Bringing value to healthcare through ambulatory services

Bringing value to healthcare through ambulatory services

Adam Saporta, PT, BSc, MScPT, CHE. Patient Care Manager, Amputee, Cardiac and Transplant Programs, Sunnybrook Health Sciences Center, St. John’s Rehab. Past Vice President of Special Projects, Canadian Association of Ambulatory Care (CAAC).

Jatinder Bains, BSc. PT, MHSc, CHE. Vice President Clinical Programs, Victoria Hospital. Past President, Canadian Association of Ambulatory Care (CAAC). Status-Only Appointment, Rank of Lecturer, Department of Physical Therapy, University of Toronto.

Denyse Henry, RN, BHA(Hons), MHM. Director of Operations, OR and Related Services, Sunnybrook Health Sciences Centre. CEO and Founder, Canadian Association of Ambulatory Care (CAAC). Adjunct Lecturer, Lawrence Bloomberg, Faculty of Nursing, University of Toronto.

Kristina M Kokorelias, PhD. Post-doctoral Fellow, St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre.

ABSTRACT: More integrated ambulatory care services are a strategy that may result in more efficient and higher quality outcomes to address the escalating costs of healthcare in Canada. With an estimate of over 24 million visits per year, ambulatory care has become one of the largest services for patients. It is not known how to best drive ongoing integration amongst ambulatory care services. In this paper, we discuss strategies for driving integration of ambulatory care services into our current healthcare environment. We argue that funding, providing incentives to flow patients into ambulatory care settings and developing a robust standardized interprovincial data collection and analysis process can be used to drive this integration. Research is needed to gain insight on how to improve quality of care and reduce costs through integrated ambulatory care.

SUBMITTED: 24 NOV 2021 | PUBLISHED: 09 MAR 2022

DISCLOSURE: The authors have no funding conflicts of interest to disclose.

CITATION: Saporta, Adam et al (2022). Bringing value to healthcare through ambulatory services. Canadian Health Policy, MAR 2022. ISSN 2562-9492 https://doi.org/10.54194/EGHX2582 www.canadianhealthpolicy.com.

INTRODUCTION

Managing ambulatory care (AC), also referred to outpatient care, has become critically important in terms of scope, expenditure and complexity. AC can be misleading and misunderstood by many. By definition, AC, is any healthcare service or care provided in or out of hospital that allows the patient to remain in the comfort of their own home (1). AC include services such as same day surgical procedures, treatment, observation, emergency department visits, telemedicine, diagnostic imaging, rehabilitation services, consultation and pharmacy. According to the Canadian Institute of Health Information (CIHI), ambulatory care sensitive conditions (ACSC) include: grand mal status and other epileptic convulsions, chronic obstructive pulmonary disease (COPD), asthma, heart failure and pulmonary edema, hypertension, angina, and diabetes (2). Individuals living with ACSC can often avoid hospitalization with preventative interventions by primary care (3). However, Canadian research has found that a lack of primary care access across the country has not been correlated with an increase in AC (4), suggesting the need to enhance AC and not just primary care. Settings where AC can be received range from hospital-based and non-hospital-based clinics to community health centers and urgent care centers. However, many individuals with ACSC continue to receive care primarily in hospitals. Unnecessary hospital-based care has negative consequences for Canada’s health service budget and resources (5-7).

Today, AC comprises of a significant portion of healthcare delivered services in Canada and has expanded over recent years in becoming one of the largest types of services for patients (8) . With the adaption of new technology, AC continues to expand as increasing numbers of procedures and treatments transition to AC settings. In particular, the COVID-19 pandemic has led to a notable increase in virtual AC adoption (9-12). Virtual care is expected to continue to deliver timely care, even after the pandemic has ended (13). While most virtual AC solutions have been implemented to ensure adequate physical distancing between patients and clinicians, their efficacy in terms of ACSC patient satisfaction have not fully been described. Moreover, the implications of virtual care for ACSC have not been described.

While elevated AC activity and novel ways of care delivery, such as virtual care, are said to increase patient access to care, there are still other aspects of healthcare reform to consider. Across the country, hospitals are struggling to balance their budget in the face of a new funding model where lower annual increases are received from the province. In fact, lately many hospitals have eliminated outpatient departments, abolishing AC programs, and cutting registered nursing positions to sustain and balance the books. This may successfully address the temporary budgetary pressures for many organizations, but it also creates an environment whereby patients are challenged in effectively maintaining and sustaining their care. In turn, patients face challenges trying to navigate the healthcare system. When patients do not know how to best meet their care needs, the overuse of more core hospital services resulting in increased occupancy and length of stay in EDs, acute care readmissions and inpatient units are common.

Recent 2019-2020 data from CIHI estimated 24.8 million AC visits per year, leading to roughly 25% increase in ACS in the last decade (14). These include emergency departments (ED), day surgeries and clinics (14). Along with the rise in the volume of ACS, the associated costs for AC have been increasing steadily (15).  Cost-effective quality of care, as the rationale for shifting into ambulatory patient-care activity is becoming less clear as managing ACS has become progressively more difficult over the last few years (6, 16). Measuring trade-offs is also a challenge for those looking to improve ACS due to a lack of consistency of data collected for AC patient visits. Additionally, there is no mandated provincial or national reporting of ambulatory rehabilitation data. While the National Ambulatory Care Report System (NACRS) reports standardized ambulatory data, it excludes a number of provinces and territories and only captures hospital based clinic visits, while excluding physician costs (17). The disparate, ineffective data that lacks a common nomenclature makes it difficult to best study AC. Timeliness and inclusive data can help drive integration and ultimately ensure funding on an evidence-based model of AC.

As a result, ways to optimize AC is growing area of interest in healthcare research in Canada (2, 6, 18), especially for The Canadian Association of Ambulatory Care (CAAC). Since the 1960s, AC has created a new dimension to the delivery of healthcare services, through the introduction of new healthcare policies and funding that allowed for safe access to procedures that once required inpatient stay to be efficiently performed on an outpatient basis (19). Since 2020, with the onset of the COVID-19 pandemic, virtual models of AC have become increasing popular, although the impact of these models of care have not fully been explored.

Ongoing demand from a growing senior population, a rise in chronic and complex diseases (many of which are ACSC) and continuing inefficiencies in the healthcare system have resulted in increased AC costs (6, 20, 21). At the same time, Canada has yet to transition from a system in which providers work in silos to one in which interdisciplinary teams collaborate to deliver integration of services through a continuum of care (22-24) . Ensuring patients have access to care when and where they need is, while lessoning the cost of expensive hospital care and ensuing continuity of care (15), is challenging. Thus, there needs to be a greater emphasis on building partnerships for ambulatory care services (ACS) with support from and in collaboration with community partners that will address the full spectrum of patient needs and ultimately, improve patient outcomes (24). We posit that improving health care system performance by building more integrated ACS that incorporates a great variety specialized services within our system is imperative to ensure optimal patient outcomes.

INTEGRATED CARE

Poor integration of care services is a significant barrier to successful ACS. Although examples of successful models have been implemented in Canada, a robust and consistent strategy needs to be developed to ensure consistent access across the country. We define integration as providing care that is more comprehensive for individuals with chronic disease by bringing together different care providers and care settings to work together and ultimately improve access to care, quality of care, patient satisfaction and health outcomes (25-27). Implementing an effective integrated care model to better meet the acute and chronic needs of ACSC patients may improve quality of life and to decrease health care costs(28, 29). An example of integrated care may be improving mechanisms for active patient follow-up following hospitalization and consideration of biopsychosocial circumstances of the patient (27). Integrated care can also involve multiple physicians working together to avoid ACSC hospitalizations (27).

Presently, funding models do not incentive physicians to avoid ACSC hospitalizations for their patients (6). Whether hospitals operate solely on global budgets, activity-based funding (ABF) models or fee-for-service models (FFS), incentives to provide exceptional quality of care focused on reducing inpatient admissions, decreasing caregiver burden and reducing volumes and repeat emergency department visits are needed. With the lack of an integrated coordinated strategy, organizations have taken it upon themselves to implement what they feel works best for their patients. Despite implementation of falls prevention programs, short stay units, geriatric outreach clinics and outpatient services expansions within hospitals, the lack of data to support these efforts have been difficult to evaluate. Standardized methods to capture patient and financial outcomes need to be established. However, in order to adequately capture key metrics, a full inventory across all local and provincial levels and all AC settings need to be undertaken. Furthermore, criteria on where AC services are located, what services are provided and what proportion of the overall healthcare budget allocated should be made explicit. Once established, these criteria should be part of a regional strategy to help guide ACS in an equitable and cost-efficient manner.

Free standing ACS have also been established to improve integrations from one sector of the system to another. The Women’s College Hospital in Toronto, Ontario, for example, operates primarily as an ACS by providing treatment, diagnostic testing and complex surgeries without requiring overnight stay (30). Other examples include physician groups creating advanced ambulatory protocols to address the needs of their patient population. Orthopedic surgeons in Ontario for example, managed challenges for timely access to quality care for those with musculoskeletal problems by treating most in ACS – 86% of the 1.3 million encounters with orthopedic surgeons were in ACS (31). In British Columbia, caring for all the comorbidities of individuals with diabetes has been embedded into diabetes ambulatory care (32).

Ontario has adopted some of the country’s most comprehensive integrated care models – in particular the Family Health Team (FHT) and now, the Ontario Health Teams (OHTs) (33-35). Other examples from the province of successful integration is the Aging at Home Strategy in Ontario – an investment of $1.1 billion by the Ontario government over a four year period. An expert emergency department (ED)/alternative level of care (ALC) panel targeted four priorities for this strategy which including increasing the number of restorative and rehab hospital beds, strategies to ensure patients receive high quality care to avoid readmissions, enhance home care supports and nursing outreach teams for high risk seniors (36). The First 48 Hours^TM, Making the Transition^TM and the Community Care for Seniors with Frailty Program provided by Saint Elizabeth, a non-for-profit charitable organization that provides a full range of integrated care solutions in AC settings, are other examples of successful approaches to integration, focused on decreasing hospital admissions, ALC rates and ED readmissions (37).

Across the country, in the remote communities of Long and Brier Islands, Nova Scotia, where the lack of physicians led to a paramedic- and nurse-based primary care program, the province uses extended-scope-of-practice paramedics to provide 24/7 ambulatory care to the residents of these communities(38). Similarly findings of the push towards integrated care are reported in other provinces and territories such as British Columbia (where residents are provided with limited access to integrated team-based models) (39) and the Northwest Territories (where there is a  team-based care through community health centers (CHCs) between community health registered nurses and physicians [mostly through technology]) (40). CHCs are also found in Nunuvut, Yukon and New Brunswick (41).

We posit that better integrated AC across the healthcare system requires standardization, funding and incentives. We discuss each of these below.

Standardization

As a lack of standardization exists across the system to ensure equal and adequate access to ACS, hospitals have traditionally addressed the care of their patients, making it challenging for those patients not admitted through acute care or inpatient settings to access ACS.  A need exists to standardize how patients are being seen and treated across all ACS in Canada. Standardized data collection, whether this continues to be captured through the CIHI directly or in collaboration with other governing bodies, would help ensure all those who provide services in emergency departments, day hospitals or clinics report to one central location, where care can be measured and outcomes defined. CIHI produces various reports that influence decisions made by policy makers however, CIHI does not mandate data submission to The National Ambulatory Care Reporting System (NACRS) the governing bodies that collects emergency department (ED) and ACS data as a result, there is a big gap in the numbers being reported as it does not capture all ACS provided in or out of hospitals in Canada (14). This makes it very difficult to do a comparison of actionable data and information that is evidenced based to help guide quality improvements in ACS for Canadians.  Using evidence and patient driven outcomes, Canadian care networks and hospitals have developed care pathways for stroke and total joint replacement (42, 43).  Standardized tools, therefore, have helped drive funding and change in ACS.

Funding

Initially hospital funding was not designated for ambulatory care initiatives. Rather, hospitals were required to utilize global budgets to address organizational pressures. ACS budgets are typically based on historical spending, inflation, negotiations and current political climates and do not provide incentives to improve access, quality or efficiency of care (20, 22, 23). Activity based funding where funding is provided based on the type and volume of services they provide, have been implemented in provinces across Canada, as they are associated with higher volumes of hospital care and shorter length of stays. Other hospitals have successfully prepared health system improvement pre-proposals, where additional funds have been allocated to support ACS within organizations. In other organizations, ACS is outsourced in order to allow for organizations to balance their budgets while maintaining their AC supports. It is also worth noting however, that the average cost per service has increased considerably in ACS as a result of higher employee compensation, increased use of new technologies, drugs and an expanded basket of services (44, 45).

Presently, privately-funded options, consisting of healthcare spending by households and private insurance firms, account for 30% of healthcare spending in Canada (15). Just as our publicly-funded system seeks to control costs while providing optimal patient care, so too does the private sectors’, in particular private health insurance plans, which accounts of 12% of healthcare spending ⁽¹⁵⁾.  As a large portion of these plans pay for paramedical services, perhaps the incentive exists for more partnering on how to use the private funds to help both systems work more efficiently.

Some organizations have private therapy options available within their AC settings, while others have outsourced to organizations that would have the incentive for strong integration required to make ambulatory care services readily available for their patients who require continuity in their care.  As per Carson (46), the private sector role has been growing either to provide new services or take over hospital functions. Furthermore, there is currently private sector ownership of some specialized surgical hospitals, such as Shouldice Hospital in Ontario for example (47), and a growing number of private clinics, especially in Quebec (48), who provide everything from primary care checkups to diagnostic imaging, laser eye surgery and optometry. The sustainability of these options needs to be further explored in future studies (46).

The formation of strategic alliances with private organizations has been proven to support fiscal pressures from publicly funded health care organizations. The Canadian Partnership Against Cancer for example, is funded by the federal government to promote cancer control by bringing together cancer experts, charitable organizations, governments, cancer agencies, national health organizations, patients, survivors, and other groups, to implement a Canada-wide cancer control strategy. Its main functions span a continuum encompassing prevention through healthy communities and lifestyle, cancer screening, system performance and quality guidelines, treatment, and follow-up and survivorship (49). Furthermore, the Ontario Telemedicine Network was formed in partnership from private entrepreneurs and our health care system to allow for patients to be seen outside of hospitals. Strategic partnerships such as this can support our healthcare system by using private funds to improve access, innovation and expertise outside as cost saving strategies while supporting the needs of our patients (46).

Incentives

As publicly funded facilities, hospitals have no profit motive in Canada. Rather their aim is to deliver quality care to those they serve within their funding envelope. As growth in hospital funding has curtailed, hospitals have had to change how they deliver care. In particular, a push towards treating less complex cases in outpatient setting has led to an overall complexity in ambulatory care environments (14). Financial incentives, however, do not follow these complex cases which is why managing patients in the AC settings are not as attractive as those for inpatient care. As hospitals evolve their operating models to meet future ambulatory care requirements and strive towards optimal results, policy makers need to revisit how they are incenting organizations. Across the country, hospitals are expected to develop strategies for patients who require complex care upon discharge at home and that were previously given inpatient therapy. These same patients are now referred to outpatient clinics or home care, with similar patient outcome expectations.

CONCLUSION

Presently, ACS have very little in common by way of objectives, dollars committed and outcomes achieved. The call to growing and strengthening ambulatory programming may be local and not coordinated among potential partnerships. We need a broadly shared vision for our system that involves ongoing collaboration and integration across the continuum of care with ambulatory care being a large player. Funding needs to shift to align with this initiative. While, we acknowledge that the COVID-19 pandemic has disrupted care delivery and funding (50), thinking of funding ACS post-pandemic should be considered.

Integrating and funding AC will not only help reduce inpatient admissions, ALC rates, unnecessary readmissions and caregiver burden, it will provide an improved patient experience including keeping patients at home and in the community (51). As local healthcare jurisdictions vary, it is crucial that each consider their ACS strategy which emphasizes the needs of their population. Each must ensure they target key performance metrics that can be collected and shared across local jurisdictions and provinces. To achieve these, our healthcare system must examine options of providing integrated services in ACS rather than standalone sectors.

ACS in Canada is fragmented and uncoordinated. Until a sustainable, integrated and a fiscally accountable approach is established in Canada, the Canadian Association of Ambulatory Care (CAAC) seeks to fill this gap through its dedication to improving practices in ambulatory care and promoting education that incorporates exceptional ACS performance in a manner that improves health, patient and caregiver experience, and cost, which are all vital to the success of our healthcare system and achieving excellent care for all. Through collaboration and sharing of best practice approaches to patient-centered care, the CAAC plans to represent Canada as the leader in the delivery of ambulatory patient care services through our research, educational agenda and practice models. Funding, providing incentives and developing a robust standardized interprovincial data collection and analysis process can help CCAC with their mission. Additionally, we argue more empirical research is needed to gain insight on how to improve quality of care and reduce costs through integrated ambulatory care.

REFERENCES

1. Gurung G, Atmore C, Gauld R, Stokes T. Integrated ambulatory care in the New Zealand health system: a scoping review. Journal of Integrated Care. 2020.
2. Sanmartin C, Khan S, team tLr. Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC): The factors that matter. Ottawa: The Minister responsible for Statistics Canada, 2011.
3. Purdy S, Griffin T, Salisbury C, Sharp D. Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians. Public health. 2009;123(2):169-73.
4. Vuik SI, Fontana G, Mayer E, Darzi A. Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation. BMJ open. 2017;7(8):e015704.
5. Anderson M, Revie CW, Stryhn H, Neudorf C, Rosehart Y, Li W, et al. Defining ‘actionable’high-costhealth care use: results using the Canadian Institute for Health Information population grouping methodology. International journal for equity in health. 2019;18(1):1-14.
6. Laberge M, Wodchis WP, Barnsley J, Laporte A. Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada. Social Science & Medicine. 2017;181:24-33.
7. Hudon C, Courteau J, Chiu YM, Chouinard M-C, Dubois M-F, Dubuc N, et al. Risk of Frequent Emergency Department Use Among an Ambulatory Care Sensitive Condition Population: A Population-based Cohort Study. Medical care. 2020;58(3):248-56.
8. Information CIfH. Emergency and Ambulatory Care. 2017.
9. Vellani K, Girdhari R. A practical approach to virtual ambulatory care during an impractical time. Canadian Family Physician. 2021.
10. Appireddy R, Jalini S, Shukla G, Lomax LB. Tackling the burden of neurological diseases in Canada with virtual care during the COVID-19 pandemic and beyond. Canadian Journal of Neurological Sciences. 2020;47(5):594-7.
11. Berlin A, Lovas M, Truong T, Melwani S, Liu J, Liu ZA, et al. Implementation and outcomes of virtual care across a tertiary cancer center during COVID-19. JAMA oncology. 2021;7(4):597-602.
12. Bhatia RS, Chu C, Pang A, Tadrous M, Stamenova V, Cram P. Virtual care use before and during the COVID-19 pandemic: a repeated cross-sectional study. CMAJ open. 2021;9(1):E107.
13. Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, et al. Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association. 2020;27(6):957-62.
14. Information CIfH. Data Quality Documentation- National Ambulatory Care Reporting System -Current-Year Information 2019–2020. Ottawa, ON: CIHI, 2020.
15. information CIfH. National Health Expenditure Trends, 1975 to 2019. Ottawa, ON: CIHI, 2019.
16. Lavoie JG, Wong ST, Ibrahim N, O’Neil JD, Green M, Ward A. Underutilized and undertheorized: the use of hospitalization for ambulatory care sensitive conditions for assessing the extent to which primary healthcare services are meeting needs in British Columbia first nation communities. BMC health services research. 2019;19(1):1-10.
17. Assessment CCOfHT. Guidance Document for the Costing of Health Care Resources in the Canadian Setting: Second Edition. 2016.
18. Lavoie JG, Philips-Beck W, Kinew KA, Kyoon-Achan G, Sinclair S, Katz A. The relationship between rates of hospitalization for ambulatory care sensitive conditions and local access to primary healthcare in Manitoba first nations communities. Canadian Journal of Public Health. 2021;112(2):219-30.
19. Mukim M, Sharma P, Gupta R, Sharma A, Nagar JC, Khalid M, et al. Ambulatory Care: A Review. Int J Pharm Sci Rev Res.60(2):63-6.
20. Sutherland JM, Crump RT. Alternative level of care: Canada’s hospital beds, the evidence and options. Healthcare Policy. 2013;9(1):26.
21. Tran DT, Thanh NX, Opgenorth D, Wang X, Zuege D, Zygun DA, et al. Association between strained ICU capacity and healthcare costs in Canada: a population-based cohort study. Journal of critical care. 2019;51:175-83.
22. Sutherland J, Hellsten E. Integrated funding: connecting the silos for the healthcare we need. CD Howe Institute Commentary. 2017(463).
23. Sutherland JM, Hellsten E. Breaking the Silos: Funding for the Healthcare We Need. CD Howe Institute Commentary. 2017(463).
24. Guerriere M. Connecting healthcare silos to improve patient outcomes. Vancouver, BC: Telus Health. 2019.
25. Kasteridis P, Mason A, Street A. Evaluating integrated care for people with complex needs. Journal of Health Services Research & Policy. 2021;26(1):46-53.
26. Hughes G. New models of care: the policy discourse of integrated care. People, Place and Policy Online. 2017;11(2).
27. Schoenfeld R, Nguyen GC, Bernstein CN. Integrated care models: optimizing adult ambulatory care in inflammatory bowel disease. Journal of the Canadian Association of Gastroenterology. 2020;3(1):44-53.
28. Agerholm J, de Leon AP, Schön P, Burström B. Impact of Integrated Care on the Rate of Hospitalization for Ambulatory Care Sensitive Conditions among Older Adults in Stockholm County: An Interrupted Time Series Analysis. International Journal of Integrated Care. 2021;21(2).
29. Stephenson MD, Lisy K, Stern CJ, Feyer A-M, Fisher L, Aromataris EC. The impact of integrated care for people with chronic conditions on hospital and emergency department utilization: a rapid review. International journal of evidence-based healthcare. 2019;17(1):14-26.
30. Hospital WsC. We are Women’s Report 2020. Available from: http://wearewomensreport2020.womenscollegehospital.ca/
31. Canizares M, MacKay C, Davis AM, Mahomed N, Badley EM. A population-based study of ambulatory and surgical services provided by orthopaedic surgeons for musculoskeletal conditions. BMC Health Services Research. 2009;9(1):1-9.
32. Moore M, Gibbons C, Cheng N, Coffman M, Petterson S, Bazemore A. Complexity of ambulatory care visits of patients with diabetes as reflected by diagnoses per visit. Primary care diabetes. 2016;10(4):281-6.
33. Harris MF, Advocat J, Crabtree BF, Levesque JF, Miller WL, Gunn JM, et al. Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries. Journal of multidisciplinary healthcare. 2016;9:35-46. doi: https://dx.doi.org/10.2147/JMDH.S97371.
34. Province announces new round of approved Ontario Health Teams [Internet]. Ontario; 2020. Available from: https://ontario.cmha.ca/news/province-announces-new-round-of-approved-ontario-health-teams/
35. Some NH, Devlin RA, Mehta N, Zaric GS, Sarma S. Team-based primary care practice and physician’s services: Evidence from Family Health Teams in Ontario, Canada. Social Science & Medicine. 2020;264(113310):21. doi: https://dx.doi.org/10.1016/j.socscimed.2020.113310.
36. Peckham A, Rudoler D, Li JM, D’souza S. Community-based reform efforts: The case of the aging at home strategy. Healthcare Policy. 2018;14(1):30.
37. Care SEH. Our Programs 2021. Available from: https://sehc.com/services.
38. Fierlbeck K. Nova Scotia: A Health System Profile: University of Toronto Press; 2018.
39. Suter E, Mallinson S, Misfeldt R, Boakye O, Nasmith L, Wong ST. Advancing team-based primary health care: a comparative analysis of policies in western Canada. BMC health services research. 2017;17(1):1-9.
40. Béland Y, Dale V, Dufour J, Hamel M, editors. The Canadian Community Health Survey: Building on the success from the past. Proceedings of the American Statistical Association Joint Statistical Meetings 2005, Section on Survey Research Methods, August 2005; 2005: Citeseer.
41. Mable AL, Marriott J, Mable M. Canadian primary healthcare policy: the evolving status of reform: Canadian Health Services Research Foundation Ottawa; 2012.
42. Gladkikh M, McMillan HJ, Andrade A, Boelman C, Bhathal I, Mailo J, et al. Pediatric hyperacute arterial ischemic stroke pathways at Canadian tertiary care hospitals. Canadian Journal of Neurological Sciences. 2021:1-8.
43. Network GTAR. Measuring and managing supply and demand: a waiting list information management proposal for musculoskeletal rehabilitation in the Greater Toronto Area. Toronto: The Network. 2003.
44. Information CIfH. Health Care Cost Drivers: The Facts. Ottawa, ON: 2012.
45. de Oliveira C, Weir S, Rangrej J, Krahn MD, Mittmann N, Hoch JS, et al. The economic burden of cancer care in Canada: a population-based cost study. CMAJ open. 2018;6(1):E1.
46. Carson AS. The Role of the Private Sector in Canadian Healthcare: Accountability, Strategic Alliances, and Governance. Managing a Canadian Healthcare Strategy. 2017:49.
47. Malik A, Bell CM, Stukel TA, Urbach DR. Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Canadian Journal of Surgery. 2016;59(1):19.
48. Guénette J, Frappier J. Private Medicine in Quebec: Montreal Economic Institute; 2013.
49. Cancer TCPA. Annual Report 2019-2020: DOING WHAT CAN ONLY BE DONE TOGETHER 2020. Available from: https://s22457.pcdn.co/wp-content/uploads/2020/10/Annual-report-2019-2020-EN.pdf.
50. Béland D, Marchildon GP, Medrano A, Rocco P. COVID-19, Federalism, and Health Care Financing in Canada, the United States, and Mexico. Journal of Comparative Policy Analysis: Research and Practice. 2021:1-14.
51. Cadel L, Guilcher SJ, Kokorelias KM, Sutherland J, Glasby J, Kiran T, et al. Initiatives for improving delayed discharge from a hospital setting: a scoping review. BMJ open. 2021;11(2):e044291.