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Long wait times for scheduled surgical procedures have long been a concern in Canadian health systems. (1) Access to health services is determined by the demand for services, the supply [...], Background: Little is known about the existing structure and function of referral networks in the prevalent referral system for specialized surgical care in Canada, which is based on direct physician referral to specialists in a largely unmanaged referral marketplace. Our objective was to describe and analyze the referral networks of referring physicians and surgeons for common surgical procedures in Ontario, to better understand potential barriers to single-entry models. Methods: We analyzed referral networks for patients between referring physicians and surgeons for 9 common scheduled surgical procedures from 2016 to 2019 using administrative data sources in Ontario. We described the connectedness of referring physician-surgeon pairs using descriptive measures and graphical social network analysis. Results: The median number of surgeons connected to a referring physician for patients having a particular surgical procedure ranged from 1 (interquartile range [IQR] 1-3) for spine surgery to 3 (IQR 1-4) for knee arthroplasty and 3 (IQR 2-5) for noncancer uterine procedures. Referral network structure varied according to the procedure studied. Spine surgery was highly clustered with a small number of larger groups; gallbladder, inguinal hernia, and noncancer uterine surgery were highly distributed with many small groups within the referral network. Breast cancer surgery occurred in a largely distributed network, but with a skewed distribution reflecting a few small groups with large numbers of patients. Conclusion: Improving surgical wait times by coordinating surgical referrals will require approaches that address the structure of existing referral networks. Most physicians refer their patients to a very small number of surgeons, suggesting that referring physicians largely do not individualize referrals to multiple different surgeons based on specific patient characteristics. Contexte : On en conna t peu sur la structure et le fonctionnement actuels des r seaux d'aiguillage du pr sent syst me de r partition des demandes de consultations en soins chirurgicaux sp cialis s au Canada car ce syst me repose sur les demandes adress es directement aux sp cialistes par les m decins traitants dans un contexte non g r . Notre objectif tait de d crire et d'analyser les r seaux d'aiguillage entre m decins traitants et sp cialistes en chirurgie pour les interventions courantes en Ontario, afin de mieux comprendre les obstacles potentiels aux mod les acc s unique. M thodes : Nous avons analys les r seaux d'aiguillage des patients et patientes entre les m decins traitants et les sp cialistes en chirurgie pour des interventions courantes planifi es de 2016 2019 partir de banques de donn es administratives ontariennes. Nous avons d crit l'appariement m decin traitant-sp cialiste en chirurgie l'aide de mesures descriptives et d'une repr sentation graphique des r seaux d'aiguillage. R sultats : Le nombre m dian de chirurgiennes et chirurgiens appari s un m decin traitant pour un type de chirurgie en particulier allait de 1 ( ventail interquartile [ I] 1-3) pour la chirurgie de la colonne vert brale 3 ( I 1-4) pour l'arthroplastie du genou et 3 ( I 2-5) pour les probl mes ut rins non canc reux. La structure des r seaux d'aiguillage variait selon l'intervention tudi e. La chirurgie de la colonne vert brale pr sentait plus de grappes, comportant un petit nombre de groupes plus denses; les chirurgies de la v sicule biliaire, de la hernie inguinale et des probl mes ut rins non canc reux taient largement distribu es, comportant plusieurs groupes restreints travers tout le r seau d'aiguillage. La chirurgie pour cancer du sein tait largement r partie, mais sa distribution tait asym trique, t moignant d'un nombre restreint de petits groupes plus nombreux de patientes. Conclusion : Pour am liorer les temps d'attente en coordonnant les demandes de consultation en chirurgie, il faudra des approches ax es sur les r seaux d'aiguillage existants. La plupart des m decins traitants orientent leur patient le vers un tr s petit nombre de chirurgiennes et chirurgiens, ce qui laisse entendre que pour une bonne part, ils n'individualisent pas leurs demandes de consultation aupr s de multiples chirurgiennes ou chirurgiens en fonction des caract ristiques sp cifiques des malades.

Adaptive leadership has become an essential skill for leaders in health systems to respond to the COVID-19 pandemic as new knowledge emerges and case counts rise, fall, and rise again. This leadership approach has been described as an iterative process of taking a wide view of the situation, interpreting the meaning of incoming data from multiple directions, and taking real-time action. This process is also common in start-ups, which attempt to create new products or services of uncertain value for consumer markets that may not yet exist. Start-ups manage uncertainty through “pivots,” which can include changes in the target group, need, features, or intended benefit of a product or service. Pivots are large changes that account for the high likelihood of getting something wrong during development, and they are distinct from the “tweaks” or small tests of change that define quality improvement methodology. This case study describes three pivots in the launch of a remote monitoring program for COVID-19. Adaptive leadership helped inform strategic decisions, with pivots providing a framework for internal and external stakeholders to articulate options for changes to address shifting needs. There is considerable uncertainty in the appropriate design and implementation of health services, and although this case example focuses on the use of adaptive leadership and pivots during a pandemic, these strategies are relevant for health care leaders at any time.

INTRODUCTION Balancing timely access with care continuity remains an important challenge in primary care. Although 90% of the population in Ontario, Canada's most populous province, report having a family physician [...], PURPOSE Primary care access is a key health system metric, but little research has compared models to provide primary care access when one's regular physician is not available. We compared health system use after a visit with a patient's own family physician group (ie, within-group physician who was not the patient's primary physician) vs a visit with a walk-in clinic physician who was not part of the patient's family physician group. METHODS We conducted a population-based, retrospective cohort study using administrative data from Ontario, Canada, including all individuals formally enrolled with a family physician, from April 1, 2019 to March 31, 2020. We compared those visiting within-group physicians to those visiting walk-in clinic physicians using propensity score matching to account for differences in patient characteristics. The primary outcome was any emergency department visit within 7 days of the initial visit. RESULTS Matched patients who visited a within-group physician (N = 506,033) were 10% less likely to visit an emergency department in the 7 days after the initial visit compared to patients who saw a walk-in clinic physician (N = 506,033; 20,117 [4.0%] vs 22,320 [4.4%]; risk difference [RD] 0.4%; 95% CI 0.4-0.5; relative risk [RR] 0.90; 95% CI, 0.89-0.92). Restricting to visits occurring on weekends, the observed association was stronger (7,964 [3.7%] vs 10,055 [4.7%]; RD 1.0%; 95% CI 0.9-1.1; RR 0.79; 95% CI, 0.77-0.82). Those accessing after-hours within-group physician visits were more likely to have >1 additional virtual or in-person within-group physician visit within 7 days (virtual RR 1.86, in-person RR 1.87). CONCLUSIONS Compared to visiting a walk-in clinic physician, seeing a within- group physician after hours might decrease downstream emergency department visits. This finding could be explained by better continuity of care and can inform primary care service models and the policies that support them.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. METHODS: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. RESULTS: There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. INTERPRETATION: The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Background: Strong primary care (PC) services are the foundation of high-performing health care systems and can support effective responses to public health emergencies. Primary care practitioners (PCPs) and PC services played crucial roles in supporting global health system responses to the COVID-19 pandemic. However, these contributions have come at a cost, impacting on PC services and affecting patient care. This secondary analysis of data from an integrative systematic review across international PC settings aimed to identify and describe burdens and challenges experienced by PCPs and PC services in the context of their contributions to COVID-19 pandemic responses. Methods: We conducted an integrative systematic review and narrative analysis, searching PubMed/Medline, Scopus, Proquest Central and Cochrane Database of Systematic Reviews, plus reference lists of key publications. Included studies were published in peer-reviewed English or Chinese language journals, and described collective responses to COVID-19 undertaken in PC settings or by PCPs. Narrative data regarding impacts on PC services and challenges experienced by PCPs were extracted and analysed using inductive coding and thematic analysis. Results: From 1745 screened papers 108, representing 90 countries, were included. Seventy-eight contained data on negative impacts, challenges or issues encountered in PC. Ten 'pressure points' affecting PC during COVID-19 were identified, clustered in four themes: demand to adopt new ways of working; pressure to respond to fluctuating community needs; strain on PC resources and systems; and ambiguity in interactions with the broader health and social care system. Conclusions: PCPs and PC services made critical functional contributions to health system responsiveness during the COVID-19 pandemic. However, both practitioners and PC settings were individually and collectively impacted during this period as a result of changing demands in the PC environment and the operational burden of additional requirements imposed on the sector, offering lessons for future pandemics. This study articulates ten empirically derived 'pressure points' that provide an initial understanding of burdens and demands imposed on the international primary care sector during the COVID-19 pandemic. The impact of these contributions should inform future pandemic planning, guided by involvement of PCPs in public health preparedness and policy design. [ABSTRACT FROM AUTHOR]

Beech leaf disease (BLD), caused by the Litylenchus crenatae ssp. mccannii (Lcm) nematode, is an emerging threat to beech trees. This disease is characterized by distinct leaf symptoms, including leaf interveinal banding and thickened leaf texture, which leads to eventual tree mortality. Understanding Lcm dispersal mechanism(s) is crucial for managing BLD, yet these remain largely unknown, posing a major barrier to its effective management. This study represents a pioneering investigation into the abiotic and biotic vectors that potentially contribute to the local dispersal of Lcm in natural American beech (Fagus grandifolia) forest systems in the Northeastern United States. An experiment was set up in Stone Valley Forest, Pennsylvania (PA), using four funnel stands placed at variable distances from naturally BLD-infected beech trees. This approach enabled the recovery of active Lcm nematodes from each funnel, demonstrating their ability to naturally disperse at least 11.74 m from the nearest BLD-infected tree. The findings highlight the role of abiotic factors involved in the dispersal dynamics of Lcm, especially wind and humidity, as indicated by a generalized linear model. The current study also uncovered the incidental association of Lcm with other organisms beneath the canopy of BLD trees, including spiderwebs and caterpillars. To our knowledge, this is the first study to document the potential vectors involved in the local dispersal of Lcm, offering valuable information for the biology of this nematode, as well as insight into the development of effective BLD management strategies. The findings contribute to broader efforts in advancing the understanding of the local spread of BLD, highlighting the complex interplay of abiotic and biotic factors in this disease dispersal. [ABSTRACT FROM AUTHOR]

How do voters react to local candidates who share their policy views but not their party identification, and vice versa? This paper presents findings from a survey experiment that cross-pressured respondents to choose between a co-partisan candidate who does not share their policy views (on housing and homelessness) and an opposing party candidate with some ideological affinity. The majority of respondents chose party over policy, indicating they would vote for co-partisans even if the candidate from the opposing party is closer to their policy positions. However, significant minorities defected and in some circumstances most did. Weak partisans, those with stronger policy views, and those who viewed the issues as highly salient were more likely to defect from their party when cross-pressured. Our findings support revising the expectation that partisanship always takes precedence over policy views and reinforces the view that partisanship may operate differently at the local level. [ABSTRACT FROM AUTHOR]