From the Editors.

It will take years before we can understand and measure the full toll that the COVID-19 pandemic has taken on our health systems. Of the many reverberations from the pandemic, one of the most concerning implications is an increase in the rates of preventable harm. Four years of unprecedented demand on healthcare services combined with health human resource shortages and clinician burnout have pushed our systems to the brink - and are impacting our capacity to improve or even maintain standards of care.

From the Editors.

There is no doubt that 2023 was a very difficult year for many Canadians, as well as people across the world. War caused massive upheaval globally, inflation continued to impose financial hardship on families and our health systems experienced another brutal respiratory season while still in recovery from the COVID-19 pandemic. Unfortunately, the year ahead is likely to bring more political and economic uncertainty, although we hope it also brings with it some opportunities for our health system, including the use of artificial intelligence (AI), research advancements and system transformation initiatives.

From the Editors.

Some of us may recall a time in healthcare when it seemed that the summer months were a bit quieter, providing an opportunity to catch our breath before the onslaught of fall and the ramp-up to flu season. Yet, with the increasing demand on our health systems, the sense of downtime has all but disappeared. This may suggest that we collectively have less time available for review, reflection and learning - all of which are critical elements for improvement and transformation. As an editorial team, our contribution is to continue synthesizing and presenting leading practices and innovative concepts to our readers, enabling them to access knowledge and ideas more easily. It is how we can help build capacity in our system to deliver better healthcare at a time when renewal is needed more than ever.

From the Editors.

As we consider the current pressures on healthcare, the options for where to focus our policy and leadership efforts are numerous and, at times, overwhelming. From health human resources capacity to access to mental health and preventative care to intermittent closures of emergency departments - the outlook is alarming. To help make sense of the situation, our Healthcare Quarterly (HQ) editorial team carefully considers a few areas to focus on in each edition. Over the past few issues, we have highlighted the importance of health equity and the challenges faced by different populations in gaining access to appropriate care and support. We continue to welcome submissions on this topic as we start to shift our focus toward other system priorities, including the mental health crisis in Canada. We are currently exploring a special focus edition on this long-neglected area of the health system and will be inviting submissions on this topic over the coming months.

From the Editors.

The recent winter months were particularly brutal for the healthcare system and its patients as we grappled with an onslaught of infectious diseases, healthcare backlogs and critical shortages of health human resources. We subsequently watched as Canada's federal and provincial leaders sought agreement on additional investments for several of our most precarious sectors, including long-term care, primary care and mental healthcare. Spring 2023 offers some optimism in that we will have new resources to make much-needed improvements to our depleted health sectors and services. While we can anticipate ongoing tensions as to how these investments will be used and how political leaders are held accountable, our healthcare leaders are gearing up to increase capacity and shore up our systems.

Shadows and Light: An Interview with Heather Patterson.

The editors of Healthcare Quarterly (HQ) recently had the opportunity to speak with Heather Patterson - emergency physician, photographer and author of the recently released book Shadows and Light (Patterson 2022). Through the photographs she took at Calgary-area hospitals during the height of the COVID-19 pandemic, Patterson created a poignant record of how the pandemic affected hospital staff, patients and their families. The book has struck a chord with many Canadians as it offers both an honest appraisal of the dreadful toll of the pandemic while also demonstrating the grace and compassion of healthcare workers.

From the Editors.

As we launch into 2023, the third year of the COVID-19 pandemic, the state of Canadian healthcare remains deeply concerning. Over the fall and winter months, our systems have experienced crippling levels of hospitalizations due to waves of infectious diseases, including influenza, respiratory syncytial virus infection and COVID-19. We have been particularly distressed by the impact to paediatric care, the insufficient capacity in mental health services and the continued strain on our healthcare workforce as well as on patients and families.

Lessons from the COVID-19 Pandemic for Long-Term Care: Where Do We Go Next?

Even before the COVID-19 pandemic, I would often hear colleagues who are intimately familiar with our health and social care system remark that they would never allow themselves or those closest to them to end up in long-term care. Sadly, the conversation often progressed to an acknowledgment that more desirable alternatives to long-term care for the most part lie outside our publicly supported care system and are only accessible to those with the means. And then we had the pandemic. For too many it turned what was often dreary and uninspiring care into a modern hell - so awful that two Canadian provinces called in the military to restore care in their worst-hit homes (Howlett 2021). There can be no doubt that the challenges that we face in providing dignified, respectful care to all our seniors have been decades in the making. It would be wrong to simply blame the long-term care homes, and it would be a travesty to lay the blame on individual care providers. On the contrary, those working in long-term care have continued to do their best, against the odds. In the early stages of the pandemic, they were not given the support that they deserved, and many paid a high personal price for their service.

From the Editors.

It would be a vast understatement to say that our healthcare systems are facing extraordinary pressure. The COVID-19 pandemic has pushed our people and our systems to their limits. We observe with trepidation that the current state of healthcare has not looked more precarious at any time in recent memory. Patients and families are feeling it. Providers, clinicians and leaders in the system are feeling it. And all of us recognize that it will take incredible political will and system-wide commitment to make the changes that are needed to renew and strengthen our front-line teams, structures and capacity. As editors for Healthcare Quarterly (HQ), we see the opportunity to contribute to the daunting task ahead by shining a light on leading practices and lessons learned from implementing change across Canada and beyond. Our commitment is to continue to showcase healthcare leadership in all forms and share opportunities for post-pandemic recovery and the future of healthcare.

From the Editors.

Although we do not yet know how or when the story of COVID-19 ends, Canadians are welcoming the summer of 2022 with the anticipation of the first prolonged period of near normalcy in two-and-a-half years. This sense of renewal coincides with the start of our roles as the new co-editors-in-chief of Healthcare Quarterly (HQ). Building on HQ's 25 years of excellence in sharing leading practices in health services delivery and policy, we are looking forward to taking the journal in new directions. Although both of us of have had long careers in healthcare and have experienced many cycles of change, this particular point in time feels different. Despite the devastating aftermath of this global pandemic, the disruption comes with an extraordinary level of opportunity. It is in thinking about the future state that we have embraced our new leadership roles with HQ.

The effectiveness of home-based phototherapy for vitiligo: A systematic review of randomised controlled trials.

BACKGROUND: Vitiligo may be treated with hospital-based phototherapy, but this requires long-term frequent appointments. Self-treatment using home-based phototherapy is a convenient alternative, which may improve adherence and results, but evidence is limited, and so it is not routinely recommended. This systematic review aims to assess the effectiveness and safety of home-based phototherapy for vitiligo. METHODOLOGY: Searches were conducted on Medline, Scopus and The Cochrane Library for randomised controlled trials comparing home-based phototherapy with institution-based phototherapy or placebo/no phototherapy for vitiligo. The primary outcome was treatment effectiveness. CASP criteria were used for quality assessment. Data were synthesised in a meta-analysis where appropriate. RESULTS: Three studies (195 participants) were included: two compared home-based with institution-based phototherapy, and one compared home-based phototherapy with placebo. Studies were of mixed quality. Therapy regimes varied across studies. Findings on effectiveness were contradictory across studies with variable rates of repigmentation. There was no significant difference in repigmentation rates between the groups, although adherence to treatment schedules was significantly better in home-based groups. Adverse effects were significantly higher in home-based groups. No long-term data were reported on maintenance of treatment benefits. CONCLUSIONS: Although adherence to treatment was significantly better with home-based phototherapy, data were insufficient to form conclusions on effectiveness. Home-based phototherapy had a significantly higher risk of adverse effects, making it difficult to recommend in clinical practice. However, as it offers logistical advantages for patients, its effectiveness alongside additional safety measures should be explored further in large-scale, good-quality RCTs, with standardised outcome measures, including patient-reported outcomes.

Resetting the Future of Healthcare Leadership.

There is no doubt that the events of the past two years will leave an indelible mark on human history. The tragic loss of so many lives during the COVID-19 pandemic, the long-term health and psychological impacts for many more and the economic and societal changes will reverberate for years to come. While the pandemic is not yet over, we are starting to appreciate how different our new future looks and feels. It is within this context that Longwoods Publishing and the Canadian College of Health Leaders (CCHL) have collaborated, for the first time, in a shared reflection on the future of leadership in Canada's healthcare system.

Leadership Perspective: Addressing Canada's Opioid Crisis - Reducing the Harm of Leadership.

While the COVID-19 pandemic has been the major focus for healthcare leaders since early 2020, the opioid crisis has been growing in the background. Confronting this emerging problem will require new thinking. Guest editors Anne Wojtak and Neil Stuart spoke with Scott Elliott, executive director, and Patrick McDougall, director of Knowledge Translation and Evaluation, at the Dr. Peter AIDS Foundation in Vancouver to gain their insights into how leaders can respond effectively.

Leadership Perspective: Partnering with Patients to Co-Design Healthcare Systems.

The ability to partner with patients to design healthcare systems is an increasingly critical skill for healthcare leaders. Guest editors Anne Wojtak and Neil Stuart spoke with Vincent Dumez, co-director of the Montreal-based Centre of Excellence on Partnership with Patients and the Public, to gain an understanding of what true patient partnership looks like and how healthcare system design can be transformed.

Necrotic Ulceration of the Hand Case Review: Think Beyond Infection.

Neutrophilic dermatosis of the dorsal hands is a rare neutrophilic dermatosis that can be associated with inflammatory bowel disease, rheumatoid arthritis, and underlying malignancies. The occurrence of trauma as an initiating factor and its early features of pain and inflammation followed by blistering or ulceration mean that it can be mistaken for necrotizing infection. Neutrophilic dermatosis of the dorsal hands should be considered in all patients who present with such features confined to the back of the hands, particularly those with negative microbiological results or lack of response to antibiotic therapy. A case review design was used to analyze the presentation of a woman aged 65 years in the United Kingdom, seeking care for a painful rash on the hand in the emergency department that was subsequently diagnosed as neutrophilic dermatosis of the dorsal hands. Emergency clinician awareness of neutrophilic dermatosis of the dorsal hands as a rare differential diagnosis for patients presenting with necrotic ulceration may prevent unnecessary antibiotic therapy and surgical intervention.

The immediate effects of winter storms and power outages on multiple health outcomes and the time windows of vulnerability.

BACKGROUND: While most prior research has focused on extreme heat, few assessed the immediate health effects of winter storms and associated power outages (PO), although severe storms have become more frequent. This study evaluates the joint and independent health effects of winter storms and PO, snow versus ice-storm, effects by time window (peak timing, winter/transitional months) and the impacts on critical care indicators including numbers of comorbidity, procedure, length of stay and cost. METHODS: We use distributed lag nonlinear models to assess the impacts of winter storm/PO on hospitalizations due to cardiovascular, lower respiratory diseases (LRD), respiratory infections, food/water-borne diseases (FWBD) and injuries in New York State on 0-6 lag days following storm/PO compared with non-storm/non-PO periods (references), while controlling for time-varying factors and PM2.5. The storm-related hospitalizations are described by time window. We also calculate changes in critical care indicators between the storm/PO and control periods. RESULTS: We found the joint effects of storm/PO are the strongest (risk ratios (RR) range: 1.01-1.90), followed by that of storm alone (1.02-1.39), but not during PO alone. Ice storms have stronger impacts (RRs: 1.04-3.15) than snowstorms (RRs: 1.03-2.21). The storm/PO-health associations, which occur immediately, and some last a whole week, are stronger in FWBD, October/November, and peak between 3:00-8:00 p.m. Comorbidity and medical costs significantly increase after storm/PO. CONCLUSION: Winter storms increase multiple diseases, comorbidity and medical costs, especially when accompanied by PO or ice storms. Early warnings and prevention may be critical in the transitional months and afternoon rush hours.

Environmental Sustainability Must Be on Our Agenda for Healthcare.

I am increasingly alarmed by climate change and environmental degradation. Many of you share my concerns, no doubt. I worry that we are not dealing with these issues in a manner that promises meaningful or timely results, and I believe we must reorder our priorities. There is also a fundamental unfairness that runs through what is happening. Environmental harm compounds existing inequities within and among our communities, inequities between richer and poorer nations and, most insidiously, generational inequity - deferring the consequences of our inaction to a future generation. Adding to these concerns is the realization that in my own professional field, healthcare, we have given little thought to the sector's role in and responsibility for environmental sustainability. To date, these issues have not been part of the mainstream healthcare conversation.

Power Outage: An Ignored Risk Factor for COPD Exacerbations.

BACKGROUND: COPD is the third leading cause of death in the United States, with 16 million Americans currently experiencing difficulty with breathing. Power outages could be life-threatening for those relying on electricity. However, significant gaps remain in understanding the potential impact of power outages on COPD exacerbations. RESEARCH QUESTION: The goal of this study was to determine how power outages affect COPD exacerbations. STUDY DESIGN AND METHODS: Using distributed lag nonlinear models controlling for time-varying confounders, the hospitalization rate during a power outage was compared vs non-outage periods to determine the rate ratio (RR) for COPD and its subtypes at each of 0 to 6 lag days in New York State from 2001 to 2013. Stratified analyses were conducted according to sociodemographic characteristics, season, and clinical severity; changes were investigated in numerous critical medical indicators, including length of stay, hospital cost, the number of comorbidities, and therapeutic procedures between the two periods. RESULTS: The RR of COPD hospitalization following power outages ranged from 1.03 to 1.39 across lag days. The risk was strongest at lag0 and lag1 days and lasted significantly for 7 days. Associations were stronger for the subgroup with acute bronchitis (RR, 1.08-1.69) than for cases of acute exacerbation (RR, 1.03-1.40). Compared with non-outage periods, the outage period was observed to be $4.67 thousand greater in hospital cost and 1.38 greater in the number of comorbidities per case. The average cost (or number of comorbidities) was elevated in all groups stratified according to cost (or number of comorbidities). In contrast, changes in the average length of stay (-0.43 day) and the average number of therapeutic procedures (-0.09) were subtle. INTERPRETATION: Power outages were associated with a significantly elevated rate of COPD hospitalization, as well as greater costs and number of comorbidities. The average cost and number of comorbidities were elevated in all clinical severity groups.

Estimating policy-relevant health effects of ambient heat exposures using spatially contiguous reanalysis data.

BACKGROUND: Regional National Weather Service (NWS) heat advisory criteria in New York State (NYS) were based on frequency of heat events estimated by sparse monitoring data. These may not accurately reflect temperatures at which specific health risks occur in large geographic regions. The objectives of the study were to use spatially resolved temperature data to characterize health risks related to summertime heat exposure and estimate the temperatures at which excessive risk of heat-related adverse health occurs in NYS. We also evaluated the need to adjust current heat advisory threshold and messaging based on threshold temperatures of multiple health outcomes. METHODS: We assessed the effect of multi-day lag exposure for maximum near-surface air temperature (Tmax) and maximum Heat Index derived from the gridded National Land Data Assimilation System (NLDAS) reanalysis dataset on emergency department (ED) visits/ hospitalizations for heat stress, dehydration, acute kidney failure (AKF) and cardiovascular diseases (CVD) using a case-crossover analysis during summers of 2008-2012. We assessed effect modification using interaction terms and stratified analysis. Thresholds were estimated using piecewise spline regression. RESULTS: We observed an increased risk of heat stress (Risk ratio (RR) = 1.366, 95% confidence interval (CI): 1.347, 1.386) and dehydration (RR = 1.024, 95% CI: 1.021, 1.028) for every 1 °C increase in Tmax on the day of exposure. The highest risk for AKF (RR = 1.017, 95% CI: 1.014, 1.021) and CVD (RR = 1.001, 95% CI: 1.000, 1.002) were at lag 1 and 4 respectively. The increased risk of heat-health effects persists up to 6 days. Rural areas of NYS are at as high a risk of heat-health effects as urban areas. Heat-health risks start increasing at temperatures much lower than the current NWS criteria. CONCLUSION: Reanalysis data provide refined exposure-response functions for health research, in areas with sparse monitor observations. Based on this research, rural areas in NYS had similar risk for health effects of heat. Heat advisories in New York City (NYC) had been reviewed and lowered previously. As such, the current NWS heat advisory threshold was lowered for the upstate region of New York and surrounding areas. Enhanced outreach materials were also developed and disseminated to local health departments and the public.

Are the current thresholds, indicators, and time window for cold warning effective enough to protect cardiovascular health?

More extreme cold weather and larger weather variations have raised concerns regarding their effects on public health. Although prior studies assessed the effects of cold air temperature on health, especially mortality, limited studies evaluated wind chill temperatures on morbidity, and health effects under the current cold warning threshold. This study identified the thresholds, lag periods, and best indicators of extreme cold on cardiovascular disease (CVD) by comparing effects of wind chill temperatures and cold air temperatures on CVD emergency department (ED) visits in winter and winter transition months. Information was collected on 662,625 CVD ED visits from statewide hospital discharge dataset in New York State. Meteorological factors, including air temperature, wind speed, and barometric pressure were collected from National Oceanic and Atmospheric Administration. A case-crossover approach was used to assess the extreme cold-CVD relationship in winter (December-February) and transition months (November and March) after controlling for PM2.5. Conditional logistic regression models were employed to analyze the association between cold weather factors and CVD ED visits. We observed CVD effects occurred when wind chill temperatures were as high as -3.8 °C (25 °F), warmer than current wind chill warning standard (≤-28.8 °C or ≤-20 °F). Wind chill temperature was a more sensitive indicator of CVD ED visits during winter with temperatures ≤ -3.8 °C (25 °F) with delay effect (lag 6); however, air temperature was better during transition months for temperatures ≤ 7.2 °C (45 °F) at earlier lag days (1-3). Among all CVD subtypes, hypertension ED visit had the strongest negative association with both wind chill temperature and air temperature. This study recommends modifying the current cold warning temperature threshold given larger proportions of CVD cases are occurring at considerably higher temperatures than the current criteria. We also recommend issuing cold warnings in winter transitional months.