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Today the world is confronted with dual crises: creeping and acute threats unfolding at the same time—for example, the manifestation of extreme weather events such as drought and flooding and the creeping crisis of climate change. To cope with dual crises, this article develops a novel temporal perspective that offers policy actors a repertoire of interrelated strategies for enhancing the robustness of institutional efforts. The repertoire consists of five temporal strategies that policy actors can use to navigate the twin challenges of immediate and latent threats in conjunction: strategic coupling of short-term shocks and creeping crises, crafting time horizons, molding the pace of public problem-solving, mobilizing anticipatory capacity through futuring techniques, and adaptive iteration of policy decisions. We illustrate the practical application of these strategies in an exploratory case study of adaptive water management in the Netherlands. De wereld wordt geconfronteerd met duale crises: sluipende en acute dreigingen op hetzelfde moment, zoals extreme weersgebeurtenissen als droogte of watersnood tegelijkertijd met de sluipende crisis van klimaatverandering. Om te reageren op duale crises, ontwikkelt dit artikel een nieuw repertoire van vijf temporele strategieën voor beleidsmakers om de robuustheid van overheidssystemen te vergroten. Dit repertoire bestaat uit de volgende strategieën: strategische koppeling van onverwachte korte termijn schokken en sluipende crises, tijdshorizonnen creëren, het tempo aanpassen van implementatie, het mobiliseren van anticiperende capaciteit door middel van scenariotechnieken, en de adaptieve iteratie van beleidsbeslissingen. We illustreren de werking van deze vijf strategieën aan de hand van een uitgewerkt voorbeeld van adaptief watermanagement in Nederland: de invoering van het programma Ruimte voor de Rivier.

Indications for reverse total shoulder arthroplasty (RTSA) have expanded to include primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Limited evidence exists on RTSA in patients with primary GHOA and no posterior glenoid wear (Walch A1, A2, and B1 morphologies). The purpose of this retrospective cohort study was to determine if glenoid morphology is associated with clinical outcomes in patients undergoing RTSA for primary GHOA.A retrospective review of prospectively collected data was performed in patients undergoing primary RTSA for GHOA with a minimum of 2-year clinical follow-up. Preoperative computed tomography and magnetic resonance imaging were used to categorize glenoid morphology as described by the modified Walch classification. Pre- and postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) pain scores, and range of motion (ROM) measurements were compared across Walch glenoid subtypes. The percentage of patients that reached previously established clinically significant thresholds for minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also comparatively assessed. Multivariable analysis was used to evaluate the association between glenoid morphology and postoperative ASES score while controlling for potentially confounding variables.Of the 247 consecutive patients, 197 were available at a minimum 2-year follow-up (80%). Significant improvements were seen in ASES, VAS pain, SANE, and ROM from baseline to final postoperative follow-up in the combined patient cohort (all P.001). Most (98.0%) patients reached MCID, and 90.9% of patients reached SCB for ASES threshold. No significant differences were found among Walch subtypes in terms of preoperative to postoperative improvement in ASES (P = .39), SANE (P = .4), VAS pain (P = .49), forward elevation (P = .77), external rotation (P = .45), or internal rotation (P= 0.1). The only significant difference in postoperative outcomes between Walch glenoid subtypes was higher postoperative ASES scores among type B3 glenoids compared with type A1 glenoids (P = .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postoperative ASES scores on multivariable analysis (P.05).Primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity. Surgeons can use these data to support the use of RTSA for glenohumeral arthritis in a more standardized way.

This reflective contribution tells the story of a veteran public sector crisis management (CM) researcher’s 35-year journey with educating students and CM practitioners, It offers preliminary insights about how the pandemic experience might – and should – induce a significant rethink of how educators conceptualize the nature of crises and the challenges governments and public agencies face in coping with them.

The presence of functional somatic syndromes (chronic physical symptoms with no identifiable organic cause) in patients undergoing elective joint arthroplasty may affect the recovery experience. We explored the prevalence of functional somatic syndromes among shoulder arthroplasty patients, as well as their association with postoperative outcomes and costs.We identified 480 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Medical records were queried for the presence of 4 well-recognized functional somatic syndromes: fibromyalgia, irritable bowel syndrome, chronic headaches, and chronic low-back pain. Multivariable linear regression modeling was used to determine the independent association of these diagnoses with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and pain scores.Nearly 1 in 5 patients (17%) reported at least 1 functional somatic syndrome. These patients were more likely to be women, to be chronic opioid users, to report more allergies, to have a diagnosis of anxiety, and to have shoulder pathology other than degenerative joint disease (all P ≤ .001). After multivariable adjustment, the presence of at least 1 functional somatic syndrome was independently predictive of lower 2-year ASES (-9.75 points) and SANE (-7.63 points) scores and greater residual pain (+1.13 points) (all P ≤ .001). When considered cumulatively, each additional functional disorder was linked to a stepwise decrease in ASES and SANE scores and an increase in residual pain (P.001). These patients also incurred higher hospitalization costs, with a stepwise rise in costs with an increasing number of disorders (P.001).Functional somatic syndromes are common in patients undergoing shoulder arthroplasty and correlate with suboptimal outcomes and greater resource utilization. Efforts to address the biopsychosocial determinants of health that affect the value proposition of shoulder arthroplasty should be prioritized in the redesign of care pathways and bundling initiatives.

Reverse shoulder arthroplasty (RSA) is increasingly being utilized for the treatment of primary osteoarthritis. However, limited data are available regarding the outcomes of RSA as compared with anatomic total shoulder arthroplasty (TSA) in the setting of osteoarthritis.We performed a retrospective matched-cohort study of patients who had undergone TSA and RSA for the treatment of primary osteoarthritis and who had a minimum of 2 years of follow-up. Patients were propensity score-matched by age, sex, body mass index (BMI), preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative active forward elevation, and Walch glenoid morphology. Baseline patient demographics and clinical outcomes, including active range of motion, ASES score, Single Assessment Numerical Evaluation (SANE), and visual analog scale (VAS) for pain, were collected. Clinical and radiographic complications were evaluated.One hundred and thirty-four patients (67 patients per group) were included; the mean duration of follow-up (and standard deviation) was 30 ± 10.7 months. No significant differences were found between the TSA and RSA groups in terms of the baseline or final VAS pain score (p = 0.99 and p = 0.99, respectively), ASES scores (p = 0.99 and p = 0.49, respectively), or SANE scores (p = 0.22 and p = 0.73, respectively). TSA was associated with significantly better postoperative active forward elevation (149° ± 13° versus 142° ± 15°; p = 0.003), external rotation (63° ± 14° versus 57° ± 18°; p = 0.02), and internal rotation (≥L3) (68.7% versus 37.3%; p0.001); however, there were only significant baseline-to-postoperative improvements in internal rotation (gain of ≥4 levels in 53.7% versus 31.3%; p = 0.009). The overall complication rate was 4.5% (6 of 134), with no significant difference between TSA and RSA (p = 0.99). Radiolucent lines were observed in association with 14.9% of TSAs, with no gross glenoid loosening. One TSA (1.5%) was revised to RSA for the treatment of a rotator cuff tear. No loosening or revision was encountered in the RSA group.When performed for the treatment of osteoarthritis, TSA and RSA resulted in similar short-term patient-reported outcomes, with better postoperative range of motion after TSA. Longer follow-up is needed to determine the ultimate value of RSA in the setting of osteoarthritis.Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

In Canada many public projects, programs, and services perform well, and many are very successful. However, these cases are consistently underexposed and commonly understudied in the public realm which, for various reasons, tends to focus on policy mistakes and learning from failures rather than successes. In fact, studies of public policy successes, as such, are rare not just in Canada, but the world over, although this has started to change. The aims of the book are to see, describe, acknowledge, and promote learning from past and present instances of highly effective and highly valued public policy-making. These aims are accomplished through detailed examination of selected case studies of policy success in different eras, governments, and policy domains in Canada.

This chapter reviews the volume’s 22 case studies of successful policies across Canada, which tracked policy histories and assessed policy outcomes over time. It seeks to generate broader lessons and themes for conceptualizing and explaining policy success. It begins by providing a summary of the success ratings arising from the case studies and considers the usefulness of the multidimensional PPPE (programmatic, process, political, endurance) framework for developing and analysing such case studies. Second, it draws on the cases to identify factors across policy domains—some common, some particular, some contingent—which contribute to the different dimensions of policy success. Third, we step back from the case studies to consider the complex influence of macro-institutions in Canada (e.g. federalism, executive-dominated parliamentary government, and the judiciary) in influencing policy success. Finally, based on lessons from the Canadian cases, future lines of research to strengthen our understanding of policy success are suggested.

Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables.Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035).LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.

Background Refugees in humanitarian settings commonly experience many health needs and barriers to access healthcare; health data from these settings are infrequently reported, preventing effective healthcare provision. This report describes health needs of refugees in Moria Camp on Lesvos, Greece—Europe’s largest refugee camp. Methods A set of routinely collected service data of 18 131 consultations of 11 938 patients, attending a primary care clinic in the camp over 6 months in 2019–20, was analysed retrospectively, focusing on chronic health conditions. Results The most frequent chronic conditions were musculoskeletal pain (25.1%), mental health (15.9%), cardiac (12.7%) and endocrine conditions (8.9%). In all, 70.4% of consultations were for acute health problems, with high rates of injuries and wounds (20.8%), respiratory infections (12.5%), gastroenteritis (10.7%) and skin problems (9.7%), particularly scabies. Conclusions The prevalence of acute and chronic health problems is high in this setting, with some likely attributable to the deplorable living conditions in the camp. Despite its magnitude, the interpretability of routine health data is limited. A research agenda is identified, and a framework for chronic disease management in refugee camps is proposed.

There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty.We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores.Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77).Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum.

This introductory chapter sets out the objectives, approach and methodology of this volume. The main rationale for the volume is to identify, reconstruct and narrate instances of governments in Nordic countries ‘getting it right’, and to do so in a manner that is analytically robust yet presented in easy-to-read and helpful-to-teach case-study narratives. It presents the central analytical tool that all case studies use, the PPPE assessment framework, which calls on analysts to ascertain cases against programmatic, process, political and endurance criteria. And it situates the question of individual instances of policy successes in Nordic instances in the context of the broader narrative about a ‘Nordic’ approach to politics, governance and public policy, in particular but not limited to socio-economic policies and the ethos and architecture of welfare states in Northern Europe. It concludes by offering some emerging patterns of success-enabling factors across the cases and by formulating implications for future research.