BMC Health Services Research

Improving primary care is a long-standing strategy to constrain health care spending. Yet, evaluations of primary care models focused on payment reform have shown minimal effects on total cost of care. We report the results from a large-scale, real-world evaluation of an advanced primary care model that restructures access through same-day and next-day appointments, on-demand video visits, asynchronous clinician messaging, and extended hours. Using a stacked-cohort difference-in-differences design with entropy balancing and inverse probability of censoring weighting, we analyzed multi-payer claims covering April 2022 through March 2025. Advanced primary care use was associated with an 8.6% reduction in total cost of care (-$729 per patient per year; P = 0.004), driven by lower specialist cost (-$939/year; P < 0.001) and, to a lesser degree, by reductions in inpatient (-$134/year; P < 0.001), urgent care (-$70/year; P < 0.001), and emergency department cost (-$16/year; P = 0.02), partially offset by higher primary care cost (+$350/year; P < 0.001). The specialist reduction was concentrated in knowledge-based consultative encounters (-$663/year; P < 0.001), while procedural specialist cost was largely unchanged (-$276/year; P = 0.09). Cost differences emerged in the first post-index month. These findings suggest that advanced primary care may reduce total health care spending, with observed savings driven primarily by lower spending on consultative specialty care.

Introduction: Antimicrobial resistance poses a major global health threat, yet evidence on its economic impact in low- and middle-income countries remains limited. This study estimated the economic burden of infections caused by ESBL-producing Escherichia coli (E. coli), a key resistant pathogen, in Laos. Methods: A prospective cost-of-illness study was conducted among patients with laboratory-confirmed infections in Setthathirath hospital in Vientiane, Laos, collecting cost data through repeated interviews and medical records. Descriptive analyses and econometric modeling approaches, including inverse probability weighting (IPW) and instrumental variable (IV) analyses, were used to estimate out-of-pocket expenditures, public expenditures, total cost of illness, and length of stay, accounting for potential confounding. Results: ESBL-producing E. coli was consistently associated with higher economic burden across all analyses. The unadjusted per-patient cost was US$ 689.0 for ESBL-producing E. coli, compared with US$ 489.4 for non-ESBL-producing E. coli and US$ 537.6 for non-E. coli. The association remained statistically significant for out-of-pocket cost after IPW-adjustment (US$156.2; 95% CI, 14.3 to 298.1; P = 0.03), while other outcomes were not statistically significant. Instrumental variable analyses showed consistent directional effects but with wide confidence intervals and no statistically significant differences. Conclusions: Findings suggest that ESBL-producing E. coli may be associated with increased economic burden in Laos; however, this association was not consistently statistically robust across analytical approaches. These findings suggest a potential economic impact of ESBL infection, although uncertainty remains regarding the magnitude of the effect. Strengthening antimicrobial stewardship, infection prevention and control, and improved diagnostic capacity remain essential to mitigate the potential AMR burden.

Objectives Emergency Department (ED) crowding is an international concern, predominantly caused by 'exit block', the lack of availability of inpatient beds for those requiring admission. The implementation of Flow Navigation Centre Plus (FNC+) services in Scotland aimed to reduce self-presentation to EDs and reduce crowding by providing remote clinical assessment for patients contacting urgent care by telephone and professional-to-professional advice on patient pathways, but their effectiveness is unknown. This study aimed to estimate the effect of board-wide implementation of FNC+ on ED attendances and long waits during the first year of FNC+ operation. Methods Controlled interrupted time series using weekly, publicly reported Public Health Scotland data. The intervention was implementation of the FNC+ in NHS Lanarkshire on 1 April 2024. Counts were summed across constituent sites and percentages derived from board totals. Co-primary outcomes were ED attendance volume and the proportions of attendances spending more than 4, 8 and 12 hours in the department. Segmented regression was fitted with contemporaneous control boards, seasonal terms, and accounted for autoregression. Results 118 pre-intervention and 52 post-intervention weeks were analysed across all 3 EDs in the implementing board. Attendances showed no detectable step change (+1.20%; 95%CIs -0.66 to +3.10) relative to the counterfactual. The estimated effect increased across follow-up, however, changing by +3.95% over 52 weeks (95% CI +0.36 to +7.67%). There was no significant step change in the proportion of attendances waiting more than 4 hours following the intervention (+1.74%; 95%CIs -0.71 to 4.20%). Some transition and structural sensitivity analyses demonstrated significant deteriorations in ED performance, and increased attendances, in the year following implementation, and none demonstrated improvements. Conclusions Board-wide implementation of a Flow Navigation Centre Plus was not associated with a step change in ED attendances or in long waits, but there is some evidence that attendances increased and long waits increased in the year following implementation. Their provision of supply-sensitive care is a possible mechanism. Additionally, given their action at the point of input, aiming to divert patients from ED attendance, it is unlikely that such services could relieve a constraint due to exit block, the availability of inpatient care for those requiring admission.

Objectives: To evaluate the sustainability of Lean Healthcare practices after the implementation phase of a national quality improvement programme and to identify organisational factors associated with maintaining results over time. Design: Multicentre cross-sectional study with a mixed-methods approach. Setting: Twelve public and philanthropic hospitals in Brazil participating in Phase 2 of the Lean in Emergency Departments Project. Participants: Key respondents in managerial or leadership roles from participating hospitals (response rate: 75.0%). Outcome measures: Sustainability of Lean practices and organisational readiness, assessed through a structured survey and triangulated with operational indicators collected across successive implementation cycles at hospital level. Results: During one year of structured follow-up, 66.7% of respondents reported maintenance of Lean practices; this decreased to 33.3% after the end of structured follow-up. Although 66.7% considered professionals capable of maintaining results, only 58.3% positively evaluated institutional structure, indicating a discrepancy between individual capacity and organisational readiness. Operational indicators showed heterogeneous behaviour across hospitals, with no consistent pattern of sustained improvement. Qualitative analysis identified professional and managerial turnover, formal governance structures, and continuous monitoring as key factors associated with sustainability. Conclusions: The sustainability of Lean Healthcare practices is more strongly associated with institutional capacity to embed and sustain changes over time than with isolated individual training. Quality improvement programmes should incorporate structured strategies for the post-implementation phase. Keywords: Lean Healthcare; Sustainability; Quality improvement; Hospital flow; Health systems; Organisational factors

Health facilities (HFs) routinely administer medicines and are expected to ensure patient safety by detecting, reporting, investigating, and analysing adverse events following exposure to drugs (AEFED). This study aimed to assess the implementation of pharmacovigilance activities in referral and regional health facilities in Cameroon and to identify pharmacovigilance training needs among healthcare personnel (HP). This was a cross-sectional descriptive study targeting referral and regional health facilities and healthcare personnel involved in patient care and pharmacovigilance activities in Cameroon. Health facilities were selected using stratified purposive sampling, while healthcare personnel were selected through exhaustive sampling. Data were collected using semi-structured electronic questionnaires administered face-to-face by trained enumerators. The questionnaires assessed the organization, resources, and implementation of pharmacovigilance activities at health facilities, as well as healthcare personnel knowledge of pharmacovigilance concepts, previous training, and perceived training needs. Of the 14 eligible health facilities, 10 (71.4%) consented to participate in the study. Of the 10 health facilities, 4 (40.0%) had an established pharmacovigilance unit, while 3 (30.0%) reported conducting neither detection nor notification activities. Among the 261 healthcare personnel approached, 214 (81.9%) participated. Only 41.6% had needed knowledge to detect an adverse event, while 72.9% were aware of adverse event notification procedures. Previous exposure to pharmacovigilance training was reported by 37.9% of healthcare personnel, and all participants expressed a need for additional training, particularly on national pharmacovigilance regulations (69.2%), organization of the pharmacovigilance system (67.3%), and adverse event detection (67.3%). The main reported challenges by healthcare personnel in the implementation of pharmacovigilance activities included insufficient budget allocation, limited access to pharmacovigilance training, lack of pharmacovigilance guidelines and insufficient qualified human resources. Pharmacovigilance implementation in referral and regional health facilities in Cameroon remains limited, with gaps in organizational structures, resources, healthcare personnel knowledge, and training. Strengthening pharmacovigilance systems through improved facility capacity, availability of essential tools, and targeted healthcare personnel training is needed to enhance drug safety surveillance.

Background The number of novel cancer therapies approved for use in England by the National Institute for Health and Care Excellence is increasing. Monitoring the adoption of new therapies is important to assess equity of access and evaluate real-world prescribing practices. OpenPrescribing Hospitals has recently been launched to facilitate analysis of open secondary care medicines data in England. Using this platform, we set out to describe the use of cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, including the frequency of dose reductions, within National Health Service (NHS) hospitals in England between January 2019 and December 2024. Methods The monthly proportion of each CDK4/6 inhibitor relative to total CDK4/6 inhibitor use was calculated at hospital level. Regional variation was assessed across Cancer Alliances by comparing the proportions of each CDK4/6 inhibitor used within each alliance in 2021 and 2024. Use of lower strength palbociclib and abemaciclib was used as a proxy for dose reductions. Findings There was more than a 3-fold increase in the use of CDK4/6 inhibitors between 2019 and 2024. In 2019, 78.6%, 11.9% and 9.5% of CDK4/6 inhibitors used were palbociclib, abemaciclib and ribociclib, compared with 40.2%, 41.2% and 18.6% in 2024. There was variation in the relative percentage change in use of each agent by Cancer Alliance. Use of lower strengths was common for both palbociclib (60%) and abemaciclib (63%). Interpretation Changes in usage appeared responsive to publication of key evidence and regulatory milestones. There was a higher apparent frequency of dose reductions than reported in clinical trials. OpenPrescribing Hospitals is an accessible, publicly available tool for understanding uptake and use of medicines in NHS hospitals in England.

Antimicrobial resistance is a growing threat to health systems, but stewardship programs must compete for funding with many urgent health priorities in low- and middle-income countries. Evidence that quantifies not only effectiveness but also economic value is therefore essential for policy and budget decisions. We evaluated targeted antimicrobial stewardship programs in four tertiary hospitals in Nepal and Laos using interrupted time-series analyses of antibiotic use, combined with micro-costing to estimate benefit-cost ratios. Stewardship was associated with immediate reductions in antibiotic use across the three Nepal hospitals, whereas effects in Laos were more heterogeneous. Economic returns were positive across sites, with the largest returns observed in the private hospital in Nepal. Here, we show that pragmatic, ward-focused stewardship can reduce antibiotic use and generate measurable economic value in resource-constrained hospital settings, supporting its prioritization as a scalable investment for antimicrobial resistance control.

Background Decision-making in emergency services involving the allocation of scarce resources is a key challenge for large, complex organisations required to prioritise demand against multiple, often competing criteria. Emergency Medical Dispatch is a case in point, where Enhanced and Critical Care Teams (ECCTs) represent a scarce and lifesaving clinical resource. Despite its operational and system-level significance, the allocation of ECCTs remains under-researched. Methods We conducted a methodological development study using the P.A.T.H.S. framework (Participants, Artefacts, Transition Stages, Historicity, Setting). We designed and piloted this in our previous work under the 999 R.E.S.P.O.N.D. project, which examined the decision-making process for ECCT dispatch. We applied P.A.T.H.S. to 17 dispatch cases (comprising 100 decision-making episodes). We analysed five data sources: recordings of emergency calls and internal dispatch-related interactions, sequence-of-events records, policy documents, and ethnographic observations. A four-phase analysis--indexing & data mapping, transcription & coding, charting, and synthesising & outputs--was undertaken taking Interactional Sociolinguistics as the theoretical approach and methodology. Results P.A.T.H.S. enables the mapping of non-linear, multifactorial textual trajectories across human and non-human actors. The case example presented herein illustrates how information on key risk indicators (e.g. mechanism of injury) were often delayed, fragmented, or lost between the caller, call-handler, and written records. P.A.T.H.S. provides a framework and analytical tool capturing the textual trajectory of information flow, and trace how dispatch decision making unfolds. We subsequently developed a template and codebook for other researchers to further study complex decision making in multi-actoral systems using a textual trajectory approach. Conclusion This methodological development work demonstrates the potential of P.A.T.H.S. to capture and clarify complex decision-making processes. P.A.T.H.S. offers a practical and theoretically grounded framework for future research, training, and policy that addresses risk points in communication between oral and written forms among teams of actors, to support optimal deployment of scarce resources.

Background Emergency Department (ED) crowding is an international crisis primarily driven by exit block. Point of care (POC) cardiac biomarker testing and reduced sampling intervals have been proposed to mitigate crowding by improving throughput, but whole-ED operational impacts remain poorly understood, and evaluations often rely on vulnerable observational designs. This study aimed to assess whether introducing POC high-sensitivity troponin testing and reduced sampling intervals changed whole-ED flow metrics, and to test the robustness of interrupted time series (ITS) methodology in this setting. Methods A multi-centre controlled interrupted time series (CITS) across two large urban intervention EDs and one untreated control ED in Glasgow, UK. The intervention combined whole-blood POC high-sensitivity troponin testing with a reduction in sampling intervals from 3 to 2 hours. Outcomes included daily ED admissions, mean occupancy, maximum occupancy, and mean length of stay. Analyses used a window of 120 days either side of each implementation date. Effects were evaluated using segmented ITS models, with and without controls, with permutation tests against 147 pre-intervention placebo dates. The minimum detectable effects of a similar study, applied to a national dataset, were simulated. Results Across 483,412 presentations to the intervention sites, the intervention produced no statistically significant change in any whole-ED flow metric against the untreated control at either site. Analysed alone, one intervention site appeared to show reductions in mean occupancy (-6.08, 95% CI -12.04 to -0.12) and maximum occupancy (-7.60, -14.47 to -0.73); the untreated control department produced reductions in the same direction at the same date, and both estimates attenuated to the null once the control was applied. Under a pre-specified 14-day transition specification the reductions in the untreated department reached statistical significance while those at the treated site did not. The study was limited by power due to the study window and limited control pool. Simulation demonstrated that a national dataset has the potential to provide operationally feasible and clinically important findings. Conclusion POC cardiac biomarker testing and reduced sampling intervals did not detectably improve whole-ED flow, though the design was underpowered. More importantly, uncontrolled ITS designs are highly vulnerable to confounding in complex healthcare systems; evaluations of operational interventions must utilise concurrent controls, and routinely report falsification tests.

Background: While critical care pharmacists (CCPs) are broadly associated with improvements in outcomes for critically ill patients, operationalizing staffing in the intensive care unit (ICU) requires further study. The purpose of this evaluation was to determine the relationship of a CCP on interprofessional rounds for weekday admissions of ICU patients on patient-centered outcomes. Methods: This post-hoc analysis of the Optimizing Pharmacist-Team Integration for ICU Patient Management (OPTIM) study included adults admitted to an ICU on a weekday in the multicenter observational study. The primary outcome was in-hospital mortality. The primary exposure was level of comprehensive medication management (CMM) during the first 24 hours of ICU stay. A secondary exposure was pharmacist-to-patient ratio. Multivariable generalized estimating equations (GEE) were used to estimate associations between mortality and patient, ICU, and institution variables. Fine-Gray sub-distribution hazards regression estimated hazard of discharge alive (HDA) from the ICU and hospital and hazard of extubation alive. Results: 21,835 patients met inclusion criteria, and 76.1% of patients had CMM delivered on interprofessional rounds. Patients who had no CMM on the first ICU day had an increased risk of mortality of 23% (Odds Ratio (OR) 1.23, 95% Confidence Interval (CI) 1.04-1.46, p=0.02) compared to those who received CMM on interprofessional rounds. Patients with no CMM also had decreased HDA from the ICU and hospital and decreased hazard of extubation alive. No difference was seen in any outcomes when comparing other levels of CMM (CMM delivered outside of interprofessional rounds or abbreviated CMM) compared to CMM delivered on rounds. Conclusions: Absence of pharmacist CMM on the first day of ICU stay for patients with weekday admission was associated with an increased risk of in-hospital mortality, but no difference was seen in other levels of CMM: this signal supports further investigation in prospective analysis.

Background The 2023 South African antiretroviral therapy (ART) guidelines recommend dolutegravir-based ART for children and adolescents with HIV (CAWH) >4 weeks old, including transition to dolutegravir-based ART if previously taking another regimen. Objectives We audited uptake of dolutegravir-based ART, viral load (VL) testing, and viral suppression among CAWH in care in eThekwini, South Africa. We also aimed to assess and improve the quality of routinely collected ART and VL data in the national HIV electronic register (TIER.Net) in this population. Methods We used TIER.Net line lists to identify CAWH aged [&le;]19 years in care in 54 eThekwini Municipality clinics between February and July 2025. CAWH who had died, transferred out, or were lost to follow-up were excluded. We reviewed clinical files and TIER.Net records simultaneously to compare all recorded ART regimens and recent (last 12 months) VL results. High or missing VLs were flagged for medical review, and data discrepancies were corrected. Results Among 3838 eligible CAWH, we reviewed files of 3379 (88%). 1991 (59%) were female and 2812 (83%) were aged 10-19 years. All 3379 (100%) were receiving dolutegravir-based ART. 193 (6%) had no recent VL result. Of those who did, 303 (10%) had a last VL [&ge;]1000 copies/mL. We identified 941 (28%), 438 (13%), and 199 (6%) TIER.Net data capture errors for ART regimens, ART regimen start/stop dates, or recent VLs, respectively. Conclusion This audit at 54 facilities showed complete transition to dolutegravir among reviewed files of CAWH in care, but highlighted gaps in viral suppression and documentation.

Background: Under the DRG/DIP payment reform, the cost structure and its driving factors for laparoscopic cholecystectomy (LC) in resource-limited plateau regions remain unclear. Methods: Based on a single-center cohort of 605 plateau LC patients from May 2020 to October 2025, natural log transformation was applied to total hospitalization costs. Pearson/Spearman correlation, multivariate linear regression (traditional clinical model vs system-driven model with year dummies), and quantile regression were used. Results: Mean hospitalization cost 8097.49+/-936.85 CNY, CV=11.6%, Gini=0.062, demonstrating high homogenization. Traditional six-variable clinical model yielded R^2=0.008 (F=0.78, P=0.587), no significant predictors. The system-driven model achieved R^2=0.143 (F=3.42, P=0.001), with year dummies as dominant predictors. The study proposes the SAO (System-Allocation-Outcome) paradigm to replace the traditional SPO framework.

Objectives Emergency department (ED) crowding is recognised as an important public health concern internationally, and is driven principally by exit block, the shortage of inpatient beds for patients requiring admission. This study aimed to evaluate whether a complex intervention targeting hospital occupancy improved ED patient flow, and quantified the change in attendances. Methods A controlled interrupted time series using weekly, publicly reported Public Health Scotland data from 1 January 2022 to 1 February 2026. The multi-component intervention focused on reducing hospital occupancy and included additional adult social care funding; engagement with regional social care providers; accelerated implementation of the Discharge without Delay programme; re-evaluation of whole-hospital escalation thresholds and response; resource and data supporting inpatient department reductions in length of stay; and additional investment in remote clinical assessment. The intervention commenced at a large tertiary ED on 01 February 2025. Primary outcomes were the proportions of attendances spending [&ge;]4, [&ge;]8 and [&ge;]12 hours in the ED. The secondary outcome was attendance volume. Segmented regression was fitted with a contemporaneous control series, seasonal terms and autoregressive moving average errors. Long waits were additionally illustrated as potentially avoided deaths. Results The analysis covered 161 pre-intervention and 52 post-intervention weeks. Relative to pre-intervention levels, the proportion of attendances waiting over 4 hours fell by 10.4% (95% CI 1.6 to 19.2%), by 16.4% (95%CI 1.3 to 31.5%) over 8 hours and by 24.3% (95%CI 2.6 to 46.1%) over 12 hours. Using established associations between long ED waits and excess mortality, by one-year the intervention was potentially associated with 54 fewer excess deaths (95%CI 19 to 93). Attendances rose by 3.8% (95%CI 1.3 to 6.4%) against the counterfactual. Conclusions A complex intervention targeting hospital occupancy was associated with a reduction in long ED waits despite rising attendances. Interventions addressing hospital occupancy can meaningfully improve ED crowding.

Objective: To assess the efficacy of an executive peer coaching program, Charting Champions Program (CCP), in helping physicians manage their administrative workload, thereby improving time management, workflow and well-being. Findings: In this longitudinal survey study, physicians self-reported significant improvements in completing charting and administrative paperwork during their clinical day. Physicians reported significant improvements in mental, cognitive and emotional states after the program. Meaning: The Charting Champions Program is an effective intervention that supports physicians in problem-solving the administrative burden of their clinical day, improving workflow efficiency, completing administrative requirements during clinical hours, and enhancing work-life balance and personal satisfaction. Background: Physicians are subject to high levels of mental, physical, and emotional stress, partly due to increasing administrative burdens. Online coaching is a proven intervention to help physicians improve workflow efficiency, reduce administrative burden and improve job satisfaction. Design: This voluntary longitudinal survey took place between 2020 and 2023. Physicians were asked to complete a survey at program entry and again 30-90 days after program completion. The survey consisted of 14 Likert scale questions, and a final sample of 280 physicians completed both surveys. Intervention: CCP contains modules that teach workflow improvements for clinical days, including timely charting, administrative task workflow, managing patient consultations and reducing interruptions. Interventions include self-paced modules, live coaching, recordings and an online peer community. Results: Post-CCP physicians reported a significant decrease in hours spent charting (P<0.0001) and completing clinical paperwork outside of clinical hours (P<0.006). Physicians also reported a decrease in work-related dread (P<0.001), feelings of burnout (P<0.001), and thoughts of quitting due to administrative burdens (P<0.001). Physicians felt more focused at work (P<0.001), felt more in control of the clinical day (P<0.001), and rated their mental energy at work higher (P<0.001). The program did not affect the number of patients seen in a full clinical day (P > 0.918). Conclusion and Relevance: The CCP reduces the time physicians spend on tasks outside of clinical hours, increasing free time without decreasing the number of patients seen per day.

Objective. Triage of rheumatology outpatient referrals is a high-volume administrative task that consumes senior specialist time without advancing patient care. The human triage system is only moderately accurate and reproducible. We assessed whether contemporary large language models (LLMs) are able to perform well enough to support automating this task in practice. In addition, the effects of different prompting techniques on triage accuracy and cost was assessed to help identify to optimal approach. Methods. Twenty referral scenarios spanning the urgency spectrum, based on real referrals were created by a certified Australian rheumatologist. Four rheumatologists triaged all cases independently and blinded, to produce a consensus reference standard. Twenty-three LLMs each triaged every referral into one of five urgency categories, three times (1380 outputs per condition). The experiment was run with a simple prompt and repeated with a advanced prompt supplying explicit triage expectations and worked examples. Results. All 2760 attempts returned valid categories. Under the simple prompt, performance separated into distinct tiers, larger models were more accurate (Spearman rho=0.42; P=.047) and accuracy tracked cost. Advanced prompting minimised between-model variance in accuracy 5.3-fold (0.014 to 0.003; Levene P=.01), abolished the size-accuracy association (rho=-0.05; P=.83) and removed the accuracy-cost relationship. Leading models matched expert consensus on most cases, within or above the range reported for human triage. Under-triage errors persisted with some LLMs. Conclusion. Contemporary LLMs categorise rheumatology referral urgency as well or better than published human triage systems. Advanced LLM prompting methods substitute for the reasoning capability of larger models, suggesting that LLM performance on this task may not require the most expensive models. The tools to automate this administrative task appear to already exist. Strong candidate LLMs that might serve a production ready solution have been identified.

Background. In 2025, the World Health Organization pre-qualified an integrated antenatal care (ANC) testing panel that tests for HIV (including p24 antigen and antibody), syphilis, and hepatitis B (HBV) with one finger prick. The panel would accelerate the triple elimination of vertically transmitted infections by shortening the HIV detection window and increasing testing rates. Nigeria is considering adoption but needs performance and cost projections. Methods. We constructed deterministic (with Microsoft Excel) and probabilistic (with Python) models, including parallel testing and treatment post-exposure prophylaxis algorithms for positive p24. We calibrated the models to Nigeria's 6.4 million women entering ANC annually using epidemiologic literature, product prices, and occasionally expert opinion. We compared costs (in 2025 US dollars) and outcomes between current and projected future (2027) practices. Results. The panel would avert 562 of the current 3,299 vertical infections per 100,000 women in ANC. Per woman in ANC, the panel would avert 0.0656 disability adjusted life years (DALYs) at a net cost of US$7.55. With low current testing rates. HBV testing averts the most DALYs (33%), followed by acute HIV (29%), chronic HIV (25%), and syphilis (14%). The incremental cost-effectiveness ratio (ICER) is $115 (95% confidence interval: $91-$143) per DALY averted--more favorable than Nigeria's conservative historical $137 average. The benefit-cost ratio is also favorable (1.19; 95% confidence interval: 0.93-1.51). Conclusions. The integrated ANC testing panel would be a valuable and cost-effective addition to ANC care. Piloting in Nigeria and similar sub-Saharan African countries would refine parameters for potential scale up.

Introduction After U.S. foreign assistance was frozen in January 2025, empirical data on the status of the HIV response has been limited. To better understand the ongoing impacts of changes in U.S. foreign assistance, we launched an open survey to assess disruptions in HIV-related care among clinics and programs in low- and middle-income countries (LMICs). Methods Conducted from August to December 2025, the survey explored U.S. foreign assistance-related disruptions in HIV service delivery, medication availability, laboratory services and clinic operations; whether disruptions were fully resolved at the survey timepoint; and the introduction of clinic mitigation strategies. Data on other impacts of U.S. funding changes were explored through an open-ended question. A convergent mixed-methods design, involving parallel quantitative and qualitative analyses and merging of findings from each, was used to examine the impacts of U.S. funding freezes on HIV-related care. Results We received 158 responses from 38 LMICs, including 30 countries supported by the U.S. President's Emergency Fund for AIDS Relief (PEPFAR) at the beginning of 2025 (n=123 responses) and eight non-PEPFAR countries (n=35 responses). Respondents represented health centers (25%), hospitals (31%), dedicated HIV clinics and drop-in centers (39%), and multi-site programs (4%), with a majority (59%) in the non-governmental/private sector. Overall, 81% reported disruptions in at least one HIV-related service since January 2025 because of changes in U.S. foreign assistance, with most also reporting disruptions in medication availability, laboratory services, and clinic operations. The largest reported disruptions were in the areas of pre-exposure prophylaxis (67%) and HIV testing (63%), along with patient tracing (67%), adherence support (63%) and services to key populations (64%). Disruptions were more prevalent in PEPFAR-supported countries and were more likely to be "not fully resolved" by time of survey completion. Qualitative data highlighted the impact of U.S. foreign assistance disruptions on the erosion of client trust in the health system and strains on staff morale. Conclusions Substantial and sustained disruptions in HIV prevention and care reported by diverse clinics in LMICs reinforce concerns that recent funding shifts could reverse progress in ending the HIV epidemic, particularly for vulnerable and key populations.

Background: Internationally, workforce planning models are focussed on balancing supply and demand, rarely addressing factors such as demographic shifts and evolving health needs. There is a clear imperative for improved workforce planning to ensure adequate staff numbers to deliver audiology safely and effectively but there is still no consensus on safe minimum staffing levels or the optimal skill mix for high-quality audiology services. Methods: This research aimed to establish markers of quality in audiology service provision and estimate the audiology workforce requirements to meet current and projected demand for services, based on population changes and anticipated changes in demand. Following stakeholder engagement, a needs-based model was developed by (1) analysing NHS England's national Audiology stocktake dataset to determine current workforce, (2) creating an epidemiological model to predict changes in service population over next 5 and 10 yrs (3) use of BAA endorsed estimates delivered in East of England on staff grade required per activity. [SR1.1] Results: The estimates for 10-year adult and paediatric audiology whole time equivalent (WTE) safe minimum staffing levels for England (bands 2-7, current waiting times maintained) based on a population change model (Model 1), and two further models for paediatrics specifically (Model 2 and Model 3) were as follows: for adult audiology Model 1 estimates a 7.40% increase by 2035 (to 1125.18 WTE). For paediatric audiology Model 1 estimates a -6.3% (to 593.47 WTE) decrease due to underlying paediatric population decline in England, whereas the case complexities considered in Model 2 (1072.33 WTE) and Model 3 estimate a 10-year increase of 71.23% ( to 1072.33 WTE) and 59.17% (to 996.82 WTE) respectively. Conclusions: This is the first study to conduct a needs-based assessment of workforce requirements for audiology services. Given the substantial need for audiology staff, investment in workforce recruitment and training is essential to ensure that future activity levels meet population needs. Consideration of changing demographics is required for planning future workforce specialisation. Further analysis to address workforce equity, the impact of changes in skill mix and service delivery models and local area demographics/prevalence variation is required alongside potential efficiencies.

Abstract Objective To describe variation in hospital costs among children with different combinations of health conditions, special educational needs or disability (SEND) and children social care (CSC) indicators. Study Setting and Design This cross-sectional study used regression analysis to test whether two-way and three-way interactions of cross-public sector service use (health, education and social care) are associated with higher hospital costs in England. Data Sources and Analytic Sample Hospital care costs between April 2022 and March 2023 for the 8.9 million children aged 5-18 years were obtained from linked administrative hospital, education or social care data in the ECHILD database. Children were classified into eight categories based on combinations of indicators of chronic health conditions, SEND or CSC. Principal Findings Over one-third (35.4%) of children had some hospital costs during the year. Average costs were 317GBP for all children and 895GBP for children with non-zero hospital costs. By age 18, few children had no indicator in any sector (35.1% of boys, 43.7% of girls) and indicators in all three sectors were not rare (7.1% of boys, 6.2% of girls). At age 5, children with indicators recorded in all three sectors had the highest hospital costs (2,952GBP for boys and 3,674GBP for girls). At age 18, males and females with indicators in all three sectors accounted for 21% and 23% of hospital costs, respectively. SEND and social care indicators without chronic health conditions were associated with only slightly higher hospital costs. Hospital costs were much higher for children with SEND if they also had a chronic health condition. Hospital costs were only higher for children with social care if they also had both a chronic health condition and SEND. Conclusions. Taking account of additional support from non-health sectors is important for understanding health sector costs. The compounding associations between use of other public sectors on health sector costs indicates scope for targeting of integrated care.

Background: Trauma-informed approaches (TIAs) are increasingly implemented across public-sector settings to improve support for young people affected by adverse childhood experiences (ACEs). However, practitioners often report difficulties translating broad trauma-informed principles into everyday practice, and young people are rarely involved in developing resources intended to support implementation. Aim: To co-design, implement and undertake a preliminary evaluation of a youth-led trauma-informed resource for professionals working with young people in public-sector settings in England. Methods: The study formed part of the UKRI-funded Attune programme and employed Accelerated Experience-Based Co-Design (AEBCD). Eighteen adolescents with lived experience of ACEs and 16 professionals from nine public-sector settings participated in three regional co-design workshops. Findings from a prior arts-based lived experience study informed the workshops. Participants collaboratively developed Validating Voices, a low-cost resource designed to increase validating interactions between professionals and young people. The resource was subsequently introduced into nine organisations and evaluated using staff surveys and semi-structured interviews. Results: Co-design participants identified professional invalidation of young peoples experiences, identities, needs and emotions as an under-recognised contributor to mental health. The resulting resource combined discussion cards, creative activities, role-play and organisational reflection exercises to promote validating practices. Five organisations implemented the resource and reported it to be feasible. Flexible local adaptation was common, while more participatory role-play elements proved harder to implement consistently. Staff observed increased opportunities for disclosure, reflection, peer connection and professional curiosity about young peoples experiences. Staff reported listening differently to young people and, in some settings, implementing changes in response to young people's recommendations. Conclusions: Youth-led co-design identified validation as a practical and meaningful mechanism for operationalising trauma-informed principles in everyday professional practice. With refinements, Validating Voices shows promise as a resource to support more relational, collaborative and trauma-informed responses to young people in public sector settings.