Wait Time Information in Priority Areas

Wait Time Information in Priority Areas

Wait Time Information in Priority Areas Definitions Canadian Institute for Health Information Last updated March 2019 waittimes.cihi.ca cihi.ca @cihi_icis Background In 2004, Canadas first ministers agreed to work toward reducing wait times for 5 priority areas: cancer treatment, cardiac care, diagnostic imaging, joint replacement and sight restoration. CIHI was mandated to collect wait time information and monitor provincial progress in meeting benchmarks.

Since 2004, CIHI and the provinces have collaboratively worked toward the development of indicators and public wait time reporting for 5 priority procedures, 2 diagnostic imaging procedures and 5 cancer sites. 2 Background (continued) In 2005, the Comparable Indicators of Access Sub Committee (CIASC) developed a pan-Canadian definition for wait time measurement that was adopted by the federal/provincial/territorial ministries. Start date for wait time measurement was defined as follows: Waiting for a health service begins with the booking of a service, which is when the patient and the appropriate physician agree to a service, and the patient is ready to receive it. Finish date for wait time measurement was defined as follows: Waiting for a service ends when the patient receives the service, or the initial service in a series of treatments or services.

3 Procedures for which wait time information is currently being reported Hip replacement Radiation therapy Knee replacement MRI scan Hip fracture repair CT scan Cataract surgery

Cancer surgery (breast, bladder, colorectal, lung and prostate) Coronary artery bypass graft (CABG) Note: Emergency department (ED) wait times are reported through the Your Health System: In Depth web tool and through Emergency Department Visits in the Quick Stats web tool. 4 Procedures for which wait time information is being considered for future reporting Diagnostic imaging wait times (PET scan and ultrasound) Specialist wait times IV chemotherapy wait times

5 Reporting for hip replacement As of 2010, the following definition and population have been applied to reporting for hip replacement surgery wait times: Definition The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a total hip replacement surgery and the patient was ready to receive it, and the date the patient received a planned total hip replacement surgery. Benchmark Within 26 weeks (182 days) Time frame April 1 to September 30, annually 6

Reporting for hip replacement (continued) Population Includes those age 18 and older Excludes emergency cases Includes all total hip replacements (primary and revision); bilateral joint replacements count as a single wait Excludes elective partial hip replacements Excludes days when the patient was unavailable Includes all priority levels Decisions/rationale The exclusion of bilateral hip replacements and inclusion of patients younger than age 18 and

out-of-province patients are not considered material to the wait times. These are not reported as exceptions for provinces that are unable to include/exclude these cases. Provinces continue to work toward removing patient unavailable days from reported wait times. This will continue to be an area of variation that CIHI will note. 7 Reporting for knee replacement As of 2010, the following definition and population have been applied to reporting for knee replacement surgery wait times: Definition The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a total knee replacement surgery and the patient was ready to receive it, and the date the patient received a planned total knee replacement surgery. Benchmark Within 26 weeks (182 days)

Time frame April 1 to September 30, annually 8 Reporting for knee replacement (continued) Population Includes those age 18 and older Excludes emergency cases Includes all total knee joint replacements (primary and revision); bilateral joint replacements count as a single wait Excludes days when the patient was unavailable Includes all priority levels

Decisions/rationale The exclusion of bilateral knee replacements and inclusion of patients younger than age 18 and out-of-province patients are not considered material to the wait times. These are not reported as exceptions for provinces that are unable to include/exclude these cases. Provinces continue to work toward removing patient unavailable days from reported wait times. This will continue to be an area of variation that CIHI will note. 9 Reporting for hip fracture repair As of 2010, the following definition and population have been applied to reporting for hip fracture repair wait times: Definition 1. Measured from the time of first registration at an emergency department with hip fracture (index admission) to the time when hip surgery was received. AND/OR 2. Measured from the time of first inpatient admission with hip fracture (index admission)

to the time when hip surgery was received. Benchmark Within 48 hours 10 Reporting for hip fracture repair (continued) Time frame April 1 to September 30, annually Population Includes those age 18 and older Includes discharge from an acute care institution Includes admission category recorded as emergent/urgent (if wait from first inpatient admission) Excludes in-hospital hip fractures

Decisions/rationale In-hospital hip fractures are excluded as the time of the fracture or start of wait is not known. 11 Reporting for cataract surgery As of 2010, the following definition and population have been applied to reporting for cataract surgery wait times: Definition The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a cataract surgery and the patient was ready to receive it, and the date the patient received a planned cataract surgery. Benchmark Within 16 weeks (112 days) Time frame

April 1 to September 30, annually 12 Reporting for cataract surgery (continued) Population Includes those age 18 and older Includes first eye only; bilateral cataract removal counts as a single wait Includes all priority levels Excludes emergency cases Excludes days when the patient was unavailable Reviewed April 19, 2011 Decisions/rationale CIHI will note the cases that have been included in which a procedure has been performed on the second eye. 13

Reporting for cataract surgery (continued) There is no universal definition of high-risk cataract surgery procedures across provinces; hence, they are not consistent across jurisdictions. CIHI will note where high-risk patients are included. Including out-of-province patients is not material to the reported wait times for cataract surgery. These are not reported as exceptions for provinces that are unable to remove these cases from their data. Provinces continue to work toward removing patient unavailable days from reported wait times. This will continue to be an area of variation that CIHI notes. Rationale for including first eye only: About 40% of all cataract surgery procedures involve the second eye. Second-eye surgery is often performed after a medically determined interval. Since these patients can be thought of as continuing under treatment rather than waiting for surgical availability, the inclusion of second-eye surgery could distort the cataract wait times results. 14 Reporting for coronary artery bypass graft (CABG) surgery As of 2011, the following definition and population have been applied

to reporting for bypass surgery wait times: Definition The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a coronary artery bypass graft (CABG) and the patient was ready to receive it, and the date the patient received a planned CABG. Benchmark Within 2 to 26 weeks (14 to 182 days), depending on how urgently care is needed Time frame April 1 to September 30, annually 15 Reporting for coronary artery bypass graft (CABG) surgery (continued) Population Includes those age 18 and older

Excludes emergency cases Includes isolated CABG only Excludes days when the patient was unavailable Includes all priority levels Decisions/rationale Including out-of-province patients and those younger than age 18 is not material to the reported wait times for bypass surgery. Inclusion of these patients will not be reported as an exception. Provinces continue to work toward removing patient unavailable days from reported wait times. This will continue to be an area of variation that CIHI notes. Due to variations in the way clinical urgency is defined across Canada, CIHI is currently unable to report on CABG benchmarks. 16

Reporting for radiation therapy As of 2011, the following definition and population have been applied to reporting for radiation therapy wait times: Definition Population The number of days a patient waited, between the date the patient was ready to treat and the date of the first radiation therapy treatment. Includes those age 18 and older Benchmark Within 4 weeks (28 days) of patient being ready to treat

Includes all referrals to start or initiate radiation treatment Includes all priority levels and all cancer types rolled up Time frame Excludes days when the patient was unavailable April 1 to September 30, annually Includes oncology planning time 17 Reporting for radiation therapy (continued) Decisions/rationale

Pediatric and emergency patients are included, as their inclusion is not material to the reported wait times for radiation therapy. The inclusion of these patients will not be reported as an exception for those provinces that do report in this manner. All referrals to start or initiate treatment may include patients who have had previous radiation treatment for the same or other cancers, patients who have metastases from a previous cancer and/or palliative patients. Provinces that include radiation treatments other than external beam will be noted in the exceptions. 18 Reporting for CT and MRI scans As of 2010, the following definition and population have been applied to reporting for CT and MRI scan wait times: Definition Population

The number of days a patient waited, between the date the order/requisition was received and the date the patient received the scan. Includes those age 18 and older Time frame Includes all priority levels April 1 to September 30, annually Excludes routine follow-up scans Includes diagnostic scans (may be inpatient or outpatient)

Excludes mammography screening and prenatal screening 19 Reporting for CT and MRI scans (continued) Decisions/rationale The inclusion of emergency patients is not considered material to the reported wait times. These are not reported as exceptions for provinces that are unable to exclude these cases. Routine follow-up scans are material to reported wait times as they comprise between 10% and 15% of all cases, and are typically scheduled at regular intervals. For those provinces that are unable to remove follow-ups, CIHI will note this as an exception. 20 Reporting for general cancer surgery As of 2014, the following definition and population have been applied

to reporting for cancer surgery wait times: Definition Population The number of days a patient waited, between the date when the patient and the appropriate physician agreed to a cancer surgery and the patient was ready to receive it, and the date the patient received a planned cancer surgery. Includes all surgeries for proven and suspected cancers Includes all surgeries for palliative patients Time frame

April 1 to September 30, annually Includes all cancer surgery for new and recurrent/metastatic cancers Excludes days when the patient was unavailable Excludes patients who received a biopsy as the sole procedure Excludes patients on neoadjuvant therapy Excludes emergency cases 21 Reporting for general cancer surgery (continued) Decisions/rationale Suspected cases are included because a pathology report may not be completed before surgery and data collection limitations do not allow for accurate collection of pathology results. Surgical treatment for palliative patients and recurrent cancers is included because it competes for operating room time, the same as treatment for newly diagnosed cancer patients.

Provinces unable to exclude biopsies as a sole procedure will be noted in the exceptions. 22 Reporting for breast cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population have been applied to reporting for breast cancer surgery wait times: Population Includes all mastectomies, resections, excisions and lumpectomies for proven or suspected cases of cancer Includes breast and sentinel node biopsies when combined with surgeries listed above for patients who have a proven or suspected cancer Excludes BRCA 1 and 2 mutations Excludes breast reconstruction surgery unless done in the same operating room session 23

Reporting for breast cancer surgery (continued) Decisions/rationale Treatment for BRCA 1 and 2 mutations is different than treatment for those with suspected or confirmed cancer and is therefore excluded. Provinces unable to exclude BRCA 1 and 2 mutations will be noted in the exceptions. Reconstruction cases will be excluded for the same reason noted in the previous bullet. However, these cases are not likely to materially affect wait times and no provincial exception will be noted if provinces are unable to remove these cases. 24 Reporting for bladder cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population have been applied to reporting for bladder cancer surgery wait times: Population

Includes resections (partial or complete) of the bladder with or without fulguration Includes cystectomy with or without ileal conduit for proven or suspected cases of cancer Excludes cystoscopy as a diagnostic procedure 25 Reporting for colorectal cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population have been applied to reporting for colorectal cancer surgery wait times: Population Includes all resections of the colon by incision or scope performed in an operating room (large intestine including cecum, ascending, transverse, descending and sigmoid) and rectum (does not include small intestine) for proven or suspected cases of cancer Includes ileostomy/colostomy for proven or suspected cancer Excludes closure of ileostomy/colostomy Excludes cancer of the stomach or small intestine

Excludes diagnostic scopes 26 Reporting for lung cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population have been applied to reporting for lung cancer surgery wait times: Population Includes thoracotomies for suspected or proven cancer with resection (partial or complete) of lung(s) Excludes bronchoscopies/mediastinoscopies Decisions/rationale Bronchoscopy/mediastinoscopy for diagnosis was excluded as most lung cancer is diagnosed using various diagnostic imaging modalities. 27

Reporting for prostate cancer surgery In addition to the general exclusions for cancer surgery, the following definition and population have been applied to reporting for prostate cancer surgery wait times: Population Includes complete resection of the prostate for proven or suspected cases of cancer Excludes transurethral resection of the prostate 28 Reporting for IV chemotherapy (for potential future reporting) Ready to treat to first treatment:* The wait time for IV chemotherapy treatment is the number of calendar days a patient waited, between the date the patient was ready to treat and the date of the first IV chemotherapy treatment (day 1, cycle 1). Referral to consult: The number of days a patient waited, between the date the referral from family physician or specialist was received and the date the patient was seen by an oncologist for the first time.

Consult to treatment: The number of days a patient waited, between the date the patient was seen by the oncologist for the first time and the date of the first IV chemotherapy treatment. Summary measures: 50th percentile, 90th percentile Body sites: Breast, colorectal, lung, all sites combined * It was agreed that the ready to treat to first treatment wait time will be the common starting point when provinces are ready to begin collecting and reporting. 29 Reporting for IV chemotherapy (continued) (for potential future reporting) Population Includes those age 18 and older Excludes multiple rounds Includes IV chemotherapy only

Excludes emergency patients who have a life-threatening condition and require immediate assessment and treatment Includes only first dose of IV chemotherapy treatment for patients with a new diagnosis of cancer or recurrent cancer Excludes inpatient cases Includes planning time Excludes patient unavailable days Excludes supportive and hormonal therapy 30

IV chemotherapy: Patient pathway Notes: This pathway is adapted from Cancer Care Ontario. The journey from diagnosis to treatment is different for each patient diagnosed with cancer. This is a simplified pathway given that there are multiple variations to this journey. Planning time: Defined as all activities that occur prior to treatment and that are part of the system response, such as patients waiting for IV PICC line or portacath insertion, a chemo chair, approval of medications and alternative options for treatment, among others. Patient-caused delays are not part of the planning time definition and are excluded (if known) from the wait time calculation. 31 PET scan and ultrasound wait times 32 PET scan and ultrasound wait times Definition

The number of days a patient waited, from the date the order/requisition was received to the date the patient received the positron emission tomography (PET)/ultrasound scan. Summary measures: 50th percentile, 90th percentile Population Includes those age 18 and older Excludes obstetrics Excludes routine follow-ups Excludes emergency patients 33 PET scan and ultrasound wait times (continued) Decisions/rationale Obstetrics scans are typically scheduled for set times, so these patients do not wait for their scan. Follow-up appointments are typically scheduled. Some provinces are unable to separate out

routine follow-ups. There is a high proportion of no-shows and rescheduled appointments across all of the provinces; given the large volume of scans, it is not possible to delete patient unavailable days as with other priority procedures. However, most provinces are able to adjust the wait time data by removing patients who initiate delays, and those that are currently unable to do so agree in principle that these patients should be removed. Provinces will move toward excluding patients who reschedule their appointment. Where this is not possible, an exception will be noted. 34 Emergency department wait times 35 ED wait times Definitions Time of Physician Initial Assessment (TPIA): The time interval between the earlier of triage date/time

or registration date/time* and date/time of physician initial assessment Time to Disposition (TtoD): The time interval between the earlier of triage date/time or registration date/time* and the disposition date/time Time Waiting for Inpatient Bed (TWIB): The time interval between the disposition date/time and the date/time patient left ED for admission to an inpatient bed or operating room ED Length of Stay (LOS): The time interval between the earlier of triage date/time or registration date/time* and one of the following times: date/time patient left ED for admitted or transferred patients, or disposition date/time for all other visit dispositions * Depending on the acuity of the case or hospital procedures, triage may occur before registration; therefore, the earlier of these 2 events is used as the starting point. When Triage Date and Time is required but unknown, the Date of Registration (data element 27) is recorded as the Triage Date and 9999 (unknown) is recorded as the Triage Time. 36 ED wait times (continued) Summary measures: 50th percentile, 90th percentile

Population Includes all patients (can be reported by triage level or by visit disposition) Inclusions/exclusions TPIA is not calculated for patients who registered but left without being seen or triaged and patients who were triaged but left before further assessment. TtoD is not calculated for patients who registered but left without being seen or triaged. TWIB is calculated only for patients who were admitted into the reporting facility as an inpatient (critical care unit [CCU], operating room [OR] or another unit). 37 Key events characterizing an ED visit Note: See slides 40 to 42 for Visit Disposition (VD) code definitions. 38

Data elements for Time to Physician Initial Assessment Data element Definition Date/Time of PIA (Physician Initial Assessment) The date/time the physician (first physician) first assessed the patient. Triage Date/Time The calendar date/time when the patient is triaged in the ED. Note the following Canadian Association of Emergency Physicians (CAEP) guideline: Triage should occur prior to registration.

Triage Level The initial triage level (adult CTAS; pediatric PCTAS) for the patient on this visit. The triage level was developed by CAEP and applies to patients seen in EDs. Date/Time of Registration/Visit The date/time when the patient presents for services to any ambulatory care functional centre and is officially registered as a patient. 39 Data elements for Time to Disposition Data element Definition

Visit Disposition 6. Admit to reporting facility as inpatient to special care unit or OR from ambulatory care visit functional centre 7. Admit to reporting facility as an inpatient to another unit of the reporting facility from the ambulatory care visit functional centre 8. Transfer to another acute care facility directly from ambulatory care visit functional centre (includes transfer to another acute care facility with entry through ED) 9. Transfer to another non-acute care facility directly from ambulatory care functional centre (e.g., stand-alone rehab, mental health) 12. Intra-facility transfer to day surgery 13. Intra-facility transfer to the ED 14. Intra-facility transfer to clinic 40

Data elements for Time to Disposition (continued) Data element Definition Visit Disposition 30. Residential Care: Transfer to long-term care home (24-hour nursing), mental health and/or addiction treatment centre or hospice/palliative care facility 40. Group/Supportive Living: Transfer to assisted living/supportive housing or transitional housing, including shelters; these settings do not have 24-hour nursing care 90. Correctional Facility: Transfer to jail or halfway house 91. Home With Support/Referral: Discharge to private home, condominium or apartment with supports from the community at home or referred to services; does not include discharge to group/supportive housing Note: A patient with instructions to return to his doctor or referral to a specialist (as part of a routine discharge order) is not considered discharge home with support services/referral.

92. Private Home: Discharge to private home, condominium or apartment without supports from the community at home or referred to services; does not include discharge to group/supportive housing 41 Data elements for Time to Disposition (continued) Data element Definition Visit Disposition 61. Leave Post Registration: Patient left at his/her own risk following registration; triage (if an ED visit), further assessment by a service provider and treatment did not occur 62. Leave Post Initial Treatment: Patient left at his/her own risk following registration, triage (if an ED visit), further assessment by a service provider and initiation of treatment

63. Left After Triage: Patient left the ED at his/her own risk following registration and triage; further assessment by a service provider and treatment did not occur 64. Left After Initial Assessment: Patient left at his/her own risk following registration, triage (if an ED visit) and further assessment by a service provider; treatment did not occur 71. Dead on Arrival (DOA): Patient is dead on arrival to the ambulatory care service; there is no resuscitation (e.g., no CPR); includes cases where the patient is brought in for pronouncement of death 72. Died in Facility: Excludes medical assistance in dying (MAID) and in-facility suicide 73. Medical Assistance in Dying (MAID): Medically assisted death 74. Suicide in Facility: In-facility suicide 42 Data elements for Time to Disposition (continued) Data element Definition

Disposition Date/ Time The date/time the service provider makes the decision about the patients disposition Notes The best available marker for the Disposition Date is the date when the service provider issues the disposition order or request. It is the end point for an ED and/or day surgery visit. When Disposition Date/Time is unknown and the patient is admitted, the admission date/time found in the inpatient record or in the facilitys electronic reporting system is recorded. 43 Specialist care wait times 44

Specialist care wait times Definition The number of days between the date the referral was received in the specialists office and the date the patient was seen by a specialist. Summary measures: 50th percentile, 90th percentile Population Includes those age 18 and older Includes new referrals (new referrals occur when a referral letter is generated by a general practitioner or other specialist) Excludes patient unavailable days Excludes emergency cases and in-hospital referrals 45 Appendix: ICD-10-CA and CCI codes defining priority procedure cohorts

46 Procedure CCI / ICD-10-CA inclusion criteria Hip replacement surgery 1.VA.53.LAPN^ Dual component prosthetic device [femoral with acetabular] - open approach 1.VA.53.LLPN^ Dual component prosthetic device [femoral with acetabular] - open anterior (muscle-sparing) approach Knee replacement surgery 1.VG.53.^^ Implantation of internal device, knee joint (except 1.VG.53.LASLN^ - Cement spacer)

Hip fracture repair See detailed inclusion criteria in CIHIs Indicator Library: 1.VP.53.^^ Implantation of internal device, patella http://indicatorlibrary.cihi.ca/pages/viewpage.action?pageId=1114199 Cataract surgery 1.CL.89.^^ Excision total, lens With at least one of the following diagnoses: H25^ Senile cataract H26^ Other cataract H28^ Cataract and other disorders of lens in diseases classified elsewhere (except H28.8^ Other disorders of lens in diseases classified)

47 Procedure CCI / ICD-10-CA inclusion criteria Radiation therapy 1.^^.27.^^ Radiation, any site Coronary artery bypass graft (CABG) 1.IJ.76^^ Bypass, coronary artery Exclusions: 1) Abandoned and revision procedures

2) CABG with any valve procedure or concomitant procedure (see CIHIs Indicator Library: http://indicatorlibrary.cihi.ca/pages/viewpage.action?pageId=10682387) CT scan 3.^^.20.^^ CT scan, any site MRI scan 3.^^.40.^^ MRI scan, any site 48 Procedure CCI / ICD-10-CA inclusion criteria

Cancer surgery A procedure from the lists indicated below, along with at least one of the following diagnoses: C^ Malignant neoplasm Z03.1^ Observation for suspected malignant neoplasm Z03.9^ Observation for suspected disease or condition, unspecified Z40.0^ Prophylactic surgery for risk-factors related to malignant neoplasm Z51.0^ Radiotherapy session Z51.1^ Chemotherapy session for neoplasm Bladder 1.PM.59.^^ Destruction, bladder 1.PM.87.^^ Excision partial, bladder 1.PM.89.^^ Excision total, bladder 1.PM.91.^^ Excision radical, bladder

1.PL.87.BA^^ Excision partial, bladder neck, using endoscopic per orifice approach Prostate 1.QT.59.^^ Destruction, prostate 1.QT.87.^^ Excision partial, prostate (except endoscopic approach: 1.QT.87.BA-GX, 1.QT.87.BA-AG, 1.QT.87.BA-AK) 1.QT.91.^^ Excision radical, prostate 49 Procedure CCI / ICD-10-CA inclusion criteria Cancer surgery A procedure from the lists indicated below, along with at least one of the following diagnoses:

C^ Malignant neoplasm Z03.1^ Observation for suspected malignant neoplasm Z03.9^ Observation for suspected disease or condition, unspecified Z40.0^ Prophylactic surgery for risk-factors related to malignant neoplasm Z51.0^ Radiotherapy session Z51.1^ Chemotherapy session for neoplasm Breast 1.YM.87.^^ Excision partial, breast 1.YM.88.^^ Excision partial with reconstruction, breast 1.YM.89.^^ Excision total, breast 1.YM.90.^^ Excision total with reconstruction, breast 1.YM.91.^^ Excision radical, breast 1.YM.92.^^ Excision radical with reconstruction, breast 50

Procedure CCI / ICD-10-CA inclusion criteria Cancer surgery A procedure from the lists indicated below, along with at least one of the following diagnoses: C^ Malignant neoplasm Z03.1^ Observation for suspected malignant neoplasm Z03.9^ Observation for suspected disease or condition, unspecified Z40.0^ Prophylactic surgery for risk-factors related to malignant neoplasm Z51.0^ Radiotherapy session Z51.1^ Chemotherapy session for neoplasm Colorectal

1.NM.59.^^ Destruction, large intestine 1.NM.77.^^ Bypass with exteriorization, large intestine 1.NM.87.^^ Excision partial, large intestine 1.NM.89.^^ Excision total, large intestine 1.NM.91.^^ Excision radical, large intestine 1.NQ.59.^^ Destruction, rectum 1.NQ.87.^^ Excision partial, rectum 1.NQ.89.^^ Excision total, rectum 51 Procedure CCI / ICD-10-CA inclusion criteria Cancer surgery

A procedure from the lists indicated below, along with at least one of the following diagnoses: C^ Malignant neoplasm Z03.1^ Observation for suspected malignant neoplasm Z03.9^ Observation for suspected disease or condition, unspecified Z40.0^ Prophylactic surgery for risk-factors related to malignant neoplasm Z51.0^ Radiotherapy session Z51.1^ Chemotherapy session for neoplasm Lung 1.GM.59.^^ Destruction, bronchus NEC 1.GM.87.^^ Excision partial, bronchus NEC 1.GR.87.^^ Excision partial, lobe of lung 1.GR.89.^^ Excision total, lobe of lung 1.GR.91.^^ Excision radical, lobe of lung 1.GT.59.^^ Destruction, lung NEC 1.GT.87.^^ Excision partial, lung NEC

1.GT.89.^^ Excision total, lung NEC 1.GT.91.^^ Excision radical, lung NEC 52 @cihi_icis [email protected] cihi.ca

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