A value-based comparison of the management of ambulatory respiratory diseases in walk-in clinics, primary care practices, and emergency departments : protocol for a multicenter prospective cohort study

Background: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. Objective: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Methods: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. Results: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. Conclusions: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative

“Older-wiser-lesbians” and “baby-dykes”: mediating age and generation in New Queer Cinema

Representations of intersections of gender, age, and sexuality can reveal deep-rooted cultural anxieties about older women and sexuality. Images of lesbian ageing are of particular interest in terms of alterity, as the old/er queer woman can combine layers of otherness—not only is she the cultural “other” within heteronormativity, but she can also appear as the opposite of popular culture’s lesbian chic. In this article, a cultural analysis of a range of films—If These Walls Could Talk 2 (dir. Anderson, Coolidge, and Heche 2000), Itty Bitty Titty Committee (dir. Babbit 2007), The Owls (dir. Dunye 2010), Hannah Free (dir. Carlton 2009), and Cloudburst (dir. Fitzgerald 2011)—considers diverse dramatisations of lesbian generations. This article interrogates to what extent alternative cinemas deconstruct normative conceptualisations of ageing. Drawing on recent critiques of post-feminist culture, and a range of feminist and age/ing studies scholarship, it suggests that a linear understanding of ageing and the generational underlies dominant depictions of oppositional binaries of young versus old, of generational segregation or rivalry, and the othering of age. It concludes that non-linear understandings of temporality and ageing contain the potential for New Queer Cinema to counteract such idealisations of youthfulness, which, it argues, is one of the most deep-rooted manifestations of (hetero)normativity

FUTURE OF THE CANADIAN OIL SECTOR: INSIGHTS FROM A HYBRID MODEL APPROACH BASED ON TIMES-CANADA

2. Soft link with a well count forecasting model 3. Soft link with an energy security model 3. Reference energy systems 1. Provinces and territories (13) 2. Oil sector 3. Energy corridor