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Frequent users (FUs) of emergency departments (EDs) attend repeatedly, placing a disproportionate burden on healthcare systems. Although known to be heterogeneous, there is limited international evidence characterising FU subpopulations or examining how healthcare costs and outcomes differ across groups. Advancing this understanding is important for developing tailored interventions to meet diverse care needs. FUs were defined as individuals with ≥5 ED attendances/year. We used two large UK datasets: Hospital Episode Statistics (HES, 2016-2019) and the Centre for Urgent and Emergency Care database (CUREd, 2017-2020). Together, these included over 148 000 FUs from 5 million ED users. Latent class analysis (LCA) was used to identify FU subgroups based on attendance patterns, healthcare use and diagnostic characteristics. We identified three consistent subgroups (HES and CUREd): (1) low-severity FUs (n=23 034, 43.2%; n=7081, 32.7%); (2) high-intensity FUs with mental health and neurological needs (n=6288, 11.8%; n=3456, 15.9%); (3) older FUs with chronic illness and high inpatient use (n=24 028, 45.0%; n=11 139, 51.4%). Subgroups differed substantially in healthcare utilisation, costs and mortality. A fourth class varied across datasets: in HES, it showed moderate morbidity and complex needs; in CUREd, high morbidity and high-intensity ED use. This is the first FU study to apply LCA across large-scale, multiyear ED datasets, identifying a potentially universal subgroup structure. Current services focus on a narrow subset of high-intensity users. Additional tailored strategies are needed to address the full spectrum of FU needs.

Homeless individuals face major barriers in accessing regular healthcare, leading to the development of street medicine as a distinct humanitarian field. To enhance continuity and quality of care, consistent documentation is crucial. However, electronic health records are rarely used in European street medicine. An interdisciplinary European workshop identified four key research fields for medical informatics in street medicine: (1) Research ethics: The creation of ethical guidelines that promote co-creation and active communication with patients. (2) System development: Designing a secure, anonymous and European Health Data Space-compliant personal Electronic Health and Social Record (pEHSR), establishing standardised health and social care datasets, and implementing dynamic consent management methods. (3) Education and training: Developing targeted programmes to improve digital and health literacy among street medicine clients and training professionals in the effective use of the pEHSR system. (4) Management and evaluation: Creating management structures and evaluation frameworks suited to the unique challenges of street medicine.This manifesto calls for internationally coordinated scientific efforts to build effective, integrated digital health solutions for vulnerable populations. It encourages researchers and practitioners from medical informatics and related fields to engage with these priorities and support innovation that advances equitable healthcare access.

Chronic obstructive pulmonary disease (COPD) affects approximately 480 million individuals globally and is projected to reach 600 million by 2050, representing a substantial burden on healthcare systems and patient quality of life. Pulmonary rehabilitation is a cornerstone intervention for COPD management, delivering clinically meaningful improvements in exercise capacity, health-related quality of life and dyspnoea. Despite strong guideline recommendations and established efficacy, only 2%-4% of eligible patients with COPD access traditional centre-based pulmonary rehabilitation due to geographical barriers, transportation difficulties, scheduling conflicts and limited healthcare resources. Digital health technologies offer promising alternatives to overcome these access barriers while potentially maintaining therapeutic benefits. Various digital delivery models have emerged, including video-based telerehabilitation, virtual reality platforms, mobile health applications and web-based programmes. However, their comparative effectiveness remains unclear, limiting evidence-based clinical decision making. This systematic review and network meta-analysis will aim to compare and rank the effectiveness and safety of different digital health delivery models for pulmonary rehabilitation in patients with COPD, providing evidence to inform optimal intervention selection in clinical practice. We will conduct a systematic review and Bayesian network meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Network Meta-Analyses guidelines. Comprehensive searches will be performed across five electronic databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL) from inception to January 2026, without language restrictions. Eligible studies will include randomised controlled trials comparing digital health delivery models for pulmonary rehabilitation in adults with COPD. Digital health interventions will be categorised into four distinct delivery models: video-based telerehabilitation, virtual reality rehabilitation, mobile health rehabilitation and web-based platform rehabilitation. Interventions combining multiple modalities will be categorised according to the predominant component based on intervention frequency, duration and primary therapeutic mechanism. Two independent reviewers will perform study selection, data extraction and risk of bias assessment using the Cochrane Risk of Bias 2 tool. The primary outcome will be change in 6 min walk distance. Key secondary outcomes will include disease-specific quality of life measures, dyspnoea severity, hospitalisation rates, exacerbation frequency, intervention adherence and adverse events. A Bayesian random-effects network meta-analysis will be conducted, calculating mean differences or ORs with 95% credible intervals. Treatment rankings will be estimated using surface under the cumulative ranking curve probabilities. Evidence certainty will be assessed using the Confidence in Network Meta-Analysis framework. Planned subgroup analyses will explore potential effect modifiers including disease severity, intervention duration, supervision mode and technological features. As this systematic review will use data from previously published studies, formal ethical approval is not required. Findings will be disseminated through peer-reviewed publication, presentations at relevant scientific conferences and communication to healthcare providers, policymakers and patient advocacy organisations. CRD420251268701.

Multimorbidity among patients with chronic hepatitis B (CHB) infection has emerged as a priority for healthcare and public health systems worldwide. This study aimed to characterise time-trends in multimorbidities among patients with CHB infection. We identified multimorbidity clusters and combinations and quantified their associations with healthcare services utilisation. A retrospective observational study, using electronic medical record data. A large tertiary general hospital in China. The study included 23&#x2009;137 patients with CHB infection admitted between 2011 and 2023. Latent class analysis and association rule mining (ARM) were performed to identify multimorbidity clusters and combinations, respectively. Multivariable logistic regression quantified associations between the identified multimorbidity patterns and length of stay (LOS), daily expense and 1-year readmission for liver-related conditions (OYRL). The mean number of multimorbidities among hospitalised patients with CHB infection was 2.82&#xb1;1.89. From 2011 to 2023, mean age increased from 44.2&#xb1;13.7&#x2009;to 48.4&#xb1;13.1 (p<0.001). The prevalence of cirrhosis (45.50%-57.10%), hepatocellular carcinoma (HCC) (13.10%-17.10%) and non-alcoholic fatty liver disease (3.15%-5.08%) increased over time. Similar trends were observed for non-liver multimorbidities, including diabetes mellitus (9.86%-11.90%), hypertension (7.34%-10.30%) and chronic kidney diseases (0.96%-1.58%). We identified three multimorbidity clusters: Cluster 1 (43.58%) included patients in the early phase of CHB infection with the lowest overall burden of multimorbidity. Cluster 2 (47.71%) was characterised prominently by cirrhosis and HCC. Patients in cluster 3 (8.70%) were the oldest and exhibited the highest probability of metabolic, circulatory and kidney-related multimorbidities. Three clusters demonstrated different association strengths with healthcare utilisation. Most multimorbidity combinations identified by ARM were significantly associated with higher LOS and OYRL, but lower daily expenses. Multimorbidity imposes a substantial burden on CHB-infected patients. Our findings highlight the importance of early diagnosis and treatment of CHB infection, as well as tailored integral strategies for multimorbidity management in individuals with CHB infection.

The aim of this study was to assess the level of continuum of maternal, newborn, childand reproductive health coverage using the composite coverage index (CCI) and to identify its determinants, including socioeconomic, community context, individual and family, and health service-related factors, among postpartum women one year after childbirth in Ethiopia. This study was a secondary analysis of longitudinal data from the second cohort of the performance monitoring for action (PMA) Ethiopia survey, which was conducted from 2021 to 2023. Data were collected at four intervals: a baseline survey, a 6&#x2009;week postpartum survey, a 6&#x2009;month postpartum survey and a 1&#x2009;year postpartum survey to track reproductive, maternal, newborn, and child health indicators. The study was conducted from the major regions of Ethiopia, namely Amhara, Oromia, Southern Nations, Nationalities and Peoples' and the city administration of Addis Ababa. A total of 2297&#x2009;women enrolled in cohort two of PMA Ethiopia. Of these, 2072 completed the 6&#x2009;week, 1874 the 6&#x2009;month and 1858 (along with their 1800 children) the 1&#x2009;year postpartum follow-up surveys. The final analysis was based on a weighted sample of 1793 participants. The outcome variable for this study was the continuum of maternal, newborn, child and reproductive health services, assessed using the CCI. We applied quantile regression analyses at the 10th, 25th, 50th, 75th and 90th quantiles of the outcome variable. Statistical significance of predictors was determined based on p values <0.05. Estimates for the regression coefficient, standard errors, p values and CIs were generated across the quantiles. The findings revealed that the mean CCI was 56.2% (95 % CI 52.5% to 59.8%), indicating the proportion of maternal, newborn, child, and reproductive health services received. Notably, only 4% of women received all 12 maternal, newborn, child, and reproductive health services as part of the continuum of care, while 1.1% did not receive any intervention. The study identified several factors significantly associated with CCI across different quantile levels, including maternal age, maternal education level, household wealth index, first antenatal care visit (ANC1), parity, previous facility delivery, partner encouragement, use of maternity waiting homes, and administrative regions. Based on the findings of this study, the coverage of continuum of maternal, newborn, child and reproductive health services in Ethiopia remains low. This highlights a substantial gap in Ethiopia's progress toward the 2030 sustainable development goal target. Ethiopia must significantly accelerate efforts to improve maternal, newborn, child and reproductive health services in order to achieve the set goals. Policymakers and programme implementers should carefully consider the identified determinants when designing policies and programmes aimed at enhancing maternal, newborn, child and reproductive health outcomes.

Healthcare is a major contributor to greenhouse gas emissions, and sector-specific policies and goals are recommended as governance tools. Despite leadership playing a critical role in reducing emissions, there is limited empirical research on how healthcare managers perceive and navigate climate goals and actions. To explore how members of a hospital's senior management team understand and respond to climate goals. Qualitative study design, semi-structured interviews were conducted, and data were analysed thematically. A hospital in Sweden. Members (n=15) of the hospital's senior management team. Five themes were identified. Senior managers recognised the importance of climate goals (theme 1), but their understanding of these varied-from perceiving them as concrete and actionable to abstract and irrelevant at the departmental level (theme 2). Climate goals were described as both visible and invisible (theme 3), and as both in alignment and in competition with other organisational goals (eg, patient safety, budget constraints) (theme 4). There was a common understanding that they, and the hospital, could do more to reduce emissions but knowledge gaps, limited resources, monitoring challenges, as well as systemic constraints, challenged advancement (theme 5). These dynamics led to two co-existing patterns of responses: a virtuous cycle of climate action and a vicious cycle of climate inaction in which uncertainty prevailed. Climate goals can act as both catalysts and inhibitors to climate actions in hospitals, depending on how they are understood and operationalised by senior managers. Policymakers and healthcare system leaders must address the uncertainty surrounding climate goals to advance climate action.

Antimicrobial resistance (AMR) is one of the most urgent global health threats, responsible for an estimated 4.95&#x2009;million deaths annually, including 1.27&#x2009;million directly linked to drug-resistant infections. Nigeria is particularly affected, ranking 19th globally in AMR-related mortality, with an estimated 64&#x2009;500 attributable and 263&#x2009;400 associated deaths in 2019. These estimates are likely conservative due to limited surveillance. Economically, AMR could cost Nigeria 5%-7% of its GDP by 2050.Despite this burden, antibiotic misuse remains widespread, with 42% of adults and over 46% of children under 5 receiving antibiotics without prescriptions. At the primary healthcare (PHC) level, where most antibiotics are prescribed, challenges such as limited diagnostics, inconsistent prescription and poor access to digital tools hinder effective antimicrobial stewardship (AMS). The primary objective of this study is to assess the knowledge, attitudes and practices regarding antimicrobial resistance (AMR) among PHC prescribers in Imo State, Nigeria. A secondary objective is to explore preliminary indicators of their digital readiness to inform future technological interventions for AMS. A cross-sectional study using an online questionnaire. PHC facilities across all 27 local government areas of Imo State, Nigeria. A purposive sample of 547 facility-based public PHC prescribers included 84% of all facility Officers-in-Charge of health facilities in the state and 16% of other PHC workers who were involved in prescription. The primary outcome measures were composite scores for knowledge (adequate/inadequate), attitude (positive/negative) and prescribing practice (good/poor), derived from a validated questionnaire. Secondary measures included sources of AMR information and indicators of digital readiness. While 77.1% demonstrated adequate knowledge, only 32.7% exhibited positive attitudes and 88.5% reported poor prescribing practices. Attitude was the strongest predictor of good practice (OR=17.585, p<0.001). Though 69.5% were aware of AMR, most learnt through professional training and colleagues, with only 13.3% citing online medical resources. Indicators of digital readiness, such as access to digital tools, were low; only 21.2% had access to an antibiogram, and 44.2% had never participated in AMS training, including virtual sessions. These findings underscore a critical gap between knowledge and practice, driven in part by limited access to digital decision-support tools. To address the documented gaps in tool access and training, strengthening digital inclusion through context-adapted e-learning, offline-compatible AMS tools and simplified digital antibiograms is a necessary implication for improving antibiotic stewardship and clinical outcomes at the PHC level.

To develop recommendations to inform development and integration of predictive digital health and artificial intelligence tools in primary care. Recommendation development involved two stages. The initial scoping phase comprised an umbrella review to identify barriers to implementation for risk prediction tools in primary care. The consensus phase involved a stakeholder workshop with 22 stakeholders. The draft recommendations were then refined via a stakeholder survey completed by 13 participants and three online meetings attended by 14 individuals to generate the final output. The umbrella review included 12 reviews and identified 15 barriers to implementation of risk prediction models, including lack of integration with electronic health records and poor interoperability across them. The final recommendations include 14 core features of risk prediction models and tools, including the need for codesign with clinicians and the public and integration with digital infrastructure and workflows. These findings particularly emphasise the value of early engagement with key stakeholders and health record system providers, and a need for shared understanding of the needs of end-users. We have developed recommendations detailing 14 key characteristics for a digital risk prediction model to be successfully used in primary care settings. This profile should be used to guide development of new risk prediction tools and is also applicable more widely to other digital health innovations within primary care. Future research should work to resolve the identified system-level barriers to implementation.

To propose and test an innovative model by integrating the Unified Theory of Acceptance and Use of Technology and Knowledge-Attitude-Practice model to explain the mechanisms influencing the adoption of digital health technologies by elderly patients with chronic diseases from the perspective of both internal and external factors, promoting the acceptance and utilisation of digital health technologies among elderly chronically ill patients. A face-to-face questionnaire survey was conducted from July to September 2023. The study was conducted in 12 medical institutions in Shanghai, including 6 tertiary hospitals, 3 secondary hospitals and 3 community hospitals. 1222 participants aged 60 years or more, diagnosed with one or more of the following chronic diseases: essential hypertension, type 2 diabetes, coronary atherosclerotic heart disease, stroke and chronic obstructive pulmonary disease, were involved in the study using convenience sampling. Critically ill emergency patients and those who were involved in medical disputes were excluded. The behavioural intention and usage behaviour of older patients with chronic diseases to use digital health technologies. The explanatory power of the proposed model for behavioural intention was 72.9%. There is a significant negative association between technology anxiety and the intention to use digital health technologies among older patients with chronic diseases (&#x3b2;=-0.224, p<0.001); effort expectancy (&#x3b2;=0.530, p<0.001) and performance expectancy (&#x3b2;=0.193, p<0.001) were also significantly associated with intention to use digital health technologies. Men (&#x3b2;=-0.104, p=0.016), relatively younger (&#x3b2;=-0.061, p=0.005), with experience in using digital health technologies (&#x3b2;=-0.452, p<0.001) were more likely to translate behavioural intention into use behaviour. Acceptance of digital health technologies among older patients with chronic diseases was associated with a combination of internal and external factors, with the former playing a dominant role. These valuable findings provided insights and inspiration for improving digital health technologies acceptance and utilisation among older patients with chronic diseases.

Interoperability, the seamless exchange and use of data across digital health systems, is essential for integrated, efficient healthcare delivery. However, evidence on its adoption in Africa remains limited and fragmented. This scoping review aimed to map existing evidence, identify key barriers and highlight emerging opportunities for strengthening interoperability across all levels on the continent. We conducted the review in line with the Joanna Briggs Institute (JBI) methodology and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) framework. Searches were carried out across PubMed/MEDLINE, IEEE Xplore, African Index Medicus and Google Scholar, focusing on English-language publications from January 2010 to March 2025. Eligible sources included peer-reviewed articles, conference papers and relevant policy documents. Sixteen studies met the inclusion criteria. The findings revealed wide disparities in the adoption of interoperability standards, with countries such as Uganda, South Africa and Kenya showing greater momentum due to national digital strategies and health information exchange initiatives. Common challenges included limited technical capacity, fragmented infrastructure and inadequate regulatory support. However, there were encouraging developments around the use of open-source platforms like OpenHIE, regional policy alignment through the African Union Digital Health Strategy and growing public-private partnerships. Progress remains uneven, shaped by each country's digital maturity, workforce capabilities and policy landscape. Capacity-building and better alignment with global standards could bridge current gaps. To build resilient digital health systems, African countries must strengthen governance, invest in infrastructure and develop technical expertise. Future work should assess how interoperability influences clinical care and explore regional readiness for cross-border data exchange.

DESIGN: Traditional encounter-based analyses overlook downstream costs and complications that follow emergency department (ED) care. To enable more comprehensive evaluations, we developed standardised episode of care definitions for five common, high-cost conditions: chest pain, congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD) and suicidality.A two-round modified Delphi panel study was conducted following a literature review and evidence synthesis. Using structured surveys with anonymous feedback, panellists rated candidate criteria. To be retained in the final episode definitions, criteria were required to meet a predefined validity threshold without panellist disagreement. Data were analysed descriptively, and meeting deliberations were recorded and reviewed thematically. Virtual, supported by an online survey platform. A multidisciplinary panel of 11 experts in emergency medicine and relevant clinical specialties with 9 members participating in each round. Criteria to determine inclusion, exclusion (including pre-trigger, post-trigger and event exclusion) and risk-adjustment standards for constructing ED-based episodes of care. Candidate criteria were presented to the panel by condition: 30 for chest pain, 54 for CHF, 30 for COPD, 79 for pneumonia and 375 for suicidality. Following deliberations and re-rating, the number of valid criteria was reduced, primarily in the episode exclusion category. Thematic analysis highlighted trade-offs between episode exclusion criteria and the use of risk adjustment to account for heterogeneity. Operational definitions for ED-based episodes of care for five conditions were established. These may support healthcare administrators, policymakers and researchers in evaluating variation in ED care delivery and its downstream cost and outcomes.

Dementia increases the risk of adverse outcomes during hospitalisation, underscoring the need for system-level strategies. In 2016, Japan introduced Dementia Care Add-on 1 (DCA1), a financial incentive requiring hospitals to establish multidisciplinary dementia care teams. The short-term impact of DCA1 has been elucidated; however, its potential for medium-term to long-term benefits remains uncertain. In this study, we aimed to evaluate the medium-term to long-term impact of DCA1 on care processes and patient outcomes in older adults with dementia in acute-care hospitals. Patients aged &#x2265;65 years with moderate-to-severe dementia who were admitted to acute-care hospitals between April 2014 and March 2020 were identified using a nationwide inpatient database. Hospital-level propensity score matching was conducted, followed by a difference-in-differences analysis comparing identified inpatients of DCA1-certified and non-certified hospitals. Outcome measures were length of stay (LOS), activities of daily living maintenance, potentially inappropriate medication prescriptions, in-hospital fractures and home discharge. A sensitivity analysis excluding hospitals certified only for the less stringent DCA2 scheme was conducted. Overall, 309&#x2009;791 patients from 235 matched hospital pairs were analysed. DCA1 certification was not associated with improvements in the measured outcomes. Notably, >60% of DCA1 hospitals billed for <20% of eligible patients, indicating limited and inconsistent implementation. In a restricted analysis excluding DCA2-certified hospitals, DCA1 certification showed a statistically significant reduction in LOS (change: -11.3%; 95% CI -19.8% to -3.0%). No significant associations were observed for the other outcomes. DCA1 was not associated with measurable improvements in patient outcomes at the certification level. However, under more homogeneous comparison conditions, an association was observed with shorter LOS. These findings show that structural certification alone may be insufficient to achieve consistent improvements in dementia care outcomes in acute hospital settings.

To explore how well the primary care system in Scotland works for adults with intellectual disabilities (ID), using the rate of unplanned hospital admissions for ambulatory care sensitive conditions (ACSC) as a proxy indicator. As part of this, to investigate those rates and rate ratios among adults with ID and without ID, adjusting for the prevalence of a given ACSC in each population. The secondary aim was to explore deaths due to ACSC among the ID and no-ID populations. A population-based retrospective cohort data linkage study of adult respondents to Scotland's 2011 Census. Self-reported or proxy-reported ID status from the Census was linked to hospital admissions data and deaths data. The cohort was followed until the end of 2019. The prevalence of ACSCs in each population was calculated from aggregate-level data published by the National Health Service, as it was not possible to use the linked dataset for this purpose. Whole population of Scotland. People aged 18+ on census day (27 March 2011), including all adults with ID (n=16 840) and a 15% randomly selected comparator sample of adults without ID (n=566 074). Crude and age-sex standardised incidence rates and ratios; cumulative incidence; prevalence ratios. The exposure was ID status, and the outcomes were (1) unplanned ACSC hospital admission, (2) death with an ACSC condition listed as the main cause on the death certificate and (3) death with an ACSC condition listed as one of the causes on the death certificate. Adults with ID under the age of 55 had only a slightly higher risk of an unplanned ACSC hospitalisation than their general population counterparts (standardised incidence ratio 1.11; 95% CI 1.03 to 1.20). After adjusting for different ACSC prevalence in ID and non-ID cohorts, this difference in risk disappeared. These findings contrast with existing evidence from England, where a much higher unadjusted risk of unplanned ACSC hospitalisations was found among people with ID. Adults with ID had a higher risk of dying due to ACSC than adults without ID (standardised mortality ratio 2.54; 95% CI 2.19 to 2.95). Our findings on unplanned ACSC hospitalisations suggest that the primary care system in Scotland appears to be similarly effective for adults with ID than for adults without ID. However, the higher risk of dying from ACSC among people with ID suggests that this system is less effective for people with ID. Future research should investigate this tension and aim to understand why the operation of the primary healthcare system seems to be worse with regards to ACSC mortality than with regards to unplanned ACSC hospitalisations.

To explore the effects of bidirectional interoperability between electronic health records (EHR) and smart infusion pumps on medication errors (MEs), system compliance and workflow efficiency and economic aspects. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 criteria. The literature search on Scopus, MEDLINE (Ovid), Web of Science, Cumulated Index in Nursing and Allied Health Literature, and Evidence-Based Medicine Reviews was conducted on 3 October 2024. Peer-reviewed studies considering bidirectional interoperability between EHR and smart pumps in hospitals were included. Study selection according to a predetermined Population, Intervention, Comparison(s) and Outcome tool, data extraction and evidence quality assessment (Joanna Briggs Institute critical appraisal tool assessment and the Grading of Recommendations Assessment, Development and Evaluation approach) were carried out by two individual reviewers. Seven studies from the USA, published between 2011 and 2024, were included. The studies used variable designs to compare the effects of bidirectional interoperability between smart infusion pumps and EHR on system compliance and workflow efficiency (n=6 studies), MEs (n=3) and economic outcomes (n=2) before and after implementation. The observed effects were mainly positive; however, evidence quality was low because of the observational nature of studies. The interoperability between EHR systems and smart infusion pumps remains a relatively novel research topic. Evidence is geographically concentrated, limiting its generalisability to different healthcare systems, regulatory environments and technology adoption patterns. While bidirectional interoperability may reduce MEs, improve system compliance and workflow efficiency and enhance hospitals' charging accuracy of provided care, future studies should prioritise controlled designs, robust data and economic outcomes to justify the investment. CRD42024538518.

Digital health apps and patient portals are proposed as part of the drive from 'analogue to digital' care for the National Health Service (NHS) 10-Year Plan. Without mitigation strategies, digital inequalities could arise as a result, and more evidence is needed to understand how to mitigate this. As part of an equality impact assessment, a retrospective cross-sectional analysis was conducted examining patient portal activation among patients invited to outpatient appointments at two large south-east London Hospital Trusts between 1 May and 1 November 2024. Of the 503&#x2009;688 patients invited to attend outpatient clinics during the study period, 52.7% had activated the patient portal. Availability of email contact details was the strongest determinant of onboarding likelihood (OR 10.86). Multivariate logistic regression models showed that the following groups were less likely to activate the patient portal: men (OR 0.84), individuals at the extremes of age (71-80 or 11-20 years), those of mixed or undefined ethnicity (OR 0.58), those of black ethnicity (OR 0.62) and those with the highest degree of socioeconomic deprivation (Index of Multiple Deprivation group 1; OR 0.68). This large-scale roll-out of a digital health portal provides empirical evidence of factors that drive digital inequalities for patients of two major London NHS Trusts. The observed disparities across demographic and socioeconomic dimensions and simple reliable digital contact mechanisms highlight the risk that digital healthcare initiatives may inadvertently produce new types of inequalities.

Early breast cancer (BC) detection enhances survival, with treatment options influenced by cancer stage, pathological characteristics and patient preferences. Patient decision aids (PDAs) promote shared decision-making (SDM), enhancing patients' engagement, adherence to treatment and satisfaction. However, few PDAs for early-stage BC patients exist in the Italian context. A first developmental phase will include a systematic review on current PDAs and semistructured interviews with patients and healthcare professionals. Outcomes will be used to develop a first draft of PDA. Following international guidelines, the PDA will be sent to patients to gather first qualitative feedback and subsequently quantitative feedback regarding the attractiveness, usability and comprehensibility of the tool and patients' health literacy. Once having reached a final version of PDA, a pilot randomised controlled trial study will be implemented: a control group will receive standard care (n=75) and an experimental group (n=75) will receive standard care and the PDA. Depression, anxiety, SDM, quality of life (QoL) and distress levels will be assessed through validated questionnaires in both groups at three different time points. Measures will include attractiveness, usability and comprehensibility of the PDA as well as efficacy measures assessed through evaluation of patients' levels of anxiety, depression, distress and QoL. This protocol was approved by the ethical committee Comitato Etico Territoriale Lombardia 2 of the Istituto di Ricovero e Cura a Carattere Scientifico European Institute of Oncology (L2-253; approved in November 2024). All participants will be given written and verbal information, and informed consent will be obtained from all participants across all phases of our project. Participation in the study will be fully voluntary. All the methodologies mentioned in this protocol will be carried out according to both national and international declarations, guidelines and regulations compliant with proper ethical research involving human subjects. Results will be published in peer-reviewed journals, through traditional academic pathways. This protocol study has been registered on clinicaltrials.gov in January 2025 (Identifier: NCT06762496). NCT06762496.

This study addresses the existing ambiguity in available definitions of clinical informatician, a challenge that complicates academic literature and practical applications in healthcare. The objective of the study is 'How can the role of clinical informaticians be clearly defined to resolve existing ambiguities and support their evolving function within healthcare systems?' Employing a six-step concept definition process, this research synthesises existing literature and expert feedback to develop a comprehensive definition. Through analysing publicly available academic and practitioner literature and 21 semistructured interviews with experts working in clinical informatics, a definition of clinical informaticians is derived. This study derives a formal definition of clinical informaticians: clinical informaticians leverage their dual expertise in technical and clinical domains to optimise health information technologies and data, and their use to enhance patient care across the healthcare system. This refined definition clarifies the professional boundaries and offers a framework for future role development in a rapidly evolving healthcare landscape.

To evaluate the efficacy of a clinical decision support system (CDSS) on stroke care quality and clinical outcomes among patients with acute ischaemic stroke. Multicentre, cluster randomised clinical trial. 77 hospitals across China. 77 hospitals (38 randomised to intervention group, 39 to control group) enrolled 21&#x2009;603 patients with acute ischaemic stroke admitted to hospital within seven days after symptom onset. Hospitals in the intervention group received stroke CDSS support including artificial intelligence assisted imaging analysis, classification of stroke causes, and evidence based treatment recommendations. Hospitals in the control group provided usual care. The primary outcome was a new vascular event (composite of ischaemic stroke, haemorrhagic stroke, myocardial infarction, and vascular death) within three months after initial symptom onset. Secondary outcomes included the composite measure and all-or-none measure of evidence based performance measures for acute ischaemic stroke care quality, a new vascular event at six and 12 months, and disability (modified Rankin Scale score 3-6) and all cause mortality at three, six, and 12 months. Safety outcomes were moderate or severe bleeding events and all bleeding events at three, six, and 12 months. 11&#x2009;054 patients in the intervention group and 10&#x2009;549 patients in the control group were enrolled from January 2021 to June 2023. New vascular events at three months occurred in 2.9% (320/11&#x2009;054) in the intervention group compared with 3.9% (416/10&#x2009;549) in the control group (adjusted hazard ratio 0.74, 95% confidence interval (CI) 0.58 to 0.93, P=0.01). The CDSS intervention effect remained significant in the cluster level analysis (-0.01, -0.02 to -0.004, P=0.003). Patients in the intervention group were more likely to have a higher composite measure (91.4% (77&#x2009;049/84&#x2009;276) v 89.8% (70&#x2009;794/78&#x2009;834), adjusted odds ratio 1.21, 95% CI 1.17 to 1.26, P<0.001). New vascular events were significantly lower in the intervention group at 12 months (4.0% (440/11&#x2009;054) v 5.5% (576/10&#x2009;549), adjusted hazard ratio 0.73, 95% CI 0.56 to 0.95, P=0.02). No significant differences were found in disability and all cause mortality. Moderate or severe bleeding, and all bleeding did not differ significantly between the two groups. Use of the stroke CDSS in patients with acute ischaemic stroke in China led to a significant decrease in new vascular events at three months. The stroke CDSS intervention was also effective in improving stroke care quality and decreasing long term vascular events. ClinicalTrials.gov NCT04524624.

The length of hospital stay for patients with physical illnesses is longer for those with mental health comorbidity, particularly in the presence of severe physical multimorbidity. Integrating psychosocial risk screening at hospital admission, with a subsequent care pathway, could address psychosomatic and social care needs early and reduce length of stay. However, implementation may be hindered by organisational factors such as increased staff workload and timely integration into existing processes. In addition, patient factors such as low acceptance of screening and follow-up may affect uptake. This pilot study aims to assess the feasibility of implementing this integrated approach to screening and follow-up in preparation for a confirmatory trial. The present study is a single centre, randomised feasibility study conducted on a pilot ward. Patients will be enrolled and assigned to the intervention or the control group. Only the intervention group will receive tablet-based psychosocial risk screening conducted by ward physicians or medical students in their practical year. If the psychosomatic screening is positive and the patient agrees, he or she is referred to the psychosomatic consultation service. If the social service screening is positive, the patient will be seen by a social worker. The main objective of this study is to assess the feasibility of conducting a full-sized confirmatory trial. An informed consent rate of 30% of eligible patients is set as the feasibility criterion. A study period of 4&#x2009;months is planned for the feasibility study. The feasibility study will be analysed using descriptive statistics. The study protocol was approved by the Ethics Committee of the Medical Faculty of Heidelberg University (S-301/2024) on 24 May 2024. The results of this feasibility study will be published in a peer-reviewed journal. NCT06651164.