CMAJ Open

BackgroundRural emergency departments (EDs) are critical to ensuring equitable access to acute care, yet face persistent systemic challenges. In Quebec, Canada, reforms to healthcare governance, funding and resource allocation, and service delivery have transformed rural ED operations. This study aimed to document characteristics, challenges, and improvement priorities for all rural EDs in the province. MethodsA participatory mixed-methods design was used. 26 rural EDs in Quebec were included. Data sources comprised administrative statistics, structured site surveys, individual stakeholder semi structured interviews, and a validation survey of identified local champions. Analyses comprised a triangulation of the quantitative and qualitative data using transversal thematic analysis to determine common issues. Potential solutions identified were validated through stakeholder questionnaires. The study was reported in accordance with the COREQ reporting guideline. ResultsMost respondents were women (64%) and professionals with more than 5 years of experience. Four main themes were identified: governance, healthcare organization, access to resources, and professional practice. Governance challenges included reduced local autonomy, administrative complexity, and budgeting models poorly adapted to rural realities. Participants emphasized the need for standardized but locally flexible administrative processes, regional emergency service managers, and rural-sensitive performance metrics. Organizational barriers included geographic isolation, limited access to primary care, and difficulties with interfacility transfers due to referral-center capacity and ambulance shortages. Resource constraints centered on shortages of human resources, diagnostic services and specialty coverage, especially anesthesia, obstetrics, and psychiatry. Professional practice was shaped by the need to maintain broad competencies in low-volume contexts, while contending with professional isolation and proximity to patients. Local champions prioritized expanding telemedicine, strengthening prehospital services, enhancing continuing education, and implementing tailored recruitment strategies. ConclusionThis study provides the first province-wide documentation of characteristics, challenges, and improvement priorities for all rural EDs. Findings highlight the need for systemic reforms that restore local decision-making authority, strengthen transfer and prehospital capacity, expand telehealth and specialty access, and support professional development. These results provide a foundation for evidence-based policies and actions to sustain equitable emergency care in rural regions.

BackgroundMore than one in five Canadians (6.5 million people) do not have a family doctor or nurse practitioner they see regularly. Access gaps are greater among immigrants and marginalized populations, who face systemic, cultural, and language barriers to care. ObjectivesTo evaluate access to primary care provider and dentist among residents of a neighborhood with a high proportion of visible minorities in Hamilton, ON. MethodsBetween 2022 and 2024, adults living in Riverdale, a neighbourhood in the city of Hamilton, Ontario in which 51% families were born outside the country, were invited to participate in a cross-sectional survey. Determinants of access to these services were identified using multivariable logistic regression modelling. Results930 people completed the survey. Of these, 48% were not born in Canada. The median age of participants was 39 years, with a median time living in Canada of 28 years. Of those who responded, 79.6% had a primary care provider; and 57.1% had a dentist. In multivariable models, living in Canada < 5 years (OR = 0.10; 95% CI: 0.05, 0.20), male sex (OR= 0.56; 95%CI: 0.38, 0.82) and being unmarried (OR = 0.41; 95% CI: 0.27, 0.64) were associated with lower odds of having a primary care provider. Living in Canada for < 5 years (OR = 0.20; 95% CI: 0.11, 0.35), male sex (OR =0.74; 95% CI: 0.55, 0.99), and employment while living below the poverty line (OR=0.50; 95% CI: 0.29, 0.90) were linked to lower access to dental care. ConclusionIn a neighborhood with high proportion of visible minority newcomers in Hamilton, ON, 20% of those surveyed did not have access to a primary care provider, and 43% did not have access to a dentist. Access to primary care was lowest amongst newcomers (within 5 years), men, and those who are unmarried.

BackgroundCOVID-19 patients seen in an emergency department (ED) are at high risk of complications including post-COVID-19 condition (PCC), commonly known as Long COVID. As evidence is emerging concerning the efficacy of early post-acute rehabilitation and therapeutic interventions, early ED identification supported by a clinical prediction rule, combined with appropriate outreach and health education, could contribute to alleviating the burden of the disease on health systems and positively impact the quality of life of those living with the post-COVID-19 condition. This study aimed to derive and validate a clinical prediction rule to identify adult ED patients at high risk of developing PCC three months after an acute infection. Methods and findingsThis derivation and validation study used data from an observational cohort recruited from 33 hospitals in five Canadian provinces participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). We included adults (age [&ge;]18 years) with confirmed COVID-19 who presented to the ED of a participating site between October 18, 2020, and October 11, 2022. We randomly assigned participants to derivation (75%) or validation (25%) datasets, and prespecified clinical variables as candidate predictors. We used a fast step-down logistic regression to reduce the model to key predictors for our clinical prediction rule. Validation was planned only if the derived rule had an AUC of at least 80% to support clinically useful discrimination characteristics to separate those who will develop PCC from those who will not. Of 6,070 eligible patients, 2,511 (41.4%) reported PCC symptoms at three months. Our derived clinical prediction rule included nine risk factors (female sex, higher arrival respiratory rate, comorbidities (rheumatologic disorder and mental health condition), acute symptoms (sputum production, dizziness, diarrhea, chest pain, and fatigue)) and one protective factor (self-reported South Asian race). In derivation, the optimism-corrected area under the curve was 0.626 (95% confidence interval [CI] 0.610-0.643). Age and vaccination status were not retained in the final clinical prediction rule. The rule was only slightly better than chance and deemed not accurate enough to meaningfully guide decision-making in the ED. Therefore, we did not proceed to examine its performance in the validation cohort. ConclusionsDespite rigorous methodology, we were unable to derive a clinical prediction rule with sufficient accuracy to predict PCC in emergency department patients at the time of the acute infection. However, we did identify several factors associated with the development of PCC that can guide future studies about the causes of PCC. The ambiguous nature of the current PCC diagnostic criteria and the extended follow-up pose challenges for deriving a useful clinical decision rule. Further research integrating comprehensive surveillance systems and biomarker data may also enhance prediction accuracy and refine personalized management strategies in the emergency department setting.

IntroductionNewfoundland and Labrador (NL) faces persistent difficulty attaching its residents to primary care. We undertook a stock and flow analysis to represent how inflows and outflows of family physicians (FPs) shape effective capacity and to provide a reconciled estimate of FP supply for 2024. This approach clarifies drivers of change, exposes intervention points, and supports timely planning. MethodsWe assembled a multi-year headcount series and linked it to CIHIs "entering/leaving direct care" flows, harmonizing definitions and time frames across sources. We compared observed year-to-year stock change with net flows to identify timing and classification gaps. Stakeholder consultations informed key parameters (graduates and retention, internationally trained entrants, migration, retirement, and scope shift). Because confirmations are released with a lag, we produced a reconciled 2024 estimate using the CIHI headcount as baseline and these validated inputs. FindingsFP headcount changed from 680 (2014) to 666 (2023) (-2.1%) after peaking at 728 (2017); the ratio fell from 129 to 124 per 100,000 population. The workforce became more urban (rural 255[-&gt;]203; urban 424[-&gt;]460) and more Canada-trained (417[-&gt;]466) while foreign trained decreased (261[-&gt;]199). Net interprovincial migration averaged -24/year, with pronounced losses in 2019 (-57) and 2022 (-42). CIHI entry-exit data point to marked volatility in the FP workforce: entries/exits were 110/96 (2019), 62/88 (2020), and 71/117 (2021), with residuals versus stock change indicating definitional/timing differences. The 2024 reconciliation yielded {approx}658 FPs (net -8.5 from 2023), {approx}507 FTE at 0.77 FTE/head, and {approx}122 per 100,000 population. ConclusionInflows from local graduates and IMGs did not fully offset exits from migration, retirement, and scope/burnout in 2024. Recruitment alone is unlikely to close access gaps; retention-first strategies, scaleup of team-based care with role optimization, targeted rural supports, and routine monitoring of flows are needed to stabilize and grow effective primary care capacity in NL.

Background/aimsSport-related concussions (SRCs) are becoming a global public health concern as new research and policies emerge. In the Province of Ontario, a 2014 Policy/Program Memorandum (PPM 158) required all school boards to establish a policy that promoted concussion education, awareness, and tracking. This was followed by Rowans Law in 2018 which emphasized sports-related treatments and tracking of concussions. The objective of this study was to examine the association between these concussion policies and emergency department (ED) visits for SRCs in children and youth (5-19) in Ontario by material deprivation from 2014-2024. MethodsThis population-based study used routinely collected administrative data from ICES in Ontario, Canada, specifically the National Ambulatory Care Reporting System (NACRS). All ED visits for children and adolescents ages 5-19 with ICD-10 (International Classification of Disease version 10) S060 identifying concussion were included with a corresponding ICD-10 mechanism of injury code related to sports. The number of SRCs and the percent of SRCs within total concussions were analyzed. An interrupted time series analysis was conducted to examine changes in ED visits for SRC from 2014-2018 (the years following the release of PPM 158 up until the release of Rowans Law), from 2020-2021 (the years during the COVID-19 pandemic), and in 2019, 2022, 2023, and 2024 (the years following Rowans Law). ResultsThe number of ED visits initially increased after the introduction of Policy/Program Memorandum No. 158 but started to decline after 2018 when Rowans Law was introduced. The numbers have remained lower post-COVID-19 pandemic suggesting that this law may have a positive impact. By material deprivation quintile, the highest income quintile saw significantly lower counts of ED ({beta} = -628.7 (p = 0.001)) following concussion laws compared to before. ConclusionsRowans Law appears to have a positive lasting impact on Ontario youths by reducing ED visits for SRCs. Educational resources related to awareness and identification of concussions should continue to be available to children and youth, coaches, and parents. What is known on this subjectSport-related concussions among youths are associated with serious long-term burdens, with social disparities impacting their access to much-needed care. In Ontario, Canada, a concussion-related policy (PPM 158) and a law (Rowans Law) that were adopted in 2014 and 2018, respectively, have yet to be analyzed in terms of its impact. What this study addsThis study contributes to a greater understanding of the association between Rowans Law and children and youth seeking care for sports-related concussions in emergency departments. Further, it provides insight into differences in emergency department visits by material deprivation quintiles. How might this affect policy, practice and researchThe results of this study may encourage other jurisdictions to enact similar legislation, and can inform school boards and sporting organizations to have an equity-driven lens when delivering concussion education to students, parents, and coaches.

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.

SARS-CoV-2 strained Ontarios health system, with social determinants of health (SDH) underexplored in cost analyses. We examined COVID-19 attributable healthcare resource use and costs from the Ontario health system perspective using health administrative data. We conducted a cohort study, matching 162,633 SARS-CoV-2-exposed individuals 1:1 to unexposed individuals. We calculated 10-day per-person mean attributable costs (2023 CAD) across care phases (pre-diagnosis, acute, post-acute, terminal), stratified by individual and area-level SDH. Among exposed individuals (mean age 40.4 years, 50.7% female), 6% were hospitalized, 1.3% admitted to critical care, and 2% died within 360 days. Mean (SD) person acute phase cost was $244 ($235-$253) and higher among males, recent immigrants, individuals living in low-income neighbourhoods and neighbourhoods with a higher proportion of crowded households. Extrapolating to the population level of 166,801 exposed individuals, the mean total survival-adjusted 360-day cost was $436 million. COVID-19 increased healthcare costs, disproportionately burdening marginalized communities.

BackgroundRespiratory viruses are major contributors to population mortality, but cause-of-death coding undercounts their impact. Ecological regression models linking viral circulation to mortality fluctuations can address this limitation. AimTo estimate the population attributable fraction (PAF) of mortality associated with influenza A and B, respiratory syncytial virus (RSV), and SARS-CoV-2 in Ontario, Canada (1993-2024). MethodsWe analysed monthly all-cause mortality data with laboratory surveillance indicators for influenza A, B, RSV, and SARS-CoV-2. Negative binomial models with secular trends, Fourier seasonal terms, and population offsets were stratified into pre-pandemic (1993-February 2020) and pandemic (March 2020-March 2024) periods. PAFs were derived from counterfactual predictions setting viral coefficients to zero. Sensitivity analyses excluded seasonal terms; Wald tests compared coefficients across model specifications. ResultsPre-pandemic, influenza A accounted for 1.8% (95% CI 1.4-2.3%) of mortality; influenza B showed no detectable impact. RSV demonstrated inverse associations in seasonally adjusted models but positive associations (PAF 1.9%, 95% CI 1.3-2.4%) without seasonal adjustment. During 2020-2024, amid elevated baseline mortality (IRR 1.050, P=0.027), SARS-CoV-2 dominated, accounting for 6.5% (95% CI 4.5-8.4%) of deaths, 3.6-times the pre-pandemic influenza A burden, despite widespread vaccination and antiviral availability. Model-estimated SARS-CoV-2 deaths (18,052) matched reported COVID-19 deaths (18,603). Meta-analyses showed substantial heterogeneity for influenza A (I{superscript 2}=93.7%) and RSV (I{superscript 2}=88.5%) across periods and modeling approaches, but minimal heterogeneity for SARS-CoV-2 (I{superscript 2}=2.5%). ConclusionSARS-CoV-2 demonstrated 3-4-fold higher mortality burden than seasonal influenza A despite available countermeasures. Estimates for influenza A and RSV were sensitive to seasonal adjustment, highlighting the importance of modelling choices when quantifying virus-attributable mortality.

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.

ObjectivesTo investigate the factors associated with the deterioration of post-COVID-19 condition (PCC) symptoms in patients who received a dose of SARS-CoV-2 vaccine [&ge;] 90 days after their infection. MethodMulticenter cohort study conducted in 33 emergency departments across Canada, including 476 patients who developed PCC according to the World Health Organization definition. Data were collected via telephone questionnaires. Statistical analyses, including logistic regression models, were performed to identify factors associated with symptom deterioration after vaccination. ResultsAmong participants, 28.8% reported a deterioration of their PCC symptoms after vaccination. Two factors were significantly associated with this deterioration: receiving the Moderna (mRNA-1273) vaccine (aOR = 1.80; 95% CI: 1.14-2.8) and a persistent cough three months after the initial infection (aOR = 1.81; 95% CI: 1.03-3.15). No association was found between symptom deterioration and sociodemographic characteristics such as age or sex. ConclusionPost-infection vaccination may be associated with increased risk of PCC symptoms deterioration in some patients, particularly those vaccinated with Moderna (mRNA-1273) or presenting with a persistent cough. While the benefits of vaccination remain substantial, these findings call for further investigation into the underlying immunological mechanisms and possible adjustments to vaccination strategies for patients with PCC.

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.

ObjectivesTo characterize emergency department (ED) clinician engagement with electronic health record (EHR)-based social drivers of health (SDOH) data; test whether engagement differs in encounters with opioid use disorder (OUD); and, among OUD encounters, assess whether engagement is associated with medications for OUD (MOUD) treatment. Materials and MethodsWe conducted a cross-sectional study of adult ED encounters (January 2023-October 2024). OUD encounters, identified with a structured phenotype, were matched (1:2) to non-OUD encounters. Audit logs captured clinician engagement with structured SDOH questions ("SDOH Wheel"), ICD-10 Z codes in the Problem List, Social History free text, and social work notes. Engagement was any SDOH documentation or review of preexisting SDOH data during the encounter. Logistic regression estimated associations. ResultsAmong 17,103 encounters (5,701 OUD; 11,402 non-OUD), clinician SDOH documentation was rare (<1%). Clinicians most often reviewed Z codes (610/620; 98.4%), followed by the SDOH Wheel (1,103/3,953; 27.9%), social work notes (1,711/10,670; 16.0%), and Social History free text (232/6,942; 3.3%). Engagement occurred in 19.5% of encounters and was higher with OUD (26.6% vs 16.0%; adjusted odds ratio [aOR] 1.91, 95% CI 1.77-2.07). Among OUD encounters, engagement showed no clear association with MOUD (aOR 1.11, 95% CI 0.84-1.47), yet racial and ethnic disparities persisted. DiscussionED clinicians infrequently document but do review structured, accessible SDOH data. Engagement is higher in OUD encounters yet shows no definitive link with MOUD, while disparities persist. Interface designs that surface SDOH and targeted EHR decision support warrant evaluation to inform equitable, time-sensitive ED care.

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

Study ObjectiveTo compare a computable structured opioid use disorder (OUD) phenotype currently used to trigger emergency department (ED) clinical decision support (CDS) with a large language model (LLM) for OUD identification, using expert physician review as the reference standard. MethodsWe conducted a retrospective study of randomly sampled adult ED encounters (January 1, 2023-October 17, 2024) at a single academic health system. Encounters were stratified by structured phenotype status and weighted to reflect population prevalence. The structured phenotype, implemented operationally to activate CDS, incorporated diagnosis codes, medications for OUD, urine toxicology results, addiction consultations, and keyword recognition. An LLM (ChatGPT 4.1) analyzed ED notes from the index visit using a zero-shot prompt. Two board-certified emergency physicians independently determined OUD status by full chart review; discrepancies were adjudicated by a third reviewer. We calculated weighted sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ResultsAmong 302 encounters, weighted OUD prevalence was 5.6% (95% CI 4.0-7.0%). The structured phenotype demonstrated sensitivity 0.84 (95% CI 0.42-0.97) and specificity 0.964 (95% CI 0.96-0.97) (PPV 0.58; NPV 0.99). The LLM demonstrated sensitivity 0.81 (95% CI 0.70-0.88) and specificity 0.996 (95% CI 0.993-0.998) (PPV 0.92; NPV 0.99). Specificity was significantly higher for the LLM (p<0.0001). ConclusionBoth approaches demonstrated strong diagnostic performance. Although the structured phenotype showed slightly higher sensitivity, the LLM achieved higher specificity and PPV, suggesting potential to reduce false-positive alerts in ED workflows. Prospective validation in larger, representative populations is needed to guide clinical implementation.

ImportanceHospital capacity constraints and rising healthcare costs necessitate innovative models for delivering acute care. While various hospital-substitution models exist, challenges in scalability and long-term viability persist. ObjectiveTo evaluate the feasibility and safety of a novel, high-acuity Next Day Clinic (NDC) as an alternative to hospitalization for select acutely ill emergency department (ED) patients. Design, Setting, and ParticipantsRetrospective matched cohort study of patients referred to the NDC between July 1, 2023-July 31, 2024, matched to patients seen in the ED during the year prior to NDC launch, within a large academic safety-net hospital. InterventionHigh-acuity outpatient therapy for one or more consecutive days in the NDC, consisting of daily IV antibiotics or diuretics, STAT labs, and rapid turnaround imaging and cardiodiagnostics. Main Outcomes and MeasuresDays alive and out of hospital (DAOH) in the 30 days following the index ED visit. Secondary outcomes were the number of hospital bed-days avoided, as well as 30- day ED revisits, hospital readmissions, and mortality. ResultsThe NDC had 1009 encounters (mean age, 54.4 years [SD 14.6]; 448 female [44%]) during the study period, 420 (42%) of which were referred from the ED. Of these, 298 (71%) matched to 4666 ED visits (mean age, 53.3 years [SD 15.2]; 2019 female [43%]) in the year prior to NDC launch on age, sex, the first set of laboratory and vital sign data obtained in the ED (i.e., presenting illness severity), and an exact match on primary diagnosis group. Unadjusted mean DAOH in the NDC cohort was 29.5 days (SD 2.3) compared to 24.9 days (SD 5.5) in the control cohort. Adjusting for the same features in the matching algorithm showed NDC treatment was associated with an average of 3.85 (SD 0.20) more DAOH compared to hospitalization (p<0.001), translating to 358-1294 hospital bed-days saved over the study period. NDC patients had significantly higher rates of 30-day ED revisits per 100 encounters (20.5 versus 13.0, p<0.001), but significantly lower rates of 30-day hospital readmissions per 100 encounters (5.7 versus 11.0, p<0.001) and morality (0% versus 0.9%, p<0.001). Conclusions and RelevanceThe NDC is a feasible and safe alternative to hospitalization, and promising strategy for managing ED and hospital capacity and reducing healthcare expenditures. KEY POINTSO_ST_ABSOuestionC_ST_ABSIs a high-acuity Next Day Clinic (NDC) a feasible and safe alternative to hospitalization for acutely ill emergency department (ED) patients? FindingsIn this matched cohort study of 1009 NDC encounters, 298 hospital admission avoidance referrals were matched with 4666 historical controls. Each avoided hospitalization through the NDC was associated with an average of 3.85 more days alive and out of the hospital over 30 days, lower readmissions and mortality, and a total of 358-1294 hospital bed-days saved. MeaningA centralized, high-acuity outpatient clinic may safely substitute for hospitalization, reducing hospital capacity strain and healthcare expenditures.

BackgroundSocioeconomic disparities in COVID-19 outcomes have been widely documented, but evidence regarding inequities in SARS-CoV-2 transmission remains mixed. In Canada, infection-induced seroprevalence appeared to converge across socioeconomic strata by late 2022, raising questions about whether transmission inequities diminished during the Omicron period. AimTo assess whether apparent convergence in SARS-CoV-2 seroprevalence reflects true equity in transmission or masks persistent socioeconomic disparities in force of infection. MethodsWe analysed serial cross-sectional SARS-CoV-2 seroprevalence data (anti-nucleocapsid antibodies) from Canadian Blood Services donors collected between April 2021 and April 2023 and stratified by area-level material deprivation quintile. We fitted a dynamic susceptible-infected model with sero-reversion to the full seroprevalence time series, estimating quintile-specific forces of infection before and after the emergence of the Omicron variant (January 2022). Models allowing differential Omicron-related amplification by socioeconomic status were compared using likelihood-based criteria. ResultsDuring the pre-Omicron period, force of infection increased monotonically with material deprivation; the most deprived quintile experienced a 71% higher force of infection than the least deprived (incidence rate ratio (IRR): 1.71; 95% CI: 1.60-1.83). Following Omicron emergence, force of infection increased markedly in all quintiles but by differing magnitudes. Relative increases were largest in the least deprived quintile (48.5-fold) and smallest in the most deprived quintile (31.8-fold), resulting in compression of the socioeconomic gradient (Q5 vs Q1 IRR: 1.12; 95% CI: 1.11-1.14). Despite this compression, materially deprived populations continued to experience elevated transmission risk. ConclusionConvergence in SARS-CoV-2 seroprevalence across socioeconomic strata masked persistent inequalities in force of infection. Dynamic modelling demonstrates that apparent equity arose from differential amplification of transmission during the Omicron period rather than from elimination of underlying socioeconomic disparities.

BackgroundOut-of-hospital cardiac arrest accounts for over 350,000 deaths annually in the United States, and survival depends on early bystander cardiopulmonary resuscitation (CPR). Although many cardiac arrests occur on or near school grounds, Massachusetts has no statewide CPR graduation requirement and little current data on school preparedness. MethodsWe conducted a cross-sectional electronic survey of all 413 public high schools in Massachusetts (including charter, vocational, and technical) between September 29 and November 17, 2025. The 14-item survey asked about enrollment, staff size, CPR and automated external defibrillator (AED) resources, student and staff training, and the presence of a cardiac emergency response plan. The CERP item was excluded from analysis due to inconsistent interpretation. We summarized resources per 1,000 students or staff, compared Title I and non-Title I schools, and explored geographic variation and multivariable predictors of AED availability and CPR teaching. ResultsOne hundred schools responded (24.2%), representing 13 of 14 counties, with a median enrollment of 662 students, and 33.0% were Title I schools. Overall, 72.0% reported teaching CPR. The median student training rate was 138.2 per 1,000 students, though only 10.0% of schools with non-missing data reported all students trained and 15.0% reported at least 70% of students trained. Among responding schools, Title I schools had fewer trained students than non-Title I schools (median 50.3 vs 199.8 per 1,000; Holm-Bonferroni adjusted p = 0.025), despite similar AED and manikin availability. This disparity persisted in sensitivity analyses using median imputation for missing student training data. County-level analyses suggested geographic variation in both training rates and AED density, although county-level estimates were based on small numbers of responding schools. ConclusionsAmong responding Massachusetts high schools, most reported some CPR instruction, but only a small minority achieved broad student coverage, with particularly low training rates in Title I schools. These exploratory findings underscore the need for policies ensuring equitable CPR training access, particularly in Title I schools, and support targeted investment in school-based cardiac emergency preparedness

ObjectivesMobile health clinics (MHCs) provide flexible, community-based care to underserved populations facing geographic and socioeconomic barriers. Maximizing coverage enables MHCs to reach more individuals, improve preventive and continuous care, and reduce health disparities. However, few strategies exist to guide placement and routing decisions. We present a framework to increase MHC utilization by optimizing service coverage. Study DesignThis is a retrospective study. MethodsWe analyzed MHC deployments for Hepatitis C Virus (HCV) screening and treatment from a local health system in South Carolina. We used a location-allocation model to identify potential MHC placement sites that maximized the number of uninsured residents within a 5-minute drive or 10-minute walk. Demand was represented by block centroids weighted by the size of the uninsured population. We compared service area population, defined as the size of the target population within driving or walking distance, for model-proposed sites with coverage from previous MHC deployments. We fit negative binomial mixed effects models to evaluate the association between service area population and MHC utilization. ResultsOptimized placements can nearly double population coverage, expanding access to uninsured residents within practical travel distances by 90% for driving and 135% for walking--without requiring additional vehicles or resources. This approach also substantially reduces redundant service areas while shortening average travel times. Results show that small geographic shifts can yield significant improvements. In rural regions, greater geographic coverage is significantly associated with higher MHC utilization for HCV screening (drive p=.0037; walk p=.0095). We applied this framework with local health partners to guide real-world MHC deployment in South Carolina. ConclusionsThis framework connects spatial analytics to service delivery, offering a replicable, operationally ready tool adaptable to various travel modes, site types, and disease contexts. It supports strategic placement in high-need locations by reducing travel time and service redundancy and ultimately improving health outcomes in medically underserved populations.

BackgroundCardiovascular disease is the leading cause of death among women, yet women have historically been underrepresented in cardiovascular research. In Canada, sex- and gender-based analysis (SGBA) policies were introduced to address these gaps, including mandatory applicant-level requirements in 2010 and reviewer-level guidance in 2018. How these policies have influenced funding allocation for women-related cardiovascular research remains unclear. ObjectiveTo examine long-term trends in CIHR investment in women-related cardiovascular research and assess changes associated with SGBA policy milestones. MethodsWe conducted a longitudinal study using Canadian Institutes of Health Research (CIHR) funding data from fiscal year 2000-2001 to 2024-2025. Women-related cardiovascular research projects were identified through terminology searches in funded project titles, keywords, and abstracts. Annual fiscal-year proportions of cardiovascular research funding allocated to women-related research were analysed using segmented regression, with interruption points in 2010 and 2018. ResultsAmong 17,168 cardiovascular research related grant annual records, 11.33% were classified as women-related projects. These projects accounted for 11.85% of total CIHR cardiovascular research funding over the 25-year period. Funding increased before 2010, declined between 2011 and 2017, and accelerated after 2018. Segmented regression showed a small immediate increase in 2010, followed by a negative post-2010 trend and a significant positive quadratic trend after 2018. ConclusionsApplication-level SGBA requirements had limited influence on investment patterns, whereas the 2018 reviewer-level guidance aligns with the subsequent acceleration in women-related cardiovascular research funding. Strengthening SGBA implementation, expanding targeted funding opportunities, and improving monitoring of sex-and-gender-disaggregated outputs may help address persistent gaps in women-related cardiovascular research.