The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review.

OBJECTIVES: Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions. METHODS: An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison. RESULTS: From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating. DISCUSSION: A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis.

INTRODUCTION: Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use. METHODS: A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada). RESULTS: Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers' access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use. CONCLUSION AND DISCUSSION: This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Economic Analysis of the Prevention and Control of Nosocomial Infections: Research Protocol.

Background: Nosocomial infections (NIs) are among the main preventable healthcare adverse events. Like all countries, Canada and its provinces are affected by NIs. In 2004, Ministry of Health and Social Services (MSSS) of Quebec instituted a mandatory surveillance NI program for the prevention and control (NIPC) in the hospitals of the province. One target of the MSSS 2015-2020 action plan is to assess the implementation, costs, effects, and return on investment of NIPC measures. This project goes in the same way and is one of the first major studies in Canada to evaluate the efficiency of the NIPC measures. Three objectives will be pursued: evaluate the cost of implementing clinical best practices (CBPs) for infection control; evaluate the economic burden attributable to NIs; and examine the cost-effectiveness of the NIPC by comparing the costs of CBPs against those of NIs. Methods: This project is based on an infection control intervention framework that includes four CBPs: hand hygiene; hygiene and sanitation; screening; and additional precautions. Four medical and surgical units in two hospitals (nonUniversity, University) in the province of Quebec will be studied. The project has four components. Component 1 will construct and content validate an observation grid for measuring the costs of CBPs. Component 2 will estimate CBP costs via 2-week prospective observations of health workers, conducted every 2 months over a 1-year period. Component 3 will evaluate, through a matched case-control study, the economic burden of the four most monitored NIs in Quebec (C-difficile, MRSA, VRE, and CPGNB). Archival patient data will be collected retrospectively. Component 4 will determine the optimal breakeven point for CBPs associated with NIPC. Discussion: This project will produce evidence of the economic analysis of NIPC and give health stakeholders an overview of NIPC cost-effectiveness. It will meet the objectives of the Canadian Patient Safety Institute and the MSSS action plan to analyze the efficiency of NIPC preventive measures. To our knowledge, this is the first such exercise in Quebec and Canada. It will provide governments with a decision support tool through a major empirical study that could be replicated nationally to capture the financial benefits of NIPC.

Designing centralized waiting lists for attachment to a primary care provider: Considerations from a logic analysis.

Access to a regular primary care provider is essential to quality care. In Canada, where 15 % of patients are unattached (i.e., without a regular provider), centralized waiting lists (CWLs) help attach patients to a primary care provider (family physician or nurse practitioner). Previous studies reveal mechanisms needed for CWLs to work, but focus mostly on CWLs for specialized health care. We aim to better understand how to design CWLs for unattached patients in primary care. In this study, a logic analysis compares empirical evidence from a qualitative case study of CWLs for unattached patients in seven Canadian provinces to programme theory derived from a realist review on CWLs. Data is analyzed using context-intervention-mechanism-outcome configurations. Results identify mechanisms involved in three components of CWL design: patient registration, patient prioritization, and patient assignment to a provider for attachment. CWL programme theory is revised to integrate mechanisms specific to primary care, where patients, rather than referring providers, are responsible for registering on the CWL, where prioritization must consider a broad range of conditions and characteristics, and where long-term acceptability of attachment is important. The study provides new insight into mechanisms that enable CWLs for unattached patients to work.

Youth and parent perceptions on participating in specialized multidisciplinary pain rehabilitation options: A qualitative timeline effect analysis.

Background: Little is known about how the specialized treatment journey is perceived by youth with pain-related disability and their parents. Aims: Describe and compare the treatment effects and outcomes as perceived by youth and their parents enrolled in intensive interdisciplinary pain treatment (IIPT) or multimodal treatment (MMT). Methods: Eleven IIPT youth and five parents and three MMT youth and five parents were recruited. All were asked to complete a treatment journey timeline, followed by separately conducted semistructured interviews. Transcribed interviews were analyzed using reflective thematic analysis. Results: The main themes spanned the treatment trajectory. All participants described similar initial struggles (Theme 1). Positive and negative treatment effects associated with acquisitions and disruptions (Theme 2), and outcomes post-discharge related to supports and realities (Theme 3) emerged. Knowledge, skills, and support acquisition during treatment and feeling empowered and confident to self-manage postdischarge were identified as IIPT benefits. However, the change effort and life disruptions required and the difficulty transitioning to real life postprogram were acknowledged as detrimental IIPT impacts. Continuing with life as usual and maintaining supports in daily contexts (e.g., school personnel, friends) were reported MMT benefits. However, the challenges of managing pain, treatment adherence within the competing demands of daily realities, and the lack of support to integrate strategies were emphasized as detrimental MMT impacts. Conclusions: Detailed impacts of two specialized multidisciplinary pain rehabilitation interventions on the lives of youth with pain-related disability and their parents are described. The treatments benefits and previously unexplored detrimental effects are unveiled.

Contexte: On en sait peu sur les parcours de traitement spécialisés tels que perçus par les jeunes ayant une incapacité liée à la douleur et par leurs parents.Objectifs: Décrire et comparer les effets et les résultats du traitement tels qu'ils sont perçus par les jeunes inscrits à un traitement interdisciplinaire intensif de la douleur ou à un traitement multimodal, ainsi que par leurs parents.Méthodes: Onze jeunes inscrits à un traitement interdisciplinaire intensif de la douleur et cinq parents, ainsi que trois jeunes inscrits à un traitement multimodal et cinq parents, ont été recrutés. Tous ont été invités à décrire le calendrier de leur parcours de traitement, puis à participer à des entrevues semi-structurées menées séparément. Les entrevues transcrites ont été analysées à l'aide d'une analyse thématique réflexive.Résultats: Les principaux thèmes couvraient la trajectoire du traitement. Tous les participants ont décrit des difficultés initiales similaires (Thème 1). L'association des effets positifs et négatifs du traitement avec les acquis et les perturbations (Thème 2), et les issues liées au soutien et aux réalités suite à leur congé (Thème 3) ont émergé. L'acquisition de connaissances et d'habiletés, l'accès à du soutien et le sentiment d'autonomisation et de confiance en sa capacité d'autoprise en charge après le congé ont été répertoriés comme des avantages du traitement interdisciplinaire intensif de la douleur. Toutefois, les efforts de changement requis et les perturbations de la vie nécessaires, ainsi que les difficultés de la vie réelle après le programme, ont été considérés comme des répercussions négatives du traitement interdisciplinaire intensif de la douleur. La possibilité de poursuivre la vie comme d'habitude et de conserver le soutien dans des contextes de la vie quotidienne (ex. : personnel scolaire, amis) ont été rapportés comme des avantages du traitement multimodal. Toutefois, les défis liés à la prise en charge de la douleur, l'adhésion au traitement dans le cadre des exigences concurrentes des réalités quotidiennes, ainsi que le manque de soutien pour intégrer les stratégies, ont été mis en relief comme des effets néfastes du traitement multimodal.Conclusions: Les effets détaillés de deux interventions multidisciplinaires spécialisées en matière de réadaptation pour la douleur dans la vie de jeunes atteints d'une incapacité liée à la douleur et de leurs parents ont été décrits. Les avantages des traitements et leurs effets néfastes qui n'avaient pas encore été étudiés ont été dévoilés.

Beyond COVID-19: Five commentaries on reimagining governance for future crises and resilience.

Several Canadian and international scholars offer commentaries on the implications of the COVID-19 pandemic for governments and public service institutions, and fruitful directions for public administration research and practice. This second suite of commentaries considers the challenges confronting governments as a result of the COVID-19 pandemic and in the decades to come with an increasingly broad lens: the need to understand and rethink the architecture of the state given recent and future challenges awaiting governments; the need to rethink government-civil society relations and policies to deliver services for increasingly diverse citizens and communities; the need for new repertoires and sensibilities on the part of governments for recognizing, anticipating, and engaging on governance risks despite imperfect expert knowledge and public skepticism; how the COVID-19 crisis has caused us to reconceive international and sub-national borders where new "borders" are being drawn; and the need to anticipate a steady stream of crises similar to the COVID-19 pandemic arising from climate change and related challenges, and develop new national and international governance strategies for fostering population and community resilience.

Plusieurs universitaires canadiens et internationaux ont offert des suggestions sur les implications de la pandémie du COVID­19 pour les gouvernements et les institutions de la fonction publique, ainsi que des orientations futures pour la recherche et la pratique en administration publique. Cette deuxième série de commentaires examine les défis que devront affronter les gouvernements en raison de la pandémie de COVID­19 et dans les décennies à venir, dans une optique large. Cette série souligne le besoin de comprendre et de repenser l'architecture de l'État, de revoir les relations entre le gouvernement et la société civile pour fournir des services à des citoyens et des communautés de plus en plus divers, d'élaborer de nouvelles façons d'identifier et d'anticiper les risques, et de s'engager malgré l'imperfection des connaissances d'experts et le scepticisme du public, de repenser les frontières, tout ceci en tenant compte des crises et défis à venir, de façon à promouvoir la résilience de la population et des communautés.

Is It Worth It? A Comparison of an Intensive Interdisciplinary Pain Treatment and a Multimodal Treatment for Youths With Pain-related Disability.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of an intensive interdisciplinary pain treatment (IIPT) day-hospital program as compared with an outpatient multimodal treatment (MMT) for youth with chronic pain. MATERIALS AND METHODS: A nonrandomized pretest posttest with control group design was used. A battery of patient-oriented measures assessing pain interference, quality of life, and depressive symptoms were completed at treatment commencement and at 3, 6, and 12 months after treatment by 44 youths enrolled in the IIPT and 138 youths engaged in the MMT, with various chronic pain conditions. Data were analyzed using longitudinal mixed-effects models. RESULTS: The main outcomes were the score difference from baseline of patient-oriented measures across 3 timepoints within 12 months of intervention initiation for both treatment groups. IIPT participants demonstrated greater improvement in pain interference, as compared with MMT at 3 and 12 months. Initially, health-related quality of life scores improved similarly in both groups, but greater improvement was seen in the MMT group at 12 months. Depressive symptom scores did not improve with either intervention. Only pain interference scores reached statistically and clinically significant difference levels. DISCUSSION: This study supports the benefits of specialized rehabilitation interventions, including both MMT and IIPT programs, for youths with chronic pain. The findings also suggest that IIPT might have a greater long-term effect for helping youths, in particular those with high pain interference scores.

How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review.

CONTEXT: Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. AIM: To understand how CWLs' design and implementation influence their use and effect on access to healthcare. METHODS: We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work). RESULTS: In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness. CONCLUSION: These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.

Current emergency response in montreal: How does it fit in the services offered to homeless people who use substances?

Background This paper presents an assessment of the current emergency response to homeless people who use substances in Montreal, a major North American city. This project addresses the rising concern about homelessness in high-income countries. Several studies have shown that homeless people frequently use emergency services (i.e., police, paramedical, and hospital), especially in the context of substance use. Yet, the key actors' perspectives are poorly documented. Method Our team conducted a needs analysis using a deliberative democratic evaluation. Data collection strategies included an intersectoral World Café (n = 34, including police, specialized professionals, community stakeholders, political representatives, researchers, and people who have been homeless) and individual interviews with health professionals (n = 5) and homeless people (n = 8). We performed a thematic content analysis based on a conceptual framework of access to health care and of collaboration. Findings This study provided key information on the role of emergency services and the needs of key actors, in terms of the dimensions of access to health care (approachability, acceptability, availability, and appropriateness) and continuity. Our main results show that, according to the participants, the emergency response is relevant when homeless people are a danger to themselves or to others, and during episodes of acute physical and psychological care. However, emergency service providers still stigmatize homelessness and substance use, which negatively affects intervention quality. Finally, our main results highlight the interdependence between the emergency services and health, social, and community services. Conclusion The emergency response is necessary and appropriate in some situations. It remains important to intervene upstream and to improve the attitudes and practices of emergency service providers. Finally, it is necessary to adapt services to the needs of homeless substance users and improve service continuity, for example, by adopting a population-based approach.

Using collaborative logic analysis evaluation to test the program theory of an intensive interdisciplinary pain treatment for youth with pain-related disability.

Intensive interdisciplinary pain treatment (IIPT) involves multiple stakeholders. Mapping the program components to its anticipated outcomes (ie, its theory) can be difficult and requires stakeholder engagement. Evidence is lacking, however, on how best to engage them. Logic analysis, a theory-based evaluation, that tests the coherence of a program theory using scientific evidence and experiential knowledge may hold some promise. Its use is rare in pediatric pain interventions, and few methodological details are available. This article provides a description of a collaborative logic analysis methodology used to test the theoretical plausibility of an IIPT designed for youth with pain-related disability. A 3-step direct logic analysis process was used. A 13-member expert panel, composed of clinicians, teachers, managers, youth with pain-related disability, and their parents, were engaged in each step. First, a logic model was constructed through document analysis, expert panel surveys, and focus-group discussions. Then, a scoping review, focused on pediatric self-management, building self-efficacy, and fostering participation, helped create a conceptual framework. An examination of the logic model against the conceptual framework by the expert panel followed, and recommendations were formulated. Overall, the collaborative logic analysis process helped raiseawareness of clinicians' assumptions about the program causal mechanisms, identified program components most valued by youth and their parents, recognized the program features supported by scientific and experiential knowledge, detected gaps, and highlighted emerging trends. In addition to providing a consumer-focused program evaluation option, collaborative logic analysis methodology holds promise as a strategy to engage stakeholders and to translate pediatric pain rehabilitation evaluation research knowledge to key stakeholders.

What really matters in pediatric chronic pain rehabilitation? Results of a multi-stakeholder nominal group technique study.

Purpose: To prioritize outcome domains sensitive to the needs of the various stakeholders involved in rehabilitation programs designed for youth with pain-related disability using the International Classification of Function Child and Youth version.Materials and methods: A 5-step nominal group technique was conducted with 13 stakeholders, including two youth with pain-related disability, two parents, five clinicians, two teachers, and two healthcare managers. Once identified by content thematic analysis and International Classification of Function linking, 15 outcome domains were ranked. Priority rank scores were then weighted.Results: Six outcome domains were prioritized: (1) activities of daily living, (2) participation in meaningful activities, (3) social roles and relationships, (4) mood and affect, (5) school engagement, and (6) self-efficacy. Discrepancies in ranking existed; parents and youth attributed importance to pain, sleep, and program satisfaction whereas clinicians and mangers underscored pain-related fear and family functioning. When compared, prioritized domain associated with three PedIMMPACT recommendations and aligned with the activity and participation components of the International Classification of Function for Child and Youth.Conclusion: These findings emphasize the importance of integrating various perspectives, including those of youth with pain-related disability and other important stakeholders and adopting a broader conceptualization of disability and function when selecting key rehabilitation evaluation outcome for this population.Implications for rehabilitationThe identification of value differences among stakeholder underscores the importance of engaging youths, their families and other stakeholders, such as teachers and health care managers in rehabilitation program evaluation.The consensus processes employed allowed for the reconciliation of the different priorities, and the achievement of agreement on participation in life and its related activities as a key desired outcome of rehabilitation programs for youth with pain-related disability.The use of the ICF-CY framework allowed a broader conceptualization of the rehabilitation outcome domains, and the examination of areas beyond reduction of pain, disability and impairment to include functional aspects such as self-care, daily routine and mobility activities, and meaningful participation in life, fostering social roles and responsibilities, and school engagement.As participation in life and its related tasks and activities were key outcomes for all stakeholders, they should be the focus of clinicians' treatment.

Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services.

Case management programs for frequent users of healthcare services are complex interventions which implementation and application are challenging to evaluate. The aim of this article was to conduct a logic analysis to evaluate a case management program for frequent users of healthcare services. The study proceeded in three phases: 1) establishing causal links between the program's components by the construction of a logic model, 2) developing an integrated framework from a realistic synthesis, and 3) making a new reading of the case management program in regard of the integrated framework. The study demonstrated, on one hand, strengths and weaknesses of the actual case management program, and, on the other hand, how logic analysis can create a constructive dialogue between theory and practice. The evaluative process with decision-makers, clinicians and patients has helped to make connexions between theory, practice, experience and services organization.

Contribution analysis to analyze the effects of the health impact assessment at the local level: A case of urban revitalization.

The health impact assessment (HIA) is a tool used to estimate the potential impact on health of non-health-related proposals prior to implementation. While it is increasingly used in Quebec, Canada, studies have not analyzed its medium-term impacts and potential long-term impacts. We conducted a contribution analysis using in-depth interviews with key stakeholders, as well as documents, observation and images related to HIA in order to analyze its impacts on the revitalization of road infrastructure, parks and green spaces, and residential housing. Our analysis not only reflects on the decision-making process through the adoption and implementation of HIA recommendations, but also on the link between actions implemented in the field and health outcomes.

Explaining variation of implementation outcomes of centralized waiting lists for unattached patients.

PURPOSE: Centralized waiting lists (CWLs) for patient attachment to a primary care provider have been implemented across Canada, including Quebec. Little is known about the implementation of CWLs and the factors that influence implementation outcomes of such primary care innovations. The purpose of this paper is to explain variations in the outcomes of implementation by analyzing the characteristics of CWLs and contextual factors that influence their implementation. DESIGN/METHODOLOGY/APPROACH: A multiple qualitative case study was conducted. Four contrasting CWLs were purposefully selected: two relatively high-performing and two relatively low-performing cases with regard to process indicators. Data collected between 2015 and 2016 drew on three sources: 26 semi-structured interviews with key stakeholders, 22 documents and field notes. The Consolidated Framework for Implementation Research was used to identify, through a cross-case comparison of ratings, constructs that distinguish high from low-performing cases. FINDINGS: Five constructs distinguished high from low-performing cases: three related to the inner setting: network and communications; leadership engagement; available resources; one from innovation characteristics: adaptability with regard to registration, evaluation of priority and attachment to a family physician; and, one associated with process domain: engaging. Other constructs exerted influence on implementation (e.g. outer setting, individual characteristics), but did not distinguish high and low-performing cases. ORIGINALITY/VALUE: This is the first in-depth analysis of CWL implementation. Results suggest important factors that might be useful in efforts to continuously improve implementation performance of CWLs and similar innovations.

Contribution to healthy places: Risks of equity free health impact assessment.

While health equity is central to health impact assessment [HIA], in reality, less is known about potential impacts of equity-free HIA on social inequalities. We assessed equity-free HIA case in a small city east of Montreal, which took place in a context of urban revitalization. We applied a combination of a quantitative review of community characteristics with a qualitative descriptive approach based on in-depth semi-structured interviews and a focus group with multiple stakeholders to shed light on the pitfalls of equity-free HIA. Our results pointed to gentrification process with a gradual relocation of low-income residents in the end. To mitigate mediating circumstances of gentrification and displacement, the municipality should support social housing or at least should ensure rent stabilization ordinance.

Area deprivation and attachment to a general practitioner through centralized waiting lists: a cross-sectional study in Quebec, Canada.

BACKGROUND: Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists. METHODS: A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients' socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs. RESULTS: Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas. CONCLUSION: Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.

Family Physicians Attaching New Patients From Centralized Waiting Lists: A Cross-Sectional Study.

PURPOSE: In response to more than 15% of Canadians not having a family physician, 7 provinces have implemented centralized waiting lists for unattached patients. The aim of this study is to analyze the association between family physicians' characteristics and their participation in centralized waiting lists. METHODS: Cross-sectional observational study using administrative data in 5 local health networks in Quebec, between 2013 and 2015. All physicians who had attached at least 1 patient were included (n = 580). Multivariate linear regressions for the number of patients and proportion of vulnerable patients attached per physician were performed. RESULTS: Physicians with more than 20 years of experience represented more than half of those who had participated in the centralized waiting lists and physicians in traditional primary care models represented more than 40%. Physicians' number of years of practice, primary care model, local health network, and the number of physicians participating in the centralized waiting lists per clinic influenced physicians' participation. Physicians with 0 to 4 years of experience and those practicing in network clinics were found to attach more patients. Practicing in a Centre Locaux de Services Communautaires (local community service center) was associated with attaching 19% more vulnerable patients compared with practicing in a Family Medicine Unit (teaching unit). CONCLUSION: Centralized waiting lists seem to be used by early career physicians to build up their patient panels. However, because of the large number of them participating in the centralized waiting lists, physicians with more experience and those practicing in traditional models of primary care might be of interest for future measures to decrease the number of patients waiting for attachment in centralized waiting lists.

Stakeholder Views on Solutions to Improve Health System Performance.

Context: Significant reforms are needed to improve healthcare system performance in Quebec. Even though the characteristics of high-performing healthcare systems are well-known, Quebec's reforms have not succeeded in implementing many critical elements. Converging evidence from political science models suggests stakeholders' preferences are central in determining policy content, adoption, and implementation. Objective: To analyze whether doctors', nurses', pharmacists' and health administrators' preferences could explain the observed inability to implement known characteristics of high-performing healthcare systems. Design: A questionnaire on various propositions identified in the scientific literature was sent to 2,491 potential respondents. Results: Overall response rate was 37%. There was considerable consensus on identified solutions to improve the healthcare system. Resistance was observed in two major areas: information systems and changes directly affecting doctors' practice. The groups' positions cannot explain the inability to implement important characteristics of high-performing systems. The findings raise new questions on the actual sources of resistance.

Centralized Waiting Lists for Unattached Patients in Primary Care: Learning from an Intervention Implemented in Seven Canadian Provinces.

Introduction: Centralized waiting lists (CWLs) are one solution to reduce the problematic number of patients without a regular primary care provider. This article describes different models of CWLs for unattached patients implemented in seven Canadian provinces and identifies common issues in the implementation of these CWLs. Methods: Logic models of each province's intervention were built after a grey literature review, 42 semi-structured interviews and a validation process with key stakeholders were performed. Results: Our analysis across provinces showed variability and common features in the design of CWLs such as same main objective to attach patients to a primary care provider; implementation as a province-wide program with the exception of British Columbia; management at a regional level in most provinces; voluntary participation for providers except in two provinces where it was mandatory for providers to attach CWL patients; fairly similar registration process across the provinces; some forms of prioritization of patients either using simple criteria or assessing for vulnerability was performed in most provinces except New Brunswick. Conclusion: Despite their differences in design, CWLs implemented in seven Canadian provinces face common issues and challenges regarding provider capacity to address the demand for attachment, barriers to the attachment of more vulnerable and complex patients as well as non-standardized approaches to evaluating their effectiveness. Sharing experiences across provinces as CWLs were being implemented would have fostered learning and could have helped avoid facing similar challenges.