Vol 66: JANUARY | JANVIER 2020 |Canadian Family Physician | Le Médecin de famille canadien
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Cost of warfarin versus direct oral anticoagulants
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n Dr Wohlgemut’s commentary “The ‘direct’ dilemma.Oral anticoagulants and the parameters of public pre- scribing,” published in the November issue of Canadian Family Physician, his point about being fiscally respon- sible and recognizing the responsibility of physicians to help politicians be good stewards of the public purse is well taken1; however, we as physicians and as a soci- ety have to be very careful about not being penny-wise and pound-foolish. The Canadian Agency for Drugs and Technologies in Health report cited in Wohlgemut’s article showed that outpatient treatment of atrial fibrillation with warfarin is cheaper than use of direct oral anticoagu- lants (DOACs).2 This is not surprising given that DOACs are many times more expensive. However, we do have to recognize that effective primary care, as well as interven- tions that potentially improve outcomes in chronic dis- eases such as atrial fibrillation, ultimately save the health care system money in the long run by reducing use of acute care. The Canadian Institute for Health Information reported that in 2019, 26.6% of health spending would go toward hospitals, which is also the single biggest cost.3 In fact, the combined cost of physicians and drugs is 30.4% of health care spending, while hospitals account for 26.6% alone. It is also worth noting that the cost of physician services increases for hospitalized patients ver- sus patients seen on an outpatient basis. It is a compli- cated scenario, but others have more recently attempted to answer this question vis-à-vis DOACs: Ortiz-Cartagena and colleagues4 conducted a study of patients enrolled in anticoagulation clinics who had hospital admis- sions related to anticoagulation treatment. Their find- ings reflected those of the earlier mentioned Canadian Institute for Health Information review,3 in that for out- patient care alone, cost was less for warfarin, but when inpatient treatment was factored in as well, warfarin was actually less cost effective, as length of stay for the warfa- rin patients was substantially longer.
While the results of one study are by no means con- clusive proof of superior cost efficacy in the Canadian system, it is worth noting these results. Ultimately it also raises another problem with these discussions: our health care system tends to be “siloed” in Canada. We talk about costs of primary care, or costs of acute care, but we don’t always look at those systems together and the way they interact with each other. In order to
provide the best care to our patients and be the best possible stewards of health care resources, we can no longer continue to do that.
—Marco G. Mannarino MD CCFP Edmonton, Alta
Competing interests None declared References
1. Wohlgemut J. The “direct” dilemma. Oral anticoagulants and the parameters of public prescribing. Can Fam Physician 2019;65:775-6 (Eng), 780-2 (Fr).
2. Canadian Agency for Drugs and Technologies in Health. New oral anticoagulants for the prevention of thromboembolic events in patients with atrial fibrillation. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2012.
3. Canadian Institute for Health Information [website]. Where is most of the money being spent in 2019? Ottawa, ON: Canadian Institute for Health Information; 2019.
Available from: http://cihi.ca/en/where-is-most-of-the-money-being-spent- in-2019. Accessed 2019 Dec 6.
4. Ortiz-Cartagena I, Orraca Gotay A, Acevedo J. Cost effectiveness of oral antico- agulation therapy for non-valvular atrial fibrillation patients; warfarin versus the new oral anticoagulants rivaroxaban, dabigatran, and apixaban. J Am Coll Cardiol 2018;71(Suppl 11):A490.
Decreasing our carbon and environmental footprint at conferences
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hank you, Dr Ladouceur, for appealing to Canadian family physicians for strategies to fight climate change and preserve our planet in your November edi- torial, “Our fight against climate change.”1One idea is for the College of Family Physicians of Canada (CFPC) and its provincial and territorial counter- parts to demonstrate leadership at conferences, starting immediately. Serving predominantly plant-based meals, avoiding single-use plastics, and offering and accrediting telepresence at conferences could all be done routinely.
This would substantially decrease our carbon and envi- ronmental footprint as a group of health professionals.2-4 These efforts could be publicized to set an example.
Regrettably, at the Wednesday lunch of the 2019 Family Medicine Forum in Vancouver, BC, in October, for every 3 rows of plant-based offerings, there were 10 rows of meat (roast beef or chicken). This is in line with neither Canada’s Food Guide5 nor the EAT-Lancet Commission.6 Thankfully, the packaging and utensils were mostly compostable. A large number of physicians flew across the country to attend the conference and it is unclear (after having inquired at the CFPC) whether there were options for participating remotely.
In line with our CanMEDS–Family Medicine roles of leadership and advocacy, the Canadian public should view family physicians as exemplars in matters of health.
We call on the CFPC and its provincial and territorial
Top 5 recent articles read online at cfp.ca
1. Praxis: Quick and painless. 2018 Updates on guideline recommendations (November 2019)
2. RxFiles: Navigating cannabinoid choices for chronic neuropathic pain in older adults. Potholes and highlights (November 2019) 3. Prevention in Practice: Measuring what really matters. Screening in primary care (November 2019)
4. Tools for Practice: Topical treatments for rosacea (November 2019)
5. Commentary: Cannabis legislation provides an opportunity to strengthen primary care substance use counseling (November 2019)
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Canadian Family Physician | Le Médecin de famille canadien}Vol 66: JANUARY | JANVIER 2020chapters to immediately organize conferences to be consistent with current scientific evidence.
—Tomislav Svoboda MD PhD CCFP FRCPC
—Kimberly Wintemute MD CCFP FCFP Toronto, Ont
Competing interests None declared References
1. Ladouceur R. Our fight against climate change. Can Fam Physician 2019;65:
766 (Eng), 767 (Fr).
2. Coroama VC, Hilty LM, Birtel M. Effects of Internet-based multiple-site confer- ences on greenhouse gas emissions. Telemat Informat 2012;29(4):362-74.
3. Tilman D, Clark M. Global diets link environmental sustainability and human health. Nature 2014;515(7528):518-22. Epub 2014 Nov 12.
4. Xanthos D, Walker TR. International policies to reduce plastic marine pollution from single-use plastics (plastic bags and microbeads): a review. Mar Pollut Bull 2017;118(1-2):17-26. Epub 2017 Feb 21.
5. Health Canada [website]. Eat protein foods. Ottawa, ON: Government of Canada; 2019. Available from: https://food-guide.canada.ca/en/healthy- eating-recommendations/make-it-a-habit-to-eat-vegetables-fruit-whole- grains-and-protein-foods/eat-protein-foods/. Accessed 2019 Dec 6.
6. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al.
Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. Lancet 2019;393(10170):447-92. Epub 2019 Jan 16. Errata in: Lancet 2019;393(10171):530, Lancet 2019;393(10191):2590. Epub 2019 Jun 27.
Response
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hank you, Dr Tomislav Svoboda and Dr Kimberly Wintemute for your interest and constructive sug- gestions for Family Medicine Forum (FMF). We appre- ciate you taking the time to provide your feedback.We will address each point you have mentioned.
First, regarding plant-based meals, approximately 20% to 30% of vegetarian and vegan selections are included at each food service area within FMF. The boxed lunches containing meat are generally a few ounces of meat-based protein accompanied by veg- etables, fruits, and grains. We make every effort to select healthy and fresh choices, while being mind- ful of budgets and efficiencies to serve thousands of meals and snacks in a limited window. We appre- ciate your suggestions and reference documents, and these will be reviewed and considered by our Conferences and Events committee. We will strive to continue to improve upon and stress the impor- tance of healthy plant-based options to be offered efficiently and at reasonable prices, as we work with all our event venues across Canada.
In regard to single-use plastics, we are proud to say that at this past FMF in Vancouver, BC, we had no single-use plastics in our food and beverage program. Corn-based, fully compostable cups and containers were used by the Vancouver Convention Centre (VCC). The VCC has a complete in-house environmental team and all waste is hand-sorted and sent to 3 different processing companies to min- imize and reduce actual garbage to extremely low levels. We were also able to come to an agreement with the facility to bring in our own Tetra Pak water cartons for instances requiring packaged water, and we confirmed in advance that these would be fully recycled through one of the VCC waste man- agement partners; the lid was also corn based and
LETTERS
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Vol 66: JANUARY | JANVIER 2020 |Canadian Family Physician | Le Médecin de famille canadien
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Make your views known!
To comment on a particular article, open the article at www.cfp.ca and click on the eLetters tab. eLetters are usually published online within 1 to 3 days and might be selected for publication in the next print edition of the journal. To submit a letter not related to a specific article published in the journal, please e-mail letters.editor@cfpc.ca.
Faites-vous entendre!
Pour exprimer vos commentaires sur un article en particulier, accédez à cet article à www.cfp.ca et cliquez sur l’onglet eLetters. Les commentaires sous forme d’eLetters sont habituellement publiés en ligne dans un délai de 1 à 3 jours et pourraient être choisis pour apparaître dans le prochain numéro imprimé de la revue. Pour soumettre une lettre à la rédaction qui ne porte pas sur un article précis publié dans la revue, veuillez envoyer un courriel à letters.editor@cfpc.ca.
compostable. We are working nearly a year ahead with each main FMF facility to put expectations, packaging, and serving options in place to eliminate all single-use plastics from our food and beverage program.
Regarding virtual attendance, we are in our third year of offering FMF Live, a live-streaming, daily reg- istration option that we promote to all members via e-mail blasts. It is Mainpro+ certified for 1 credit per hour, and can be delivered straight to your electronic device. This live-streaming option is available on our website (fmf.cfpc.ca) under “Educate” then “FMF Live”
(the direct link is fmf.cfpc.ca/fmf-live/). Early this year we are launching FMF On Demand, which will also be found at fmf.cfpc.ca under “Educate” then “FMF On Demand” (direct online link is fmf.cfpc.ca/fmf-on- demand/). This will offer Mainpro+ certified 1-credit- per-hour sessions that were captured at FMF, with postevaluation questions. We also plan to promote this to all members and hope this contributes to our quest of providing high-quality and accessible continuing professional development content to all our members.
Thank you again for the inquiry, and we look for- ward to continuing to learn, improve, and build upon the health and environmental awareness of all our CFPC events.
Competing interests None declared
—Jennifer Campbell CMP CEM CFPC Director, Conferences and Events
Standing for issues
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hile reading the November issue of Canadian Family Physician, I was struck by the title of Dr Ladouceur’s editorial: “Our fight against climate change.”1 Perhaps as a matter of public health, we could have a policy of refram- ing the issue, from a fight against climate change to stand- ing for a whole series of interrelated issues: clean air, clean water, a flourishing of all living things together, etc.We understand the toxicity of anxiety and depression.
Neither one is a nursery for effective action. Taking any action in the direction of what one loves and appreci- ates does ignite the participation of others: in actuality, a lot is going on in this direction even though our tradi- tional media culture focuses on our failures. There cer- tainly are plenty of failures to focus on.
Nevertheless, those who cultivate and pursue some vision (almost any vision) outlive those who remain dis- heartened, however much data there might be to support the general view that things are going badly. We know how discouraged and disheartened many people are.
Let us consciously advocate for, and leave to others the fighting against.
—Frances Griffiths MD CCFP Ladysmith, BC
Competing interests None declared Reference
1. Ladouceur R. Our fight against climate change. Can Fam Physician 2019;65:766 (Eng), 767 (Fr).
The opinions expressed in letters are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
