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.

Background: Foreign body airway obstruction (FBAO) is a life-threatening emergency; however, bystander treatment recommendations rely on retrospective data. We evaluated the feasibility of a population-based prospective cohort study of FBAO interventions. Methods: We conducted a prospective observational pilot study in Alberta, Canada, between November 2025 and April 2026. We identified individuals with out-of-hospital FBAO who called emergency medical services or attended an emergency department using a validated health-record case definition. Participants were stratified into adults and children (aged>2 years) and younger children (aged< 2 years) cohorts. The primary outcome was included cases per month, with several secondary feasibility (proportion of eligible cases included, data completeness) and clinical outcomes (FBAO relief, survival to acute care discharge, favourable neurological outcome, intervention-associated injuries). Results: Among 5,208 screened encounters, 147 FBAO cases were identified. Of these, 91 adults and children (89.2%) and 39 young children (86.7%) were enrolled. Mean recruitment was 15.2 participants/month (SD=1.1) in the adult and child cohort, exceeding the predefined feasibility threshold ([&ge;]13/month), and 6.5 participants/month (SD=1.3) in the young child cohort, meeting the amber-zone criterion (6-8/month). Data completeness exceeded 90% across all participants. In adults and children, bystander intervention relieved the obstruction in 59 cases (66.3%), and 80(87.9%) survived to acute care discharge. In young children, bystander intervention relieved the obstruction in 33 cases (84.6%); all survived with favourable neurological outcomes. Conclusions: Prospectively identifying and recruiting individuals with FBAO is feasible using population-based prehospital and emergency department records. These findings support a larger adequately powered prospective cohort study comparing the effectiveness and safety of FBAO interventions.

Background: General purpose language models such as ChatGPT are increasingly used by physicians and triage nurses during emergency triage. A recent study reported 51.6% undertriage of emergencies when patients queried ChatGPT directly (Ramaswamy et al., 2026). DR. INFO is an agentic AI based clinical assistant that retrieves over a curated clinical knowledge base, and an MTS specific retrieval configuration is available in which the system also retrieves the Manchester Triage System (MTS) textbook at inference time. The safety of these systems as a triage adjunct against a structured framework has not been characterised. Methods: We adapted the clinical scenarios published by Ramaswamy et al. and mapped them to the Manchester Triage System, yielding 39 emergency cases covering all five MTS priority levels. Each case was evaluated in two variants, one without and one with the objective clinical data block (vital signs, examination findings, and laboratory results), and permuted across two genders, giving 156 prompts per condition. Three systems were tested with and without a misleading GP referral statement prepended as an anchoring statement, giving 312 prompts per system: DR. INFO Baseline, DR. INFO with MTS retrieval, and OpenAI GPT-5.1. The primary outcome was the undertriage rate on the ordered MTS scale, tested with Fisher's exact test. Results: GPT-5.1 undertriaged 44.2% of cases (69/156; 95% CI 36.7 to 52.1), including 75.0% of Red and 73.4% of Orange presentations. Both DR. INFO configurations undertriaged 11.5% of cases (18/156; 95% CI 7.4 to 17.5; Fisher's exact p = 1.0 x 10^-10 versus GPT-5.1). GPT-5.1 produced 6 dangerous misses (3.8%), and both DR. INFO configurations produced none (p = 0.030). When the anchoring statement was prepended, GPT-5.1 undertriaged 8 of 8 Red cases, while both DR. INFO configurations continued to undertriage none. Adding objective clinical data to the input reduced undertriage in DR. INFO with MTS retrieval from 19.2% to 3.8% (p = 0.005). DR. INFO Baseline and GPT-5.1 showed no comparable change. There was no significant effect of gender. Conclusion: On this benchmark, replacing a general purpose language model with an agentic retrieval augmented system over a curated clinical knowledge base substantially reduced the undertriage and dangerous miss rates. Adding retrieval of the Manchester Triage System textbook to the agentic system was further associated with a reduced susceptibility to the anchoring statement and with an appropriate change in the assigned MTS priority when objective clinical data became available. Of the three configurations evaluated here, only DR. INFO with MTS retrieval combined a clinically conservative assignment at first contact with appropriate updating as additional clinical information arrived.

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.

Background: Spatial accessibility measures estimate how much hospital capacity a community can reach but do not show how that capacity is distributed across health systems. A community may have several reachable hospitals but still depend on one or a few systems. Methods: We used the enhanced two-step floating catchment area method to estimate staffed-bed spatial accessibility for New Jersey census tracts. We included short-term acute care hospitals in New Jersey and neighboring states within a 30-minute drive of at least one New Jersey tract. For each tract, we grouped hospital-level accessibility contributions by health system and calculated a Herfindahl-Hirschman Index (HHI). Spearman correlations examined associations of E2SFCA and HHI with tract-level sociodemographic characteristics. Results: Of 163 reachable hospitals, 94 were outside New Jersey and supplied 62.7% of reachable staffed beds. Across 2,172 tracts, the mean E2SFCA score was 1.98 beds per 1,000 distance-weighted residents; among 2,161 tracts with positive scores, the median HHI was 0.31. Using cutoffs of E2SFCA <2.0 and HHI [&ge;]0.18, 934 tracts met both criteria, while an E2SFCA-only rule missed 655 tracts with higher accessibility but high concentration. E2SFCA and HHI correlations had opposite signs for seven of eight sociodemographic characteristics. Conclusions: E2SFCA and HHI classified New Jersey tracts differently under the illustrative cutoffs. Contribution-based HHI identifies tracts in which a closure, service relocation, or capacity reduction involving a major contributing system could affect a large share of modeled accessible capacity. Keywords: Spatial accessibility; hospitals; E2SFCA; health systems; Herfindahl-Hirschman Index

Background: Healthcare has witnessed administrative staffing roles balloon to twice the number of employed clinicians, resulting in $950 billion per year in administrative costs to deliver healthcare. Administrative workflows, like fax routing, are ripe for automation given the high human labor cost necessary to complete these tasks. Facsimile transmissions remain a key mode of communication in modern healthcare, requiring substantial manpower, and incurring significant, though not well-characterized, costs to health systems. Opportunities may exist for agentic artificial intelligence (AI) to automate this administrative task. Methods: This quality improvement study was performed in 2 phases at Duke University's Division of Cardiology, a single tertiary-care cardiac referral center. The first retrospective phase employed an observational time study design surveying manual fax routing processes at 3 representative cardiology clinics from April 1, 2024, to July 12, 2024. The second phase quantified all inbound faxes received through the division's communication hub from July 1, 2025, to December 31, 2025, and applied direct labor costs observed in the time study to quantify the economic burden of manual fax routing across the hub. Results: The observational time study (Phase 1) demonstrated fax routing processing times ranging from 4.4 to 9.4 minutes depending on fax type, with a mean processing time of 6.0 minutes per fax. On average, the ambulatory clinics received 1,694 faxes per month and spent 169.1 person-hours routing faxes. The divisional communication hub (Phase 2) received 24,420 faxes over the study period, averaging 4,070 inbound faxes and 13,341 pages of information per month. Extrapolating direct labor efforts from the time study, 407 person-hours per month were spent processing inbound faxes. For our institution, this translated to $10,663.40 in total monthly costs, roughly 2.5 full-time equivalents. Conclusion: Manual fax routing represents a substantial, measurable, and previously under-characterized operational and administrative burden. Given the significant opportunity to reduce labor time and costs, our study establishes fax routing as a high-value target for automation. Future work is needed to determine the impact of AI-automated fax routing on the time, labor, accuracy, and economics within clinical settings.

Background and importance Emergency Department (ED) crowding is an increasing public health concern, with evidence of harms to patients, the public and healthcare systems. When the number of patients requiring emergency care exceeds the capacity of EDs, operational decisions must be made regarding the best place of care for patients. It is not known if there is an association between place of escalation area care (for example 'ramping' in an ambulance, or in an ED corridor) and patient outcomes. Objective(s) This study aimed to assess the association between the relative proportion of all escalation area care that a site provided in an ambulance (the Ambulance:Escalation Index) and all-cause 28-day mortality. Design A secondary analysis of a prospective cohort study. Adult patients of 16 years or older, attending EDs in England, Wales and Northern Ireland in March 2025. Intervention or exposure (if any) The Ambulance:Escalation Index, a site-level indicator of the proportion of all time in escalation area care provided in an ambulance. Outcome measures and analysis The profile of site-level ambulance use was presented descriptively. Multivariable survival analysis was used to assess the primary outcome, all-cause 28-day mortality. Main results Of 131 EDs using escalation area, 82 (62.6%) used ambulances as a place of escalation area care. There was a significant association between a site's increasing use of ambulances as escalation areas and mortality; for each 5% increase in the proportion of a site's total escalation area care delivered in ambulances, there was a 2.1% increase in the hazard of death by 28 days (HR 1.021, 95% CI 1.002-1.041, p=0.032). Conclusion Emergency Department crowding is associated with poor outcomes irrespective of where departments are forced to deliver care; however this study suggests that there is excess mortality where escalation area care is more often delivered in ambulances.

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.

Objectives: The North Carolina Integrated Care for Kids (NC InCK) pediatric demonstration model created a whole-child risk stratification approach to identify children for enhanced care management. Unlike traditional approaches that rely primarily on healthcare data, NC InCK integrates health, education, social, and juvenile justice data. We described the NC InCK risk stratification approach and compared its output to Medicaid managed care organization (MCO)-assigned risk levels, with the hypothesis that these approaches would identify distinct populations. Methods: This was a cross-sectional study including NC Medicaid participants aged 0-20 years residing in a five-county region in central NC in October 2022. The NC InCK risk stratification algorithm was used to assign participants to Service Integration Levels (SILs) 1, 2, or 3, reflecting increasing anticipated need for integrated cross-sector support. Descriptive analyses compared participant baseline characteristics by NC InCK and Medicaid MCO risk level. Results: Of 99,564 children, 90,151 (90.5%) were assigned to SIL 1, 5,482 (5.5%) to SIL 2, and 3,931 (4%) to SIL 3. About 24% and 20% of children assigned to SILs 2 or 3 by NC InCK were identified as low risk by their Medicaid MCO. Conclusions: The NC InCK risk stratification approach assigns children to SILs 2 and 3 using health, education, social, and juvenile justice data. These populations differ from those identified by Medicaid MCO risk stratification, suggesting that inclusion of non-clinical variables adds unique value. This approach is a step forward in demonstrating the feasibility of methods that proactively identify populations for preventive support by including upstream risk factors.

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.

Purpose: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, yet screening participation remains low. We evaluated whether a brief informational video nudge delivered immediately before a scheduled clinical encounter increased LCS ordering and baseline LCS completion. Patients and Methods: We conducted a randomized feasibility trial within Kaiser Permanente Colorado from March through October 2025. LCS-eligible patients with an upcoming primary care or pulmonology appointment were assigned to intervention or usual care based on birth month. Intervention patients were split into two group, a group who received the LCS informational video nudge via text message within 24 hours of an eligible appointment; and second group who received the text plus a QR code video link during appointment rooming. Outcomes included LCS orders, baseline LCS-LDCT completion, and video engagement. Multivariable logistic regression was used to evaluate factors associated with LCS ordering. Results: Among 1,093 patients, 549 were assigned to intervention and 544 to usual care. Intervention patients were more likely to receive an LCS order within 1 day of their appointment (22.6% vs 16.4%; p=.010) and any time during follow-up (32.6% vs 24.1%; p=.002). Baseline LCS-LDCT completion was 51% higher in the intervention group, although the difference was not statistically significant (8.6% vs 5.7%; p=.078). Among the intervention group, 93 individuals (17%) viewed the video, generating 114 total views, and viewers watched an average of 79% of the video. Most views (82.5%) occurred through text-message delivery rather than QR codes. Conclusion: A brief, low-burden LCS informational video delivered immediately before a clinical encounter and integrated into existing workflows significantly increased LCS ordering and was associated with higher screening completion. Timely, scalable digital nudges may provide an effective strategy for improving LCS participation. Based on the observed effectiveness, feasibility, and efficiency of the intervention, KPCO incorporated the behavioral nudge into standard clinical care in February 2026.

Objectives Emergency Department (ED) crowding is an international concern, predominantly caused by 'exit block', the lack of availability of inpatient beds for those requiring admission. The implementation of Flow Navigation Centre Plus (FNC+) services in Scotland aimed to reduce self-presentation to EDs and reduce crowding by providing remote clinical assessment for patients contacting urgent care by telephone and professional-to-professional advice on patient pathways, but their effectiveness is unknown. This study aimed to estimate the effect of board-wide implementation of FNC+ on ED attendances and long waits during the first year of FNC+ operation. Methods Controlled interrupted time series using weekly, publicly reported Public Health Scotland data. The intervention was implementation of the FNC+ in NHS Lanarkshire on 1 April 2024. Counts were summed across constituent sites and percentages derived from board totals. Co-primary outcomes were ED attendance volume and the proportions of attendances spending more than 4, 8 and 12 hours in the department. Segmented regression was fitted with contemporaneous control boards, seasonal terms, and accounted for autoregression. Results 118 pre-intervention and 52 post-intervention weeks were analysed across all 3 EDs in the implementing board. Attendances showed no detectable step change (+1.20%; 95%CIs -0.66 to +3.10) relative to the counterfactual. The estimated effect increased across follow-up, however, changing by +3.95% over 52 weeks (95% CI +0.36 to +7.67%). There was no significant step change in the proportion of attendances waiting more than 4 hours following the intervention (+1.74%; 95%CIs -0.71 to 4.20%). Some transition and structural sensitivity analyses demonstrated significant deteriorations in ED performance, and increased attendances, in the year following implementation, and none demonstrated improvements. Conclusions Board-wide implementation of a Flow Navigation Centre Plus was not associated with a step change in ED attendances or in long waits, but there is some evidence that attendances increased and long waits increased in the year following implementation. Their provision of supply-sensitive care is a possible mechanism. Additionally, given their action at the point of input, aiming to divert patients from ED attendance, it is unlikely that such services could relieve a constraint due to exit block, the availability of inpatient care for those requiring admission.

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.

Introduction Aging populations are placing increasing pressure on Emergency Medical Services (EMS) providers to address the potentially suboptimal use of scarce resources. EMS utilization that falls outside the established deployment framework, referred to here as non-indicated use, may constitute an important source of such suboptimal resource use. Frequent users of EMS represent a key target group in efforts to reduce non-indicated utilization. The focus on frequent users is driven by the substantial workload and costs associated with their use of EMS, as well as by the need to address potential underlying quality-of-care issues reflected in high, persistent, or intensive EMS utilization. Addressing possible non-indicated EMS use among frequent users requires the development of monitoring systems that can be applied in both clinical practice and research to identify such use and support appropriate action once it has been detected. This study aims to explore the relationships between the drivers of frequent EMS use, potential remedies for non-indicated use, and subsequent reductions in utilization. Based on these insights, the study seeks to develop, through prototyping, a framework to guide the design of monitoring systems for research and clinical practice. Methods and analysis We will employ a mixed-methods observational study design. A systematic literature review and interviews with stakeholders who play key roles in the EMS referral process will be conducted to identify the drivers of frequent use and non-indicated EMS use and their potential remedies. Pseudonymized routinely collected data covering 2013-2026 from three Dutch EMS providers will be analyzed using machine learning (ML) and artificial Intelligence (AI) techniques to develop a typology of drivers and trustworthy, interpretable models for identifying frequent use and non-indicated use. A prototype monitoring system will be developed to demonstrate the online and the offline functionalities of the proposed framework for use in both clinical practice and research. The prototype usability, trustworthiness, and interpretability will be evaluated in collaboration with relevant stakeholders involved in the EMS referral process. Ethics and dissemination The data is routinely collected for administrative purposes only. Accordingly, the data will be completely pseudonymized, and as such this study falls outside the scope of the Dutch Medical Research Involving Human Subjects Act. After assessment we obtained a full waiver for using pseudonymized data from the EMS services from the Medical Ethics Review Board of the University Medical Center Groningen (reference number METc 2022/053). Patients and/or the public are not involved in the design, conduct, reporting, or dissemination plans of this research. Interviewees and participants in evaluating prototype monitoring systems (e.g. EMS clinicians, medical directors, ambulance nurses, emergency physicians, general practitioners (GPs), policy makers and police officers) will provide informed verbal consent prior to their participation in the study. The study findings will be disseminated through peer-reviewed publications, presentations at conferences, and in social media. Also, summary reports will be made available to participating institutions and relevant stakeholders.

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.

Introduction Inappropriate use of echocardiograms and stress tests with nuclear components in the evaluation of cardiopulmonary complaints (chest pain, dyspnea/shortness of breath (SOB), dizziness, and syncope) is common, despite Cardiology society guidelines for appropriate use. Such overuse raises healthcare costs, impairs the availability of resources for other patients, and exposes patients to radiation unnecessarily. Our Emergency Department (ED) runs an observation unit that sees thousands of patients annually with cardiopulmonary complaints. We observed many have echocardiograms and stress tests with nuclear components without indications for either. Working with our Department of Cardiology, we promoted guidelines for appropriate use of echocardiograms and stress tests with nuclear components in the evaluation of such patients. Methods We collected 2024 and 2025 data regarding OU admissions. Patents were included if they were [&ge;]18 years, in the ED OU between 1/1/24 and 12/31/25, aad an OU admission complaint of chest pain, dyspnea/SOB, dizziness, and syncope. We calculated the percent of patients with such presentations who received either an echocardiogram or a stress test with a nuclear component. We then compared the 2024 (pre-implementation) data with full-year data from the first full year of implementation (2025). Results After introducing educational guidelines, there were statistically-significant reductions in nuclear stress tests ordered for dyspnea/SOB (absolute reduction 9.3%; p = 0.0009) and overall usage of nuclear stress tests (absolute reduction 2.4%; p = 0.0095). This was offset by increases in echocardiograms ordered for chest pain (absolute increase 3.7%; p = 0.005) and overall usage of echocardiograms (absolute increase 2.0%; p = 0.0454). There was no net change in the overall use of echocardiograms and nuclear stress tests when considered together: 85.2% of patients had one or the other study in 2024 vs. 84.8% in 2025; p = 0.5768. Discussion Introducing and promoting appropriate-use guidelines for echocardiograms and stress tests with nuclear components in the evaluation of cardiopulmonary complaints was associated with a reduction in unnecessary nuclear stress tests, but not echocardiograms. Success of this program to reduce nuclear stress tests may be attributed to several factors. First, the relevant specialties (emergency medicine, cardiology) were engaged. Second, we relied on guidelines adopted by professional organizations. Third, the initiative corresponds to nationwide efforts to decrease cost of care by providing evidence-based diagnostic and treatment management. Failure to reduce echocardiograms may be due to a well-documented multi-year time lag between changes in medical knowledge and wide-scale adoption; failure to develop the guidelines in collaboration with house staff and mid-level providers and promote them at multiple times and venues in a multi-modal manner; and utilize Department leadership to promote their usage.