Digestive Health Strategic Clinical Network - Alberta Health Services

 
Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

                                                 Digestive Health
                                       Strategic Clinical Network

                                                      Transformational Roadmap
                                                                      2017-2021

    AHS Vision:
    Healthy Albertans. Healthy Communities.
    Together.

    Our Vision:
    The best digestive health for all Albertans.

    Our Mission:
    Innovate and collaborate to create a person-focused,
    high quality digestive health system through
    prevention, research, and best practices.

                                                                                                     February 20, 2018

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

    Table of Contents
    A Word from our Leadership Team                                                                    3

    Executive Summary                                                                                   4

    Summary Infographic                                                                                 6

    Introduction                                                                                        7

    About the Digestive Health SCN                                                                      7

    Development of our Transformational Roadmap 2017 – 2021                                             8

    Our Strategic Goals                                                                                 9

       Strategic Goal: Integrate Primary/Specialty Care                                                10

       Strategic Goal: Deliver high quality, standardized digestive healthcare                         12

       Strategic Goal: Provide clinically appropriate and efficient care                               14

       Strategic Goal: Prevent Digestive Diseases                                                      15

    Our Principles                                                                                     17

    Our Enablers                                                                                       19

    Research and Innovation                                                                            21

    Conclusion                                                                                         23

    Appendix A: Strategic Clinical Network Leadership and Core Committee Members                       24

    Appendix B: Glossary                                                                               26

    Appendix C: References                                                                             31

November 1, 2017

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

    A Word from our Leadership Team
    The Digestive Health Strategic Clinical Network™ (SCN™) is dedicated to achieving the best
    digestive health for all Albertans. This four year transformational roadmap is a dynamic and
    integrated plan that sets an ambitious collective vision for the future of digestive healthcare in
    Alberta. We have asked questions, analyzed data, and sought answers broadly on how to improve
    care and outcomes for people with or at risk for digestive diseases. With input from patients and
    families, physicians, front-line healthcare workers, researchers, administrators, community-based
    organizations, and policy makers, we have created a roadmap that outlines the SCN’s strategic
    goals and describes how these goals will be accomplished.

    The Digestive Health SCN’s goals are to: improve access to gastroenterology services for all
    Albertans and integrate the care delivered by primary care providers and specialty teams; support
    the delivery of high quality digestive healthcare and reduce variation across the province; ensure
    care is appropriate and efficient; and address the preventable causes of digestive diseases.
    Foundational to all of our activities will be a focus on patients and families and fostering a culture of
    inquiry, innovation, and quality improvement. This roadmap reflects the shared priorities of Alberta
    Health Services and the SCNs, and is well aligned with the AHS 2017-20 Health Plan.

    Thank you to our Core Committee for their exceptional passion, enthusiastic participation, and
    dedication to improving the lives of individuals with digestive health concerns. This is their vision
    and transformational roadmap for an improved future for digestive healthcare in Alberta. We look
    forward to sharing our progress with you in achieving that vision.

    The DHSCN is proud to be collaborating and aligning with our partners to lead a transformation in
    digestive healthcare, one that is driving quality, innovation, and value to achieve better outcomes for
    patients and families. We hope this roadmap will present you with the opportunity to engage with the
    Digestive Health SCN and become a part of that transformation.

    Many thanks to our past and future contributors,

    Louise and Sander

    Sander Veldhuyzen van Zanten                                          Louise Morrin
    Senior Medical Director                                               Senior Provincial Director
    Digestive Health Strategic Clinical                                   Digestive Health Strategic Clinical
    Network™                                                              Network™
    Alberta Health Services                                               Alberta Health Services

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Executive Summary
Digestive disorders, which include any conditions affecting the digestive organs (e.g. esophagus,
stomach, small and large intestines, liver, and pancreas), impact more than 2 million Albertans and
cost the Canadian healthcare system $18 billion dollars annually, with rates for many of these
disorders continuing to rise.

The Digestive Health Strategic Clinical Network™ (SCN™) was launched in November 2016 to
address key gaps in care and outcomes related to digestive healthcare across Alberta.
SCNs are province-wide teams bringing together the experiences and expertise of healthcare
professionals, researchers, administrators, government, communities, non-governmental
organizations, and patients and their families to improve our healthcare system. SCNs are the
mechanism through which Alberta Health Services empowers and supports physician and clinical
leaders both within Alberta Health Services and the community to work with patients and their
families to develop and implement evidence-informed, clinician-led, team-delivered health
improvement strategies across Alberta.

This transformational roadmap was developed through collaborative Core Committee meetings,
surveys, and by engaging a variety of interested stakeholders who provided valuable guidance and
input into the direction and activities for the SCN over the next four years.

The vision of the Digestive Health SCN is “The best digestive health for all Albertans.”

The mission statement, or how we will achieve this vision, is: “Innovate and collaborate to create a
person-focused, high quality digestive health system through prevention, research, and best
practices.”

To reach this vision and mission, the Digestive Health SCN has identified four strategic goals
to achieve over the next four years. These strategic goals are to:
    1) Integrate Primary/Specialty Care approaches to digestive diseases and improve access
    2) Deliver high quality, standardized digestive healthcare
    3) Provide clinically appropriate and efficient care
    4) Prevent digestive diseases

The Strategic Clinical Network has identified nine priorities under these strategic goals in order to
focus the work.

Priorities for Strategic Goal: Integrate Primary/Specialty Care approaches to digestive
diseases and improve access
    1) Implement and monitor a complete, standardized provincial referral process and use
          innovative models to improve access to care
    2)   Enhance support and resources for primary healthcare providers to manage digestive
         diseases
    3)   Create a standardized wait time management system for consultations and endoscopic
         procedures

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

    Priorities for Strategic Goal: Deliver high quality, standardized digestive healthcare
        1) Develop and implement provincial clinical pathways for patients to improve disease
              prevention, management, and continuity of care
        2) Address unwarranted clinical variation and improve quality of care for endoscopy
              procedures
        3) Standardized education and support for patients, families, and providers

    Priorities for Strategic Goal: Provide clinically appropriate and efficient care
        1)   Improve appropriateness of testing and therapies

    Priorities for Strategic Goal: Prevent digestive diseases
        1) Prevent chronic liver disease through better identification and management of preventable
              causes of this disease
        2)   Decrease incidence of C. difficile in acute care facilities

    The Digestive Health SCN has developed seven Principles that provide the foundation for the
    Network and will serve as the basis for establishing and achieving our strategic goals. These
    principles are:
            Patient and family focus
            Engagement and collaboration
            Culture of quality
            Standardized, evidence-based approaches
            Sustainability
            Research and innovation
            Healthcare equity

    Five key Enablers have also been identified that are essential to the success of the Digestive
    Health SCN. These Enablers are:
            Information technology and quality data
            Patient and provider education
            Clinical pathways
            Performance measurement
            Communication

    By focusing on the strategic goals, priorities, principles, and enablers described throughout this
    document, digestive healthcare in Alberta will be more integrated, of higher quality, and more
    clinically appropriate. This will result in improved patient outcomes, and bring us closer towards
    achieving the SCN’s vision of the best digestive health for all Albertans.

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

    Introduction
    Strategic Clinical Networks™ (SCNs™) are province-
    wide teams bringing together the experiences and
    expertise of healthcare professionals, patients and
    families, researchers, government, administrators,
    communities, and non-governmental organizations to
    improve our healthcare system. To achieve this, SCNs
    are responsible for generating innovation, implementing
    best evidence into practice, and utilizing change
    management strategies to improve the quality of care
    and outcomes and ensure long-term sustainability and
    success of all initiatives. They also build capacity with
    and within operations, using local improvements to drive
    system innovation.
    As a major stakeholder in health service delivery, the
    work of the SCNs is aligned with Alberta Health
    Services’ (AHS’) four foundational strategies, and the              Figure 1: AHS' Four Foundational Strategies
    quadruple aim approach (Figure 1). SCNs are the
    mechanism through which AHS empowers and supports physician and clinical leaders both within AHS
    and the community to work with patients and their families to develop and implement evidence-
    informed health improvement strategies across Alberta.

    About the Digestive Health SCN
                                                                                                 As an SCN, we
    The Digestive Health SCN™ was officially launched on November 18,                           are here to: ask
    2016 as the fourteenth SCN. It is comprised of a Leadership Team and                         questions, find
    a Core Committee, which has representation from a wide-range of                             answers, inspire
    multi-disciplinary stakeholders across the province with a keen interest                       change, and
    in digestive health. A complete list of our Leadership Team and Core                          transform the
    Committee can be found in Appendix A.                                                           healthcare
                                                                                                     system.
    The scope of our work includes all digestive diseases, all liver diseases,
    and cancers of the digestive system across the lifespan. A number of
    project teams and working groups are being formed and will be responsible for the development and
    implementation of priority projects aligned with the Digestive Health SCN’s strategic goals and
    priorities.

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Development of our Transformational Roadmap 2017 – 2021

Figure 2: Development of our Transformational Roadmap

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Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

    Our Strategic Goals

            Integrate Primary / Specialty Care Approaches
             to Digestive Diseases and Improve Access

       Deliver High Quality, Standardized
        Digestive Healthcare

    Provide Clinically Appropriate and
     Efficient Care

 Prevent Digestive Diseases
Digestive Health Strategic Clinical Network - Alberta Health Services
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

WHAT
Strategic Goal: Integrate Primary/Specialty Care approaches
to digestive diseases and improve access

Our Priorities:
     Implement and monitor a complete, standardized provincial referral process and use innovative
      models to improve access to care
     Enhance support and resources for primary healthcare providers to manage digestive diseases
     Create a standardized wait time management system for consultations and endoscopic
      procedures

WHY
     Currently available resources are inadequate to meet the demand for investigations and care
      of patients referred for specialty gastroenterology care, leading to ever-increasing wait times
      and unacceptable limitations to access1.
     Triage processes and wait times vary across the province by reason for referral, with urgent
      referrals prioritized to be seen first while non-urgent referrals may wait up to two years1.
     Demand is expected to increase as the number of people living with chronic digestive diseases
      continues to rise. The estimated number of referrals to Gastrointestinal (GI) services in the
      Edmonton Zone alone exceeds 40,000 annually2.
     The vast majority of referrals processed in Alberta remain outside of any electronic
      management system, with little transparency into wait times, priority allocation (triage), and
      endoscopy allocation, as these are determined individually/privately1. The different systems
      have resulted in safety incidents as referrals are lost or misplaced and the patient is not seen
      within the appropriate timeframe.
     Strategies to improve access to GI services have been implemented in many sites/programs
                                                          across Alberta. For example, innovations
                                                          such as Central Access and Triage, Specialist
                                                          Link, and Primary Care Clinical Pathways in
                    Did you know?                         the Calgary Zone resulted in a 43% reduction
                                                          in routine referrals between 2014 and 20161.
               The Canadian Association                    The GI Provincial Referral Guide has
                  of Gastroenterology
                                                          recently been completed and is ready for
              recommended wait time for
                                                          implementation across the province.
             consultation and endoscopy
              for indications FIT positive,
                rectal bleeding, and iron
                 deficiency anemia is 8
             weeks3. Currently in Alberta,
             less than half of patients are
                  meeting this criteria.

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     HOW
          Improve collaboration and integration between primary and
                                                                                                        Did you
           specialty care to ensure patients are better supported in their
           medical home.
                                                                                                        know?
          Develop standardized referral processes based on best
                                                                                                  After implementing
           evidence and implement these broadly.                                                  eConsult in Ottawa,
          Collaborate with primary care stakeholders to develop and                               70% of cases did
           implement innovative care models and clinical pathways to                               not require a face-
                                                                                                   to-face specialist
           support primary care and increase access to underserviced
                                                                                                  visit, and in 40% of
           areas, including outreach to rural and remote communities.                                   cases, an
          Work with the Access Improvement team to implement Alberta                                unnecessary
                                                                                                      referral was
           Netcare eReferral (advice request and consult request), creating
                                                                                                        avoided4.
           a common referral management platform for gastroenterology
           services across the province.
          Work with the Alberta Coding and Access Targets System (ACATS) team to expand utilization
           of their wait time management solution to include endoscopy procedures.

     MEASURING SUCCESS
          Increased number of gastroenterology sites participating in eReferral.
          Increased number of referring providers utilizing eReferral Advice Request.
      •    Increase in number of avoided gastroenterology consults (based on Advice Request
           utilization and outcomes).
          Reduction in wait time for gastroenterology consults at sites participating in eReferral.
          Decreased wait times for endoscopy procedures.
           Primary care providers are supported to manage their patients’ digestive diseases in a
           variety of situations, including: prior to specialist consultation, in lieu of specialist
           consultation, and after specialist consultation.

                  “As a family physician, I know that the digestive system is long and complex. Accessing
                  healthcare for the digestive system ideally should not be long and complex, yet challenges
                  exist in the current system that affect our patients' healthcare journey. I joined the Digestive
                  Health Strategic Clinical Network because I saw that there was a need for innovative
                  solutions to address access, continuity of care, and management of digestive health
                  concerns within a patient's medical home, and in the specialty care system. I am also
                  passionate about disease prevention, and saw an opportunity to be involved in preventative
                  health at the system level. Prior to joining, I was told that the gastroenterologists involved in
                  the Digestive Health SCN were highly motivated to hear what family physicians have to say,
                  and that has certainly been the case so far, but what has impressed me the most is that the
                  patient experience has been front and centre throughout. I am confident that, with such an
                  inclusive approach, the Digestive Health SCN will help Alberta lead the way in providing high
                  quality digestive healthcare."
                       -     Dr. Julia Carter, Family Physician and DHSCN Core Committee Member

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

WHAT
Strategic Goal: Deliver high quality, standardized digestive
healthcare

Our Priorities:
     Develop and implement provincial clinical pathways for patients to improve disease prevention,
      management, and continuity of care
  

     Address unwarranted clinical variation and improve quality of care for endoscopy procedures
  

     Standardized education and support for patients, families, and providers

WHY
     In 2015, the prevalence of Inflammatory Bowel Disease (IBD) in Alberta was 0.67%, among
      the highest worldwide5, and is expected to increase to ~1% by 20306.
     There are marked disparities in access to care in rural and small urban sites where there is
      limited access to a full range of gastroenterology services7.
     The prevalence of Irritable Bowel Syndrome (IBS) is rising. The self-reported prevalence in
      Canada was 2.4% in 2007-20088 and rose to 3.2% in 20149. This is an underestimation of the
      actual prevalence given as few as 30% of patients consult a physician regarding IBS10 and there
      is under diagnosis of IBS in the presence of established criteria11.
     IBS puts considerable strain on healthcare resources, incurring a significant financial burden,
      and accounts for up to 50% of gastroenterology consultations12.
     There is a lack of standardized care for IBS due to the availability of a wide range of treatments
      with varying effectiveness13.
     While excellent educational resources for a variety of
      GI disorders are available throughout the province,
      these resources are not standardized or available to                       Did you know?
      all Albertans or clinicians, nor have they been
      developed for all digestive diseases.                                      Inflammatory Bowel
                                                                              Disease (IBD) is expected
     Across the province, there are multiple versions of                    to impact ~1% of Albertans
      patient materials with variation in content and advice.                   by 20306, a prevalence
      In the Edmonton Zone alone, there were 37 different                         among the highest
                                                                             worldwide, and costs ~$2.8
      patient handouts being used across the zone on how
                                                                                  billion in direct and
      to prepare for a colonoscopy.                                            indirect costs in Canada
     Endoscopy is performed at 65 sites across the                                    each year14.
      province. Over 315,000 endoscopy procedures were
      performed in Alberta in 2016-1715. There is no
      province-wide approach to endoscopy quality.

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

          The Alberta Colorectal Cancer Screening Program endorses the adoption of the Canada-
           Global Rating Scale (C-GRS©) for all sites performing screening colonoscopy within Alberta
           and is seeking organizational support to mandate this standard province-wide. This quality
           improvement program improves quality of care and enhances the patient experience.
          To date, 19 of 52 sites in Alberta are using the C-GRS© to assess the quality of their endoscopy
           processes and procedures.

     HOW
          Collaborate with primary care providers to adapt existing or develop new clinical pathways for
           digestive disorders. The initial focus will be on primary care oriented pathways.
          Clinical pathways for more complex digestive diseases, such as IBD and liver disease, that
           span      the   care     continuum,      will   be     developed     and    implemented    for
            conditions where there is significant variation in care and outcomes across the province.
          In partnership with the Alberta Colorectal Cancer Screening Program, we will develop and
           implement a strategy to improve the quality of endoscopy care, which includes broad
           implementation of the C-GRS©.
          Work with clinical experts across the province to develop and strengthen the information
           provided to Albertans on digestive diseases, using MyHealth Alberta as a platform for
           information that is accurate, peer-reviewed, and evidence-based.

     MEASURING SUCCESS
          Reduced variation in care and outcomes for Albertans with digestive disorders.
          All sites that perform endoscopy in Alberta are using the C-GRS© and have quality
           improvement initiatives underway.
          Improved endoscopy quality indicators.
          Standardized digestive health related educational materials are universally accessible and
           meet the information needs of Albertans

                 "It was an honour to be asked to join the Digestive Health SCN Core
                 Committee. After decades of working towards improvement of quality of GI
                 care within our zone, it is very refreshing to participate in thoughtful discourse
                 in a room with individuals who have such a great mix of vision, passion,
                 pragmatism, and varying life and occupational experiences related to
                 gastrointestinal disease. Also, the ability to tap resources that produce
                 evidence-based data to guide our deliberations will result in the crystallization
                 of vision into more effective outcomes for our patients. What a very nice
                 group of people! I am confident that patients in this province will ultimately
                 receive improved care, going forward, through this process of collaboration."
                      -     Dr. Dave Koegler, Gastroenterologist and DHSCN Core
                          Committee Member

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

                  “As a Patient Advisor on the Core Committee for the Digestive Health SCN, I have
                  been able to share my experiences and knowledge, not just with Digestive Health, but
                  with the Alberta Health System. It has been an insightful experience to see the process
                  that goes into designing policy and strategic goals and truly invaluable to be able to
                  provide feedback and participate as the patient voice within those conversations. It’s a
                  challenging position, but the chance to help improve those suffering from Digestive
                  Health diseases and illnesses makes it incredibly rewarding."
                       -   Amy van Engelen, Patient Advisor, DHSCN Core Committee Member and
                           PaCER (Patient and Community Engagement Research) Graduate

WHAT
Strategic Goal: Provide clinically appropriate and efficient care

Our Priority:
     Improve appropriateness of testing and therapies

WHY
     Up to 30% of selected medical tests and therapies are not clinically indicated, resulting in
      increased costs to the healthcare system and exposure of patients to risk16.
     There is a high prevalence of use and overuse of Proton Pump Inhibitors (PPIs). Pantoprazole
      was the fifth most common drug prescribed in 2012, with more than 11 million prescriptions
      dispensed in Canada17. Spending on PPIs by public drug programs (excluding Quebec and
      the territories) totalled $249.6 million of the $7.8 billion spent on prescription drugs by these
      programs in 201318.
     Chronic use of PPI’s is problematic, with studies showing a lack of documented ongoing
      indication for between 40% and 65% of hospitalized patients19.
     The Canadian Association of Gastroenterology’s Choosing Wisely recommendation is: don’t
      maintain long-term PPI therapy for gastrointestinal symptoms without an attempt to
      stop/reduce PPI at least once per year in most patients20.
     Inappropriate and inconsistent use of the Fecal Immunochemical Test (FIT) stool test for colon
      cancer screening outside the target population continues to be a problem across Alberta21.
     Colorectal Cancer Screening Clinical Practice Guidelines recommend asymptomatic
      individuals aged 50-74 who are at average risk complete a FIT test every 1-2 yrs22.
     Colon cancer screening using the FIT will lead to colon cancer diagnosis in 3.7% of
      patients2

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     HOW
            We will partner with Pharmacy Services, the Physician Learning Program, and other SCNs to
             develop and implement an appropriate prescribing strategy for PPIs.
            In collaboration with the Alberta Colorectal Cancer Screening program, we will develop and
             implement approaches to improve appropriateness of FIT testing.

     MEASURING SUCCESS
            Reduced prescriptions for PPIs.
            Increased appropriateness of FIT testing.

           "In my current role as the manager of ambulatory care at the QE II, I am responsible for the
           Endoscopy program and the IBD and Hepatology Clinics. As a core team member of the
           Digestive Health Strategic Clinical Network, I am excited to build great networking
           opportunities and to learn from other’s successes as we strive to improve our patients’
           healthcare experience. Through the work of this SCN, I look forward to working to
           standardize and advance our approach to optimal care for every one of our North Zone
           digestive health patients."
                -   Tracey Parsons, Manager, Ambulatory Care, QEII Hospital and DHSCN Core
                    Committee Member

     WHAT
     Strategic Goal: Prevent Digestive Diseases

     Our Priorities:
            Prevent chronic liver disease through better identification and management of preventable
             causes of this disease
            Decrease incidence of C. difficile in acute care facilities

     WHY                                                                                                      Did you
            Digestive diseases account for an annual cost of $18 billion dollars                             know?
             per year in Canada due to healthcare costs and lost productivity23.                                Digestive
                                                                                                           disorders impact
            By preventing the onset and progression of diseases related to the
                                                                                                              more than 2
             digestive system, we can decrease the impact these diseases have                              million Albertans,
             on patients, families, clinicians, and our healthcare system.                                   and rates for
                                                                                                            many of these
            It is estimated that one in 10 Canadians, or more than three million                          disorders are on
             people, has some form of liver disease24.                                                          the rise23.
            The most common forms of liver disease – viral hepatitis, fatty liver
             disease, and liver cancer – are all on the rise.

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     Death from liver disease in Canada increased by 30% from 2000-2008 and is expected to
      rise further in the future25.
     Hepatitis C Virus infection hospitalization costs increased by an average of 41% per year
      in the Calgary Zone from 2000-200426. These costs are continuing to rise and aren’t
      expected to peak until 2020-203027.
     Non-Alcoholic Fatty Liver Disease (NAFLD) is the most common cause of liver disease25,
      is directly related to obesity, and impacts approximately 1/3 of Albertans28.
     Hospital-acquired Clostridium difficile infection (CDI) increases healthcare costs four-fold
      which translates into additional costs of $100 million dollars annually in Canada29.
     It is estimated that approximately 3000 Albertans are impacted by CDI each year, leading to
      about 30-50 deaths yearly30.
     For patients with Recurrent CDI (RCDI),
      Fecal Microbiota Transplantation (FMT) has
      been shown to be the most effective therapy
      (success rate > 80%) and the most cost
      effective treatment31,32,33,34,35.
     A timely FMT, offered after the 3rd episode
      of RCDI, has been shown to reduce
      healthcare spending by approximately
      $30,000 per patient36.
                                                                Figure 3: The Fecal Microbiota Transplantation Team
                                                                receiving the 2017 President’s Excellence Award for
                                                                Outstanding Achievement in Innovation and Research
                                                                Excellence from AHS President and CEO Dr. Verna Yui,
                                                                (front row, fourth from left).
HOW
     We will work with stakeholders to implement effective policies and screening, diagnostic,
      and treatment options to address the preventable causes of liver disease.
     In partnership with researchers, Infection Prevention & Control and gastroenterology
      clinicians, and clinical operations, we will develop strategies to improve antimicrobial
      stewardship, reduce in-hospital transmission of CDI, and operationalize effective and
      timely treatment strategies for recurrent CDI.

MEASURING SUCCESS
     Decrease in CDI and its associated costs in Alberta’s acute care facilities.
     Decrease in incidence of chronic liver disease.
     Increase in appropriate screening for liver diseases.

      “The Digestive Health Strategic Clinical Network was created as a vehicle to deliver the best
      digestive healthcare possible to Albertans; including better quality, better outcomes, and better
      value. The mandate for the DHSCN is to help focus resources on what patients need, to help
      develop and support local models of patients care, and then effectively transfer them across
      Alberta. In essence, the DHSCN is designed to enhance innovative healthcare delivery by
      using the input of patients alongside scientific evidence and expertise of frontline providers. I
      look forward to seeing many improvements supported by this network.”
           -    Dr. Mark Swain, Hepatologist, Head of the Calgary Division of
                Gastroenterology, and DHSCN Core Committee Member

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Our Principles
Our guiding principles provide the foundation for our work and
are the basis for establishing and achieving our strategic goals

 Patient and family focus

 Engagement and collaboration

 Culture of quality

       Standardized, evidence-based approaches

               Sustainability

                            Research and innovation

                                      Healthcare equity
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Patient and family focus
From conception through to implementation and evaluation, our initiatives will be centered on the
needs, priorities, and experiences of patients and their families. We recognize that we can only focus
on these needs by involving patient advisors throughout the process.

Engagement and collaboration
We will engage the broader digestive health community across the continuum of care, including
primary healthcare and end of life care, and spectrum of age (including children and the elderly) and
seek input in all stages of an initiative’s cycle – from planning to implementation to evaluation and
sustainability. We know that to be successful, we must collaborate with a wide variety of
stakeholders, including front-line providers, researchers, government, other SCNs, and patients and
families. Our approach to stakeholder engagement will be articulated in a Communications and
Engagement Plan, to be developed in fall 2017.

Culture of quality
We will foster a culture of quality improvement, based on the six dimensions of quality (as defined by
the Health Quality Council of Alberta), to achieve safe, effective, patient-centred, timely, efficient,
and equitable digestive healthcare.

Standardized, evidence-based approaches
We will endeavor to minimize provincial variations in practice; ensuring practice is based on current
scientific knowledge and best available evidence, while taking into account local context and the
needs and preferences of patients and families.

Sustainability
We are committed to optimal use of limited healthcare resources to drive a sustainable system of
digestive healthcare based on quality.

Research and innovation
We will foster and support research throughout the digestive health community by building and
embedding evidence into our practice, and actively supporting knowledge creation and translation.
We will lead a culture of innovation to improve outcomes, where innovation is any evidence-
informed, value-added service, device, technology, or model of care.

Healthcare equity
We will promote equitable access and fairness in the distribution, quality, production, and control of
healthcare resources for all communities and Albertans.

                                                                                                          18
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

    Our Enablers
    Our enablers are the elements we need to focus on as an SCN in
    order to achieve success in our strategic goals

                        Information technology and quality data

             Patient and provider education

       Clinical pathways

   Performance pathways

 Communication
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

                                                                                             Did you know?

                                                                                            Specialist Link in
                                                                                           Calgary receives ~40
                                                                                          calls per month, many
                                                                                              of which avoid
                                                                                               unnecessary
                                                                                               consultation.

Photo Credit: Edmonton University Hospital Foundation

    Information technology and quality data
    Quality outcomes and improvement will be achieved by using information technology to measure
    and record reliable, provincially consistent data that we will use to drive change and monitor impact.

    Patient and provider education
    Evidence-based provincially consistent patient education, knowledge translation, and multi-
    disciplinary provider education strategies will be employed to support uptake of all SCN initiatives.

    Clinical pathways
    The Digestive Health SCN will help design, evaluate, and utilize clinical pathways consisting of
    evidence-informed, patient-centred interdisciplinary care to help patients affected by digestive
    diseases achieve optimal health outcomes.

    Performance Measurement
    Performance measurement, based on reliable provincially consistent data, is required to improve the
    quality of decisions made regarding priorities for digestive healthcare improvement, the evaluation of
    improvement initiatives, and the sustainability of positive outcomes.

    Communication
    Digestive Health SCN initiatives will incorporate strategies to optimize communication between
    providers, and between patients and providers, to ensure that information is accessible throughout
    the patient’s journey, and thereby improve the delivery and integration of digestive healthcare and
    health outcomes.
                                                                                                                  20
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     Research and Innovation
     The Digestive Health SCN recognizes Alberta’s well-developed research landscape. As outlined by
     our Scientific Office’s six pillars of activity in Figure 4 below, our Scientific Director (Dr. Gil Kaplan)
     and Assistant Scientific Director (Dr. Susan Jelinski) partner directly with researchers to increase
     communication and collaboration, support and
     champion research projects, increase capacity for
     research in the health system, and translate
                                                                             Did you know?
     knowledge generated from research into the clinical
     setting. Through 2017-2021, we will continue to
                                                                      The Scientific Office created the
     work collaboratively with research teams across the              Alberta IBD Surveillance cohort,
     province to identify knowledge gaps aligned to the                   the first of its kind in the
     priorities of the SCN and bring more research into               province. This allows us to track
     practice.                                                       incidence, prevalence, healthcare
                                                                           utilization, variation in care, and
                                                                           outcomes for Albertans with IBD.

                      Figure 4: Six Pillars of Activity of the SCN Scientific Offices

21
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

The Digestive Health SCN has developed a research plan outlining our research goals and the role
the SCN will have in research and innovation for digestive health, and our accountabilities in relation
to research and innovation underway in Alberta. Our Scientific Office has initiated an annual Seed
Grant competition, awarding grant funds to researchers to complete research projects and
systematic reviews related to the SCN’s priorities. Another major priority is to focus on data
liberation to support the development of provincial cohorts of digestive diseases that can be used
by the Digestive Health SCN to inform evidence-based decision making and to track outcomes
overtime. For example, the Scientific Office created the Alberta IBD surveillance cohort that allows
us to track incidence, prevalence, healthcare utilization, variation in care, and outcomes for
Albertans with IBD.

                                               Did you know?

                             The SCN Scientific Office partners directly with
                              researchers to increase communication and
                             collaboration, support and champion research
                          projects, increase capacity for research in the health
                            system, and translate knowledge generated from
                                     research into the clinical setting.

               "I am excited to be part of the Digestive Health SCN and to work with such passionate and
               enthusiastic people in the area of digestive health. The challenges faced by healthcare today are
               complex and require innovation and new ways of doing things. I believe that the Digestive Health
               SCN can be instrumental in the translation of research into the clinical environment which in turn will
               improve health outcomes for patients. Collaborations between many different individuals are
               necessary to identify common obstacles and to induce positive changes. I am proud to be part of
               the Digestive Health SCN and to contribute to the transformation of digestive healthcare in
               Alberta."
                    -    Dr. Karen Madsen, Clinical Researcher and DHSCN Core Committee Member

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     Conclusion
     The strategies identified in this four year Transformational Roadmap will push Alberta to a
     leadership position within Canada in the prevention and management of digestive diseases. By
     focusing on the strategic goals and priorities described throughout this document, we are
     confident we will be delivering care that is integrated, high-quality, and clinically appropriate,
     and ultimately improving patient outcomes. We look forward to working together with our
     network members to meet the challenges and opportunities ahead.

                       “Digestive health involves complex systems that are difficult for patients, such as myself, to
                       understand and navigate. I feel privileged to provide a patient voice in association with a
                       group of medical professionals dedicated to improving care within the Digestive Health SCN.
                       I believe that the group will ultimately provide improved patient care through more uniform
                       practices and attention to the patient perspective.”
                            -    Brendan Murphy, Patient Advisor and DHSCN Core Committee Member

23
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Appendix A: Strategic Clinical Network Leadership and Core
Committee Members
SCN Leadership and Core Committee Members as of: October 2017

             Name                                                    Title
 Leadership Team
 Dr. Sander Veldhuyzen van
                                Senior Medical Director
 Zanten
 Louise Morrin                  Senior Provincial Director
 Leanne Reeb                    Executive Director
 Jessica McLarty                Manager
 Dr. Gilaad Kaplan              Scientific Director
 Dr. Susan Jelinski             Assistant Scientific Director
 Core Committee
 Amy van Engelen                Patient Advisor
 Barb Kathol                    Senior Program Officer, CIS
 Brendan Murphy                 Patient Advisor
 Dr. Brennan Walters            Head of Gastroenterology, Misericordia Hospital
 Dr. Chris Sikora               Medical Officer of Health
 Dr. Christian Turbide          Gastroenterologist
 Clare McCabe Woodrow           IBD Nurse
 Dr. Clarence Wong              Provincial Physician Lean, Colon Cancer Screening
 Dr. Dan Sadowski               Director, Division of Gastroenterology, UofA
 Deon Druteika                  Clinical Practice Lead – Pharmacy
 Derek Drager                   Patient Advisor
 Dr. Diana Mager                Associate Professor UofA, Clinical Nutrition
 Dr. Doug Simmonds              Gastroenterologist, Red Deer
 Dr. Hien Huynh                 Director, Pediatric Gastroenterology
 Holly Knight                   Director, Health Professions Strategy & Practice
                                Executive Director, Outpt Medicine, Allied Health, Transition Units & Neuro
 Jennifer Coulthard
                                Rehab , Foothills Medical Centre
 Jennifer Courtney              Unit Manager, Medicine
 Dr. Jessica Abraham            General Surgeon, Medicine Hat
 Jodi Glassford                 Director, Access Improvement
 Jon Ashmead                    Patient Advisor

                                                                                                              24
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     Dr. Julia Carter              Family Physician
     Karen Hamilton                Patient Advisor
     Dr. Karen Madsen              Director - CEGIR
     Dr. Kerri Novak               Gastroenterologist; QA/QI Medical Lead, Calgary Zone
                                   Executive Director, Ambulatory Care, Emergency, Endoscopy &
     Kim Kostiuk
                                   Ophthalmology (Edmonton Zone)
     Dr. Leah Gramlich             Gastroenterologist, AHS Provincial Medical Advisor Nutrition Services
     Dr. Linda Slocombe            Lead, Calgary pan-PCN Group
     Lindsay Steward               Manager, Edmonton North PCN
     Lisa Westin                   Case Manager, Gastroenterology, Med. Specialty Clinics, RDRH
     Lorna Driedger                Director, Nutrition Services, Calgary Zone
     Lynn Goughnour                Director, Patient Care Surgery, Chinook Regional
     Dr. Mark Swain                Head, Division of Gastroenterology and Hepatology, Calgary
     Michelle Carbonneau           Nurse Practitioner, Cirrhosis Care Clinic
     Dr. Naseem Hoque              Gastroenterologist
     Peter Campbell                Alberta Health Policy Advisor
     Dr. Puneeta Tandon            Director, Cirrhosis Care Clinic; Associate Professor of Medicine, UofA
     Ralph Ennis-Davis             Patient Care Manager, Endoscopy, Edmonton Zone
     Dr. Rick Ward                 Family Physician; Medical Director, Primary Care
     Sandra Owen                   Senior Planner, AHS Primary Care
     Dr. Smitha Yaltho             Family Physician
     Steve Lucas                   Program Manager, Operative, Endoscopic & Recovery Services, GNCH
     Dr. Steven Heitman            Head, Colon Cancer Screening Clinic
     Tracey Parsons                Unit Manager, QEII Hospital
     Dr. Yolande Westra            Physician, Internal Medicine, Grand Prairie
     Business Support Team
     Darryl Lacombe                Senior Consultant, Engagement & Patient Experience
     Jessica Lamb                  Senior Consultant, Engagement & Patient Experience
     Dr. Stafford Dean             Senior Program Officer, Analytics
     Stewart Lee                   HTA Analyst
     Susan Miskiman                Business Relationship Partner, Clinical Services IT
     Susan Sobey-Fawcett           Senior Planner
     Terry Baker                   Senior Consultant, SCNs

25
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Appendix B: Glossary
Alberta Innovates (formerly           A provincially-funded Corporation tasked with delivering on
Alberta Innovates Health              the research and innovation priorities of the Government of
Solutions)                            Alberta. In the health sector, Alberta Innovates provides
                                      leadership for Alberta’s health research and innovation
                                      enterprise by directing, coordinating, reviewing, funding,
                                      and supporting health research and innovation. Working
                                      with its many partners in the health system, Alberta
                                      Innovates ensures that health research achieves innovation
                                      in care, policy, and practice, and that the needs of patients
                                      and clinicians influence research.
Antimicrobial Stewardship             Antimicrobial stewardship is an interdisciplinary activity that
                                      promotes optimal antimicrobial therapy including
                                      assessment of the need for antimicrobials, and if
                                      antimicrobials are needed, the appropriate selection,
                                      dosing, route and duration of antimicrobial therapy.
Appropriateness                       Health services are relevant to user needs and are based
                                      on accepted or evidence based practice. Appropriateness
                                      refers to the collaboration between the patient and the
                                      healthcare provider to determine the care respects the
                                      needs and preferences of the patient and is supported by
                                      evidence-informed practice.
Best Evidence                         Best evidence, also known as primary evidence, usually
                                      denotes an original writing, which is considered the most
                                      reliable proof for the existence and/or content for a
                                      particular topic (e.g., Gastroenterology and Hepatology).
                                      Best evidence is usually found in clinically relevant research
                                      that has been conducted using sound methodology. It is
                                      one of the components in Evidence Based Practice, the
                                      other two being clinical expertise and patient preferences
                                      and values.
Best Practice                         Systematically developed statements of recommended
                                      practice in a specific clinical or healthy work environment
                                      area, that are based on best evidence, and are designed to
                                      provide direction to practitioners and managers in their
                                      clinical and management decision-making.

Canada-Global Rating Scale            The Global Rating Scale (GRS) is a web-based survey tool
(C-GRS)                               that offers a comprehensive, systematic approach to the
                                      measurement of endoscopy quality to assess the quality of
                                      the colonoscopy service and patient experience. The self-
                                      assessment tool can be used to help teams in endoscopy
                                      units to prioritize and create action plans targeting specific
                                      quality improvement initiatives. The C-GRS© examines 12

                                                                                                        26
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

                                           items related to clinical quality and the quality of the patient
                                           experience:
                                                Consent process including patient information
                                                Safety
                                                Comfort
                                                Quality of the procedure
                                                Appropriateness
                                                Communicating results
                                                Equality of access
                                                Timeliness
                                                Booking and choice
                                                Privacy and dignity
                                                Aftercare
                                                Ability to provide feedback

     Change Management                     Change management is the process, tools, and techniques
                                           to manage the people side of change to achieve the
                                           required business outcome. Change management
                                           incorporates the organizational tools that can be utilized to
                                           help individuals make successful personal transitions
                                           resulting in the adoption and realization of change.

     Cirrhosis                             Cirrhosis represents a diffuse liver disease characterized by
                                           structurally abnormal nodules of liver cells surrounded by
                                           fibrosis.
     Clinically Indicated                  A complex term encompassing appropriate patient
                                           treatment/intervention based on, but not limited to:
                                               i. the clinician’s unique body of knowledge and
                                                   expertise;
                                              ii. a patient’s clinical presentation;
                                             iii. the cost of treatment;
                                             iv. the scientific merit to the treatment/intervention (e.g.,
                                                   scientifically supported clinical pathways); and,
                                              v. ethics.
     Clinical Pathway                      A description of evidence-informed, clinician recommended
                                           interdisciplinary care to help a patient with a specific health
                                           condition or concern move progressively toward optimal
                                           health outcomes.
     Clinician                             A physician or other healthcare provider who is involved in
                                           the treatment and observation of patients, as distinguished
                                           from one engaged in research.
     Digestive Diseases                    Ailments affecting the digestive organs (e.g. esophagus,
                                           stomach, small and large intestines, liver, and pancreas).
     Digestive Health                      Any action or activity that would affect the improvement,
                                           maintenance, and/or prevention of the overall functioning of
                                           the digestive health system.

27
Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Digestive System                      Consists of the digestive tract and other abdominal organs
                                      that play a role in digestion such as the liver and pancreas.
                                      The system, or group of organs, that break down food in
                                      order to absorb its nutrients into the body.
Endoscopy                             Endoscopy is a procedure in which a physician uses
                                      specialized instruments to view and operate on the internal
                                      organs and vessels of the body. It allows the doctor to view
                                      inside the body without making large incisions. An
                                      endoscope is a flexible tube with an attached camera that
                                      allows the doctor to see.

Evidence-Based Practice               It is the conscientious, explicit and judicious use of current
(EBP)                                 best evidence in making decisions about the care of the
                                      individual patient. It is the integration of: (a) clinical
                                      expertise/expert opinion, (b) external scientific evidence,
                                      and (c) client/patient/caregiver perspectives to provide high-
                                      quality services reflecting the interests, values, needs, and
                                      choices of the individuals we serve.
Evidence-informed                     Using evidence to identify the potential benefits, harms, and
                                      costs of any intervention and also acknowledging that what
                                      works in one context may not be appropriate or feasible in
                                      another.
Fecal Immunochemical Test             The Fecal Immunochemical Test (FIT) is a screening test
(FIT)                                 for colon cancer. FIT detects blood in your stool.
Fibrosis                              The thickening and scarring of connective tissue, usually as
                                      a result of injury.
Gastroenterology                      The medical subspecialty that deals specifically with the
                                      investigation, diagnosis, and management of disorders of
                                      the digestive system including the pancreas and liver.
Gastrointestinal (GI)                 Adjective referring collectively to the stomach and small and
                                      large intestines. The commonly used abbreviation for
                                      gastrointestinal is GI.
Healthcare Equity                     Healthcare equity refers to the distribution and quality of
                                      healthcare resources, including the accessibility,
                                      acceptability, and appropriateness of health services. It also
                                      implies justice or fairness in the production and control of
                                      healthcare resources.
Hepatologist                          A specialist who diagnosis and treats disorders of the liver,
                                      pancreas, gall bladder, and biliary tree. It is a sub-specialty
                                      of gastroenterology, which studies the digestive systems as
                                      a whole.
Hepatology                            Hepatology is the branch of medicine that incorporates the
                                      study of liver, gallbladder, biliary tree, and pancreas as well
                                      as management of their disorders.
Innovation                            A device, drug, technique, method, system, or a service
                                      procured from outside an organization or developed within,
                                      with ideally clear evidence of its added value over existing
                                      approaches.

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     Knowledge Translation                 A dynamic and iterative process that includes the synthesis,
                                           dissemination, exchange and ethically sound application of
                                           knowledge to improve health, provide more effective health
                                           services and products, and strengthen the healthcare
                                           system.
     Pan-SCN                               Concepts or initiatives that are applicable or of interest to
                                           multiple Strategic Clinical Networks.
     Partnership for Research and          A partnership between Alberta Innovates (AI) and Alberta
     Innovation in the Health              Health Services (AHS) that provides a partnered funding
     System (PRIHS)                        opportunity targeting high impact research activities within
                                           the SCNs that align with the priorities identified in the
                                           Alberta Health Research and Innovation Strategy and the
                                           AHS Health Plan. PRIHS supports networks of health
                                           researchers and clinical practitioners to reassess potentially
                                           inefficient activities within the health system and identify
                                           sustainable solutions to improve overall quality of care and
                                           value for money in the health system.
     Patient-and Family-Centered           Patient - and family-centered care sees patients and
     Care                                  families as integral members of the healthcare team, and
                                           encourages their active participation in all aspects of care,
                                           including as partners in planning, implementation and
                                           evaluation of existing and future care and services.
     Person-focused                        A popular term for healthcare and social services which
                                           reflect the individual’s unique preferences, values and
                                           needs, identified and agreed upon in partnership with the
                                           physician.
     Proton Pump Inhibitors (PPIs)         A group of drugs whose main purpose is the prolonged
                                           reduction of the production of gastric acid.
     Quadruple Aim                         AHS' approach to achieve four key objectives:
                                             1. Improve patient and family experiences.
                                             2. Improve patient and population health outcomes.
                                             3. Improve the experience and safety of our people.
                                             4. Improve financial health and value for money.
     Quality                               The Health Quality Council of Alberta (HQCA) defines
                                           quality within the Alberta Quality Matrix for Health
                                           framework, which includes six quality dimensions:
                                               1. Acceptability
                                               2. Accessibility
                                               3. Appropriateness
                                               4. Effectiveness
                                               5. Efficiency
                                               6. Safety.

     Quality Improvement                   A continuous process which includes identifying issues and
                                           opportunities, applying well thought out and often innovative
                                           solutions, and then learning from the process and resulting
                                           outcomes.

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

Referral                                The act of referring someone or something for consultation,
                                        review, or further action:
                                             The directing of a patient to a medical specialist by a
                                                primary care physician.
                                             A person whose case has been referred to a
                                                specialist doctor or a professional body.
Strategic Clinical Networks             Networks developed by Alberta Health Services comprised
(SCNs)                                  of people who are passionate and knowledgeable about
                                        specific areas of health, challenging them to find new and
                                        innovative ways of delivering care that will provide better
                                        quality, better outcomes, and better value for every
                                        Albertan.
Strategic Goals                         Strategic goals determine the long range direction of the
                                        DHSCN based on their mission and vision. Each strategic
                                        goal’s name reflects what the DHSCN wants to change in
                                        order to better meet their mission and help resolve strategic
                                        targets identified through stakeholder consultation and
                                        engagement.

Sustainability                          Incorporation of measures intended to ensure the ongoing
                                        maintenance of initiatives once project funding has ended.
The Scientific Office of the            Includes the Scientific Director and the Assistant Scientific
Digestive Health Strategic              Director of the SCN. It leads the promotion, adoption, and
Clinical Network                        diffusion of innovation as well as the creation and use of
                                        evidence to drive decision making in digestive health. The
                                        six pillars of activity are:
                                             1. Knowledge Translation
                                             2. Advancing Research Knowledge
                                             3. Building Partnerships for Research
                                             4. Research Facilitation
                                             5. Research Capacity Building and Training
                                             6. Research Prioritization
Transformational Roadmap                The strategic plan of a Strategic Clinical Network that
(TRM)                                   outlines how they will transform healthcare over a three -
                                        four year time period. Includes vision and mission
                                        statements, foundational principles, enablers of success,
                                        and strategic goals with corresponding priorities.

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

     Appendix C: References
       1. Novak, K. (2017). Gastroenterology Access in the Calgary Zone.

       2. Veldhuyzen van Zanten, S. (2017). Gastroenterology Access in the Edmonton Zone.

       3. Paterson WG, Depew WT, Pare P, Petrunia D, Switzer C, Veldhuyzen van Zanten SJ,
          Daniels S, Canadian Association of Gastroenterology Wait Times Consensus Group.
          Canadian consensus on medically acceptable wait times for digestive healthcare. Can J
          Gastroenterol 2006 Jun;20(6):411-23. PMID: 16779459

       4. Champlain Base eConsult. (2017, July 31). Stats and publications: eConsult by the
          numbers. http://docs.wixstatic.com/ugd/ac5147_f028730d997d42ea8439683ea25c72e2.
          .pdf

       5. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the
          inflammatory bowel diseases with time, based on systematic review. Gastroenterology.
          Jan 2012;142(1):46-54 e42
       6. Coward S, Clement F, Williamson T, et al. The Rising Burden of Inflammatory Bowel
          Disease in North America from 2015 to 2025: A Predictive Model. Am J Gastroenterol.
          2015;110(S835).

       7. Benchimol E, Kaplan GG, Nguyen GC, et al. The influence of rural/urban environment
          on the risk of inflammatory bowel disease in Canada: A population-based and birth
          cohort study from the Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC).
          Gastroenterol. 2015;148(4 (Suppl 1)):S-3.

       8. Fedorak RN, Vanner SJ, Paterson WG, Bridges RJ. Canadian Digestive Health
          Foundation Public Impact Series 3: irritable bowel syndrome in Canada. Incidence,
          prevalence, and direct and indirect economic impact. Can J Gastroenterol.
          2012;26(5):252-256.

       9. Statistics Canada. Canadian Community Health Survey, Public Use Microdata File.
          2014.
       10. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin
           Epidemiol. 2014;6:71-80.

       11. Spiller R, Aziz Q, Creed F, et al. Guidelines on the irritable bowel syndrome:
           mechanisms and practical management. Gut. 2007;56(12):1770-1798.

       12. Gunn MC, Cavin AA, Mansfield JC. Management of irritable bowel syndrome. Postgrad
           Med J. 2003;79(929):154-158.
       13. Sainsbury A, Ford AC. Treatment of irritable bowel syndrome: beyond fiber and
           antispasmodic agents. Therap Adv Gastroenterol. 2011;4(2):115-127.

       14. Rocchi A, Benchimol EI, Bernstein CN, et al. Inflammatory bowel disease: a Canadian

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Digestive Health Strategic Clinical Network™ Transformational Roadmap 2017-2021

   burden of illness review. Canadian journal of gastroenterology. Nov 2012;26(11):811-
   817.

15. AHS DIMR Analytics. (2017). Endoscopy volume for zones, hospitals and LGA’s by
    residency [Data file]. Retrieved from
    https://tableau.albertahealthservices.ca/#/views/EndoscopyVolumesforZonesHospitalsan
    dLGAsbyResidency/ResidentInfo?:iid=1
16. Canadian Institute for Health Information. Unnecessary Care in Canada. Ottawa, ON:
    CIHI; 2017.

17. Lang, E. & Lang, R. (2017, July 27). Consider possible alternatives to proton pump
    inhibitors. Calgary Herald. Retrieved from: https://www.pressreader.com/canada/calgary-
    herald/20170727/282295320271403

18. Canadian Institute for Health Information. Prescribed Drug Spending in Canada, 2013: A
    Focus on Public Drug Programs. Ottawa, ON: CIHI; 2015.
19. Scagliarini, R., Magnani, E., Praticò, A. et al. Dig Dis Sci (2005) 50: 2307.
    https://doi.org/10.1007/s10620-005-3052-4

20. Canadian Association of Gastroenterology. (2017, June). Five Things Physicians and
    Patients Should Question. Retrieved from
    https://choosingwiselycanada.org/gastroenterology/

21. Wong, C. (2016). Colorectal cancer screening in Alberta: inappropriate use of the Fecal
    Immunochemical Test (FIT) [Abstract]. Presented at the 2016 Annual Scientific
    Assembly of Alberta College of Family Physicians https://www.acfp.ca/wp-
    content/uploads/2016/02/61ASA_FinalProgram.pdf

22. Toward Optimized Practice (TOP) Working Group for Colorectal Cancer Screening.
    (2013 Nov). Colorectal cancer screening: clinical practice guideline. Edmonton, AB:
    Toward Optimized Practice. Available from: http://www.topalbertadoctors.org
23. Canadian Digestive Health Foundation. (2017). Statistics: All disorders. Retrieved from
    http://www.cdhf.ca/en/statistics

24. Canadian Liver Foundation. Liver Disease in Canada: A Crisis in the Making. March
    2013. Available at:
    http://www.liver.ca/files/PDF/Liver_Disease_Report_2013/Liver_Disease_in_Canada_-
    _E.pdf.

25. Sherman, M., Bilodeau, M., Cooper, C., Mackie, D., Depew, W., Villeneuve, J-P., MD,
    Bain, V. , Liver Disease in Canada: A Crisis in the Making. 2013. March: p. 1-72.

26. Myers, R.P., M. Liu, and A.A. Shaheen, The burden of hepatitis C virus infection is
    growing: a Canadian population-based study of hospitalizations from 1994 to 2004. Can
    J Gastroenterol, 2008. 22(4): p. 381-7.

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