BackgroundImproving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.MethodsWe searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.ResultsWe identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.ConclusionThe categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3745-y) contains supplementary material, which is available to authorized users.

IntroductionCentralized intake is integral to healthcare systems to support timely access to appropriate health services. The aim of this study was to develop key performance indicators (KPIs) to evaluate centralized intake systems for patients with osteoarthritis (OA) and rheumatoid arthritis (RA).MethodsPhase 1 involved stakeholder meetings including healthcare providers, managers, researchers and patients to obtain input on candidate KPIs, aligned along six quality dimensions: appropriateness, accessibility, acceptability, efficiency, effectiveness, and safety. Phase 2 involved literature reviews to ensure KPIs were based on best practices and harmonized with existing measures. Phase 3 involved a three-round, online modified Delphi panel to finalize the KPIs. The panel consisted of two rounds of rating and a round of online and in-person discussions. KPIs rated as valid and important (≥7 on a 9-point Likert scale) were included in the final set.ResultsTwenty-five KPIs identified and substantiated during Phases 1 and 2 were submitted to 27 panellists including healthcare providers, managers, researchers, and patients in Phase 3. After the in-person meeting, three KPIs were removed and six were suggested. The final set includes 9 OA KPIs, 10 RA KPIs and 9 relating to centralized intake processes for both conditions. All 28 KPIs were rated as valid and important.ConclusionsArthritis stakeholders have proposed 28 KPIs that should be used in quality improvement efforts when evaluating centralized intake for OA and RA. The KPIs measure five of the six dimensions of quality and are relevant to patients, practitioners and health systems.Electronic supplementary materialThe online version of this article (doi:10.1186/s13075-015-0843-7) contains supplementary material, which is available to authorized users.

BackgroundComplexity has been linked to health interventions in two ways: first as a property of the intervention, and secondly as a property of the system into which the intervention is implemented. The former recognizes that interventions may consist of multiple components that act both independently and interdependently, making it difficult to identify the components or combinations of components (and their contexts) that are important mechanisms of change. The latter recognizes that interventions are implemented in complex adaptive systems comprised of intelligent agents who modify their behaviour (including any actions required to implement the intervention) in an effort to improve outcomes relative to their own perspective and objectives. Although an intervention may be intended to take a particular form, its implementation and impact within the system may deviate from its original intentions as a result of adaptation. Complexity highlights the challenge in developing interventions as effective health solutions. The UK Medical Research Council provides guidelines on the development and evaluation of complex interventions. While mathematical modelling is included in the guidelines, there is potential for mathematical modeling to play a greater role.DiscussionThe dynamic non-linear nature of complex adaptive systems makes mathematical modelling crucial. However, the tendency is for models of interventions to limit focus on the ecology of the system - the ‘real-time’ operation of the system and impacts of the intervention. These models are deficient by not modelling the way the system reacts to the intervention via agent adaptation. Complex intervention modelling needs to capture the consequences of adaptation through the inclusion of an evolutionary dynamic to describe the long-term emergent outcomes that result as agents respond to the ecological changes introduced by intervention in an effort to produce better outcomes for themselves. Mathematical approaches such as those found in economics in evolutionary game theory and mechanism design can inform the design and evaluation of health interventions. As an illustration, the introduction of a central screening clinic is modeled as an example of a health services delivery intervention.SummaryComplexity necessitates a greater role for mathematical models, especially those that capture the dynamics of human actions and interactions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12874-016-0149-8) contains supplementary material, which is available to authorized users.

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Mathematics is a foundational subject in education. Learning outcomes in mathematics build on previous competencies and students are well-served by real-time intervention and feedback. However, contemporary math education is limited by technology, scalable learning, shareable experiences (both teaching and learning), and accessible modes of practice. Most assessment platforms do not have the functionality to support symbols and equations. During the pandemic we have diverted assessments in high enrolment mathematics courses from paper to electronic delivery. We developed randomized examinations for Introductory Statistics and Introduction to Calculus I and we developed an entire course with assessment using OERs (open educational resources) for Business Mathematics. Our team developed highly interactive, traceable, and intervenable content in math problem solving using the Möbius (https://digitaled.com/mobius) platform. We enabled an LTI integration of the platform into our LMS (learning management system) to provide seamless access for students. Möbius promotes cognitive learning through a powerful math engine, student feedback, analytics, and interactive STEM (science, technology, engineering, math) curriculum content. We are serving 3,000 learners with effective assessment and have relieved faculty and staff of administering and marking alternative examinations through a long pandemic. We have seen improvements in student feedback, increased accessibility, reduced administrative burden, and enhanced exam security. Möbius is a truly scalable and cost-effective platform for math educators and students that provides more efficient and effective management of educational delivery.