Takeaway food outlets ('takeaways') sell hot food for consumption off the premises. Takeaway management zones are areas around schools where new takeaways are not allowed to open. They are the most common planning intervention targeting takeaways across local authorities in England to date. We conducted an evaluation of these zones to: model their impact on adult health model their associated economic costs and benefits explore their acceptability and perceived effectiveness among young people investigate support and perceived effectiveness among adults explore barriers to and facilitators of their adoption and implementation among local authority staff. We used a forecast of takeaway growth and a statistical model to estimate the impact of zones on diet-related health outcomes, quality-adjusted life-years and healthcare costs to 2040. We did this for adults aged 25-64 years in six different local authorities. We conducted a linked economic analysis to understand the future costs and benefits of zones to local authorities, the National Health Service and national government. We estimated costs when denial of planning permission results in a 3-, 6- or 12-month vacancy before alternative retail uptake. We asked 46 young people about how acceptable they thought the policy was. By conducting 'go along' interviews, we gained insights into their everyday food habits within and outside the school gates. We used survey data to understand public acceptability and perceived effectiveness of zones. We also asked whether having fewer takeaways near schools could reduce how often young people consume takeaway food. To evaluate adoption and implementation, we interviewed 29 local authority public health and planning officers about what lessons they had learned. Compared to no intervention, future reductions in takeaway exposure ranged from 3 outlets/person in Fenland to 28 outlets/person in Manchester. Obesity prevalence was reduced in both sexes in all local authorities, for example, in Manchester, by 2.3 percentage points for males. We observed reductions in disease incidence, for example, in Manchester, by 964 type II diabetes cases/100,000 males. Zones produced a positive net economic impact of, for example, £8.49-12.78M in Manchester. Despite objections on economic grounds, zones are associated with economic benefits for local authorities, the National Health Service and national government. Young people found zones to be acceptable and perceived them to have some positive impacts. But, a wider policy, including other types of outlets selling convenience food, may better limit dietary risk. Out of 3323 adults, 51% supported zone adoption. Almost three-quarters believed that zones would help young people to eat better. Among those aged 16-17 years, 33% agreed that young people would consume takeaway food less often if there were fewer takeaways near schools. Effective working relationships between local authority colleagues were important for adoption and implementation. Some local authorities ensured this by developing cross-departmental roles and policy 'champions'. A formal implementation process ensured confidence and consistency in implementation. Takeaway management zones around schools were forecast to reduce obesity prevalence and disease incidence by 2040, with no net economic costs. The public see zones as acceptable and potentially effective. However, the reality of adopting and implementing zones is challenging, while other aspects of food retail also influence the behaviours of young people. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR130597. There are many ways in which our neighbourhoods can make it hard to make healthy choices. Having more takeaway outlets means people tend to eat more of the unhealthy foods they sell. Designating zones around schools where new takeaways are not allowed to open is one way that local councils can encourage healthier lifestyles in children and adults. By 2019, 41 of 325 local councils in England had takeaway ‘management’ zones around schools. However, these councils have been working in the absence of evidence of their impact and acceptability. These evidence gaps have made it difficult for councils to demonstrate the value of management zones, curtailing further adoption and successful implementation. We used a computer model to estimate the impact of takeaway management zones on health to 2040. We also wanted to understand the costs and benefits of zones to local and national economies and the National Health Service over this period. We ran a survey to understand how acceptable and effective people thought zones would be and spoke to young people directly about what they thought of the policy overall. Finally, we asked public health and planning colleagues in local councils about their experiences of zones and what lessons they had learned. Although imperfect, takeaway management zones around schools were forecast to reduce obesity and related disease. For example, in Manchester, we forecast obesity prevalence for males to reduce by 2.3 percentage points. These health benefits were achieved with no overall economic harm. In fact, in Manchester, we forecast their adoption to save the council between £8M and £12M. Local communities saw zones as acceptable and potentially effective. However, the reality of adopting and managing the ongoing implementation of zones was a challenge for councils, while other aspects of high street food retail also influence young people’s diets.
LLM-based exercise and health guidance creates a distinctive risk-management challenge: seemingly modest changes in product claims, target users, data inputs, personalization, automation, human oversight, or updates may move a tool from general wellness support toward higher-risk medical use. In exercise prescription and rehabilitation, an unsafe recommendation can affect physical load, recognition of warning symptoms, and timely referral. We conducted a structured narrative review and doctrinal/comparative legal analysis, anchored in China's National Medical Products Administration (NMPA) framework and informed by the European Union Medical Device Regulation (MDR), the EU Artificial Intelligence Act, and US Food and Drug Administration (FDA) and International Medical Device Regulators Forum (IMDRF) materials. Peer-reviewed literature was primarily searched for 2019-2026, with foundational regulatory, legal, and technical guidance included where directly relevant. We propose a six-dimensional trigger matrix covering intended use and claims, user context, depth of personalization, data and sensor sources, automation, human oversight and closed-loop control, and upgrade and change pathways. The framework includes anchored Green/Yellow/Red coding rules, non-compensatory aggregation rules, a structured governance checklist, and a lifecycle pathway for evidence generation, risk management, and change control. In a preliminary application exercise, three independent raters applied the coding rules to seven standardized hypothetical scenarios and achieved complete agreement on all dimension-level and overall designations (Fleiss' kappa = 1.00). This small exercise supports initial reproducibility of the rubric but does not establish legal classification accuracy, clinical validity, or real-world effectiveness. The proposed framework is intended to support earlier risk identification, evidence planning, procurement review, and dialogue among developers, healthcare institutions, and regulators; it does not replace product-specific legal analysis or regulatory determination. Large language models can give advice about exercise, weight management, rehabilitation, and healthy living. A tool may begin as general fitness coaching but become riskier when it starts to use medical records or medical-device data, gives advice for people with a disease, changes plans automatically, or claims to treat or monitor a health condition. In these situations, an unsafe recommendation could ask a person to exercise too hard, fail to respond appropriately to warning symptoms, or delay professional care. This study offers a practical way to identify these changes early. We reviewed Chinese medical-device rules and compared them with European and US approaches. We propose six questions about a tool’s purpose, users, tailoring, data, automation, professional review, and updates. Three independent raters used the draft questions on seven example tools and reached the same overall judgments. This early test does not prove that the framework can determine a product’s legal status or clinical safety. It can help developers, health services, and regulators ask the right safety questions before a tool is widely used.
Although ischemic heart disease (IHD) and asthma are major contributors to the global disease burden, the geographical distribution patterns of their comorbidity and its macro-level drivers remain unclear. This study aims to analyze the global spatial distribution of IHD-asthma comorbidity and to identify the key risk factors driving this comorbid pattern. Based on a secondary analysis of the Global Burden of Disease Study 2021, this study categorized 204 countries and territories worldwide into three spatial patterns-namely "concordant type", "IHD-dominant type", and "asthma-dominant type"-using the quartile method of disability-adjusted life years (DALYs). A three-stage screening approach was employed to identify significant risk factors: random forest modeling combined with Shapley additive explanations was first used to rank and select candidate variables, followed by negative binomial regression analysis to confirm significant associations. Furthermore, population attributable fraction and a composite risk index were constructed to quantify cumulative exposure levels. Approximately one-quarter of countries worldwide exhibit a "concordant pattern" of disease burden levels, primarily located in Asia, Africa, and Oceania. Thirteen significant risk factors were identified, with deficiency in omega-6 polyunsaturated fatty acids and iron deficiency being common risk factors for both diseases. Overall, 43.083% of IHD DALYs and 28.963% of asthma DALYs were attributable to the combined exposure to their respective risk factors. The global joint burden of IHD and asthma exhibits substantial spatial heterogeneity, with particularly severe challenges in socioeconomically resource-limited regions of Africa and Asia. Comprehensive strategies integrating nutritional interventions, environmental improvements, and metabolic risk control are crucial for mitigating the global burden of cardiopulmonary comorbidities. Ischemic heart disease and asthma are among the world’s most common chronic diseases. When people live with both conditions, they face unique health challenges. Yet researchers have not fully explored where this combination appears most often or what drives it. Our team used data from the Global Burden of Disease 2021 study to map how ischemic heart disease and asthma co-occur across 204 countries and territories. We combined spatial analysis, machine learning, and statistical models to identify geographic patterns and key risk factors.We found that nearly one in four countries carries a high burden of both diseases simultaneously — a pattern we call “concordant”. These countries cluster mainly in Africa, Asia, and Oceania. We identified 13 significant risk factors. Two — low intake of omega-6 fats (a type of healthy dietary fat) and iron deficiency — increased the risk of both diseases. Others affected only one condition: kidney dysfunction raised ischemic heart disease risk, while household air pollution from solid fuels raised asthma risk. We also created a composite risk index to measure each country’s overall risk exposure, revealing that nations in Africa and Asia face the greatest cumulative risk. These results show that ischemic heart disease and asthma should be treated as interconnected health problems. Strategies targeting their shared risk factors — such as improving nutrition and reducing indoor air pollution — could ease the burden of both diseases, especially in the hardest-hit regions.
Cardiovascular disease (CVD) represents a significant health and economic burden in China. Despite extensive research on CVD management in primary care, the cost-effectiveness of current practices remains suboptimal. The overall aim of this study is to test the efficacy of an integrated, cost-effectiveness-oriented management (CEOM) intervention to improve CVD risk and harm management in primary healthcare settings in Anhui, China. This open-label, multi-centre, cluster-randomised controlled trial will be conducted in 32 village clinics in Anhui Province, China. Clinics will be randomised (1:1) to the CEOM intervention or usual care. The CEOM intervention integrates a prospective cost-effectiveness analysis from a societal perspective into the clinical workflow. It assesses patient eligibility and prioritises intervention themes and specific items based on predicted incremental cost-effectiveness ratios (ICER), guiding clinicians to deliver tailored management procedures. Implementation is supported by standardised training, automated performance feedback and peer support. Participants (n=1920) are permanent residents aged ≥35 years with diagnosed hypertension, diabetes and/or CVD. The primary outcome is the ICER, using Quality-Adjusted Life Years (QALYs) as the primary effect measure. The ICER will be evaluated based on cumulative QALYs and direct and indirect costs assessed at 12 and 24 months. Secondary outcomes include changes in knowledge, attitudes and practices, major adverse cardiovascular events, QALYs as estimated using the EQ-5D-5L ratings and direct and indirect costs. Data will be analysed using linear mixed models and generalised estimating equations following intention-to-treat principle. The study was approved by the Medical Ethics Committee of Anhui Medical University (83230358). Results will be disseminated via peer-reviewed journals, conferences and policy briefs. ISRCTN registry, ISRCTN87887485. Registered on 28 January 2026.
Polypharmacy is a major challenge for patient safety and effective resource use. High-quality evidence supporting polypharmacy management is lacking. To develop, optimise and evaluate a primary care complex intervention for reducing medically defined potentially inappropriate prescribing among patients experiencing polypharmacy. Phase 1: Qualitative interviews and focus groups with patients and professionals explored views/experiences of existing National Health Service Scotland interventions, informing development of core intervention components. Phase 2: An external pilot-feasibility study was conducted in five general practitioner practices to optimise the Improving Medicines use in People with Polypharmacy in Primary care intervention. A formative mixed-methods process evaluation examined intervention implementation, alongside evaluating trial processes and collecting data to inform phase 3. Phase 3: A pragmatic, open-label two-arm parallel cluster-randomised trial was conducted in English general practice. The intervention (19 practices) comprised a structured, collaborative and patient-centred approach to medication review, supported by informatics, clinician training, performance feedback and financial incentivisation. The comparator was usual care (18 practices). Up to 50 adults receiving ≥ 5 regular medications, with ≥ 1 indicator of potentially inappropriate prescribing, were reviewed per practice over 6 months. Primary outcome was number of potentially inappropriate prescribing indicators at 26-week follow-up. Secondary outcomes included patient-reported measures and service use. Cost-effectiveness and cost-utility analyses were conducted (primary economic outcome quality-adjusted life-years). A mixed-methods process evaluation (patient surveys, patient/clinician interviews, audio-recorded observations) explored implementation. Phase 1: Intervention component design was informed by findings related to elements of the medication review, informatics and clinician training. Phase 2: Core intervention elements were successfully implemented in the pilot, although clinical delivery was hampered by disruptions due to the coronavirus disease pandemic. Phase 3: Participants were recruited between January and June 2022 (intervention N = 891, usual care N = 836), median age 73 years, 49% female, with median four long-term conditions and eight medications. No improvement in the primary outcome was observed (mean difference potentially inappropriate prescribing count - 0.007; 95% confidence interval -0.21 to 0.199). Treatment burden was slightly improved, and subgroup analysis suggested potential improvements in less complex patients. The process evaluation found general practitioners and pharmacists valued and benefitted from the model of interprofessional collaboration, which strengthened working relationships and provided an opportunity for knowledge sharing and joint decision-making that supported management of clinical uncertainty. Most patients (73.2%) reported satisfaction with the review, with satisfaction strongly associated with perceptions of shared decision-making. There was no evidence of cost-effectiveness, although the economic evaluation did not quantify the aforementioned benefits or other broader factors of potential interest to decision-makers. Key limitations include concurrent changes in usual care, potentially insensitive outcome measures and limited study-population generalisability. A complex medication optimisation intervention did not reduce potentially inappropriate prescribing in patients with polypharmacy. Findings strongly support revisiting current medication optimisation policy, with one-off structured reviews, even when enhanced with digital healthcare solutions and clinical pharmacy investment, not guaranteed to improve key clinical outcomes. Nevertheless, the positive patient and clinician findings are important: protected time for interprofessional collaborative working, plus effective integration of shared decision-making within patient-facing reviews, may facilitate improved patient care more broadly. Research should develop new patient-centred outcomes and identify higher-risk patients. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 16/118/14. Prescribing medicines is the commonest way doctors treat illness and improve health. Our population is steadily ageing, and people often have several long-term health conditions. This means people often take many different medicines – this is called polypharmacy. Polypharmacy can be necessary to help keep people well, but it can also cause problems such as side effects or confusion about which medicines to take and when. We do not know the best way for doctors and pharmacists in general practice to make sure medicines are used as effectively and safely as possible for people with polypharmacy. This project aimed to create a new approach for general practitioners and pharmacists to help people with polypharmacy get the most out of their medicines. The research team spoke with patients and healthcare staff to help decide what the new approach should look like. The new approach included a clear process for reviewing medicines, with general practitioners and pharmacists working more closely together and making sure patient concerns were prioritised. Staff received training and were helped by using a computer program. The project then tested this approach in 19 general practitioner surgeries, with 891 patients. It compared this with normal care being delivered in 18 other surgeries (836 patients). The new approach was not found to be any better than normal care for preventing problems due to medicines. However, the new approach appeared to help reduce the effort patients had to put into managing their treatments. Patients were generally satisfied with the new approach to care. The new approach also helped the healthcare team to have better discussions about patients’ medicines. The findings suggest that simply building on current National Health Service approaches may not improve care for people with polypharmacy. Care might be improved if patients’ views are better accounted for, and pharmacists and general practitioners work more effectively together.
Building on prior development work, the objective of this study of health care utilization of all Weill Cornell Medicine health insurance beneficiaries over a six-year period was to demonstrate the validity of the Charlson Comorbidity Health Analytics (CCHA), a summed weighted measure of 38 chronic conditions in adults and children, that prospectively predict longitudinal risk of hospital admissions, repeated admissions and resultant high cost in populations. The objective of the Charlson Comorbidity Health Analytics (CCHA) is to provide a new foundational framework for population management strategies by identifying the highest risk patients who can then be the focus for interventions designed to reduce unplanned hospitalizations and resultant high costs. All 27,190 Weill Cornell Medicine beneficiaries in the years 2016-2021, that is, employees and their dependents, including spouses/partners and their children, were linked across the years in a de-identified way, and CCHA was calculated from claims data. In addition to basic demographics, data included all outpatient and inpatient claims, including payments for each service over each year, excluding pharmacy. While two pharmaceuticals are part of the CCHA (anticoagulants and anti-psychotics), no data about pharmaceuticals was available for this analysis. First, CCHA from each year 2016-2021 was evaluated cross-sectionally as a predictor of that year's hospitalizations and costs. Second, the CCHA from 2016 beneficiaries who were followed for five years were used to predict longitudinal risk of hospitalizations, repeated hospitalizations, and costs in each of the next five years. Then the CCHA was compared to the CMS Chronic Conditions Warehouse 30 (CCW30) measure. Finally, the CCHA from any given year (2016-2021) was analyzed for its predictive ability over the remaining one to five years of follow-up to predict hospitalizations, repeated hospitalizations, and costs. Of the total 27,190 beneficiaries over the six years, 55.8% were employees (66.2% women with an average age of 40.9 years), and 25.7% children (average age of 6.1 years). The Charlson Comorbidity Health Analytics (CCHA) score from an index year longitudinally predicts the risk of hospitalizations--including repeated hospitalizations--which drive healthcare costsover six years (p < .01), providing the foundation for interventions in the highest risk patients. Moreover, the 2016 CCHA was a more significant predictor of readmission in 2017-2021 than a 2016 admission. In addition, comorbidity from any index year can be used to predict subsequent admissions and costs; therefore, it works in dynamic populations, like employers and unions that have changes in beneficiaries over time. The Charlson Comorbidity Health Analytics is a method for prospectively identifying the small percent of patients who are at high longitudinal risk for unplanned hospitalizations and high costs. Intervention efforts can then be focused on high-comorbidity patients at high risk [1], with the goal of preventing health deterioration leading to health crises. Comorbidity Health Analytics provides a new foundational framework for population management strategies and specifically for interventions designed to reduce unplanned hospitalizations and thereby reduce costs.
Two decades after the patient safety movement reshaped how medicine understands harm, emergency care remains a complex and risk-laden environment. Despite major advances in measurement, reporting, and accountability, most safety frameworks still look backward - analyzing errors after they occur rather than anticipating and preventing them. The next frontier in safety is not more reporting; it is real-time learning. It demands systems that can detect and respond to risk as it unfolds, while learning and adapting in response to every signal. To meet that challenge, the authors developed and, in January 2023, implemented a systems-based model for quality and safety surveillance that turns the emergency department (ED) into a continuous learning environment. This model, Safety Evaluation and Networked Tracking for Real-Time Yield (SENTRY), combines Safety I (error prevention) and Safety II (adaptive resilience) principles to build a continuous surveillance and feedback ecosystem across three phases: prehospital care, emergency care including hospital-based transfers, and postdischarge care transitions and follow-up. Safety signals are captured through multiple inputs - including incident reports, key performance indicators, rapid-response activations, and 72-hour return audits - and reviewed through a standardized rubric grounded in national frameworks such as Agency for Healthcare Research and Quality Patient Safety Indicators and Reason's Swiss cheese model. Structured data from each case are integrated into a centralized Research Electronic Data Capture (REDCap) repository, enabling longitudinal analysis, recognition of recurring patterns, and prioritization of targeted interventions. Since implementation, automated pharmacist consults for prostacyclin medication have been associated with no observed delays in recognition and medication reconciliation. Comparing preintervention with postintervention, the mean and median time from ED arrival to prostacyclin reconciliation decreased by half. Automated aspiration precautions and nothing-by-mouth standing orders for high-risk patients were associated with the prevention of aspiration-related ED safety events, which decreased to zero events in 2024-2025, from an average of three identifiable events in 2023-2024. Use of an artificial intelligence-based triage tool was associated with improved throughput, alignment of acuity with clinical risk, and improved triage inequities. Same-day specialty pathways, including an outpatient diuresis clinic for heart failure patients, have been credited with averting more than 27 inpatient admissions over a 7-month period. Beyond these discrete outcomes, the framework has reshaped how safety is lived in daily practice - transforming surveillance from a retrospective exercise into a culture of continuous learning. Embedded feedback loops, charge nurse reporting, and nurse-driven safety rounds sustain engagement and momentum. Quantitative and qualitative insights now drive workflow redesign, policy, and education, allowing the ED to function as both a mirror reflecting vulnerability and a compass guiding improvement. While challenges such as alert fatigue, infrastructure demands, and sustainability remain, this model shows that continuous surveillance and adaptive learning can coexist within the realities of emergency care.
Suicide is a leading cause of death among young people worldwide and remains a significant cause of mortality across all age groups, especially in older adults. The underlying causes of suicide span various disciplines and are deeply influenced by societal attitudes, which fluctuate between glorification and severe condemnation of suicide. This study aims to evaluate the role of court rulings on suicidal behavior, with particular attention to implications for healthcare policy in Israel. We searched the national court rulings databases for alleged psychiatry malpractice in suicide-related cases and of pre-trial settlements from 1985 to 2023. For court decisions, we collected patients' socio-demographic and clinical characteristics, lawsuit characteristics, and the quality of medical documentation and decision-making processes. For pre-trial settlements, we collected data about lawsuit characteristics. Two researchers reviewed the qualitative data, while the quantitative data was analyzed with descriptive statistics. Over the 38-year period, there were 20 psychiatry malpractice court lawsuits related to patient suicides, including 17 deaths and 3 life threatening attempts. Of these, 12 (60%) of cases were won by the plaintiff, and eight (40%) by the defendant. In 14 cases, the suicides occurred in inpatient units and in six cases in community settings. The number of lawsuits notably increased over time for suicide events, with 17 pre-court settlements between 1985 and 1997, and 56 cases in each of the subsequent periods (1998-2010 and 2011-2023). The number of malpractice lawsuits related to suicide in Israel is increasing over time. Our findings, which show a rise in both litigation and pre-trial settlements, may put pressure on psychiatrists to avoid certain kinds of work, especially in the public sector. Such a shift could have broader effects on the quality of suicide prevention efforts and overall mental health care. The study highlights the structural tension between retrospective legal accountability and prospective clinical and public-health approaches to suicide prevention. Addressing this challenge requires balanced policy responses, including strengthening patient-safety and risk-management systems, improving clinical documentation and decision transparency, fostering constructive collaboration between legal and mental health systems, and considering alternative compensation mechanisms that reduce adversarial pressures while supporting affected families.
To establish evidence-based annual procedural volume thresholds and surgical pairing standards for Orthopedics and Obstetrics-Gynecology (OB-GYN), and to validate these benchmarks against clinical incident rates as a proactive risk management tool. This study utilized a sequential mixed-methods design. In Phase 1, a Delphi technique was employed with 36 senior experts from the Bangkok Dusit Medical Services (BDMS) network to reach a consensus on minimum annual volumes and co-surgeon requirements. In Phase 2, a retrospective analysis of clinical incidents (Levels 4-5 and Sentinel Events) from 2022 to 2024 was performed to validate these thresholds. Statistical analysis included Mann-Whitney U and Kruskal-Wallis tests to evaluate the association between sustained compliance with these standards and clinical incident rates. Expert consensus established a recommended safety threshold of 10 cases per year for high-volume procedures (eg, cesarean delivery, anterior cruciate ligament [ACL] reconstruction), with specific thresholds of 6 cases for proximal humerus fracture and 5 cases for shoulder rotator cuff repair. Quantitative validation demonstrated that surgeons meeting these thresholds had significantly lower incident rates in cesarean delivery (p < 0.001), proximal humerus fractures (p = 0.027), and shoulder rotator cuff repair (p < 0.001). Furthermore, sustained multi-year compliance over three consecutive years was strongly correlated with lower incident rates (p < 0.001). For high-complexity, low-volume procedures, the strategy shifted from numerical frequency to system-based redundancy, requiring a mandatory co-surgeon (Median Score = 5.0 on a 5-point scale). Maintaining a minimum annual procedural volume serves as a core proxy for surgical competency, directly reinforcing the knowledge, skill, and attitude required for patient safety. These established thresholds and team-based safety models provide a data-driven framework for institutional clinical privileging, offering hospital administrators an objective policy tool for proactive risk management.
Veterinary pharmaceuticals often enter into ecosystems through the disposal of unused and expired medicines and animal excreta. Consequently, these substances are emerging as a global threat, posing risks to ecosystems, biodiversity and public health. However, despite the increasing concerns attributed to veterinary pharmaceuticals, there is a lack of empirical data regarding awareness and practices related to ecopharmacovigilance (EPV) among veterinary professionals in Ethiopia. EPV is an emerging discipline focused on the detection, evaluation, understanding and the prevention of the environmental impacts of pharmaceuticals. This knowledge gap highlights the need for evidence-based assessment of veterinary professionals' awareness and practices of EPV in Ethiopia. Therefore, this study aimed to assess veterinary professionals' knowledge, attitudes and practices (KAP) regarding EPV and pharmaceutical waste management. A cross-sectional survey was conducted between January 2024 and May 2025 among 37 veterinary healthcare providers in and around Gondar City. The data were collected using a structured, self-administered questionnaire. Data were analysed using SPSS version 25 through descriptive statistics and chi-square tests to identify associations between socio-demographic characteristics and KAP indicators. The study found that 73% of respondents had never heard of EPV, 78.4% had not received relevant training, and 67.6% reported the absence of pharmaceutical disposal guidelines in their facilities. Although 94.6% acknowledged the harmful effects of improper drug disposal on human and environmental health, only 16.2% were familiar with the term EPV. Knowledge was marginally associated with reading scientific literature (p = 0.084), whereas attitudes were significantly related to prior knowledge (p = 0.001), training (p = 0.001) and reviewing related reports (p = 0.001). Practices were influenced by prior knowledge (p = 0.023) and engagement with literature (p = 0.032). About 40.5% of participants disposed of pharmaceuticals in regular trash, and only 27% returned unused drugs to appropriate authorities. Overall, 62.8% of respondent's demonstrated poor knowledge, 56.8% held negative attitudes, and practices were inadequate. This baseline study reveals low awareness of EPV and poor waste management practices among veterinary healthcare providers. The study shows the urgent need for targeted training, policy enforcement and the integration of environmental education into veterinary curricula in Ethiopia. This is necessary to promote responsible pharmaceutical stewardship and safeguard the environment and public health.
Patient safety culture (PSC) in home healthcare centres (HHCs) remains insufficiently examined compared with hospital settings. HHCs are licensed facilities that coordinate and deliver skilled nursing, rehabilitation and other professional services directly to patients' own homes. The present study investigates the dimensions of PSC in HHCs from the perspectives of both healthcare providers and family caregivers. This study was conducted using a qualitative approach and the conventional content analysis method (Graneheim and Lundman). Participants (n=15) included managers, nurses, physiotherapists, physicians, a nurse assistant and family caregivers recruited by purposive sampling. Data were collected through semi-structured interviews (45-90 min), participant observations (15 hours total) and field notes. Data collection continued until saturation was achieved. We extracted 1103 initial codes and grouped them into 32 primary subcategories, 15 subcategories and three main categories. Trustworthiness was ensured based on Lincoln and Guba's criteria, addressing credibility, transferability, dependability and confirmability. Three main interconnected categories emerged (1): professional competency of healthcare staff for patient safety (values and beliefs, professional commitment, skill and technical proficiencies, individual-level risk assessment and management) (2); safety governance and organisational support (leadership commitment, supervision, open communication, learning from errors, training, policy development, teamwork climate, resource allocation, competency assurance); and (3) patient and family engagement (patient-centred empowerment and family-centred empowerment, involvement in care planning and risk management). The PSC in HHCs is shaped by the collaboration of skilled professionals, supportive organisational structures and the active participation of patients and their families. Concurrent attention to these three domains is essential for strengthening PSC in this rapidly growing sector.
Direct-placement dental restorative materials are required to replace the loss of tooth substance and restore the functional structural integrity of damaged posterior teeth. Whilst dental amalgam was traditionally used for these restorations, there are concerns about toxicity to human health and the environment. The Minamata Convention on Mercury recommends a phase-down of amalgam use in dentistry. Alternative mercury-free direct-placement restorative materials are available and have been evaluated in systematic reviews. To summarise the evidence from Cochrane and other systematic reviews evaluating the clinical effectiveness and longevity of restorative materials for direct-placement coronal restoration in the permanent posterior dentition. To summarise the evidence from economic studies for the cost-effectiveness of restorative materials for direct-placement coronal restoration in the permanent posterior dentition. In April 2025, we searched the Cochrane Library, MEDLINE, Embase, Epistemonikos and PROSPERO for systematic reviews that compared restorative materials for direct-placement coronal restoration in the permanent posterior dentition in children and adults. We included reviews reporting quantitative syntheses and comparing at least two restorative materials, from: resin-based composite (RBC), resin-modified glass ionomer cement (RMGIC), glass ionomer cement (GIC), compomer, dental amalgam, or other material. For RBC, we also compared bulk-fill with incremental-layered (conventional) RBC. We used Cochrane methodology to conduct an overview of the evidence from eligible reviews, and assessed the methodological quality of reviews using ROBIS. We prioritised data from selected reviews when we found a high degree of overlap of primary studies between reviews. Critical outcomes were: tooth loss (owing to restoration failure), restoration failure, time to failure, and adverse effects. Additionally, we searched for relevant economic evaluations of direct-placement restorative materials and developed a brief economic commentary. Overall, we found 14 reviews including 57 primary studies; only one was a Cochrane review. Very few primary studies (about 10%) were conducted in general practice. We prioritised data at the longest time point from six reviews, including 23 primary studies. Two reviews were at low risk of bias, and the others were at high risk. However, results across all reviews were largely comparable. RBC compared with dental amalgam. One Cochrane review reported low-certainty evidence that the risk of restoration failure may be 7% less with dental amalgam than RBC (RD 0.07, 95% CI 0.05 to 0.09; 2 studies, 3010 restorations; 5 to 7 years follow-up; class I and II restorations). Studies in this review began recruitment in the late 1990s, which may affect the generalisability of this evidence to contemporary practice, and the failure rate for RBC in these studies was higher than in contemporary evidence of RBC in other reviews (almost 15% compared with approximately 5%). Although there was similar evidence of restoration failure from two other reviews, the certainty of this evidence was very low and, therefore, we had little confidence in the risk reductions reported in these reviews. Only one review reported postoperative pain and discomfort (about 5% in both groups), which reviewers judged to be very low-certainty evidence. RBC compared with GIC. In one review, there may be little or no difference in the risk of restoration failure between RBC or GIC (RD -0.07, 95% CI -0.17 to 0.04, favours RBC; 1 study, 60 restorations; 10 years follow-up), or the risk of postoperative sensitivity (RD 0.03, 95% CI -0.03 to 0.10, favours GIC; 2 studies, 118 restorations); low-certainty evidence in a small sample size. Evidence for postoperative sensitivity in another review was very low certainty (overall events ranging from zero to 10%) and therefore we are uncertain of any benefit for either restorative material. Whilst this evidence included class I and II restorations, most reported were class I restorations (occlusal non-load bearing). Bulk-fill compared with incremental-layered RBC. We found the most reviews for this comparison (n = 8), all reporting similar risk differences, and therefore this evidence was judged to be of moderate certainty. The risk of restoration failure is likely to be low, and no different between groups, at less than 5% (RD 0.00, 95% CI -0.03 to 0.03; 7 studies, 511 restorations; 1 to 10 years follow-up). In one review, there was almost no postoperative sensitivity for either type of RBC (RD 0.00, 95% CI -0.01 to 0.02; 5 studies; 510 restorations; 2 to 3 years follow-up). Overall, more restorations were in class II restorations (multiple-surface load bearing). RMGIC compared with GIC. In one review, RMGIC may be more likely to reduce the risk of restoration failure than GIC in class I restorations (RD -0.19, 95% CI -0.37 to -0.02; 1 study, 50 restorations), and class II restorations (RD -0.71, 95% CI -0.93 to -0.48; 1 study, 38 restorations), both at two years follow-up from low-certainty evidence in a very small sample. GIC compared with dental amalgam, and GIC compared with compomer. No reviews reported critical outcome data for these comparisons. Brief economic commentary: Six economic reports identified no strong conclusions regarding the cost-effectiveness of mercury-free restorative materials. One report, using data from older studies, found that amalgam lasted longer and was less costly than RBC; however, we identified no economic evaluations based on contemporary clinical evidence for amalgam. Most evidence compared bulk-fill with incremental-layered RBC; there is probably no difference between these materials in restoration failure. Although we found evidence of fewer restoration failures with dental amalgam than RBC, this may not be comparable to contemporary practice owing to changes in properties of RBC materials and practitioner experience. We identified few economic evaluations to provide strong conclusions to support the clinical effectiveness findings for mercury-free restorative materials. Regarding implications for policy and practice, little evidence in this overview is from general practice. The results of clinical effectiveness should be considered alongside cost, acceptability, clinical presentation, time required for restoration placement (which may be technique-sensitive), and the health and environmental considerations of the materials. These conclusions emphasise that caries prevention is critical to effective and sustainable oral health. Cochrane Oral Health (COH) is supported by a collaborative research agreement between The University of Manchester and the University of Pennsylvania. Protocol (2025): https://www.crd.york.ac.uk/PROSPERO/view/CRD420251004182.
Heart failure (HF) is a major global public health challenge and a leading cause of morbidity and mortality, particularly among older adults. The rising prevalence of HF is driven by aging populations and the increasing burden of chronic conditions such as hypertension, diabetes, and obesity. In Canada alone, over 750,000 individuals live with HF, with over 100,000 new cases diagnosed annually. Despite advancements in pharmacological and device-based treatments, HF remains a primary cause of hospital admissions, with readmission rates exceeding 20% within 30 days. The associated healthcare costs are projected to reach $2.8 billion annually by 2030. Older adults experiencing homelessness represent a particularly vulnerable population at risk for HF. Homelessness is associated with increased exposure to cardiovascular risk factors, including inadequate access to preventive healthcare, high rates of comorbid conditions, and environmental stressors. Evidence suggests that individuals experiencing homelessness have a significantly higher incidence and earlier onset of HF compared to the general population, yet this intersection remains underexplored in the literature. This paper outlines the protocol for a systematic review and meta-analysis that aims to address this gap by synthesizing the prevalence, incidence, and mortality of HF among older adults who have experienced homelessness. This systematic review will follow the PRISMA and MOOSE guidelines and has been registered on the Open Science Framework. We will include studies examining the prevalence, incidence, or mortality of HF among older adults (aged 50 and above) with a history of homelessness. The decision to lower the age threshold to 50 reflects the accelerated aging process observed in this population, who often experience age-related conditions at a younger chronological age. Eligible study designs include cross-sectional, cohort, and case-control studies. Quantitative data from peer-reviewed publications and grey literature will be included, with no language or date restrictions. A comprehensive search strategy will be applied across major electronic databases, including Medline, Embase, Cochrane Library, and ISI Web of Science. We will also perform grey literature searches through Google Scholar and governmental websites. Backward citation tracking will be conducted to identify additional relevant studies. Study selection will involve independent screening by three reviewers, with disagreements resolved by consensus. Data extraction will include study characteristics, participant demographics, and HF-related outcomes. Risk of bias will be assessed using the Joanna Briggs Institute Checklist for Prevalence Studies and the ROBINS-E tool for non-randomized studies. The review will estimate pooled prevalence, incidence, and mortality rates of HF in older adults experiencing homelessness. Where possible, we will conduct subgroup analyses based on age, sex, and comorbidities. Meta-regression and sensitivity analyses will be performed to assess the robustness of the findings. This systematic review and meta-analysis will provide the first comprehensive synthesis of HF epidemiology in older adults experiencing homelessness. By identifying disparities in cardiovascular health outcomes, this study aims to inform public health policies, healthcare delivery, and future research to improve cardiovascular care for this marginalized population.
Direct oral anticoagulants such as apixaban and rivaroxaban, have transformed the management of thromboembolic disorders. Randomized controlled trials were initiated in 2017 (COBRRA-VTE [Comparison of Bleeding Risk Between Rivaroxaban and Apixaban for the Treatment of Acute Venous Thromboembolism]) and 2021 (COBRRA-AF [Comparison of Bleeding Risk Between Rivaroxaban and Apixaban in Patients With Atrial Fibrillation]) to directly compare apixaban and rivaroxaban on the risk of bleeding in patients with venous thromboembolism (VTE) and atrial fibrillation (AF). We aimed to emulate the design and measurements of these ongoing trials and use US health care insurance claims data to predict their findings. In cohort studies designed to emulate COBRRA-VTE (REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05264168) and COBRRA-AF (NCT05256797) in 3 US health care insurance claims databases (Medicare, Optum Clinformatics, Merative MarketScan), the risk of bleeding with apixaban was evaluated relative to the risk with rivaroxaban. Pretreatment confounding factors were adjusted for via 1:1 propensity score matching. The primary outcome was a composite of major bleeding and clinically relevant non-major bleeding (defined using International Classification of Diseases, Ninth Revision and Tenth Revision diagnosis codes) recorded in the inpatient setting. Results across databases were pooled using fixed-effects meta-analyses. Protocols were preregistered on ClinicalTrials.gov before inferential analyses were conducted. In the COBRRA-VTE emulation (N=14 023 matched pairs, mean age=67 years, 55% women), we observed a 31% decreased risk of bleeding for apixaban compared with rivaroxaban (incidence rate per 100 person-years: apixaban, 12.8; rivaroxaban, 19.1; hazard ratio, 0.69 [95% CI, 0.59-0.79]). For the COBRRA-AF emulation (N=176 990 matched pairs, mean age=74 years, 50% women), we similarly observed a 31% decreased risk for apixaban compared with rivaroxaban (incidence rate per 100 person-years: apixaban, 6.4; rivaroxaban, 9.2; hazard ratio, 0.69 [95% CI, 0.66-0.71]). In database studies that closely emulated the design and measurements of the COBRRA-VTE and COBRRA-AF trials, a substantially lower risk of bleeding with apixaban was observed, consistent with the results of COBRRA-VTE (published after completion of our analyses), and indirect comparisons from other trials.
Artificial intelligence (AI) is increasingly used to predict deterioration, classify risk, prioritise workload, support diagnosis, tailor communication and monitor patients across healthcare settings. Existing safety discussions rightly emphasise model performance, bias, explainability, regulatory approval and post-deployment monitoring. However, these domains do not fully answer a prior risk-management question: when should an AI output be released into clinical or organisational action under the active healthcare regime? This Perspective develops a Deterministic Systems Intelligence (DSI) framework for feasibility-first clinical AI risk management. The proposed admissible-state layer evaluates candidate AI outputs against data fitness, population fit, clinical actionability, workflow capacity, equity, authority, monitoring and reversibility before action is permitted. It classifies outputs into five governance states: release, restricted release, active monitoring, rollback and HOLD. HOLD denotes disciplined non-release when evidence, feasibility or safeguards are insufficient. A worked deterioration-alert example shows how the same technically plausible output may be released, restricted, monitored, rolled back or held depending on local capacity, equity and safety controls. The framework complements reporting, audit, regulatory and algorithmovigilance approaches by inserting an explicit admissibility step between AI output and healthcare action. Responsible clinical AI therefore requires not only prediction, but release readiness, monitoring and the capacity to withhold.
Sub-Saharan Africa (SSA), including Tanzania, is double-burdened with high rates of teenage pregnancy and new HIV infections among adolescent girls and young women (AGYW) aged 15-24 years. Moreover, pregnant AGYW living with HIV in SSA have poorer adherence and retention on HIV treatment and elevated risks of vertical HIV transmission to their infants, as compared with older women. This paper describes the methods for the ENGAGE project, aiming to investigate and optimise healthcare for prevention of vertical HIV transmission (commonly prevention of mother-to-child transmission (PMTCT)) for AGYW living with HIV in Tanzania. ENGAGE uses a mixed-methods design to co-create and prototype an intervention package for pregnant/postpartum AGYW living with HIV through three phases in three Tanzanian regions. Phase 1 characterises the problem by investigating care engagement and outcomes in a cohort of N=10 147 AGYW receiving PMTCT services in routine healthcare. Phase 2 uses qualitative interviews to understand the social-structural drivers of care engagement from the perspective of AGYW, healthcare providers and community stakeholders and an evidence review of potential solutions. In phase 3, we will use findings from phase 1 and 2 to co-create (together with AGYW and healthcare providers) an intervention package to optimise PMTCT care for most at-risk AGYW. The co-creation will be done through an intervention development action cycle, where ideas are presented, feedback sought and refinements made iteratively via several workshops over about 6 months. The resulting co-created intervention package will be prototyped at selected facilities/communities and refined into a final version, ready for piloting for feasibility, acceptability and preliminary effect in a later phase. This protocol focuses on the co-creation phase 3 and its preceding phases 1 and 2. ENGAGE has received ethical approval from the Tanzania National Health Research Ethics Committee (NIMR/HQ/R.8a/Vol.IX/4637), and the Swedish Ethical Review Authority (2024-05745-01) for analysis of data in Sweden. Findings will be disseminated to AGYW, healthcare providers, community stakeholders, health officials, researchers, policy makers and the wider local and global scientific community.
Digital transformation is a key priority for modernizing China's public hospitals. However, a standardized and context-specific framework to evaluate their digital maturity remains absent. This study aims to develop and validate a comprehensive, multidimensional evaluation framework tailored to Chinese tertiary public hospitals to support systematic assessment and inform policy decisions. Based on systematic literature review and policy analysis, we constructed a framework comprising Digital Readiness, Technology Application, and Data Management Capability, with 11 subdimensions and 65 indicators. Indicator weights were derived using a two-round Delphi consultation, analytic hierarchy process, and criteria importance through intercriteria dependence method. The framework was applied to 1,361 tertiary public hospitals across 28 mainland provincial-level divisions in China. Digital maturity scores were analyzed using global sensitivity analysis (GSA), k-means clustering, and logistic regression with Firth's penalized likelihood. Digital Readiness received the largest combined weight (34.9%), followed closely by Technology Application (34.7%) and Data Management Capability (30.4%), suggesting that hospital digital maturity reflects a balanced combination of organizational readiness, technology-enabled service application, and data governance. GSA further revealed discrepancies between combined weights and empirical sensitivity rankings, indicating that these approaches captured different aspects of indicator importance. Clustering and regression analyses showed that higher-maturity hospitals had higher values across many indicators, particularly in clinical digital applications and data quality management, whereas data sharing and exchange remained relatively weak across maturity groups. Robustness checks using alternative weighting and clustering methods generally supported the stability of the main findings, while also indicating residual sensitivity to methodological choices. The proposed framework provides a structure- and process-oriented diagnostic tool for assessing digital maturity in Chinese tertiary public hospitals. It can support policy monitoring, institutional benchmarking, and targeted improvement of hospital digital transformation. Future research should update the framework with more recent data and validate maturity scores against healthcare quality, safety, efficiency, patient experience, and equity outcomes.
EQ-5D is widely used in economic evaluations and population health assessments. This study used a large population-based cohort with EQ-5D-3L data to describe the health-related quality of life (HRQoL) of the general population in Stockholm County and investigate potential inequalities and variations in HRQoL. This study analysed data from 52,714 respondents aged 23-104 years from the 2021 Stockholm Public Health Cohort (SPHC). Calibration weights were used to address non-response bias and improve representativeness. Differences in mean EQ-VAS and EQ-5D-3L index values were analyzed using multivariable regressions, and modified poison regression was used to explore the likelihood of reporting problems across the EQ-5D dimensions. Splines were used to flexibly model the nonlinear relationship between age and HRQoL. A total of 169 health states were observed, with 37% of the respondents reporting "no problems" in all dimensions ("11111"). Further, 0.05% (n = 14) respondents reported the worst possible health state ("33333"). The HRQoL of the general population was generally good but variations across sociodemographic and risk factor groups were observed. HRQoL demonstrated a non-linear relationship with age, with relatively lower scores observed among the youngest adults, increasing through midlife, followed by a marked decline in older age, particularly among those aged 80 years and above. The mean EQ-5D-3 L index was lower among females (0.79 [95% CI: 0.79-0.80]) than males (0.83 [95% CI: 0.83-0.84]), and a similar pattern was observed for the mean EQ-VAS scores (75.96 [95% CI: 75.59-76.33] vs. 78.3 [95% CI: 77.62-78.42], respectively). People with lower education, low disposable income as well as those born outside of the European union and UK reported relatively lower HRQoL. Adjusting for age attenuated but did not eliminate these demographic and socioeconomic differences. Persistent associations between behavioural risk factors and HRQoL were also observed. Similarly, people with chronic health conditions, particularly those with long-term illness or multiple health conditions, exhibited markedly lower HRQoL. This study demonstrated substantial variations in HRQoL across sociodemographic groups, behavioural risk factors, and self-reported health conditions, providing insights that can inform healthcare planning and future investments in health and research. The results may also serve as reference values in clinical and economic evaluations, and for comparing outcomes from specific patient subgroups with the general population.
Healthcare professionals' behaviours are central to effective multimorbidity management yet remain underexplored in behavioural medicine. Co-existing type 2 diabetes (T2D) and cardiovascular disease (CVD) present intertwined behavioural and biomedical challenges; however, the organizational and professional factors that shape integrated care are poorly understood. The objective of this study was to identify behavioural and organizational determinants of integrated T2D-CVD care and to apply behaviour change theory to provider practice. Sixteen healthcare professionals in North-West England participated in semi-structured interviews. Data were analysed inductively using reflexive thematic analysis within a critical realist framework. The COM-B model (capability, opportunity, motivation, behaviour) informed interpretation of these inductive findings. Three interconnected themes: Compartmentalized conditions; inhibition of meaningful interactions; and gap between understanding and supporting illustrate how limitations in capability (confidence and training), opportunity (siloed records, absence of psychological pathways) and motivation (risk aversion and entrenched norms) collectively reinforce fragmented biomedical care. These mechanisms operate across organizational and cultural boundaries and explain persistent gaps in risk communication, cross-disciplinary collaboration and limited psychological support. This study provides a theory-informed qualitative application of the COM-B model to healthcare professional behaviour in multimorbidity care, demonstrating how system design and professional culture shape interacting determinants. Conceptualizing cardiometabolic care as a behavioural and communicative system identifies priority intervention targets: staff training, service redesign, interoperable records and leadership development. These support practitioner well-being, interdisciplinary collaboration and patient engagement. The findings reframe integrated T2D-CVD care as a multidirectional capability model, informing policy and practice.
Compassion fatigue (CF) is a significant occupational challenge among nurses and is associated with adverse workforce and patient-care outcomes. In China's demanding healthcare system, identifying nurses at elevated risk of CF may help inform targeted support strategies. This study aimed to develop and internally validate an explainable machine learning (ML)-based model for CF risk stratification among clinical nurses. A cross-sectional survey was conducted among 969 clinical nurses in Liaoning Province, China. CF status was classified using established Professional Quality of Life Scale questionnaire cutoff criteria. A hybrid approach combining the Boruta algorithm and Least Absolute Shrinkage and Selection Operator regression was employed. Eight ML algorithms were developed and compared. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, recall, and F1-score. Shapley Additive exPlanations (SHAP) analysis was used to interpret the optimal model and quantify the contribution of important risk factors. Based on questionnaire-defined criteria, 56.2% of participants were classified as having elevated CF symptoms. Among the evaluated algorithms, the Naïve Bayes (NB) model demonstrated the best overall performance, achieving an AUC of 0.924 (95% confidence interval [CI]: 0.894-0.954) in the testing set. It also showed favorable calibration and potential net benefit. SHAP analysis indicated that social support, work engagement, and mindfulness were important protective factors, whereas exposure to workplace violence, frequent night shifts, prolonged daily working hours, and department assignment were important risk factors associated with elevated CF symptom classification. The NB-based model demonstrated strong discrimination and interpretability for stratifying nurses at elevated risk of CF within this study population. The findings highlight potentially modifiable factors associated with elevated CF symptoms and may support targeted occupational health strategies. External and prospective validation studies are still needed before broader implementation in clinical or administrative settings.