooted in administrators' reluctance to move ahead decisively without knowing exactly what types and methods of screening will prove to be the most efficacious.

Good intentions, as you know, can kill. Approaching potential new hospital procedures with caution is a good thing -- unless policy becomes paralyzed for a decade or longer waiting for the perfect piece of evidence.

Even its proponents admit that universal screening for domestic violence may not be sufficiently supported by the reams of research and piles of data needed to conduct a systematic review, and the screening methods and tools may not be as precise yet as one might hope. But given the extent of domestic-violence morbidity going unrecognized as such by emergency medical staff -- "Domestic violence," write another group of McMaster researchers in in this month's Journal of Bone and Joint Surgery (American Volume), "is the most common cause of nonfatal injury to women in North America" -- the need for some kind of intervention or other is urgent, even in the absence of conclusive data.

Ms Mackay writes in her editorial:
[L]et us not wait for the impossible — a one-[size-]fits-all intervention that is proven to be effective and can therefore justify screening for IPV. There is simply no panacea intervention that will bring an end to this perplexing health, social and community ill.
Waiting for a panacea is a Samuel Beckett exercise in futility. What is needed is some tangible commitment by hospital and ED administrators across Canada to improve the outcomes of victims of the domestic-violence blight that has for so long been under-diagnosed and under-treated on an institutional level in the Canadian healthcare system. Until someone develops a more targeted method that clinicians can easily put to use, universal screening seems to be the best option.

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