In the UK, a range of services provide same day, urgent and emergency care (UEC). Urgent medical needs can be addressed through pharmacy services, same day general practice (GP) appointments, phone or online triage services, out-of-hours GP appointments and urgent treatment centres (or equivalents). For emergency medical needs, patients can access emergency departments (EDs) and ambulance services. These services are highly vulnerable to excessive strain due to rising, unpredictable demand and limitations in patient flow across the system. The workforce operates in time-critical situations, often with limited resources, which can lead to staff burnout, low job satisfaction and retention and poor health. The organisation of services and their workforce continues to evolve in response to local and national pressures and varies considerably across the UK, where there are four distinct, publicly funded healthcare systems managed separately in each country. This makes it difficult to describe and compare services within and across regions and understand the impact of workforce organisation on service delivery, staff well-being and patient care. This study aims to develop a comprehensive understanding of the range and types of UK UEC services, the relative experiences of the workforce and the available workforce data. This mixed-methods study includes two components, integrated through an explanatory sequential design. Study 1 will use data on NHS service availability and direct enquiry to map UEC services and populate a structured database, which will facilitate the generation of a UEC typology of the range and types of services and regional variation across the UK. Multiple case studies will be conducted in a subset of services using qualitative interviews (n=136-220) with service leaders (n=3-5), workforce (n=10-12), and patients or carers (n=4-5), as well as document analysis where relevant, in each service of interest (n=8-10). Study 2 will create a metadata catalogue of workforce data and produce descriptive summaries of key metrics (eg, staffing levels and skill mix). The study will be supported by our Community Inclusion and Engagement (CIE) panel and Patient and Public Advisory Group (PPAG) to ensure relevance, inclusivity and impact. This study received ethical approval from Yorkshire and The Humber - Sheffield Research Ethics Committee (04/08/2025, IRAS ID: 357276, REC Reference: 25/YH/0125) and HRA and Health and Care Research Wales approval (12/08/2025). Data collection poses minimal risk, informed consent will be obtained, and participants may withdraw at any time. Dissemination will follow knowledge mobilisation principles to maximise impact. We will build on our existing networks and work with our CIE panel and PPAG to tailor study outputs to different audiences. The outputs will improve understanding of the variation in how UEC services and workforces are organised across the UK, as well as the type and format of available workforce data, and provide benchmarks for future research. Research Registry (REF: researchregistry11555; https://www.researchregistry.com/register-now/%23home/registrationdetails/68d402672341e502cd0ce888/).
Digital health tools, particularly patient portals, can support caregiving, but there is limited understanding of how sociodemographic and geographic factors influence digital health engagement among U.S. caregivers, especially dementia caregivers. Dementia caregiving involves complex coordination, medication management, and frequent healthcare interactions. Therefore, access to online medical records is particularly valuable. Moreover, most previous research focuses on general digital health adoption or patient portal use among patients, not caregivers, particularly among dementia caregivers, and rarely considers geographic differences or the interaction effects between age and caregivers' self-rated health. Comparing dementia caregivers to those without is essential because dementia caregiving entails more extensive care, longer duration, behavioral challenges, and emotional strain. These factors may increase reliance on digital health tools like online medical records. However, national studies often do not distinguish between dementia and non-dementia caregiving in digital health analyses. This study explored how sociodemographic and geographic factors are associated with caregivers' frequency of accessing care recipients' online medical records, especially for caregivers of individuals living with dementia compared to those caregivers of individuals without dementia. We also evaluated the interaction effect between age and health condition, motivated by the hypothesis that digital engagement is influenced not only by age but also by functional health status. This study examined caregivers' portal access frequency using data from the 2022 National Health Interview Survey, collected between March 7th and November 8th, 2022. Descriptive statistics captured differences in access frequency and sociodemographic characteristics between dementia caregivers and non-dementia caregivers. Three ordered logistic regression models examined predictors of accessing online medical records for dementia caregivers, non-dementia caregivers, and all caregivers, followed by an all-caregiver model with interaction terms to assess moderation effects between caregiver age and self-reported health. ArcGIS Pro was adopted to visually capture the geographic regional divide in portal access frequency across the U.S. Of the 6,252 total responses, 916 caregivers provided data on portal access frequency. More than half of dementia caregivers (60.25%) and non-dementia caregivers (51.11%) did not access online medical records in the past 12 months. Frequent access (≥ 10 times/year) was low across both groups (dementia caregivers (7.03%) vs. non-dementia caregivers (12.66%)). Survey-weighted ordered logistic regression models identified significant sociodemographic and geographic disparities in portal access frequency. Being female (OR = 1.931, SE: 0.074), having a bachelor's degree (OR = 1.769, SE: 0.168), and being married (OR = 1.749, SE: 0.068) were associated with higher portal access frequency in the all-caregivers model, and similar results were found in dementia caregivers and non-dementia caregivers. Regarding geographic disparities, dementia caregivers residing in micropolitan areas had substantially lower odds of frequent portal access than those in metropolitan areas (OR = 0.633, SE: 0.071); a similar trend was observed among dementia and non-dementia caregivers. Rural residence was also associated with lower portal access among dementia caregivers (OR = 0.529, SE: 0.152) and non-dementia caregivers (OR = 0.654, SE: 0.097). In the all-caregiver sample, caregivers in small-town areas (OR = 0.522, SE: 0.071) had lower odds of portal access compared to metropolitan caregivers. Health status showed differential patterns across caregiving groups. Among dementia caregivers, reporting very good health (vs. excellent) was associated with lower odds of portal access (OR = 0.268, SE: 0.023), whereas among non-dementia caregivers, very good health was associated with higher portal access (OR = 1.246, SE: 0.062). Good or fair health was associated with lower portal access across all caregiver groups. Interaction analysis revealed that as caregiver age increased, those in poor health had a significantly lower portal access frequency. Accessing online medical records among family caregivers remains limited and varies notably by gender, educational attainment, geographic location, and the interaction between age and health status. These findings highlight the importance of developing tailored digital support strategies that address the intersecting socioeconomic and health-related barriers faced by caregivers, particularly as artificial intelligence-enabled tools become more prevalent in dementia care. Older caregivers in poor health are especially unlikely to adopt digital resources, underscoring the urgent need for targeted outreach and educational initiatives. Additionally, the persistent geographic digital divide among dementia caregivers, especially those in small towns, calls for increased support to promote equitable access to caregiving technologies. This study conducted a secondary data analysis, so trial registration is NOT required because it does not run a prospective randomized trial. And Institutional Review Board approval is also not needed because the dataset is de-identified and public.
The number of older people in Germany has risen steadily in recent decades. One in four people is now aged 65 or over. As people age, their health problems tend to increase, as do their fundamental care needs. Nurses play a key role in addressing these needs through a holistic approach. To fulfil this responsibility effectively, it is necessary to examine existing nursing research on the fundamentals of care for older people and to identify gaps in the current evidence base. Therefore, we plan to conduct a mapping review with the aim of mapping the extent, range and nature of nursing research activities on the fundamentals of care, as defined in the physical, psychosocial and relational components of the Integration of Care dimension of the Fundamentals of Care Framework for older people in Germany. We will search the electronic databases PubMed/MEDLINE, CINAHL, CareLit and GeroLit, the catalogue of the German Federal Ministry of Research, Technology and Space and the German National Library for publications on nursing research based on the Integration of Care dimension of the Fundamentals of Care Framework among older people (≥ 65 years). There will be no time limit. We will include studies published in English and German. Initial screening of the first ten per cent of titles and abstracts and other stages will be carried out by two independent researchers. This process will be repeated until full agreement between the researchers. Any discrepancies will be resolved with consultation of a third reviewer. Results will be reported in a narrative synthesis and complemented by tabular and numerical presentations. To the best of our knowledge, this mapping review will be the first to provide an overview of current nursing research on the fundamentals of care for older people in Germany. The inclusion of German-language texts and the absence of time limits in this review are intended to complement previous reviews. The planned mapping review will also identify the evidence gap in research in this area and contribute to the determination of future scientific research in Germany. Consequently, the findings of the mapping review could be of great interest to nurses and other health professionals for evidence-based practice, research and educational programmes. In addition, the data can be used to develop a programme for the provision of age-friendly and caring living conditions for older people in the future. The protocol was registered with Open Science Framework (osf.io/9e3uv).
Homelessness is a significant issue in the context of violence, particularly for Indigenous women in settler colonial countries, as are the long-lasting impacts of violence such as traumatic brain injury (TBI) including concussion. Understanding of the relationship between homelessness and healthcare access for TBI from violence among Indigenous women is critical for informing service delivery; however, research in this area remains limited. Situated within the broader experiences of accessing healthcare following violence-related TBI, this study aimed to explore the relational dynamics between violence, homelessness, healthcare access, and the implications for long term recovery and wellbeing. Using purposive and snowball sampling, semi-structured interviews and focus groups were completed with 18 Indigenous women who have experienced TBI from violence, 28 community members, and 90 community-based frontline workers to gather insights into the experiences of living with TBI family violence or supporting someone with this injury. All data were transcribed verbatim and analyzed using thematic analysis. Two themes were identified regarding how responses to family violence-related homelessness created barriers for Indigenous women to access healthcare for TBI: (1) Housing service barriers affect access to healthcare and TBI management, and (2) The (in)visibility of TBI within crisis accommodation and housing services. The dominant experience for Indigenous women who had experienced violence and homelessness was characterized by complexity, uncertainty, and distress, largely due to service delays and barriers encountered across housing pathways. Some Indigenous women were required to relocate away from their home region to secure temporary accommodation. While crisis accommodation services were widely viewed as places of safety, many did not consider TBI in environmental design or service delivery. Multi-agency case management and outreach were identified as valuable approaches for improving healthcare access. The findings illustrate the importance of TBI-informed policy and practice within housing and homelessness services, especially for Indigenous women in rural and remote regions, alongside strengthened workforce training. Stronger linkages between women's shelters, housing services, and healthcare systems - including concussion clinics - are critical for supporting both immediate and long-term care. Needs-based funding is required to ensure regional and remote housing systems can support women-led responses, including more streamlined transitions from crisis or short-term accommodation to secure housing.
Peer support workers (PSWs) provide support to others through their personal lived experiences of mental health. However, their work is often undervalued by their colleagues, and they frequently face challenges in the workplace, resulting in occupational stigma. Currently, there are limited insights into how PSWs experience and manage the stigma they face. Therefore, this study examines how PSWs in the UK National Health Service experience and navigate occupational stigma in their roles. Seventy semi-structured interviews were conducted with PSWs and their colleagues. Interviews explored their experiences in the role, workplace interactions, and subsequently perceptions and experiences of stigma, and how they dealt with stigmatising experiences. The data were analysed using thematic analysis to identify how stigma manifested and how they navigated it. PSWs reported experiencing stigma both covertly and explicitly. Covert stigma included subtle devaluation of their knowledge and exclusion from decision-making, while explicit stigma involved direct questioning of competence and disrespectful behaviour from colleagues. In response, PSWs navigated stigma through three main strategies. First, they demonstrated commitment to their role via reliability, dedication, and consistent performance, reinforcing the value of their work. Second, PSWs leveraged experiential knowledge as expertise, emphasising practical skills and lived experience in patient care. Third, they used their roles to create reciprocal benefits, where they supported service-users, which in turn helped their own mental health and recovery. Occupational stigma towards PSWs is pervasive, manifesting in both subtle and overt ways that can undermine their role. PSWs actively counter stigma through commitment, expertise, and reciprocal relationships, highlighting their resilience and adaptability. Addressing stigma in healthcare settings is critical for improving team dynamics and ensuring high-quality care. Going forward to support the role, policymakers and organisations that employ PSWs should focus on improving organisational culture, recognition of the role, and collaborative practices to reduce stigma, strengthen workforce sustainability and recognise the value of lived experience in the workforce.
The utilization of breast and cervical cancer screening services among women remains low in Turkiye, despite their importance for early diagnosis. Therefore, this study examines the influences of financial and physical barriers in accessing healthcare and socio-economic and demographic factors on Turkish women's participation in mammography and Pap smear screenings. The microdata from the Turkey Health Survey (TSA) conducted by the Turkish Statistical Institute (TURKSTAT) in 2014, 2016, 2019, and 2022 were pooled. A total of 26,931 women aged 35 and over were included. To analyze the factors affecting the likelihood of undergoing mammography and Pap smear tests, separate binary logistic regression (logit) models were estimated for each dependent variable. In the first stage, the effects of the variables were reported as odds ratios, and in the second stage, average marginal effects (AME) were calculated and presented through graphs. Participation rates were 43.73% for breast cancer screening and 43.06% for cervical cancer screening. 20% of women faced financial barriers in accessing healthcare services, while 34% faced physical barriers. Encountering financial barriers, education and income levels, having access to a physician, and performing self-breast examinations were related to the level of mammography and Pap smear screening. To increase the effectiveness of screening programs, health policies must prioritize reducing financial barriers, promoting healthy behaviors, and improving physician services. Furthermore, strengthening the role of primary care services in this regard would also be a significant contribution. Not applicable.
To examine rural-urban disparities in telehealth utilization during the post-pandemic period and assess whether these disparities persist after adjusting for individual-level characteristics. We used multivariable logistic regression and propensity score matching to estimate differences in telehealth use by rurality and examined self-reported reasons for non-use. We analyzed 2022 and 2024 Health Information National Trends Survey (HINTS) data, a nationally representative survey of noninstitutionalized US adults. The analytic sample included 11,106 respondents after excluding missing observations. Overall, 38.7% of adults reported telehealth use in the past 12 months. After adjusting for covariates, rural residents were significantly less likely to use telehealth than urban core residents; remote rural residence was associated with a 10-percentage point lower probability (95% CI, -16.2 to -2.8; p < 0.01). Propensity score analyses yielded similar results (-7.7% points; 95% CI, -16.2 to -2.8; p < 0.01). Among non-users, rural respondents were more likely to report not being offered telehealth. We observed significant rural-urban disparities in telehealth use in the post-pandemic period. Rural non-users were more likely to report not being offered telehealth, indicating delivery-side barriers.
Healthcare systems operate within a VUCA (Volatile, Uncertain, Complex, and Ambiguous) environment, shaped by economic, demographic, and systemic transformations. These rapid and unpredictable changes create ethical challenges, resource constraints, and heightened emotional and moral distress for healthcare professionals. The increasing complexity of care delivery, shifting institutional priorities, and external pressures contribute to moral injury, impacting professionals' ability to provide patient-centered care while maintaining their ethical and professional integrity. This qualitative study aimed to explore how healthcare professionals experience and cope with moral injury in a VUCA healthcare ecosystem. Through 35 semi-structured interviews, the study explores how healthcare professionals experience and cope with moral injury in such a dynamic healthcare ecosystem. The research uses an abductive analysis guided by the VUCA framework to examine the systemic roots of moral conflict. The analysis identified six themes highlighting how instability, unpredictability, ambiguity, and systemic overload shape clinical decision-making, emotional burden, and ethical distress. Participants described moral injury as emerging from the misalignment between professional values and institutional demands, intensified by resource shortages, role ambiguity, and crisis normalization. These pressures affect professionals' well-being, compromise ethical integrity, and contribute to long-term psychological consequences. The findings emphasize the need to move beyond individual-level resilience strategies and focus on systemic reforms. Strengthening institutional support structures-including ethical leadership, reflective spaces, and alignment between organizational policy and professional ethics-is essential for protecting both clinicians' integrity and care quality in today's complex healthcare landscape.
Type 2 diabetes mellitus (T2DM) and degenerative or mechanical spinal disorders frequently co-occur and amplify one another's clinical and socioeconomic burden. T2DM has been associated with greater pain severity, prolonged disability, and higher reported risks of surgery and opioid use, although the underlying mechanisms remain hypothesized rather than established. In South Korea's dual healthcare system, patients may access both Western medicine (WM) and Korean medicine (KM), yet national-level evidence on spine-T2DM multimorbidity care patterns is limited. This study examined 10-year healthcare utilization, expenditures, and medication use among patients with coexisting T2DM and degenerative or mechanical spinal disorders. We conducted a retrospective study using the Health Insurance Review and Assessment Service-National Patient Sample (HIRA-NPS) from 2010 to 2019. Patients with both T2DM (E11) and at least one degenerative spinal diagnosis (M47, M48, M51, M54, S33) were included. KM users were defined as those with ≥ 1 KM claim per year. Outcomes included annual claim counts, expenditures, service categories, medication use, and facility type. Annual percent change (APC) was estimated using log-linear regression, and baseline characteristics were compared using standardized mean differences (SMDs). A total of 188,716 patients generated 9,590,400 claims over 10 years; 62.9% were KM users. KM users were more often female and slightly older; back pain (M54) showed the largest imbalance (SMD = 0.26). Total claims increased from 715,279 (2010) to 1,157,475 (2019). KM users had substantially more annual claims; yet per-patient expenditures were similar, reflecting reliance on lower-cost outpatient KM services, notably acupuncture. Medication use peaked in 2012 and declined thereafter following national drug pricing reforms. Non-users received fewer but higher-cost prescriptions, particularly for pain and inflammatory medications. Adults with coexisting T2DM and degenerative spinal disorders demonstrate increasing and complex healthcare needs driven primarily by chronic pain rather than glycemic management alone. KM users engage in high-frequency, multimodal outpatient care at lower unit cost, whereas non-users rely more heavily on tertiary WM services and higher-cost pharmaceuticals. Korea's dual healthcare system appears to support differentiated care pathways in this multimorbidity population. Findings underscore the need for integrated, longitudinal chronic care models that combine conservative pain management with diabetes care to reduce disability and long-term healthcare burden.
Men with obesity infrequently engage with weight management services. To determine: (1) percentage weight loss at 12 and 24 months for text messages with or without financial incentives compared to control; (2) secondary outcomes; (3) cost-effectiveness; (4) moderators of effectiveness and (5) participant and stakeholder perspectives. Assessor-blinded randomised controlled trial. United Kingdom National Health Service perspective cost-effectiveness over 24 months and modelled lifetime horizon. Mixed-methods process evaluation. Five hundred and eighty-five men with body mass index ≥ 30 kg/m2 enrolled (July 2021-May 2022) in Belfast, Bristol and Glasgow; final follow-up June 2024. Random allocation to 12 months of behavioural text messages plus financial incentives (N = 196), same texts alone (N = 194) or 12-month waiting list control group offered 3 months of texts between 12 and 15 months (N = 195). A £400 financial incentive was lost if weight loss targets were not met. Weight change as a percentage of baseline weight at 12 and 24 months comparing control with (1) texts with financial incentives and (2) texts alone. Of 585 men (mean age 51 years; mean weight: 119 kg), 227 (39%) lived in lower socioeconomic areas, 146 (25%) reported a mental health condition and 253 (40%) had multiple long-term conditions. Follow-up was completed by 426 (73%) at 12 months and 377 (64%) at 24 months. At 12 months, mean percentage weight changes (standard deviation) were -4.8% (6.1) (-5.7 kg), -2.7% (6.3) (-3.0 kg), and - 1.3% (5.5) (-1.5 kg) for the incentives, text-only, and control groups, respectively. Compared to control, weight loss was significantly greater with incentives [-3.2% (97.5% confidence interval -4.6 to -1.9; p < 0.001)] but not texts alone (-1.4%; confidence interval -2.9 to 0.0; p = 0.053). At 24 months, changes were -3.9% (-4.6 kg), -2.6% (-3.1 kg), and -2.2% (-2.6 kg), no significant between-group differences. Intervention costs were £243 for texts with incentives, £110 for texts alone. There were no significant differences between 24-month costs and quality-adjusted life-years. Long-term modelling found texts with incentives versus control were: quality-adjusted life-year difference (95% confidence interval): 0.02 (0.007 to 0.029); cost difference: £176 (£43; £311); incremental cost-effectiveness ratio: £9748 (£7705 to £11,791). For texts alone versus control: quality-adjusted life-year difference: 0.03 (0.015 to 0.037); cost difference: £16.5 (-£117; £152); incremental cost-effectiveness ratio: £628 (-£5914 to £5384). There were no moderator effects for socioeconomic, health or well-being status for either comparison versus control. The texts with incentives group had a higher engagement in weight goal setting, food changes, self-weighing, confidence, satisfaction and quality of life compared to the control. Generalisability to women, diverse ethnic groups and people with low literacy is uncertain. Not generalisable to people with no mobile phone access. Retention was lowest in the text messages alone group. Texts with financial incentives have a modest but important effect to 12 months with clinically relevant weight loss maintenance to 24 months, are cost-effective and equally effective regardless of socioeconomic or health characteristics. Implementation, adapt for women, other cultures and longer-term follow-up. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129703. The Game of Stones study aimed to help men lose weight and keep it off for at least 2 years. Five hundred and eighty-five men living with obesity across the United Kingdom were split into three groups by chance: supportive text messages for 1 year and opportunity to get money for weight loss the same text messages alone for 1 year neither for 1 year, then text messages for 3 months. The first two groups received the same daily text messages about changing weight-related behaviours. Group 1 was told at the start that £400 had been put aside for them and that money would be lost if weight targets were missed. The targets were 5% weight loss at 3 months, 10% at 6 months and maintaining that 10% loss at 12 months. Money was then paid to the men after being weighed at 12 months. Every man was asked questions about their health, well-being and experiences of being in the study. After 1 year, the men in group 1 lost the most weight (5%, 5.7 kg). The men in group 2 lost some weight (3%, 3.0 kg) but not as much as the first group. The men in group 3 lost the smallest amount of weight (1%, 1.5 kg). On average, men in group 1 received £128 for meeting weight loss targets. One year after the 12-month measures, men in groups 1 and 2 had gained back some weight. Men in group 3 lost a bit more weight between year 1 and 2. Weight loss was similar whether or not men had long-term health conditions, disability, mental health issues or lived in the most deprived areas. This study showed that Game of Stones was a popular, low-cost and modestly effective way of helping men to lose weight.
To co-develop the Stay-At-Work (SAW) intervention, a person-centred, interdisciplinary, cross-sectoral vocational rehabilitation (VR) programme for individuals on, or at risk of, sick leave due to chronic low back pain (CLBP) and to advance methodological understanding of how evidence, qualitative insights, stakeholder input and programme theory can be systematically integrated and operationalised into concrete intervention components. A three-stage intervention development study, guided by the Medical Research Council framework for complex interventions, involving evidence review and stakeholder consultation (previously reported); multistakeholder co-design; and prototyping in clinical settings. The intervention was developed within a Danish public healthcare and welfare context, involving a secondary care spinal service, municipal employment services (n=3), municipal rehabilitation services (n=3) and general practice. Stage 1: 17 individuals on long-term sick leave due to CLBP participated in interviews and focus groups. Stages 2 and 3: The co-design group included individuals living with CLBP (n=2); clinicians from a secondary care spine service (n=2) and municipal rehabilitation services (n=6); general practitioners (n=2); municipal employment service professionals (n=3) and local managers (n=3); and employer and employee representatives (n=2). Participants were purposively recruited based on their roles and experience in VR and return-to-work processes and contributed across different stages of intervention development. The SAW intervention consists of eight structured activities, developed through multistakeholder co-design and underpinned by a programme theory with four core mechanisms: (1) strengthened interprofessional and cross-sectoral understanding and collaboration; (2) stronger alignment around functional capacity and work ability; (3) addressing psychological vulnerability through systematic screening and support; and (4) enhanced coordination of care and rehabilitation efforts across services.Stakeholder input from the co-design group informed the intervention's content and procedures, thereby improving alignment with local contexts and strengthening cross-sector collaboration. Some proposals were excluded due to inconsistency with clinical guidelines. This study demonstrates how a structured, theory-informed co-development process can be used to integrate evidence, stakeholder input and programme theory into a coherent, cross-sectoral VR intervention. The approach enhanced transparency, supported alignment with real-world practice, and provides methodological insight to strengthen the reproducibility and transferability of complex interventions.Registration number: The Region of Southern Denmark's Research Registry (journal no. 23/44927).
This study aimed to co-design a tailored model of care for older people with long COVID. Using a human-centred design approach, semistructured interviews were conducted with patients and health professionals from a long COVID service to explore their experiences. Insights were further developed during a co-design workshop involving patients, health professionals and community members who identified as older people and who had experience with chronic illness. Key themes were identified and used to map an ideal patient journey and inform the final model of care. Long COVID outpatient service in a tertiary hospital in Adelaide, South Australia. Four patients and four health professionals participated in the interviews. The workshop included four patients, five health professionals and seven community members. The co-design process identified challenges experienced by people with long COVID, including lack of validation, delayed multidisciplinary care, mental health deterioration and difficulties navigating the healthcare system. These challenges were described as having particular relevance for older adults. In response, a model of care was developed focused on comprehensive assessment, coordinated multidisciplinary care, education for self-management, mental health support and opportunities for research participation. A comprehensive and adaptable model of care is needed to address the complex and multifaceted nature of long COVID. This human-centred design approach ensured the model was grounded in lived experience, clinically informed and aligned with patient priorities. While not unique to older adults, the findings highlight areas that may require particular attention in this population, including care coordination, validation and support for comorbidities and social vulnerabilities. While developed in a single tertiary service, these principles may inform the design of services for similar populations in other healthcare settings.
Hospitalizations among older adults differ by dementia status, gender, and living arrangements. Understanding these differences, particularly in advanced age (age 85 and above), can inform appropriate healthcare strategies. Using health claims data for Germany, we followed the 1918 to 1923 birth cohort (n = 4,065 men and 13,302 women), who reached age 85 between 2004 and 2009 until death or age 95. Two-level mixed-effects linear probability models with repeated observations were conducted, adjusting for age, gender, dementia status, nursing home residency, dependency on long-term care, comorbidities, and quarter of death. Men consistently exhibited higher probabilities of hospitalization compared to women, and individuals with dementia (PwD) had a greater probability of hospitalization than those without dementia (non-PwD). Specifically, when compared to male non-PwD, the probability of hospitalization increased by 0.10 (p ≤ 0.001) for male PwD; female non-PwD demonstrated a 0.02 (p ≤ 0.001) lower probability of hospitalization, while female PwD had an increased probability of 0.06 (p ≤ 0.001). Hospitalization probabilities increased with age among non-PwD (men: +0.052 from p85=0.14 [95%CI = 0.13-0.14] to p95=0.19 [95%CI = 0.18-0.20]), women: +0.021 from p85=0.12 [95%CI = 0.12-0.13] to p95=0.14 [95%CI = 0.14-0.15]), remained almost stable among male PwD (+ 0.018 from p85=0. 24 [95%CI = 0.23-0.26] to p95=0.26 [95%CI = 0.24-0.28]), but declined among female PwD (-0.023 from p85=0.22 [95%CI = 0.21-0.22] to p95=0.20 [95%CI = 0.19-0.20). The quarter of death strongly elevated hospitalization probabilities for all groups, though less so among women with dementia who had a lower probability than women without dementia (-0.04; pnon-PwD=0.58 [0.58-0.59], pPwD=0.54 [0.53-0.55]). Dependence on long-term care significantly reduced hospitalization risk among women, especially those with dementia (-0.5; pno long-term care=0.21 [0.21-0.21], plong-term care =0.16 [0.16-0.17]), but showed no substantial effect for men. Nursing home residency increased hospitalization probabilities mainly for women without dementia (+ 0.02), but slightly decreased probabilities for women with dementia (-0.01). Higher comorbidity was consistently associated with greater hospitalization risk. Gender and dementia status significantly modulate hospitalization risks in advanced age. A gender-sensitive healthcare approach that accounts for dementia status and care needs is crucial for ensuring adequate hospital care in advanced age.
Workforce needs are growing in older people care, exacerbated by the aging population. Technological solutions offer potential means to address this challenge. However, their effects on work and worktime management remain unclear, especially in the setting of assisted living services. Our aim was to assess the potential of two established technologies, automatic medicine dispensing and night-time monitoring, in alleviating workforce needs in Finnish assisted living facilities. The effects of the two technologies on workforce needs were studied using a convergent mixed-methods design, incorporating quantitative time and motion analysis and qualitative analysis of two open-ended survey questions. Linear regression analysis and data-driven thematic analysis were employed. The quantitative and qualitative results were integrated and compared afterward. Our quantitative results indicated that medicine dispensing technology can streamline medicine management and administration, but effects on direct care time were not found. Use of night-time monitoring technology was associated with more direct care during nights and reduced nightly staffing. The qualitative analysis highlighted medicine dispensers freeing up time for other work and night-time monitoring reducing the need for nightly rounds. However, several technology-related problems and a loss of medication competencies were perceived. Our results converged on several positive workforce effects, notably optimizing medication management and promoting individualized care during nights. Technology use could be promoted in assisted living services, when it demonstrably streamlines care work, increases work efficiency, allows for reduced staffing, or promotes individualized and patient-centered care. National care policy can incentivize the use of similar technologies, for example, through staffing level legislation. However, care unit management should prepare for potential technology-related errors and acute emergencies by upkeeping both technology and medication competencies of nurses and ensuring the presence of sufficient staff. Importantly, the potential efficiency gains must not come at the expense of quality or safety of care.
This study aimed to describe and compare patient-reported outcome measures (PROMs) and objective clinical outcome measures (CROMs) in the treatment of age-related macular degeneration (AMD), exploring the concordance between these measures within a value-based healthcare (VBH) framework. This prospective, multicenter, observational, real-world study was conducted at three tertiary referral hospitals specializing in the treatment of neovascular AMD. Clinical outcomes (CROMs) and patient-reported outcomes (PROMs) were analyzed using the National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25) questionnaire as a functional assessment tool. Data were collected at baseline and at three, six, and 12 months following initiation of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy. Statistical analysis was primarily descriptive. The comparison between baseline and 12 months in the global NEI VFQ-25 score was performed using the Wilcoxon signed-rank test for paired samples. Concordance between CROMs and PROMs was assessed using the intraclass correlation coefficient (ICC). A total of 235 eyes were included, receiving 2338 intravitreal injections. The mean age of participants was 81 years (SD = 8.57), and 55.8% were female. The mean baseline NEI VFQ-25 score was 67.83 (SD = 10.39). The median best-corrected visual acuity was 63 ETDRS letters (interquartile range [P25 - P75]: 41 - 75) at baseline, increasing to 65 letters at three months and remaining stable through 12 months of follow-up. The comparison between baseline and 12 months revealed a statistically significant difference in visual acuity (Wilcoxon signed-rank test, Z = 4.2; p < 0.001). A reduction in the proportion of patients classified as legally blind was observed, together with an increase in the proportion of patients in the reading-vision and driving-vision categories. At 12 months, 58.7% of patients reported stabilization or improvement in visual function on the NEI VFQ-25 questionnaire. Concordance between the variation in visual acuity and the variation in the global NEI VFQ-25 score showed good agreement between CROMs and PROMs (ICC = 0.76; p < 0.001). The integrated analysis of CROMs and PROMs suggests that anti-VEGF treatment for neovascular AMD is associated with stabilization or improvement in visual acuity and patients' perceived visual function. The implementation of the VBH-AMD model proved feasible in a real-world clinical setting, reinforcing the importance of integrating patient-centered measures into the evaluation of therapeutic outcomes. Introdução: O objetivo deste estudo foi descrever e comparar os resultados reportados pelos doentes (patient-reported outcome measures, PROM) e os resultados clínicos objetivos (clinical-reported outcome measures, CROM) no tratamento da degenerescência macular da idade (DMI), explorando a concordância entre estas medidas no contexto de um modelo de cuidados de saúde baseados em valor (value-based healthcare, VBH). Métodos: Conduziu-se um estudo prospetivo, multicêntrico e observacional, da prática clínica, realizado em três hospitais terciários de referência no tratamento da neovascularização macular secundária à DMI. Foram analisados os resultados clínicos e os resultados reportados pelos doentes, utilizando o questionário National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25) como instrumento de avaliação funcional. Os dados foram recolhidos no início do tratamento e aos três, seis e 12 meses após o início da terapêutica com injeções intra-vítreas de agentes anti-fator de crescimento endotelial vascular (anti-VEGF). A análise estatística baseou-se em estatística descritiva. A comparação entre o baseline e os 12 meses do score global do NEI VFQ- 25 foi realizada através do teste de Wilcoxon para amostras emparelhadas. A concordância entre os CROM e os PROM foi avaliada através do intraclass correlation coefficient (ICC). Resultados: Foram incluídos 235 olhos, tratados com 2338 injeções intravítreas. Na amostra, a idade média dos participantes foi de 81 anos (DP = 8,57), sendo 55,8% do sexo feminino. Relativamente ao questionário, o score médio na avaliação basal foi de 67,83 (DP = 10,39). A mediana da melhor acuidade visual corrigida foi de 63 letras ETDRS (intervalo interquartil [P25 - P75]: 41 - 75) na baseline, aumentando para 65 letras aos três meses e mantendo-se estável até aos 12 meses de seguimento. A comparação entre a baseline e os 12 meses revelou uma diferença estatisticamente significativa na acuidade visual (Wilcoxon signed-rank test, Z = 4,2; p < 0,001). Observou-se uma redução da proporção de doentes classificados como cegueira legal e um aumento das proporções de doentes nas categorias de visão de leitura e visão de condução. Aos 12 meses, 58,7% dos doentes reportaram estabilização ou melhoria da funcionalidade visual no questionário NEI VFQ-25. A concordância entre a variação da acuidade visual e a variação do score global do NEI VFQ-25 revelou boa concordância entre CROM e PROM (ICC = 0,76; p < 0,001). Conclusão: A análise integrada de CROM e PROM sugere que o tratamento da neovascularização macular secundária à DMI com anti-VEGF se associa a uma estabilização ou melhoria da acuidade visual e da perceção funcional da visão. A implementação do modelo VBH-DMI demonstrou ser aplicável em contexto de prática clínica real, reforçando a importância de integrar medidas centradas no doente na avaliação dos resultados terapêuticos.
Fibromyalgia is a functional syndrome characterized by musculoskeletal pain and a variety of associated symptoms. Previous research has shown that close relatives are at a higher risk of developing the syndrome compared to the general population. Previous findings also suggest that symptoms tend to decrease with age. Our primary objective is to examine whether having a close relative with fibromyalgia is associated with greater symptom severity among patients in primary care. In addition, we assess the relationship between age and symptom severity. The study is based on a cross-sectional design. The data were collected at the Nokia Health Centre, Finland, in 2016. Patients meeting the ACR 2010 criteria were included in this study (n = 91). We used three validated questionnaires to assess disease severity (PSD, FIQ and EQ-VAS) and patient-reported information on fibromyalgia in a close relative. The independent-samples t-test was used to examine the association. Participants were divided into four age groups, and differences in symptom severity between age groups were assessed using one-way analysis of variance (ANOVA). There were no statistically significant differences between family history and symptom severity, nor age groups and symptom severity. Furthermore, there was no statistically significant linear association between age and symptom severity, nor between symptom severity and family history of fibromyalgia. These findings remained unchanged after adjusting for family history. However, given the lack of statistical significance and our small sample size, these observations should be interpreted cautiously. Symptom severity and functional limitations appeared broadly similar across age groups in our sample, which may suggest that increasing age is not necessarily associated with substantial symptom relief. However, these findings should be interpreted with caution given the cross-sectional design and small sample size.
Persistent negative symptoms (PNS) often emerge early in the course of schizophrenia spectrum disorders, significantly impair long-term functional outcomes, and remain difficult to treat, with no consistently effective interventions available. The manifestation of PNS in individuals with first-episode psychosis (FEP) engaged in coordinated specialty care (CSC) in the United States remains largely unknown. This study characterizes negative symptoms in routine clinical care using data from the Early Psychosis Intervention Network's Connection Learning Healthcare System, with a focus on a subcohort of individuals with PNS. Practice-based data were collected every 6 months over a 2-year period from 1289 participants across 23 CSC programs using a Core Assessment Battery (CAB) comprised of clinician-rated and self-report measures. Negative symptoms were quantified across CAB items, allowing for categorization of participants into PNS (n = 79) and non-PNS groups (n = 455). Group comparisons examined outcomes across CAB items, and exploratory mediation analyses focused on the role of engagement in outcomes relative to PNS. Individuals with PNS had higher rates of schizophrenia and lower social and role functioning compared to those in the non-PNS group. Exploratory analyses indicated that service engagement at 6 months mediated the negative relationship between PNS and 12-month social and role functioning. These findings highlight the challenge of PNS in individuals with FEP receiving CSC, the importance of early service engagement, and an opportunity to develop targeted interventions and refine treatment approaches to improve outcomes in this unique subgroup.
The early phase of psychosis is critical for interventions to modify long-term outcomes. It is unclear what proportion of individuals' exhibit early persistent psychosis and the long-term implications. An epidemiologic sample of individuals with acute psychosis was recruited at first admission and followed for 25 years. Early persistent psychosis was defined as presence of active psychosis for ≥90% of the days of the 4 years after first hospitalization for psychosis. Multivariable regression analyses were conducted, testing the association between baseline predictors and persistent psychosis, and between persistent psychosis and 25-year outcomes. Out of 526 individuals (age = 27.4 ± 9.4 years, males = 56.8%, baseline schizophrenia/schizoaffective disorder = 30.0%), 101 (19.2%) had early persistent psychosis. At baseline, low premorbid cognitive performance (odds ratio (OR) = 2.08, 95% CI, 1.05-4.12), lower Global Assessment of Functioning (OR = 1.59, 95% CI, 1.16-2.13), low role function (OR = 1.49, 95% CI, 1.03-2.16) and worse social function (OR = 1.52, 95% CI, 1.03-2.22) were predictive of persistent psychosis. At 25-year follow-up (n = 307, 58.9%), early persistent psychosis was associated with worse avolition ($\beta$=0.25, 95% CI, 0.14-0.35), more severe reality distortion ($\beta$=0.19, 95% CI, 0.07-0.31), disorganization ($\beta$=0.21, 95% CI, 0.09-0.32), worse social ($\beta$=-0.18, 95% CI, -0.06 to -0.30), role ($\beta$=-0.22, 95% CI, -0.09 to -0.34), and global function ($\beta$=-0.28, 95% CI, -0.17 to -0.38), greater odds of being on public assistance (OR = 2.13, 95% CI, 1.15-3.95), lower odds of living independently (OR = 0.43, 95% CI, 0.23-0.80) or recovery (OR = 0.09, 95% CI, 0.02-0.38). One in 5 individuals with first-episode psychosis had early persistent psychosis without clearly modifiable premorbid factors, and with strong associations with adverse long-term outcomes. Individuals experiencing early persistent psychosis require focused long-term interventions.
Adolescents experiencing emotional distress are at increased risk of developing mental health problems, which can negatively impact their academic performance, social relationships and long-term well-being. Schools provide a key setting for implementing preventive interventions that promote emotional and psychological resilience. This study presents the protocol for a randomised controlled trial designed to evaluate the effectiveness of a multicomponent, school-based intervention grounded in emotional intelligence (EI) in improving mental well-being, EI levels and resilience among adolescents aged 14-16 years experiencing emotional distress. The trial will be conducted in public and publicly funded secondary schools in Terrassa, Spain, during the 2025-2026 academic year. Eligible participants will be identified using the short version of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS). The intervention consists of nine 55-minute group sessions delivered during school hours by a nurse and a physiotherapist, supported by the school's psychopedagogue. Sessions focus on emotional regulation, self-esteem, mindfulness, assertiveness and other socio-emotional skills. Assessments will be conducted at baseline, postintervention and 24-week follow-up. The primary outcome is mental well-being (WEMWBS); secondary outcomes include EI (Trait Meta-Mood Scale-24 items) and resilience (Child and Youth Resilience Measure-32 items). It is anticipated that adolescents in the intervention group will show significantly greater improvements in mental well-being, emotional intelligence and resilience compared with the control group, with effects sustained at follow-up. This study will provide evidence on the effectiveness of a scalable, school-based intervention led by community health professionals. The programme could be integrated into educational and public health strategies to promote adolescent mental health and reduce emotional distress. Approved by CEIm Consorci Sanitari de Terrassa (01-24-1CR-102). Low-risk study; predefined procedures are in place for participants at risk (eg, suicidal ideation, abuse) with referral pathways to health/social services. Findings will be disseminated via peer-reviewed publications, conferences and a plain-language summary to schools/stakeholders. NCT06713460.
This study aimed to evaluate the impact of a social prescribing intervention (the Central Locality Integrated Care Service (CLICS)) on unplanned hospital usage in the city of Bradford. A quasi-experimental study applying a dynamic staggered difference-in-differences (DID) analysis on a propensity matched cohort between 2019 and 2023, using data from the Connected Bradford dataset, a pseudonymised linked health dataset on the whole Bradford population. CLICS was delivered within general practices in deprived and ethnically diverse inner-city areas of Bradford, Yorkshire, UK. In total, 1304 CLICS patients were matched to 5216 control patients on key characteristics including ethnicity, deprivation, age, gender and health conditions. A proactive social prescribing intervention that integrates clinical and non-clinical services, including an individualised approach to tailor support based on the patient's needs, both within primary care services and by linking them to appropriate community-based assets/services. The primary outcome was the rate of unplanned hospital admissions and the secondary outcome was unplanned accident and emergency (A&E) attendances. CLICS patients were 2.1% (95% CI -3.8% to -0.4%, p=0.013) less likely to have an unplanned hospital admission and 2.4% (95% CI -4.6% to -0.2%, p=0.03) less likely to have an unplanned A&E attendance compared with the matched control. The DID analysis demonstrated a gradual increase in the association over time. Subanalyses revealed heterogeneity by ethnicity, the reduction in unplanned hospital admissions was observed only in patients of the Pakistani group, whereas the reduction in A&E attendances was statistically significant only in the white British group. The CLICS intervention was associated with a reduction in unplanned hospital usage. Social prescribing may be a valuable component of strategies to reduce health inequalities in unplanned hospital usage.