CMAJ Open

IntroductionUsing an open enrollment process in 2023, California funded 28 emergency departments (EDs) to implement or expand HIV and syphilis screening programs. Californias 2026 state budget now commits an additional $60 million, over six years, to renew support for this screening. How renewed funds are allocated will determine which communities they reach. This analysis establishes a framework derived from public information to simulate and compare several funding strategies, highlighting the tradeoffs across disease burden, geographic reach, and social vulnerability. MethodsPublicly available data were used to construct ED-level profiles for the 282 EDs in the 35 California counties with populations exceeding 100,000. Profiles were then linked to corresponding HIV and syphilis burden (z-score), measures of social vulnerability for the surrounding service area , and socioeconomic and demographic characteristics of the population each ED serves. At a 28 ED award scale, allocation strategies (random selection, prior 2023 awardees, federal priority-county targeting, ranking on burden alone, and a composite of burden, vulnerability, and visit volume) were then compared, simulating ED participation across 100,000 Monte Carlo draws at 70% participation. Sensitivity analyses included varied (50% and 90%) participation and a larger (n=64) ED award scale. Analyses were conducted in 2026. ResultsNo single strategy performed best. Ranking on burden alone reached the highest mean county burden but only 4 of 35 counties, whereas a composite approach reached 8 counties, the highest social vulnerability, and the largest share of patients who identified as Hispanic. Every targeted strategy performed better than both random selection and the prior 2023 awardees on burden but reached fewer counties than either. In sensitivity analyses, the tradeoffs between burden and reach persisted across participation rates and at the 64-ED scale.

PurposeRural Alaska relies on air ambulances ("medevacs") to connect remote villages off the road system to higher-level care. Yet medevac decision-making is complicated by limited guidelines, high costs, and delayed transport. We aimed to quantify variability in physician medevac decisions and identify contributing factors. MethodsWe conducted a cross-sectional survey of physicians (n=20) within the Alaska Tribal Health System using 20 clinical vignettes representing varying levels of transport complexity. Participants selected transport modality (medevac, commercial, or remain in village) and rated confidence. Interrater agreement was assessed using Gwets AC1. A generalized linear mixed model evaluated predictors of medevac use. FindingsAgreement was "almost perfect" for clearly critical cases ("always medevac," AC1=0.97) but declined substantially for intermediate scenarios ("possible medevac" AC1=0.39; "never medevac" AC1=0.26; "special considerations" AC1=0.12). Confidence strongly correlated with agreement (r=0.83, p<0.001), forming distinct clusters of high-, medium-, and low-certainty decisions. Vignette type was the dominant driver of medevac use (OR 455.5 for "always medevac"), but decisions did not change with experience (OR=0.99, 0.94-1.04). Between-physician variability persisted after adjustment (ICC 3.8%; MOR 1.67), consistent with differences in risk tolerance. ConclusionsMedevac decision-making is highly consistent in certain clinical cases but interrater agreement is limited for intermediate cases. Without a shared gold standard of "correct" medevac decisions, future clinical decision support cannot rely on automated medevac decision making. Efforts to improve care should focus on deconstructing decisions, enhancing outcome feedback, and developing targeted decision support rather than prescriptive decision models.

Introduction: Hospitals face increasing financial pressures. Hospital reimbursement is tied to the Case Mix Index (CMI). The CMI is a measure of complexity of care provided by the hospital and the total reimbursement is the CMI multiplied by a base pay factor, multiplied by the total number of discharges from the hospital. The few studies in the literature have involved logistically complex attempts to improve documentation. We sought to determine whether limited, structured chart review by surgeons can improve CMI in a multihospital system. Methods: We performed a prospective, observational study in a four-hospital academic medical system on all surgical patients from 10/2022 to 7/2026. Two clinically busy trauma surgeons performed limited structured chart reviews for select surgical patients. In the limited intervention period (1/2024-9/2024) this focused only on the trauma division. In the full intervention period (10/2024-7/2026) expanded to all surgical patients across the system. The main outcome was surgical case mix index (CMI). Results: A total of 35,695 patients were included (13,811 pre-intervention, 9,337 limited intervention, 12,547 full intervention). CMI increased significantly among surgical patients across the whole system (2.68 (95%CI 2.65-2.71) to 2.87 (95%CI 2.82-2.92) to 2.97 (95%CI 2.93-3.01), ANOVA p <0.001). Overall length of stay was unchanged among surgical patients across the whole system. The estimated increase in revenue per patient attributable to this intervention was $3,912 in surgical patients across the system. Conclusion: Having trauma surgeons review targeted surgical patients for high value documentation capture significantly enhanced the CMI and estimated revenue of surgical services across a multi-hospital integrated health system. Such documentation reviews may represent a practical method to improve hospital documentation and revenue.

BackgroundIn rural Alaska, where most communities lack road access, air ambulances serve as a critical link between remote communities and hospital services. ObjectiveTo examine how air ambulance utilization decisions are made within the rural Alaskan health organization ecosystem. MethodsWe conducted semi-structured interviews with five key stakeholders. Transcripts were analyzed thematically using the Practical, Robust Implementation and Sustainability Model (PRISM). ResultsFour themes emerged that collectively define the structure of the air ambulance decision-making system, each reflecting interactions across multiple PRISM domains: limited formal guidance, logistical constraints affecting transport options, variability driven by communication and clinician risk tolerance, and reliance on unwritten rules. Together, these describe decision-making in a limited information state with incomplete feedback, leading to experiential and locally evolved practices. ConclusionAir ambulance use reflects clinical-logistical constraints rather than critical illness alone. Linking transport decisions to outcomes and developing structured decision support may improve consistency and optimize care delivery.

Abstract Importance Patients with behavioral health presentations leave the emergency department (ED) before evaluation more often than other patients, but outcomes after leaving without being seen (LWBS) have not been described in this population. Objective To compare return visits, admission, and mortality after LWBS vs completed care among behavioral health ED episodes. Design, Setting, and Participants This retrospective episode-level cohort study used a multisystem deidentified electronic health record database of US health systems (data snapshot June 4, 2026). Participants were patients of all ages with an ED visit and same-day behavioral health diagnosis. Index visits (recorded January 26, 2001 to April 13, 2025) each opened a 30-day episode window; in-window were counted as outcomes, and patients could contribute episodes to either group. Data were analyzed in October 2026. Exposure LWBS (diagnosis code Z53.21 on a date with an ED encounter) vs completed care ending in discharge home. Main Outcomes and Measures The primary outcome was ED return visit within 7 days. Secondary outcomes were return visit within 3 and 30 days; admission on day 0, on days 1-7 (principal measure), and within 30 days; and all-cause death within 7 and 30 days, assessed among episodes from 2017 through 2023 using a verified death-record definition. Results The analysis included 1,305,812 episodes (12,248 LWBS; 1,293,564 completed care) from 525,490 patients; 666,930 episodes (51.1%) involved female patients and 66,733 (5.1%) involved patients younger than 18 years. Return visit within 7 days followed 24.5% of LWBS episodes vs 13.2% of completed-care episodes (risk ratio [RR], 1.86; 95% CI, 1.81-1.92), and admission on days 1-7 followed 17.1% vs 3.9% (RR, 4.41; 95% CI, 4.24-4.59). Among 2017-2023 episodes, 30-day mortality was 0.69% (70 of 10,141) after LWBS vs 0.32% (2,426 of 756,140) after completed care (RR, 2.15; 95% CI, 1.70-2.73). Results were similar under alternative episode definitions. Conclusions and Relevance Among patients with behavioral health ED presentations, LWBS was followed by higher rates of return visits, admission, and short-term mortality than completed care. These unadjusted findings describe outcome burden, not causal effects, and highlight patients who leave as a target for rapid follow-up.

This paper examines the impact of Cancer Care Ontario's regionalization of lung cancer surgery on blood transfusion use for thoracic surgery at The Ottawa Hospital. Using aggregate data scraped from the paper ''Changing trends in blood transfusion: an analysis of 244,013 hospitalizations'' by Shehata et al. (2014) we estimated the effect regionalization on the log mean number of blood transfusions among thoracic surgeons (who treat lung cancer), utilizing other surgical specialties as controls. We found that the average number of blood transfusions increased significantly among thoracic surgeons following the opening of a new cancer care centre at the hospital in December 2009, while control specialties showed no parallel change. Contextualizing these results in a modified ''population level'' treatment threshold model, it is argued that the main driver of this increase in blood transfusions among thoracic surgeons was due to the influx of less skilled thoracic surgeons to The Ottawa Hospital, and the closing of thoracic surgery units at smaller hospitals which was part of the broader regionalization process.

Background Pediatric neurocritical care (PNCC) has emerged as a distinct field, and many hospitals have moved to establishing dedicated PNCC programs. How practice change is implemented within these programs is not well understood. This study had two objectives. First, we sought to understand the barriers and facilitators of practice change in PNCC from the perspectives of the multiprofessional clinicians who deliver it. Second, we sought to characterize how well the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation determinant framework captures them. Methods We conducted semi-structured interviews with a purposive sample of clinicians involved in PNCC at three U.S. academic medical centers. The interview guide was developed using i-PARIHS to organize barriers and facilitators of practice change across the innovation, recipients, context, and facilitation constructs. We applied framework analysis, combining deductive i-PARIHS, study-specific, and inductively derived categories. Two coders independently indexed the transcripts and reconciled them to consensus, with first-author adjudication. Preliminary site-level findings were validated with participants. Results We interviewed 33 clinicians: 24 physicians, 7 nurses, and 2 advanced practice providers. Most determinants of practice change mapped to existing i-PARIHS constructs, but three were not adequately captured by the framework as currently specified. The most consequential was an interprofessional authority gradient that determined whose preferences prevailed when intensive care, neurology, and neurosurgery disagreed. The other two were clinician autonomy, which served as the lens through which the acceptability of a change was judged, and the affective state clinicians bring to practice change. Receptivity depended more on recipients' values, prior experience, and capacity to absorb change into a demanding workflow. Facilitation was variable, frequently under-resourced, and dependent on credibility across professional groups. We translated these findings into three propositions linked to implementation strategies and outcomes. Conclusions Participants attributed practice change in PNCC more to the recipients of change, the multiprofessional context, and the availability of facilitation than to the strength of evidence for a given practice. i-PARIHS captured most barriers and facilitators well but may be adapted in this setting. Credible, resourced, authority-sensitive facilitation may improve the prospects for sustained practice change as institutions develop PNCC programs.

Background Traumatic brain injury (TBI) is a major cause of morbidity and mortality in low- and middle-income countries (LMICs), where the burden of injury is disproportionately high, and healthcare resources are often limited. Clinical Practice Guidelines (CPGs) improve the consistency and quality of TBI care by shifting medical decision-making from individual judgement to evidence-based recommendations. The strong link between improved TBI outcomes and CPG adoption has largely been established in high-income country (HIC) hospital settings; evidence on implementing TBI CPGs in LMIC hospital settings is limited. Objective This study explored healthcare providers experiences to identify barriers and facilitators to implementing a TBI CPG in the Emergency Department (EMD) at Kilimanjaro Christian Medical Center in Northern Tanzania, guided by the Consolidated Framework for Implementation Research 2.0 (CFIR). Methods We conducted semi-structured in-depth interviews (IDIs) with doctors and nurses who regularly managed TBI patients at the EMD. We purposively sampled participants between June and August 2023. The research team analysed data using thematic content analysis guided by CFIR domains, developing codes and memos iteratively. Results 7 nurses and 8 doctors with an average of 5 years of experience caring for patients in the EMD completed in-person, in-depth interviews. Most providers reported frequent exposure to TBI cases and regular use of the CPG in routine clinical practice. However, not all participants reported consistent CPG use, highlighting variation in implementation among providers. Key facilitators included strong interprofessional teamwork, readily accessible guideline materials in clinical areas, availability of diagnostic imaging, and perceived improvements in patient outcomes. Barriers to consistent adherence included ICU bed shortages, limited operating theatre capacity, equipment and medication stock-outs, high patient volumes, staffing pressures, and a lack of structured refresher training or formal audit and feedback mechanisms. Variability in procedural confidence, particularly among less experienced providers, also affected implementation consistency. Conclusion Our findings show that a TBI CPG is well accepted and largely integrated into routine care among experienced providers. However, sustainability depends on strengthening training, mentorship, audit, and feedback systems for CPG use and on addressing system-level resource constraints. Institutional investment in capacity building is essential to ensure consistent and sustained CPG uptake in our setting.

Background: The practice of hospitalizing emergency department (ED) patients with chest pain after ruling out acute myocardial infarction (AMI) varies widely. The long-term outcome and cost implications of this variation are uncertain. Methods: Analyzing 2007-2021 claims from a national commercial insurer, we identified 223,569 adults (18 years or older) ED visits with a principal diagnosis of chest pain without major secondary cardiopulmonary diagnoses, seen by 19,001 clinicians in 2,273 EDs. Within each ED, clinicians with the highest and lowest terciles of risk-adjusted hospitalization rates were classified as high- versus low-admitting. Primary outcomes were 30- and 180-day subsequent AMI hospitalizations. Secondary outcomes included 7-day cardiac testing, 30-day coronary intervention, and 30-day total and out-of-pocket costs. We estimated adjusted rate ratios (aRRs) and relative cost differences using generalized estimating equations, adjusting for patient and visit characteristics. Results: Patients had a mean age of 48.6 years, and 53.9% were female; measured characteristics were similar between groups. Compared with low-admitting clinicians, visits to high-admitting clinicians had higher 7-day cardiac testing (13.1% vs 10.8%; aRR 1.22, 95% CI 1.17-1.27) and 30-day coronary interventions (4.3% vs 3.8%; aRR 1.16, 95% CI 1.09-1.23). AMI hospitalization did not differ at 30 days (0.60% vs 0.60%; aRR 1.00, 95% CI 0.84-1.15) or 180 days (0.85% vs 0.87%; aRR 0.97, 95% CI 0.85-1.10). Thirty-day total costs were higher after visits to high-admitting clinicians (relative change 11.3%, 95% CI 8.8-13.8), and out-of-pocket costs $1,000 or more were more common (32.0% vs 29.6%; relative change 8.2%, 95% CI 6.1-10.3). Conclusions: Higher clinician hospitalizing tendency for ED chest pain is associated with greater downstream testing, more coronary interventions, and higher costs without lower short- or intermediate-term AMI risk. Reducing marginal admissions among high-admitting clinicians may decrease spending and practice variation with minimal impact on AMI outcomes.

We develop an age- and immunity-structured COVID-19 model with setting-specific contacts, calibrated to Ontario incidence and hospital admissions before Omicron. We simulate counterfactual vaccination strategies and contact restrictions in schools, workplaces, and other community settings, evaluating projected severe-case demand against an illustrative healthcare-capacity benchmark. Vaccination combined with workplace and community contact restrictions keeps simulated demand within capacity. In contrast, relaxing restrictions in either setting produces large surges and repeated capacity threats, even when school restrictions remain. School-only changes produce smaller effects on severe disease. These findings highlight the value of vaccination and setting-specific contact restrictions that prioritize workplace and community settings for pathogens with adult-concentrated severe outcomes.

Abstract: Background: Opioid Use Disorder (OUD) imposes a rising mortality and health system burden, with opioid related deaths increasing from 8,400 in 2000 to 110,037 in 2023. Medications for opioid use disorder (MOUD) reduce mortality and morbidity, yet only 25.1% of people with OUD are treated with these medications, and inpatient MOUD initiation is inconsistent. Inpatient and Emergency Department (ED) treatment initiation and connection to outpatient care is suboptimal, missing critical opportunities to engage at-risk populations during acute care visits. Our goals were to determine the proportion of patients with OUD treated with MOUD during a hospital/ED stay, and the proportion successfully connected to outpatient care. Methods: This retrospective cohort study included patients 18 years or older with an OUD diagnosis at Duke University Hospital and Duke Regional Hospital (7/1/2023 to 12/31/2025) who had an inpatient or ED encounter with an associated OUD diagnosis code. Primary outcomes were buprenorphine at discharge, 30-day acute care return, and 30 day outpatient follow up. Adjusted modified Poisson regression models with cluster robust standard errors evaluated associations with age, sex, race/ethnicity, insurance, area deprivation index, encounter type, and comorbidity score. Results: Of 5,390 patients with OUD, 42.1% (2,267) had an acute care encounter, generating 3,893 encounters. Neither buprenorphine nor methadone was prescribed at discharge for 46.0% of encounters. Acute care return occurred in 33.6% and outpatient follow up in 32.2% of encounters within 30 days; only 7.4% of follow-ups included a buprenorphine prescription. ED encounters had lower discharge prescribing than inpatient encounters (RR 0.72, 95% CI 0.61,0.86). Black patients had higher 30 day acute care return than White patients (RR 1.16, 95% CI 1.02,1.30) Conclusions: Acute care encounters represent repeated, missed opportunities for MOUD initiation. Disparities were concentrated in post-discharge return and follow up rather than at initial prescribing, and attrition occurred at each transition along the screening-treatment-referral pathway.

Background Best practice alerts (BPAs) used in emergency departments (EDs) to identify patients with possible sepsis lack specificity and some ED patients with sepsis BPAs are discharged. We evaluated factors associated with ED discharge following a sepsis BPA and with subsequent 7-day return admissions with sepsis or infection. Methods We conducted a retrospective cohort study using an electronic health record data query from five hospitals (2022-2024). Using logistic regression, we evaluated the association of participant demographics and clinical characteristics with ED discharge and factors at the initial ED visit associated with return admission. Results Among 62,068 ED visits with a sepsis BPA, one third resulted in ED discharge. Discharged participants were younger and more often female, Black, multiracial, and/or Hispanic; they more often had an initially normal pulse, respiratory rate, blood pressure, and lactic acid than admitted participants. Discharged participants more often had a fever on arrival (adjusted odds ratio (aOR) 6.03; p<0.001) and a white blood cell (WBC) count 11,000-14,999 (aOR 4.57; p<0.001) or 15,000-19,999/uL (aOR 2.01; p<0.001). One percent of discharged participants experienced a 7-day return admission with a diagnosis of sepsis or infection, which was associated with older age, White or Asian race, diastolic hypotension, WBC count [&le;]15,000/uL or <4,000/uL, and an index visit BPA response indicating sepsis or non-response. Conclusions Return admissions among discharged ED patients with a sepsis BPA are rare. Several factors are associated both with hospital admission at the index visit and return admission, indicating a need for additional risk-stratification tools.

Abstract Background The Simplified Geneva Score (SGS) incorporates two heart-rate thresholds. Multiple heart-rate measurements are commonly recorded during emergency department (ED) assessment. While the original SGS specifies use of mean heart rate, real-world implementation is unlikely to reflect this, and the effect of alternative heart-rate selection methods on score performance is unknown. Methods SCORES was a retrospective within-subject study of consecutive ED patients at a single urban hospital undergoing computed tomography pulmonary angiography (CTPA) for suspected pulmonary embolism (PE). Four SGS variants were calculated using the first, highest, mean, and lowest recorded pre-CTPA heart rate. Outcomes included score output, risk classification, diagnostic performance, reclassification flow, and downstream imaging utilisation. Precision estimates and comparisons were derived using empirical resampling techniques. Results 590 episodes were reviewed with 581 included for analysis. PE was confirmed in 50 cases (8.6%). Mean SGS differed significantly across all heart-rate implementations (p<0.0001). The proportion classified as high risk varied from 15% using the lowest heart rate to 40% using the highest heart rate. Reclassification across the SGS threshold was common, with 25% of episodes changing risk category unidirectionally between lowest and highest heart rate implementations. SGS(lowest HR) compared with SGS(mean HR) and SGS(highest HR) demonstrated higher specificity (87.6% vs 73.4% vs 62.1%), improved AUROC (0.744 vs 0.704 vs 0.659), and reduced downstream CTPA utilisation (818 vs 876 vs 920 scans per 100 PEs diagnosed), with no additional pulmonary emboli missed within the complete diagnostic pathway. Conclusions Heart-rate selection materially influences SGS output, risk classification, diagnostic performance, and imaging utilisation. In this retrospective cohort, use of the lowest recorded heart rate produced the most favourable overall balance of discrimination and diagnostic efficiency, supporting prospective validation.

Importance: With a recent shift towards summer seasonal predominance of COVID-19 across much of the US, debate continues over optimal COVID-19 vaccination strategies regarding timing (including summer vaccination), eligibility, and dosing frequency. We evaluated the population-level impact of alternative vaccine strategies to inform US and state vaccine policy. Objective: To compare reductions in COVID-19 hospitalizations under different vaccination timing, eligibility, and dosing frequency. Design: Decision analytical model using a stochastic individual-based model of SARS-CoV-2 transmission, calibrated to US COVID-19 hospitalization incidence from May 2024-April 2025. Setting: Simulated US national population, with additional scenarios representing state-level seasonal patterns. Participants: Simulated population of 5 million individuals with US age structure, stratified by risk group (immunocompetent, high risk with comorbid conditions, or immunocompromised). Exposures: Vaccination timing, universal or age- and risk-based eligibility, and dosing frequency, including a hybrid strategy of universal annual vaccination with a second dose for adults [&ge;]65 years and immunocompromised adults (US vaccine policy during the study period). Main Outcomes and Measures: COVID-19 hospitalization risk per 100,000 persons by age-risk group, measured among vaccinated individuals and in the total population. Results: If summer COVID-19 vaccination timing is feasible, annual universal vaccination in July minimized risk (441 [95% UI: 423-463] COVID-19 hospitalizations per 100,000 persons among adults [&ge;]65 years) compared to a counterfactual scenario with no additional vaccination given during the study period (578 [553-601]). If timing does not change, hybrid vaccination minimized risk, followed by semiannual risk-based vaccination (460 [440-487] and 477 [454-499] hospitalizations per 100,000 in adults [&ge;]65 years, respectively). The advantage of summer timing diminished if vaccine coverage decreased by 5-10 absolute percentage points (25-50% relative decrease). The magnitude of benefit from summer-timed vaccination and semiannual doses in the highest-risk groups varied regionally. Conclusions and Relevance: Although annual COVID-19 vaccination has historically been timed for winter transmission, summer vaccination may avert more hospitalizations if coverage is maintained, especially in states with predominantly summer transmission including Western and Southern states. The comparative impact of vaccination strategies, especially the benefit of a semiannual dose in the highest-risk groups, may vary regionally. COVID-19 vaccination timing and eligibility may warrant reconsideration.

Background Emergency Department (ED) overcrowding is associated with adverse outcomes including delays to treatment, patients leaving without being seen and increased mortality. Increasingly, evidence suggests that crowding may disproportionately affect those of lower socioeconomic status, worsening health inequalities. This study investigates the relationship between prolonged ED length of stay and vulnerable patient groups choosing not to wait to be seen. Methods A retrospective cohort study analysed monthly ED attendance data from a large district general hospital between January 2020 and July 2025. Patients who did not wait to be seen (DNW) were assessed for vulnerability based on age, presenting complaint and inferred frailty. Associations were explored using generalised estimation equation model with binary outcome. Results During the 66-month study period, 317,978 patients attended the ED, of whom 35,403 (11.1%) did not wait to be seen. Of these, just under one third met vulnerability criteria. As the percentage of patients staying in the ED for more than 8-hours increased, so did the proportion of patients leaving the department without being seen. With each 10% increase in LOS>8h percentage, the odds of any patient choosing not to wait increases by 48% (OR=1.48, 95% CI(1.47 to 1.49), p<0.001). Of the three vulnerability groups assessed, paediatric patients, those presenting with mental health complaints and frailty, frail patients were the most affected when lengths of stay in the ED increased and crowding became a problem (OR=1.73, 95% CI(1.72 to 1.74), p<0.001). Conclusion These findings demonstrate that while all patient groups are more likely to leave without being seen as crowding worsens, elderly and paediatric patient cohorts are significantly more likely to leave without being seen as crowding worsens. This raises genuine concerns about the accessibility of healthcare, in the presence of crowding, in these vulnerable groups.

Importance: The Medicare Physician Fee Schedule values ambulatory services using survey-based estimates of physician time, a costly process vulnerable to inaccuracy. EHR audit logs are passively and universally collected and likely meet the American Medical Association Relative Value Scale Update Committee (AMA RUC) Extant Database Standards for alternative data to inform service valuation estimates. However, audit logs' validity for estimating face-to-face time, a core component of many of the most used procedural codes, is unknown. Objective: To assess whether EHR audit logs can facilitate accurate estimation of physician-patient face-to-face time during ambulatory visits. Design: Single-site validation study pairing EHR audit logs with direct audio/video recordings of ambulatory primary care visits (reference standard). We assessed agreement between audit-log estimates and recorded visit duration with Bland-Altman analysis and mean absolute error. Setting: University of Pennsylvania Observer data repository, a multi-modal database of ambulatory visits to Penn Medicine primary care clinics including video and audio recordings, transcripts, clinical EHR data, and EHR audit-log data. Participants: 75 visits from 12 physicians with data collected between August 2023 and February 2025. Exposures: A rule-based algorithm estimated face-to-face time via clusters of physician EHR activity relative to patient check-in time. Inactivity thresholds were applied to differentiate intraservice time with no EHR activity (e.g., a physical exam) from the end of a visit, with longer thresholds used for longer visits. Main Outcomes and Measures: Duration of recorded face-to-face visit time. Results: Recorded face-to-face time averaged 31.6 minutes (SD, 13.9). The audit-log estimator was unbiased (mean bias: -0.63 minutes; 95% CI: -6.0 to 2.6; mean absolute error: 9.0 minutes) and estimated face-to-face time within approximately 2% (38 seconds) of the recorded visit time with no proportional bias (slope: 0.13; P = .25). The 95% limits of agreement were -25.7 to 24.4 minutes, and 37% of estimates fell within 10% of recorded duration. Conclusions and Relevance: In this validation study, EHR audit logs recovered unbiased estimates of ambulatory face-to-face time. Larger-scale studies are required to verify generalizability, but EHR audit logs offer a scalable means to improve the rigor of retrospective physician work relative value unit estimation. This study represents a first step in a potential paradigm shift for measuring components of the fee schedule across procedures, settings, and provider types.

Objective: Rural hospitals in the United States have fewer specialists, fewer critical care resources, and longer transport distances than urban hospitals, yet national studies disagree on whether rural patients are more likely to die after emergency care. The goal of this study was to determine whether short-term mortality differs between rural and urban patients receiving emergency or trauma care and to estimate the size of the difference. Methods: We conducted a systematic review and meta-analysis reported in line with PRISMA 2020. PubMed was searched on October 11, 2026, for studies published from 2010 onward, supplemented by web searching. Eligible studies were US observational studies that compared rural with urban patients or hospitals and reported mortality after emergency or trauma care. Odds ratios (ORs) were pooled with a DerSimonian-Laird random-effects model, with Hartung-Knapp confidence intervals (CIs) as a sensitivity analysis. Injury and trauma studies formed the primary analysis. Certainty of evidence was rated with GRADE. Results: Of 161 records identified, 14 studies were included and 12 were pooled. Across seven injury and trauma studies, rural setting was associated with higher odds of death (OR, 1.27; 95% CI, 1.07-1.52), with substantial heterogeneity (I^2 = 84%; 95% prediction interval, 0.74-2.19). Across all 12 studies, the pooled OR was 1.23 (95% CI, 1.09-1.40; I^2 = 96%). With Hartung-Knapp intervals, the overall estimate remained significant (95% CI, 1.05-1.45) and the trauma estimate was borderline (95% CI, 0.99-1.64). Study estimates ranged from 0.65 to 1.97. Three pediatric trauma studies gave a consistent estimate (OR, 1.32; 95% CI, 1.18-1.47; I^2 = 0%). Subgroup analyses by rurality definition, age group, and geographic scope did not explain the heterogeneity. Certainty of evidence was very low. Conclusions: In pooled US observational data, rural patients receiving emergency and trauma care had about 23% higher odds of short-term death than urban patients, most consistently among injured children. The evidence is inconsistent, rests on a single-database search with several reports assessed from abstracts only, and should be treated as preliminary. Why rural patients die more often, and at what point in the pathway from injury to definitive care, remains unanswered.

Objectives: Heatwaves drive surges in acute care demand, yet heat-health action plans (HHAPs) lack tools to scale emergency care responses. This study validated a forecasting tool for heatwave-related emergency department (ED) demand across four clusters comprising the emergency care network of Ticino Canton, Switzerland. Methods: This retrospective, ecological, time-series study modeled daily mean temperature and ED presentations using a distributed lag non-linear model framework with autoregressive and calendar adjustment components. The model was trained on summers (June-August) 2016-2024 and tested on summer 2025, defining heatwaves as daily mean temperature >25 {degrees}C for [&ge;]3 consecutive days. Results: A non-linear temperature-demand association was shown across the clusters, with ED visits increasing at higher temperatures. Model fit varied across clusters (R2 0.389-0.672), and the reference model consistently outperformed naive baselines. During two heatwaves in 2025, prediction errors remained within acceptable ranges. Baseline demand, heatwave occurrence, and model performance varied substantially within the canton. Conclusions: These findings have implications for the design of HHAPs, suggesting that emergency care preparedness should rely on locally calibrated demand forecast rather than standardized activation protocols.

Background: During emergency tracheal intubation, clinicians use waveform capnography or colorimetric carbon dioxide (CO2) detection to confirm exhaled CO2 from the endotracheal tube to determine its location. Both devices reliably yield a negative result when the tube is in the esophagus. However, in most emergency intubations the tube is correctly located in the trachea, and in this circumstance the relative diagnostic accuracy of the two devices is uncertain. If one device more often fails to detect exhaled CO2 despite correct tube placement (a false negative result), this could lead to unnecessary tube removal, repeated intubation attempts, and an increased risk of serious complications. Research Question: Among critically ill adults undergoing emergency tracheal intubation, is waveform capnography or colorimetric CO2 detection more sensitive for identifying an endotracheal tube correctly placed in the trachea? Study Design and Methods: The WAVE study is a pragmatic, prospective, paired diagnostic accuracy study conducted in emergency departments and intensive care units in the United States. The study compares waveform capnography and colorimetric CO2 detection (index tests) against a non-CO2-based reference standard for endotracheal tube location among 2,092 critically ill adults undergoing tracheal intubation. The primary outcome is the sensitivity of each index test for identifying a tube located in the trachea. The secondary outcome is specificity for identifying a tube located outside the trachea. Results: Enrollment began on April 21, 2025 and is ongoing, with completion anticipated in 2026. Interpretation: The WAVE study will provide prospective evidence comparing waveform capnography with colorimetric CO2 detection for determination of endotracheal tube location in critically ill adults. These findings may inform clinical practice and guideline recommendations regarding the optimal test of exhaled CO2 for use in the ED and ICU. Prespecifying the protocol and statistical analysis plan before completion of enrollment enhances the rigor, reproducibility, and transparency of the study.

Objectives: To assess the feasibility and early performance of an AI-assisted screening workflow that reviews inpatient discharge summaries to identify potential treatment injuries for clinician review and, where appropriate, Accident Compensation Corporation (ACC) treatment injury claim consideration in New Zealand. Design: Single-site, six-month pilot reported as a quality-improvement/service-evaluation activity. A large language model (LLM)-enabled system acted as an index screening test over discharge summaries to generate candidate treatment injury signals for structured clinician adjudication and escalation. Setting: A New Zealand district hospital (Wairarapa). Screening operated on routinely produced inpatient discharge summaries. Participants: All inpatient discharge summaries produced during the pilot period were screened (n = 2,642). The unit of analysis was one discharge summary per inpatient episode. Intervention: An LLM-based screening workflow that outputs structured candidate harm signals with supporting excerpts and a certainty label. Outputs were reviewed by clinicians using a structured adjudication template. Suitable cases could be escalated to senior clinicians and followed through the local ACC treatment injury process. Main outcome measures: Primary outcomes were yield, positive predictive value (PPV) of AI- flagged signals for clinician-adjudicated iatrogenic harm, and the rate of unsupported/hallucinated outputs. Secondary outcomes included overlap with incident reporting and administrative coding, downstream ACC claim outcomes, and clinician review workload. Results: Across 2,642 inpatient discharge summaries screened, the AI-assisted workflow generated 237 candidate signals (yield 9.0%; 95% CI 7.9% to 10.1%). Clinician adjudication classified 102 as confirmed iatrogenic harm, 43 as possible harm requiring additional context, 81 as no harm, and 11 as unsupported/hallucinated outputs. PPV for confirmed harm was 43.0% (95% CI 36.8% to 49.4%). PPV for confirmed-or-possible harm was 61.2% (95% CI 54.9% to 67.1%). Seven ACC treatment injury claims were lodged as a direct result of AI-assisted surfacing; three were accepted, two declined, and two were held/pending at analysis. Organisational ACC data identified 68 treatment injury claims lodged during the same period, of which 17 overlapped with AI-identified cases. Conclusions: AI-assisted screening of discharge summaries can feasibly increase detection of potential treatment injuries for structured clinician review and may support more systematic ACC consideration and safety learning. Safe scaling requires transparent reporting of model and prompt details, robust human adjudication and escalation pathways, and governance controls to mitigate false positives and unsupported outputs. A next-stage evaluation should estimate diagnostic accuracy against a chart-review reference standard and examine implementation outcomes including workload, acceptability, fidelity and sustainability.