The availability, accessibility, and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of

Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a significantly significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient’s medications could be immensely useful to a clinician in decision-making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways for analyzing and reporting trial results which would add more information about this aspect of drug effectiveness to the clinician’s evidence base.

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

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BackgroundAt the 2011 Annual Business Meeting of the Canadian Geriatrics Society (CGS), an ad hoc Work Group was struck to submit a report providing an estimate of the number of physicians and full-time equivalents (FTEs) currently working in the field of geriatrics, an estimate of the number required (if possible), and a clearer understanding of what has to be done to move physician resource planning in geriatrics forward in Canada.MethodsIt was decided to focus on specialist physicians in geriatrics (defined as those who have completed advanced clinical training or have equivalent work experience in geriatrics and who limit a significant portion of their work-related activities to the duties of a consultant).ResultsIn 2012, there are 230–242 certified specialists in geriatric medicine and approximately 326.15 FTE functional specialists in geriatrics. While this is less than the number required, no precise estimate of present and future need could be provided, as no attempts at a national physician resource plan in geriatrics based on utilization and demand forecasting, needs-based planning, and/or benchmarking have taken place.ConclusionsThis would be an opportune time for the CGS to become more involved in physician resource planning. In addition to this being critical for the future health of our field of practice, there is increasing interest in aligning specialty training with societal needs (n = 216).