BMC Health Services Research

Introduction Care home (CH) influenza vaccination of staff improves resident health, yet uptake remains low at just over 11% (England, 2025/2026). We report an economic evaluation (EE) of "FluCare", an intervention to increase staff influenza vaccination through: vaccination clinics at CHs; promotional materials; and CH financial incentives. Method Seventy-five CHs were randomised to FluCare or control. A cost-consequence analysis took the influenza vaccination programme funder perspective, but also extended to the National Health Service (NHS) and CH perspective. Costs included: influenza vaccination; administration fee; FluCare components; CH resident NHS utilisation. Outcomes were: staff influenza vaccination rates; staff sickness; and resident mortality. Sensitivity analyses excluded intervention CHs that did not host vaccination clinics. Results Compared to control CHs, adjusted analysis found intervention homes with a mean absolute increase in vaccination rates of 1.8% (95% CI: -6.0%, 10.8%; p=0.572) at an increased cost of {pound}451 (95% CI: {pound}239, {pound}675; p<0.001) to the vaccination programme funders: {pound}249 per additional percentage point (PAPP) per CH. Vaccination clinics were delivered late in the influenza season, with 80% taking place from February 2023. Including only intervention CHs that hosted staff flu vaccination clinics (23/35), increases the mean difference to 10.1% (95% CI: 0.9%, 21.9%; p=0.018) and costs to {pound}805 (95% CI: {pound}603, {pound}1,079; p<0.001): {pound}79 PAPP per CH. Differences between trial arms in other costs and outcomes were marginal and generally non-significant. Conclusions FluCare delivered little improvement when staff flu vaccination clinics did not occur and had little impact on other costs/outcomes. Cost-effectiveness depends on willingness-to-pay for increased staff vaccination, but cost PAPP per CH improved from {pound}249 to {pound}79 when only CHs hosting clinics were considered. Late implementation, likely reduced impact by limiting clinic delivery, as reflected in sensitivity analysis. Future evaluations should implement FluCare earlier in the season.

Objectives: The Pharmacy First (PF) service was introduced across England from 31 January 2024 to expand the clinical role of community pharmacies and improve access to primary care. This paper describes use of PF in its first 12 months, in terms of uptake, access routes, consultation outcomes, geographic variations, service costs and antimicrobial supply. Methods: A descriptive analysis of all PF consultations submitted for payment to NHS Business Services Authority in England between 31 January 2024 and 31 January 2025. Pharmacy-level consultation data were linked to national data on population, location and pharmacy characteristics. PF use was examined using population-standardised consultation rates and consultations per pharmacy. Results: During the first year of implementation, 2,205,731 PF consultations were recorded as delivered across 11,349 pharmacies, with payment of GBP123 million to pharmacies. Uptake increased steadily over time. Most consultations were for acute sore throat (33%) and uncomplicated urinary tract infection (27%), with corresponding antibiotics, phenoxymethylpenicillin and nitrofurantoin being the most supplied. Most people self-referred (74%) into the service, with 95% of consultations managed without onward referral. Substantial geographic variation was observed. Northern regions had higher use based on the eligible population. The South East and Midlands had higher activity per pharmacy. London showed a distinct pattern, with higher self-referral into the service, lower medication supply and higher referral to other healthcare services. Higher consultation volume was weakly associated with pharmacy characteristics, including opening hours, pharmacy type and retail setting, and local context, in terms of socio-economic and geographic factors. Conclusions: PF had immediate uptake and is operating primarily as a direct-access model for common acute conditions. Findings suggest that PF is contributing to improved access to care and may shift demand away from general practice. However, the service uptake appears to be shaped by geographic location, proximity to other healthcare services and pharmacy characteristics.

Introduction Primary care productivity and performance are hard to measure because patient health is not measured systematically and consistently. In England, productivity is measured using output (appointment volume) and two value-based metrics: waiting times and patient satisfaction. Higher productivity should improve all these metrics: more appointments should shorten waits, and shorter waits should raise patient satisfaction. However, little evidence tests how output and value-based metrics are associated. Methods We conducted a retrospective observational study of NHS primary care in England, 2018 to 2024, using Appointments in General Practice and the GP Patient Survey. Across Integrated Care Boards (ICBs), we examined the relationship between changes in appointment volume, waiting times, and patient dissatisfaction over two periods, 2018-2022 and 2022-2023, stratified by staff group and appointment mode. Results Completed appointments rose between 2018 and 2024, with care shifting towards non-GP staff and virtual delivery. Across ICBs in 2018-2022, per million additional appointments, waiting time changed by -0.04 days (95% CI: -0.10, 0.03) and dissatisfaction by 0.02 percentage points (95% CI: -0.36, 0.40). Per additional day of waiting, dissatisfaction changed by -1.40 percentage points (95% CI: -3.21, 0.42). In 2022-2023, the corresponding estimates were -0.31 days (95% CI: -0.57, -0.04), -0.75 percentage points (95% CI: -3.05, 1.56), and 2.85 percentage points (95% CI: 1.20, 4.51). Conclusion Increased appointment volume was not associated with shorter waiting times or lower patient dissatisfaction, and shorter waiting times were not associated with lower patient dissatisfaction. Either quality metrics do not respond to output, the key factor providers control, or they do not capture the dimensions of quality that matter. Performance frameworks that assess primary care productivity through these metrics should be reviewed.

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.

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.

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.

Strong primary healthcare (PHC) is associated with lower costs and better population health outcomes when supported by appropriate financing. Costing analysis enables evidenced-based decisions for estimating budgets for PHC and defining provider payments. In 2021, a project supported by the World Health Organization was launched in Ukraine to collect cost data from 100 PHC providers. The objective was to assess costs for delivering services within the state-funded benefits package, with the aim of informing tariff-setting, and assessing budget need. This study used statistical analysis on the collected cost data. We applied multivariable linear regression (MLR) to assess variation in cost-per-person across locality (rural vs. urban) and ownership type (public vs. private) of the providers, after adjusting for confounders. The mean (standard deviation) cost-per-person across the sample providers was 45.46 (18.46) USD. MLR analysis showed that rural providers had a higher cost-per-person of 6.70 USD (95% CI: 1.54, 11.85) compared to urban providers, after adjusting for confounding (p=0.011). We also found strong evidence that private providers had a lower cost-per-person of 36.15 USD (95% CI: -41.82,-30.48) compared to public providers, after adjusting for confounding (p<0.001). Although our findings do not capture the impact of the Russian hostile invasion of Ukraine, they still provide valuable insights for policy discussions within Ukraine and for other nations examining PHC financing reforms. Our findings align with international evidence suggesting that rural providers incur higher costs, supporting the need to adjust capitation payments for providers in these areas. Ownership type also affects costs, potentially reflecting differences in quality standards between public and private providers. These differences allow private providers to opportunistically reduce costs by limiting staff numbers and optimizing facility size to maximize profits. To ensure equitable access to high-quality PHC, uniform service delivery standards should be applied to all PHC providers, regardless of ownership type.

Background In 2024 incidence of tuberculosis in England rose to 9.4 per 100,000, which is close to exceeding the low-incidence designation threshold. Addressing the rising incidence requires policy making to ensure sufficient staff, hospital resources and budgets are available to meet the increasing demand. However, costing of active pulmonary TB in the UK are limited and better clarity is needed on the clinical pathway of tuberculosis and the resources involved. Objective This study aims to estimate the costs of active pulmonary drug-sensitive tuberculosis care in England using a micro-costing approach. Method The analysis was performed from the perspective of the National Health Service (NHS), capturing direct medical costs only. The clinical pathway for different severities of tuberculosis care was defined through a review of the literature, clinical guidelines, and interviews with clinicians. Costs were mainly drawn from the British National Formulary and the eMIT national database for drug costs, and the National Cost Collection (2021-22) for diagnostics, monitoring, nursing and hospitalisation alongside a desk-based review. Results Per-patient costs in 2021 ranged from approximately GBP2,000 for community-managed cases to over GBP50,000 for the most complex patients. An estimated 70% of patients cost between GBP4,971 and GBP7,307. The weighted average cost of treatment across all complexities was GBP8,125 per patient reflective of the proportion of cases at each severity. For the 4,423 patients in 2021, it is estimated that the costs of direct treatment were at least GBP36 million, highlighting the significant financial implications of increasing tuberculosis. Conclusion The findings demonstrate that tuberculosis care imposes a substantial and highly variable cost burden on the NHS. Overall, this study provides cost estimates that can inform service planning, resource allocation, and future economic evaluations. Further research is needed on the costs of drug-resistant TB to support comprehensive TB control strategies.

Background: Adults with severe mental health conditions (often referred to as severe mental illness, SMI) experience 15 to 20 year mortality gap relative to the general population, with lung cancer a significant contributor. National cancer policy targets earlier diagnosis but does not explicitly address how pathways function for this group. Aims: This study aimed to describe lung cancer risk, prevalence, screening eligibility, referral activity and diagnostic pathway performance for adults with SMI in South East London (SEL), and to examine where along the pathway inequalities arise. Methods: Co-designed with experts with lived experience and voluntary sector, this exploratory mixed-methods service evaluation combined quantitative analysis of routinely collected data from the Quality Outcomes Framework (QOF), SMI Register and Cancer Waiting Times Record (April 2023-March 2024) with semi-structured qualitative interviews (n=11 clinical staff) and focus groups (n=6 adults with lived experience of SMI). Quantitative and qualitative data were analysed using descriptive statistics and framework-based thematic analysis respectively, and findings were integrated using a joint display approach, organised by the Consolidated Framework for Implementation Research (CFIR). Results: Lung cancer prevalence was approximately double among adults with SMI (0.17% vs 0.09% in the general population). Despite Urgent Suspected Cancer (USC) referral rates being more than twice as high in the SMI population (63 vs 28 per 100,000), fewer cancers were detected via planned general practice (GP) routes (11% vs 20%), the 28-day Faster Diagnosis Standard was not met for any SMI patient diagnosed with lung cancer during the study period; overall FDS performance was 76% in the SMI population compared with 84% in the general population; and appointment non-attendance was more than double that in the general population (6% vs 3%). Qualitative findings identified individual, service and system-level mechanisms, including stigma, diagnostic overshadowing, fragmented coordination, and rigid pathway protocols, that compound disadvantage across lung cancer pathway stages. Conclusions: Inequality in lung cancer outcomes for adults with SMI accumulates across the pathway rather than arising at a single point of failure. Addressing this requires proportionate adaptations within existing cancer pathways, alongside routine reporting of cancer outcomes stratified by SMI population. Keywords: severe mental health conditions, lung cancer, health inequalities, cancer screening, diagnostic pathway, mixed methods

Introduction: Differentiated service delivery (DSD) models aim to reduce time healthcare providers spend with DSD clients, increasing time available for non-DSD clients. We measured nurses' time allocation and explored their experiences with DSD models in South Africa. Methods: We conducted time and motion observations and surveyed nurses at 24 public primary healthcare facilities across two SENTINEL study rounds (09/2022-07/2023 and 11/2023-07/2024). We report median time nurses spent by activity, model of care, and interaction type. Log binomial regression investigated factors associated with high direct nurse-client interaction (above median minutes) and extended work-days ([&ge;]9 hours), and estimated adjusted risk ratios (aRR). Survey questions were related to client care, additional time availability, and policy changes post DSD implementation, with key themes presented alongside illustrative quotes. Results: 176 nurses (88% female, median age 44) were observed for 344 working days; of these, 60 (34%) participated in the provider survey. Nurses spent a median of 293 minutes (53% of their work-day) on direct nurse-client interaction, 89 minutes (22%) on client-support or facility-related tasks, and the remainder on other activities including personal breaks. Time spent per client was similar across conventional care clients (11 [IQR: 8-15] minutes) but ranged between 9 (7-13) to 11 (8-15) minutes for DSD clients; number of direct nurse-client interactions did not differ meaningfully. Nurses at facilities with 2,000-3,999 total remaining on ART (TROA) (aRR 1.56, 95% CI: 1.02-2.37) and in urban areas (aRR 1.43, [1.08-1.89]) had more direct nurse-client interactions than those at facilities with <1,999 TROA and in rural areas, respectively. Nurses at facilities with 4,000+ TROA (aRR 2.22, [1.36-3.63]) and those observed in SENTINEL 3.0 (aRR 1.53, [1.13-2.07]) were more likely to work standard or longer workdays than those at lower TROA facilities (<1,999), those in SENTINEL 2.0 and urban areas. Nurses reported DSD models improved client care (90%), freed up time (60%), and changed clinic procedures and policies (60%). Conclusions: While DSD models did not significantly reduce direct nurse-client interaction time, nurses reported improved client care and gained additional time. DSD impact may vary by facility context. As DSD implementation expands, effective time reallocation may enhance facility performance and provider productivity.

Background: Post-checkup health guidance in Japan has traditionally relied on paper-based communication and manual administrative processes. These workflows are time-consuming, prone to transcription errors, and can delay timely engagement with health guidance recipients. Objective: To assess whether replacing a paper-based workflow with an integrated digital system using Microsoft Access, robotic process automation (RPA), and web-based responses could improve administrative efficiency, operational reliability, and engagement among health guidance recipients. Methods: This single-site quality improvement initiative redesigned the existing letter-based workflow. Access served as a central interface for managing recipients and generating guidance letters. RPA (EzRobot) automated repetitive clerical and billing-related tasks. A web form accessed via a QR code enabled recipients to respond digitally. Outcomes included manual administrative handling time per case, occurrence of transcription-related errors, health guidance completion rate, and guidance duration distribution. Results: Following implementation, staff active handling time per case decreased from approximately 10 minutes to less than 1 minute (approximately 30 seconds), while automated RPA execution typically required about 4-5 minutes per case without staff input. No transcription-related errors were detected during the post-implementation observation period. Health guidance completion rates improved from 28.3% to 39.2% (chi-square test, P<0.01; R4 (FY2022) n=184, R5 (FY2023) n=536). Guidance duration distributions, calculated using the corrected method, shifted towards shorter durations: cases with >=200 days decreased from 30.5% to 20.9% and cases with >=240 days decreased from 13.6% to 8.9% (R4 n=59, R5 n=158). Conclusion: An integrated Access-RPA-Web workflow was associated with improvements in administrative efficiency and operational reliability in post-checkup health guidance while retaining human verification and exception handling. This pragmatic, non-AI-dependent approach may offer a useful model for process-level improvement in preventive care settings.

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.

Scaling HIV pre-exposure prophylaxis (PrEP) services in health systems will require collaboration and clear role distinction among professionals, and between specialist and primary care. This study examined how power dynamics shape efforts to expand PrEP care beyond specialised HIV clinics in Belgium. We conducted semi-structured interviews with 36 HIV clinic providers and two community-based organisation (CBO) representatives, and 16 online group discussions with general practitioners (GPs). We analysed data thematically, guided by the concepts of collaborative and competitive power to examine how providers negotiated expertise and role division in PrEP delivery across professional and organisational boundaries. We found that reimbursement regulations anchored PrEP initiation and follow-up within HIV clinics, embedding specialist jurisdiction in care pathways. HIV specialists reinforced this position by drawing on their recognised expertise in HIV medicine to justify clinical coordination and authority in determining standards of care. GPs emphasised accessibility and preventive care roles but made limited claims to PrEP provision, linked to misaligned organisational incentives, role blurring, limited training opportunities, and the historical concentration of HIV care in specialist services. CBOs facilitated access, enabling coordination between vulnerable communities and clinics while remaining weakly embedded in formal care structures. Findings show that expanding integrated PrEP services beyond specialised care is not only shaped by operational issues such as training and resources but also by the structural dynamics of regulations, institutional mandates, and professional jurisdictions that influence collaboration. Effective scale-up will require policies that align incentives, clarify responsibilities, and support collaboration across specialised, primary care, and community settings.

Background: Leprosy reactions (LR) are immune-mediated complications associated with disability, emotional distress, and social isolation. We identified a gap in affected-individual-informed interventions that aim to improve the management of LR in healthcare settings. To address this gap, we assessed the acceptability of three peer-support interventions co-created with people affected by LR in Indonesia. Methods: Using an interactive learning and action approach, we co-created peer counselling, telesupport groups, and participatory video interventions which were piloted in an urban hospital and 13 rural community clinics. A mixed-methods design was applied with interviews, focus group discussions, and pre-post assessments involving four participant groups. Data were analyzed thematically using an acceptability framework. Results: One hundred participants were enrolled, and 92 completed the pilot intervention between November 2022 and July 2023. Qualitative findings showed that all interventions were acceptable. Peer counselling provided emotional reassurance through shared experiences and was perceived as trustworthy and supportive. Perceived burdens differed by setting, with time constraints in urban facilities and geographical barriers in rural clinics. Knowledge improved significantly among participants of peer counselling and telesupport groups in rural settings. Telesupport groups facilitated connection, information exchange, and continuity of care. Digital access and literacy limited participation for some, particularly in rural areas. The participatory video was perceived as reassuring and informative. Improvements in knowledge, attitude, practices, and mental well-being domain scores were observed among urban participants, but responses in rural settings showed less change. Participants and co-implementers reported increased self-efficacy, participants confidence to perform required behaviors within peer support interventions, with effects shaped by intervention and setting. Conclusions: The three co-created peer-support interventions were acceptable for individuals with LR in diverse healthcare settings. These outcomes highlight the importance and effectiveness of selective, and context-sensitive implementation of one or more peer-support modalities.

Background: Healthcare has witnessed administrative staffing roles balloon to twice the number of employed clinicians, resulting in $950 billion per year in administrative costs to deliver healthcare. Administrative workflows, like fax routing, are ripe for automation given the high human labor cost necessary to complete these tasks. Facsimile transmissions remain a key mode of communication in modern healthcare, requiring substantial manpower, and incurring significant, though not well-characterized, costs to health systems. Opportunities may exist for agentic artificial intelligence (AI) to automate this administrative task. Methods: This quality improvement study was performed in 2 phases at Duke University's Division of Cardiology, a single tertiary-care cardiac referral center. The first retrospective phase employed an observational time study design surveying manual fax routing processes at 3 representative cardiology clinics from April 1, 2024, to July 12, 2024. The second phase quantified all inbound faxes received through the division's communication hub from July 1, 2025, to December 31, 2025, and applied direct labor costs observed in the time study to quantify the economic burden of manual fax routing across the hub. Results: The observational time study (Phase 1) demonstrated fax routing processing times ranging from 4.4 to 9.4 minutes depending on fax type, with a mean processing time of 6.0 minutes per fax. On average, the ambulatory clinics received 1,694 faxes per month and spent 169.1 person-hours routing faxes. The divisional communication hub (Phase 2) received 24,420 faxes over the study period, averaging 4,070 inbound faxes and 13,341 pages of information per month. Extrapolating direct labor efforts from the time study, 407 person-hours per month were spent processing inbound faxes. For our institution, this translated to $10,663.40 in total monthly costs, roughly 2.5 full-time equivalents. Conclusion: Manual fax routing represents a substantial, measurable, and previously under-characterized operational and administrative burden. Given the significant opportunity to reduce labor time and costs, our study establishes fax routing as a high-value target for automation. Future work is needed to determine the impact of AI-automated fax routing on the time, labor, accuracy, and economics within clinical settings.

Importance: OPAT is an underutilized strategy in low- and middle-income countries (LMICs). Addressing the knowledge gaps among frontline physicians through structured interventions is vital for optimizing hospital bed utilization and antimicrobial stewardship. Objective: To assess whether a structured multidisciplinary care bundle is associated with improved patient enrollment and clinical care quality in an OPAT program in India. Design, Setting, and Participants: This pre-post quality improvement study was conducted in the Department of General Medicine at a tertiary care referral hospital in Rishikesh, India. Data from patient encounters during a 6-month pre-intervention period (December 1, 2023 to May 31, 2024) were compared with encounters during a 6-month post-implementation period (January 1, 2025 to June 31, 2025). Participants included all postgraduate residents serving as frontline clinical practitioners. Interventions: A structured OPAT bundle comprising a formalized educational curriculum (interactive didactic sessions and bedside practical training), standardized eligibility screening, and a coordinated telephonic monitoring protocol (from June 1, 2024 to December 31, 2024). Main Outcomes and Measures: The primary outcome was the change in the number of eligible patients enrolled in OPAT. Secondary outcomes included clinical process quality indicators (counseling, IV access arrangement, and monitoring compliance), 30-day rehospitalization rates, and therapy-related complications. Results: A total of 20 preintervention patient encounters were compared with 39 postintervention encounters, with similar baseline characteristics between groups (mean age, 37 vs 40 years; male gender, 65% vs 69.2%). Prior to implementation, only 33.3% (20 of 60) of eligible patients received OPAT, whereas 100% (39 of 39) of eligible patients were enrolled following the intervention (p < 0.001). Key clinical processes reached 100% compliance post implementation, including patient counseling (40% vs 100%; p < 0.001), pre-discharge IV access (40% vs 100%; p < 0.001), and daily telephonic monitoring (10% vs 100%; p < 0.001). Safety outcomes remained stable, with no significant differences in readmission rates (5.0% vs 0%; p = 0.34) or drug-related complications. Conclusions and Relevance: This quality improvement study provides evidence that a structured package of OPAT bundle interventions is associated with a transition to universal enrollment of eligible patients and perfect adherence to safety indicators. These results suggest that standardizing the outpatient transition through physician education and coordinated monitoring is a feasible and effective strategy for optimizing hospital resource utilization in LMICs.

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.

People with a learning disability experience marked health inequalities. In Wales, Acute Learning Disability Liaison Services (ALDLS) are delivered by specialised learning disability services, and all roles within them are undertaken by Learning Disability Liaison Nurses (LDLN). These services aim to enable access to, and delivery of, secondary care by supporting reasonable adjustments, facilitating communication, and coordinating care for people with learning disability during hospital encounters. However, independent evidence of the impact of ALDLS on patient care remains limited. This evaluation tries to address this evidence gap by examining hospital staff perceptions of the visibility, role, and impact of ALDLS across Welsh Health Boards, with the aim of informing service design and development and improving secondary care access and care for people with learning disability. The service evaluation used a qualitative approach involving interviews and a focus group with hospital staff across the seven Welsh Health Boards who had experience working with or interacting with ALDLS staff to care for patients with learning disability. Findings cover six key areas including i) visibility and delivery of ALDLS, ii) Barriers and challenges to effective ALDLS delivery, iii) Enablers of effective ALDLS delivery, iv) Positive impacts for patients with learning disability, v) Negative impacts and unintended consequences when the service is absent or limited, and vi) Participants recommendations for future improvements of ALDLS. To synthesise the findings, we developed an overview diagram, which illustrates how ALDLS may influence care quality in acute hospitals. The overview places the liaison service at the centre, showing how organisational enablers and barriers shape its delivery, and how its core functions support improvements in safety, timeliness, effectiveness, efficiency, equity, and patient-centred care. From the findings we have identified recommendations for practice and policy. These include that ALDLS should be recognised as a core, safety-critical component of acute hospital care for people with a learning disability, rather than an optional add-on. In practice, services should be more visibly embedded within routine pathways, with consistent site-based presence, clear referral criteria, early identification through electronic flagging and notification systems, and routine involvement in multidisciplinary planning for complex admissions and procedures. At policy level, ALDLS provision should be recognised within equality and patient safety frameworks as an essential service requiring sustained investment, national minimum configuration standards, adequate staffing, and better-integrated digital systems to support continuity, equitable access, and person-centred care.