1
|
Butler S, Sculley D, Santos D, Girones X, Singh-Grewal D, Coda A. Paediatric Rheumatology Fails to Meet Current Benchmarks, a Call for Health Equity for Children Living with Juvenile Idiopathic Arthritis, Using Digital Health Technologies. Curr Rheumatol Rep 2024; 26:214-221. [PMID: 38466514 PMCID: PMC11116247 DOI: 10.1007/s11926-024-01145-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE OF REVIEW This critical review begins by presenting the history of Juvenile Idiopathic Arthritis (JIA) management. To move the conversation forward in addressing the current shortcomings that exist in the clinical management of children living with JIA, we argue that to date, the advancement of successful treatments for JIA has been historically slow. Factors implicated in this situation include a lack of rigorous research, JIA being considered a rare disease, and JIA's idiopathic and complex pathophysiology. RECENT FINDINGS Despite the well-intended legislative changes to increase paediatric research, and the major advancements seen in molecular medicine over the last 30 years, globally, paediatric rheumatology services are still failing to meet the current benchmarks of best practice. Provoking questions on how the longstanding health care disparities of poor access and delayed treatment for children living with JIA can be improved, to improve healthcare outcomes. Globally, paediatric rheumatology services are failing to meet the current benchmarks of best practice. Raising awareness of the barriers hindering JIA management is the first step in reducing the current health inequalities experienced by children living with JIA. Action must be taken now, to train and well-equip the paediatric rheumatology interdisciplinary workforce. We propose, a resource-efficient way to improve the quality of care provided could be achieved by embedding digital health into clinical practice, to create an integrative care model between the children, general practice and the paediatric rheumatology team. To improve fragmented service delivery and the coordination of interdisciplinary care, across the healthcare system.
Collapse
Affiliation(s)
- Sonia Butler
- School of Bioscience and Pharmacy, University of Newcastle, 10 Chittaway Rd, Ourimbah, NSW, 2258, Australia.
| | - Dean Sculley
- School of Bioscience and Pharmacy, University of Newcastle, 10 Chittaway Rd, Ourimbah, NSW, 2258, Australia
| | - Derek Santos
- School of Health Sciences, Queen Margaret University, Musselburgh, EH21 6UU, UK
| | - Xavier Girones
- Faculty of Health Sciences, Universities de Catalunya, Via Laietana, 2. Planta 4, 08003, Barcelona, Spain
| | - Davinder Singh-Grewal
- Department of Rheumatology, Sydney Children's Hospitals Network, Randwick and Westmead, Westmead, NSW, 2145, Australia
- John Hunter Children's Hospital, New Lambton Heights, NSW, 2305, Australia
- Discipline of Child and Adolescent Health, University of Sydney, Camperdown, NSW, 2006, Australia
- School of Women's and Children's Health, University of NSW, Sydney, NSW, 2052, Australia
| | - Andrea Coda
- School of Health Sciences, University of Newcastle, Chittaway Rd, Ourimbah, NSW, 2258, Australia
- 'Equity in Health and Wellbeing Research Program' at the Hunter Medical Research Institute (HMRI), Lot 1, Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| |
Collapse
|
2
|
Cooper SM, Currie GR, Kromm S, Twilt M, Marshall DA. Evaluating key performance indicators of the process of care in juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2023; 21:37. [PMID: 37085775 PMCID: PMC10120096 DOI: 10.1186/s12969-023-00818-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/07/2023] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVE To determine whether and how often the information to measure a set of key performance indicators (KPIs) in juvenile idiopathic arthritis (JIA) is found in data collected routinely in a Pediatric Rheumatology Clinic. METHODS A retrospective electronic chart review and administrative data analysis was conducted for a cohort of 140 patients with JIA at a tertiary Pediatric Rheumatology Clinic between 2016-2020. The set of KPIs include measuring patient outcomes (joint assessment, physician's global assessment of disease activity, assessment of functional ability, composite disease activity measurement), access to care (waiting time between referral and first visit, visit with the rheumatologist within the first year of diagnosis, annual follow-up visits with the rheumatologist), and safety (tuberculosis screening, and laboratory monitoring). Documentation was assessed as a binary variable indicating whether the required information was ever found. Documentation frequency for each KPI was assessed with counts and percentages of the number of times the required information was documented for each clinic visit. Compliance with the safety KPI definitions was assessed using administrative databases. RESULTS Data for each KPI were found at least once in the cohort and documentation varied in frequency and consistency. Access to care and safety KPIs were documented more frequently than patient outcome KPIs. A joint assessment was documented at every visit for 95% of patients, 46% for an assessment of pain, and none for a physician's global assessment of disease activity, an assessment of functional ability, or a composite disease activity measurement. CONCLUSION Although feasible to measure, there is an opportunity for improving the consistency of documentation. Having an active system of monitoring KPIs and tools to simplify measurement is a key step in the process toward improved patient care outcomes. Streamlining the collection of KPI data can increase the likelihood of compliance. Next steps should involve replicating this study in various centres.
Collapse
Affiliation(s)
- Sarah M Cooper
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gillian R Currie
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
- Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Seija Kromm
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Maternal Newborn Child & Youth Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
| | - Marinka Twilt
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Section of Rheumatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
3
|
Cánovas R, Cobb J, Brozynska M, Bowes J, Li YR, Smith SL, Hakonarson H, Thomson W, Ellis JA, Abraham G, Munro JE, Inouye M. Genomic risk scores for juvenile idiopathic arthritis and its subtypes. Ann Rheum Dis 2020; 79:1572-1579. [PMID: 32887683 PMCID: PMC7677485 DOI: 10.1136/annrheumdis-2020-217421] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Juvenile idiopathic arthritis (JIA) is an autoimmune disease and a common cause of chronic disability in children. Diagnosis of JIA is based purely on clinical symptoms, which can be variable, leading to diagnosis and treatment delays. Despite JIA having substantial heritability, the construction of genomic risk scores (GRSs) to aid or expedite diagnosis has not been assessed. Here, we generate GRSs for JIA and its subtypes and evaluate their performance. METHODS We examined three case/control cohorts (UK, US-based and Australia) with genome-wide single nucleotide polymorphism (SNP) genotypes. We trained GRSs for JIA and its subtypes using lasso-penalised linear models in cross-validation on the UK cohort, and externally tested it in the other cohorts. RESULTS The JIA GRS alone achieved cross-validated area under the receiver operating characteristic curve (AUC)=0.670 in the UK cohort and externally-validated AUCs of 0.657 and 0.671 in the US-based and Australian cohorts, respectively. In logistic regression of case/control status, the corresponding odds ratios (ORs) per standard deviation (SD) of GRS were 1.831 (1.685 to 1.991) and 2.008 (1.731 to 2.345), and were unattenuated by adjustment for sex or the top 10 genetic principal components. Extending our analysis to JIA subtypes revealed that the enthesitis-related JIA had both the longest time-to-referral and the subtype GRS with the strongest predictive capacity overall across data sets: AUCs 0.82 in UK; 0.84 in Australian; and 0.70 in US-based. The particularly common oligoarthritis JIA also had a GRS that outperformed those for JIA overall, with AUCs of 0.72, 0.74 and 0.77, respectively. CONCLUSIONS A GRS for JIA has potential to augment clinical JIA diagnosis protocols, prioritising higher-risk individuals for follow-up and treatment. Consistent with JIA heterogeneity, subtype-specific GRSs showed particularly high performance for enthesitis-related and oligoarthritis JIA.
Collapse
Affiliation(s)
- Rodrigo Cánovas
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia
| | - Joanna Cobb
- Childhood Arthritis, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marta Brozynska
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia
| | - John Bowes
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Yun R Li
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Helen Diller Family Comprehensive Cancer Center, Department of Radiation Oncology, University of California San Francisco, San Francisco, California, United States
| | - Samantha Louise Smith
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Wendy Thomson
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom.,National Institute of Health Research Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Justine A Ellis
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Faculty of Health, Centre for Social and Early Emotional Development, Deakin University, Burwood, Victoria, Australia
| | - Gad Abraham
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia.,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,Department of Clinical Pathology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane E Munro
- Childhood Arthritis, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Rheumatology Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Inouye
- Cambridge Baker Systems Genomics Initiative, Baker Heart Research Institute - BHRI, Melbourne, Victoria, Australia .,Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,Department of Clinical Pathology, University of Melbourne, Melbourne, Victoria, Australia.,British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.,British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, United Kingdom.,Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom.,The Alan Turing Institute, London, United Kingdom
| |
Collapse
|
4
|
Barber CEH, Then KL, Bohm V, Hall M, Marshall DA, Rankin JA, Barnabe C, Hazlewood GS, Li LC, Mosher D, Homik J, MacMullan P, Tsui K, English K, Lacaille D. Development of a Patient-centered Quality Measurement Framework for Measuring, Monitoring, and Optimizing Rheumatoid Arthritis Care in Canada. J Rheumatol 2020; 48:326-334. [PMID: 33452175 DOI: 10.3899/jrheum.200688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to develop a patient-centered quality measurement framework to address a predefined vision statement and 7 strategic objectives for rheumatoid arthritis (RA) care that was developed in prior qualitative work with arthritis stakeholders. METHODS One hundred forty-seven RA-related performance measures (PMs) were identified from a systematic review. A candidate list of 26 PMs meeting predefined criteria and addressing the strategic objectives previously defined was then assessed during a 3-round (R) modified Delphi. Seventeen panelists with expertise in RA, quality measurement, and/or lived experience with RA rated each PM on a 1-9 scale based on the items of importance, feasibility, and priority for inclusion in the framework during R1 and R3, with a moderated discussion in R2. PMs with median scores ≥ 7 on all 3 items without disagreement were included in the final set, which then underwent public comment. RESULTS Twenty-one measures were included in the final framework (15 PMs from the Delphi and 6 published system-level measures on access to care and treatment). The measures included 4 addressing early access to care and timely diagnosis, 12 evidence-based care for RA and related comorbidities, 1 addressing patient participation as an informed partner in care, and 4 on patient outcomes. CONCLUSION The proposed framework builds upon existing measures capturing early access to care and treatment in RA and adds important PMs to promote high-quality RA care and outcome measurement. In the next phase, the authors will test the framework in clinical practice in addition to addressing certain areas where no suitable PMs were identified.
Collapse
Affiliation(s)
- Claire E H Barber
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, D.A. Marshall, PhD, Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, Department of Medicine, Department of Community Health Sciences Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada;
| | - Karen L Then
- K.L. Then, ACNP, CCN(C), PhD, Professor, M. Hall, MSc, CCRP, Research Associate, J.A. Rankin, ACNP, PhD, Professor, Faculty of Nursing, University of Calgary, Calgary, Alberta
| | - Victoria Bohm
- V. Bohm, MSc, MPH, Research Associate, D. Mosher, MD, FRCPC, Professor, P. MacMullan, MBBCh, BAO, MRCPI, MD, Clinical Associate Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Marc Hall
- K.L. Then, ACNP, CCN(C), PhD, Professor, M. Hall, MSc, CCRP, Research Associate, J.A. Rankin, ACNP, PhD, Professor, Faculty of Nursing, University of Calgary, Calgary, Alberta
| | - Deborah A Marshall
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, D.A. Marshall, PhD, Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, Department of Medicine, Department of Community Health Sciences Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada
| | - James A Rankin
- K.L. Then, ACNP, CCN(C), PhD, Professor, M. Hall, MSc, CCRP, Research Associate, J.A. Rankin, ACNP, PhD, Professor, Faculty of Nursing, University of Calgary, Calgary, Alberta
| | - Cheryl Barnabe
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, D.A. Marshall, PhD, Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, Department of Medicine, Department of Community Health Sciences Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada
| | - Glen S Hazlewood
- C.E. Barber, MD, FRCPC, PhD, Assistant Professor, D.A. Marshall, PhD, Professor, C. Barnabe, MD, FRCPC, MSc, Associate Professor, G.S. Hazlewood, MD, FRCPC, PhD, Associate Professor, Department of Medicine, Department of Community Health Sciences Cumming School of Medicine, University of Calgary, Calgary, Alberta, and Arthritis Research Canada
| | - Linda C Li
- L.C. Li, PT, PhD, Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, and Arthritis Research Canada
| | - Dianne Mosher
- V. Bohm, MSc, MPH, Research Associate, D. Mosher, MD, FRCPC, Professor, P. MacMullan, MBBCh, BAO, MRCPI, MD, Clinical Associate Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Joanne Homik
- J. Homik, MD, FRCPC, MSc, Professor, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Paul MacMullan
- V. Bohm, MSc, MPH, Research Associate, D. Mosher, MD, FRCPC, Professor, P. MacMullan, MBBCh, BAO, MRCPI, MD, Clinical Associate Professor, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Karen Tsui
- K. Tsui, MScPT, ACPAC, Arthritis Patient Advisory Board (APAB) member, K. English, Arthritis Patient Advisory Board (APAB) member, Arthritis Patient Advisory Board
| | - Kelly English
- K. Tsui, MScPT, ACPAC, Arthritis Patient Advisory Board (APAB) member, K. English, Arthritis Patient Advisory Board (APAB) member, Arthritis Patient Advisory Board
| | - Diane Lacaille
- D. Lacaille, MD, FRCPC, MHSc, Professor, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada, and Scientific Director, Arthritis Research Canada
| | | |
Collapse
|
5
|
Barber CEH, Twilt M, Pham T, Currie GR, Benseler S, Yeung RSM, Batthish M, Blanchette N, Guzman J, Lang B, LeBlanc C, Levy DM, O'Brien C, Schmeling H, Soon G, Spiegel L, Whitney K, Marshall DA. A Canadian evaluation framework for quality improvement in childhood arthritis: key performance indicators of the process of care. Arthritis Res Ther 2020; 22:53. [PMID: 32192528 PMCID: PMC7083048 DOI: 10.1186/s13075-020-02151-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/09/2020] [Indexed: 01/22/2023] Open
Abstract
Background The evaluation of quality of care in juvenile idiopathic arthritis (JIA) is critical for advancing patient outcomes but is not currently part of routine care across all centers in Canada. The study objective is to review the current landscape of JIA quality measures and use expert panel consensus to define key performance indicators (KPIs) that are important and feasible to collect for routine monitoring in JIA care in Canada. Methods Thirty-seven candidate KPIs identified from a systematic review were reviewed for inclusion by a working group including 3 pediatric rheumatologists. A shortlist of 14 KPIs was then assessed using a 3-round modified Delphi panel based on the RAND/UCLA Appropriateness Method. Ten panelists across Canada participated based on their expertise in JIA, quality measurement, or lived experience as a parent of a child with JIA. During rounds 1 and 3, panelists rated each KPI on a 1–9 Likert scale on themes of importance, feasibility, and priority. In round 2, panelists participated in a moderated in-person discussion that resulted in minor modifications to some KPIs. KPIs with median scores of ≥ 7 on all 3 questions without disagreement were included in the framework. Results Ten KPIs met the criteria for inclusion after round 3. Five KPIs addressed patient assessments: pain, joint count, functional status, global assessment of disease activity, and the clinical Juvenile Arthritis Disease Activity Score (cJADAS). Three KPIs examined access to care: wait times for consultation, access to pediatric rheumatologists within 1 year of diagnosis, and frequency of clinical follow-up. Safety was addressed through KPIs on tuberculous screening and laboratory monitoring. KPIs examining functional status using the Childhood Health Assessment Questionnaire (CHAQ), quality of life, uveitis, and patient satisfaction were excluded due to concerns about feasibility of measurement. Conclusions The proposed KPIs build upon existing KPIs and address important processes of care that should be measured to improve the quality of JIA care. The feasibility of capturing these measures will be tested in various data sources including the Understanding Childhood Arthritis Network (UCAN) studies. Subsequent work should focus on development of meaningful outcome KPIs to drive JIA quality improvement in Canada and beyond.
Collapse
Affiliation(s)
- Claire E H Barber
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marinka Twilt
- Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Tram Pham
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gillian R Currie
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Susanne Benseler
- Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Rae S M Yeung
- Departments of Pediatrics, Immunology and Medical Science, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Batthish
- Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, ON, Canada
| | - Nicholas Blanchette
- The Hospital for Sick Children, Toronto, ON, Canada.,Trillium Health Partners, Mississauga, ON, Canada
| | - Jaime Guzman
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Claire LeBlanc
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Deborah M Levy
- Departments of Pediatrics, Immunology and Medical Science, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Heinrike Schmeling
- Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Gordon Soon
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Lynn Spiegel
- The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Deborah A Marshall
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|