“It’s True” — OHIP Billing Software -...

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OMR Full 63.pdf 1 4/14/2011 2:29:49 PM

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Committee Chairs

Agreement

(OMA-Ministry of Health and

Long-Term Care)

Agreement Board Co-ordinating

Committee

Dr. M. Toth

Forms Committee

Dr. A. Studniberg

Joint Committee on the Schedule

of Benefits

Dr. P. Conlon

Medical Audit Oversight Committee

Dr. D. Hellyer

Medical Services Payment Committee

Dr. L. Colman

Physician LHIN Tripartite Committee

Dr. T. Nicholas

Physician Services Committee

Dr. M. Toth

Workplace Safety & Insurance Board

Steering Committee

Dr. J. Tracey

Governance

Board Governance Committee

(Board Co-ordinating Committee)

Dr. M. Toth

Annual Meeting Planning Committee

Dr. M. MacLeod

Audit Committee

Dr. R. Mann

Awards Committee

Dr. J. Willett

Board Planning Committee

Dr. D. Weir

Budget Committee

Dr. V. Tandan

Committee on Committees

Dr. R. Mann

Council Committee on Structure & Bylaws

Dr. J. Willett

Nominations Committee

Dr. M. MacLeod

Staffing Committee

Dr. V. Walley

Health Policy

Health Policy

(Board Co-ordinating Committee)

Dr. S. Chris

eHealth Working Group

Dr. S. Chris

Hospital Issues Committee

Dr. V. Tanden

Member Services

Member Services

(Board Co-ordinating Committee)

Dr. V. Walley

Physician Health Program Advisory Panel

Dr. D. Puddester

Public & Political Advocacy

Communications Advisory Committee

(Board Co-ordinating Committee)

Dr. D. Weir

Outreach to Women Physicians Committee

Dr. R. Forman

Executive, Board, Council, Committee Chairs

Executive Committee

President

Dr. M.S. Kennedy, Thunder Bay

President Elect

Dr. D. Weir, Toronto

Past President

Dr. M. MacLeod, London

Chair of the Board

Dr. S. Wooder, Stoney Creek

Honorary Treasurer

Dr. V. Tandan, Hamilton

Secretary

Dr. M. Toth, Aylmer

Board of Directors

District

1 Dr. D.J. Hellyer, Windsor

2 Dr. M. MacLeod, London

Dr. M. Toth, Aylmer

3 Dr. C. Cressey, Palmerston

4 Dr. V. Tandan, Hamilton

Dr. R. Tytus, Hamilton

5 Dr. S. Whatley, Mount Albert

Dr. J. Tracey, Brampton

6 Dr. J. Ludwig, Peterborough

7 Dr. A. Steacie, Brockville

8 Dr. G. Beck, Ottawa

Dr. A. Kapur, Ottawa

9 Dr. P. Bonin, Sudbury

10 Dr. M.S. Kennedy, Thunder Bay

11 Dr. S. Chris, North York

Dr. L. Colman, Etobicoke

Dr. C. Jyu, Scarborough

Dr. C. Pinto, Etobicoke

Dr. A. Studniberg, Scarborough

Elected by Council

Dr. A. Donohue, Ottawa

Dr. W. Tanner, Toronto

Dr. V. Walley, Peterborough

Dr. D. Weir, Toronto

Dr. S. Wooder, Stoney Creek

Academic Representative

Dr. R.K. Edwards, Kingston

CouncilChair

Dr. A. Hudak, Orillia

Vice-Chair

Dr. E. Barker, Wiarton

Mar12_executive_committee_p1.indd 1 12-03-05 10:14 AM

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INDICATIONS AND CLINICAL USEZOSTAVAX® is indicated for the prevention of herpes zoster (shingles) in individuals50 years of age or older.

SELECTED IMPORTANT SAFETY INFORMATIONZOSTAVAX® is not a treatment for zoster or postherpetic neuralgia (PHN). If anindividual develops herpes zoster despite vaccination, active current standard ofcare treatment for herpes zoster should be considered. Vaccination with ZOSTAVAX®may not result in protection of all vaccine recipients. ZOSTAVAX® is contraindicatedin patients with a history of hypersensitivity to any component of the vaccine,including gelatin; a history of anaphylactic/anaphylactoid reaction to neomycin;primary and acquired immunodeficiency states due to conditions such as: acuteand chronic leukemias; lymphoma; other conditions affecting the bone marrowor lymphatic system; immunosuppression due to HIV/AIDS, cellular immunedeficiencies; immunosuppressive therapy (including high-dose corticosteroids);active untreated tuberculosis; pregnancy. In clinical trials, ZOSTAVAX® has beenevaluated for general safety in more than 32,000 adults 50 years of age or older.ZOSTAVAX® was generally well tolerated. Vaccine-related injection-site andsystemic adverse experiences reported at an incidence ≥1% are shown below.The overall incidence of vaccine-related injection-site adverse experiences wassignificantly greater for subjects vaccinated with ZOSTAVAX® versus subjects whoreceived placebo (48% for ZOSTAVAX® and 17% for placebo among recipientsaged≥60 (Shingles Prevention Study [SPS]) and 63.9% for ZOSTAVAX® and 14.4%for placebo among recipients aged 50-59) (ZOSTAVAX® Efficacy and Safety Trial[ZEST]). Vaccine-related injection-site and systemic adverse experiences reported in≥1%of adults who received ZOSTAVAX® (N=3,345) or placebo (N=3,271) (0-42DaysPostvaccination) in the Adverse Event Monitoring Substudy of the SPS were:erythema† (35.6%, 6.9%), pain/tenderness† (34.3%, 8.6%), swelling† (26.1%,4.5%), hematoma (1.6%, 1.4%), pruritus (7.1%, 1.0%), warmth (1.7%, 0.3%),headache (1.4%, 0.9%). Most of these adverse experiences were reported asmild inintensity. The remainder of subjects in the SPS received routine safetymonitoring, butwere not provided report cards. The types of events reported in these patients weregenerally similar to the SPS subgroup of patients in the Adverse Event MonitoringSubstudy. Vaccine-related injection-site and systemic adverse experiencesreported in ≥1% of adults who received ZOSTAVAX® (N=11,094) or placebo(N=11,116) (1-42 Days Postvaccination) in the ZEST were: pain† (53.9%, 9.0%),erythema† (48.1%, 4.3%), swelling† (40.4%, 2.8%), pruritus (11.3%, 0.7%),warmth (3.7%, 0.2%), hematoma (1.6%, 1.6%), induration (1.1%, 0.0%),headache (9.4%, 8.2%), pain in extremity (1.3%, 0.8%).

THE FIRST AND ONLY VACCINE INDICATEDTO HELP PREVENT HERPES ZOSTER

IN INDIVIDUALS 50 YEARS OF AGE OR OLDER

* ZOSTAVAX® is not indicated to reduce the morbidity and complications associated with herpes zoster.† Designates a solicited adverse experience. Injection-site adverse experiences were solicited only from Days 0-4 postvaccination in SPSand from Days 1-5 postvaccination in ZEST.

Please visit our website at:www.merck.ca

VACC-1008558-0000-E-CDN-AUG-12

A DISEASE THAT MAY CAUSEBURNING, STABBING,SEARING PAIN2*

® Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license.© 2011 Merck Canada Inc., a subsidiary of Merck & Co., Inc. All rights reserved.

Approximately 95% of Canadian adults have hadchickenpox and are therefore at risk for herpes zoster1

And there is no way to predictwho will develop herpes zoster3

ZST-076 SP Ad OntMedRev:Layout 1 8/8/11 3:16 PM Page 1

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7 Editorial: Response to the Drummond Report Too many of Drummond’s recommendations are distanced from the realities of

frontline patient care, and do not adequately acknowledge the significant vari-

ables that impact the provision of services in various disciplines, care settings,

and geographic areas of the province. The potential impacts on public health

and the social determinants of health are not well articulated. And, the related

costing — both immediate and long term — is absent or vague.

10 132nd OMA Annual General and Council Meeting:

calendar of events, registration information

16 General surgery in Ontario: volume and mix changes

over time An analysis by the OMA Economics Department shows that while Ontario’s

wait time strategy (WTS) initiative in general has been successful in reducing

wait times for patients receiving a select group of services, it has done so at

the cost of hindered access to patients needing non-WTS services, and work

opportunities for physicians providing those services.

20 OMA programs and workshops strengthen physician

leadership roles in Ontario Member feedback regarding the many leadership initiatives offered by the

OMA continues to be very positive. The Physician Leadership Development

Program is now accepting applications for its third cohort, which will begin in

September 2012. Details are posted online — the deadline to apply is May 5.

22 Medical societies partner with Physician Health

Program to present “mindfulness” seminar Markham Stouffville and York County medical societies recently joined forces

with the OMA Physician Health Program to provide local physicians with an

opportunity to partake in a unique event entitled “Mindfulness in Medicine.”

28 Interpretive Bulletin: pre-dental/pre-operative

assessments, fee code Z110 The Education and Prevention Committee has prepared a review of 2011

changes to the Schedule of Benefits regarding pre-dental/pre-operative

assessments, and fee code Z110 (extensive debridement of an onychogry-

photic nail involving the removal of multiple laminae).

33 The promising value of an MBA for the Canadian MD As the Canadian health-care system evolves, the fundamental skills taught

through a Master of Business Administration program — such as change

management, leadership, learning to work in a team, and financial literacy —

are likely to increase in value to physicians.

March 2012

Volume 79 Number 3

www.oma.org

March 2012 Volume 79 Number 3

www.oma.org

PM

4114

4507

Dedicated to Doctors. Committed to Patients.

OMA Annual General Meeting132nd OMA AGM/Council Meeting May 3-6 in

Toronto: calendar of events, registration

EditorialResponse to the Drummond Report

Electronic Medical RecordsHow to select an EMR that best meets your

practice needs

Physician LeadershipPhysician Leadership Development Program now

accepting third cohort applications — May 5 deadline

General Surgery in OntarioVolume and mix changes over time

Interpretive BulletinSchedule of Benefits changes to pre-dental/

pre-operative assessments, fee code Z110

Successfully managing your career in medicine

Publications Mail

Agreement # 41144507

Undeliverables, please return to:

Ontario Medical Review

150 Bloor St. West, Suite 900

Toronto, Ontario M5S 3C1

FEATURES

March 20123ONTARIO MEDICAL REVIEW

44 Successfully

managing your career

in medicine

Generally speaking, physicians

graduate from medical school in

their mid-to-late 20s, and retire

in their mid-to-late 60s. Thus,

a medical career tends to span

at least 40 years. What sustains

and excites us at the start of our

professional journey may not be

enough to fulfil us during other

phases of our career. Dr. Mamta

Gautam, a pioneer in the area

of physician health and keynote

speaker at the upcoming 13th

Annual Women’s Health Care

Seminar, provides strategies and

knowledge to help physicians

assess and reshape their goals

to ensure they maintain a high

level of satisfaction throughout

their professional and personal

lives.

Mar12_table_contents_p3_p5.indd 1 12-03-09 4:22 PM

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Bell comes to your aid with a variety of telecommunication solutions.

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Bell can provide you with simple solutionsat rates exclusive to OMA members.

For more information dial 1 855 662-2355

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24 Electronic Medical Records: selecting an EMR that

meets your practice needs OntarioMD has prepared a step-by-step guide to selecting the right electronic

medical record system for your practice, including tips on arranging vendor

demonstrations, co-ordinating site visits with existing users of various systems,

conducting vendor reference checks, and negotiating a contract.

26 Ask the EMR Expert: maintaining patient engagement

when using a computer during consultation There are a number of approaches to the placement and organization of office

furniture that can help physicians maintain a positive dialogue and rapport

with patients when using an EMR/computer during the consultation.

46 OMA Insurance Update: will power — the importance

of estate planning The right insurance and investment strategies are two important parts of sound

financial planning. The third part — your will — is an essential component of

an effective estate plan, providing for an orderly transfer of your assets to your

chosen beneficiaries, and the opportunity to choose the executor of your estate.

COLUMNS

March 20125ONTARIO MEDICAL REVIEW

Editor

Jeff Henry

Managing Editor

Elizabeth Petruccelli

Associate Editor

Matthew Radford

Advertising/Circulation Co-ordinator

Kim Secord

Production Co-ordinator

Angelica Santacroce

Classifieds Co-ordinator

Vita Ferrante

Art Direction

Artful Dodger Communications Inc.

Publisher’s Notes

Published 11 times yearly by the

Ontario Medical Association

150 Bloor St. West

Suite 900

Toronto, Ontario

M5S 3C1

Tel. 416.599.2580 or

Toll-free: 1.800.268.7215

Fax: 416.340.2232

Email: [email protected]

OMA website: www.oma.org

ISSN 0030 302X

Any opinions expressed in articles and

claims made in advertisements are

the opinions of the authors/advertisers

and do not imply endorsement by the

Ontario Medical Association.

The Ontario Medical Review welcomes

readers’ views. Letters to the editor

should be addressed to Ontario Medical

Review, 150 Bloor St. West, Suite

900, Toronto, Ontario M5S 3C1; fax

416.340.2232; email: jeff.henry@oma.

org. Note: letters may be edited for

space and clarity. Please include name,

address and daytime phone number.

(Additional “Publisher’s Notes” appear

on page 63)

March 2012

Volume 79 Number 3

www.oma.org

CAPSULE NEWS

9 13th Annual Women’s Health Care Seminar to be held May 3 in Toronto

13 Education and Prevention Committee presents complimentary

accredited medical billing seminar, May 4 in Toronto

32 Update re opioid prescribing and dispensing

37 Members invited to provide input on OMA policy priorities

41 Ontario Medical Student Bursary Fund 8th Annual Fundraising Golf

Tournament: June 15, Angus Glen Golf Club

48 OMA 2012 Corporate Hotel Directory: preferred rates for members

DEPARTMENTS

1 OMA Executive, Board, Council,

Committee Chairs

6 OMA Section Chairs

38 Health Policy Report

40 Board of Directors Report:

February 8-9, 2012

43 In Memoriam

58 Classifieds

64 Medectoon/Advertisers’ Index

Mar12_table_contents_p3_p5.indd 2 12-03-09 4:22 PM

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Addiction Medicine Dr. R. Cooper

Allergy and Clinical Immunology

Dr. B. Wong

Anesthesiology Dr. J. Watson

Cardiac Surgery Dr. F. Rubens

Cardiology Dr. W. Hughes

Chronic Pain Physicians Dr. H. Jacobs

Clinical Hypnosis Dr. M. Dales

Clinical Teachers Dr. R. Edwards

College and University Student Health

Dr. D. Grant

Community Health Centre & Aboriginal

Health Access Centre Physicians

Dr. I. Tamari

Complementary and Integrative Medicine

Dr. C. Appleyard (Acting Chair)

Critical Care Medicine Dr. M. Warner

Dermatology Dr. S. Gupta

Diagnostic Imaging Dr. M. Prieditis

Emergency Medicine Dr. M. Haluk

Endocrinology and Metabolism

Dr. J. Shaban

French-Speaking Physicians Dr. T. Dufour

Gastroenterology Dr. D. Baron

General and Family Practice Dr. J. Lusis

Genetics Dr. L. Velsher

Geriatrics and Long-Term Care Dr. A. Baker

GP Psychotherapy Dr. M. Paré

Group Practice Dr. G. Maley

Hematology and Medical Oncology

Dr. P. Kuruvilla

Hospitalist Medicine Dr. L. Bustani

HSO Physicians Dr. J. Craig

Hyperbaric Medicine Dr. A.W. Evans

Independent Physicians Dr. J. Szmuilowicz

Infectious Diseases Dr. N. Rau

Internal Medicine Dr. M. Wilson

Interns and Residents Dr. M. Dufour

Laboratory Medicine Dr. C.M. McLachlin

Medical Students

Ms. S. Kenny, Ms. M. Olszewski

Nephrology Dr. C. Edwards

Neurology Dr. E. Klimek

Neuroradiology Dr. S. Symons

Neurosurgery Dr. F. Gentili

Nuclear Medicine Dr. C. Marriott

Obstetrics and Gynecology Dr. B. Mundle

Occupational and Environmental Medicine

Dr. M. Cividino

Ophthalmology Dr. N. Nijhawan

Orthopedic Surgery Dr. D. MacKinlay

Otolaryngology - Head and Neck Surgery

Dr. O. Smith

Palliative Medicine Dr. D. Cargill

Pediatrics Dr. H. Yamashiro

Physical Medicine and Rehabilitation

Dr. D. Berbrayer

Plastic Surgery Dr. B. Vanbrenk

Psychiatric Hospitals, Schools

Dr. S. Allain

Psychiatry Dr. D. Brownstone

Public Health Physicians Dr. H. Shapiro

Radiation Oncology Dr. D. D'Souza

Reproductive Biology Dr. C. Librach

Respiratory Disease Dr. H. Ramsdale

Rheumatology Dr. P. Baer

Rural Practice Dr. S. Cooper

Sleep Disorders Dr. A. Soicher

Sport and Exercise Medicine

Dr. T. Jevremovic

Surgery, General Dr. A. Maciver

Surgical Assistants Dr. D. Esser

Thoracic Surgery Dr. R. Zeldin

Urology Dr. F. Papanikolaou

Vascular Surgery Dr. A. Dueck

Section Chairs

March 20126ONTARIO MEDICAL REVIEW

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EDITORIAL

ONTARIO MEDICAL REVIEW March 20127

THE RECENT RELEASE OF THE REPORT OF THE COMMISSION ON THE REFORM OF ONTARIO’S PUBLIC

SERVICES, CHAIRED BY ECONOMIST DON DRUMMOND, PROMPTED A TREMENDOUS VOLUME OF MEDIA

COVERAGE AND PUBLIC COMMENTARY, MUCH OF IT FOCUSED ON HEALTH CARE.

The OMA issued an initial response,

which we communicated to members

via the President’s Update, and our

internal analysis of the Drummond file

is continuing as this issue of the OMR

goes to press.

Our policy, economics and legal

departments, and other program areas

within the Association, are doing a

thorough review of the Commission’s

research and recommendations. We

will notify members once that work is

concluded.

The Commission’s emphasis on

patient-centred care and improved

efficiency, quality and integration are

already significant components of the

health-care system that we have been

engaged in for a number of years.

Of course, we support the call to

more actively promote healthy lifestyles

and preventive care among Ontarians.

Though we cannot overlook the gibe

that “doctors address diet and exercise

issues before reaching for the prescrip-

tion pad when dealing with...cardio-

vascular disease and late-onset Type 2

diabetes.” This is an insult to physicians

and discredits the report and its authors.

The OMA shares the commitment

to advance team-based care and inter-

professional collaboration, and more

reliance on information technology in

doctors’ offices. Unfortunately, the re-

port is void of any discussion regarding

the inherent related costs to the system.

And, we firmly believe that a move

toward more specialized treatment cen-

tres outside of hospital, and enhanced

home care and community-based

services are in the best interests of

patients, providers, and government.

In its focus on physicians, the Com-

mission urges government to “aggres-

sively negotiate with the Ontario Medical

Association for the next agreement.”

The Commission makes the glib

(and inaccurate) assertion that Ontario

doctors are the highest paid in Canada,

therefore “it is reasonable to set a goal

of allowing no increase in total compen-

sation.”

The Commission further proposes

that negotiations “must go well beyond

compensation. They must also address

the integration of physicians into the

rest of the health-care system and the

objective of working towards the best

possible health quality regime.” We can

safely predict that integration and qual-

ity will be priorities for doctors and gov-

ernment.

Drummond uses the terms “total

compensation” and “total compensa-

tion envelope” in assigning the govern-

ment’s negotiations goal for doctors.

Nowhere are the terms defined, but this

does warrant some attention.

The population of Ontario contin-

ues to grow and age. The number of

complex patients is increasing. And the

College of Physicians and Surgeons of

Ontario has certified an unprecedented

number of new physicians in the effort

to keep pace with the medical require-

ments of the citizens of this province.

At the same time, the Ministry of

Health and Long-Term Care recently

announced its ambitious Action Plan

for Health Care, which sets out a broad

range of new initiatives.

If there is no increase in total com-

pensation — as Drummond advises

— how will government address the

Response to Drummond

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ONTARIO MEDICAL REVIEW

growing public need for medical ser-

vices associated with demographic

trends?

And how will we sustain the tremen-

dous improvements in patient access

to care and system innovation that we

have worked so hard to achieve?

Is Drummond suggesting that gov-

ernment ration or cut certain services to

patients in order to fund new or alterna-

tive areas of health investment? This

scenario is plainly unacceptable.

The health-care segment of this

report reflects a basic cut and paste

of the Commission’s discussions with

individuals, organizations, corporations

and government.

The report lacks the evidence to

support many of its recommendations.

There is no costing associated with

suggestions to expand certain health

services, and it lacks an implementation

schedule that takes into consideration

impacts on patient care.

Overall, too many of Drummond’s

recommendations are distanced from

the realities of frontline patient care,

and do not adequately acknowledge

the significant variables that impact the

provision of services in various disci-

plines, care settings, and geographic

areas of the province.

Also, the potential impacts of the

Commission’s recommendations on

public health and the social determi-

nants of health are not well articulated.

While the report offers 105 recom-

mendations on health care alone, it

rings hollow in terms of presenting

any new ideas or innovative thinking to

guide the system forward.

And, as noted earlier, the related

costing — both immediate and long

term — is absent or vague.

Also, the tone of the Commission’s

Report toward physicians is dismissive

and abrupt, and frankly not helpful in

encouraging a constructive dialogue.

The physicians of Ontario have

worked exceptionally hard and excep-

tionally well throughout the past decade

to improve public access to care and to

address many long-standing targeted

problems in the health-care system.

We have achieved this progress

working together in partnership with the

Ministry of Health and Long-Term Care

and other health-care stakeholders and

organizations.

The Drummond Report chooses to

ignore or diminish a lot of these accom-

plishments, much like the Auditor

General’s recent Annual Report.

Instead, doctors are painted as barriers

to progress and innovation, wedded to

the status quo.

Not only is this untrue, but it is unfair

and inappropriate, and a disservice to

the medical profession in Ontario.

It has taken years to improve the

province of Ontario’s reputation as a

preferred place to practise medicine.

We have worked very hard to address

the physician shortage, to attach

patients to family doctors, and bolster

our medical training programs.

We’ve developed very unique and

innovative means to address both local

and systemic problems, to incent pro-

viders, encourage collaboration, and

transform the delivery of care.

The evidence is found in our master

agreements, varied payment mecha-

nisms, and tailored programs and

services designed by physicians and

government to enhance the provision

of care to patients throughout this prov-

ince.

Yet, rather than acknowledge the

leadership role of Ontario doctors in

affecting real positive change in the

health-care system, the Drummond

Report espouses that physicians

should be dealt with arbitrarily, if at all.

The report advocates that the prov-

ince of Ontario is the leader among

al l provinces in health care. The

Commission cites the need to invest

in medical innovation and to imple-

ment more incentives in health care

to advance change and efficiency. Of

course, these are all laudable objec-

tives.

Unfortunately, the numerous contra-

dictions and narrow focus throughout

the report serve to undermine its many

positive recommendations.

As I stated recently to the media:

Now is not the time to put the brakes on

progress. Nor can we afford to back-

slide based on ill-informed assump-

tions.

The OMA is determined to work

with government and others to main-

tain the positive course that we have

set in health care, to tackle current chal-

lenges, and forge a better system for

patients and providers in the future.

Dr. Stewart Kennedy

OMA President

EDITORIAL

8 March 2012

Do you have an OMA-related question and

don’t know who to contact?

Send the Response Centre an email at

[email protected] or call 1.800.268.7215 and

press 0.

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ONTARIO M EDICAL ASSOC IAT ION

The 13th annual Women’s Health Care Seminar

is complimentary to OMA members, and has

been accredited in previous years for CME

credits. To register, visit www.oma.org/AGM, or

contact Jennifer Csamer at 1.800.268.7215, ext.

3461, or via email ([email protected]).

Featuring Dr. Mamta Gautam on Understanding Physician Health

Current Challenges in Mental Health

C

M

Y

CM

MY

CY

CMY

K

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ONTARIO MEDICAL REVIEW

132nd OMA Annual General and Council MeetingCalendar of Events

Thursday, May 3 – Sunday, May 6, 2012

Toronto Marriott Downtown Eaton Centre Hotel, Toronto, Ontario

Pre-registration is required for all meetings. You may register online at: www.oma.org/AGM

March 201210

WOMEN’S HEALTH CARE SEMINAR:

CURRENT CHALLENGES IN MENTAL HEALTH

– THURSDAY, MAY 3

The OMA Outreach to Women Physicians Committee

presents the 13th Annual Women’s Health Care Seminar,

“Current Challenges in Mental Health.” This year features a

keynote address by Dr. Mamta Gautam on Understanding

Physician Health (see page 9 for more details).

EDUCATION AND PREVENTION COMMITTEE

BILLING SESSIONS – FRIDAY, MAY 4

The Education and Prevention Committee (EPC), in con-

junction with the OMA, will host educational billing sessions

on Friday, May 4, from 0900 – 1200 and 1400 – 1700. The

morning session, beginning at 0900, will focus on recent

changes to the Schedule of Benefits (and what they mean

to you). This session is intended for all physicians, regard-

less of specialty or experience. At 1000, the Ministry of

Transportation will address obligations and requirements

under the Highway Traffic Act for mandatory reporting of

a medical condition. The final topic, at 1045 – 1200, is

intended primarily for physicians practising in the specialty

of internal medicine (including internal medicine sub-special-

ties). Billing cases/scenarios will be discussed.

The afternoon session, from 1400 – 1700, will be dedi-

cated to FHO/FHG Primary Care Billing. This session is

intended only for physicians participating in either a FHO

or FHG billing model. Topics include Q codes, after-hours

obligations, preventive care bonuses, and more (please

refer to page 13 for the registration form, or register online

at www.oma.org/AGM).

0900 – 1630

13th Annual Women’s

Health Care Seminar:

Current Challenges in

Mental Health (see p. 9

for more details)

Throughout the Day

and Evening

Section Annual Meetings

(see p. 12 for more

details)

0730 – 1700

Annual Meeting and

Council Registration (see

p. 11 for more details)

0730 – 1700

Annual Meeting and

Council Registration

(see p. 11 for more details)

Morning and Evening

Section Annual Meetings

Educational Sessions

and Training

(see p. 12 for more details)

1200 – 1400

Adam Linton Memorial

Feature Luncheon

(see p. 11 for more details)

1400 – 1700

Council Policy Discussion

0730 – 1700

Council Registration

(see p. 11 for more details)

0900 – 1700

Annual Meeting of Council

(see p. 11 for more details)

1230 – 1330

Council Luncheon

1830 – 2400

Awards Presentations,

Presidential Installation,

Gala Dinner/Dance

(see p. 11 for more details)

0730 – 1200

Council Registration

(see p. 11 for more details)

0900 – 1700

Annual Meeting of Council

(see p. 11 for more details)

1230 – 1330

Council Luncheon

SUMMARY OF EVENTS

Thursday,May 3

Friday,May 4

Saturday,May 5

Sunday,May 6

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ONTARIO MEDICAL REVIEW

SOCIAL MEDIA TRAINING – FRIDAY, MAY 4

The Social Media Training 101 workshop will offer you a

hands-on approach to understanding social media and set-

ting up your own personal social media presence. The social

media universe may seem complicated and confusing, but

this introductory course will allow you to understand the

basics of operating such social media networks. You will

be able to sign up for these social networks in a detailed

step-by-step walk-through, understand some of the com-

mon social media language, and connect with users from

across the web. Questions about setup, privacy settings,

and benefits of having an online presence will be answered

at this workshop.

ADAM LINTON MEMORIAL FEATURE LUNCHEON

– FRIDAY, MAY 4

The 20th Annual Adam Linton Memorial Feature luncheon

and lecture will be presented on Friday, May 4, from 1200

– 1400, as part of the Annual General Meeting. The lecture

honours the memory and accomplishments of Dr. Adam

Linton, OMA President from June 1991 to January 1992.

Dr. Linton was a nationally renowned educator who spent

much of his time working to improve Ontario’s health-care

system. The lecture will be presented by Andrew Coyne,

writer for The National Post, and the former national editor of

Maclean’s — one of Canadian journalism’s most prestigious

and influential positions. An original member of The National

Post, where he held the position of national affairs columnist,

Mr. Coyne has established himself over the last two decades

as one of this country’s most thoughtful, passionate and

articulate commentators on political and economic issues.

There is no charge for this event, thanks to a generous

contribution from the Canadian Medical Association and its

subsidiary, MD Management.

COUNCIL ORIENTATION SESSION – FRIDAY, MAY 4

The Chair and Vice Chair of Council will be holding a Council

orientation session for Delegates. The session will focus on

providing participants with:

a) Information on your role as Council Delegates;

b) Information on the process for developing and submitting

motions to Council.

The session will be held on Friday evening, May 4, from

1730 – 1830.

ANNUAL MEETING OF COUNCIL

– SATURDAY, MAY 5 AND SUNDAY, MAY 6

Council is the governing body of the Ontario Medical

Association. The power to vote and put forward resolutions

is limited to Council Delegates, elected by the members of

each OMA Territorial Division, District and Section. However,

any OMA member who registers is entitled to attend the

meeting as an observer.

AWARDS PRESENTATIONS, PRESIDENTIAL

INSTALLATION AND GALA DINNER/DANCE

– SATURDAY, MAY 5

This year’s event will take place at The Carlu, 444 Yonge

Street (at College), 7th floor.

OMA members are invited to join in celebrating the many

contributions and accomplishments of our medical col-

leagues. The evening commences at 1830 with the awards

presentations and presidential installation. A brief reception

will follow at approximately 1930, and dinner will be held at

approximately 2000. A dance will take place after dinner,

featuring the music of the band “Blush.”

The gala dinner is presented, in part, by a generous con-

tribution from the Canadian Medical Association and its

subsidiary, MD Management.

March 201211

FEATURED EVENTS

REGISTRATION

Please register online for all meetings, including Council,

via the following link: www.oma.org/AGM. You may also

register for Council by contacting Suzi Mijango, Membership

Operations, at 416.599.2580 or 1.800.268.7215, ext. 2975,

or email: [email protected].

HOTEL RESERVATIONS

Rooms have been reserved at the Toronto Marriott

Downtown Eaton Centre Hotel at the rate of $199 for either

single or double occupancy. You may telephone the hotel

directly at 416.597.9200 or 1.800.905.0667. When reserv-

ing, please indicate that you are attending the meetings of

the Ontario Medical Association to ensure you receive the

preferred rate. The deadline for reservations is April 2, 2012.

After this date, reservations will be accepted on a space-

available basis only.

NOVEMBER 2012 COUNCIL MEETING AND

2013 ANNUAL MEETING

The 2012 Fall Council Meeting will be held on Saturday,

November 24 and Sunday, November 25 in Toronto at the

Toronto Marriott Downtown Eaton Centre Hotel. The 133rd

OMA Annual General and Council Meeting will be held in

Hamilton at the Hamilton Convention Centre from Thursday,

May 2 to Sunday, May 5.

GENERAL INFORMATION

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ONTARIO MEDICAL REVIEW March 201212

Pre-registration is required for all meetings (you may register online at: www.oma.org/AGM). This schedule is preliminary

and may be amended. Your Section flyer outlining agenda items will be distributed in the coming weeks.

SECTION PROGRAM LISTING (alphabetical)

CHRONIC PAIN

Friday, May 4

& Scientific Session

0830 – 1200

CLINICAL HYPNOSIS

Thursday, May 3

1830 – 1900

1900 – 2100

CME: Mindful Treatment

of Sexual Dysfunction:

Dr. Frank Sommers

GENERAL AND FAMILY

PRACTICE

Friday, May 4

1700 – 1830

1830 – 2100

A COLLABORATIVE

OMA SESSION —

MENTAL ILLNESS/

MENTAL HEALTH

The OMA Section on GP

Psychotherapy, in association

with the OMA Sections on

Ontario Psychiatric Hospitals

and Hospital Schools,

Complementary & Integrative

Medicine, Interns and Residents,

Occupational & Environmental

Medicine and Psychiatry

Thursday, May 3

1800 – 2100

Friday, May 4

(continued)

0900 – 1100

Section on GP

Psychotherapy

1100 – 1200

HOSPITALIST MEDICINE

Friday, May 4

0800 – 1000

1000 – 1200

HSO PHYSICIANS

Friday, May 4

& Dinner

1830 – 2030

INTERNAL MEDICINE

Friday, May 4

1900 – 2000

LABORATORY MEDICINE

Friday, May 4

900 – 1200

NEPHROLOGY

Friday, May 4

& Dinner

1830 – 2100

NEUROLOGY

Friday, May 4

1730 – 1200

ONTARIO PSYCHIATRIC

HOSPITALS & HOSPITAL

SCHOOLS & OPDPS

Friday, May 4

1100 – 1200

OPHTHALMOLOGY

Friday, May 4

(Executive Members Only)

1500 – 1700

and Dinner

1800 – 2030

PHYSICAL MEDICINE AND

REHABILITATION

Friday, May 4

0800 – 1100

- 0800 – 0900

Ultrasound-Guided

Intervention in Musculoskeletal

Pain Management:

Dr. Philip Peng

- 0900 – 1000

Assessment and

Management of Those

with Persistent

Symptoms Post

Concussion:

Dr. Mark Bayley

- 1000 – 1100

Approach to Myopathy in

Clinical Practice:

Dr. Mark Tarnopolsky

- 1100 – 1200

Annual General Meeting

and Discussion of Billing

Pearls or Pitfalls

Mar12_AGM_calender_events_pp10-12.indd 3 12-03-05 3:45 PM

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Education and Prevention Committee

Complimentary Accredited Medical Billing Seminar

Friday, May 4, 2012

Toronto Marriott Downtown Eaton Centre Hotel

9:00 a.m. - 10:00 a.m. 1) Ministry of Health Presentation: Summary of Schedule Changes 2011

Intended for all physicians regardless of specialty or experience. There may be limited time

for questions related to the items covered in the presentation; however, questions will be

addressed after the presentation and pending available time.

10:00 a.m. - 10:45 a.m. 2) Ministry of Transportation (MTO) Presentation: Mandatory Reporting of Medical

Condition to MTO (fee code K035)

Intended for all physicians regardless of specialty or experience. Staff from MTO will ad-

dress obligations and requirements under the Highway Traffic Act for mandatory reporting

of a medical condition. EPC members will also be on hand to discuss the OHIP payment

requirements for eligibility of payment for K035 (form fee for the mandatory reporting).

10:45 a.m. - 12:00 p.m. 3) Ministry of Health Presentation: Internal Medicine Billing for

Assessments/consultations for Hospital In-patients

Intended primarily for physicians practising in the specialty of Internal Medicine (including

Internal Medicine sub-specialties). Billing cases/scenarios will be discussed. This session

may be of interest to other specialists working in hospitals however it will only address

internal medicine specialty services.

The EPC would request that any advance questions/scenarios from Internal Medicine specialists treat-

ing hospital in-patients be faxed in advance to the number below. Only scenarios provided in advance

will be addressed in this session. The ministry will make every effort to accommodate all requests in

the allotted time.

12:00 p.m. - 2:00 p.m. Adam Linton Lunch

2:00 p.m. - 5:00 p.m. 4) FHO & FHG Primary Care Billing

Intended for physicians that are practicing in a FHO or FHG primary care model. Topics

include new codes to the schedule of benefits, clarification of existing Q codes, after hours

care, and more. A question and answer period will be available for specific issues not

covered during the presentation.

NOTE: The seminar is open only to physicians and all events are available on a first-come, first-served basis.

To register, please log on to www.oma.org/AGM by April 27, 2012.

For questions please contact Practice Advisory Services at [email protected].

Name (surname first)

Address

City Postal Code

Phone

Fax

Email

Specialty

Please register me for:

Session 1: Schedule Changes

Session 2: Ministry of Transportation

Session 3: Internal Medicine

Adam Linton Lunch (note you must register to attend

the lunch)

Session 4: Primary Care Billing

If submitting a question/scenario for discussion during

session 3, please fax your question to 416.340.2244.

All questions will be forwarded to the EPC anonymously.

The Education and Prevention Committee (EPC) is a joint

committee of the Ontario Medical Association and the

Ministry of Health and Long-Term Care.

CouncilBillingSeminarOMRadV2.indd 1 12-02-27 2:00 PM

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See prescribing summary on page

®

DOV.05.11.AdOMR.indd 1 6/14/11 11:00:24 AM

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ONTARIO MEDICAL REVIEW 15

DID YOU KNOW?50% to 80%

of psoriasis patients have

SCALP INVOLVEMENT

et al J Eur Acad

Dermatol Venerol

See prescribing summary on page

12

In need of medical-legal

advice?OMA Legal Services can provide advice to members on

the following issues relating to practice:

Inquiries should be directed to OMA Legal Services:

Jim Simpson

Tel. 416.340.2940 or 1.800.268.7215, ext. 2940

Email: [email protected]

Robert Lee

Tel. 416.340.2934 or 1.800.268.7215, ext. 2934

Email: [email protected]

Adam Farber

Tel. 416.340.2894 or 1.800.268.7215, ext. 2894

Email: [email protected]

Jennifer Gold

Tel. 416.340.2889 or 1.800.268.7215, ext. 2889

Email: [email protected]

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FEATURE

ONTARIO MEDICAL REVIEW

Also, despite this growth in the hospital

sector, many hospital-based physicians

(particularly those in surgical specialties)

have reported constraints in their abil-

ity to provide patient access to needed

services. These constraints include

hospital OR closures during certain

times of the year, reduced OR availabil-

ity, and an increasing trend toward last-

minute surgery cancellations.

The purpose of this paper is to exam-

ine if Ontario general surgeons, and their

patients, have experienced constrained

access to hospital resources, despite

the large expenditure increases on hos-

pitals by the provincial government.

Recently, there has been anecdotal

evidence that new surgeons have been

having difficulty finding work, and estab-

lished surgeons have been restricted

in their ability to perform surgery due

to constraints and cost-cutting mea-

sures implemented by hospitals (i.e.,

lack of OR time, nursing resources,

beds, etc.). If such restrictions are wide-

spread, they have an adverse effect on

patient access to care and wait times.

A recent national physician sur-

vey by the Fraser Institute indicates

that the most frequently cited reason

for increasing wait times has been the

“availability of OR time.”1

These views have been expressed

most recently by Ontario surgeons dur-

ing the OMA negotiations consultation

process. The surgeons cited that lack

of OR time, cancelled surgeries, etc.,

were impacting their patient access

to timely care, and that WTS services

were given priority by hospitals at the

expense of other needed services.

However, system-wide data that sub-

stantiate these claims has not been

available, and it was felt that it would

be difficult to obtain this data from hos-

pitals.

In an attempt to gather system-wide

data from administrative records, we

conducted an analysis to see if such

patterns can be discerned. If these

hospital behaviours/constraints are as

prevalent as our discussions seem to

suggest, they should be discernible in

the data. In particular, we focused on

an analysis of the number of surgeries

per general surgeons and surgery as

a share of total activity over time, and

compared all surgeries to WTS-related

surgeries. The study methodology and

results are presented below.

Summary of Results

Results of the analysis indicate that

there has been a statistically significant

decline in the number of surgeries per

doctor and in the share of surgeries in

the physician’s total practice.

The results also indicate that the

decline in the overall number of sur-

geries comes predominantly from the

decline in the non-wait time strategy-

related surgeries.

Specifically, the decline is statistically

significant only for the non-wait time

surgeries (p-value < 0.05), but not for

March 201216

General surgery in Ontario:

volume and mix changes over timepatient access to WTS services maintained at

the expense of non-WTS services

by Boris Kralj, PhD, OMA Economics Department

Jasmin Kantarevic, PhD, OMA Economics Department

OVER THE PAST DECADE, ONTARIO GOVERNMENT SPENDING ON HOSPITALS HAS DOUBLED. IN THE LATE

1990s, THESE EXPENDITURES AMOUNTED TO ABOUT $8 BILLION. TODAY, THEY APPROACH $18 BILLION.

SOME OF THIS GROWTH IS DUE TO A GROWING AND AGING POPULATION, AND MAJOR INITIATIVES SUCH AS

THE WAIT TIME STRATEGY (WTS). YET, WHILE HOSPITAL EXPENDITURES HAVE INCREASED, THE ACTUAL NUMBER

OF BEDS, HOSPITALIZATIONS AND SURGICAL DISCHARGES HAS DECLINED (SEE FIGURES OPPOSITE).

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ONTARIO MEDICAL REVIEW

General Surgery in Ontario

17 March 2012

the wait time surgeries (p-value > 0.1).

Between fiscal 2005/06 and 2009/10,

the number of surgeries performed per

general surgeon declined by about 9%,

or about 28 surgeries. Similarly, sur-

gery as a share of total surgeon activity

declined by about 11%.

These results support the hypoth-

esis that surgeons are facing hospital

restrictions and that these restrictions

mostly apply to non-WTS services and

patients.

Study Methodology

The sample includes all physicians in

the OHIP Specialty 03 (General Surgery)

with any claims from fiscal 2005/06

through 2009/10. For each physician,

the number of surgeries is calculated as

the number of all A-suffix services with

M, N, R, or S prefixes. These surgeries

are further divided into surgeries that

are on the wait time strategy list and

surgeries that are not on the wait time

list. The main categories of the wait time

surgeries include cancer, cardiac, and

knee and hip surgeries.

We use the multivariate regression

framework to test for statistically sig-

nificant differences in the number of

surgeries over time. We report both

unadjusted estimates as well as esti-

mates adjusted for the confounding

effects of physician age, gender, and

geographic location of practice (Local

Health Integration Network).

We adjust for age using eight age

intervals because there is a well-known

inverted U-shape relationship between

age and phys ic ian product iv i ty .

Similarly, we adjust for gender because

of well-documented differences in pro-

ductivity between male and female phy-

sicians.

Lastly, we control for potential

regional variation by including a full set

of 14 LHIN indicators.

Study Results

The summary statistics are presented

in Table 1 and Figures 3 and 4 (see pp.

18-19). For the sample of all general

surgeons, the average number of sur-

geries per physician decreased from

298 in fiscal 2005/06 to 271 in fiscal

2009/10 (about a 9% decline). This

declining trend is also evident for the

share of surgeries in the physician’s

total practice (a decline of 11%).

Furthermore, the decline is more

pronounced for the non-wait time sur-

geries (-12%) than for the wait-time sur-

geries (-5%).

Lastly, this declining trend is even

stronger when we limit our analysis to

the sample of general surgeons who

are present in each year over the sam-

ple period — a panel (a 12% decline

over the sample period).

These summary statistics do not

adjust for the known influence of age,

gender, and regional variation on the

physician practice profiles. In Table 2,

we present the results from the multi-

variate regression that adjusts for these

6,000

7,000

8,000

9,000

10,000

11,000

12,000

13,000

14,000

15,000

16,000

17,000

18,000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: OMA Economics, CIHI

Figure 1:

Ontario Government Spending on Hospitals

1998-2011 ($ millions)

850,000

900,000

950,000

1,000,000

1,050,000

1,100,000

1,150,000

1,200,000

Source: OMA Economics, CIHI

1995

-199

6

2009

-201

0

1996

-199

7

1997

-199

8

1998

-199

9

1999

-200

0

2000

-200

1

2001

-200

2

2002

-200

3

2003

-200

4

2004

-200

5

2005

-200

6

2006

-200

7

2007

-200

8

2008

-200

9

Figure 2:

Ontario Inpatient Hospitalizations

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ONTARIO MEDICAL REVIEW

General Surgery in Ontario

18 March 2012

Panel of Same General Surgeons (2)

All Surgeries

(3)

All Surgeries/

Total Services

(4)

Non-WTS

Surgeries

(5,7)

WTS

Surgeries

(6,7,8)

362 6.4% 210 152

345 5.8% 200 145

330 5.5% 190 140

325 5.4% 182 143

318 5.3% 177 141

-12% -17% -16% -7%

All General Surgeons (1)

Fiscal Year All Surgeries

(3)

All Surgeries/

Total Services

(4)

Non-WTS

Surgeries

(5,7)

WTS

Surgeries

(6,7,8)

2005 298 6.1% 178 120

2006 292 5.6% 173 119

2007 280 5.4% 165 115

2008 271 5.3% 155 116

2009 271 5.4% 156 115

2009 vs.

2005-9% -11% -12% -5%

Notes

1) All physicians in OHIP Specialty 03 (General Surgery) with any FFS claims.

2) All physicians in OHIP Speciality 03 (General Surgery) with any FFS claims in each year 2005/06 to 2009/10.

3) Surgeries are defined as all A-suffix services with M, N, R, or S prefix.

4) Surgeries as defined in (3) as a percentage of total professional services.

5) Surgeries as defined in (3) for fee codes that are not on the list of wait time codes.

6) Surgeries as defined in (3) for fee codes that are on the list of wait time codes.

7) Full list of wait time fee codes is available upon request.

Table 1: Average Number of Surgeries per Physician, by Type of Surgery (Wait Time vs. Other), Fiscal 2000/01-2009/10,

OHIP Specialty 03 (General Surgery)

Table 2: Average Number of Surgeries per Physician, by Type of Surgery (Wait Time vs. Other), Fiscal 2005/06 vs. 2009/10

All General Surgeons (1) Panel of Same General Surgeons (2)

Estimated Difference p-value (8) Estimated Difference p-value (8)

All Surgeries (3)

Unadjusted

Adj. for Age (9)

Adj. for Age, Gender, Location (9,10)

-27.1

-30.9

-28.6

0.03

0.01

0.01

-43.5

-40.2

-40.3

0.01

0.00

0.00

Ratio of All Surgeries/All Services (4)

Unadjusted

Adj. for Age

Adj. for Age, Gender, Location

-0.7%

-0.7%

-0.8%

0.02

0.01

0.00

-1.1%

-1.2%

-1.2%

0.00

0.00

0.00

Surgeries for Wait Time Fee Codes (6,7)

Unadjusted

Adj. for Age

Adj. for Age, Gender, Location

-5.7

-7.4

-7.1

0.31

0.13

0.14

-10.8

-6.9

-8.2

0.15

0.28

0.20

Surgeries for Non-Wait Time Fee Codes (5,7)

Unadjusted

Adj. for Age

Adj. for Age, Gender, Location

-21.4

-23.5

-21.5

0.03

0.01

0.02

-32.7

-33.3

-32.1

0.01

0.00

0.00

Notes

1) All physicians in OHIP Specialty 03 (General Surgery) with any FFS claims.

2) All physicians in OHIP Speciality 03 (General Surgery) with any FFS claims in each year 2005/06 to 2009/10.

3) Surgeries are defined as all A-suffix services with M, N, R, or S prefix.

4) Surgeries as defined in (3) as a percentage of total professional services.

5) Surgeries as defined in (3) for fee codes that are not on the list of wait time codes.

6) Surgeries as defined in (3) for fee codes that are on the list of wait time codes.

7) Full list of wait time fee codes is available upon request.

8) p-value associated with a test that the difference between 2009/10 and 2005/06 is not statistically significant.

9) Differences are adjusted for eight five-age intervals in a regression framework.

10) Location is defined as the LHIN of physician practice. The regression includes 14 such indicators.

Mar12_general_surgery_pp16-19.indd 3 12-03-07 2:42 PM

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OntariO Medical review

General Surgery in Ontario

19 March 2012

factors. These results indicate that the decline in the number of surgeries and the share of surgeries in the physician’s total practice is statistically significant, even when controlling for age, gen-der and location of practice (p-value < 0.05). These results hold for both the sample of all general surgeons and the sub-sample of general surgeons who were present in each year between 2005/6 and 2009/10.

The results also indicate that the decline in the overall number of sur-geries comes predominantly from the decline in the non-wait time surgeries. Specifically, the decline is statistically significant only for the non-wait time surgeries (p-value < 0.05), but not for the wait time surgeries (p-value > 0.1).

Concluding RemarksThis analysis indicates that there is a reduction in the number of surgeries per physician between 2005/06 and 2009/10. This result holds for the num-ber of surgeries, as well as the share of surgeries in physician total practice.

Moreover, the result holds even after adjusting for the confounding factors of age, gender, and location of practice.

Lastly, the reduction is statistically significant only for the non-wait time sur-geries, but not for the wait time surger-ies. WTS surgeries have not declined, but other surgeries have declined sig-nificantly.

While the WTS initiative in general has been successful in reducing wait times for patients receiving a select group of services, it has done so at a cost of hindered access to patients needing non-WTS services and work opportunities for physicians providing those services.

Reference

1. http://www.fraserinstitute.org/uploadedFiles/

fraser-ca/Content/research-news/research/

publications/why-we-wait.pdf

Dr. Kral j is Execut ive Director, OMA Department of Economics and OMA Chief Economist. Dr. Kantarevic is Senior Director, OMA Department of Economics.

0

50

100

150

200

300

250

350

2000

132

195

131

195

127

187

122

186

120

181

120

178

119

173

115

165

116

155

115

156

2001 2002

Non-Wait Time Codes Wait Time Codes

2003 2004 2005 2006 2007 2008 2009

Figure 3: Average Surgeries per Physician, Fiscal 2000/01 to 2009/10

OHIP Specialty 03 (General Surgery)

7.2% 7.1% 6.8% 6.8% 7.0%

6.1% 5.6%

5.4% 5.3% 5.4%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Figure 4: Average Share of Surgeries per Physician, Fiscal 2000/01 to 2009/10

OHIP Specialty 03 (General Surgery)

Mar12_general_surgery_pp16-19.indd 4 12-03-27 10:59 AM

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FEATURE

ONTARIO MEDICAL REVIEW

Launched two years ago in col-

laboration with the Canadian Medical

Association, the immensely success-

ful Physician Leadership Development

Program (PLDP) saw its first group of

participants graduate in June 2011.

The PLDP is currently running its sec-

ond session, with participants due to

graduate this June.

With the first cohort of graduates now

successfully applying their learning to

practice, and the second cohort more

than half-way through the program, the

response from all PLDP participants to

date has been extremely positive.

Applications for the program’s third

cohort, set to begin in September 2012,

are now being accepted. Interested

physicians can find up-to-date infor-

mation and application packages on

the PLDP website, or by contacting the

program by phone or email (see contact

information at the end of this article).

Physicians from across Ontario,

in any specialty, and at any stage in

their career, are encouraged to apply.

Applicants should be currently involved

in an institutional, community-based, or

professional leadership role, and have

the desire to reflect deeply on their own

leadership and how it both inhibits and

enhances the transformation of the

health-care system.

Also, the OMA will be hosting its

first ever Medical Student Leadership

Summit on March 31. This project was

initiated by the student leaders of the

Ontario Medical Student Association

(OMSA), a Section of the OMA, who

requested leadership training as a

supplementary learning experience

to complement their current medical

school curriculum.

The event wil l be faci l i tated by

Brenda Zimmerman, a professor of

strategic management and an expert

in complexity science and manage-

ment in health care. Speakers and

guests will include OMA CEO Ron

Sapsford; Dr. Joshua Tepper, vice-

president, education, Sunnybrook

Health Sciences Centre; former OMA

President Dr. Suzanne Strasberg; Dr.

Shital Gandhi, medical director, clini-

cal teaching unit, Mount Sinai Hospital;

Dr. Andrew Brown, founder of Altitude

Mentoring; and Mark Bowden, creator

of TruthPlane, and renowned body lan-

guage expert.

The day will be an interactive learning

experience that focuses on allowing par-

ticipants to better understand their own

learning styles, and apply the knowledge

gained to their own leadership roles.

The OMA is at the forefront of leader-

ship development for physicians, and

is working to make leadership educa-

tion more widely available to interested

members. While future initiatives are

at the very early stage of investigation

to determine their feasibility, the OMA

is pleased to discuss any of its current

member programs by email or phone.

Reminder: application materials for

cohort 3 of the Physician Leadership

Deve lopment Program are now

posted. The deadline for applica-

tions is May 5, 2012. For more infor-

mation, please visit the Physician

Leadership Development Program

website at www.oma.org/pld, or con-

tact 1.800.268.7215, ext. 2239, or

416.340.2239, or email Physician.

[email protected].

March 201220

Physician Leadership Development

OMA programs and workshops strengthen

physician leadership roles in Ontario:new programs being considered to reach more members

by Octavia Davidson

Chris Cartwright

OMA Member Services

POSITIVE MEMBER FEEDBACK REGARDING THE MANY LEADERSHIP PROGRAMS AND WORKSHOPS HOSTED

BY THE OMA IN RECENT YEARS — INCLUDING THE PHYSICIAN LEADERSHIP DEVELOPMENT MASTER’S

CERTIFICATE PROGRAM, LEADERSHIP TRAINING FOR MEDICAL STUDENTS, AND SEVERAL REGIONAL LEADER-

SHIP INITIATIVES — HAS ENCOURAGED THE OMA TO WORK TOWARD DEVELOPING ADDITIONAL PROGRAMS TO

REACH MORE MEMBERS, AND TO FURTHER STRENGTHEN PHYSICIAN LEADERSHIP IN ONTARIO.

REV_Mar12_physician_leadership_p20.indd 1 12-03-09 12:12 PM

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The OMA Physician Health Program is a

confidential service for physicians, residents,

medical students and their family members.

Our caring, helpful, health-care professionals

assistance to those who may be

problems ranging from stress,

or family issues, through to

psychiatric illness.

Confidential Toll-Free Line 1.800.851.6606

php.oma.org

BECAUSE EVERY MOMENT COUNTS

Good Health Matters

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FEATURE

ONTARIO MEDICAL REVIEW

Joining forces with its neighbouring

territorial division — the York Central

Medical Society — a co-hosted meet-

ing was held on January 24, 2012. The

focus of the event, determined in part-

nership with the PHP, was “Mindfulness

in Medicine.”

In an ever-changing, fast-paced

medical environment, physicians need

to refocus themselves from time to time

in the context of their professional and

personal lives.

As OMA District 5 Director Dr. Shawn

Whatley explained, “Physicians tend to

be quite conservative. The mindfulness

presentation was geared to provide a

safe environment to learn about some-

thing a little different, that seems to

show promise for some patients” — as

well as physicians.

PHP presenters Ted Bober and Ann

Davidson noted, “The essence of the

Mindfulness in Medicine workshop is

to introduce physicians to evidence-

based mindfulness practices.”

These workshops provide an oppor-

tunity to enhance physician health and

well-being, as well as improve attention

and situational awareness. Participants

also learn how to communicate and

act skillfully during a difficult clinical

encounter, and how to lead with greater

openness and flexibility, rather than in a

manner that may compromise patient

care and team functionality.

Mindfulness is not simply the prac-

tice of meditation, although this is one

potential component. True mindfulness

is also being present in everything that

one does throughout the day.

For physicians working in a fast-

paced environment, such as the emer-

gency department, operating room,

or busy family practice office, it is

important to always be present in the

moment and not be distracted by extra-

neous stimuli.

Many physicians at the meeting

expressed interested in receiving tips

for their patients who may benefit from

a calming, centering approach to life.

Dr. Scott Kapoor, an emergency

physician in Markham, appreciated

the helpful tips, which can be of use to

physicians and patients alike. “After

this meeting, I use the STEPP method

all the time — Stop, Take a breath,

Expand your awareness, Pause,

Proceed,” said Dr. Kapoor.

Dr. Brigitte Monrose, a family physi-

cian in Markham, appreciated that the

workshop provided her with “new infor-

mation as to what is available through

the OMA. I enjoyed the meeting and

the enlightening topic of mindfulness. In

this stressful type of work, there is defi-

nite benefit to be able to calm the mind

and focus on the moment.”

All participants benefited in some

way from the workshop. Many were

impressed by the focus on literature

and evidence that underlies the prac-

tice of mindfulness, and some partici-

pants were inspired to seek advanced

information on the topic.

To find out about events in your area,

engage with your local physician col-

leagues, or obtain more information on

OMA Regional Engagement Services,

please contact [email protected], or call

1.800.268.7215.

March 201222

Spotlight on Local Leadership

“Mindfulness in Medicine”Markham Stouffville,York Central medical societies

partner with OMA Physician Health Program

by OMA Regional Engagement Services

IN EARLY 2011, THE MARKHAM STOUFFVILLE MEDICAL SOCIETY EXECUTIVE SURVEYED ITS MEMBERSHIP TO

DETERMINE INTERESTS FOR FUTURE MEETINGS. WITH A NEW LEADER IN PLACE, AND A DESIRE TO ENGAGE

MORE MEMBERS, THE EXECUTIVE POLLED OVER 400 DOCTORS TO GATHER FEEDBACK ON A VARIETY OF

POTENTIAL TOPICS. CONTINUING A TREND SEEN IN OTHER AREAS OF THE PROVINCE, A WORKSHOP FROM THE

OMA PHYSICIAN HEALTH PROGRAM (PHP) WAS IDENTIFIED AS A PREFERRED OPTION.

Mar12_regional_engagement_p22.indd 1 12-03-07 2:54 PM

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Physician Health: Breaking Bad News & Doing it Well, Balancing Boundaries in Medicine

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FEATURE

ONTARIO MEDICAL REVIEW

During the Prepare stage, you estab-

lished your EMR system requirements.

You did this by specifying your vision

and goals, and by completing an on-

site readiness assessment and work-

flow analysis. Now, during the Select

stage, you make use of this work. You

compare the capability of the various

EMR systems against those system

requirements. You make your selec-

tion, and sign a contract with the cho-

sen vendor.

To simplify the process, OntarioMD

has done much of the background

research. OntarioMD has assembled

a list of vendors and tested their prod-

ucts to ensure that they meet spe-

cific functionality. The government of

Ontario, through eHealth Ontario and

OntarioMD, provides financial support

for the purchase of these funding-eligi-

ble EMR offerings.

To assist in the selection process,

Ontar ioMD has created a simple

“EMR Solution Selection Guide and

Workbook.” This guide helps your

selection team compare different

EMR offerings against a specific set of

functions. With it, you should be able

to identify the two or three systems

that come closest to meeting your

needs.

The Selection Team

The project leader and project team

members from the Prepare stage now

turn their attention to assessing and

selecting the EMR product. The team

membership can remain as originally

constituted, or be altered if additional

skills are required. In any case, the

members must be intimately familiar

with the work that has already gone

into the project. Furthermore, the team

must possess the business judgment

to decide what features are nice-to-

have versus must-haves, and the con-

sequences of those decisions.

The Selection Process

Your Practice Advisor will help you

develop your specific selection pro-

cess. A selection process typically

includes vendor demonstrations, site

visits with existing users of the vari-

ous systems, and vendor reference

checks.

Negotiating the contract with the

supplier involves specifying the equip-

ment, defining the scope of work (who

does what, and by when) and setting

out the training support. Many prac-

tices have their lawyer review the con-

tract before they sign it.

Types of EMR Service Models

One of the first decisions to be made

is the type of EMR service delivery

model. There are two types: the local

solution model, and the application

service provider (ASP) model. In gen-

eral, the former is less expensive, but

requires more on-site technology skills

for ongoing maintenance. The oppo-

site is true for the ASP model.

With the local solution, you own

and manage the computer server. The

server is physically located in a secure

spot in your facility, with the physicians

and staff accessing the data from their

offices and workstations. You are

March 201224

Electronic Medical Records

Managing change in the medical practice: Part 3 — “Select” an EMR that meets your needs

by OntarioMD

SUCCESSFULLY IMPLEMENTING AN ELECTRONIC MEDICAL RECORD SYSTEM CAN BE A DAUNTING TASK.

TO HELP GUIDE PHYSICIANS AND STAFF THROUGH THE PROCESS, ONTARIOMD HAS PREPARED A SERIES

OF ARTICLES THAT DRAW ON THE PRINCIPLES OF CHANGE MANAGEMENT. LAST MONTH, WE EXAMINED HOW

TO PREPARE. BELOW WE EXPLORE STAGE TWO — HOW TO SELECT AN EMR.

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ONTARIO MEDICAL REVIEW

responsible for the maintenance of the

server, backups, software updates,

disaster recovery and data security.

Some practices perform these activi-

ties internally. Others have an outside

contractor do it.

With the ASP model, the server and

all the software resides at the secure

eHealth Ontario data centre. You own

the data, but not the server or the soft-

ware. Everything outside of your facility

is managed for you on a fee-for-ser-

vice basis. eHealth Ontario looks after

software and data security, disaster

recovery, updates, etc.

Vendor Demonstrations

For the systems that you want to

investigate, your Practice Advisor will

arrange vendor demonstrations and

prepare you with questions to ask.

These demonstrations allow you to see

how well the EMR products would fulfil

your practice needs. Be ready to ask

as many questions as you see fit. The

more information you have, the better

you will be able to make an informed

choice.

Visit Existing Users and Check

Vendor References

The vendors and your Pract ice

Advisor can refer you to existing users

whose practices are similar to your

own. You can learn much by visit-

ing them and talking to them about

their experience. Ask them about their

likes and dislikes regarding the prod-

uct and vendor support. In addition,

inquire about the terms and costs in

their vendor contracts. Have them

identify what they were, and were not,

able to negotiate.

Negotiate the Contract

In acquiring your EMR system, you are

not technically buying the software.

You don’t own it. Instead, you are

licensing the rights to use it. Vendors

typically start with a standard agree-

ment and then allow some flexibility

in the terms and conditions. Review

all aspects of the agreement. If any

part of it is unclear, ask for additional

wording to clarify the meaning. Be

guided by what you learned on your

site visits.

Finally, consider having your lawyer

review the final agreement before sign-

ing it. The purpose of the legal review

is not necessarily to comment on the

specific business deal, rather, it is to

ensure that you understand each par-

ty’s rights and obligations under the

agreement.

Scope of Work Document

The Scope of Work document is an

addendum to the contract. It contains

a list of the many tasks that must be

completed during the EMR imple-

mentation, and sets out who will be

responsible for doing what, and by

when — whether it is you, the vendor,

or any third parties.

Training Requirements

The better the training, the smoother

and faster your start-up wi l l be.

Consequently, training is a very impor-

tant aspect of the contract that you

sign with the vendor. OntarioMD has

created a “Training Requirements

Guide” to help you address the intri-

cacies of specifying the amount, type

and schedule of vendor-supplied train-

ing support.

From an implementation perspec-

tive, all staff members need to receive

some level of training, and the more

that they receive the better. Minimizing

initial training may save you some

money at the start, but there is a good

chance you will pay for it later on with

the cost of resolving post-implementa-

tion difficulties.

Recap of “Select” Stage

At the end of the Select stage, you

wil l have a signed contract with a

vendor for your EMR system. At this

point, you can take a bit of a breather

as the vendor gets everything ready

for the “implement” stage. In next

month’s article, we will delve into what

is involved in that stage of the change

management process.

More Information

To learn more about EMR adoption,

contact OntarioMD at 1.866.744.8668,

or email [email protected]. All

guides and tools referenced in this arti-

cle are available online at: www.ontario

md.ca.

Electronic Medical Records

25 March 2012

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FEATURE

ONTARIO MEDICAL REVIEW

There are a number of strategies you

can use to help maintain a positive

dialogue and rapport with your patient

when using an EMR/computer dur-

ing the consultation. These strategies

involve both the layout of the physi-

cal space, and your communication

approach.

A variety of factors impact examining

room organization and furniture place-

ment:

the desk and chairs are arranged.

-

ments where placement is not at the

sole discretion of the physician.

There is no single best solution or

layout that will work for all physicians

across the diversity of practice situa-

tions. Each arrangement has its advan-

tages and disadvantages.

However, a layout that provides

both patient and physician access to

the computer screen while maintaining

sight of each other — a triangle con-

sisting of patient/physician/computer

screen at each corner — can aid in

communication and rapport.

Any number of potential office con-

figurations can achieve this objective,

as illustrated in Figure 1 and Figure 2

below.

In some examination rooms the

computer screen wil l be between

the patient and practitioner in order

to keep the practitioner’s body facing

the patient to maintain eye contact.

Having a swivelling screen will help

share EMR information and educa-

tional materials with the patient in this

configuration (see Figure 3).

Regardless of your office layout,

maintaining an open posture while

using the computer is important. It

is quite easy to be physically drawn

toward the computer screen/keyboard,

and hunched over the desk when typ-

ing or reading, which can contribute to

patients feeling isolated and ignored.

An open posture will not only help your

patients feel more connected, but will

help you avoid potential back problems.

Developing and maintaining rapport

with patients is essential for a success-

ful physician/patient relationship; by

attending to spatial relationships, and

adjusting communication techniques,

you can seamlessly integrate the EMR

into your consultation process to build

and strengthen patient interactions.

Next month’s column will delve fur-

ther into the specifics of rapport build-

ing communication techniques with

your EMR.

To submit queries to “Ask the EMR Expert”

please email communications@ontariomd.

com.

March 201226

Electronic Medical Records

“Ask the EMR Expert”maintaining patient engagement when

using an EMR during consultation

by Anne DuVall, MD

T

Figure 3Figure 1

EMR

PtMD

EMR

Pt

MD

EMR

MD

Pt

Figure 2

Mar12_EMR_ask_expert_pp26.indd 1 12-03-06 11:37 AM

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March 2012ONTARIO MEDICAL REVIEW

INTRODUCTION

What is the Education and Prevention Committee (EPC)?

The Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA) have jointly established the

Education and Prevention Committee (EPC). The EPC’s primary goal is to educate physicians about submitting OHIP

claims that accurately reflect the services provided and that are in compliance with the law.

What is an Interpretive Bulletin?

Interpretive Bulletins are prepared jointly by the Ministry and the OMA to provide general advice and guidance to physi-

cians on specific billing matters. They are provided for education and information purposes only and express the Ministry’s

and OMA’s understanding of the law at the time of publication. The information provided in this Bulletin is based on the

September 1, 2011, Schedule of Benefits — Physician Services (Schedule). While the OMA and Ministry make every

effort to ensure that this Bulletin is accurate, the Health Insurance Act (HIA) and Regulations are the only authority in this

regard and should be referred to by physicians. Changes in the statutes, regulations or case law may affect the accuracy

or currency of the information provided in this Bulletin. In the event of a discrepancy between this Bulletin and the HIA or

its Regulations and/or Schedule under the regulations, the text of the HIA, Regulations and/or Schedule prevail.

EPC Bulletins are available on the OMA website (http://www.oma.org/Resources/Pages/EPCbulletins.aspx). The Schedule

is available on the Ministry website (http://www.health.gov.on.ca/english/providers/program/ohip/sob/sob_mn.html).

Education and Prevention Committee Interpretive Bulletin - Volume 10, No. 3

Schedule Changes to Pre-Dental/Pre-Operative

Assessments, and Fee Code Z110

28

PurposeThe purpose of this Interpretive Bulletin is to provide physi-

cians with information on specific changes to the Schedule,

which came into effect in 2011.

While there were several changes to the Schedule in 2011,

this Bulletin focuses on revisions specific to:

-

photic nail involving the removal of multiple laminae).

Pre-Dental/Pre-Operative AssessmentsNew fee codes for pre-dental/pre-operative assessments

rendered by specialists (A904, C904 and W904) were

added to the Schedule, effective July 1, 2011. In addition,

amendments were made to the pre-dental/pre-operative

general assessment (A903, C903 and W903).

A pre-dental/pre-operative assessment, listed on page A3

of the Schedule, is described as the service “required to

provide history and physical exam information to the peri-

operative team that will be assessing suitability for surgery

and anaesthesia.”

There are separate listings for the pre-dental/pre-operative

assessment, depending on the level of assessment ren-

dered and the specialty of the physician. The location of the

patient determines the appropriate prefix:

(non-emergency long-term care inpatient) — when a

Mar12_EPC_bulletin_pp28-30.indd 1 12-03-05 1:57 PM

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March 2012ONTARIO MEDICAL REVIEW

Education and Prevention Committee Interpretive Bulletin - Volume 10, No. 3

29

full general assessment is rendered by the primary care

physician in the specialty of general/family practice, pedi-

physician in any other specialty.

Payment RequirementsA/C/W903 require that a full medically necessary general

assessment be rendered, the elements of which include a

full history, family medical history, an examination of all body

parts and systems, and other requirements listed on page

GP18.

A/C/W904 require, at a minimum, that a medically neces-

sary partial assessment be rendered, which includes a his-

tory of the presenting complaint and the necessary physical

examination (see page GP20).

These services are not eligible for payment for filling out a

hospital’s pre-operative form, unless the payment require-

ments of the service have been met (i.e., these are not form

fees).

Limits and maximums:

patient per physician over a 12-month period (they also

constitute “general assessments” for the purpose of cal-

culating the general assessments limits stated on page

GP18).

Note: When a claim for a pre-dental/pre-operative assess-

ment for an individual patient is payable by OHIP, and that

patient is subsequently admitted to hospital for elective

surgery within 30 days of the pre-dental/pre-operative

assessment, the admission general assessment (C003)

or a general re-assessment (C004) is not eligible for pay-

ment.

The patient’s medical record must document the findings

of the assessment, and meet the payment requirements

for the level of assessment rendered. The assessment

must also be personally rendered by a physician and can-

not be delegated to a non-physician for OHIP payment

purposes.

ExamplesExample 1

Dr. W is a family physician. On October 3, 2011, she

performed a pre-operative assessment prior to cataract

extraction from Mrs. F’s left eye.

Is Dr. W eligible for payment of A903?

Yes, provided the payment requirements are met (includ-

ing a complete general assessment) and the maximums

for general assessments (including A003) for the 12-month

period have not been reached. If a complete general

assessment is not medically necessary or not performed, a

minor or intermediate assessment should be claimed based

upon their specific payment requirements.

Example 2

Dr. T, an anesthesiologist, evaluates 78-year-old Mr. B prior

to Ministry of Health and Long-Term Care pre-approved

day surgery to extract Mr. B’s remaining teeth. Is Dr. T

eligible for payment of A904 for this service?

If the purpose of Dr. T’s evaluation is only to provide the

peri-operative team with patient history and physical exami-

nation, the evaluation is not on the same day as surgery,

and the evaluation is not performed as the pre-anesthetic

evaluation that is included in the anesthetic service (see

GP70), then A, C or W904 may be eligible for payment,

provided the requirements of the pre-dental assessment

are met.

A/C/W903 A/C/W904

Assessment

required

General

Assessment

Partial assessment at a

minimum

Eligible

specialties

General/Family

Practice (00),

Emergency

Medicine (12), or

Pediatrics (26)

All specialties other than

00, 12 or 26

Limits Maximum of two

per patient per

physician per

12-month period

Not eligible on day of

surgery

Regarding a patient and his or her surgery:

assessment is eligible for payment (i.e., one

a pre-dental/pre-operative assessment.

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April 2011ONTARIO MEDICAL REVIEW

Education and Prevention Committee Interpretive Bulletin - Volume 9, No. 2

March 2012ONTARIO MEDICAL REVIEW

Education and Prevention Committee Interpretive Bulletin - Volume 10, No. 3

30

If Dr. T is the physician who administers the anesthesia for

Mr. B, and the evaluation is performed on the same day as

surgery, A904 is not eligible for payment based on the pay-

ment rules for A904.

Example 3

Dr. H, a family physician, assesses Mrs. G. on admission for

an elective hysterectomy. Is Dr. H eligible for payment of a

pre-operative general assessment?

Provided that a pre-operative general assessment has not

been performed by Dr. H in the last 30 days, he is eligible for

payment of A/C903. However, if Dr. H or any other physi-

cian has performed a pre-operative assessment in the last

30 days, that service constitutes the admission assess-

ment, and an additional admission assessment (e.g., C003

or C004) is not eligible for payment.

Example 4

Dr. S, a surgeon, renders a consultation to a patient and

recommends surgery at the visit. The information required

for the peri-operative team (which includes Dr. S as sur-

geon) is gathered and documented during the assessment/

consultation, thereby satisfying the hospital’s requirements

for pre-operative paperwork. Is A904 payable in addition to

the consultation?

No, A904 is not payable on the same day as a consultation

as, in general, only one assessment is eligible for payment

to a physician on the same day. In the example above,

because the information required to fill out a pre-operative

form was obtained during the consultation, a separate

service is not payable as A904 is not simply a form fee.

Z110 – Extensive Debridement of an Onychogry-photic Nail, Involving Removal of Multiple LaminaeEffective September 1, 2011, the Schedule was amended to

personally by the physician in order to be eligible for payment

of the listed fee. If the service is not rendered personally by

the physician (e.g., delegated to a non-physician) it remains

insured for the patient (which means that the patient cannot

be charged), and payable at zero to the physician.

may be eligible for payment to a physician who personally

removes multiple layers of the onychogryphotic nail. As with

all insured services, the patient’s medical record must doc-

for payment for trimming or clipping of nails. The provision

of medically or therapeutically necessary general foot care

services that are not separately listed in the Schedule are

specific elements of the assessment. See page M19 of the

Your feedback is welcomed and appreciated!The Education and Prevention Committee welcomes your feedback on the Bulletins in order to help ensure that these are

effective educational tools. If you have comments or questions on this Bulletin, or suggestions for future Bulletin topics, etc.,

please submit them in writing (referencing this Bulletin) to:

Physician Services Committee Secretariat

150 Bloor Street West , 9th Floor

Toronto, Ontario M5S 3C1

Fax: 416.340.2961

Email: [email protected]

Dr. Laura Anweiler, Co-Chair (Acting)

Dr. Larry Patrick, Co-Chair

Education and Prevention Committee

The PSC Secretariat will anonymously forward all EPC Interpretive Bulletin comments, questions or suggestions to the

Co-Chairs of the EPC for review and consideration.

For specific inquiries on Schedule interpretation, please submit your questions IN WRITING to:Health Services Branch

Physician Schedule Inquiries

370 Select Drive

P.O. Box 168

Kingston, Ontario K7M 8T4

Mar12_EPC_bulletin_pp28-30.indd 3 12-03-05 1:57 PM

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Take Advantage of the OMA’s affinity program.

OMA Advantages provides OMA members with special offers and

services to benefit your personal and professional life.

Please visit our website to learn more about this exclusive program.

www.oma.org/Advantages

Travel and Leisure

Moving and Relocation

Services

Car Lease and

Purchase

Fitness and Health

Medical Office

Communications

Wireless

Communications

AdvantagesAd201107_v4a.indd 1 11-06-22 9:09 AM

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ONTARIO MEDICAL REVIEW

The OMA, Col lege of Physic ians

and Surgeons of Ontario, Ontario

Pharmacists’ Association, and Ontario

College of Pharmacists have developed

the following message to share with our

respective members:

After a fatality apparently resulting

from a change in prescription from

OxyContin to another opioid analgesic,

physicians and pharmacists are being

advised to work closely in determining

the appropriate dosage for medications

prescribed to replace the discontinued

OxyContin.

Over the next several weeks and

months, physicians and pharmacists

will be facing situations that may require

either a direct shift in prescribing and

dispensing from OxyContin to the new,

tamper-resistant OxyNEO or a more

complex conversion from OxyContin to

another opioid alternative. In the latter

scenario, both physicians and pharma-

cists must be aware of the challenges

associated with such conversions, say

the regulatory bodies and associations

of both professions.

The College of Pharmacists and

the Ontario Pharmacists’ Association

are encouraging their members to

contact the prescribing physician for

clarification of dose changes where

possibly unintentional dose escalation

is noted. The College of Physicians

and Surgeons of Ontario and the

Ontario Medical Association are urg-

ing physicians to be receptive to this

contact and work closely with phar-

macists in determining the equi-

analgesic dose of alternative opioid

therapies for chronic non-cancer pain

management.

Conversion charts are available to

help health practitioners determine the

equi-analgesic dose of alternative opi-

oid therapies for chronic non-cancer

pain management. These charts and

other important and useful practice

tools can be found on the Michael G.

DeGroote National Pain Centre website

(http://nationalpaincentre.mcmaster.

ca/).

Physicians may have a number of

questions about the Ministry of Health

and Long-Term Care’s removal of

OxyContin from the Ontario Drug

Benefit Formulary/Comparative Drug

Index and its replacement, OxyNEO.

Answers to frequently asked questions

are available at: http://www.health.

gov.on.ca/english/providers/program/

drugs/opdp_eo/notices/exec_office_

odb_20120217.pdf.

This information was distributed to members

via President’s Update on March 7, 2012.

32 March 2012

Opioid Prescribing and Dispensing:

Physicians and Pharmacists Urged to Work Together

Are you thinking of starting or adding to your family?

Take advantage of the Pregnancy and Parental Leave Benefit Program (PPLBP) which allows you to take paid time away from your practice. Part of the wonder of parenting is experiencing the changes your child goes through during his or her first few months at home. Don’t miss out on these precious milestones — apply for the PPLBP.

To find out more information about this program, including eligibility requirements, please visit https://www.oma.org/Benefits/Pages/PPLBP.aspx or call 1.800.268.7215, ext. 2896 or 416.340.2896.

Learn and grow together.

Mar12_opiod_prrescribing_p32.indd 1 12-03-07 4:56 PM

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FEATURE

ONTARIO MEDICAL REVIEW

Since this statement restricts profiting

from the delivery of health care, what

would motivate a physician to pursue

formal business training, and how

would he or she utilize such training in

the Canadian health-care system?

If the recent and rapid growth in

the number of MD/MBA2 programs

being offered in the United States is

any indication, there appears to be an

increase in the number of physicians

interested in acquiring an MBA.3

One may say that this trend exists

because of the privatized nature of the

U.S. health-care system; however, two

MD/MBA programs are now being

offered at Canadian universities.3

Numerous complementary skills

to the practice of medicine may be

acquired through an MBA program.

Parekh and Singh found that,

according to physicians, the five most

applicable skills to their career learned

by completing an MBA “were related

to evaluating systems operations and

implementing improvements, learning

how to be a more effective leader,

comprehending financial principles,

working within a team setting, and

negotiating effectively.”4

Despite the many skills that a phy-

sician may obtain by completing for-

mal management training, it does not

come without its share of sacrifices.

Sohn and Germain state that pursuing

an MBA is costly from a time and finan-

cial perspective.5 The authors also cite

a sentiment that a physician’s time

may be better served pursuing educa-

tion to enhance his or her clinical skills

and expertise.5

Some scholars even note that

among their colleagues, a stigma

exists for MD/MBAs with respect to

putting profit ahead of patient care.6,7,8

This presumes that management

education is all about making a profit,

even though many MBA programs

offer specialization in management of

not-for-profit and health-care organi-

zations.

The skills that may be gained by a

physician completing an MBA hold the

potential to improve patient care and

drive positive change in the Canadian

health-care system.

As a result of the gap in Canadian

data and the abundant benefits that

may result from an increase in MD/

MBAs, the purpose of this article is

to understand the rationale as to why

Canadian physicians would pursue an

MBA, what skills they learn by com-

pleting this degree, and how MD/

MBAs are applying their skills in the

Canadian health-care system.

This article also seeks to under-

stand from a dual-degree holder’s

perspective what MBA skills they feel

should be incorporated into under-

graduate medical education, and

whether or not Canadian physician

MBAs are stigmatized (as appears

evident in the U.S.) as a result of their

education.

March 201233

The promising value of an MBA

for the Canadian MDby Matthew Solomon, BSc., MBA

THE CANADA HEALTH ACT REQUIRES THAT “THE HEALTH CARE INSURANCE PLAN OF A PROVINCE MUST BE

ADMINISTERED AND OPERATED ON A NON-PROFIT BASIS BY A PUBLIC AUTHORITY APPOINTED OR DESIGNATED

BY THE GOVERNMENT OF THE PROVINCE.”1

Given the changing landscape of clinical medicine

toward a team-based approach, MBA skills are

becoming increasingly applicable to health care.

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ONTARIO MEDICAL REVIEW

Methodology

After a comprehensive l i terature

review, personal interviews were con-

ducted with 10 physicians (nine prac-

tising in Canada and one in the U.S.),

in person or via telephone. All nine

Canadian physicians had acquired

both an MD and an MBA, and the

American physician was in the process

of acquiring an MBA. Each interviewee

was provided with directed questions

in advance. Numerous follow-up ques-

tions were posed based on the con-

versations that emerged.

Results of Research and Discussion

An MBA is a generalist degree, and the

skills taught may be applied to a broad

range of careers. Therefore, it comes

as no surprise that each physician who

pursued an MBA had a unique ratio-

nale for doing so. Each interviewee

indicated that he or she was applying

(or planning to apply) his or her learned

skills in his or her own way. The 10

participants were utilizing their MBA

skills in health-care administration,

health-care consulting, clinical practice,

teaching, entrepreneurial pursuits, and

in their personal lives.

Canadian subjects revealed a great

degree of consistency in terms of the

skills learned by completing an MBA.

The skills most cited were (in no par-

ticular order):

These skills are consistent with

scholarly texts written on this topic,

and reflect an appreciation for both the

soft skills and hard skills that may be

learned by completing an MBA.

To date, a strong emphasis on man-

agement training has not been incor-

porated into medical school education.

Interviewees were asked to comment

on what skills they felt should be inte-

grated into medical school curriculum.

Participants indicated that given the

changing landscape of clinical medi-

cine toward a team-based approach,

MBA skills are becoming increasingly

applicable to health care.

All interviewees felt at least some

of the management skills that they

attained through their MBA should be

incorporated into undergraduate med-

ical education or residency training to

a greater extent than they have been

previously. This was particularly true

for the soft skills, namely learning how

to work well in a team-based environ-

ment and change management.

In many ways, this information

builds upon the work of Healey, et. al.,

who indicated that since the medical

school curriculum does not include

leadership training, physicians are

often unprepared for the task when

they attain leadership roles.9

Moreover, Desai, et. al. state that

“it is commonly (incorrectly) assumed

that a physician successful in clinical

practice could easily transfer to the

duties of managing (or leading) a surgi-

cal suite, a hospital, or any other large

organization; however, leadership and

management, like medicine, require

specific talents, study and experi-

ence.”10

There is a fundamental difference in

the way in which managers behave.10

Physicians are used to one-to-one

interactions with their patients and are

typically autonomous, while managers

frequently interact using a team-based

approach, and value collaboration.10

There is an increasing need to

include leadership training for al l

physicians. Physicians and health-

care managers need to learn to work

together to ensure that Canadian

patients are receiving the highest qual-

ity care. A more comprehensive under-

standing of management principles

among physicians may be useful to

bring about this change.

Team-based learning was cited by

eight of the 10 study participants as

a valuable skill obtained in their MBA

and/or a skill they feel should be incor-

porated into all medical school curri-

cula.

Forty per cent (40%) of the inter-

viewees also cited a need for some

basic business training for all medical

students to help them effectively

manage and run a practice.

An MBA would not be required for

medical students to acquire these

basic skills, but they are important

given the structure of health care in

Canada.

In essence, each physician or group

practice is itself a small business,

MBA for the Canadian MD

34 March 2012

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ONTARIO MEDICAL REVIEW

and in order to provide patients with

the best possible health care, each

practice must be operating efficiently

and effectively.

The most significant data gleaned

from this study was the stark contrast

between Canadian MD/MBAs’ per-

spective of a stigma, and that cited

by U.S.-based research. The subjects

in this study revealed very little, if any,

stigma for a Canadian physician hold-

ing an MBA.

Only one interviewee indicated that

he felt that other physicians negatively

view the fact that he holds an MD and

an MBA. Specifically, he said: “Those

credentials (MD/MBA) have a certain

commercialization slant to it. So, in

some ways, I would say people view

me as someone who is trying to profit

more than another person with a

similar degree.”

In contrast, another interviewee

said, “Colleagues really embrace (the

MBA).” He continued by explaining that

physicians “Build credibility among…

peers by being a good doctor (and) if

your colleagues respect you as a phy-

sician, then it’s what else can you offer

and how can there be synergy.”

The remaining Canadian inter-

viewees indicated that an MBA did not

draw any negative judgment from their

physician colleagues.

Conclusions

As the Canadian health-care system

evolves, the fundamental skills taught

through MBA programs are likely to

increase in value to physicians.

There are many soft skills offered

by an MBA that have the potential to

directly improve patient care through

an individual’s understanding of peo-

ple and team dynamics.

As the Canadian health-care sys-

tem struggles with sustainability con-

cerns, the problem-solving approach

and business savvy that MD/MBAs

possess, paired with their medical

knowledge, may be of significant value

going forward.

An MBA is not the only way that

a physician may learn relevant man-

agement skills. Management training

may be acquired by completing other

graduate programs, such as an MPH

(Master of Public Health), MHA (Master

of Health Administration or Master

of Healthcare Administration) or MS

(Master of Science).

Also, these skills can be acquired

less formally through continuing medi-

cal education courses or through work

experience.

However, according to Lyons, the

aforementioned degrees “are not seen

as equivalent to the MBA.”11 Moreover,

acquiring the skills informally may not

provide the same level of rigor that

would come from the completion of a

graduate level degree.

But, an MBA is not right for all phy-

sicians given the tremendous time

and cost required to complete such

a program. As a result, the best com-

promise may lie in incorporating some

management training into all medical

school curricula.

Key Takeaways

1. The MBA ski l ls most c i ted by

interv iewees to be valuable to

health care in Canada are change

management, leadership, learning

to work in a team, and financial

literacy.

2. The apparent stigmatization of MD/

MBAs by colleagues in the U.S. is

seemingly absent among Canadian

MD/MBAs.

3. With the changing landscape in the

Canadian health-care system, the

skills that MD/MBAs provide are

becoming increasingly relevant.

MD/MBAs should be valued and

respected for the skills they can

offer to improve health care in

Canada.

Study Limitations

There are limitations to this study:

not completely capture the range of

opinion of Canadian MD/MBAs.

by networking rather than random

selection. This resulted in 70% of the

interviewees being physicians who

currently practise medicine in an

urban/suburban academic hospital,

and their opinions may not be gener-

alized to a larger population.

any research of this nature, there

is an inherent subject bias. The

interviewees have each invested a

MBA for the Canadian MD

35 March 2012

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ONTARIO MEDICAL REVIEW

tremendous amount of time, effort

and money into their MBA, and they

have a vested interest in describing

all of the benefits that they obtained

by completing this education.

representative number of male and

female interviewees. Although one

female was included in the study, the

data may have a gender bias.

Editor’s Note: an excerpt of this study

appeared in the fall 2011 issue of the

Canadian Society of Physician Executives

newslet ter (Vol . 13, No. 3) . The fu l l

study may be obtained from the author:

[email protected]

Matthew Solomon recently graduated from

the MBA program at the Schulich School

of Business with a specialization in Health

Industry Management and Organizational

Studies. He is working to gain entrance into

medical school in hopes of acquiring the

credentials to become a physician leader in

the Canadian health-care system.

References

1. Canada. Department of Justice. Canada

Hea l t h Ac t , R .S .C . , 1985 , c . C-6 .

[Internet]. Ottawa, ON: Department of

Justice [updated 2012 Feb 7] ; [about 16

screens]. Available from: http://laws-lois.

justice.gc.ca/eng/acts/C-6/FullText.html.

Accessed: 2012 Feb 29.

2. Please note that in this article MD/MBA is

used to refer to both combined MD/MBA

programs as well as acquiring an MD and

an MBA separately.

3. Butcher L. The rapid growth of MD/MBA

programs: are they worth it. Physician

Exec. 2011 Jan-Feb;37(1):22-6.

4. Parekh SG, Singh B. An MBA: the utility

and effect on physicians’ careers. J Bone

Joint Surg Am. 2007 Feb;89(2):442-7.

5. Sohn N, Germa in M. Does an MBA

enhance a physician’s ability to manage

a medical practice? Med Econ. 2011 Jan

25;88(2):38, 40-1.

6. Desai AM, Trillo RA Jr, Macario A. Should

I get a Master of Business Administration?

The anesthesiologist with education train-

ing: training options and professional

opportunities. Curr Opin Anaesthesiol.

2009 Apr;22(2):191-8.

7. Sherrill WW. The traitor complex. MD/MBA

students struggle with medicine vs. man-

agement dilemma. Physician Exec. 2005

Jan-Feb;31(1):48-9.

8. Duda J. The management of medicine:

will you need an MBA to practice? The

New Physician. 2011 Mar-Apr; 60(2):13-

14. [Internet]; [updated 2011 Apr 26] ;

[about 4 screens]. Available from: http://

www.amsa .o rg /AMSA/Homepage/

Publications/TheNewPhysician/2011/0311

AcademicTactics.aspx. Accessed: 2012

Feb 29.

9. Healey BJ. Marchese M, Kile J. Physician

executive education. Academy of Health

Care Management Journal 2009; 5(1-2).

10. Desai AM, Trillo RA Jr, Macario A. Should

I get a Master of Business Administration?

The anesthesiologist with education train-

ing: training options and professional

opportunities. Curr Opin Anaesthesiol.

2009 Apr;22(2):191-8.

11. Lyons MF. The MBA mystique. Physician

Exec. 1996 Nov;22(11):39-41.

MBA for the Canadian MD

36 March 2012

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The mandate of the Health Policy Committee is to develop

and maintain a policy agenda for the Ontario Medical

Association, subject to Board approval and direction, and

to facilitate the development and approval of policies that

are required to support that agenda and the OMA strategic

plan. It is the Board vehicle for ensuring effective director

oversight of the OMA’s health policy work. Member input

and involvement will be sought in policy development.

In pursuing member input and involvement in policy devel-

opment, the Health Policy Committee of the OMA is pre-

paring a list of members interested in participating in the

development of important health policy issues as they arise.

Physicians who have completed the annual registration will

be contacted on an as-needed basis to review and com-

ment upon policy documents relevant to the topics the phy-

sician has selected. In addition, members may be asked to

participate in member fora or time-limited working groups.

Areas of Health Policy Committee Focus

The OMA’s health policy work is both proactive and respon-

sive to external forces. There are certain practice domains

where the OMA maintains a watching brief, including hospi-

tals, long-term care, primary care, mental health, and public

health. In addition, we are active in terms of interprofessional

care and expanding scopes of practice for various health

professions. We monitor and respond to the regulatory envi-

ronment, including CPSO policy, legislation, and the work

of the Health Professions Regulatory Advisory Commission

(HPRAC). We are engaged in issues relating to drugs and

pharmacotherapy and the increasing influence of e-health

upon physician practice.

We intend to focus heavily in the next three years upon the

quality agenda and how it translates into practice.

In addition to our ongoing work, the OMA undertakes

specific short-term projects. In 2011, these included

regionalization, models of delivery for specialty care, and

community-based care (home care).

Time Commitments

Most review and comment work will take one or two hours.

Physician fora and working groups will generally involve half-

day meetings. There is no obligation to respond at any time.

Compensation

Members are paid at the hourly rate for their review/

comments and in accordance with the existing policy on

member honoraria for meetings.

To Register

Complete the form below and fax to Patricia Graham at

416.340.2238, or visit the OMA website (http://www.oma.

org/Member/Resources/Documents/HPInput.html). To

obtain a copy of the form by email or surface mail, contact

Patricia Graham via email ([email protected]), or

phone 416.599.2580, ext. 3434. Register to be contacted

to provide input on heath policy as needed:

First Name: ______________________________________

Last Name: ______________________________________

OMA Membership #: ______________________________

Email: ___________________________________________

Check topics that you are interested

in being contacted about:

Hospital Issues

Long-Term Care

Primary Care

Mental Health

Public Health

Interprofessional Care and Scopes of Practice

CPSO Policies

Drugs and Pharmacotherapy

eHealth

Quality

Regionalization

Models of Delivery for Specialty Care

Community-Based Care

System Issues

Value for Money

Areas of expertise and/or experience relevant to the above:

__________________________________________________

__________________________________________________

__________________________________________________

37 March 2012ONTARIO MEDICAL REVIEW

Members Invited to Provide Input on OMA Policy

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ONTARIO MEDICAL REVIEW

Change in Funding Status of Oxycodone Controlled-Release TabletAs reported to members in a recent

OMA President’s Update, effective

March 1, 2012, Purdue Pharma dis-

continued the production of Oxy Contin

in Canada, and replaced it with another

oxycodone controlled-release drug,

OxyNEO.

A s a r e s u l t , O x y C o n t i n w a s

removed from the Ontario Drug Benefit

Formulary/Comparative Drug Index,

effective February 29, 2012.

OxyNeo will only be funded through

the Exceptional Access Program and

through the Facil itated Access to

Palliative Care Drugs mechanism.

The reimbursement mechanism,

and the doses of OxyNEO available,

depend on the patient’s condition.

Special provisions have been made

for Ontario Drug Benefit recipients

who submitted a claim for OxyContin

between September 1, 2011, and

February 28, 2012.

Please note that OxyContin and

OxyNEO prescriptions are not inter-

changeable. Therefore, patients cur-

rently receiving OxyContin will require a

new prescription.

Regrettably, the OMA was not pro-

vided the opportunity for advance con-

sultation on this change. However, the

Association is now working with the

Ministry of Health and Long-Term Care

to address physician concerns.

Details regarding the criteria for

funding, the available reimbursement

mechanisms, and the provisions made

for current OxyContin recipients, are

posted on the Ministry website at:

http://www.health.gov.on.ca/english/

providers/program/drugs/opdp_eo/

notices/exec_office_odb_20120217.

pdf

OMA Staff Contact: Jessica Katul, ext. 2859

Family Health Team (FHT) Issues CommitteeCurrently, more than 2,000 family phy-

sicians and 2.7 million patients are

attached to Family Health Teams in

Ontario.

To help address the issues physi-

cians face while practising as part of

a FHT, the OMA Board of Directors

approved the establishment of the

Family Health Team Issues Committee.

This Committee will proactively

identify, analyze, and make recom-

mendations on key FHT issues that

directly or indirectly impact both physi-

cians and patients, including, but not

limited to: actual or potential policy

or practice issues; governance and

accountability requirements; strategies

for improving relationships between

physicians and interdisciplinary health

professionals; and priorities and initia-

tives of the Ontario government and its

agencies.

The FHT Issues Committee mem-

bers are:

To correspond with the FHT Issues

Committee, please contact Peter

Brown, senior policy analyst, OMA

Health Policy Department, by email at

[email protected], or by phone

416.340.2989.

OMA Staff Contact: Peter Brown, ext. 2989

March 201238

Change in Funding Status of Oxycodone Controlled-Release Tablet

Family Health Team Issues Committee

by OMA Health Policy Department

HEALTH POLICY REPORTA summary of current health legislation and policy developments

OMR Ads Hit Home!

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Mar12_health_policy_p38.indd 1 12-03-07 4:39 PM

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ONTARIO MEDICAL REVIEW 39 March 2012

DedicDedicated to Dococtors. tients.

Dedicated to Doctors. Committed to Patients.

Doctorsd to Doctors. Committed to Patients.

Dr. Sanja Avdic Dr. Michel Bonin Dr. David Diodati

Dr. Elena Dyachuk Dr. Peter Evans Dr. Jacob Feldman

Dr. Kenneth M Fung Dr. Ghulam Khan Dr. Hasnain Khandwala

Dr. Vinod Malik Dr. David Newman Dr. Mahsa Safavi

Dr. Kenneth Sewchand Dr. Jill Starkes Dr. Julie Webb

The winners each received a Blackberry® Playbook or cash equivalent for getting a quote

from the only OMA-endorsed auto, home or office/clinic insurance program.

If you are looking for significant savings and exceptional service on your auto, home and

office/clinic insurance, call 1.877.277.7165 or visit www.omainsurance.com for a quote!

Congratulations to our Property & Casualty contest winners!

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ONTARIO MEDICAL REVIEW

Health Policy

-

Economic

Appointments

OntarioMD Board of Directors

March 201240

OMA Board of Directors Meeting

February 8-9, 2012

BOARD REPORTSummary of resolutions

Mar12_board_resolutions_p40.indd 1 12-03-06 11:19 AM

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Ontario Medical Student Bursary Fund 8th Annual Fundraising Golf Tournament

Friday, June 15, 2012 — 7:45 a.m. Shotgun Start

Angus Glen Golf Club, host site of the 2002 & 2007 Canadian Open

$400 per ticket / $1,600 per foursome. Price includes: 18 holes of golf with cart, breakfast, lunch, and participation in

golf contests with great prizes!! Partial tax receipts will be issued to those who pay directly to OMSBF.

Call Sandra Zidaric, Senior Campaign Director, at 1.800.268.7215, ext. 2985 or 2259, to register or become a sponsor.

All proceeds fund student bursaries from OMSBF. Reserve now — last year’s tournament sold out early!Register by March 31, 2012 and your name will be entered in a contest for a free foursome at the 2013 OMSBF Golf Tournament!

Deadline for registration is April 30, 2012. For more information about the OMSBF and future golf tournaments please contact Sandra Zidaric,

Senior Director. Phone: 1.800.268.7215, ext. 2985 or 2259 | Email: [email protected] | Web: http://omsbf.oma.org

Platinum Tee

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Mar2012_Ad_v1.indd 1 12-02-16 3:41 PM

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ONTARIO MEDICAL REVIEW 42 March 2012

With OMR Classifieds,

your message...

Hits Home!OMR classified advertising reaches

31,000+ physicians, interns, and

medical students every issue.

The Ontario Medical Review publishes

classif ied advert isements in the

following categories:

RATES:

each line approximately 35 characters;

$5 per line thereafter; $5 for each line

billed at $20 per issue.

DEADLINES:

of cancellation and/or changes to

existing advertisements must be

submitted in writing no later than the

10th of the month prior to the month

of publication.

REGULATIONS: The Ontario Medical

Review reserves the right to make

The Ontario Medical Review

to comply with the provisions of the

assumes no responsibility or endorses

any claims or representation offered or

urges readers to investigate thoroughly

any opportunities advertised.

For more information, please contact:

[email protected]

Mar12_torkin+hamilton+classifieds_filler_p42.indd 1 12-03-02 4:09 PM

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Bergeron, Joseph Aurele O.

Sudbury

Laval University, 1955

January 2012 at age 89

Duffin, Donald Forester

Sault Ste. Marie

University of Western Ontario, 1950

November 2011 at age 88

Elek-Baan, Susanna

Toronto

Franz Joseph University of Kolozsvar,

1952

November 2011 at age 85

Fabris, Gilbert

Bolton

University of Calgary, 1988

December 2011 at age 55

Fishell, Eve Kelton

Toronto

University of Toronto, 1955

November 2011 at age 80

Gingrich, Ronald Gordon

Bright

University of Western Ontario, 1967

January 2012 at age 69

Sellors, John William

MacTier

McMaster University, 1972

December 2011 at age 65

Sewell, Ian MacIntosh

Thunder Bay

University of Toronto, 1950

November 2011 at age 86

Ziolkowski, Rosemary “Rose” Jean

Trenton

English Conjoint Board, 1946

December 2011 at age 91

March 201243ONTARIO MEDICAL REVIEW

IN MEMORIAMThe OMA would like to express condolences to the families and friends of the following members.

The OMA publishes brief notices about deceased members as a service to their colleagues. Information concerning these members should

be sent to [email protected]. If you know a colleague or a relative of a deceased member who has practice-related questions and

needs advice, or would like an information package on winding down a practice, please have them contact Practice Management and

Advisory Services at 1.800.268.7215, or email [email protected].

TAKE ADVANTAGE OF NEW RULES.GET THE NEW EDITION.Since the first book was published in 2004, there have been many changes that have a direct impact on your Professional Corporation. New rules and regulations have created even more opportunities for professionals to keep more of what they make.The new version of Professional Corporations “The Secret to Success” is larger, more in depth, and is the foremost resource for successful professionals.

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Mar12_in_memoriam_4C_p43.indd 1 12-03-05 3:09 PM

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ONTARIO MEDICAL REVIEW March 201244

Successfully managing your career in medicineby Mamta Gautam, MD

PRACTICE MANAGEMENT

Most of us looked ahead to becoming a doctor, but likely gave little thought to

what would come after that. Generally speaking, physicians graduate from

medical school in their mid-to-late 20s, and retire in their mid-to-late 60s. Thus, we

have at least a 40-year career in medicine. What excites and sustains us at the start

may not be enough to fulfil us at other phases of our career.

Luckily, there are strategies and knowl-

edge that we can harness to manage

our career in medicine and continue to

enjoy it, including:

1. Realizing we have choices: The

key to career satisfaction is to pro-

actively shape your own career

path. Think about this consciously.

Some of us may choose to con-

tinue to do the same thing through-

out our entire career, while others

may choose to have varying areas

of interest and focus at different

times. There is no right answer.

What is important is that we see it

as a choice that we can make at

any point in the process.

2. Three normal stages of a career

— energy/excitement, reality, leg-

acy: We start off with energy and

excitement, then reality sets in and

we can feel tired and discouraged.

We then redefine and set more

accessible goals, so we can leave a

legacy. We will all go through these

three stages. This is normal and

natural, so expect and embrace

this process.

3. The seven-year rule: One can only

do something and truly enjoy it for

about seven years at a time. Thus,

we can plan to regularly reassess

what we are doing, and modify it in

some minor or major way to con-

tinue to enjoy it further.

4. Consider why: Identify why you may

want to make a change. Define

what you like and do not like about

what you are now doing. State your

needs, interests, and values. Once

you can recognize these factors,

you can better ensure that your new

choice is what you are looking for.

5. The three-step rule for change:

There are generally three steps in

making a change in your medical

career — modify, change within

medicine, and change outside of

medicine. Just because you are

no longer feeling fulfilled does not

mean that you have to throw it all

away. Many people successfully

modify part of what they are cur-

rently doing, or how they do it, and

the situation improves. Sometimes,

it may require a change of focus

within medicine, either a new clini-

cal focus, or adding new roles in

medical education, research,

writing, politics or administration.

Finally, some of us make choices

that will take us out of medicine

entirely.

6. Consider what: Start to explore the

new area of focus you have identi-

fied. Talk to colleagues and men-

tors, and network with people in

the field. Browse related websites,

attend conferences, and/or volun-

teer on related committees.

7. The 80%-20% overlap: If possible,

do not plan to make a complete

change all at once. Plan to have the

next step overlap this one by 80%.

Start with modifying 20% of what

you are currently doing to include

your new area of focus; maintain

80% as is for now. This will allow

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ONTARIO MEDICAL REVIEW

you to assess and adjust as neces-

sary, and confirm your choice.

8. Consider when: Making a change

in career in midlife is not easy. We

need to consider many factors,

such as finances, family needs, or

willingness to relocate. Set a real-

istic timeline, as it usually takes

two to three years to make a major

change.

9. More educat ion : Review and

update your CV. Education and

qualifications are important, but

you already possess a great deal

of both, and more is not necessarily

better. Consider what you want to

do first, and then work backwards

to see if you will need to build on

your current knowledge and skills

to achieve your goals.

10. Expect to grieve and manage loss:

Even if you want and choose it,

there is still a loss associated with

change. Anticipate this, and the

associated feelings of denial, pro-

test, anger, sadness, and accep-

tance, both within yourself, as well

as the people around you who will

be impacted by the change.

Using a positive, proactive approach,

you must plan to continuously assess

and reshape your career goals. You

can actively mould your career paths,

and ensure that you develop personally

and professionally, and remain satisfied

throughout your entire career.

(Note: for further information on this

topic, please refer to Dr. Gautam’s

website at www.peakmd.ca.)

Dr. Mamta Gautam is a psychiatrist in

Ottawa, and a pioneer in the area of physi-

cian health. She is a keynote speaker at the

upcoming 13th Annual Women’s Health

Care Seminar (see p. 9 for details).

The Practice Management column is pro-

v ided by the OMA Member Serv ices

Department. Do you have a topic or ques-

tion you would like to see appear in the

Ontario Medical Review? Please let the

Practice Advisory Service team know at

416.340.2911 or 1.800.268.7215, ext. 2911,

or email: [email protected].

45 March 2012

PRACTICE MANAGEMENT

PMAS provides OMA members with:Practice management seminars

CyberMed online learning

Billing inquiries and advocacy

Practice management resources and toolkits

General inquiries on managing your practice

Contact us: web: www.oma.org | phone: 1.800.268.7215

email: [email protected]

OMA Practice Management and Advisory Services (PMAS) can help you manage your practice.

g | phone: 1.800.268.7215

[email protected]

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ONTARIO MEDICAL REVIEW March 201246

Will power: the importance of estate planningby OMA Insurance Services

OMA INSURANCE UPDATE

“All three parts line up to form your

overall plan,” says Judy Wood, a senior

insurance advisor with OMA Insurance.

A will provides for an orderly transfer

of your assets to your chosen beneficia-

ries, and the opportunity to choose the

executor of your estate.

Are you aware of what happens

if you die without a valid will? This is

what is known as dying “intestate.” In

such cases, Ontario law stipulates how

your estate is distributed, and it often

goes to family or other living relatives.

Although there are rules in place, issues

can occur, including:

your wishes. Having the court settle

your estate can lead to a possible

undesired division, to unintended

consequences (such as the govern-

ment looking after your children’s or

grandchildren’s inheritance until they

are 18), or to family feuds.

money or property (from real estate

to possessions) to more distant rela-

tives, friends, or charity.

-

trator of your estate, and no one will

have the authority to act on behalf

of your estate until that time. This

could mean a significant delay for

your beneficiaries to receive the pro-

ceeds. As a result, your estate might

pay more in additional legal costs

and taxes. The best way to defer

tax upon death is to leave everything

to your spouse, but this cannot be

done if you die intestate.

-

ianship of minor children, based on

what he or she sees as being in the

child’s best interest (which may be

contrary to your desires).

For more information, visit the online

resources listed at the end of this article.

Lacking a valid will can also cause

lengthy problems. For instance, Jimi

Hendrix, Pablo Picasso, and Howard

Hughes all died intestate. Their siz-

able estates took many years to

settle, and were eventually divided

up among multiple claimants simply

because they did not have a will.

While having a will is a priority, it

doesn’t end your estate planning. “With

significant life changes, you want to

review your will,” says Ms. Wood.

Changes, such as marriage, divorce,

remarriage, a common-law relation-

ship, children, stepchildren, grandchil-

dren, the status of dependents, and

retirement, can all affect your will.

It is easy to let such updates fall

through the cracks, especially when

work and life are so busy. However, it

is important to talk to your tax lawyer

or accountant to ensure that your will

is current.

Keep your accountant, financial con-

sultant and insurance advisor informed

to ensure that you have adequate

Where there’s a will there’s a way” to protect your estate. The right insurance

and investment strategies are two important parts of sound financial planning.

The third part — your will — is essential for developing an effective estate plan.

Nobody likes to think about their death, but

knowing your estate will be settled as you wish, in

an efficient manner, provides peace of mind.

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ONTARIO MEDICAL REVIEW

insurance working in concert with your

estate, and that the financial well-being

of your loved ones is secure.

When writing or updating your will,

you may want to consider two addi-

tional needs:

attorney prepared while writing or

updating a will. A power of attorney

for property means appointing some-

one to manage your financial affairs if

you cannot do so. With a power of

attorney for personal care, you can

also appoint someone to make deci-

sions on your behalf regarding your

personal care and consent to treat-

ment if you are unable to do so.

will,” which most physicians are very

familiar with. A living will is a docu-

ment that expresses your desires

and directives around medical treat-

ment should you be in a terminal

state. Not all family members may

agree on life-support decisions; a liv-

ing will removes that doubt, helping

to keep harmony in the family during

a difficult time.

“Nobody likes to think about their

death, but knowing that your estate will

be settled as you wish, and in the most

efficient way possible, provides peace

of mind,” says Ms. Wood.

For assistance in finding the right

insurance solutions to suit your needs,

please contact OMA Insurance at

1.800.758.1641, or emai l in fo@

omainsurance.com to schedule an

appointment with one of our non-com-

missioned OMA Insurance Advisors.

Additional information is available on

the OMA Insurance website at: www.

omainsurance.com.

Online resources

1. “When someone dies with or without a

will,” Government of Ontario, http://www.

ontario.ca/en/life_events/death/004689.

html.

2. “How an estate is distributed,” Ministry of

the Attorney General, http://www.attorney

heirclaim.asp.

47 March 2012

OMA INSURANCE UPDATE

Exciting improvements are coming

to your OPIP program – the first

enhancement is scheduled for

April 1, 2012, with more to

follow in 2013.

For details visit:

www.omainsurance.com

Funded Health

Benefits For Ontario’s

Practicing Physicians

OMA Priority Insurance Program

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Feature Name

1ONTARIO MEDICAL REVIEW 48 March 2012

The 2012 OMA Corporate Hote l

Directory is onl ine year-round in

the “OMA Advantages (Aff in i ty &

Discounts)” area of the OMA WebLink

site (www.oma.org).

To ensure you receive the rate

quoted in the directory, please state

that you are an OMA member at the

time of booking a reservation.

Note that the rates quoted are not

always the lowest available rate at

the time of booking. Many hotels will

offer special rates at certain times of

the week or year. Please inquire when

making your reservation to ensure you

receive the lowest possible rate.

Also note that most rates quoted

in the directory are subject to avail-

ability, thus you may be offered the

“best available rate” if the hotel has

sold out of the type of room for which

the OMA has contracted. Rates are

quoted for standard accommodation,

unless otherwise noted.

To ensure a late arrival guarantee, a

credit card number must be given at the

time of booking a reservation.

All rates listed in the directory are

effective from January 1, 2012 to

December 31, 2012, unless otherwise

noted, and are subject to applicable

taxes.

Please note, you may be asked

to present corporate identification at

the time of check-in, so remember

to carry your OMA membership card

with you.

For further information on pre-

ferred hotel room rates for OMA

members, please contact OMA Con-

ference Planning at 416.599.2580;

1.800.268.7215 or jennifer.csamer@

oma.org.

ONTARIO MEDICAL REVIEW

OMA Conference

Planning has negotiated

an extensive listing of

preferred 2012 rates for

OMA members at hotels

located throughout

Ontario.

2012 OMA

CORPORATE

HOTEL DIRECTORY

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ONTARIO MEDICAL REVIEWONTARIO MEDICAL REVIEW 49

BARRIE

Holiday Inn

BELLEVILLE

Ramada Hotel, Resort & Conference Centre

Travelodge Hotel Belleville

BRANTFORD

Best Western Brant Park Inn

BURLINGTON

Homewood Suites by Hilton

CAMBRIDGE

Homewood Suites by Hilton

Cambridge-Waterloo

COLLINGWOOD

Tyrolean Village Resorts at

Blue Mountain

CORNWALL

Best Western Parkway Inn &

Conference Centre

GANANOQUE

Colonial Resort & Spa

GRIMSBY

Casablanca Winery Inn

GUELPH

Delta Guelph

HAMILTON

Sheraton Hamilton Hotel

KINGSTON

Ambassador Conference Resort

Courtyard Marriott Kingston

Days Inn Kingston

Four Points Hotel & Suites by

Sheraton Kingston

Holiday Inn Express & Suites Kingston

Holiday Inn Kingston-Waterfront

Radisson Hotel Kingston Harbourfront

KITCHENER-WATERLOO

Best Western St. Jacobs Country Inn

Delta Kitchener-Waterloo

Destination Inn & Suites

Hampton Inn & Suites by Hilton

Holiday Inn Kitchener-Waterloo Hotel

& Conference Centre

Radisson Hotel Kitchener Waterloo

LONDON

Delta London Armouries

Hilton London

Homewood Suites by Hilton

StationPark All Suite Hotel

MISSISSAUGA

Delta Meadowvale-Mississauga

Delta Toronto Airport West

Four Points by Sheraton Toronto

Mississauga

Hilton Garden Inn Toronto Airport

Hilton Garden Inn Mississauga/

Toronto Airport

Homewood Suites by Hilton

Toronto-Mississauga

MUSKOKA & AREA

Delta Grandview – Huntsville

Delta Rocky Crest – Muskoka

Delta Sherwood – Port Carling

NIAGARA FALLS

Crowne Plaza

DoubleTree Fallsview Resort &

Spa by Hilton

Hilton Fallsview Niagara Falls

Marriott Gateway

Sheraton on the Falls

NIAGARA-ON-THE-LAKE

Hilton Garden Inn Niagara-on-the-Lake

Pillar and Post

Prince of Wales

Queen’s Landing

White Oaks Resort

OAKVILLE

Hilton Garden Inn Toronto/Oakville

Homewood Suites by Hilton

Toronto-Oakville

OTTAWA

Albert at Bay Suite Hotel

Best Western Victoria Park Suites

Brookstreet Resort

Delta Ottawa Hotel and Suites

Fairmont Chateau Laurier

Holiday Inn Hotel & Suites

Ottawa Downtown

Lord Elgin Hotel

Novotel Ottawa

Sheraton Ottawa

Westin Ottawa

PETERBOROUGH

Holiday Inn Peterborough Waterfront

SARNIA

Holiday Inn Sarnia/Point Edward

SAULT STE. MARIE

Delta Sault Ste. Marie Waterfront Hotel

and Conference Centre

SUDBURY

Holiday Inn

Homewood Suites by Hilton

THUNDER BAY

Valhalla Inn Thunder Bay

TORONTO (GTA)

Cosmopolitan Toronto

Courtyard by Marriott Downtown Toronto

Delta Chelsea-Downtown Toronto

Delta Markham

Delta Toronto East

Doubletree by Hilton Toronto Airport

Fairmont Royal York

Four Points by Sheraton Toronto Airport

Four Seasons (closing in March)

Hampton Inn by Hilton Toronto Airport

Corporate Centre

Hilton Garden Inn Toronto/Ajax

Hilton Garden Inn Toronto/City Centre

Hilton Garden Inn Toronto/Downtown

Hilton Garden Inn Toronto/Vaughan

Hilton Suites Toronto/Markham

Conference Centre & Spa

Hilton Toronto

Homewood Suites by Hilton Toronto

Airport Corporate Centre

Hyatt Regency Toronto on King

InterContinental Toronto Centre

InterContinental Toronto Yorkville

Le Meridien King Edward

Metropolitan Hotel

Minto Suite Hotel

Novotel Toronto Centre

Pantages Hotel

Park Hyatt Toronto

Renaissance Toronto Hotel Downtown

Sheraton Centre Toronto

Sheraton Gateway Hotel

Sheraton Toronto Airport Hotel &

Conference Centre

The Old Mill Inn

The Sutton Place

Toronto Marriott Downtown Eaton Centre

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March 2012ONTARIO MEDICAL REVIEW

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Modified Release Tablets 375 mg enteric-coated naproxen/20 mg immediate release esomeprazole & 500 mg enteric-coated naproxen/20 mg immediate release esomeprazole

Prescribing Summary

Patient Selection Criteria

THERAPEUTIC CLASSIFICATION: NSAID and H+, K+-ATPase inhibitor INDICATIONS AND CLINICAL USE: Adults: VIMOVO (naproxen/esomeprazole) is indicated for the treatment of the signs and symptoms of osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and to decrease the risk of developing gastric ulcers in patients at risk for developing NSAID-associated gastric ulcers. VIMOVO is not recommended for initial treatment of acute pain because the absorption of naproxen is delayed (as with other modified release formulations of naproxen). For patients with an increased risk of developing cardiovascular (CV) and/or gastrointestinal (GI) adverse events, other management strategies that do NOT include the use of NSAIDs should be considered first (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS). Use of VIMOVO should be limited to the lowest effective dose for the shortest possible duration of treatment in order to minimize the potential risk for cardiovascular or gastrointestinal adverse events (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS). VIMOVO, as a NSAID, does NOT treat clinical disease or prevent its progression. VIMOVO, as a NSAID, only relieves symptoms and decreases inflammation for as long as the patient continues to take it. Geriatrics (>65 years of age): Evidence from naproxen clinical studies and postmarket experience suggest that use in the geriatric population is associated with differences in safety (see WARNINGS AND PRECAUTIONS; Special Populations and Product Monograph, CLINICAL TRIALS). Pediatrics (<18 years of age): VIMOVO should not be used in children or adolescents under 18 years of age. The safety and efficacy of VIMOVO in this population has not been established.CONTRAINDICATIONS: VIMOVO is contraindicated in: the peri-operative setting of coronary artery bypass graft surgery (CABG) (although VIMOVO has NOT been studied in this patient population, a selective COX-2 inhibitor NSAID studied in such a setting has led to an increased incidence of cardiovascular/thromboembolic events, deep surgical infections and sternal wound complications); the third trimester of pregnancy, because of risk of premature closure of the ductus arteriosus and prolonged parturition; women who are breastfeeding, because of the potential for serious adverse reactions in nursing infants; patients with severe uncontrolled heart failure; patients with known hypersensitivity to naproxen, esomeprazole, substituted benzimadazoles or to any of the components/excipients (see DOSAGE FORMS, COMPOSITION AND PACKAGING); patients with history of asthma, urticaria, or allergic-type reactions after taking ASA or other NSAIDs (i.e. complete or partial syndrome of ASA-intolerance–rhinosinusitis, urticaria/angioedema, nasal polyps, asthma) (fatal anaphylactoid reactions have occurred in such individuals. Individuals with the above medical problems are at risk of a severe reaction even if they have taken NSAIDs in the past without any adverse reaction. The potential for cross-reactivity between different NSAIDs must be kept in mind [see WARNINGS AND PRECAUTIONS; Hypersensitivity Reactions, Anaphylactoid Reactions]); patients with active gastric/duodenal/peptic ulcer, active GI bleeding; patients with cerebrovascular bleeding or other bleeding disorders; patients with inflammatory bowel disease; patients with severe liver impairment or active liver disease; patients with severe renal impairment (creatinine clearance <30 mL/min or 0.5 mL/sec) or deteriorating renal disease (individuals with lesser degrees of renal impairment are at risk of deterioration of their renal function when prescribed NSAIDs and must be monitored) (see WARNINGS AND PRECAUTIONS; Renal); patients with known hyperkalemia (see WARNINGS AND PRECAUTIONS; Renal, Fluid and Electrolyte Balance) and children and adolescents less than 18 years of age.

Safety Information

WARNINGS AND PRECAUTIONS:

Serious Warnings and PrecautionsRisk of Cardiovascular (CV) Adverse Events: Ischemic Heart Disease, Cerebrovascular Disease, Congestive Heart Failure (NYHA II-IV) (See WARNINGS AND PRECAUTIONS; Cardiovascular). Naproxen is a non-steroidal anti-inflammatory drug (NSAID). Use of some NSAIDs is associated with an increased incidence of cardiovascular adverse events (such as myocardial infarction, stroke or thrombotic events) which can be fatal. The risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

Caution should be exercised in prescribing NSAIDs such as naproxen, which is a component of VIMOVO (naproxen/esomeprazole), to any patient with ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina), cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) and/or congestive heart failure (NYHA II-IV). Use of NSAIDs such as naproxen, which is a component of VIMOVO, can promote sodium retention in a dose-dependent manner, through a renal mechanism, which can result in increased blood pressure and/or exacerbation of congestive heart failure (see also WARNINGS AND PRECAUTIONS; Renal, Fluid and Electrolyte Balance). Randomized clinical trials with VIMOVO have not been designed to detect differences in cardiovascular events in a chronic setting. Therefore, caution should be exercised when prescribing VIMOVO. Risk of Gastrointestinal (GI) Adverse Events (see WARNINGS AND PRECAUTIONS, Gastrointestinal and Product Monograph, CLINICAL TRIALS) Use of NSAIDs such as naproxen, which is a component of VIMOVO, is associated with an increased incidence of gastrointestinal adverse events (such as peptic/duodenal ulceration, perforation, obstruction and gastrointestinal bleeding).

General: Frail or debilitated patients may tolerate side effects less well and therefore special care should be taken in treating this population. To minimize the potential risk for an adverse event, the lowest effective dose should be used for the shortest possible duration. As with other NSAIDs, caution should be used in the treatment of elderly patients who are more likely to be suffering from impaired renal, hepatic or cardiac function. For high-risk patients, alternate therapies that do not involve NSAIDs should be considered. VIMOVO, which contains naproxen, is NOT recommended for use with other NSAIDs, with the exception of low-dose ASA for cardiovascular prophylaxis, because of the absence of any evidence demonstrating synergistic benefits and the potential for additive adverse reactions (see DRUG INTERACTIONS; Drug/Drug Interactions, Acetylsalicylic acid (ASA) or other NSAIDs). VIMOVO should not be used concomitantly with other naproxen containing drugs since they all circulate in plasma as the naproxen anion. Concomitant administration with atazanavir or nelfinavir is not recommended (see DRUG INTERACTIONS). In the presence of any alarm symptom (e.g., significant unintentional weight loss, recurrent vomiting, dysphagia, hematemesis or melena), and/or when gastric ulcer is suspected or present, malignancy should be excluded, as treatment may alleviate symptoms and delay diagnosis.Special Populations: Pregnant Women: VIMOVO is CONTRAINDICATED for use during the third trimester of pregnancy because of risk of premature closure of the ductus arteriosus and the potential to prolong parturition (see TOXICOLOGY). Caution should be exercised in prescribing VIMOVO during the first and second trimesters of pregnancy. Inhibition of prostaglandin synthesis may adversely affect pregnancy and/or the embryofetal development. Data from epidemiological studies suggest an increased risk of miscarriage and of cardiac malformation after use of a prostaglandin synthesis inhibitor in early pregnancy. In animals, administration of a prostaglandin synthesis inhibitor has been shown to result in increased pre- and post-implantation loss and embryo-fetal lethality. In addition, increased incidences of various malformations, including cardiovascular, have been reported in animals given a prostaglandin synthesis inhibitor during the organogenetic period. VIMOVO, which contains naproxen, is not recommended in labour and delivery because naproxen-containing products, through their prostaglandin synthesis inhibitory effect, may adversely affect fetal circulation and inhibit uterine contractions, thus increasing the risk of uterine hemorrhage. Nursing Women: See CONTRAINDICATIONS. Pediatrics (<18 years of age): See CONTRAINDICATIONS. Geriatrics: Patients older than 65 years and frail or debilitated patients are more susceptible to a variety of adverse reactions from NSAIDs. The incidence of these adverse reactions increases with dose and duration of treatment. In addition, these patients are less tolerant to ulceration and bleeding. Most reports of fatal GI events are in this population. Older patients are also at risk of lower esophageal injury including ulceration and bleeding. For such patients, consideration should be given to a starting dose lower than the one usually recommended, with individual adjustment when necessary and under close supervision. Of the total number of patients who received VIMOVO (n=1157) in clinical trials, 387 were ≥65 years of age, of which 85 patients were 75 years and over. No meaningful differences in efficacy (reduction in gastric ulcer rates or pain relief) or safety were observed between these subjects and younger subjects. Elderly patients in the VIMOVO group compared with the naproxen group (n=426) were consistently observed to have significantly lower gastric ulcer rates, 1.5% vs 28.5% in patients ≥65 years of age (p<0.001), and 0% vs 19.2% in patients ≥75 years of age (p=0.019). VIMOVO non-inferiority to celecoxib for pain relief was maintained in elderly patients >65 years of age, generally considered to be at greater risk of GI side effects. The incidence of adverse events was generally consistent between age populations (see WARNINGS AND PRECAUTIONS; Gastrointestinal and Product Monograph, CLINICAL TRIALS).

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ADVERSE REACTIONS: Adverse Drug Reaction Overview: Since VIMOVO contains both naproxen and esomeprazole, the same pattern of undesirable effects reported for these individual substances may occur. The most common adverse reactions seen with naproxen are gastrointestinal, of which peptic ulcer, with or without bleeding, is the most severe. Fatalities have occurred particularly in the elderly. Other common adverse reactions include dyspepsia, stomach pain, nausea and vomiting. Common reactions seen with esomeprazole in clinical trials include headache, diarrhea, flatulence, abdominal pain, nausea, vomiting and dizziness, which are thought to be causally related. The most commonly reported adverse reactions with VIMOVO are erosive gastritis, dyspepsia and gastritis. No new safety findings were identified during VIMOVO treatment compared to the established safety profile for the individual substances. To report a serious or unexpected reaction to this drug, you may notify Health Canada by toll-free telephone: 866-234-2345 or toll-free fax: 866-678-6789.

Administration

Dosing considerations: VIMOVO must be swallowed whole with water, and not split, chewed or crushed. VIMOVO should be taken at least 30 minutes before meals. VIMOVO does not allow for administration of lower daily doses of naproxen or esomeprazole. If a lower daily dose of either naproxen (i.e. ≤750 mg/day) or immediate-release (IR) esomeprazole (i.e. ≤40mg/day) is more appropriate, alternate therapy should be considered. Since VIMOVO is a combination product, carefully consider the implications of any dosing schedule on both components. Recommended dose and dose adjustment: For osteoarthritis/rheumatoid arthritis/anklyosing spondylitis, the recommended daily dosage of VIMOVO is 375/20 mg (naproxen/esomeprazole) twice daily or 500/20 mg (naproxen/esomeprazole) twice daily. Dosing Considerations in Special Populations: Geriatrics: See WARNINGS AND PRECAUTIONS; Special populations. Pediatrics (<18 years): VIMOVO is not recommended for use in pediatric patients (see CONTRAINDICATIONS).Dosage Forms and Packaging: VIMOVO contains an enteric-coated (EC) naproxen core and immediate-release (IR) esomeprazole film coat. The formulation is designed to release the active ingredients in a sequential fashion: esomeprazole is rapidly released in the stomach followed by the delayed release of naproxen in the small intestine. VIMOVO (naproxen/esomeprazole) 375/20 mg tablets are yellow, oval film coated tablets printed “375/20” in black ink on one side; 500/20 mg tablets are yellow, oval film coated tablets printed “500/20” in black ink on one side. VIMOVO tablets contain the following non-medicinal ingredients: carnauba wax, croscarmellose sodium, glycerol monostearate, hypromellose, iron oxide black, iron oxide yellow, macrogols, magnesium stearate, methacrylic acid-ethyl acrylate copolymer (1:1) dispersion, methyl parahydroxybenzoate, polydextrose, polysorbate, povidone, propylene glycol, propyl parahydroxybenzoate, silica colloidal anhydrous, titanium dioxide and triethyl citrate. VIMOVO 375/20 mg or 500/20 mg tablets are supplied in HDPE bottles of 60 tablets.SUPPLEMENTAL PRODUCT INFORMATIONWARNINGS AND PRECAUTIONS: Carcinogenesis and mutagenesis: There is no evidence from animal data that either naproxen or esomeprazole are carcinogenic or mutagenic. In the long-term repeat-dose/carcinogenicity studies with omeprazole, gastric enterochromaffin-like (ECL) cell carcinoids were noted in the rat, but not the mouse or dog. It has been demonstrated that this is a result of an indirect mode of action, rather than being a direct effect of omeprazole on the ECL-cells; prolonged acid suppression leads to prolonged hypergastrinemia, provoking ECL cell hyperplasia, which eventually progresses into ECL cell carcinoids (see Product Monograph, TOXICOLOGY). Treatment with esomeprazole for up to 1 year in more than 800 patients has not resulted in any significant pathological changes in the gastric oxyntic endocrine cells. Short-term treatment and long-term treatment with the racemate, omeprazole, capsules in a limited number of patients for up to 11 years have not resulted in any significant pathological changes in gastric oxyntic endocrine cells. Cardiovascular: Naproxen is a non-

steroidal anti-inflammatory drug (NSAID). Use of some NSAIDs is associated with an increased incidence of

cardiovascular adverse events (such as myocardial infarction, stroke or thrombotic events) which can be fatal.

The risk may increase with the duration of use. Patients with cardiovascular disease or risk factors for

cardiovascular disease may be at greater risk. Caution should be exercised in prescribing VIMOVO, which

contains naproxen, to patients with risk factors for cardiovascular disease, cerebrovascular disease or renal

disease, such as any of the following (NOT an exhaustive list): Hypertension, dyslipidemia/hyperlipidemia,

diabetes mellitus, congestive heart failure (NYHA I), coronary artery disease (atherosclerosis), peripheral

arterial disease, smoking, creatine clearance <60 mL/min or 1 mL/sec. Use of NSAIDs such as naproxen, which is a component of VIMOVO, can lead to new hypertension or can worsen pre-existing hypertension, either of which may increase the risk of cardiovascular events as described above. Thus blood pressure should be monitored regularly. Consideration should be given to discontinuing VIMOVO, should hypertension either develop or worsen with its use. Use of NSAIDs such as naproxen, which is a component of VIMOVO, can induce fluid retention and edema, and may exacerbate congestive heart failure, through a renally-mediated mechanism (see WARNINGS AND PRECAUTIONS; Renal, Fluid and Electrolyte Balance). For patients with a high risk of developing an adverse CV event, other management strategies that do NOT include the use of NSAIDs should be considered first. To minimize the potential risk for an adverse CV event, the lowest effective dose should be used for the shortest possible duration. Endocrine and Metabolism: Corticosteroids: VIMOVO is NOT a substitute for corticosteroids. It does NOT treat corticosteroid insufficiency. Abrupt discontinuation of corticosteroids may lead to exacerbation of corticosteroid-responsive illness. Patients on prolonged corticosteroid therapy should have their therapy tapered slowly if a decision is made to discontinue corticosteroids (see DRUG INTERACTIONS; Drug-Drug Interactions, Glucocorticoids). Gastrointestinal: Serious GI toxicity (sometimes fatal), such as ulceration, inflammation, perforation, obstruction and gastrointestinal bleeding, can occur at any time, with or without warning symptoms, in patients treated with NSAIDs, such as naproxen, which is a component of VIMOVO. While VIMOVO has been shown to significantly decrease the occurrence of gastric ulcers compared to EC-naproxen alone, ulceration and associated complications can still occur. Minor upper GI problems, such as dyspepsia, commonly occur at any time. Health care providers should remain alert for ulceration and bleeding in patients treated with VIMOVO, even in the absence of previous GI tract symptoms. Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore special care should be taken in treating this population. To minimize the potential risk for an adverse GI event, the lowest effective dose should be used for the shortest possible duration. For high risk patients, alternate therapies that do not involve NSAIDs should be considered (see WARNINGS AND PRECAUTIONS; Special Populations, Geriatrics). Patients should be informed about the signs and/or symptoms of serious GI toxicity and instructed to discontinue using VIMOVO and seek emergency medical attention if they experience any such symptoms. The utility of periodic laboratory has NOT been demonstrated, nor has it been adequately assessed. Most patients who develop a serious upper GI adverse event on NSAID therapy have no symptoms. Upper GI ulcers, gross bleeding or perforation, caused by NSAIDs, appear to occur in approximately 1% of patients treated for 3-6 months, and in about 2-4% of patients treated for one year. These trends continue, thus increasing the likelihood of developing a serious GI event at some time during the course of therapy. Even short-term therapy has its risks. Caution should be taken if prescribing VIMOVO to patients with a history of ulcer disease or gastrointestinal bleeding. If GI bleeding or ulceration occurs, VIMOVO should be discontinued immediately and appropriate treatment sought. Other risk factors for GI ulceration and bleeding include the following:

Helicobacter pylori infection, increased age, prolonged use of NSAID therapy, excess alcohol intake, smoking, poor general health status or concomitant therapy with any of the following: Anti-coagulants (e.g. warfarin); anti-platelet agents (e.g. ASA, clopidogrel); oral corticosteroids (e.g. prednisone); Selective Serotonin Reuptake Inhibitors (SSRIs) (e.g. citalopram, fluoxetine, paroxetine, sertraline). In studies comprising patients who were older than 50 years of age and/or had a prior history of peptic ulcer, VIMOVO was shown to significantly lower gastric ulcer rates compared to EC-naproxen, regardless of concomitant therapy with low-dose ASA (see Product Monograph, CLINICAL TRIALS). Gastrointestinal symptomatic response to therapy with VIMOVO does not preclude the presence of gastric malignancy. Genitourinary: Some NSAIDs are associated with persistent urinary symptoms (bladder pain, dysuria, urinary frequency), hematuria or cystitis. The onset of these symptoms may occur at any time after the initiation of therapy with a NSAID. Should urinary symptoms occur, in the absence of an alternate explanation, treatment with VIMOVO should be stopped to ascertain if symptoms disappear. This should be done before urological investigations or treatments are carried out. Hematologic: NSAIDs inhibiting prostaglandin biosynthesis interfere with platelet function to varying degrees; patients who may be adversely affected by such an action, such as those on anti-coagulants or suffering from hemophilia or platelet disorders should be carefully observed when VIMOVO is administered. Anti-coagulants: Numerous studies have shown that the concomitant use of NSAIDs and anti-coagulants increases the risk of bleeding. Concurrent therapy of VIMOVO, which contains the NSAID naproxen, with warfarin requires close monitoring of the international normalized ratio (INR). Even with therapeutic INR monitoring, increased bleeding may occur. Anti-platelet Effects: NSAIDs inhibit platelet aggregation and have been shown to prolong bleeding time in some patients. Unlike acetylsalicylic acid (ASA), their effect on platelet function is quantitatively less, or of shorter duration, and is reversible. NSAIDs have no proven efficacy as anti-platelet agents and should NOT be used as a substitute for ASA or other anti-platelet agents for prophylaxis of cardiovascular thromboembolic diseases. Anti-platelet therapies (e.g. ASA) should NOT be discontinued (see DRUG INTERACTIONS; Drug-Drug Interactions, Acetylsalicylic Acid (ASA) or other NSAIDs). Blood dyscrasias: Blood dyscrasias (such as neutropenia, leukopenia, thrombocytopenia, aplastic anemia and agranulocytosis) associated with the use of NSAIDs are rare, but could occur with severe consequences. Anemia is sometimes seen in patients receiving NSAIDs. This may be due to fluid retention, GI blood loss, or an incompletely described effect upon erythropoiesis. Patients on long-term treatment with NSAIDs, should have their hemoglobin or hematocrit checked if they exhibit any signs or symptoms of anemia or blood loss. Hepatic/Biliary/Pancreatic: With NSAIDs, borderline elevations of one or more liver enzyme tests (AST, ALT, alkaline phosphatase) may occur in up to 15% of patients. These abnormalities may progress, may remain essentially unchanged, or may be transient with continued therapy. Chronic alcoholic liver disease and probably other forms of cirrhosis reduce the total plasma concentration of naproxen, but the plasma concentration of unbound naproxen is increased. The implication of this finding for naproxen dosing is unknown, but caution is advised when high doses are required. It is prudent to use the lowest effective dose. A patient with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver function test has occurred, should be evaluated for evidence of the development of a more severe hepatic reaction while on therapy with this drug. Severe hepatic reactions including jaundice and cases of fatal hepatitis, liver necrosis and hepatic failure, some of them with fatal outcomes, have been reported with NSAIDs. Although such reactions are rare, if abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop (e.g. jaundice), or if systemic manifestations occur (e.g. eosinophilia, associated with rash, etc.), this drug should be discontinued. If there is a need to prescribe this drug in the presence of impaired liver function, it must be done under strict observation. Hypersensitivity Reactions: Anaphylactoid Reactions: As with NSAIDs in general, anaphylactoid reactions have occurred in patients without known prior exposure to naproxen, a component of VIMOVO. In post-marketing experience, rare cases of anaphylactic/anaphylactoid reactions and angioedema have been reported in patients receiving naproxen. VIMOVO, which contains naproxen, should NOT be given to patients with the ASA-triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit severe, potentially fatal bronchospasm after taking ASA or other NSAIDs (see CONTRAINDICATIONS). ASA-Intolerance: VIMOVO, which contains naproxen, should NOT be given to patients with complete or partial syndrome of ASA-intolerance (rhinosinusitis, urticaria/angioedema, nasal polyps, asthma) in whom asthma, anaphylaxis, urticaria/angioedema, rhinitis or other allergic manifestations are precipitated by ASA or other NSAIDs. Fatal anaphylactoid reactions have occurred in such individuals. As well, individuals with the above medical problems are at risk of a severe reaction even if they have taken NSAIDs in the past without any adverse reaction (see CONTRAINDICATIONS). Cross-sensitivity: Patients sensitive to one NSAID may be sensitive to any of the other NSAIDs as well. Serious skin reactions: See WARNINGS AND PRECAUTIONS; Skin. Immune: See WARNINGS AND PRECAUTIONS; Infection, Aseptic Meningitis. Infection: Naproxen, a component of VIMOVO, as with other NSAIDs, may mask signs and symptoms of an underlying infectious disease. Aseptic Meningitis: Rarely, with some NSAIDs, the symptoms of aseptic meningitis (stiff neck, severe headaches, nausea and vomiting, fever or clouding of consciousness) have been observed. Patients with autoimmune disorders (systemic lupus erythematosus, mixed connective tissue diseases, etc.) seem to be pre-disposed. Therefore, in such patients, the health care provider must be vigilant to the development of this complication. Pseudomembranous colitis: Pseudomembranous colitis has been reported with nearly all antibacterial agents, including clarithromycin and amoxicillin, and may range in severity from mild to life threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea subsequent to the administration of antibacterial agents. Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of Clostridia. Studies indicate that a toxin produced by Clostridium difficile is a primary cause of “antibiotic-associated colitis”. After the diagnosis of pseudomembranous colitis has been established, therapeutic measures should be initiated. Mild cases of pseudomembranous colitis usually respond to discontinuation of the drug alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation, and treatment with an antibacterial drug clinically effective against C. diff colitis. Decreased gastric acidity due to any means, including any proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to a slightly increased risk of gastrointestinal infections such as Salmonella, Campylobacter and possibly C. diff. Neurologic: Some patients may experience drowsiness, dizziness, blurred vision, vertigo, tinnitus, hearing loss, insomnia or depression with the use of NSAIDs, such as naproxen, a component of VIMOVO. If patients experience such adverse reaction(s), they should exercise caution in carrying out activities that require alertness. Ophthalmologic: Blurred and/or diminished vision has been reported with the use of NSAIDs. If such symptoms develop, VIMOVO, which contains naproxen, should be discontinued and an ophthalmologic examination performed. Ophthalmologic examination should be carried out at periodic intervals in any patient receiving VIMOVO for an extended period of time. Peri-Operative Considerations: See CONTRAINDICATIONS; Coronary Artery Bypass Graft Surgery. Psychiatric: See WARNINGS AND PRECAUTIONS; Neurologic. Renal: Long term administration of NSAIDs to animals has resulted in renal papillary necrosis and other abnormal renal pathology. In humans, there have been reports of acute interstitial nephritis, hematuria, low grade proteinuria and occasionally nephrotic syndrome. Renal insufficiency due to NSAID use is seen in patients with pre-renal conditions leading to reduction in renal blood flow or blood volume. Under these circumstances, renal prostaglandins help maintain renal perfusion and glomerular filtration rate (GFR). In these patients, administration of a NSAID may cause a reduction in prostaglandin synthesis leading to impaired renal function. Patients at greatest risk of this reaction are those with pre-existing renal insufficiency (GFR <60 mL/min or 1 mL/s), dehydrated patients, patients on salt restricted diets, those with congestive heart failure, cirrhosis, liver dysfunction, taking angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, cyclosporin, diuretics, and those who are elderly. Serious or life-threatening renal failure has been reported in patients with normal or impaired renal function after short term therapy with NSAIDs. Even patients at risk who demonstrate the ability to tolerate a NSAID under stable conditions may decompensate during periods of added stress (e.g. dehydration due to gastroenteritis). Discontinuation of NSAIDs is usually followed by recovery to the pre-treatment state. Caution should be used when initiating treatment with NSAIDs, such as naproxen, a component of VIMOVO, in patients with considerable dehydration. Such patients should be rehydrated prior to initiation of therapy. Caution is also recommended in patients with pre-existing kidney disease. Advanced Renal Disease: See CONTRAINDICATIONS. Fluid and Electrolyte Balance: Use of NSAIDs such as naproxen, a component of VIMOVO, can promote sodium retention in a dose-dependent manner, which can lead to fluid retention and edema, and consequences of increased blood pressure and exacerbation of congestive heart failure. Thus, caution should be exercised in prescribing VIMOVO in patients with a history of congestive heart failure, compromised cardiac function, hypertension, increased age or other conditions predisposing to fluid retention (see WARNINGS AND PRECAUTIONS; Cardiovascular). Use of NSAIDs such as naproxen, a component of VIMOVO, can increase the risk of hyperkalemia, especially in patients with diabetes mellitus, renal failure, increased age, or those receiving concomitant therapy with adrenergic blockers, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, cyclosporin, or some diuretics. Electrolytes should be monitored periodically (see CONTRAINDICATIONS). Respiratory: ASA-induced asthma is an uncommon but very important indication of ASA and NSAID sensitivity. It occurs more frequently in patients with asthma who have nasal polyps. Sexual Function/Reproduction: The use of naproxen as with any drug known to inhibit cyclooxygenase/prostaglandin synthesis, may impair fertility and is not recommended in women attempting to conceive. Therefore, in women who have difficulties conceiving, or who are undergoing investigation of infertility, withdrawal of VIMOVO, which contains naproxen, should be considered. Skin: In rare cases, serious skin reactions such as Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis and erythema multiforme have been associated with the use of some NSAIDs. Because the rate of these reactions is low, they have usually been noted during post-marketing surveillance in patients taking other medications also associated with the potential development of these serious skin reactions. Thus, causality is NOT clear. These reactions are potentially life threatening but may be reversible if the causative agent is discontinued and appropriate treatment instituted. Patients should be advised that if they experience a skin rash they should discontinue their NSAID and contact their physician for assessment and advice, including which additional therapies to discontinue.SPECIAL POPULATIONS:Hepatic Insufficiency: VIMOVO is not recommended for use in patients with severe hepatic impairment due to increased risk of NSAID associated bleeding and/or renal failure (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS; Hepatic/Biliary/Pancreatic). In patients with mild to moderate hepatic impairment VIMOVO should be used with caution and hepatic function closely monitored. Renal Insufficiency: VIMOVO is not recommended for use in patients with severe renal impairment or deteriorating renal disease (see

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CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS; Renal). In patients with mild to moderate renal impairment VIMOVO should be used with caution and renal function closely monitored. Poor Metabolizers: The CYP 2C19 and CYP 3A4 isozymes are responsible for metabolism of esomeprazole. The CYP 2C19 isozyme, which is involved in the metabolism of all available proton pump inhibitors, exhibits polymorphism. Some 3% of Caucasians and 15-20% of Asians lack CYP 2C19 and are termed “poor metabolizers”. At EC-esomeprazole steady state (40 mg for 5 days), the ratio of AUC in poor metabolizers to AUC in the rest of the population is approximately 2. Dosage adjustment of VIMOVO based on CYP 2C19 status is not necessary (see DOSAGE AND ADMINISTRATION and Product Monograph ACTION AND CLINICAL PHARMACOLOGY; Pharmacokinetics, Special Populations).MONITORING AND LABORATORY TESTS:Patients on long-term treatment with VIMOVO should have their blood pressure monitored regularly and an ophthalmic examination should be carried out at periodic intervals (see WARNINGS AND PRECAUTIONS; Cardiovascular and Ophthalmic). Hemoglobin, hematocrit, red blood cells (RBCs), white blood cells (WBCs), and platelets should be checked in patients on long-term treatment with VIMOVO. Additionally, concurrent therapy with warfarin requires close monitoring of the international normalized ratio (INR) (see WARNINGS AND PRECAUTIONS; Hematology). Serum transaminase and bilirubin should be monitored regularly during VIMOVO therapy (see WARNINGS AND PRECAUTIONS; Hepatic, Biliary, Pancreatic). Serum creatinine, creatine clearance and serum urea should be checked in patients during VIMOVO therapy. Electrolytes including serum potassium should be monitored periodically (see WARNINGS AND PRECAUTIONS; Renal). Monitoring of plasma lithium concentration is recommended when stopping or starting VIMOVO therapy.ADVERSE REACTIONS:Since VIMOVO contains both naproxen and esomeprazole, the same pattern of undesirable effects reported for these individual substances may occur. The most common adverse reactions seen with naproxen are gastrointestinal, of which peptic ulcer, with or without bleeding, is the most severe. Fatalities have occurred particularly in the elderly. Other common adverse reactions include dyspepsia, stomach pain, nausea and vomiting. Common reactions seen with esomeprazole in clinical trials include headache, diarrhea, flatulence, abdominal pain, nausea, vomiting and dizziness, which are thought to be causally related. The most commonly reported adverse reactions with VIMOVO are erosive gastritis, dyspepsia and gastritis. No new safety findings were identified during VIMOVO treatment compared to the established safety profile for the individual substances.Clinical Trial Adverse Drug Reactions: Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates. Adverse event data is provided from controlled studies using VIMOVO, involving 2317 patients ranging in duration from 3-12 months. Patients received either 500/20 mg of VIMOVO twice daily (n=1157), 500 mg of enteric-coated (EC) naproxen twice daily (n=426), 200 mg of celecoxib once daily (n=488), or placebo (n=246). All adverse reactions, regardless of causality, occurring in ≥2% of patients from two 6-month randomized, double-blind, parallel-group controlled clinical studies (Study 301 and 302) conducted in patients at risk of developing NSAID-associated ulcers compared to EC-naproxen are presented in the below table.Table 1: Adverse Reactions, regardless of causality, occurring ≥2% in arthritisa patients at risk of NSAID-induced ulcers from Studies 301 and 302 (pooled, 6 months duration)

Preferred term (sorted by SOC) Percentage of Subjects With Adverse Events

VIMOVO (500/20 mg) BID(n=428)

EC-naproxen 500 mg BID(n=426)

Gastrointestinal disorders

Gastritis Erosive 19.4 38.0

Dyspepsia 18.0 26.8

Gastritis 17.1 14.1

Diarrhea 6.1 5.2

Gastric Ulcer 5.6 23.7

Abdominal Pain Upper 5.6 8.7

Nausea 5.1 4.9

Hiatus Hernia 4.2 5.9

Abdominal Distension 3.7 3.8

Flatulence 3.7 3.1

Esophagitis 3.5 7.5

Constipation 2.6 2.8

Abdominal pain 2.3 1.6

Erosive Duodenitis 2.1 11.7

Abdominal pain lower 2.1 2.6

Duodenitis 1.4 7.3

Gastritis hemorrhagic 1.2 2.1

Gastroesophageal reflux disease 0.9 3.5

Duodenal ulcer 0.7 5.4

Erosive esophagitis 0.5 5.6

Infections and infestations

Upper respiratory tract infection 4.9 3.8

Bronchitis 2.3 1.9

Urinary tract infection 2.3 1.4

Sinusitis 1.9 2.1

Nasopharyngitis 0.9 2.3

Musculoskeletal and connective tissue disorders

Arthralgia 1.2 2.3

Nervous system disorders

Headache 2.6 1.4

Dysgeusia 2.1 1.4

Respiratory, thoracic, and mediastinal disorders

Cough 2.3 2.6

a Studies also included 23% patients with chronic musculoskeletal conditions requiring ongoing NSAID therapy

Patients taking VIMOVO had significantly fewer pre-specified NSAID-associated upper GI adverse events (including duodenal ulcers) (53.3%) compared to patients taking EC-naproxen alone (70.4%). As well, patients taking VIMOVO had significantly less discontinuations due to adverse reactions compared to patients taking EC-naproxen alone (7.9% vs. 12.5% respectively). The most common reasons for discontinuations due to adverse events in the VIMOVO treatment group were upper abdominal pain (1.2%, n=5), duodenal ulcer (0.7%, n=3) and erosive gastritis (0.7%, n=3). Among patients receiving naproxen alone, the most common reasons for discontinuations due to adverse events were duodenal ulcer 5.4% (n=23), dyspepsia 2.8% (n=12) and upper abdominal pain 1.2% (n=5). The proportion of patients discontinuing treatment due to pre-specified NSAID-associated upper gastrointestinal adverse events (including duodenal ulcers) in patients treated with VIMOVO was 4.0% compared to 12.0% for patients taking EC-naproxen (p<0.001).Adverse reaction data for VIMOVO, regardless of causality, occurring in ≥2 % of patients, and greater than placebo from two 3-month randomized double-blind, placebo-controlled clinical studies conducted in patients with osteoarthritis of the knee are presented below.

Table 2: Adverse Reactions, regardless of causality, occurring ≥2% in patients with osteoarthritis of the knee from Studies 307 and 309 (3 months duration)

Preferred term (sorted by SOC) Percentage of Subjects With Adverse Events

VIMOVO (500/20 mg) BID(n=490)

Celecoxib 200 mg QD(n=488)

Placebo(n=246)

Gastrointestinal disorders

Dyspepsia 8.4 10.7 12.2

Diarrhea 5.5 2.9 3.7

Abdominal Pain Upper 4.1 4.3 3.3

Constipation 3.5 2.0 1.2

Nausea 3.5 3.1 3.7

Nervous system disorders

Dizziness 3.1 0.8 2.0

Headache 2.7 3.7 5.3

General disorders and administration site conditions

Peripheral edema 3.1 1.2 1.2

Musculoskeletal and connective tissue disorders

Arthralgia 1.4 2.9 1.6

Back pain 1.2 2.9 2.0

Respiratory, thoracic and mediastinal disorders

Cough 1.4 0.6 2.8

Infections and infestations

Sinusitis 1.0 1.2 2.4

Similar percentages of subjects receiving either VIMOVO or celecoxib withdrew from these studies due to treatment emergent adverse events (6.9% and 7.8% respectively). There were no adverse reactions in which more than 1% of subjects withdrew from any treatment group. The long-term safety of VIMOVO was evaluated in an open label clinical trial of 239 patients, of which 135 patients received 500/20 mg of VIMOVO for 12 months. There were no differences in frequency or types of adverse reactions seen in the long-term safety study compared to shorter-term treatment in the randomized controlled studies above. In the pooled data from all VIMOVO clinical trials in patients (n=2317), there were 4 reports of atrial fibrillation/flutter. All 4 events occurred in patients assigned to VIMOVO but all were assessed as unrelated or unlikely to be related to study drug.Other Adverse Events: Post-Market Adverse Drug Reactions: Because post-marketing events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or clearly establish a causal relationship to the product. The following post-marketing adverse events have been reported with NSAIDS including naproxen and naproxen sodium, taken alone. Gastrointestinal: Peptic ulcers, perforation, or GI bleeding, sometimes fatal, particularly in the elderly. Heartburn, nausea, esophagitis, vomiting, diarrhea, flatulence, constipation, dyspepsia, abdominal pain, nonpeptic gastrointestinal ulceration, melena, hematemesis, stomatitis, ulcerative stomatitis, exacerbation of ulcerative colitis and Crohn’s disease, pancreatitis, gastritis. Infections: Aseptic meningitis. Blood and Lymphatic System Disorders: Agranulocytosis, aplastic anemia, eosinophilia, hemolytic anemia, leucopenia, thrombocytopenia. Immune System Disorders: Anaphylactoid reactions. Metabolic and Nutrition Disorders: Hyperkalemia. Psychiatric Disorders: depression, dream abnormalities, insomnia. Nervous System Disorders: Dizziness, drowsiness, headache, lightheadedness, retrobulbar optic neuritis convulsions, cognitive dysfunction, inability to concentrate. Eye Disorders: Visual disturbances, corneal opacity, papillitis, papilledema. Ear and Labyrinth Disorders: Hearing impairment, hearing disturbances, tinnitus, vertigo. Cardiac Disorders: Palpitations, cardiac failure has been reported in association with NSAID treatment, congestive heart failure. Vascular Disorders: Hypertension, vasculitis. Respiratory, Thoracic and Mediastinal Disorders: Dyspnea, pulmonary edema, asthma, eosinophilic pneumonitis. Hepatobiliary Disorders: Hepatitis (some cases of hepatitis have been fatal), jaundice. Skin and Subcutaneous Tissue Disorders: ecchymoses, itching (pruritus), purpura, skin eruptions, sweating, alopecia, epidermal necrolysis, very rarely toxic epidermal necrolysis, erythema multiforme, bullous reactions, including Stevens-Johnson syndrome, erythema nodosum, fixed drug eruption, lichen planus, pustular reaction, skin rashes, SLE, urticaria, photosensitivity reactions, including rare cases resembling porphyria cutanea tarda (“pseudoporphyria”) or epidermolysis bullosa and angioneurotic edema. If skin fragility, blistering or other symptoms suggestive of pseudoporphyria occur, treatment should be discontinued and the patient monitored. Musculoskeletal and Connective Tissue Disorders: myalgia, muscle weakness. Renal and Urinary Disorders: hematuria, interstitial nephritis, nephrotic syndrome, renal disease, renal failure, renal papillary necrosis. Reproductive System and Breast Disorders: Female infertility. General Disorders and Administration Site Conditions: Edema, thirst, pyrexia (chills and fever), malaise. Investigations: Abnormal liver function tests, raised serum creatinine. From esomeprazole post-marketing experience there have been uncommon reports (<1%) of peripheral edema, insomnia, paresthesia, somnolence, vertigo and increased liver enzymes. There have also been rare reports (<0.1%) of blurred vision, hypersensitivity reactions (e.g. angioedema, anaphylactic reaction/shock), myalgia, leukopenia, thrombocytopenia, depression, alopecia, hepatitis with or without jaundice, hyponatremia, agitation, confusion, taste disturbance, bronchospasm, stomatitis, GI candidiasis, rash, dermatitis, photosensitivity, arthralgia, malaise, and hyperhidrosis. Very rarely (<0.01%) agranulocytosis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, pancytopenia, aggression, hallucination, hepatic failure, hepatic encephalopathy, interstitial nephritis, muscular weakness, gynecomastia, and hypomagnesaemia have been reported.DRUG INTERACTIONS:Drug-Drug Interactions: Overview: Studies conducted with VIMOVO have shown no interactions between its two components, naproxen and esomeprazole. Interaction studies have not been conducted with VIMOVO and other drugs. Interactions for VIMOVO would be expected to reflect those of the monocomponents, taken separately, which are detailed below. NSAID related drug-drug interactions: Acetylsalicylic acid (ASA) or other NSAIDs: The use of VIMOVO in addition to an NSAID, including over-the-counter ones (such as ASA and ibuprofen) for analgesic and/or anti-inflammatory effects is NOT recommended because of the absence of any evidence demonstrating synergistic benefits and the potential for additive adverse reactions. The exception is the use of low-dose ASA for cardiovascular protection, when another NSAID containing product, such as VIMOVO is being used for its analgesic/anti-inflammatory effect, keeping in mind that combination NSAID therapy is associated with additive adverse reactions. However, in clinical trials, patients taking VIMOVO in combination with low-dose ASA did not have an increased occurrence of gastric ulcers compared to patients taking VIMOVO alone. Ulcer complications such as bleeding, perforation and obstruction were not studied in VIMOVO trials. Some NSAIDs (e.g. ibuprofen) may interfere with the anti-platelet effects of low-dose ASA, possibly by competing with ASA for access to the active site of cyclooxygenase-1. Albumin Bound Drugs: The naproxen anion may displace from their binding sites other drugs which are also albumin-bound and may lead to drug interactions. For example, in patients receiving bishydroxycoumarin or warfarin, the addition of VIMOVO, which contains naproxen, could prolong the prothrombin time. These patients should, therefore, be under careful observation. Similarly, patients receiving VIMOVO and a hydantoin, sulfonamide or sulfonylurea should be observed for adjustment of dose if required. Antacids: The rate of absorption of naproxen is altered by concomitant administration of antacids but is not adversely influenced by the presence of food. Anti-coagulants: See WARNINGS AND PRECAUTIONS; Hematologic, Anti-coagulants. Anti-hypertensives: NSAIDs may diminish the anti-hypertensive effect of Angiotensin Converting Enzyme (ACE) inhibitors. Combinations of ACE inhibitors, angiotensin-II antagonists, or diuretics with NSAIDs might have an increased risk for acute renal failure and hyperkalemia. Blood pressure and renal function (including electrolytes) should be monitored more closely in this situation, as occasionally there can be a substantial increase in blood pressure. Naproxen and other NSAIDs can reduce the antihypertensive effect of propranolol and other beta blockers as well as other antihypertensive agents. Anti-platelet Agents (including ASA): There is an increased risk of bleeding, via inhibition of platelet function, when anti-platelet agents are combined with NSAIDs, such as naproxen, a component of VIMOVO (see WARNINGS AND PRECAUTIONS; Hematologic, Anti-platelet Effects). Cyclosporin: Inhibition of renal prostaglandin activity by NSAIDs may increase the plasma concentration of cyclosporine and/or the risk of cyclosporine induced nephrotoxicity. Patients should be carefully monitored during concurrent use. Cholestyramine: Concomitant administration of cholestyramine can delay the absorption of naproxen, but does not affect its extent. Digoxin: Concomitant administration of an NSAID with digoxin can result in an increase in digoxin concentrations which may result in digitalis toxicity. Increased monitoring and dosage adjustments of digitalis glycosides may be necessary during and following concurrent NSAID therapy. Diuretics: Clinical studies as well as post-marketing observations have shown that NSAIDs can reduce the effect of diuretics. Glucocorticoids: Some studies have shown that the concomitant use of NSAIDs and oral glucocorticoids increases the risk of GI adverse events such as ulceration and bleeding. This is especially the case in older (>65 years of age) individuals. Lithium: Monitoring of plasma lithium concentrations is advised when stopping or starting a NSAID, as increased lithium concentrations can occur. Methotrexate: Caution is advised in the concomitant administration of naproxen and methotrexate since naproxen and other NSAIDs have been reported to reduce the tubular secretion of methotrexate in an animal model, thereby possibly enhancing its toxicity. Probenecid:

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ONTARIO MEDICAL REVIEW March 201253

Probenecid given concurrently increases naproxen anion plasma levels and extends its plasma half-life significantly. Caution is advised when probenecid is administered concurrently. Selective Serotonin Reuptake Inhibitors (SSRIs): Concomitant administration of NSAIDs and SSRIs may increase the risk of gastrointestinal ulceration and bleeding (see WARNINGS AND PRECAUTIONS; Gastrointestinal). Tacrolimus: As with all NSAIDs caution is advised when tacrolimus is co-administered because of the increased risk of nephrotoxicity. Esomeprazole related drug-drug interactions: Esomeprazole magnesium is metabolized by the cytochrome P-450 system (CYP), mainly in the liver, through CYP 2C19 and CYP 3A4. There are no clinically significant interactions between esomeprazole and diazepam, phenytoin, quinidine or cisapride (cisapride not marketed in Canada). Drugs known to inhibit CYP 2C19 or CYP 3A4 or both (such as clarythromycin and voriconazole) may lead to increased esomeprazole serum levels by decreasing the rate of esomeprazole’s metabolism. Drugs known to induce CYP 2C19 or CYP 3A4 or both (such as rifampin and St. John’s Wort) may lead to decreased esomeprazole serum levels by increasing the esomeprazole metabolism (see DRUG-HERB INTERACTIONS). Diazepam: Concomitant administration of EC-esomeprazole (30 mg once daily for 5 days) resulted in a 45% decrease in the clearance of diazepam in healthy male volunteers. Studies in females have not been conducted. Increased levels of diazepam were seen some 12 hours after dosing and later when the plasma levels of diazepam were below its therapeutic range. Therefore, this interaction is unlikely to be of clinical significance. Warfarin: Concomitant administration of 40 mg EC-esomeprazole (once daily for 3 weeks) to male and female patients on stable anticoagulation therapy with warfarin, resulted in a 13% increase in trough plasma levels of R-warfarin (the less potent enantiomer) while that of S-warfarin was unchanged. Coagulation times were stable throughout the entire study period. No clinically significant interaction was observed. However, from post marketed use, cases of elevated international normalized ratio (INR) of clinical significance have been reported during concomitant treatment with warfarin. Close monitoring is recommended when initiating and ending treatment with warfarin or other coumarin derivatives (refer to approved Product Monograph for warfarin or relevant coumarin derivative). Cilostazol (not marketed in Canada): Omeprazole as well as esomeprazole act as inhibitors of CYP 2C19. Omeprazole, given in doses of 40 mg to healthy subjects in a cross-over study, increased C

max and AUC for cilostazol by 18% and 26% respectively, and one of its active metabolites,

3,4-dihydrocilostazol, by 29% and 69% respectively. Phenytoin: Concomitant administration of 40 mg EC-esomeprazole (once daily for 2 weeks) to male and female epileptic patients stabilized on phenytoin, resulted in a 13% increase in trough plasma levels of phenytoin. This minor interaction is unlikely to be of clinical relevance as dose reduction was not required in any patient nor was the profile and frequency of adverse events affected. Results from a range of interaction studies with EC-esomeprazole versus other drugs indicate that daily doses of 40 mg EC-esomeprazole, given for 5 to 21 days in male and/or female subjects, has no clinically relevant interactions with CYP 1A2 (caffeine), CYP 2C9 (S-warfarin), and CYP 3A (quinidine, estradiol and cisapride [cisapride not marketed in Canada]). Antiretroviral Drugs: Omeprazole, the racemate of esomeprazole, like other acid-reducing agents, has been reported to interact with some antiretroviral drugs. The clinical importance and the mechanisms behind these interactions are not always known. A change in gastric pH may change the absorption of the antiretroviral drug. Other possible interaction mechanisms are via CYP 2C19. Reports indicate that omeprazole has a significant impact on atazanavir exposure, decreasing AUC, C

max and C

min. This interaction is only partially overcome by

the addition of ritonavir to the atazanavir treatment regimen. Similarly, decreased serum levels of nelfinavir have also been reported when given together with omeprazole. Concomitant administration of omeprazole with atazanavir and nelfinavir is not recommended. For other antiretroviral drugs, such as saquinavir, increased serum levels have been reported. There are also some antiretroviral drugs where unchanged serum levels have been reported when given with omeprazole. Due to the similar pharmacodynamic effects and pharmacokinetic properties of omeprazole and esomeprazole, concomitant administration of EC-esomeprazole and antiretroviral drugs such as atazanavir and nelfinavir is not recommended (see WARNINGS AND PRECAUTIONS). Voriconazole: Concomitant administration of EC-esomeprazole with a combined inhibitor of CYP 2C19 and CYP 3A4 may result in more than double the levels of esomeprazole exposure. As with all drugs that reduce gastric acidity, changes in plasma levels of other drugs whose absorption is pH dependent (e.g. ketoconazole or itraconazole) must be taken into account when they are co-administered with esomeprazole. Digoxin: The absorption of digoxin can increase during treatment with esomeprazole and other drugs that reduce gastric acidity. Concomitant treatment with omeprazole (20 mg daily) and digoxin in ten healthy subjects increased the bioavailability of digoxin by an average of 10% (up to 30% in two out of ten subjects). Other interactions: As demonstrated with other PPIs, prolonged use may impair the absorption of protein-bound Vitamin B

12 and may contribute to the development of Vitamin B

12 deficiency. Drug-Food Interactions: Concomitant

administration of food can delay the absorption of the naproxen component of VIMOVO, but does not affect its extent of absorption. Concomitant administration of food however, does not delay the absorption of the esomeprazole component of VIMOVO, but significantly reduces its extent of absorption (see DOSAGE AND ADMINISTRATION; Dosing Considerations and Product Monograph ACTIONS AND

CLINICAL PHARMACOLOGY; Pharmacokinetics, Absorption, Food Effect). Drug-Herb Interactions: Use of St. John’s Wort may lead to decreased esomeprazole serum levels by increasing the esomeprazole metabolism (see DRUG INTERACTIONS, Esomeprazole related Drug-Drug Interactions). Drug-Laboratory Interactions: During treatment with antisecretory drugs, chromogranin A (CgA) increases due to decreased gastric acidity. The increased CgA level may interfere with investigations for neuroendocrine tumours. To avoid this interference esomeprazole treatment should be temporarily stopped five days before CgA measurements. (See also WARNINGS AND PRECAUTIONS; Special Populations, Monitoring and Laboratory Tests). Drug-Lifestyle Interactions: There are no specific studies about effects on the ability to drive vehicles and to use machinery. It should be taken into account that some of the adverse effects (e.g. dizziness) reported following the use of VIMOVO may reduce the ability to react. Patients who experience visual disturbances or other central nervous system disturbances should refrain from these activities. Concurrent use of alcohol with an NSAID may increase the risk of gastrointestinal side effects, including ulceration and hemorrhage.DOSAGE AND ADMINISTRATION:Missed Dose: The missed dose should be taken as soon as remembered, and then the regular dosing schedule should be continued. Two doses of VIMOVO should not be taken at the same time. Special Populations: Hepatic Insufficiency: VIMOVO is not recommended for use in patients with severe hepatic impairment (see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS; Hepatic/Biliary/Pancreatic and WARNINGS AND PRECAUTIONS; Special Populations). Renal Insufficiency: VIMOVO is not recommended for use in patients with severe renal impairment or deteriorating renal disease (see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS; Renal and WARNINGS AND PRECAUTIONS; Special Populations). Poor Metabolizers: Dosage adjustment based on CYP 2C19 status is not necessary (see WARNINGS AND PRECAUTIONS; Special Populations and Product Monograph ACTION AND CLINICAL PHARMACOLOGY; Pharmacokinetics, Special Populations).OVERDOSAGE:

For management of suspected drug overdose, contact your regional Poison Control Centre.

There is no clinical data on overdosage with VIMOVO. Any effects of an overdose with VIMOVO would be expected to reflect those of the monocomponents of naproxen and esomeprazole, taken separately. Naproxen: Significant overdosage may be characterized by drowsiness, dizziness, disorientation, heartburn, indigestion, epigastric pain, abdominal discomfort, nausea, vomiting, transient alterations in liver function, hypoprothrombinemia, renal dysfunction, metabolic acidosis and apnea. A few patients have experienced convulsions, but it is not clear whether or not these were naproxen related. Gastrointestinal bleeding may occur. Hypertension, acute renal failure, respiratory depression and coma may occur after the ingestion of NSAIDs but are rare. Anaphylactoid reactions have been repeated with therapeutic ingestion of NSAIDs, and may occur following an overdose. Patients should be managed by symptomatic and supportive care following NSAIDs overdose. There are no specific antidotes. Prevention of further absorption (e.g. activated charcoal) may be indicated in patients seen within 4 hours of ingestion with symptoms or following a large overdose. Forced diuresis, alkalinization of urine, hemodialysis, or hemoperfusion may not be useful due to high protein binding. Esomeprazole: Limited information is available on the effects of higher doses in man, and specific recommendations for treatment cannot be given. Experience from a patient who deliberately ingested an overdose of EC-esomeprazole (280 mg), demonstrated symptoms that were transient, and included weakness, loose stools and nausea. Single doses of 80 mg EC-esomeprazole have been shown to be uneventful. No specific antidote is known. Esomeprazole is extensively protein-bound and is therefore not readily dialyzable. Treatment should be symptomatic and general supportive measures should be utilized.Product Monograph is available upon request from AstraZeneca Canada Inc.Revision date: January 13, 2011.

VIMOVO® and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. © AstraZeneca 2011

AstraZeneca Canada Inc.1004 Middlegate Road, Mississauga, Ontario L4Y 1M4

www.astrazeneca.ca T 1-800-668-6000 F 1-800-250-1909VIM105E

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ONTARIO MEDICAL REVIEW March 201254

Prescribing Summary

THERAPEUTIC CLASSIFICATION Live, attenuated virus varicella-zoster vaccine

INDICATIONS AND CLINICAL USE ZOSTAVAX® is indicated for the prevention of herpes zoster (shingles).

ZOSTAVAX® is indicated for immunization of individuals 50 years of age or older.

SPECIAL POPULATIONSFor use in special populations, see Supplemental Product Information, WARNINGS AND PRECAUTIONS, Special Populations.

CONTRAINDICATIONSHistory of hypersensitivity to any component of the vaccine, including gelatin. History of anaphylactic/anaphylactoid reaction to neomycin (each dose of reconstituted vaccine contains trace quantities of neomycin). Neomycin allergy generally manifests as a contact dermatitis. However, a history of contact dermatitis due to neomycin is not a contraindication to receiving live virus vaccines.

Primary and acquired immunodeficiency states due to conditions such as: acute and chronic leukemias; lymphoma; other conditions affecting the bone marrow or lymphatic system; immunosuppression due to HIV/AIDS; cellular immune deficiencies. Immunosuppressive therapy (including high-dose corticosteroids); however, ZOSTAVAX® is not contraindicated for use in individuals who are receiving topical/inhaled corticosteroids or low-dose systemic corticosteroids or in patients who are receiving corticosteroids as replacement therapy, e.g., for adrenal insufficiency.

Active untreated tuberculosis.

Pregnancy (see WARNINGS AND PRECAUTIONS - Pregnant Women in the Supplemental Product Information).

WARNINGS AND PRECAUTIONS GeneralThe health care provider should question the patient about reactions to a previous dose of any varicella-zoster virus (VZV)-containing vaccines (see CONTRAINDICATIONS).

As with any vaccine, adequate treatment provisions, including epinephrine injection (1:1000), should be available for immediate use should an anaphylactic/anaphylactoid reaction occur. Deferral of vaccination should be considered in the presence of fever >38.5°C (>101.3°F). ZOSTAVAX® does not protect all individuals against the development of Herpes Zoster or its sequelae. See ACTION AND CLINICAL PHARMACOLOGY and CLINICAL TRIALS in the product monograph.

The duration of protection beyond 4 years after vaccination with ZOSTAVAX® is unknown. The need for revaccination has not been defined.

ZOSTAVAX® has not been studied in individuals who have previously experienced an episode of herpes zoster.

Transmission In clinical trials with ZOSTAVAX®, transmission of the vaccine virus has not been reported. However, post-marketing experience with varicella vaccines suggests that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts. Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported and is therefore a theoretical risk for vaccination with ZOSTAVAX®. The risk of transmitting the attenuated vaccine virus to a susceptible individual should be weighted against the

risk of developing natural herpes zoster and potentially transmitting wild-type VZV to a susceptible contact.

ADVERSE REACTIONS Adverse Drug Reaction Overview In clinical trials, ZOSTAVAX® has been evaluated for general safety in more than 32,000 adults 50 years of age or older. ZOSTAVAX® was generally well tolerated.

ZOSTAVAX® Efficacy and Safety Trial (ZEST) in Subjects 50 to 59 Years of Age

In the ZEST study, subjects received a single dose of either ZOSTAVAX® (n=11,184) or placebo (n=11,212) and were monitored for general safety throughout the study. During the study, a vaccine-related serious adverse experience was reported for 1 subject vaccinated with ZOSTAVAX® (anaphylactic reaction).

All subjects received a vaccination report card (VRC) to record adverse events occurring from Days 1 to 42 postvaccination in addition to undergoing routine safety monitoring throughout the study.

Vaccine-related injection-site and systemic adverse experiences reported at an incidence of ≥1% are shown in Table 1. The overall incidence of vaccine-related injection-site adverse experiences was significantly greater for subjects vaccinated with ZOSTAVAX® versus subjects who received placebo (63.9% for ZOSTAVAX® and 14.4% for placebo).

Table 1: Vaccine-Related Injection-Site and Systemic Adverse Experiences Reported in ≥1% of Adults Who Received

ZOSTAVAX® or Placebo (1-42 Days Postvaccination) in the ZOSTAVAX® Efficacy and Safety Trial

ZOSTAVAX® Placebo (N = 11,094) (N = 11,116) Adverse Experience % %

Injection-Site Pain† 53.9 9.0 Erythema† 48.1 4.3 Swelling† 40.4 2.8 Pruritus 11.3 0.7 Warmth 3.7 0.2 Hematoma 1.6 1.6 Induration 1.1 0.0

Systemic Headache 9.4 8.2 Pain in extremity 1.3 0.8

† Designates a solicited adverse experience. Injection-site adverse experiences were solicited only from Days 1-5 postvaccination.

Within the 42-day postvaccination period in the ZEST, noninjection-site zoster-like rashes were reported by 30 subjects (15 for ZOSTAVAX® and 15 for placebo). Of 21 specimens that were adequate for Polymerase Chain Reaction (PCR) testing, wild-type VZV was detected in 10 (3 for ZOSTAVAX®, 7 for placebo) of these specimens. The Oka/Merck strain of VZV was not detected from any of these specimens.

Within the same 42-day postvaccination reporting period in the ZEST, varicella-like rashes were reported by 115 subjects (64 for ZOSTAVAX® and 51 for placebo). Of 21 specimens that were available and adequate for PCR testing, VZV was detected in one of these specimens from the group of subjects who received ZOSTAVAX®; however, the virus strain (wild type or Oka/Merck strain) could not be determined.

Shingles Prevention Study (SPS) in Subjects 60 Years of Age and Older

In the largest of these trials, the Shingles Prevention Study (SPS), 38,546 subjects received a single dose of either ZOSTAVAX® (n=19,270) or placebo (n=19,276) and were monitored for safety throughout the study. During the study, vaccine-related serious adverse experiences were reported for 2 subjects vaccinated with ZOSTAVAX® (asthma exacerbation and polymyalgia rheumatica) and 3 subjects who received placebo (Goodpasture’s syndrome, anaphylactic reaction, and polymyalgia rheumatica).

In the Adverse Event Monitoring Substudy, a subgroup of individuals from the SPS (n=3,345 received ZOSTAVAX® and n=3,271 received placebo) were provided vaccination report cards to record adverse events occurring from Days 0 to 42 postvaccination in addition to undergoing routine safety monitoring throughout the study.

Patient Selection Criteria

Safety Information

Table 2: Number of Subjects with ≥1 Serious Adverse Events (0-42 Days Postvaccination) in the Shingles Prevention Study

ZOSTAVAX® Placebo n/N n/N Relative Risk Cohort % % (95% CI)

Overall Study Cohort

All ages 255/18671 254/18717 1.01 1.4% 1.4% (0.85, 1.20)

60-69 years old 113/10100 101/10095 1.12 1.1% 1.0% (0.86, 1.46)

≥70 years old 142/8571 153/8622 0.93 1.7% 1.8% (0.74, 1.17)

AE Monitoring Substudy Cohort

All ages 64/3326 41/3249 1.53 1.9% 1.3% (1.04, 2.25)

60-69 years old 22/1726 18/1709 1.21 1.3% 1.1% (0.66, 2.23)

≥70 years old 42/1600 23/1540 1.76 2.6% 1.5% (1.07, 2.89)

N=number of subjects in cohort with safety follow-upn=number of subjects reporting an SAE 0-42 Days postvaccination

The incidence of death was similar in the groups receiving ZOSTAVAX® or placebo during the Days 0-42 postvaccination period: 14 deaths occurred in the group of subjects who received ZOSTAVAX® and 16 deaths occurred in the group of subjects who received placebo. The most common reported cause of death was cardiovascular disease (10 in the group of subjects who received ZOSTAVAX®, 8 in the group of subjects who received placebo). The overall incidence of death occurring at any time during the study was similar between vaccination groups: 793 deaths (4.1%) occurred in subjects who received ZOSTAVAX® and 795 deaths (4.1%) in subjects who received placebo.

Vaccine-related injection-site and systemic adverse experiences reported at an incidence ≥1% are shown in Table 3. Most of these adverse experiences were reported as mild in intensity. The overall incidence of vaccine-related injection-site adverse experiences was significantly greater for subjects vaccinated with ZOSTAVAX® versus subjects who received placebo (48% for ZOSTAVAX® and 17% for placebo).

Table 3: Vaccine-Related Injection-Site and Systemic Adverse Experiences Reported in ≥1% of Adults Who Received ZOSTAVAX® or Placebo (0-42 Days

Postvaccination) in the Adverse Events Monitoring Substudy of the Shingles Prevention Study

ZOSTAVAX® Placebo (N = 3345) (N = 3271)Adverse Experience % %

Injection Site Erythema† 35.6 6.9 Pain/tenderness† 34.3 8.6 Swelling† 26.1 4.5 Hematoma 1.6 1.4 Pruritus 7.1 1.0 Warmth 1.7 0.3

Systemic Headache 1.4 0.9

† Designates a solicited adverse experience. Injection-site adverse experiences were solicited only from Days 0-4 postvaccination.

The remainder of subjects in the SPS received routine safety monitoring, but were not provided report cards. The types of events reported in these patients were generally similar to the subgroup of patients in the Adverse Event Monitoring Substudy. Within the 42-day postvaccination reporting period in the SPS, the number of reported noninjection-site zoster-like rashes among all subjects was small (17 for ZOSTAVAX®, 36 for placebo; p=0.009). Of these 53 zoster-like rashes, 41 had specimens that were available and adequate for PCR testing. Wild-type VZV was detected in 25 (5 for ZOSTAVAX®, 20 for placebo) of these specimens. The Oka/Merck strain of VZV was not detected from any of these specimens.

The number (n=59) of reported varicella-like rashes was also small. Of these varicella-like rashes, 10 had specimens that were available and adequate for PCR testing. VZV was not detected in any of these specimens. The results of virus testing in subjects with varicella-like and zoster-like rashes should be interpreted with caution due to the number of samples that were not available for testing.

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ONTARIO MEDICAL REVIEW March 201255

The numbers of subjects with elevated temperature (≥38.3°C [≥101.0°F]) within 7 days postvaccination were similar in the ZOSTAVAX® and the placebo vaccination groups [6 (0.2%) vs. 8 (0.3%), respectively].

Other StudiesIn other clinical trials conducted prior to the completion of the SPS, the reported rates of noninjection-site zoster-like and varicella-like rashes within 42 days postvaccination were also low in both zoster vaccine recipients and placebo recipients. Of the 17 reported noninjection-site zoster-like and varicella-like rashes, 10 specimens were available and adequate for PCR testing. The Oka/Merck strain was identified by PCR analysis from the lesion specimens of only two subjects who reported varicella-like rashes (onset on Day 8 and 17).

To address concerns for individuals with an unknown history of vaccination with ZOSTAVAX®, the safety and tolerability of a second dose of ZOSTAVAX® was evaluated. In a placebo-controlled, double-blind study, 98 adults 60 years of age or older received a second dose of ZOSTAVAX® 42 days following the initial dose; the vaccine was generally well tolerated. The frequency of vaccine-related adverse experiences after the second dose of ZOSTAVAX® was generally similar to that seen with the first dose.

Post-Marketing Adverse Drug ReactionsThe following additional adverse reactions have been identified during post-marketing use of ZOSTAVAX®. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to the vaccine.

Skin and subcutaneous tissue disorders: rash.Musculoskeletal and connective tissue disorders: arthralgia; myalgia.General disorders and administration site conditions: injection-site rash; injection-site urticaria; pyrexia; injection-site lymphadenopathy.Immune system disorders: hypersensitivity reactions including anaphylactic reactions.

To report a suspected adverse reaction, please contact Merck Canada Inc. by:Toll-free telephone: 1-800-567-2594Toll-free fax: 1-877-428-8675By regular mail: Merck Canada Inc., P.O. Box 1005, Pointe-Claire – Dorval, QC H9R 4P8

DRUG INTERACTIONS

OverviewZOSTAVAX® must not be mixed with any other medicinal product in the same syringe. Other medicinal products must be given as separate injections and at different body sites.

Concurrent administration of ZOSTAVAX® and antiviral medications known to be effective against VZV has not been evaluated.

Use with Other VaccinesZOSTAVAX® and PNEUMOVAX® 23 (pneumococcal vaccine, polyvalent, MSD Std.) should not be given concomitantly because concomitant use resulted in reduced immunogenicity of ZOSTAVAX® (see CLINICAL TRIALS in the product monograph).

DOSAGE AND ADMINISTRATION(see Product Monograph for complete information) Recommended Dose and Dosage Adjustment

FOR SUBCUTANEOUS ADMINISTRATION.

Do not inject intravascularly.

Individuals should receive a single dose consisting of the entire content of the vial (approximately 0.65 mL).

ZOSTAVAX® is not a treatment for zoster or postherpetic neuraligia (PHN). If an individual develops herpes zoster despite vaccination, active current standard of care treatment for herpes zoster should be considered.

At present, the duration of protection after vaccination with ZOSTAVAX® is unknown. In the Shingles Prevention

Study (SPS), protection was demonstrated through 4 years of follow-up. The need for revaccination has not yet been defined.

Reconstitute immediately upon removal from the freezer.

To reconstitute the vaccine, use only the diluent supplied, since it is free of preservatives or other antiviral substances which might inactivate the vaccine virus.

Vial of diluent:To reconstitute the vaccine, first withdraw the entire contents of the diluent vial into a syringe.

To avoid excessive foaming, slowly inject all of the diluent in the syringe into the vial of lyophilized vaccine and gently agitate to mix thoroughly. Withdraw the entire contents into a syringe, and using a new needle, inject the total volume of reconstituted vaccine subcutaneously, preferably into the upper arm - deltoid region.

IT IS RECOMMENDED THAT THE VACCINE BE ADMINISTERED IMMEDIATELY AFTER RECON-STITUTION, TO MINIMIZE LOSS OF POTENCY. DISCARD RECONSTITUTED VACCINE IF IT IS NOT USED WITHIN 30 MINUTES.

Do not freeze reconstituted vaccine.

CAUTION: A sterile syringe free of preservatives, antiseptics, and detergents should be used for each injection and/or reconstitution of ZOSTAVAX® because these substances may inactivate the vaccine virus.

It is important to use a separate sterile needle and syringe for each patient to prevent transfer of infectious agents from one individual to another.

Needles should be disposed of properly.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. ZOSTAVAX® when reconstituted is a semi-hazy to translucent, off white to pale yellow liquid.

OVERDOSAGEThere are no data with regard to overdose.

For management of a suspected drug overdose, contact your regional Poison Control Center.

STORAGE AND STABILITYStorageZOSTAVAX® SHOULD BE STORED FROZEN at an average temperature of -15°C or colder until it is reconstituted for injection (see DOSAGE AND ADMINISTRATION). Any freezer, including frost-free, that has a separate sealed freezer door and reliably maintains an average temperature of -15°C or colder is acceptable for storing ZOSTAVAX®. The diluent should be stored separately at room temperature (20 to 25°C) or in the refrigerator (2 to 8°C). Do not store the diluent in a freezer.

Before reconstitution, protect from light.

DISCARD IF RECONSTITUTED VACCINE IS NOT USED WITHIN 30 MINUTES.

DO NOT FREEZE THE RECONSTITUTED VACCINE.

References:

1. National Advisory Committee on Immunization. Update on varicella. CCDR 2004;30(ACS-1):1-28.

2. Oxman MN. Clinical manifestations of herpes zoster. In: Arvin AM, Gershon AA, editors. Varicella-zoster virus virology and clinical management. Cambridge Press 2000:246-75.

3. Data on file, Merck Canada Inc.: Product Monograph. ZOSTAVAX®, 2011.

Supplemental Product InformationWARNINGS AND PRECAUTIONS

Special Populations

Geriatric: The mean age of subjects enrolled in the largest (N=38,546) clinical study of ZOSTAVAX® was 69 years (range 59-99 years). Of the 19,270 subjects who received ZOSTAVAX®, 10,378 were 60-69 years of age, 7,629 were 70-79 years of age, and 1,263 were 80 years of age or older. ZOSTAVAX® was demonstrated to be generally safe and effective in this population.

Pregnant Women: There are no studies in pregnant women. It is also not known whether ZOSTAVAX® can cause foetal harm when administered to a pregnant woman or can affect reproduction capacity. However naturally-occurring varicella-zoster virus infection is known to sometimes cause foetal harm. Therefore, ZOSTAVAX® should not be administered to pregnant women; furthermore, pregnancy should be avoided for three months following vaccination (see CONTRAINDICATIONS).

Nursing Women: It is not known whether VZV is secreted in human milk. Therefore, because some viruses are secreted in human milk, caution should be exercised if ZOSTAVAX® is administered to a nursing woman.

Pediatrics: ZOSTAVAX® is not recommended for use in this age group.

HIV-AIDS Patients: The safety and efficacy of ZOSTAVAX® have not been established in adults who are known to be infected with HIV with or without evidence of immunosuppression (see CONTRAINDICATIONS).

Immunocompromised Subjects: Data are not available regarding the use of ZOSTAVAX® in immunocompromised subjects (see CONTRAINDICATIONS).

® Registered trademarks Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license.

11-05_139888

VACC-1008558-0000-E-CDN-AUG-12

PRODUCT MONOGRAPH AVAILABLE ATwww.merck.caOR UPON REQUEST AT 1-800-567-2594

Administration

MERCK CANADA INC.P.O. BOX 1005, POINTE-CLAIREDORVAL, QUEBEC H9R 4P8

www.merck.ca

Study References

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ONTARIO MEDICAL REVIEW March 201256

THERAPEUTIC CLASSIFICATIONTopical Antipsoriatic Agent Vitamin D Analogue/Corticosteroid

INDICATIONS AND CLINICAL USEDovobet® ointment is indicated for the topical treatment of psoriasis vulgaris for up to 4 weeks. Dovobet® should not be used on the face.

CONTRAINDICATIONSKnown hypersensitivity to any of the ingredients of Dovobet® ointment; not for ophthalmic use; treatment of viral, fungal or bacterial skin infections, tuberculosis of the skin, syphilitic skin infections, chicken pox, eruptions following vaccinations, and in viral diseases such as herpes simplex, varicella and vaccinia.

WARNINGS AND PRECAUTIONSGeneralIf Dovobet® is used in excess of the maximum recommended weekly amount of 100 g, it is important to monitor the serum calcium levels at regular intervals due to the risk of hypercalcaemia secondary to excessive absorption of calcipotriol. If the serum calcium level becomes elevated, therapy should be discontinued and the serum calcium level monitored until it returns to normal.

SkinDovobet® should not be used on the face since this may give rise to itching and erythema of the facial skin. Patients should be instructed to wash their hands after each application of Dovobet® in order to avoid inadvertent transfer to the face. Should facial dermatitis develop in spite of these precautions, Dovobet® therapy should be discontinued.Prolonged use of corticosteroid-containing preparations may produce striae or atrophy of the skin or subcutaneous tissues. Therefore, it is recommended that corticosteroid treatment be interrupted periodically, and that one area of the body be treated at a time. Topical corticosteroids should be used with caution on lesions of the face, groin and axillae as these areas are more prone to atrophic changes than other areas of the body. If skin atrophy occurs, discontinue treatment. There may be a risk of rebound psoriasis when discontinuing corticosteroids after prolonged periods of use.

CarcinogenesisCalcipotriol when used in combination with ultraviolet radiation (UVR) may enhance the known skin carcinogenic effect of UVR. (See TOXICOLOGY, Carcinogenicity, in the Product Monograph).

Endocrine and MetabolismApplication on large areas of damaged skin, under occlusive dressings, or in skin folds should be avoided since it increases systemic absorption of corticosteroids and the risk of adverse effects such as adrenal suppression with the potential for glucocorticosteroid insufficiency after withdrawal of treatment. Manifestations of Cushing’s syndrome, hyperglycaemia and glucosuria can also be produced in some patients by systemic absorption of topical corticosteroids. Occlusive dressings should not be applied if body temperature is elevated. All of the adverse effects associated with systemic use of corticosteroids, including adrenal suppression, may also occur following topical administration of corticosteroid-containing products such as Dovobet®, especially in children.

SPECIAL POPULATIONSPregnant Women: The safety of calcipotriol and/or topical corticosteroids for use during pregnancy has not been established. The use of Dovobet® is not recommended in pregnant women.

Nursing Women: The safety of calcipotriol and/or topical corticosteroids for use in nursing women has not been established. The use of Dovobet® is not recommended in nursing women. Pediatrics (<18 years of age): There is no clinical trial experience with the use of Dovobet® in children. Children may demonstrate greater susceptibility to systemic steroid-related adverse effects due to a larger skin surface area to body weight ratio as compared to adults.

MONITORING AND LABORATORY TESTSTreatment with Dovobet® in the recommended amounts does not generally result in changes in laboratory values. In patients at risk for hypercalcaemia it is recommended that baseline serum calcium levels be obtained before starting treatment with subsequent monitoring of serum calcium levels at suitable intervals.

ADVERSE REACTIONSIn clinical trials, the most common adverse reaction associated with Dovobet® was pruritus. Pruritus was usually mild and no patients were withdrawn from treatment. Calcipotriol is associated with local reactions such as transient lesional and perilesional irritation. Topical corticosteroids can cause the same spectrum of adverse effects associated with systemic steroid administration, including adrenal suppression. Adverse effects associated with topical corticosteroids are generally local and include: dryness, itching, burning, local irritation, striae, atrophy of the skin or subcutaneous tissues, telangiectasia, hypertrichosis, folliculitis, skin hypopigmentation, allergic contact dermatitis, maceration of the skin, miliaria, or secondary infection. If applied to the face, acne rosacea or perioral dermatitis can occur. In addition, there are reports of the development of pustular psoriasis from chronic plaque psoriasis following reduction or discontinuation of potent topical corticosteroid products.Rare cases of hypersensitivity reaction have been reported.To report an adverse reaction please notify Health Canada at 1-866-234-2345 or LEO Pharma Inc. at 1-800-263-4218.

DRUG INTERACTIONSThere is no experience of concomitant therapy with other antipsoriatic drugs.

Dosing ConsiderationsDovobet® is FOR TOPICAL USE ONLY. Not for ophthalmic use. There is no clinical trial experience with the use of Dovobet® in children.

Recommended Dose and Dosage AdjustmentDovobet® should be applied topically to the affected areas once daily for up to 4 weeks. After satisfactory improvement has occurred, the drug can be discontinued. If recurrence takes place after discontinuation, treatment may be reinstituted.

The maximum recommended adult dose of Dovobet® ointment is 100 g per week.

SUPPLEMENTAL PRODUCT INFORMATION

SUPPLEMENTAL SAFETY INFORMATION

Missed DoseIf a dose is missed, the patient should apply Dovobet® as soon as he/she remembers and then continue on as usual.

OverdosageDue to the calcipotriol component of Dovobet® (calcipotriol and betamethasone dipropionate), excessive administration (i.e. more than the recommended weekly amount of 100 g) may cause elevated serum calcium, which rapidly subsides when treatment is discontinued. In such cases, it is recommended to monitor serum calcium levels once weekly until they return to normal. Excessive or prolonged use of topical corticoster-oids can suppress pituitary-adrenal function, resulting in secondary adrenal insufficiency and manifestations of hypercorticoidism, including Cushing’s disease. Recovery is usually prompt and complete upon steroid discontinuation. In cases of chronic toxicity, slow withdrawal of corticosteroids is recommended.

For further information, please contact Medical Information at LEO Pharma Inc. 1-800-263-4218. ® Registered trademark of LEO Pharma A/S used under license and distributed by LEO Pharma Inc., Thornhill, ON.

Patient Selection Criteria

Prescribing Summary

Safety Information

Administration

LEO Pharma Inc. Thornhill, Ontario L3T 7W8 www.leo-pharma.com/canada

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ONTARIO MEDICAL REVIEW March 201257

THERAPEUTIC CLASSIFICATIONTopical Antisporiatic Agent Vitamin D Analogue/Corticosteroid.

INDICATIONS AND CLINICAL USEXamiol® (calcipotriol and betamethasone dipropionate) gel is indicated for the topical treatment of moderate to severe scalp psoriasis for up to 4 weeks.

CONTRAINDICATIONSKnown hypersensitivity to Xamiol® (calcipotriol and betamethasone dipropionate) or any ingredient; ophthalmic use; patient with known disorders of calcium metabolism; viral lesions of the skin; fungal or bacterial skin infections; parasitic infections; skin manifestations in relation to tuberculosis or syphilis; perioral dermatitis, atrophic skin; striae atrophicae; fragility of skin veins; ichthyosis; vulgaris and rosacea acne; rosacea; ulcers and wounds; guttate, erythrodermic, exfoliative and pustular psoriasis; severe renal insufficiency or severe hepatic disorders.

WARNINGS AND PRECAUTIONSGeneralDue to the content of calcipotriol, hypercalcaemia may occur if the maximum weekly dose (100 g) is exceeded. Serum calcium is quickly normalized when treatment is discontinued. The risk of hypercalcaemia is minimal at recommended dosing.

CarcinogenesisCalcipotriol when used in combination with ultraviolet radiation (UVR) may enhance the known skin carcinogenic effect of UVR.

Endocrine and MetabolismXamiol® contains a potent group III steroid and concurrent treatment with other steroids on the scalp must be avoided. Application on large areas of broken skin or under occlusive dressings should be avoided since it increases systemic absorption of corticosteroids; adverse effects such as adrenocortical suppression with the potential for glucocorticosteroid insufficiency after withdrawal of treatment; manifestations of Cushing’s syndrome, and affects on the metabolic control of diabetes mellitus can also be produced in some patients by systemic absorption of topical corticosteroids.

SkinFacial skin is very sensitive to corticosteroids and Xamiol® is not indicated for use in this area. The patients must wash their hands after each application to avoid accidental transfer to the face, mouth and eyes. If facial dermatitis or corticosteroid related adverse effects develop, Xamiol® should be discontinued. There may be a risk of generalised pustular psoriasis or of rebound psoriasis when discontinuing corticosteroids after prolonged periods of use. Patients who apply Xamiol® to exposed skin (e.g. a bald scalp) should avoid both natural and artificial sunlight.

SPECIAL POPULATIONSPregnant Women: The safety of calcipotriol and/or topical corticosteroids for use during pregnancy has not been established. The use of Xamiol® is not recommended in pregnant women.Nursing Women: The safety of calcipotriol and/or topical corticosteroids for use in nursing women has not been established. The use of Xamiol® is not recommended in nursing women. Pediatrics (<18 years of age): There is no clinical trial experience with the use of Xamiol® in children, use is therefore not recommended. Children may demonstrate greater susceptibility to systemic steroid related adverse effects due to a larger skin surface area to body weight ratio as compared to adults.

MONITORING AND LABORATORY TESTSIn patients at risk of hypercalcaemia, it is recommended that baseline serum

calcium levels be obtained before starting treatment and subsequent monitoring of serum calcium levels at suitable intervals. (see OVERDOSAGE)

ADVERSE REACTIONSApproximately 8% of patients treated with Xamiol® experienced an adverse reaction. Based on data from clinical trials, the most common adverse reaction is pruritus. The following adverse reactions led to discontinuation of the treatment with Xamiol® in 0.1-0.2% of patients: pruritus, skin pain or irritation, dermatitis, eye irritation, rash, burning sensation, face oedema, folliculitis and dry skin. Other adverse reactions were observed for the individual drug substances calcipotriol and betamethasone dipropionate. Systemic effects due to topical use of corticosteroids in adults occur infrequently but can be severe. To report an adverse reaction please notify Health Canada at 1-866-234-2345 or LEO Pharma Inc. at 1-800-263-4218.

DRUG INTERACTIONSThere is no experience of concomitant therapy with other anti psoriatic drugs.

Dosing ConsiderationsXamiol® (calcipotriol and betamethasone dipropionate) is not recommended for use in patients below the age of 18 years. Xamiol® is FOR TOPICAL USE ONLY and not for ophthalmic use.Xamiol® should be applied to affected areas of the scalp once daily for up to 4 weeks. After satisfactory improvement has occurred, the drug can be discontinued. If recurrence takes place after discontinuation, treatment may be reinstituted. The maximum daily dose including other calcipotriol-containing products on the body should not exceed 15 g and the maximum weekly dose should not exceed 100 g. If a dose is missed, the patient should apply Xamiol® when remembered, but only once a day and then continue on as usual.

SUPPLEMENTAL PRODUCT INFORMATIONADVERSE REACTIONSTwo pivotal and 4 supporting controlled clinical studies were conducted in scalp psoriasis. The incidence of patients with at least one ADR was lowest in the Xamiol® gel group.

Table 1. Adverse Drug Reactions Occurring in 1% of Patients for the Pivotal Scalp Studies: safety analysis set

Detailed and/or summarized report

Xamiol® gel (n=1093)

Betamethasone gel

(n=1104)

Calcipotriol gel (n=548)

Gel vehicle (n=135)

Primary System Organ Class1

Preferred Term1

Number of

Patients%

Number of

Patients%

Number of

Patients%

Number of

Patients%

Nervous system disorders

Headache 6 0.5 11 1.0 1 0.2 1 0.7

Burning sensation 2 0.2 6 0.5 10 1.8 0 0.0

Skin and subcutaneous tissue disorders

Pruritus 25 2.3 18 1.6 45 8.2 7 5.2 Skin irritation 5 0.5 5 0.5 15 2.7 3 2.2

Alopecia 4 0.4 6 0.5 3 0.5 2 1.5

Erythema 4 0.4 4 0.4 16 2.9 1 0.7 Dry skin 1 0.1 3 0.3 6 1.1 0 0.0

General disorders and administration site conditions

Pain 1 0.1 0 0.0 3 0.5 3 2.21Coded according to MedDRA version 6.1

OVERDOSAGE:Use of Xamiol® (calcipotriol and betamethasone dipropionate) above the recommended dose may cause elevated serum calcium which should rapidly subside when treatment is discontinued. In such cases, it is recommended to monitor serum calcium levels once weekly until they return to normal. Excessive prolonged use of topical corticosteroids may suppress the pituitary-adrenal functions, resulting in secondary adrenal insufficiency which is usually reversible. If this occurs, symptomatic treatment is indicated. In cases of chronic toxicity, treatment with Xamiol® must be discontinued gradually.

® Registered trademark of LEO Pharma A/S used under license by LEO Pharma Inc., Thornhill, ON.

Full Product Monograph available on request by contacting LEO Pharma Inc. at 1-800-263-4218.

50 mcg/g calcipotriol (as monohydrate) and 0.5 mg/g betamethasone (as dipropionate) gel

Prescribing Summary

Patient Selection Criteria

Safety Information

Administration

LEO Pharma Inc. Thornhill, Ontario L3T 7W8 www.leo-pharma.com/canada

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ONTARIO MEDICAL REVIEW

OFFICE SPACE AVAILABLE

Bayview and Elgin Mills: New medical space available with Shoppers Drug Mart within property. Leasehold improve-ments and rent subsidy available.Contact: LorraineTel. 905.882.2320

Beautiful workplace setting in the heart of Thornhill: Lots of natural light and latest equipment, EMR in every room. Passionate, well-trained staff of nurses, medical assistants, students and administrators are ready to serve you and make your transition smooth and stress-free. We are interested in friendly physicians who are dedicated to delivering excellent patient care. Oppor-tunity for family doctor, pediatrician or OB/GYN entry into our lucrative practice with competitive split. Tel. 416.670.7393Email: [email protected]

Boxgrove Medical Centre — now open: Four-storey, 60,000 sq. ft. medical building located at the 9th Line and Highway 407. Prime medical space available for lease. X-ray, lab, rehab and urgent care on-site. Contact: HowardTel. 416.357.7509

Brampton — looking for general prac-titioner for busy family practice/walk-in clinic. Retiring physicians/IMG welcome. Supervision available. Excellent split.Tel. 647.278.5358Email: [email protected]

Mississauga — excellent medical office for family physicians: Fully furnished, recently renovated suites with private underground free parking. Units have 3-6 spacious exam rooms, private reception and common patient waiting area. Great location inside a medical centre, close to Credit Valley & Trillium hospitals in a dense residential and commercial area near Square One. Lab services and pharmacy on-site. Low rent and relocation incentives. Tel. 416.587.9430

Oakville professional medical building: Steps to Oakville Trafalgar Memorial. 2,671 sq. ft. can divide 1,298/1,373 sq. ft. Improvements available to suit needs. All floors serviced by elevator. Private doctor parking. Free patient parking. Highway access, public transportation. Contact: Nat Assenza, Real Estate Sales Rep, Royal LePage Your Community RealtyTel. 905.832.6656Email: [email protected]

Opportunity for general practitioner or specialist (F/T, P/T) in a new modern dental/medical multispecialty practice located in central Mississauga. Contact: Elaine Tel. 905.270.5112Email: [email protected]

Ottawa — medical office space for lease: Three months free rent, near Hunt Club and Merivale. Newly built medical centre, space already set up and avai lable for immediate occu-pancy, ground floor, beautiful working environment, 2,200 sq. ft. (can be divided 900/1,300 sq. ft.).Contact: Dominic Dostie, Real Estate Broker, CBRE Ltd.Tel. 613.751.2874Email: [email protected]

PAR-Med Realty Ltd.: Specializing in medical office building leasing, property management, and building sales. We have over 70 medical office buildings in our portfolio throughout Ontario. For leasing inquiries:Contact: Brad StoneburghTel. 416.364.5959, ext. 403Email: [email protected]: www.par-med.com

58 March 2012

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I S S U E D E A D L I N E

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credit card information by phone only to Vita

Ferrante 416.340.2263 or 1.800.268.7215,

ext. 2263, at time of booking.

Rates: $50 for first 4 lines (minimum), each line

approximately 35 characters; $5 per line there-

after; $5 for each line of contact information.

Spot colour billed at $20 per issue.

Send advertisements to:

Vita Ferrante

Ontario Medical Association

150 Bloor Street West

Suite 900

Toronto, Ontario M5S 3C1

Tel. 1.800.268.7215, ext. 2263 or

416.340.2263

Fax: 416.340.2232

Email: [email protected]

The Ontario Medical Review is required to com-

ply with the provisions of the Ontario Human

Rights Code 1990 in its editorial and advertis-

ing policies, and assumes no responsibility or

endorses any claims or representation offered

or expressed by advertisers.

Added Value

Classified ads are posted online and acces-

sible to OMA members and the general public:

https://www.oma.org/Pages/OMR.aspxA Classified Advertisement Insertion Order

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ONTARIO MEDICAL REVIEW

Pickering medical building — two suites available of 835 sq. ft. and 1,186 sq. ft. Price starts at $2,196 all inclusive. Available now. Central and busy. Contact: Donald Lesley, BrokerRE/MAX First Realty Ltd., BrokerageTel. 416.798.7288Email: [email protected]

Psychiatrist to share office suite: Spacious office, shared waiting room. Yonge and St. Clair, Toronto. Contact: Dr. Joseph Feldmann Tel. 416.961.2282Email: [email protected]

Psychotherapy offices available — full time & part time: Furnished. Full-time office manager on-site 8 am-5 pm. Evening hours available. Internet and telephone included.Contact: Dr. Kasra KhorasaniTel. 416.627.4590Email: [email protected]

Scarborough — space available in a medical building: Located at Eglinton and McCowan. Ideal for family physi-cians. Fully renovated and ready to move in with physiotherapy clinic and spa on property. Pharmacy to come. Available 500-2,000 sq. ft. Ample free parking. TTC & GO Train within walking distance. Dense residential area. Basic rent and no TMI.Email: [email protected]

Special rent for qualified tenants: Furnished, turnkey medical off ice opportunity in Toronto. Up to eight exam rooms available. Tel. 416.564.7585Email: [email protected]

Start your practice in Markham! New medical clinic in retail plaza with T&T supermarket, Hwy. 7 & Kennedy Rd. Next to upscale downtown Markham. Ground floor, 1,500 sq. ft., experienced staff.Contact: Dr. Shawn SeitTel. 416.617.2883

Steeles/York University: Golden opportunity for a new medical centre. X-ray, laboratory, walk-in clinic, 5,150 sq. ft. corner unit in a busy plaza with ample parking, TTC service, fronting on Steeles. Reasonable rent. Contact: Dan Tel. 416.629.7799

We have an opening for family phy-sician/clinical investigator with Con-solidated Clinical Research of Canada, Mississauga, Ontario. Looking for an MD interested in opening a new family practice and also conducting clinical trials. Medical office available shortly. Setting up the conduct of clinical trials in diabetes and pain management. Cl in ical research co-ordinator and required systems provided. All interested individuals, please contact us.Contact: George E. Markus, M.Sc.President, Consolidated ClinicalResearch of CanadaTel. 416.873.1836 (cell)Email: [email protected]

59 March 2012

Classifieds

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ONTARIO MEDICAL REVIEW

Yonge/Lawrence medical office with parking at TTC. See website for photos.Tel. 416.357.8530Website: http://viewitbiz.ca/2916

LOCUM TENENS

Two full-time locums needed in May and in July to cover for maternity leaves. Instant full practice in the big FHG, congenial colleagues, extremely busy, fully EMR. Full time available after the locum.Contact: Dr. Thomas VanTel. 647.227.5088Email: [email protected]

REAL ESTATE

Collingwood, 43 acre estate on Blue Mountain: Four-bedroom chalet-style house, pond, Silver Creek with spawn-ing trout, 18 stall barn, arena. Permit for second residence pending. Spec-tacular view of Georgian Bay. Use as is or build your dream home. Tel. 416.520.9274

Disney/Orlando real estate, former Ontario resident. Contact: Kathy JaworskiExit Realty Cozy HomesEmail: [email protected]

Realty engineer: Over 20 years help-ing the medical community engineer their real estate portfolios. Investment, office leasing/sales or residential.Contact: Itamar Teich, B.Eng., MBAReal Estate Sales RepresentativeRe/Max Realtron Realty Inc., BrokerageTel. 905.764.6000, Cell: 416.823.8735Email: [email protected]

POSITIONS WANTED

Family physician looking to either share office, to take over existing practice, or replace retiring physician in Toronto (North York or Scarbor-ough).Email: [email protected]

Two qualified and licensed physi-cians are looking for work opportu-nities in methadone clinics. Willing to travel from northern GTA up to Sudbury.Email: [email protected]

POSITIONS VACANT

70:30 split or better: South Ottawa. Family medicine or specialists. Flexible schedule, full EMR, excellent nursing and resident support, full time, part time or locum, and opportunity of joining FHO. Enjoy life, earn a phenomenal wage, get home for a hot meal and stop fretting about stuff! Let us do all the administrative work. Contact: FaizaTel. 613.692.5433Email: [email protected]

$200/hour: GP required immediately at Mississauga outpatient clinic. Hours: 8 a.m. to 11 p.m. seven days a week.Contact: AngelaTel. 905.272.5200

$250 per hour minimum: Pediatrician, internist, surgeon, subspecialist in busy outpatient clinic in Mississauga.Contact: Dr. SteinTel. 416.464.0238

Brampton, Ontario: F/T, P/T family physicians & specialists required for a very busy family practice/walk-in clinic.Very modern and computerized exam rooms, paperless, attractive split, guar-anteed number of patients per hour and guaranteed income available.Contact: WilliamTel. 647.627.4170Email: [email protected]

Brampton, Ontario: Full-time/part-time family physicians and GP psy -cho thera pist required for busy family pract ice/walk- in cl in ic. Attract ive modern office. Option to join FHG. High fee-for-service split or flat monthly rate. Best EMR.Tel. 416.949.3830Fax: 647.340.2586Email: [email protected]

Busy walk-in clinic in Brampton looking for doctors (F/T, P/T). All office expenses covered. Experienced and competent staff. Excellent split offered. Great hours. Contact: [email protected]

C-era (Cardiometabolic Evaluation and Risk Assessment) in Calgary is seeking a F/T general internist, endocrinologist or cardiologist (pref-erably with echo training) to join our team. We offer an exceptional lifestyle, excellent remuneration, opportunity for clinical stimulations and continued growth and engagement as part of a multidisciplinary team.Contact: Dr. A. Nanji, Medical DirectorTel. 403.209.1115Fax: 403.541.0073Email: [email protected]: www.c-era.com

Clinics in St. Catharines require the following: 1) Retired physician required who is registered with the College of Physicians and Surgeons of Ontario (CPSO) to work in a St. Catharines clinic three to five hours per day pro-viding supervision of nurses in a low- stress environment. The hourly pay is $80. 2) Physician registered with the CPSO required to join existing walk-in clinic which pays 80 per cent split in St. Catharines. Close proximity to lab and X-ray facilities. 3) Physician regis-tered with the CPSO to join a group that is opening a walk-in clinic, 80 per cent split in Niagara area. 4) Family physician or specialist registered with the CPSO to share space in a medical building in St. Catharines. Lots of free parking, each room has its own sink, shared waiting room, eight private offices, newly renovated, located near hospital. Please email interest and resumé.Email: [email protected]

Davisville/Yonge — busy family/walk-in clinic seek part-time/full-time MD, FHG. Very convenient location.Contact: Dr. Liang Tel. 647.776.8433Email: [email protected]

Dermatologist and psychiatr ist required for a group of 14 GPs with a huge population base. Extremely busy, EMR and PACS, great income low overhead. Contact: Dr. Thomas Van Tel. 647.227.5088Email: [email protected]

60 March 2012

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ONTARIO MEDICAL REVIEW

Downsview, Ontar io: Paper less computerized new clinic in a medical building with pharmacy, lab and X-ray. No set-up cost. Part time or full time. Move existing practice or bui ld up from walk-in clinic. Support staff for EKGs, PFTs, venipuncture for income supplement. Contact: Mr. SamuelTel. 647.400.0401

Downtown, Toronto — physician required at mental health cl inic specializing in integrated assessment and treatment of ADHD individuals and families across the lifespan. Staff at present includes professionals in medicine, health education, psychol-ogy, and counseling. Part time, full time and locum hours available.Contact: LaurenTel. 416.901.3077Email: [email protected]

Downtown Toronto — Yonge and College new medical office: Close to many hospitals. High traffic, high vis-ibility. New, fully equipped medical office in busiest part of Yonge St., 13 exam rooms, plus three offices. EMR or paper, P/T, F/T, one of many GPs. Move ex-isting practice or build up from walk-in clinic. Very attractive split or flat rent.Contact: DavidTel. 416.895.4745Email: [email protected]

Endocrine clinic at Yonge and Eglinton: Available to share with another endo-crinologist or internist. It is a newly set-up specialty clinic, located at a busy and diversified area in Toronto with nearby medical support facilities. It has indoor parking, across from Eglinton subway.Contact: ViVienTel. 416.481.7720Email: [email protected]

Exceptional practice opportunity available in an attractive mid-western Ontario city – university city, good schools, parks and recreational facili-ties. Immediate possession of well-established family practice (FHO billing format) progressing to FHT format. Excellent income, very low overhead, unique and attractive practice loca-tion, wonderful staff with opportunity for diversification into non-OHIP billing opportunities. Email: [email protected]

Family and walk-in doctor: Locum/part time/full time. Instant full practice. Extremely busy! Congenial colleagues and low overhead. EMR, FHG, partner-ship option, >700K billing for a five-day work week. Contact: Thomas VanTel. 647.227.5088Email: [email protected]

Family and walk-in physicians needed in Thornhill, Ontario: Great patient population. Eight fully equipped modern and spacious exam rooms. Specialists & new grads welcome. No financial investment. Flexible hours. IMG super-vision available.Tel. 416.305.4269 or 416.823.4750Email: [email protected]

Full-time or part-time medical doctors required for a busy walk-in located in downtown Mississauga. Contact: AdelTel. 416.904.2929 or 905.897.6160 (office)

GP and specialists are needed for a very busy clinic in Mississauga.Contact: EvaTel. 647.291.1489Email: [email protected]

Internal medicine and/or subspecial-ties required immediately for outpa-tient coverage in Mississauga. FT/PT/locum. No on-call. Top take-home pay.Contact: Dr. SekelyTel. 416.464.0238

London, Ontario: Full time/part time. Anesthesiologists or any other doctors that have experience treating chronic pain. The London Pain Institute is a reputable, soon to be open, pain man-agement facility with a passion for ex-cellence. Is seeking to fill the position of anesthesiologist and chronic pain specialists for our London location. As a team member, the successful candi-date will be responsible for designing and implementing pain management protocols or performing a variety of procedures, including epidural steroid injections, facet joint blocks, para-vert-ibal blocks, trigger point injections, and other nerve blocks. We offer you: flex-ible weekday hours, stimulating work environment, the chance to join a team in making a positive difference. Com-pensation: excellent/negotiable.Fax: 416.941.7933

Email: [email protected] [email protected]

Looking for family physicians (F/T, P/T) for busy family practice/walk-in medi-cal clinics in Scarborough, Markham, Keswick, Cambridge, Mississauga and Welland. Excellent split or salary. Contact: AntoniaTel. 416.949.9373 Email: [email protected]

Looking immediately for general practitioner (F/T, P/T), split or minimum. Guaranteed for Clarkson Medical Clinic. Located on a busy residential area in Mis-sissauga/Oakville. For details, please call.Tel. 416.219.3191

Medical Psychotherapy Clinic: Over the last eight months we have expanded our clinic twice. We must be doing something right! Physicians needed — enjoy medicine more — enjoy medicine again! If you have an interest in this im-portant clinical area. We would like you to join our busy clinic. We need fam-ily doctors, GPs, GP psychotherapists, psychiatrists, semi-retired, part time or full time. We are open weekends and weeknights. We provide comfortable offices, professional staff, excellent f inancial arrangements, professional supervision, and CME programs are available.Contact: Dr. Michael ParéWebsite: www.medicalpsychclinic.org

MedVisit Doctors Housecall Service: Greater Toronto or Ottawa. P/T or F/T. Net income $250/hour + bonus. Afternoon, evening or weekend shifts. No overnight call. Drivers available to accompany physician on calls.Contact: Dr. Tom Burko Tel. 416.631.0298 or 1.800.355.6668Email: [email protected] Website: www.medvisit.ca/doctors

Milton — shifts available in a very busy walk-in/family clinic.Tel. 905.864.9898Email: [email protected]

Mississauga, ON: Shifts available in a busy well-established walk-in/family clinic. We welcome new graduates. Clinic also needs a dermatologist.Tel. 416.995.1600 Email: [email protected]

61 March 2012

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ONTARIO MEDICAL REVIEW

NR medical clinic is a multidisci-plinary medical clinic looking to have onboard fully licensed family physi-cians, cardiologists, and other special-ists. The posting is for temporary to permanent positions. EMR, EKG, and support staff. Start date is April 1, 2012. Location: 1250 Castlemore Ave., Unit #1, Markham, ON L6E 0H7. Flexible hours: Monday to Friday, 9 a.m.-5 p.m., Saturday, 10 a.m.-3 p.m.Contact: Naheed RizviTel. 905.201.7770Email: [email protected]: www.nrmedicalclinic.com

Pain physicians — The Jacobs Pain Centre is seeking pain medicine physicians to join a dynamic team of physicians. The clinic is an interven-tional pain clinic certified by the CPSO. Training will also be offered to suitable candidates who may be interested in changing their scope of practice. For further information, please call.Contact: Dr. Howard JacobsMedical DirectorTel. 905.305.9484

OB/GYN — busy office practice: Toronto downtown. Flexible hours, locum or for sale. Three exam rooms, Ritter tables, two ultrasound machines, colposcopy, cryotherapy, LEEP. Ideal for new grads, semi-retired gynecol-ogist. Tel. 416.923.7311Fax: 416.923.1287Email: [email protected]

Opportunity in Richmond Hil l & midtown Toronto, Ontario: Wel l-established family practice seeking physician full time or part time. Walk-in shifts also available. No financial commitments, clinics are fully EMR integrated (EMR training included). On-site lab. Above-average compen-sation package. Tel. 416.709.8876Email: [email protected], [email protected]

Ottawa — central/east: Sunshine Medical Clinic is expanding and looking for physicians of all specialties. Join us. Low overhead. Best EMR.Tel. 613.695.9001 Email: [email protected]

Ottawa — family medicine: Full-time or part-time positions available in an attractive building in a beautiful new community. Free parking. Contact: Dr. AshikianTel. 613.822.0171 (9 a.m. to noon, or 1 p.m. to 3 p.m., Monday to Friday)Fax: 613.822.1838Email: [email protected]

Psychiatrists, medical psychothera-pists are needed at a busy private mental health clinic. Turnkey office. Support available as needed.Tel. 416.778.1496

Richmond Hill, Ontario: Richmond Hill After-Hours Clinic requires phy sicians for daytime shifts 9 a.m. to 5 p.m., as well as evenings and weekends. Guaranteed minimum 70:30 split. Con tact: Dr. Ian ZatzmanTel. 905.884.7711Fax: 905.553.5360Email: [email protected]

Scarborough and North York Loblaws Superstores: Busy, expanded walk-in clinics/family practice located inside Loblaws seeking family physicians, pediatrician and specialists. Physi-cians required for walk-in shifts as well as opportunity to relocate an existing practice or build a new practice. Flex-ible hours and very attractive split. Tel. 647.206.0790

Scarborough, Ontario: F/T, P/T family physicians required for medical clinic serving mainly Cantonese and Manda-rin-speaking seniors. Open to public. Pharmacy on-site.Contact: Martin ChaiTel. 416.299.0555, ext. 12Email: [email protected]

Specialists — Brampton, Ontario: Dermatologist, pediatrician, internist, and psychiatrist required for medical centre with several GPs and large pa tient base. Attractive modern office with seven days/week reception service. Fee-for-service split or low flat monthly rate. Tel. 416.949.3830Fax: 647.340.2586Email: [email protected]

Stouffville Family Health Centre: Opening 2012. Connected to a large daycare. Ideal for pediatrician/primary care physician. North of Stouffville Road, on 10th Line. If interested now, would have choice of square footage/design. Varying attractive inducement options available. Fulfils OMA rural requirement.Contact: SarahTel. 905.479.2571

Thornhill/Brampton, ON: F/T, P/T family physicians required for family practice/walk-in clinic. New graduates welcome. Attractive modern office. Option to join FHG. Guaranteed 70:30 split.Contact: Jenny A.Tel. 905.731.5707Email: [email protected]

Vaughan, Jane and Rutherford — new clinic in a medical building. Part time or full time GPs needed. No set-up cost, move existing practice or build up from walk-in clinic. Contact: Mr. SamuelTel. 647.400.0401

West end Ottawa — supportive group of four family physicians looking for a fifth physician to join us. New 2,500 sq. ft. clinic to be completed for November 2012. Payment structure is that of a FHO. Looking for an associate to be an equal member of the FHO. EMR based. Competitive overhead.Contact: Nisha SoniTel. 613.719.7774Email: [email protected]

PRACTICES

Dawson Road Family Medical Clinic: Guelph FHT/FHO clinic accepting two GPs. Supported by NPs, nurse clini-cians, counselors, IT, EMR. Full admin. Progressive collaborative environment. Outstanding opportunity.Contact: KevinEmail: [email protected]

Looking for family physician to take over existing full practice. Clinic has lab, four exam rooms. Existing MD closing practice due to illness. Missis-sauga, Ontario — walking distance from Square One. Free.Contact: Sharmil MithiaTel. 416.624.8318

62 March 2012

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ONTARIO MEDICAL REVIEW 63 March 2011

Classifieds

Need family physician to take over an established practice. English/Chinese speaking preferred. GTA location.Email: [email protected]

Practice for sale — turnkey: Great GTA location. Modern, bright medical office. Close proximity to hospitals. Minutes from major highways. Easy access, ample parking.Tel. 416.888.1362

SERVICES AVAILABLE

Arya & Sher, health lawyers: Prac-tice focused on representing medical practitioners, clinics, hospitals, and health-care companies. Business and regulatory issues, including profes-sional incorporations, business reg-istrations, contracts, partnership/shareholder issues, tax and estate planning, employment, leasing, medi-cal real estate, and regulatory matters. Contact: Kashif Sher, LLB, MBATel. 416.218.8373Email: [email protected]: www.aryasher.com

Bil l ing agent — electronic data transfer to MOHLTC for all practices, specialties and locums. Medical Billing and Secretarial Services.Contact: Edith ErdelyiTel. 416.576.6788

Experience and knowledge matter: Insurance broker specializing in disabil-ity and life insurance, financial/retirement planning and planned giving programs for sole practitioners and professional cor-porations. Dedicated to giving high-qual-ity and personalized service since 1986.Contact: James Corrigan, RHU, CLUTel. 866.235.1754, ext. 23Website: www.thelivingbenefitsgroup.com

Free record storage for closing practices: RSRS is Canada’s leading paper and digital storage provider. No prohibitive fees to patients. Physician managed since 1997.Tel. 1.888.563.3732, ext. 221 Website: www.RSRS.com

Going EMR? Need to scan your pa tient records? We can find you an affordable solution that fits your budget. For more information and many references:Contact: Sid Soil, DOCUdavit SolutionsTel. 1.888.781.9083, ext. 105Email: [email protected]

MedBill — for all your billing needs: Accepting new clients. All specialties. Over 20 years of billing experience. Reasonab le ra tes . Now o f fe r ing “MedBill Mobile” service.Tel. 416.906.1434Email: [email protected]: www.medbill.ca

Medical Billing Clerks: Getting you paid — on time, every time! Professional and efficient. Specializing in OHIP and all other types of medical claims sub-mission in all practice areas. Reasonable rates. Contact us today to get your billings underway.Contact: KamiTel: 416.888.6076Email: [email protected]

Medical Transcription Services: Telephone dictation and digital recorder f i les. PIPEDA compliant; excel lent quality, next business day service. All specialties, patient notes, letters, reports, including medical-legal and IME reports.Tel. 416.503.4003 or 1.866.503.4003Website: www.2ascribe.com

Moving or moved to EMR? Still have lots of paper? RSRS scans your re-cords and offers full electronic access to your active patient records. It’s easier than you think. PHIPA compliant. Contact: RSRS Tel. 1.888.563.3732, ext. 221 Website: www.RSRS.com

Retiring, moving or closing your practice? Physician’s estate? DOCU-davit Medical Solu tions provides free paper or electronic patient record storage with no hidden costs. Contact: Sid Soil, DOCUdavit SolutionsTel. 1.888.781.9083, ext. 105Email: [email protected]

UPCOMING EVENTS

Disney Wonder Alaska Cruise: Psy-chiatry Review Course CME, July 9-16, 2012: Join us for an unforget-table experience as only Disney can provide aboard the elegant Disney Wonder cruise ship, sailing to spec-tacular Alaska. Great for adults and children alike. Companion cruises free.Tel. 647.882.1427Email: [email protected]: www.psychiatryreviewcourse.com

Publisher’s Notes (continued from page 5)

REPRINTING OF ARTICLES

Material in the Ontario Medical Review

may not be reproduced in whole or in

part without the express written permis-

sion of the Ontario Medical Association.

Requests for reprinting or use of articles

should be forwarded in writing to the

OMA c/o the Editor.

SUBSCRIPTION RATES

The Ontario Medical Review is

distributed to all members of the

Ontario Medical Association.

Others may subscribe to the Review

at the following rates: in Canada $55;

in the United States $62; in other

countries $79 (Canadian funds).

Single copies are $6, back issues $7.

HST applicable.

DISPLAY ADVERTISING

Current display advertising rate card,

effective January 1, 2012, available

on request.

Advertising representative:

Marg Churchill

Keith Communications Inc.

1599 Hurontario Street, Unit 301

Mississauga, Ontario L5G 4S1

Tel. 905.278.6700 / 1.800.661.5004

Fax: 905.278.4850

Email: [email protected]

CLASSIFIEDS ADVERTISING

Classifieds advertising inquiries should

be directed to:

Vita Ferrante

Tel. 416.340.2263 / 1.800.268.7215,

ext. 2263, Fax: 416.340.2232

Email: [email protected]

The Ontario Medical Review is required to

comply with the provisions of the Ontario

Human Rights Code 1990 in its editorial

and advertising policies, and assumes no

responsibility or endorses any claims or

representation offered or expressed by

advertisers. The Ontario Medical Review

urges readers to investigate thoroughly

any opportunities advertised.

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Advertisers’ Index

Arya & Sher Health Lawyers ................ 35

AstraZeneca .................................... OBC

Bell Canada ........................................... 4

CME at Sea ......................................... 59

Hamilton Medical Walk-In Clinic ........... 42

Klinix Software Inc .............................. IFC

Leo Pharma.................................... 14,15

Manjog Holding Inc.............................. 25

MD Physician Services

Software .............................................. 47

Merck Canada .................................... 2,6

Queen’s University .............................. 39

Record Storage and Retrieval

Services .............................................. 40

Rosen Sunshine LLP ........................... 36

Sea Courses Cruises ........................... 45

TD Bank Financial ................................ 27

TPC Financial Group Ltd ..................... 43

Torkin Manes LLP ............................... 42

Yes Medical System ............................ 34

OMA Programs and Services

OMA Advantages Partner

Discount Program .............................. 31

OMA CME Cruises .............................. 23

OMA Insurance Services ......... 39,47,IBC

OMA Legal Services ............................ 15

OMA Physician Health Program .......... 21

OMA Practice Management and

Advisory Services ........................... 13,45

OMA Pregnancy and Parental Leave

Benefit Program .................................. 32

OMA Response Centre ......................... 8

OMA Women’s Health Care

Seminar ................................................. 9

OMSBF Annual Golf Tournament ........ 41

OMR Classifieds .................................. 42

Prescribing Information

Dovobet .............................................. 56

Vimovo ...........................................50-53

Xamiol ................................................. 57

Zostavax ........................................54-55

64 March 2012ONTARIO MEDICAL REVIEW

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“Ever since I signed up for Twitter, I get the feeling that people are following me!”

REV_Mar12_medectoon_p64.indd 1 12-03-09 2:15 PM

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Insurance Solutions

Designed exclusively for physicians, medical students and

residents.

Portability: OMA plans move with you wherever you go

Cancellation protection: Unlike other group plans, your plan cannot be

cancelled by the insurer

Premium refund: Money not used to pay claims and expenses for certain

plans may be refunded to our members

Non-commissioned Insurance Advisors: We provide education,

information and advice

phone: 1.800.758.1641

email: [email protected]

web: www.omainsurance.com

InsuranceSolutions2012JanV1.indd 1 12-01-09 10:29 AM

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We’re in this together

VIMOVO® and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. © AstraZeneca 2012

11/12

VIMOVO is indicated for the treatment of the signs and symptoms of osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and to decrease the risk of developing gastric ulcers in patients at risk for developing NSAID-associated gastric ulcers.

VIMOVO is not recommended for initial treatment of acute pain because the absorption of naproxen is delayed (as with other modified-release formulations of naproxen).

For patients with an increased risk of developing cardiovascular (CV) and/or gastrointestinal (GI) adverse events, other management strategies that do NOT include the use of NSAIDs should be considered first. Use of VIMOVO should be limited to the lowest effective dose for the shortest possible duration of treatment in order to minimize the potential risk for cardiovascular or gastrointestinal adverse events.

VIMOVO, as an NSAID, does NOT treat clinical disease or prevent its progression.

VIMOVO, as an NSAID, only relieves symptoms and decreases inflammation for as long as the patient continues to take it.

Evidence from naproxen clinical studies and postmarket experience suggest that use in the geriatric population is associated with differences in safety.

VIMOVO is contraindicated in the peri-operative setting of coronary artery bypass graft surgery (CABG); in women in the third trimester of pregnancy or who are breastfeeding; in patients with severe uncontrolled heart failure, known hypersensitivity to naproxen, esomeprazole, substituted benzimidazoles or to any of the components/excipients; history of asthma, urticaria, or allergic-type reactions after taking ASA or other NSAIDs; active gastric/duodenal/peptic ulcer or active gastrointestinal bleeding; cerebrovascular bleeding or other bleeding disorders; inflammatory bowel disease; severe liver impairment or active liver disease; severe renal impairment or deteriorating renal disease; known hyperkalemia and in children and adolescents less than 18 years of age.

WARNING

Risk of cardiovascular (CV) adverse events: ischemic heart disease (IHD), cerebrovascular disease, congestive heart failure (HF) (NYHA II-IV) Naproxen is a non-steroidal anti-inflammatory drug (NSAID). Use of some NSAIDs is associated with an increased incidence of cardiovascular adverse events (such as myocardial infarction, stroke or thrombotic events) which can be fatal. The risk may increase with duration of use. Patients with cardiovascular disease or risk factors for cardiovascular disease may be at greater risk.

Caution should be exercised in prescribing NSAIDs such as naproxen, which is a component of VIMOVO (naproxen/esomeprazole), to any patient with ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina), cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax) and/or congestive heart failure (NYHA II-IV).

Use of NSAIDs such as naproxen, which is a component of VIMOVO, can promote sodium retention in a dose-dependent manner, through a renal mechanism, which can result in increased blood pressure and/or exacerbation of congestive heart failure.

Randomized clinical trials with VIMOVO have not been designed to detect differences in cardiovascular events in a chronic setting. Therefore, caution should be exercised when prescribing VIMOVO.

Risk of gastrointestinal (GI) adverse events Use of NSAIDs such as naproxen, which is a component of VIMOVO, is associated with an increased incidence of gastrointestinal adverse events (such as peptic/duodenal ulceration, perforation, obstruction and gastrointestinal bleeding).

The recommended daily dosage of VIMOVO is 375/20 mg or 500/20 mg (naproxen/esomeprazole) twice a day.

The most common adverse reactions seen with naproxen are gastrointestinal, of which peptic ulcer, with or without bleeding, is the most severe. Fatalities have occurred, particularly in the elderly.

The most commonly reported adverse reactions for VIMOVO were dyspepsia (11.8%), erosive gastritis (7.2%) and gastritis (6.5%).

See the Product Monograph for full contraindications, warnings, precautions, dosing and administration. Reference: VIMOVO® Product Monograph. AstraZeneca Canada Inc. January 13, 2011.

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