ProfessorNancy Baxter
Honorary Professor
Faculty of Medicine and Health
Orcid identifier0000-0003-4793-4620 (opens in a new tab)
- Honorary ProfessorFaculty of Medicine and Health
SERVICE & LEADERSHIP SUMMARy
Professor Nancy N. Baxter has built a distinguished international career in academic, clinical, and health system leadership, spanning Australia, Canada, and the United States. Her service has focused on strengthening institutions, improving health system performance, and advancing equity, quality, and impact in healthcare and research. She currently serves as the Deputy Dean, Research Centres in the Faculty of Medicine and Health, University of Sydney.
She has held senior executive roles across major universities, including Head of the Melbourne School of Population and Global Health, Associate Dean of Academic Affairs at the University of Toronto’s Dalla Lana School of Public Health, and Interim Executive Dean of the Faculty of Medicine and Health at the University of Sydney. In these roles, she led complex organisations through periods of change, introduced new academic programs, strengthened research culture and performance, restructured centres and schools, and implemented governance and quality improvement processes that enhanced decision-making, transparency, and sustainability.
Professor Baxter has also played a prominent role in health system leadership. As Provincial Clinical Gastrointestinal Endoscopy Lead for Cancer Care Ontario, she provided oversight of endoscopy services, led major funding and quality reforms, and worked closely with clinicians, hospitals, and policymakers to improve access, efficiency, and quality of care. Earlier in her career, she served as Head of General Surgery at a large academic teaching hospital, overseeing clinical services, education, and research while mentoring surgeons and trainees.
Her service extends to national and international boards, advisory committees, editorial roles, and peer review panels across research funding agencies and professional societies. She has held leadership positions with organisations including Cancer Care Ontario, the American College of Surgeons, the American Society of Clinical Oncology, and multiple global health and public health bodies. Her board and advisory roles with Luminesce Alliance, the Burnet Institute, and global health organisations; senior editorial responsibilities with leading journals; leadership of national and international guideline panels; and extensive grant peer review for NHMRC, CIHR, NIH, and European funding bodies. Collectively, these roles demonstrate a career-long commitment to leadership that delivers measurable institutional, system, and societal impact.
Across her career, Professor Baxter has demonstrated sustained commitment to academic leadership, public service, mentorship, and the translation of research into policy and practice.
SERVICE & LEADERSHIP
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- GRANTS (OTHER)Beyond the Binary: Gender diversity in cancer health services research1 Jan 2023Gender diverse people, or more commonly transgender, nonbinary, and gender nonconforming people, may be at risk of receiving worse cancer care and having worse outcomes when compared to other groups. Although there is some research supporting this belief, it is difficult to identify gender diverse people in data that are regularly used for cancer research. Without this information, leaders and health care providers cannot make helpful changes to their organizations or to how they provide cancer care. The first part of this project will explore ways gender is included in other cancer research and data infrastructure. We will also ask researchers and gender diverse people about what is important to improve how gender diverse people are included in cancer research. Through exploring what is currently being done and from the conversations with researchers and gender diverse people, we will identify best practices and next steps for research. This will include the ways gender diverse people should be included and described in research. Ultimately, this project will help us do research better so that gender diverse people receive the best possible care.
- GRANTS (OTHER)Emergency general surgical conditions in pregnancy and the post-partum period: A population-based study of maternal and peri-natal outcomes1 Jan 2023Emergency general surgical (EGS) conditions are very common. EGS patients present with a variety of infectious and obstructive conditions of the gastrointestinal tract which often require urgent infection control and/or the resolution of obstruction through surgical, image-guided, and/or endoscopic interventions. Non-obstetric abdominopelvic surgery for EGS conditions such as appendicitis and gallstone disease occurs in 0.2-0.5% of pregnancies - with over 358,000 deliveries in Canada per year this is equivalent to over 1,800 emergency procedures during pregnancy every year for appendicitis and gallstone disease alone. Despite how common these conditions are, significant diagnostic and management challenges during pregnancy remain. Risks of ionizing radiation from CT scans and lower diagnostic yield of abdominal sonography, as well as the presence of physiologic leukocytosis and nausea during pregnancy, can lead to delayed diagnosis. Despite the fact that emergency surgery is often necessary and supported by guidelines, patients and surgeons may be reluctant to proceed out of concern for fetal wellbeing intraoperatively, and fetal loss or preterm birth postoperatively. Our objective is to improve the care of EGS conditions during pregnancy and postpartum by filling these knowledge gaps through a population-based analysis of a broad group of EGS conditions in pregnancy and the post-partum period with a focus on maternal and peri-natal outcomes. Our work will inform opportunities for care standardization which may lead to more timely diagnosis. Understanding maternal and neonatal outcomes can support pregnant patients and their health care providers in understanding risks and benefits of undergoing a major surgery during pregnancy and inform their choices.
- GRANTS (OTHER)Firearm-related injury and death in Canada: Identifying research priorities1 Jan 2022Healthcare providers, researchers, criminologists, sociologists, community groups, injury prevention organizations, advocacy groups, and victims of firearm violence will gather for a series of virtual meetings in which we will define a Canadian research agenda that focuses on the prevention of violent firearm-related injury and death as well as understand the needs of survivors of firearm violence and their communities. We propose to hold three virtual meetings, with each meeting building on the content of the previous one. These meetings will be moderated by a certified professional facilitator who is not a member of the study team. Meeting # 1 - Setting the Stage: The participants will: 1) discuss the current needs and gaps in this field of research and 2) identify opportunities. Needs, gaps, and opportunities will be collated and shared with all study participants prior to the next meeting. Meeting #2 - Ranking of Priorities. Participants will rank the research opportunities identified in the first meeting into top priority research areas. Participants will be divided into breakout rooms to foster additional multidisciplinary discussions. In each breakout room, the participants will agree on their top three priorities based on need and feasibility. Each small group will then present their top three areas along with a rationale for their choices to the full group. Low feasibility high need projects will also be discussed. Meeting # 3 - Develop a plan to support how top research priorities may be operationalized. Will discuss data sources and methodological approaches, strategies to mitigate limitations, knowledge translation strategies, and potential impact. These meetings will be the starting point for the development of The Pan-Canadian research collaborative for firearm violence prevention and will act as a catalyst for CIHR project grants that address the top research priority areas identified for the prevention of firearm injuries in Canada.
- GRANTS (OTHER)Impact of Physician Sex and Patient Gender on Patient Outcomes in Obstetrics & Gynecology1 Jan 2022Sex-and-gender based disparities are known to occur in health care. Research has shown female patients experience different care for similar conditions and presentations when compared to males. Sex-and-gender biases also exist such that female physicians are underrepresented in leadership, lag behind in career advancement, and earn less than male counterparts. These disparities are often referred to as the "Gender Gap" in medicine. A "Gender Gap" also exists with respect to health outcomes, with female physicians being associated with lower mortality, complications and readmission. In fact, it appears physician sex and patient gender may interact. New Canadian research suggests female patients of male surgeons experience poorer outcomes than when female patients are treated by female surgeons. This raises concerns about the quality of Obstetrics & Gynecology care, which is delivered to a biologically female population, who may or may not identify as women. This study uses linked administrative health data, which is routinely collected about all people seeking healthcare, to explore a number of outcomes in the fields of Obstetrics and Gynecology, many of which have not yet been explored through a sex-and-gender lens. Additionally, the study is novel and explores impact of physician sex at time of delivery on a long term post-partum outcome (surgery for pelvic floor disorders). The information generated by this study will provide further evidence about Canada's sex-and-gender disparities in healthcare. Results will be shared with numerous stakeholders, in order to advocate for innovations in policies that will protect female, women and gender-minority patients. Additionally, this work creates a foundation for further research into the causes of sex- and gender-based differences in this discipline, and opportunities to align medical outcomes of male and female physicians through avenues such as undergraduate, post-graduate and continuing medical education.
- GRANTS (OTHER)Physical, psychological, and functional late effects and health care use in survivors of adolescent and young adult cancer: A population-based study.1 Jan 2022Over 2,300 adolescents and young adults (AYA) in Canada develop cancer annually. With advances in treatment and supportive care, over 85% of AYA with cancer will become long-term survivors. Unfortunately, the intensive therapies needed to cure these AYA can lead to long-term physical and mental problems (known as "late effects") as well as impacts on their day-to-day function. Currently, we know very little about how common these late effects are among survivors of AYA cancer, and what impact it has on survivors' quantity and quality of life. With this in mind, our study has 3 objectives: 1) to identify physical (such as early death, new cancers, dementia, diabetes, heart failure and heart attack, stroke, solid organ transplant, kidney failure), mental (such as depression, anxiety, substance abuse, suicide and self-harm) and functional (e.g. living in assisted living residences) effects surviving AYA cancer 2) to determine risk factors (such as age, sex, type of cancer, type of treatment) for developing late effects of cancer therapy in AYA; and 3) to document health care utilization by survivors of AYA cancers, because evidence has indicated that cancer survivors in this age group have increased use of health care such as hospitalization and ED visits and it is not clear if regular care from a family doctor or oncologist can decrease that risk. We will do this by taking advantage of databases in Ontario, Canada that capture all contacts with the healthcare system. We will be able to identify over 100,000 survivors of AYA cancer and compare them to over 500,000 individuals without cancer. We believe our study results will improve the care AYA receive by more accurately predicting their risk of late effects and by informing strategies to monitor and prevent these late effects. In addition, our results will allow us to determine what other research needs to be conducted and help the healthcare system plan for the needs of this population.
- GRANTS (OTHER)Toward equity in cancer genetics: identifying racial disparities in cancer genetics services1 Jan 2022Cancer screening of high-risk populations for predisposition genes (e.g., breast cancer and BRCA1/2) is critical for early detection, cancer prevention and genetic testing for at-risk relatives. Yet, there are racial and ethnic disparities at every stage of the genetics service pathway: Racial and ethnic disparities occur at each stage in the cancer genetics service pathway: racialized and ethnic individuals are less likely to be referred for genetic tests, and are more likely to receive inconclusive genetic test results. Both can be barriers to appropriate screening for, and prevention of, cancer. We will use multiple methods to 1) explore experiences, needs, barriers and enablers to accessing cancer genetics services among racialized and ethnic patients and among health care providers, and 2) characterize the nature and extent of racial and ethnic disparities in cancer genetics services, genetic diagnoses, and recommendations for risk-reducing management. First, we will use qualitative methods to explore racialized patients' and providers' experiences, needs, barriers and enablers to accessing cancer genetics services. We will then use quantitative methods to characterize the nature and extent of racial disparities in cancer genetics services, genetic diagnoses, and recommendations for risk-reducing management. Evidence on which populations are experiencing disparities, and at which junctures in the care pathway disparities occur is a critical first step to address these disparities. This project will lay the groundwork for subsequent work to co-design and evaluate interventions to optimize access and delivery of cancer genetics services.
- GRANTS (OTHER)Addressing Inequity and Optimizing Prioritization in Liver Transplantation: Application of Artificial Intelligence to Improve Clinical Practice and Survival1 Jan 2021The current organ allocation system for liver transplantation (LT) was developed to prioritize the sickest patients and improve equality. However, access to LT has remained compromised among women and other subgroups. The current prioritization system does not adequately serve the changing LT candidate population, where there has been a dramatic increase in non-alcoholic fatty liver disease (NAFLD) and older patients with comorbidities. Organ supply is insufficient to meet the demand, and up to 25% die on the waiting list for LT in Canada. There is an urgent need to revise this prioritization system and make it more equitable. We have confirmed the significant inequalities and dynamics for specific patient subgroups (women, NAFLD, frailty, increasing age, cholestatic liver disease) on the waiting list. Additionally, the evolution in patient clinical characteristics is resulting in a predominance of cancer and cardiac complications after transplant. We have recently developed an Artificial intelligence (AI) algorithm to predict mortality after transplant and personalize patient care. In the proposed project, we will develop a uniquely Canadian framework beyond the MELD Na score using AI for equitable patient prioritization on the waitlist. We will also refine our AI-based algorithm to predict the major complications after LT and provide personalized recommendations for prevention and therapy. Despite a publicly funded health service and a generosity-base organ donation system, there remains an urgent need to reform the current prioritization system, as it is inequitable and results in excessive deaths of specific patient subgroups. We will use Canadian data aligned with new technology to serve patients more equitably on the waiting list and after transplant, and reset survival to normal based on personalized risk profiles.
- GRANTS (OTHER)Impact of the COVID-19 pandemic on obstetrical care and maternal, perinatal and early childhood outcomes in Ontario1 Jan 2021A central goal of pregnancy care is to give children the best possible start in life through improving the health of mothers and identifying/modifying risk factors. The COVID-19 pandemic has resulted in profound system-wide changes in pregnancy care. Virtual care was rapidly introduced to reduce in-person prenatal visits, to reduce spread of infection. In the third wave of the pandemic, severe illness in pregnancy increased across Canada. In some cases, severe COVID-19 infection in pregnancy requires delivery of premature infants to improve the health of the mother; prematurity can have significant negative long-term health effects for children and their families. In response to the rise in severe illness in pregnancy, pregnant women were prioritized for COVID-19 vaccination. Vaccination in pregnancy and during breastfeeding may confer protection to children after birth, but the impact of vaccination on early childhood outcomes is not yet determined. The impact of (i) new patterns of pregnancy care, (ii) the burden of COVID-19 infection itself in pregnancy, and (iii) vaccine uptake in pregnancy on outcomes of children, is largely unknown. Further investigation is warranted to determine if changes in obstetrical care (eg. virtual care) may be safely continued in subsequent lockdowns and after the pandemic, and to evaluate perinatal and childhood outcomes after COVID-19 infection and/or vaccination in pregnancy. Increasing knowledge of the safety/ benefits of vaccination in pregnancy is important to inform decision-making. COVID-19 is not a socially neutral disease: marginalized populations are disproportionately affected with COVID-19 infection. Health outcomes of children born to affected mothers may inform interventions aimed to further reduce directly-related and indirectly-related health inequities for these children in Ontario. We will engage families of babies born prematurely during the pandemic to discuss supports that may improve their long-term outcomes.
- GRANTS (OTHER)Improving outcomes across the cancer journey for adolescents and young adult with central nervous system tumours: The IMPACT-CNS Cohort1 Jan 2021Cancer is the most common cause of disease-related death among adolescents and young adults (AYA). Despite this, their chances of survival have not improved as much as those of younger or older patients. AYA with brain tumours are particularly vulnerable. Treatment approaches to childhood and adult brain tumours differ. We do not yet know which of these approaches is better for AYA. Also, cancer care for AYA is spread across many centres, so that many are treated by doctors who do not have much expertise specifically in AYA cancer. We therefore want to build a comprehensive database of all AYA diagnosed with any brain tumour between the ages of 15 years to 29 years in Ontario between 1992-2017 (called the IMPACT-CNS Cohort). From their medical charts, we will get information on their disease, how they were treated, whether their cancer came back, and whether they survived. We will also link this information to healthcare databases that can identify all hospitalizations, visits to doctors, and visits to the emergency room. We will then use this database to answer different questions about the care for these patients. First, we will determine what treatments AYA with brain tumours received, what determined who got which treatment, and whether different treatments were associated with different chances of survival. Second, we will look at the long-term side-effects these patients experience, including things like hearing loss or developing another cancer. Finally, for those AYA who die, we will examine what kind of care was received before death. Together, the answers to these questions may tell us what we can do to better improve outcomes for AYA with brain tumours at different phases of the cancer journey. The IMPACT-CNS Cohort will also be available in the future for any scientist who wants to improve outcomes for these patients.
- GRANTS (OTHER)Maternal outcomes and mode of delivery following pregnancy in women with inflammatory bowel disease1 Jan 2021A significant proportion of female patients with inflammatory bowel disease (IBD) are diagnosed before or during their childbearing years. One of the difficulties faced by young women with IBD is a lack of information about how their disease will affect their pregnancy, delivery, and post-pregnancy outcomes, and how pregnancy and delivery may affect their IBD outcomes in the long-term. These fears may be magnified in women who have had prior major abdominal surgery to improve IBD control. There are a number of studies evaluating outcomes for the baby, but little data on how pregnancy and mode of delivery (vaginal vs. cesarean delivery) can affect outcomes in mothers with IBD. In this study, we will use large administrative databases from Ontario, which contain important clinical information on a substantial number of young women with IBD, to improve an understanding of maternal outcomes in women with IBD. Specifically, we will gain a detailed appreciation of the management of women with IBD in pregnancy in Ontario with respect to where care is delivered, mode of delivery, and complications after delivery. We will then determine whether maternal outcomes differ from the general population (women without IBD), and if this is influenced by mode of delivery. The proposed research is very timely in an era when IBD patients are striving to be active participants in decision making around their IBD care. This research is hugely important in allowing young women with IBD and their partners better prepare and plan for pregnancy and delivery as an important, life altering event. Our findings will be shared with relevant healthcare providers (obstetricians, family physicians, midwives, gastroenterologists, and colorectal surgeons) at conferences and published in peer-reviewed journals. We will also share our findings with patients through education materials.
- GRANTS (OTHER)The Surgical EQUITY initiative: Establishing equitable access to surgery following the pandemic1 Jan 2021COVID-19 has disproportionately impacted marginalized populations. Not only were these patients at higher risk of becoming infected, but hospitals that cared for these patients prior to the pandemic were also disproportionately affected. Existing gradients in access to care were likely worsened. The dearth of research examining inequities in access to surgical care in Canada may stem from a belief that our universal healthcare system generally succeeds at its mission of ensuring all services are triaged according to need rather than socioeconomic status. Yet, there exists Canadian data that suggest the existence of gradients in access to other areas of care across many measures of marginalization. At the patient level, we will measure gradients in access to surgery across measures of marginalization prior to and during the pandemic. At the hospital level, we will examine whether hospitals with more COVID-19 admissions had larger surgical backlogs and how this impacted marginalized groups. At a system level, we will use mathematical modeling to examine provincial funding strategies proposed to clear the surgical backlog and assess how different strategies affect access and equity for the most marginalized populations. This will be the largest study to date to evaluate whether COVID-19 worsened access to surgical conditions across gradients of marginalization in Canada. This work will set the stage for further research directed at elucidating the consequences of socioeconomic position on patient-centered surgical outcomes, as well as specific mechanisms by which marginalization impacts surgical care. Moreover, this research is expected to have an impact beyond clinical care and research by contributing to ongoing, high-profile policy debates about the causes, consequences, and solutions to socioeconomic inequality in Canada. By framing inequality as a health issue, the proposed study has the potential to motivate public engagement on the issue.
- GRANTS (OTHER)BEFORE: Education and dissemination of an oncofertility decision aid1 Jan 2020Young adults diagnosed with cancer may be at an increased risk of infertility as a result of their cancer treatment. Fertility in survivorship is of great importance to many cancer patients and infertility can lead to lower quality of life. While fertility risks should be discussed with all patients, clinicians report having low levels of knowledge on the available fertility options and resources available for patients. Clinicians require more education on fertility and resources to help them feel comfortable raising this topic with their patients. To help fertility discussions, our team created a decision aid for young adults with breast cancer, called the Begin Exploring Fertility Options, Risks and Expectations (BEFORE) decision aid. This decision aid is being disseminated to 21 sites across Canada. To assist with the dissemination of the aid, we host a webinar for nurses and support staff on fertility in young adults with breast cancer and provide an introduction to the BEFORE decision aid. Due to the positive response from the webinar and BEFORE DA, we recognize the need to broaden the content and provide this education to more clinicians. We aim to revise the webinar to include the fertility options, risks and available resources for all young adults with any cancer type and disseminate it more widely to clinicians. The webinar will be hosted through the Canadian Association of Nurses in Oncology national webinar platform allowing nurses and other interested clinicians from across Canada to attend. A post-webinar survey will assess webinar attendees intended behaviour changes, current fertility care practices and needs when discussing fertility, enabling our team to identify new initiatives that are required to enhance the fertility care provided to YA with cancer in Canada.
- GRANTS (OTHER)Design and evaluation of a system-wide surveillance system for late effects of treatment in childhood cancer survivors1 Jan 2020There are over 14,000 survivors of childhood cancer in Ontario. Unfortunately, the therapy needed to cure their cancer puts them at high risk of developing new cancers and/or heart problems. Most adult survivors of childhood cancer do not complete the recommended tests to check for these problems. There are many reasons for this. One important reason is that once these survivors become young adults, most of them are 'lost' to the cancer system. There is a need to build a system that can ensure that childhood cancer survivors continue to get the follow-up care they need when they transition from the intensive childhood cancer care system to the routine health care system in adulthood. We will develop a sustainable, centralized solution that builds upon our experience conducting similar work. We will use existing data sources to build a provincial registry of survivors that can benefit from early detection of the health problems that are at high risk of developing. We will send these survivors personalized information about the surveillance tests they are due for, based on their cancer treatment history. Before launching this solution, we will work with stakeholders and survivors, to ensure the intervention is user-centred. We will test the solution in a province-wide experiment to determine whether the reminder system leads to an increase in adult survivor screening test completion. If the reminder system is effective, it will be implemented as a program for all Ontario childhood cancer survivors. It will be applicable to other age groups (e.g. young adults) and high-risk groups (e.g. patients with genetic risks for cancer) who can benefit from routine surveillance for new cancers and other long-term side effects of therapy. Furthermore, our national partners have expressed interest in sharing it with pediatric cancer centres across Canada. Let's not save the lives of children with cancer only to have them die from heart disease or a new cancer as young adults.
- GRANTS (OTHER)Patterns of care and outcomes for localized melanoma: Population-based cohort study1 Jan 2020Melanoma is a deadly type of skin cancer. Currently, the quality of skin biopsies and the optimal wait time between diagnosing and treating melanoma are unclear. Our study will look at the patterns of care for diagnosing and treating melanoma across Ontario, including the type of doctor involved and the timing of surgery they receive. We want to identify the risk factors for incomplete biopsies or treatment delays (longer wait times). We also wish to see if incomplete biopsies and treatment delays lead to more deaths from melanoma. To achieve these project goals, we will use information from biopsy reports and health databases for all melanoma patients in Ontario. Our results will provide guidance to health practitioners in creating a diagnosis and treatment plan for patients with melanoma.
- GRANTS (OTHER)Patterns of care and outcomes for localized melanoma: Population-based cohort study1 Jan 2020Melanoma is a deadly type of skin cancer. Currently, the quality of skin biopsies and the optimal wait time between diagnosing and treating melanoma are unclear. Our study will look at the patterns of care for diagnosing and treating melanoma across Ontario, including the type of doctor involved and the timing of surgery they receive. We want to identify the risk factors for incomplete biopsies or treatment delays (longer wait times). We also wish to see if incomplete biopsies and treatment delays lead to more deaths from melanoma. To achieve these project goals, we will use information from biopsy reports and health databases for all melanoma patients in Ontario. Our results will provide guidance to health practitioners in creating a diagnosis and treatment plan for patients with melanoma.
- GRANTS (OTHER)Pilot study of the rectal cancer checklist and a reminder system to improve pre-operative surgeon evaluation of surgical margins among patients with rectal cancer1 Jan 2020Our research group keeps finding evidence that Ontario surgeons often do not properly assess how advanced a patient�s rectal cancer is, and that in some cases this likely leads to terrible outcomes like local recurrence � the tumour comes back in the pelvis and patients then suffer a slow painful death � or futile surgery � patients have surgery with no chance the tumour can be removed. We think Patient Safety concepts and methods (e.g., checklists) can lower the chances of such outcomes. The main goal is to measure if Ontario surgeons will take part in a study that uses new tools that may help surgeons better assess how advanced a patient�s rectal cancer is. The tools will make surgeons do things they normally do not do, and so they may not want to take part. A second minor goal is to see if there are things we can measure to suggest new tools to do what we think they should do � make surgeons do a better job at assessing a patient�s rectal cancer. We will try and get 6 hospitals � and their surgeons � to take part in the study. Our group developed a Checklist that shows surgeons key steps they should follow when assessing how advanced a patient�s rectal cancer is. We will remind surgeons to complete the Checklist for a patient and send the completed Checklist to the patient's chart. In the first four months of the study the reminders will be voluntary. In the second four months surgeons must complete the Checklist to book surgery. We think using Patient Safety concepts and methods can help make cancer care better. If this pilot study is positive � surgeons are willing to take part in the study and complete the Checklist - we will take these results to help set up a very large trial involving hospitals across Canada. For patients having rectal cancer surgery, this bigger trial will test if our new thinking and tools can actually lower rates of bad outcomes like local tumour recurrence and futile surgery.
- GRANTS (OTHER)A population-based study of emergency general surgery conditions in patients with solid organ transplants1 Jan 2019For patients with end-stage organ failure, transplantation is lifesaving and improves quality of life. Because more people are receive a transplant each year, and patients with transplants are living longer, the number of patients living with a transplant in Canada increases each year. The success and expansion of organ transplantation has resulted in a large number of transplant recipients that routinely require care outside of transplant centres for non-transplant issues such as emergency general surgery (EGS) conditions such as inflammation of the gallbladder or the appendix. EGS patients have 8-fold higher mortality and 50% more complications compared to non-emergent general surgical patients such as those coming in for planned bowel resections. Multiple small studies suggest even worse outcomes amongst the transplant population who suffer EGS conditions likely because their immune system needs to be suppressed. EGS conditions are of particular importance in the solid organ transplant population given their high incidence, morbidity, and mortality. This study will use information from a registry of all patients having a solid organ transplant in Ontario linked to information from large administrative databases that capture most healthcare interactions in Ontario. We are interested in evaluating if transplant patients develop EGS conditions more frequently, have more complications, and/or higher death rates compared to non-transplant patients. We will be able to understand how EGS conditions are treated in transplant vs. non-transplant patients as well as if there are differences in transplant vs. non-transplant hospitals. If we identify differences in strategies that lead to less complications or death in transplant patients we can then develop and disseminate these strategies to improve outcomes. We will gather together experts in the field of transplantation and EGS care in order for the results of our study to be maximally useful and have an impact.
- GRANTS (OTHER)Active surveillance of low risk papillary thyroid cancer: program expansion in quebec1 Jan 2019The incidence of small, localized very low risk papillary thyroid cancer (VL-PTCs) is rising. VL-PTC is treated by surgery to remove the thyroid (often followed by thyroid hormone treatment). The option of active surveillance (AS) mitigates overtreatment of VL-PTCs that may not progress or limit lifespan. Most AS research has focused on microcarcinomas (VL-PTCs < 1 cm in size). Long-term outcome AS research is needed, including larger tumors and previously unstudied patient reported outcomes. We will expand an Ontario study on safety and outcomes of AS for low risk PTC to multiple Quebec sites, to increase sample size and generalizability. We will translate and linguistically validate study materials in French-Canadian, including standardized information on disease management choice, patient-reported outcome questionnaires, and a qualitative patient interview script. An in-depth qualitative study will inform Quebecers� experience following their disease management choice. We have pilot-tested feasibility of studying AS of VL-PTC in Canada in an ongoing prospective observational study at University Health Network, which is enrolling untreated patients with VL-PTC < 2 cm in size that is confined to the thyroid (funded partly by a Canadian Cancer Society Innovation Grant). We will build on our ongoing success to recruit a total of 600 patients at multiple Canadian sites, including 3 sites in the province of Quebec, which are the focus of this application. The disease management goals of VL-PTC patients choosing AS (avoiding thyroidectomy with no disease progression) differ from the goals of those choosing surgery (cure of cancer). We expect that the rates of disease management success will be comparable in patients who choose AS and those who choose surgery. This study will form a critical first informative step in transforming primary disease management options in VL-PTC and are likely to impact change in North American clinical practice guidelines and health policies. Our results will ultimately inform future AS decision-making and addressing patients' disease management needs.
- GRANTS (OTHER)Active surveillance or surgery for primary management of very low risk papillary thyroid cancer: How often are the long-term disease management goals achieved?1 Jan 2019Treatment of low risk cancers that are detected early must be balanced with the possible risks of negative effects of therapy. Low risk cancers are those that cause no symptoms and are highly unlikely to become life-threatening. A traditional approach in managing low risk solid tumors is surgery with the intent to cure the cancer. An alternative approach to reduce potential overtreatment of low risk cancers that may never cause harm, is to consider close monitoring, with the intent to perform curative surgery if there is evidence of disease progression; this approach is referred to as active surveillance (AS). AS may reduce the risk of treatment-related complications and associated potential quality of life impairment, in individuals whose disease is unlikely to progress. Very low risk papillary thyroid cancer (VL-PTC) is defined as papillary thyroid cancer that is smaller than 2 cm in maximum diameter, which has not spread outside the gland. In this prospective multi-centre long-term follow-up study, we will determine how often disease management goals are met in patients with VL-PTC who choose AS or surgery, respectively. The disease management of goals will be defined as follows for respective groups: active surveillance group - survival without thyroid surgery (in absence of significant growth of the primary tumor or development of metastatic disease), and for the surgical arm - an excellent response to therapy (analogous to cure), as defined by current clinical practice guidelines. Our study will also compare the following outcomes in AS and surgical groups: quality of life, psychological distress, quality of life, rate of requirement for long-term thyroid hormone treatment, and healthcare resource utilization. We will also conduct an in-depth qualitative analysis of the experiences of a subgroup of study participants in the AS and surgical groups. This study will inform disease management options for future VL-PTC patients.
- GRANTS (OTHER)Average risk colonoscopy in Ontario: understanding risks and subsequent follow-up after a complete negative colonoscopy1 Jan 2019While colonoscopy is an important diagnostic and therapeutic test for colorectal cancer (CRC), many scopes are unnecessary. Current evidence shows that those undergoing colonoscopy with no findings have low risk of subsequent CRC. However, how low this risk is has not been established, and further controversy surrounds the interval recommended for repeat screening for those with a previous negative colonoscopy. Our study will build on prior work by conducting a more comprehensive evaluation of those who have had a complete negative colonoscopy within a 20 year time period and examine patient, endoscopist and primary care provider characteristics associated with a second colonoscopy. Our study is needed to establish the risk following a complete negative colonoscopy because existing studies vary in risk estimation and include colonoscopies performed from some time ago that may not reflect the impact of high-quality contemporary colonoscopy. In addition, our study results have the potential to affect practice change by describing recommendations for future screening of patients after a negative colonoscopy and have implications for maximizing efficient use of colonoscopy resources.
- GRANTS (OTHER)Development of the Innovative, Multicentre, Patient-Centred Approach to Clinical Trials in Surgery (IMPACTS) Program1 Jan 2019Each time a surgeon interacts with a patient, they make countless decisions; for example, the location of an incision, the choice of medication(s) to help prevent an infection and the type of stitches to use. In surgery, these decisions are much less likely to be based on high-quality evidence as compared to other areas of medicine. The type of comparative study that gives the most high-quality evidence is a randomized controlled trial (RCT). While important to help guide decision-making, these trials are rarely done in surgery, in large part due to practical reasons. We are developing a program called IMPACTS (The Innovative, Multicenter, Patient-centered Approach to Clinical Trials in Surgery) to address many of the challenges that are associated with carrying out RCTs in surgery. We have assembled a committee that includes patients, surgeons, and policy-makers and will follow a systematic and patient-oriented approach to choose trials to carry out as part of the IMPACTS program. This grant will support our team in collecting questions to study, examining the evidence for each question, and holding a workshop with members of key groups to prioritize the questions. We will also develop the components (e.g., databases) needed to carry out trials in the future. The IMPACTS program will provide evidence to help surgeons make important decisions; minimizing healthcare inefficiency and improving the quality of patient-centred care.
- GRANTS (OTHER)Disparities in Lung and Colorectal Cancer Stage of Diagnosis1 Jan 2019Lung cancer and colorectal cancer are the two most common cancers, and the two most common causes of cancer death, in Canada. Approximately 50% of all cases of LC diagnosed in Canada between 2011 and 2015 were diagnosed at stage IV; 49% of CRC cases diagnosed in the same time period were diagnosed at stage III or IV. Stage of diagnosis is directly related to survival, with stage IV survival estimated at less than 10% for lung cancer and 11% for colorectal cancer. As with many other health outcomes, there is evidence for disparities in stage of diagnosis based on social factors. However, although disparities in cancer screening for immigrants are well documented, little is known on disparities in diagnosis of lung cancer or colorectal cancer among immigrants to Canada, despite foreign-born persons making up approximately 20% of the national population. Reducing mortality due to these two cancers will require rich data to develop an understanding of where disparities lie in early stage diagnosis, and how they can be addressed. In this study, we will explore stage of diagnosis for these two cancers for immigrants as compared to Canadian-born persons. We will also examine the role of other factors in early-stage diagnosis, such as primary care access, socio-economic status and health status. We will use Ontario-level databases housed at the Institute for Clinical Evaluative Sciences to conduct this work, including the Immigration Refugee & Citizenship Canada database, which includes data on country of birth, immigrant class, and date of landing, and the Ontario Cancer Registry, which includes all incidence cases of common adult cancers including LC and CRC. Our findings will provide important new knowledge on how to reduce disparities, and target interventions, for lung cancer and colorectal cancer diagnosis and survival in Canada for immigrants and other potentially marginalized groups.
- GRANTS (OTHER)Exploring the Existence of Gender Inequity with an Intersectionality Lens in Academic Health Care, Health Sciences and Health Policy and Interventions to Optimise Gender Equity1 Jan 2019For gender equity to be present among the health research community, we expect fairness in the distribution of benefits and responsibilities between women and men. However, women are less likely to be promoted, awarded grants, and receive lower salaries than men. Findings from gender equity studies, however, are often derived from a single organisation or only focus on a few issues. To fully understand whether gender inequity is present for researchers, we require a full review of all variables that may influence the career development and success of a researcher. We must also uncover and understand what strategies have already been tested to promote gender equity in the research setting. First, we will conduct a large scoping review to synthesise evidence about gender inequity in the academic health sector. We will supplement this with a national environmental scan and survey to determine the proportion of women and their intersections with Indigenous peoples, persons with disabilities and members of visible minorities in health faculty leadership for Canada's research-intensive universities versus the student body and Canadian population. Our second scoping review will synthesise evidence on interventions to optimise gender equity and inform knowledge users about existing strategies targeted to individuals, organisations or systems used to promote gender equity. These reviews will be updated every 6 months so our knowledge users are always provided with the latest research findings available. Results will be particularly important for members of funding agencies, professional associations, academic institutions, gender and equity committees and researchers. Next, we will discuss the findings from the reviews with knowledge users and work with them to determine what area(s) require further exploration using an agreement-building approach. This exercise will inform future research projects on gender equity.
- GRANTS (OTHER)Genomics ADvISER 2.0: Creating and evaluating a digital decision support tool on incidental genomic findings1 Jan 2019BACKGROUND: Oncologists are increasingly using genomic sequencing to diagnose and optimize care for their patients, but this test also generates incidental findings (IF) about thousands of other current and future diseases. Guidelines recommend patients choose which IF they wish to receive before their genomes are sequenced. There are limited clinical resources and expertise to counsel patients on the thousands of possible IF; decision aids (DAs) can fill this gap. PRELIMINARY DATA: We produced a DA prototype,www.genomicsadviser.com, to guide patients' selection of IF and evaluated its usability and effectiveness. Participants found the prototype informative, acceptable and intuitive to use but some still required decisional support by a clinician, and clinicians wanted to adapt the categories based on their clinical capabilities. OBJECTIVES: 1. Transform our DA prototype into an adaptable, interactive, patient-centered digital decision support tool that supports clinical scalability. 2. Evaluate the effectiveness of our tool among patients being offered IF. DESIGN: 2 phased mixed methods study. Phase 1- User centered design to transform the tool: 1-Discover patient attributes, key counseling qualities, and end user requirements to create user profiles; and construct user profiles. 2-Design content hierarchy, information flow on various platforms and detailed wireframes. 3-Test usability of the beta version with patients and clinicians. 4-Deliver a fully functional and widely compatible web-based tool. Phase 2 -RCT to evaluate the effectiveness of our tool: Population: Cancer patients offered IF. Intervention: Genomics ADvISER to select IF. Control: Standard genetic counseling (GC) to select IF. Outcomes: Primary: Decisional conflict, knowledge. Secondary: satisfaction, preparation for decision-making, and anxiety. IMPACT: Our patient-centered, adaptable and interactive digital support tool will improve decision quality, reduces consult time and healthcare costs.
- GRANTS (OTHER)Is mechanical bowel preparation necessary to reduce surgical site infection following colon surgery? A randomized controlled trial1 Jan 2019Background: Following colon surgery, surgical site infection (SSI) is the most common complication and leads to longer recovery time for patients as well as increased health care costs. Currently, there is high quality evidence to show that the combination of intravenous antibiotics (IVA), mechanical bowel preparation (MBP) and antibiotics (OA) is the most effective bowel preparation to reduce SSI. However, there are no studies comparing IVA+MBP+OA and IVA+OA. This is an important question because if IVA+OA works the same as IVA+MBP+OA, then MBP may be safely omitted as part of the bowel preparation to reduce SSI and patients would avoid the side effects of MBP prior to their surgery. Objectives: Therefore, the objective of this study is to perform a trial to determine if IVA+OA works the same as IVA+MBP+OA to reduce SSI following colon surgery. Methods: This study will be performed in 4 hospitals across Canada. Patients are eligible to participate in the study if they are (i) undergoing elective colon surgery, (ii) are 18 years of age or older and (3) provide informed consent. Eligible patients will be randomly assigned (i.e. flip of a coin) to one of two groups, either IVA+MBP+OA or IVA+OA. The primary outcome for the study is the number of patients that develop a SSI within 30 days after surgery. At the end of the study, the number of SSI between the two groups will be compared to determine if IVA+OA works the same as IVA+MBP+OA. Relevance: This study is important because we expect that IVA+OA will work similarly to IVA+MBP+OA and will show that MBP is not necessary to reduce SSI. This will be important to both patients and physicians as it will improve both patient experience and outcomes following colon surgery. Given the high volume of colon surgeries done annually, as well the impact SSI has on patient outcomes, our results have potential to change practice in Canada and worldwide.