CMAJ Open

BackgroundAdvanced Practice Providers (APPs), including physician assistants and nurse practitioners, represent a growing proportion of the emergency medicine workforce, including in high-acuity community emergency departments (EDs). Despite this growth, many sites lack formal onboarding structures, particularly for new graduate or inexperienced APPs transitioning to practice. Unlike postgraduate residencies and fellowships, limited literature exists on structured onboarding models outside academic settings. This study evaluated the feasibility and perceived impact of a structured onboarding program for APPs in a non-academic community ED. MethodsThis mixed-methods feasibility study was conducted at a single-site community ED without an existing formal onboarding process. New graduate or inexperienced APPs hired within 12 months of program implementation completed a post-intervention survey assessing satisfaction across five domains derived from a conceptual framework of human resource practices and retention. Quantitative data was collected using 5-point Likert-scale items, and qualitative data was obtained through open responses. Leadership and preceptors completed a secondary survey evaluating feasibility and perceived impact. Descriptive statistics and thematic analysis were performed. ResultsFour new graduate APPs (100% response rate) completed the post-implementation survey. Mean scores across domains ranged from 3.33 to 5.00, with highest ratings observed in supervisor support (mean = 5.00), employee engagement (4.33), and alternative training via online modules (4.67). Qualitative themes included clear communication of expectations, value of asynchronous educational modules, and strong mentorship support. Fifteen leaders and preceptors reported that although the program required additional effort, it improved tracking of APP progress, preparedness for transition to practice (4.67), and was perceived as worthwhile to reduce attrition. ConclusionsA structured onboarding program for new graduate APPs in a community ED was feasible, well accepted, and perceived to support transition to practice. These findings support the need for further study of structured onboarding as a scalable strategy to enhance preparedness, engagement, and potential retention in high-acuity clinical settings.

BackgroundStandardized training and competency testing is needed for appropriate point-of-care ultrasound (POCUS) clinical use. Our study objective assesses a low-fidelity simulation pig model workshop and tests the knowledge and technical skills of emergency medicine (EM) clinicians when performing simulated ultrasound-guided serratus anterior nerve block (UG-SANB). MethodsEM residents, attendings, and advanced practice providers (APP) participated in a prospective cohort study, completing a one-time simulation-based UG-NB training session at a single academic medical center between November 2024 to February 2025. Training model acceptability, appropriateness, and feasibility was assessed using the validated AIM-IAM-FIM tool (pre/post-surveys). Effectiveness outcomes were participant knowledge score, technical skill score, and self-rated confidence in performing NBs pre-, post-, and 3-months post-intervention. Clinical ED-performed ultrasound-guided nerve blocks were reported pre-/post-intervention. Scores were summarized using mean (S.D.) and total question percent correct. Paired individual assessments were compared pre/post-intervention using paired t-tests and group assessments using t-tests for normal data distribution. Results63/104 ED providers (60.6%) responded to surveys pre-intervention and 57 post-intervention (54.8%). 63 providers (16 EM attendings, 33 residents, and 14 APPs) underwent SANB training and testing. Participant survey responses reported the training model was acceptable, appropriate, and feasible (at least 54/57 agreed or strongly agreed for all three). Mean knowledge scores were 85% (SD 14.8%) post- and 70% (SD 18.2%) 3-months post-workshop. Mean technical skills exam scores were 98% (SD 4.5%) post- and 95% (5.8%) 3-months post-intervention. Perceived confidence in teaching clinical NBs increased pre-/post-intervention (from 11.3% to 58.2%) and for SANB (3.2% to 70.2%). Clinically performed NBs at pre and post were 21 and 15 respectively. ConclusionEmergency clinicians knowledge, technical skills, and confidence scores increased after an UG-NB training intervention. This standardized, reproducible simulation model could improve clinical skills and patient care outcomes but needs additional steps to increase clinical UG-NB performance.

BackgroundIn the United States, emergency clinicians are often the first to care for injured patients in the hospital setting. To better understand end-user needs, we evaluated emergency clinician priorities and preferences in accessing, interpreting, and applying trauma clinical guidance. MethodsEmergency clinicians were recruited via email for semi-structured video conference interviews. Rapid directed qualitative analysis of interview notes and audio recordings yielded initial insights about guidance barriers and facilitators. A subsequent quantitative survey was developed and distributed via email to members of relevant professional associations. Survey results were analyzed using descriptive and inferential statistics. ResultsTwelve emergency clinicians participated in interviews. 154 eligible participants responded to the survey. Clinicians expressed support for trauma clinical guidance overall but often find resources lacking. Barriers to guidance usage include lack of awareness, difficulty locating guidance, and cumbersome design. Clinical guidance should be objective, concise, updated, and easy-to-use at bedside. The strongest determinant of guidance usability was being quickly understood in a time-pressured situation. Clinicians prefer to access guidance through mobile applications or multi-modal channels. Rural clinicians reported additional difficulties in staffing and having resources needed to follow guidance. ConclusionWhen developing trauma clinical guidance, the trauma community should continue to consider the variety of end users and clinical settings, including emergency clinicians. Developing mobile device-friendly, quickly understandable guidance should be a priority for authors of trauma clinical guidance.

ObjectivesEmergency Medical Services (EMS) demand is increasing, with a growing proportion of low-acuity encounters. Prior studies are limited by regional sampling, inconsistent definitions, narrow observation periods, and limited theoretical grounding. The objective of this study was to identify predisposing, enabling, and need-based factors associated with EMS transport among low-acuity emergency department (ED) patients, guided by Andersens Behavioral Model of Health Services Use. MethodsWe conducted a secondary, retrospective observational study using a 10% random sample of multicenter electronic health record (EHR) data from 21 emergency departments in the southeastern United States. To be eligible to be included in the analysis, the visit had to be for: (1) patient age >17 years of age, (2) occur between January 1, 2016, to April 29, 2025, (3) triaged as Emergency Severity Index (ESI) 4 or 5, and (4) ended in a final visit disposition of being discharged. The primary outcome was EMS utilization. Independent variables were categorized as predisposing, enabling, or need-based factors according to Andersens model. We used multivariable logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals. ResultsAmong 41,772 low-acuity ED encounters, 3,233 (7.7%) arrived by EMS. Increased odds of EMS use were associated with older age (per 10-year increase; aOR 1.30, 95% CI=1.27-1.33), male sex (aOR 1.20, 95% CI=1.12-1.30), being retired or disabled (aOR 3.60, 95% CI=3.15-4.10), being unemployed (aOR 2.26, 95% CI=2.04-2.52), having a nighttime presentation (aOR 1.63, 95% CI=1.51-1.76), and mental health diagnosis (aOR 1.76, 95% CI=1.62-1.90). Protective factors included White race (aOR=0.89, 95% CI=0.83-0.96), established primary care (aOR=0.57, 95% CI=0.57-0.62), weekend presentation (aOR 0.91; CI = 0.84-0.99), and visits during (aOR 0.63, 95% CI=0.55-0.71) or after (aOR 0.54, 95% CI=0.48-0.61) the COVID-19 period. Rurality, insurance, and primary language were not associated with EMS use. ConclusionsPredisposing and enabling factors were the predominant drivers of low-acuity EMS utilization in this sample. Expanding access to primary care and behavioral health services, especially for older patients, may reduce EMS use for low-acuity complaints while preserving EMS capacity for higher-acuity emergencies.

ObjectiveTo explore emergency medical dispatchers (EMD) experiences of prioritising patients and stewarding ambulance resources when system capacity is constrained. DesignQualitative interview study using inductive qualitative content analysis. SettingEmergency medical communication centres (EMCCs) in Sweden operated by the national emergency call provider, responsible for receiving 112 calls and dispatching ambulances. ParticipantsThirteen purposively sampled EMDs with at least one year of professional experience. Data analysisInterviews were analysed inductively using qualitative content analysis (Elo and Kyngas) through open coding, grouping into subcategories and abstraction into generic categories and one main category. ResultsDispatchers described prioritisation under scarcity as system work that simultaneously addresses individual patient acuity and population-level readiness. One main category captured this work: Stewarding scarce response capacity. Three interrelated generic categories characterised stewardship: (1) prioritising by clinical urgency within geographic and operational constraints; (2) producing availability through anticipation, reassessment and queue governance in a virtual waiting room; and (3) coordinating response through information infrastructures and interprofessional collaboration. Across categories, dispatchers described redistributing risk across patients and time while attempting to avoid both under-response to urgent need and over-allocation that would leave areas without coverage. ConclusionsDispatch under scarcity is best understood as active stewardship of a safety-critical dispatch queue. Strengthening patient safety therefore requires organisational support for reassessment and escalation during prolonged waits, and governance that makes queue dynamics and geographic coverage trade-offs visible, rather than relying solely on initial triage decisions or aggregate response-time targets. Strengths and limitations of this studyO_LIStrengths and limitations of this study C_LIO_LIAn inductive qualitative content analysis allowed categories to emerge from dispatchers own descriptions, rather than imposing predefined theoretical frameworks. C_LIO_LIInclusion of emergency medical dispatchers with varied ages, professional experience and EMCC locations enhanced the richness of the data and potential transferability. C_LIO_LIAnalyst triangulation, an explicit abstraction pathway and data-to-category quotations strengthened analytic transparency and trustworthiness. C_LIO_LIInterviews were conducted via video, which may have limited access to non-verbal cues compared with in-person interviews. C_LIO_LIThe study was conducted within a single national dispatch system, and participation was voluntary, which may limit transferability and introduce self-selection of more experienced or engaged dispatchers. C_LI

BackgroundSalbutamol is the most commonly prescribed inhaler for adults discharged from the Emergency Department (ED) with uncontrolled asthma. However newer options, e.g. Maintenance and Reliever Therapy (MART), are now recommended due to growing concerns over risks linked to salbutamol over-prescription. Transitioning to new inhalers requires support for both patients and healthcare professionals (HCP). This paper outlines how we developed an implementation package based on evidence, theory and the person-based approach to support asthma medication optimisation in the ED. MethodsThe purpose of this study was to use person-based intervention development methods in a three phase process: (1) understanding behaviour - collating and synthesising evidence from in-depth interviews with the target population (patients and HCPs); secondary deductive analysis using the theoretical domains framework (TDF) to understand barriers and facilitators to prescribing; developing guiding principles and logic model based on underlying theory (2) identifying behavioural content and implementation options - behaviour change techniques were selected and translated into intervention content (3) intervention materials developed and refined with input of stakeholders. ResultsWe identified modifiable target behaviours for HCPs to support guideline-based care in the ED. These included identifying eligible patients, communicating rationale, providing patients with inhaler and resources, and communicating changes to primary care. Key theoretical domains included knowledge, skills, addressing beliefs about consequences, and targeting professional role perceptions. These domains were targeted through a clinical decision aid and training materials for ED HCP, template discharge summary for primary care, and visual and written materials for patients. Minor refinements were made based on stakeholder feedback (six ED doctor think-aloud interviews; two patient workshops with eight and five participants respectively; and 12 survey responses to final draft of video). ConclusionWe developed an intervention grounded in theory, evidence, and stakeholder feedback aimed at promoting and supporting delivery of guideline recommendation. KEY MESSAGESO_ST_ABSWhat is already knownC_ST_ABSED visits represent teachable moments where patients may be receptive to optimising asthma medication, yet guideline-concordant prescribing is often limited in fast-paced settings. What this study addsThis study describes AMEND, a behaviourally informed implementation package including a clinical decision aid, HCP training, and patient-facing materials, designed to support initiation of Maintenance and Reliever Therapy (MART) at discharge. Using stakeholder-informed, iterative development, the package was feasible to integrate into routine ED workflows. How this study might affect research, practice or policyFindings highlight how theory-driven interventions can translate guidelines into practice, improve adherence, and potentially reduce repeat ED attendances.

BackgroundThe physician assistant (PA) workforce has expanded rapidly in the United States, increasing the importance of effective physician-PA collaboration. Although PAs improve patient outcomes and access to care, the determinants of effective collaboration has not been well studied. North Carolina provides a relevant context due to its growing PA workforce and supervisory regulatory structure, in which physicians retain administrative responsibility for PA supervision across practice settings. This study examines determinants of effective physician-PA collaboration in ambulatory care settings in North Carolina. MethodsFour virtual focus groups were conducted with practicing physicians (n=7) and PAs (n=9) across multiple specialties in NC. Transcripts were analyzed using thematic analysis to identify facilitators and barriers to collaboration. ResultsThematic analysis identified six major themes reflecting relational, organizational, and systemic influences on teamwork. Findings demonstrate collaboration evolves over time through early-career mentorship, continuity of working relationships, and progressive trust development. Differences in professional identity, power dynamics, and misunderstanding of PA scope of practice influenced autonomy and delegation. Systemic factors such as reimbursement structures and organizational supervisory policies hindered efficient teamwork. LimitationsFindings are based on a small, purposive sample within a single state and may not be generalizable to all ambulatory settings or regulatory environments. Perspectives may also reflect self-selection bias among participants with strong views on collaboration. ConclusionsEffective physician-PA collaboration depends on intentional onboarding, role clarity, interprofessional education, and alignment of organizational policies with regulatory standards to support team-based care.

Students who frequently miss school are at greater risk for academic difficulty. High levels of absenteeism as early as kindergarten have been associated with long-term consequences, such as low reading proficiency in Grade 3 and low academic achievement in Grade 5, both of which have been associated with lower rates of high school graduation and enrollment in post-secondary education. The prevalence of school absenteeism has increased significantly since the COVID-19 pandemic and there have been sustained shifts in student attendance rates from kindergarten to Grade 12 since 2020. The goals of this population-level, repeated cross-sectional cohort study were to compare rates of chronic absenteeism, defined as being absent from school at least 10% of the time, in kindergarten in Canada before and after the onset of the COVID-19 pandemic, and examine the association between childrens chronic absenteeism and their concurrent developmental vulnerability. A total of 513,159 kindergarten children participated in the study, with 284,712 (55.5%) being in the pre-COVID-19 cohort (2017-2020) and 228,447 (44.5%) in the post-COVID-19 cohort (2020-2023). Across Canada, rates of chronic absenteeism increased from pre- to post-COVID-19, from 17.7% to 41.3%, with differences by jurisdiction. The greatest increase was seen in Ontario, while the smallest increase was seen in British Columbia. Children attending kindergarten in the post-COVID-19 cohort were three times more likely to be chronically absent compared to their peers attending kindergarten before the onset of the pandemic. Despite this, chronic absenteeism in the post-COVID-19 period was associated with reduced odds of overall developmental vulnerability, a pattern that is likely attributable to shifts in the composition of chronically absent children. In the post-COVID-19 cohort, a greater percentage of children who were chronically absent resided in higher SES neighbourhoods compared to their chronically absent peers attending school before the onset of the pandemic. While increasing rates of school absenteeism should not be ignored, our results suggest that chronic absenteeism following COVID-19 might be more nuanced than before. The jurisdictional differences in rates of chronic absenteeism observed in this study could be due to the various public health measures put in place by the various provincial and territorial governments. It is also possible that the children from higher SES neighbourhoods missed more school after the onset of the COVID-19 pandemic because their parents had the capability to work from home, making it easier to keep their child(ren) home from school. The decreased association between chronic absenteeism and developmental vulnerability post-COVID-19 may reflect improved access to online resources, which enables students to stay on track academically from home. Gaining a better understanding of the reasons behind missing school and the relation between absenteeism and academic achievement at various developmental stages is crucial to support successful learning trajectories.

BackgroundApproximately 33% of U.S. Veterans live in rural areas, often facing significant barriers to accessing healthcare due to staffing shortages at VA facilities. The Contract Buyout (CBO) program, authorized under the PACT Act of 2022, was designed to address rural healthcare staffing shortages by enabling Veterans Health Administration (VHA) facilities to buy out existing service contracts to work in rural VA facilities. Despite its potential, uptake of the program has been limited, with just 18 hires and $1.5M in expenditures, despite a congressional spending authorization of up to $40M. This evaluation explores the barriers and facilitators in implementation of the CBO program across rural VA facilities. MethodsUsing the RE-AIM framework, we conducted a mix-method qualitative evaluation. Semi-structured interviews were completed by 15 interviewees across 8 rural VA facilities, including hiring leaders and physicians. Data were analyzed using rapid qualitative analysis, supported by a descriptive survey to capture the CBO program awareness and experience. We conducted 15 interviews across 8 rural VA medical centers with facility-level hiring leaders and clinicians who were familiar with or involved in using the CBO program. ResultsHR-related delays and procedural ambiguities disrupted contract execution and undermined the CBO programs effectiveness globally. However, sites with strong internal champions and proactive HR teams reported greater success. Interviewees reported the CBO program as a promising tool, though its lack of dedicated funding and resource dissemination hindered broader adoption. ConclusionThe CBO program holds potential as a flexible rural recruitment incentive but faces structural barriers that limit its reach and adoption. Future evaluations should Evaluate whether individual rural VA sites have budgetary flexibility, funding mechanisms, and related resources required to effectively utilize the CBO program.

BackgroundEmerging in January 2020, the SARS-CoV-2 pandemic quickly exposed the limitations of traditional contact tracing and overwhelmed the contact tracing efforts of US health departments. In response, Kaiser Permanente partnered with the Public Health Institute to launch the California Contact Tracing Support Initiative. This innovative, clinically integrated program aimed to link Kaiser Permanente members diagnosed at their facilities directly with contact tracing and supportive clinical care via their network. This approach promised to address key logistical and behavioral challenges hampering traditional public health agencies. This paper evaluates the programs implementation in two California counties. MethodsWe conducted a retrospective, mixed-methods process evaluation of program activities from August 2020 to June 2021, including contact tracing implementation in Fresno and San Bernardino Counties. Our methods included scoping discussions with program stakeholders, development of an epidemiological timeline and program impact model, and document review. We also conducted semi-structured interviews with program stakeholders and staff. Interviews were conducted and audio-recorded via Zoom, transcribed, and analyzed in NVivo using inductive and deductive coding with a Framework Approach. ResultsWe reviewed 474 program documents and interviewed 47 participants. Study findings highlighted difficulties in adapting program scope due to competing partner visions of program mission and collaboration. Unforeseen data demands and complex external data sharing with public health systems further complicated and delayed program implementation. ConclusionEvaluation of this contact tracing program offers key insights into public health interventions during emergencies. While the California Contact Tracing Support Initiatives integrated design showed promise, challenges arose from data systems, inter-organizational dynamics, and planning. Findings emphasize the need for clear operational steps, real-time data monitoring, defined roles, and formalized public-private partnerships in preparedness planning. These are key lessons for future complex public health interventions, especially regarding adapting programs versus maintaining fidelity amidst evolving contexts.

This study explores the influence of social determinants of health (SDOH) on follow-up behavior among patients referred to community-based organizations (CBOs) in the Emergency Department (ED) of Long Island Jewish (LIJ) Medical Center. A retrospective analysis was conducted on data collected from 342 patients who were screened for SDOH between February and July 2023. Descriptive statistics and Chi-squared tests were used to identify potential associations between demographic and social factors (race, language, age, gender, employment status, and insurance status) and follow-up rates. The results revealed several trends: non-White patients (73.2%) and non-English speakers (81.8%) followed up more frequently than their counterparts, as did older adults (80.0%) and insured patients (77.8%). However, none of the variables reached statistical significance (all p-values > 0.05). The findings suggest that while demographic and social factors may influence follow-up behavior, the lack of statistical significance could be attributed to the limited sample size. These trends align with previous literature on SDOH and follow-up behavior, highlighting the need for further research with larger, more representative samples. Addressing the complex interplay of SDOH, including factors such as language, insurance, and cultural differences, is crucial for improving follow-up rates and ensuring better health outcomes for underserved populations. Future research should focus on refining referral systems, exploring additional socioeconomic factors, and conducting longitudinal studies to develop more effective strategies for integrating SDOH interventions in healthcare systems.

ImportanceFunding of womens health research has been low, with a narrow focus on what is considered womens health. Understanding which lifespan stages and areas of womens health are funded is essential to determine the breadth of womens health research and identify where gaps in research are concentrated. ObjectiveTo examine which lifespan stages and areas of womens health were more likely to be funded in open Canadian grant competitions. Evidence ReviewPublicly available funded Canadian Institutes of Health Research (CIHR) Project Grant abstracts from 2009 and 2023 were coded for mention of a hormonal transition period (puberty, menstrual cycle, pregnancy/postpartum, perimenopause/menopause), exogenous hormone use (hormonal contraception, fertility treatments, menopause hormone therapy), and/or a female-specific health condition. Abstracts were also coded for Indigenous health and Two Spirit, Lesbian, Gay, Bisexual, Trans, Transgender or Trans Identified, Queer, Intersex, Asexual, Plus (S2/LGBTQIA+) populations. Remaining grant abstracts were grouped by common theme.Abstracts were analyzed for changes in research representation and funding over time and whether funding was lower than expected based on population prevalence or proportion of the lifespan spent in that stage. FindingsNearly 50% of female-specific research focused on cancers (breast, gynecologic) or pregnancy and did not significantly increase in funding or representation over time. Of the funded grant abstracts that focused on pregnancy, ~22% examined outcomes pertaining only to the fetus/offspring, not the birthing parent. Over 15 years, 2.37% of all CIHR abstracts over 15 years were devoted to pregnancy, whereas only 0.24% was devoted to other hormonal life stages (menstrual cycles, menopause). For all hormonal transition stages except pregnancy, the proportion of grants and funding devoted to that stage was lower than expected based on the proportion of the lifespan spent in that stage. Conclusions and RelevanceThese findings reflect the narrow breadth of womens health, which largely focused on cancers (breast, gynecologic) or pregnancy, rather than being distributed across key life course stages that shape womens health. To advance science for all, the heterogeneity and complexity in womens health across the lifespan must be embraced and barriers for womens health research must be removed. Key PointsO_ST_ABSQuestionC_ST_ABSWhich areas and life stages of womens health are most likely to be funded in Canadian open grant competitions, and where are funding gaps concentrated? FindingsNearly half of female-specific grants focused on cancer or pregnancy, with little change over time. Pregnancy dominated hormonal-stage research, often excluding maternal outcomes, while menstrual and menopausal stages were rarely funded. For most life stages, funding was lower than expected based on lifespan representation. MeaningWomens health research funding remains narrowly focused. Broader, life-course-inclusive investment is needed to address critical gaps and advance equitable health science.

ObjectiveWe aimed to prospectively validate and compare published prediction models and clinician-assigned triage categories for early trauma care. DesignProspective multicentre cohort study. SettingThree public hospitals in urban India: one secondary care hospital in Mumbai and one tertiary care teaching hospitals in Delhi and Kolkata each. ParticipantsAdult patients aged over 18 years presenting to the emergency department with a history of trauma between 2016 and 2022. A total of 13,041 patients were included in the final analysis. MethodsWe externally validated five published trauma prediction models (GAP, Gerdin, KTS, MGAP, and RTS) and clinician-assigned triage categories based on initial assessment. The primary outcome was 30-day all-cause mortality. Models were recalibrated using a separate updating sample prior to evaluation, and model performance was assessed in terms of discrimination (AUC), calibration (calibration slope and plots), and decision curve analysis. ResultsAll models and clinician gestalt-based triage demonstrated excellent discrimination (AUC range: 0.90-0.96) and good calibration after updating. The GAP model achieved the highest AUC (0.96, 95% 0.94-0.97), and RTS demonstrated the highest sensitivity (0.70). ConclusionSimple, physiology-based prediction models and clinician gestalt both demonstrated excellent performance in predicting 30-day mortality among adult trauma patients in Indian emergency departments. These findings provide a practical foundation for further development of trauma triage systems.

BackgroundThe 340B Drug Pricing Program was established to expand access to care for low-income and uninsured patients by allowing safety-net hospitals and clinics to purchase outpatient drugs at discounted prices. Over time, the program has expanded substantially, raising questions about whether participating hospitals are meeting the programs intended objectives. MethodsUsing 2023 hospital financial data from the RAND Corporation, we conducted cross-sectional descriptive comparisons of 340B and non-340B hospitals nationwide. Key measures included charity care as a percentage of operating expenses, Medicaid admissions as a share of hospital days, uncompensated care, and costs associated with uninsured patients approved for charity care. Subgroup analyses also examined the performance of Disproportionate Share Hospitals (DSH), Critical Access Hospitals (CAH), Rural Referral Centers (RRC), Sole Community Hospitals (SCH), and National Cancer Institute (NCI) designated hospitals. ResultsAmong 3,999 hospitals analyzed, 340B hospitals provided, on average, lower levels of charity care than non-340B hospitals (2.16% vs. 2.82% of operating expenses) and lower costs of charity care for uninsured patients (1.60% vs. 2.26%). However, 340B hospitals served a higher proportion of Medicaid patients (19.69% vs. 17.76%). Substantial variation was observed across 340B subcategories: DSH hospitals reported the highest Medicaid utilization, while CAH hospitals reported the lowest levels of charity care and Medicaid days. ConclusionsParticipation in the 340B program does not uniformly correlate with greater provision of charity care or uncompensated care. These findings suggest a misalignment between program intent and outcomes and support the need for greater transparency, standardized eligibility criteria, and minimum charity care requirements to ensure that 340B savings directly benefit underserved populations.

BackgroundA Hospital Medicine Advanced Practice Provider (HMAPP)-led care model developed in response to the high acuity and increased patient volumes associated with the Covid-19 pandemic. Although anecdotally perceived as a successful model, questions remained if there was adequate pre-planning and formal implementation strategy for stakeholder buy-in. ObjectiveTo elicit HM physicians and APPs perceptions of the HMAPP-led care model implementation and consider necessary steps for optimal future APP care model development and operation. Design, Setting and ParticipantsThis qualitative study used 10 (5 physicians and 5 APPs involved in the care model pre- and post-implementation) individual semi-structured, virtual interviews based on the Consolidated Framework for Implementation Research (CFIR). Deductive and inductive rapid analysis was utilized to analyze the data. ResultsTwo themes emerged as strengths: 1) Experienced APPs delivered the care model, 2) Acceptance of the care model evolved over time. Four themes suggested opportunities for future development: 1) Guidelines should expand from patient distribution to include minimal collaboration and escalation expectations, 2) Culture change was a barrier to model implementation and acceptance, 3) Intentional collaboration between APPs and Physicians is necessary, 4) Investment in standardized onboarding enhances buy-in of the care model. ConclusionThe impact of an APP care model can be elevated if implemented with key principles and strategies. This is critical in an evolving health care landscape where all providers need to collaborate and practice with their full expertise to maximize safe, efficient and quality patient care.

BackgroundGenerative artificial intelligence (GenAI) in healthcare may reduce administrative burden and enhance quality of care. Large language models (LLMs) can generate draft responses to patient messages using electronic health record (EHR) data. This could mitigate increased workload related to high message volumes. While effectiveness and feasibility of these GenAI tools have been studied in the United States, evidence from non-English contexts is scarce, particularly regarding user experience. ObjectiveThis study evaluated the effectiveness, feasibility and barriers and facilitators of implementing Epics Augmented Response Technology (Art) GenAI tool (Epic Systems Corporation, Verona, WI, USA) in a Dutch academic healthcare setting among a broad range of end users. It explored healthcare professionals (HCP) usage metrics, expectations, and early user experiences. MethodsWe conducted a hybrid type 1 effectiveness-implementation design. HCPs of four clinical departments (dermatology, medical oncology, otorhinolaryngology, and pulmonology) participated in a six-month study. Effectiveness of Art was assessed using efficiency indicators from Epic (including all InBasket users in the hospital) and survey scales measuring well-being and clinical efficiency at three time points: PRE, POST-1 (1 month), and POST-2 (4 months). Feasibility of Art was evaluated through adoption indicators from Epic and survey scales on use and usability. Barriers and facilitators of Art implementation were collected through the survey and thematized using the NASSS framework (Nonadoption, Abandonment, Scale-up, Spread and Sustainability). Results237 unique HCPs generated a total of 8,410 drafts. Review and drafting times were similar for users with and without Art, indicating minimal differences. Perceived clinical efficiency declined significantly from PRE to POST-2, while well-being remained unchanged. Adoption was initially high but decreased over time, averaging 16.7% across departments. Usability and intention-to-use scores also declined significantly. Oualitative findings highlighted time savings, well-structured drafts, and patient-centered language as facilitators. Reported barriers included limited impact on time, low practical utility, content inaccuracies, and style misalignment. ConclusionsThis evaluation of a GenAI tool for patient-provider communication in a non-English academic hospital revealed mixed perceptions of effectiveness and feasibility. High initial expectations contrasted with limited perceived impact on time-savings, well-being and clinical efficiency, alongside declining adoption and usability. Barriers and facilitators revealed contrasting views. These findings underscore the need for a workflow for the handling of user feedback, guidance on clinical responsibilities, along with clear communication about the tools purpose and limitations to manage expectations. Additionally, establishing consensus on a set of quality indicators and their thresholds that indicate when a GenAI tool is sufficiently robust will be critical for responsible scaling of GenAI in clinical practice.

ObjectiveAlthough trauma-focused psychotherapies are effective for posttraumatic stress disorder (PTSD), recovery under routine outpatient conditions remains variable. We examined whether participation in a structured Specialty Care (SC) model integrating clinician specialization, flexible treatment density, and coordinated navigation was associated with accelerated PTSD recovery compared with standard outpatient care. MethodsWe conducted a retrospective matched cohort study (2024-2025) of U.S. adults with active PTSD symptoms (PTSD Checklist for DSM-5 score [&ge;]31) receiving care through an employer-sponsored digital mental health platform. Access to SC was determined by employer benefit design. Propensity-score matching with weighting balanced cohorts on baseline severity and demographics. Primary outcomes included longitudinal PTSD symptom trajectories and time to recovery, remission, and reliable improvement. Secondary outcomes assessed depressive symptoms (PHQ-9). Linear mixed-effects and Cox proportional hazards models were applied. ResultsThe matched sample included 356 SC and 9,409 standard care participants. SC participants received higher treatment intensity, including greater session volume and faster early follow-up, and greater care navigation engagement. SC participation was associated with steeper PTSD symptom decline ({beta} = -1.3 per log-week, p < .001) and a higher likelihood of recovery (hazard ratio = 1.31; 95% CI, 1.10-1.57). At 12 weeks, predicted recovery was 29% in SC versus 23% in standard care. Depressive symptoms improved in both groups, without significant differences in time to categorical recovery. ConclusionsUnder routine outpatient conditions, a structured SC model was associated with accelerated PTSD recovery, suggesting that reorganization of outpatient delivery may improve real-world outcomes.

PurposeWe introduce PRE-CISE, a pre-calibration workflow that integrates coverage analysis, local sensitivity, and collinearity diagnostics to streamline model calibration and transparently address nonidentifiability. We demonstrate the benefits of PRE-CISE using a four-state Sick-Sicker Markov testbed and a COVID-19 case study. MethodsPRE-CISE begins with a coverage analysis to verify that model outputs generated with parameter sets drawn from their prior distribution span calibration targets, followed by local sensitivities to quantify the influence of parameters on model outputs, guiding the resizing of the prior distribution bounds to improve coverage. Identifiability is then assessed via collinearity analysis; large indices indicate practical nonidentifiability. For the testbed model, we calibrated 3 parameters to survival, prevalence, and the proportion of Sick to Sicker at 10, 20, and 30 years. For the COVID-19 model, we calibrated 11 parameters to match daily confirmed incident cases. Bayesian calibration was conducted on both analyses. ResultsCoverage analyses flagged initial misfits; local sensitivities identified the Sick-to-Sicker transition probability has a greater effect on model outputs, and resizing its prior distribution bounds improved coverage. Collinearity analyses showed that combining multiple calibration targets across time points enabled recovery of all three parameters. In the COVID-19 model, local sensitivity analyses prioritized time-varying detection rates and contact-reduction effects, reducing the search space, thereby improving calibration efficiency. Daily incident case calibration targets yielded collinearity indices below practical thresholds (e.g., < 15) for all parameter combinations, whereas weekly calibration targets were larger and closer to the cutoff. ConclusionsPRE-CISE provides a practical, transparent pathway that helps modelers refine prior distribution bounds and calibration targets before intensive calibration, improving uncertainty reporting and strengthening the reliability of model-based health policy analyses.

ObjectiveTo examine adherence to COVID-19 public health measures among culturally and linguistically diverse (CALD) and low socio-economic status (SES) populations in Victoria using a unique longitudinal cohort. Study DesignThe Optimise Study was a mixed-methods longitudinal cohort and social networks study (September 2020 - December 2023) assessing the impact of COVID-19 and related public health measures in Victoria, Australia. We used a serial cross-sectional design to analyse adherence to public health recommendations, restrictions, and requirements. Settings, participantsThe study examines two 28-day periods during the COVID-19 pandemic in Victoria: April 23- May 20, 2021 ( non-lockdown), and September 13-October 10, 2021 ( lockdown). We explored adherence to three categories of COVID-19 public health measures -- Recommendations (non-enforced, longer-term), Restrictions (mandated during lockdown periods), and Requirements (mandated, longer-term) -- among participants who completed questionnaires during these periods. Participants were grouped as: 1) non-CALD high SES (did not meet CALD or low-SES criteria), 2) CALD, or 3) non-CALD low-SES. Main outcome measuresPrimary outcomes were adherence to Recommendations, Restrictions, and Requirements during the two study periods. ResultsOf 782 participants recruited, 579 (75%) completed a survey or diary during at least one study period and were included in the analysis. Of these, 275 (47%) were in the non-CALD high-SES group, 114 (20%) in the CALD group, and 190 (33%) in the non-CALD low-SES group. Across all groups, risk-reduction behaviours increased during the lockdown. CALD participants showed higher adherence to some Recommendations and Restrictions compared to the other groups. Overall, 28% left home while awaiting a COVID-19 test result, commonly due to work. ConclusionsHigh adherence among CALD and non-CALD low-SES groups suggest structural barriers, rather than behavioural non-compliance, contributed to higher COVID-19 impacts, highlighting the need for tailored support. During future public health emergencies, better supports are needed for individuals working outside of home to remain in isolation while awaiting a test result. Summary box O_TEXTBOXWhat is already known about this subject? In Australia, priority populations such as culturally and linguistically diverse (CALD) and low socio-economic status (SES) groups experienced higher COVID-19 infection, mortality and a disproportionate impact from public health restrictions. What does this study add? CALD populations had an overall higher level of adherence to public health behavioural measures during both lockdown and non-lockdown periods compared to non-CALD populations. Over 25% of participants did not comply with stay-at-home requirements while awaiting a COVID-19 test result, largely due to work responsibilities. How might this impact on clinical practice? Pandemic preparedness efforts should focus on understanding the reasons for non-adherence with isolation requirements and considering tailored support during future pandemics to address the diverse C_TEXTBOX

IntroductionRecent evidence has shown that vitamin C has analgesic properties in immediate postoperative context. However, while a clinical trial is currently underway to evaluate vitamin C for reducing opioid consumption in acute musculoskeletal (MSK) injuries emergency department (ED) patients, its direct analgesic effect in this population has not yet been established. This pilot study evaluated the feasibility of conducting a randomized placebo-controlled trial to determine the analgesic effect of vitamin C alone compared with placebo in acute MSK injured ED patients. MethodsWe conducted a double-blind, randomized controlled pilot trial stratified by fracture status in a tertiary care center. Adults ([&ge;]18 years) presenting to the ED with MSK injuries of [&le;] 48 hours duration and pain intensity >3/10 were randomized to receive vitamin C 900 mg twice daily for three days or placebo. Participants completed a six-day diary (electronic or paper) and were contacted on day six to document analgesic use, treatment adherence, and pain intensity. ResultsOverall, 147 patients were screened; 63 (42.9%) were excluded, 24 (16.4%) refused, leaving 60 (41.1%) participants, with a consent rate of 13.0/month. Mean age (SD) was 41.8 years (14.23) and 50% were female. Lost to follow-up rate differed between participants with electronic diary (n=7; 16.7%) and participants with paper diary (n=10; 55.6%). Patients compliance with treatment was 97.6%. The least-squares mean difference between group A and group B in the time-weighted sum of pain intensity differences over 72 hours (SPID72) was 348.7 (95% confidence interval [CI]:-698.9 to 1396.4) for the intention-to-treat analysis and 357.6 (95%CI:-709.67 to 1424.82) for the per-protocol analysis. ConclusionThis pilot study supports the feasibility of a larger randomized controlled trial on the analgesic properties of vitamin C for acute MSK injured ED patients. Strategies to reduce the missed patients and lost to follow-up rates are proposed. Trial registration numberNCT06306183, ClinicalTrials.gov