Canadian Guideline Urges Preventive Care for Health Equity

Marilynn Larkin

September 25, 2023

A new Canadian guideline provides preventive care recommendations to promote health equity by prioritizing interventions for patients experiencing disadvantages.

Key recommendations include prioritizing colorectal cancer screening for patients starting at age 45 years (rather than 50 years), offering human papillomavirus self-testing to patients eligible for cervical cancer screening, and screening for latent tuberculosis with a tuberculin skin test or interferon-γ release assay.

The guideline will "prioritize people who have long been deprioritized in our system," guideline author Aisha Lofters, MD, PhD, a scientist and family physician at Women's College Hospital and associate professor at the University of Toronto in Ontario, told Medscape Medical News.

The document was published online September 25 in the Canadian Medical Association Journal.

Global Shift Urged

The guideline was developed by a primary care provider–patient panel with input from a patient–partner panel with diverse lived experiences. It includes 15 screening and other preventive care recommendations plus one policy recommendation, all of which are graded according to available evidence.

"Health inequities exist in Canada for many people, including Indigenous people, racialized people, people who identify as 2SLGBTQI+ (2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and intersex), people with functional limitations, and those with a low income," the guideline authors write. "Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized."

"The COVID-19 pandemic highlighted inequities that had been longstanding and mostly ignored," said Lofters. The current period offers "an opportunity to make changes by providing recommendations for preventive care with a focus on addressing inequities, she added.

"Our recommendations are generally consistent and complementary with recommendations for the general population," she said, "but our goal is ultimately to make health outcomes fairer."

In addition to the screening recommendations for colorectal and cervical cancers and tuberculosis, the guideline recommends screening adolescents and adults for depression and providing appropriate support, screening for social risk factors such as poverty in all families with children and connecting those in need with resources and support, and prioritizing access to primary care for disadvantaged patients with automatic enrollment, like the way children are automatically enrolled in schools.

The guideline also recommends prioritizing outreach efforts for lung cancer screening with low-dose CT, prioritized cardiovascular risk assessment and shared decision-making about management options, prioritized diabetes screening for those at increased risk, HIV screening and self-screening, hepatitis C virus screening, screening for substance use, and screening for dental caries, along with oral health education and referrals to dentists for children under age 5 years.

Overall, the suggested frequency of screening and other preventive care is every 3-5 years.

The guideline offers details for each recommendation, including the rationale, benefits, and potential harms. It also provides a table that compares the new recommendations with existing recommendations from other guideline groups, including the Canadian Task Force on Preventive Health Care and the United States Preventive Services Task Force.

In addition, the guideline authors launched a website to facilitate access to screening recommendations.

"Health inequities are not unique to Canada," said Lofters. "A global shift to prioritizing health equity allows for a meaningful chance at finally eliminating these inequities."

Better Patient Outcomes

Commenting on the guideline for Medscape Medical News, the American Academy of Family Physicians (AAFP) said: "While the AAFP has not formally reviewed the specific guidelines suggested in the Canadian Medical Association Journal, we are encouraged by any efforts to advance health equity, especially by focusing on primary care."

The group noted that disparities in healthcare access and outcomes persist, disproportionately affecting marginalized populations. "Family physicians play an important role in identifying and addressing healthcare disparities impacting minority populations, with deep knowledge of communities and experience caring for diverse patient populations," it said.

Data indicate that when healthcare systems prioritize access to primary and preventive care, the approach results in improved patient outcomes and lower healthcare costs, including decreases in hospitalizations and emergency department visits. "By making preventive services like vaccinations, screenings, and health education more accessible and emphasizing their importance, physicians can empower patients to take control of their health and well-being, leading to better health outcomes and a higher quality of life," said the AAFP.

The Equitable Preventive Praxis Initiative, which developed the guideline, was funded by the Canadian Institutes of Health Research. Lofters has reported receiving an institutional grant from Pfizer Canada related to the care of Black women with metastatic breast cancer, outside the submitted work.

CMAJ. Published September 25, 2023. Full text

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