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.
PurposeTo examine the relationship between fall-related mortality, disability-adjusted life years (DALY), healthcare expenditures, and research funding and determine whether fall prevention funding is proportional to fall-related public health impact.DesignCross-sectional.SettingUnited States.SampleNot applicable.MeasuresMortality rates (2018-2022) for leading causes of death were obtained from CDC WONDER. Disability-adjusted life-year (DALY) rates (2021) were obtained from the World Health Organization. Healthcare expenditures (2016) were obtained from the Institute for Health Metrics and Evaluation. Research funding data (2018-2022) were obtained from NIH ExPORTER and linked to causes of death using MeSH term searches.AnalysisLinear regression models were used with log-transformed research funding as the dependent variable and log-transformed mortality rates, DALY rates, and healthcare expenditures as predictors.ResultsFall mortality rate was 13.1 deaths per 100 000 individuals, fall-related DALY rate was 713.2 per 100 000, and fall-related healthcare expenditures were $106.6 billion. Falls ranked 12th in mortality, 8th in DALY, and 5th in healthcare costs but 20th in research funding, receiving $489 million over 5 years. Falls received significantly less funding than expected based on mortality rates (predicted $1.95 billion), DALY rates (predicted $3.27 billion) and healthcare expenditures (predicted $5.63 billion).ConclusionAlthough falls have a significant impact on older adults' health and mortality, fall research funding is disproportionately low. To reduce mortality and mitigate rising healthcare costs associated with falls, federal investment in fall prevention research should be a higher priority.
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.
Health literacy is a core competency in nursing education and an essential component of person-centered care. Its association extends beyond clinical communication to shaping attitudes that support sustainable, ethical, and environmentally responsible healthcare. However, this relationship remains under examined among nursing students in Middle Eastern settings. To investigate the relationship between health literacy dimensions and sustainable healthcare attitudes among Saudi nursing students and to determine whether health literacy predicts sustainability-related awareness, values, and behavioral intentions. A cross-sectional design was conducted using three independent samples: exploratory factor analysis (n = 385), confirmatory factor analysis (n = 514), and hypothesis-testing correlational analysis (n = 652). This multi-sample validation design represents a key methodological strength ensuring robust psychometric evaluation. Participants completed validated Arabic measures assessing health literacy (information literacy, communication and navigation, self-management and promotion) and sustainable healthcare attitudes (awareness/knowledge, attitudes/values, behavior/action). Correlation analysis, multiple regression, and two-way ANOVA were performed. Ethical approval and informed consent were obtained. Strong positive correlations were observed between all health literacy and sustainable healthcare dimensions (r = .776, p < .001). Regression analysis showed that health literacy collectively predicted 60.3% of the variance in sustainable healthcare attitudes (F(3,648) = 328.147, p < .001), with information literacy representing the strongest predictor (β = 0.349). Residence demonstrated a significant effect favoring urban students (p < .001), while gender showed no significant influence. Findings highlight that students with stronger meaning-making capacities, reflective awareness, and ability to interpret information demonstrated more developed sustainability attitudes and intentions, with the behavioral dimension reflecting self-reported intentions rather than observed behaviors. Health literacy is strongly associated with sustainability attitudes among future nurses. Integrating literacy-enhancing pedagogies may strengthen environmental stewardship, ethical responsibility, and holistic care orientations within nursing curricula.
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.
Virtual interventions for patients with substance use disorders (SUDs), including intensive outpatient treatment, were developed during the COVID-19 pandemic and later maintained in some clinical settings. However, the effectiveness of this type of intervention in healthcare professionals (HPs) has not been studied so far. This is a quasi-experimental cohort study with both retrospective and prospective data comparing the main treatment outcomes of HPs in treatment for SUDs: (1) 29 patients following a 40-hour synchronous virtual group intervention; and, (2) 31 patients following a an 80-hour in-person group psychotherapy. They both underwent in-person psychiatric and psychological individual treatment as well as addictive drug use monitoring. Logistic regression analyses were performed to find predictors of abstinence from addictive substances and of working status. A Cox proportional hazards regression was used to compare time to first lapse (positive addictive drug use monitoring). Satisfaction rates at the end of each intervention were also compared in both groups using a non-parametric test. The sample consisted of 60 HPs, with a mean age of 49.5 years (range: 30-67). Of these, 53.3% (n = 32) were women. Physicians represented 53.3% of all patients. Patients in the virtual group were more likely to be working during the intervention compared with those in the in-person group. At one-year follow-up, 55% of the sample remained abstinent from addictive substances. After multivariate analysis, the type of intervention did not predict abstinence when controlling for other variables, although having dual diagnosis was inversely correlated with remaining abstinent (OR: 0.24; 95% CI: 0.07-0.85). HPs receiving in-person intervention were more likely to be working one year after the treatment (OR = 8.3; 95% CI: 2.1-33.3). Time to first lapse was similar between groups, although the in-person sample showed a more heterogeneous distribution. Satisfaction rates were similar in both groups. Virtual interventions may be an effective alternative to in-person interventions for HPs with SUDs. More studies are needed to more deeply analyze these preliminary findings.
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Somalia has one of the lowest childhood immunization coverage rates globally, with only 34.8% of children aged 0-59 months having received at least one vaccine and a high burden of zero-dose children. Immunization uptake is influenced by socioeconomic, maternal, healthcare access, and geographic factors. This study examined determinants of childhood immunization coverage in Somalia to inform equity-focused strategies. A cross-sectional analysis was conducted using nationally representative data from the 2020 Somalia Demographic and Health Survey (SDHS), including 7,373 mother-child pairs. bivariate and multivariable logistic regression models assessed associations between sociodemographic, economic, maternal, healthcare access, and geographic characteristics and child vaccination status, accounting for survey design and confounders. Overall vaccination coverage was 34.8%. Health facility delivery was the strongest independent predictor (AOR = 1.93; 95% CI:1.68-2.22; p < 0.001). Children from the highest household wealth quintile had higher odds than the poorest (AOR = 2.45; 95% CI:2.00-3.00; p < 0.001). Maternal primary and secondary education were positively associated with vaccination (AOR = 1.58; 95% CI:1.34-1.87 and AOR = 1.94; 95% CI:1.40-2.67; respectively; p < 0.001). Nomadic residence was associated with higher odds compared with rural residence (AOR = 1.69; 95% CI:1.46-1.96; p < 0.001). Compared with infants aged 0-11 months, children aged 12-23 months (AOR = 1.36; 95% CI:1.10-1.69; p = 0.005) and 24-59 months (AOR = 1.33; 95% CI:1.12-1.59; p = 0.001) were more likely to be vaccinated. Lack of radio exposure was associated with lower vaccination odds (AOR = 0.64; 95% CI:0.50-0.82; p < 0.001). Children living in Gedo region had markedly lower odds of vaccination than those in Awdal region (AOR = 0.26; 95% CI:0.17-0.39; p < 0.001). Childhood immunization coverage in Somalia remains critically low, reflecting socioeconomic, maternal, healthcare access, and geographic inequalities that require strategies targeting disadvantaged populations and regions.
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.
Previous studies have not demonstrated sufficient effects of intensive care unit (ICU) follow-up clinics on health-related quality of life. This may also be influenced by the design and implementation of these studies. Feasibility and context of such studies have yet to be sufficiently researched. It is therefore crucial to investigate these contextual factors. This study aimed to explore the experiences of patients, relatives, and healthcare professionals with both the randomised controlled trial (RCT) and the ICU follow-up clinic, to assess the feasibility and acceptability of the intervention and the study design from the perspectives of those involved. This qualitative research was embedded in the process evaluation of a pilot RCT on an ICU follow-up clinic. We conducted 18 semi-structured interviews with former ICU patients, relatives and the clinical study team who participated in the PINA study and used field notes from the clinical study team. Data analysis was carried out using qualitative content analysis. The pilot RCT was well received by potential patients and their relatives, and the motivation to participate was high, as was the motivation of the clinical study team. The main benefits of the ICU follow-up clinic intervention named by participants were being taken seriously and receiving referrals that they would not typically get from a general practitioner. The offer of home visits for patients with long travel distances to the ICU follow-up clinic was highly appreciated. It was feasible to integrate the perspectives of patients, relatives, and healthcare professionals within a pilot RCT on an ICU follow-up clinic. Across all stakeholder groups, the ICU follow-up clinic and the RCT trial design were considered acceptable and valuable, suggesting that such follow-up care meets patient needs and that a large-scale study appears feasible. ClinicalTrials.gov US NLM, NCT04186468, Submission: 02/12/2019, Registration: 04/12/2019, https://clinicaltrials.gov/ct2/show/NCT04186468.
Nurses, as central providers of healthcare, face considerable occupational stress that threatens both their well-being and the quality of patient care. This study investigates the relationship between caring stress management and quality of working life (QWL) among Iranian nurses, with a focus on the mediating role of hope. Using a cross-sectional design, 300 nurses from two Tehran hospitals completed validated instruments measuring Caring stress management, QWL, and hope. Data were analyzed with SPSS and AMOS, employing structural equation modeling and bootstrapping methods. Structural equation modeling revealed that caring stress management significantly predicted hope (β = 0.65, p < 0.001), and hope significantly predicted quality of working life (β = 0.45, p < 0.001). The direct effect of caring stress management on quality of working life was significant (β = 0.38, p < 0.001), and the indirect effect through hope was also significant (β = 0.29, 95% CI [0.23, 0.36], p < 0.001), confirming hope's partial mediating role. The model demonstrated good fit (χ²/df = 1.95, CFI = 0.96, RMSEA = 0.05). Findings highlight that caring stress management is not only directly associated with quality of working life but is also indirectly associated with it through higher levels of hope. These results underscore the importance of implementing caring stress management and hope-promoting strategies to support nurses' psychological resilience, which is linked to better quality of working life and healthcare outcomes. Not applicable.
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.
Compassion fatigue is an occupational hazard among nurses that arises from prolonged exposure to patient suffering and to work-related stress. In resource-limited healthcare settings, such as public district hospitals in Bangladesh, high patient loads, staffing shortages, and limited organizational support may increase nurses' vulnerability to CF. However, evidence from district-level hospitals in low- and middle-income countries is limited. A cross-sectional study was conducted between January and June 2025 among nurses working at a 250-bedded district hospital in Bangladesh. Using stratified random sampling, 380 nurses from the medicine, surgery, pediatrics, and intensive care/emergency units were recruited. Compassion fatigue was assessed using the Professional Quality of Life Scale (ProQOL-5). Descriptive statistics were used to estimate the prevalence. Chi-square tests and multivariate logistic regression were performed to identify the demographic and occupational predictors of high compassion fatigue. Overall, 44.2% of nurses reported high compassion fatigue, and 37.6% reported moderate levels. The highest prevalence was observed among nurses working in intensive care/emergency units (52%). Multivariate analysis identified lack of organizational support (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.6-4.1), more than 10 years of service (OR 2.3, 95% CI 1.4-3.8), and intensive care/emergency assignment (OR 1.9, 95% CI 1.2-2.9) as significant predictors of high compassion fatigue scores. Subscale analyses indicated higher burnout and secondary traumatic stress among nurses working in high-acuity departments. Compassion fatigue is highly prevalent among nurses in a resource-limited district hospital in Bangladesh, particularly among those working in high-acuity settings and those reporting insufficient organizational support. These findings highlight the need for targeted organizational strategies, including improved support systems, workload management, and mental health interventions, to promote nurses' well-being and sustain quality patient care in similar healthcare contexts.
Patients recently hospitalized for heart failure (HF) face a high risk of readmission and mortality. Remote monitoring programs (RMPs) may offer a scalable, non-invasive strategy to improve outcomes in this vulnerable population. This prespecified sub-analysis of the TELESAT-HF study included HF patients with at least one HF-related hospitalization in the year preceding study entry. Patients enrolled in the RMP and controls were identified from the French national health database. Controls were then weighted to create a group comparable to the RMP group. The primary endpoint was all-cause mortality, while secondary endpoints included HF-related rehospitalizations and cumulative days spent in hospital. Healthcare costs were also explored. After weighting, ∼1258 patients managed with RMP (mean age 73 years, 33% women) and ∼2321 controls were included. Compared with SoC, RMP was associated with a lower risk of all-cause mortality (23.5% vs. 39.6%; HR 0.54, [95%CI 0.47; 0.63]; P < .001), a lower rate of HF-related hospitalizations (rate ratio: 0.85, [95%CI 0.78; 0.94]; P = .002), including fewer admissions via emergency departments (-32%), reduced need of intensive care (-35%), and fewer cumulative days spent in hospital (estimated absolute difference: -1.77, [95%CI -2.81; -0.72] days; P < .001). Mean total healthcare costs did not differ significantly between groups at 6, 12, or 24 months, despite numerically higher costs in the RMP group at later time points. Subgroup analyses showed consistent associations across age, sex, RMP modality, and the number of prior HF hospitalizations. Among patients recently hospitalized for HF, participation in a non-invasive RMP was associated with lower mortality, fewer HF rehospitalizations, less time spent in hospital, and a broadly cost-neutral profile. These findings support the potential role of RMP as part of routine post-discharge HF care.
Hospitalization often imposes significant psychological and physiological demands on patients. Mandala coloring may help reduce these challenges. This meta-analysis aimed to evaluate the effectiveness of mandala coloring interventions across psychological and physiological symptoms in adult hospitalized patients. A comprehensive search was conducted using nine databases. Randomized controlled and controlled studies comparing mandala coloring with control groups were included. Data extraction was performed independently by two authors, and risk of bias was assessed using the Cochrane RoB tool. GRADE Pro software was used to assess the quality of the evidence. Standardized mean differences (SMD) with 95% confidence intervals (CIs) were pooled using RevMan (version 5.4). Subgroup analyses were performed by session frequency and duration. Seventeen studies with a total of 987 participants were included. Mandala coloring significantly reduced anxiety (SMD = - 2.16, 95% CI [-3.38, - 0.95]) and stress (SMD = - 2.45, 95% CI [-3.06, - 1.85]). Improvements were also observed in well-being (SMD = 4.51, 95% CI [0.81, 8.21]) and hope (SMD = 0.42, 95% CI [0.09, 0.75]). No significant effects were found for resilience, pain, fatigue, nausea, comfort, or vital parameters. Subgroup analyses indicated that brief (≤ 30 min) and multiple-session interventions were especially effective in alleviating anxiety. The level of evidence, as assessed using GRADE, was, however, low. Mandala coloring provides nurses and healthcare professionals with an inexpensive, low-resource, and patient-friendly method to enhance psychological well-being during hospitalization. Incorporating short, repeated sessions into routine care may strengthen resilience and patient comfort. Further large-scale and high-quality trials are required to establish standardized protocols and clarify effects on physiological symptoms. PROSPERO meta-analysis registration: CRD420251130565.
Understanding the supply-demand relationship of medical services is essential for regional planning. Existing city-scale studies typically exclude cross-city flows, whereas national-scale studies often overlook intra-city heterogeneity. In urban agglomerations, healthcare resources and transport infrastructure are usually planned by cities, although patients may cross city boundaries to seek care. The implications of cross-city trips for regional medical services remain insufficiently understood. Taking the Pearl River Delta as a case, this study investigates cross-city hospital visiting trips and their implications for medical service evaluation. Using 91.2 million automobile navigation records collected in 2019, 1.37 million hospital visiting trips to Grade 3 hospitals were identified through a modified spatial join method. A population-hospital bipartite network and a multi-scale analytical framework were constructed. Cross-city demand and supply indices were developed at the city, subdistrict, and hospital scales to characterize cross-city medical service patterns and influencing factors. Accessibility and Gini coefficients were computed under intra-city and regional evaluation scenarios to assess how incorporating cross-city hospital visiting trips affects medical service evaluation. Based on automobile navigation data, 9.1% of identified hospital visiting trips crossed city boundaries. Guangzhou and Shenzhen served as dominant regional suppliers, with cross-city supply indices of 55.9% and 21.8%, respectively. Cross-city demand was negatively associated with distance to boundary, GDP per capita, and hospital beds. Cross-city service share was negatively associated with distance to boundary, whereas contributions to regional cross-city service provision were positively associated with hospital size and hospital grade. Incorporating cross-city flows increased accessibility in most peripheral areas and reduced the regional population-weighted Gini coefficient from 0.596 to 0.522. Based on automobile navigation data, cross-city hospital visiting trips constitute an important component of medical service utilization in urban agglomerations. At the subdistrict scale, cross-city demand was jointly associated with boundary proximity and local economic and medical conditions. At the hospital scale, the cross-city service share was higher among hospitals closer to city boundaries, whereas contributions to regional cross-city medical service provision were greater among larger and higher-grade hospitals. Evaluation frameworks relying solely on intra-city data tend to underestimate accessibility in boundary areas and, in most cases, overestimate the Gini coefficient.
Accurate hospital bed occupancy forecasting is essential for effective resource planning and patient flow management. While complex machine learning models have gained popularity in healthcare forecasting, their operational utility often falls short due to high maintenance costs and limited interpretability. This study evaluates the performance and practicality of Prophet, a parsimonious time-series model, for mid-term hospital bed occupancy forecasting. We applied the Prophet model to daily bed occupancy data from the Medical Center - University of Freiburg (2010-2023), incorporating public holidays and a COVID-19 pandemic indicator as exogenous regressors. Prophet decomposes time series into trend, seasonality, and holiday effects, offering interpretable components. Forecast accuracy was assessed via rolling cross-validation over 2022-2023 for horizons of 30, 60, 90, and 180 days. A production-ready forecasting pipeline and dashboard were also implemented using cloud-native tools. Prophet achieved low MAPE values across all horizons (3.21%-3.53%) with coverage above 80%, demonstrating reliable accuracy comparable to or better than more complex models that often require higher computational resources and operational costs, such as deep neural networks. Component analysis revealed patterns aligned with hospital operations; weekly and yearly cycles, and holiday effects, highlighting the model's interpretability. This study shows that mid-term hospital bed occupancy can be accurately forecasted using a simple, interpretable model like Prophet. In contrast to more complex architectures, Prophet offers robust performance with minimal tuning, faster deployment, and clearer insights that are critical in operational settings. These findings reinforce the argument that, for structured forecasting tasks like bed occupancy, simple models can rival complex ones, not only in accuracy, but also in reproducibility, scalability, and operational value.
In the complex and dynamic landscape of healthcare, preventing medical disputes has become a critical aspect of medical practice. Medical disputes often arise from miscommunication, medical errors, or unmet patient expectations, leading to a breakdown in the doctor-patient relationship and potentially resulting in litigation. Despite the growing recognition of the importance of dispute prevention, current medical education often lacks comprehensive training in communication and conflict resolution. This study aims to explore the feasibility and preliminary educational effects of integrating Objective Structured Clinical Examinations (OSCE) into medical education to enhance medical students' ability to prevent and manage medical disputes. This quasi-experimental pilot study involved 24 sixth-year medical students from Chang Gung University, divided into two groups: one received traditional classroom instruction on medical dispute prevention, while the other participated in formative OSCE-based simulation sessions. Both groups later underwent a summative OSCE. Group allocation was based on existing timetable assignments; no randomisation was performed. Data were collected through MCQ assessments, OSCE performance scores, and a semi-structured group interview conducted by an independent researcher, recorded and transcribed verbatim. Quantitative data were analysed using descriptive statistics, paired t-tests, and ANOVA; qualitative data were analysed using thematic analysis. The results suggested preliminary improvements in students' ability to manage and prevent medical disputes following simulation-based familiarisation. The simulation group demonstrated higher scores across all five OSCE communication domains: rapport building (18.4 ± 1.3 vs. 16.2 ± 1.8, p = 0.004), issue identification (17.9 ± 1.2 vs. 15.7 ± 1.9, p = 0.007), active listening (17.5 ± 1.5 vs. 14.8 ± 2.2, p = 0.002), patient-centred language (17.8 ± 1.6 vs. 15.6 ± 2.0, p = 0.006), and respectful discussion of sensitive topics (17.7 ± 1.4 vs. 15.2 ± 2.3, p = 0.003). MCQ scores showed greater gains in the simulation group (pre = 72.5 ± 6.4; post = 85.3 ± 5.8) than in the traditional instruction group (pre = 73.1 ± 7.2; post = 79.4 ± 6.6). Qualitative findings revealed three themes: learning effectiveness, course evaluation, and confidence levels. Students in the simulation group perceived OSCE-based training as more realistic and described increased confidence in handling disputes. This pilot study provides preliminary evidence that simulation-based familiarisation using formative OSCEs may support the development of medico-legal communication and dispute prevention competencies in senior medical students. As a pilot study with a non-randomised design and small sample size, these findings should be interpreted as exploratory and hypothesis-generating. A key limitation is that the simulation group practised in the identical format as the summative assessment, which may confer a rehearsal advantage independent of genuine learning. Larger randomised studies are needed before broader curricular implementation can be recommended.
Children and adolescents presenting with acute behavioral agitation are increasingly admitted to pediatric emergency departments. Agitation management requires a structured and multidisciplinary approach that integrates effective communication strategies with pharmacological and non-pharmacological interventions. However, evidence-based guidance in this field remains limited, and healthcare professionals' knowledge and training levels are heterogeneous. This study aimed to evaluate the impact of a structured training program on pediatric and child psychiatry residents' knowledge and perceived self-efficacy in the management of agitation. This quasi-experimental educational study was conducted in a tertiary pediatric emergency department between January and August 2025. A total of 39 physicians, including pediatric residents, pediatric emergency medicine fellows, and child psychiatry residents, participated in a training program developed using the ADDIE instructional design model. The program combined theoretical instruction with case-based workshops focusing on verbal de-escalation, pharmacological management, and ethical application of physical restraint. Knowledge and self-efficacy were assessed before and after the intervention using structured questionnaires. Thirty-nine physicians completed the study. Post-test knowledge scores were significantly higher than pre-test scores (Z = - 3.56; p < 0.001; r = 0.56), and score improvement was observed in 64.1% of participants. No significant association was found between professional experience and pre-test or post-test scores; however, a significant negative correlation was identified between professional experience and score difference (post-test - pre-test) (r = - 0.480; p = 0.002). This finding indicates that participants with lower baseline knowledge levels achieved greater gains from the training. Structured, case-based, and multidisciplinary training significantly enhances physicians' knowledge and self-efficacy in managing agitated pediatric patients in emergency settings. These findings demonstrate that systematically designed, institution-specific training programs can support physician competency in pediatric emergency departments.
Parkinson's disease (PD) remains underdiagnosed in Thailand, and its rising prevalence presents a growing challenge for the healthcare system. The previously validated CheckPD digital population screening platform has been implemented nationally in collaboration with the Thai Red Cross Society (TRCS) and the National Health Security Office (NHSO), enabling integration of digital PD risk screening into preventive health frameworks. To evaluate the early phase of a national rollout of the CheckPD platform, focusing on population reach, adoption, predictive performance, exploratory usability, and implementation factors influencing scalability across diverse real-world settings. This RE-AIM-guided implementation study in 10 Thai provinces assessed reach, adoption, completion, system performance and positive predictive value among neurologist-evaluated screen-positive participants. Preliminary usability was assessed in 30 post-screening completers using the SUS and UEQ-S. Supplementary implementation feedback was collected from Village Health Volunteers and public health officers. Between January 2024 and October 2025, 13,381 out of 18,520 users completed screening across 10 provinces (completion rate: 72.3%). The mean SUS score was 83, with a 92% first-time task completion rate. Programme reach was achieved through multiple channels, including Village Health Volunteers (6,742 participants), community field campaigns (5,207), facilitated online training initiatives (3,448), and self-initiated app downloads (3,123). When compared with neurologists' diagnoses among 730 screen-positive participants who underwent evaluation, the screening demonstrated a positive predictive value of 81.23% (593/730; 95% CI 78.39%-84.07%). Key facilitators of implementation included TRCS endorsement and network support, community volunteer engagement, and user-centred app design. Exploratory multivariable logistic regression analysis identified educational attainment and geographic context as significant predictors of screening completion, with higher educational attainment and residence outside Bangkok associated with a higher likelihood of completing the screening workflow. The CheckPD programme demonstrates that national-scale digital screening for neurological disorders is feasible in a low-to-middle-income country when embedded within trusted institutions, supported by community networks, and aligned with data protection standards. Thailand's experience provides an early, promising, and potentially scalable model for implementing population-level improvements in brain health by enabling earlier detection and assessment of individuals at risk, in alignment with the World Health Organization's Brain Health framework.