BMJ Open Quality

Background Falls are a major safety concern in healthcare. In palliative care, patients are particularly vulnerable due to complex symptom burdens and rapid physical decline. However, standard falls risk assessment tools, primarily designed for acute clinical environments, rely on static risk scores and lack efficacy in hospice settings. The Falls Early Warning Score (FEWS) is a observational tool developed to address the specific contributing factors and complex needs of palliative patients. Aims To explore and understand staff views regarding the implementation, utility, and benefits of the FEWS tool to identify people at risk of falling in a specialist palliative care inpatient unit. Methods A mixed-methods study was conducted at a UK hospice. Healthcare professionals with clinical experience using the FEWS chart completed an electronic questionnaire assessing their confidence, practice, and perceived barriers. Questionnaire outcomes informed subsequent face-to-face, semi-structured interviews. Qualitative data were evaluated using reflexive thematic analysis. Results Eleven staff completed the questionnaire, and five participated in interviews. Three major themes were identified: (1) Education, highlighting staff preferences for 1:1 training and the necessity of dedicated user guides; (2) Location and format of the FEWS tool, contrasting the data collection benefits of electronic formats against the bedside accessibility of paper charts; and (3) Recognised benefits of the FEWS tool, including its ability to prompt safe staffing levels, highlight variable patient presentation, and mitigate the emotional and physical impact of falls. Conclusions It is feasible and highly acceptable to integrate bespoke falls risk assessment tools into palliative care. By addressing the unique complexities of hospice patients, customised tools like FEWS can empower staff and support dynamic clinical decision-making. Further research is required to evaluate their clinical efficacy in reducing falls.

Background: Chronic intestinal failure is a devastating rare disease in which patients require complex and life-saving parenteral nutrition or intravenous fluids delivered through a central venous catheter. There is a shortage of clinical expertise to manage chronic intestinal failure and patients in the United States lack access to the limited number of expert care centers. We developed a patient intestinal failure (PIF) ECHO intervention with patient advocates who have lived experience with the goal of connecting patients and family caregivers virtually to multidisciplinary intestinal failure experts for best practice learning. Objective: We pilot-tested the acceptability and feasibility of a direct-to-patient telelearning program based on the well-established ECHO Model focused on best practices in chronic intestinal failure care. Setting and Participants: 19 adults with chronic intestinal failure attended the pilot PIF-ECHO program for 12 consecutive weeks via Zoom between April and July 2026. All participants completed the post intervention questionnaire and 16 individuals participated in 3 focus groups. Design: A mixed methods evaluation was conducted. Questionnaires were assessed according to seven domains of the Theoretical Framework of Acceptability and qualitative data from the virtual focus groups were coded and analyzed using iterative thematic analysis. A data-derived PIF-ECHO logic model was developed to illustrate pathways between the program content and anticipated outcomes. Results: There was strong or very strong agreement that sessions were accessible, enjoyable, worth the time spent, and improved understanding of intestinal failure and its management. Information learned increased confidence for self-advocacy in navigating healthcare needs, disease and therapy self-management, and improved well-being. Interaction with facilitators, expert presenters, and peers was positive, judgement free, validating, and respectful. Participants felt empowered and reported lower levels of emotional strain due to the supportive resources and knowledge gained. Conclusions: A patient-facing tele-learning program in chronic intestinal failure is feasible, accessible, and acceptable to patients and appears to result in important short-term and medium-term benefits. The program was perceived as valuable and notably different from patient and peer-led support groups. The model could be applied more widely to other rare diseases. Lived Experience and Patient Contributions: Four patient advocates with lived experience in chronic intestinal failure were involved throughout the study including pre-study interviews and focus groups to inform PIF-ECHO design and content, recruitment, as presenters on topics of self-advocacy and role of patient support groups, and in the analysis and refinement of the program logic model. Their input shaped the relevance and acceptability of the PIF-ECHO pilot program. All four patient advocates fulfil uniform requirements for authorship and are co-authors on this paper. This work documents a meaningful partnership in the creation of a patient-facing virtual tele-learning adaptation of the ECHO model and establishes a valuable collaboration for future study of PIF-ECHO on a larger scale.

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.

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

Background: Timely carbidopa-levodopa administration is a recognized inpatient safety priority in Parkinson disease, and mistiming is common, but where in the medication-use process it arises is uncharacterized. Objectives: To localize where inpatient mistiming arises and where to target intervention. Methods: In a single-center retrospective analysis of hospitalized adults with Parkinson disease on home carbidopa-levodopa, each dose's administration time was compared with the individualized home schedule. Mistiming was defined a priori as more than 15 minutes from the home time (Parkinson's Foundation Hospital Care Standard 2). We characterized the deviation distribution, tested whether administrations tracked the schedule or the standard grid, and examined length-of-stay and readmission. Results: Across 947 doses in 101 patients, ordering was accurate, yet 62.9% (596 of 947) missed the home time by more than 15 minutes and 99% of patients had at least one mistimed dose. Administrations tracked the individualized schedule almost exactly (Pearson r 0.98), not the standard grid: only 10% fell within 15 minutes of the default times, and the median dose sat 24 minutes from its home time but 76 from the nearest default. Deviation was symmetric drift (median absolute deviation 24 minutes; 16.5% beyond 60 minutes). Conclusions: Mistiming in this study reflected imprecise bedside execution, not ordering or a mismatch between fixed rounds and individualized regimens. These findings may point medication-safety efforts toward protecting bedside administration as complementary redesigning orders.

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 [≥]4, [≥]8 and [≥]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.

Background Digital legacy (the digital information available about someone following their death) has increasing societal importance as personal assets and interactions become increasingly digitized. Healthcare professionals often have a limited understanding of how to address digital legacy in practice, and there is a lack of interdisciplinary networks to improve education, research, and professional development in digital legacy. Objective This paper describes the development of an interdisciplinary initiative designed to build research capacity and develop consensus-based recommendations for integrating digital legacy into palliative care. Method Over 12-months, we conducted interdisciplinary engagement activities with diverse stakeholders, including clinicians, designers, and sociologists. We used a modified World Cafe method to facilitate dialogue and capture feedback on how memories are digitally curated, the management of digital estates, and intergenerational perspectives on digital legacy. Results We identified eight core recommendations for research and policy, including promoting digital legacy education, supporting policy development, and broadening the scope of interdisciplinary research. Our discussions highlighted the complexity of modern digital estates and the need for legal and ethical frameworks to protect individual rights. Conclusions The Network demonstrates that interdisciplinary collaboratives can address important issues relating to digital legacy, which provides a foundation to conduct collaborative research that improves the management of digital legacies in society.

Background: Post-abortion care (PAC) encompasses emergency treatment, counselling, contraceptive services, and referral linkages. Emergency post-abortion care (EPAC), the life-saving component of PAC, addresses acute abortion-related complications, including haemorrhage, sepsis, retained products of conception, and severe pain. In Uganda, where abortion is legally restricted and socially stigmatised, womens care experiences are shaped by clinical urgency, fear, moral vulnerability, provider interactions, and structural health system constraints. Despite EPACs centrality to maternal survival, qualitative evidence on how women interpret and evaluate their care experiences in referral hospital settings in Uganda remains limited. This study explored womens experiences of EPAC at Kawempe National Referral Hospital (KNRH) and identified the factors that shaped those experiences. Methods: A qualitative phenomenological design was employed. Sixteen in-depth interview transcripts from women who received EPAC at KNRH in March-April 2026 were analysed using inductive thematic analysis. The Socio-Ecological Model (SEM) was applied as an interpretive framework. Results: Six themes were identified: (1) survival and physical relief as the immediate measure of good care; (2) pain, fear, and emotional distress during treatment; (3) reassurance and support as buffers against vulnerability; (4) dignity under pressure: communication and privacy in EPAC; (5) structural barriers across the pathway of care; and (6) experiences beyond discharge: incomplete recovery and uncertainty. Care was frequently evaluated through the lens of survival, yet these accounts co-existed with intense procedural pain, compromised privacy, delays, financial burden, and inadequate post-discharge support. EPAC at KNRH was experienced as a complex encounter shaped by bodily vulnerability, interpersonal dynamics, and system-level constraints. Conclusions: Strengthening EPAC requires patient-centred approaches that integrate clinical effectiveness with respectful communication, pain management, improved triage, and structured post-discharge support.

Background: Clinician-scientists translate clinical observation into discovery, trials, and policy, yet this workforce is shrinking across health systems worldwide. Integrated MB-PhD training, pausing medical training to complete a PhD before clinical exposure or specialisation, is one route into this career. We aimed to evaluate the long-term value of MB-PhD training and the barriers to clinical-academic careers these face after graduation. Methods: We evaluated all 131 graduates (29.8% female) who entered the University College London (UCL) MB-PhD programme over a 25-year period (1994-2018). Bibliometric outputs were collated via an inter-linked information system. Concurrently, all 131 graduates were invited to respond to open-ended questions on career benefits and structural barriers; 99 (75.6%) responded, and responses were independently coded into themes, which were then reviewed and confirmed by a Study Group of 107 individuals, including the 91 respondents who agreed to participate further. Results: Graduates produced 5,877 publications (1,141 first-author, 819 corresponding-author), attracting 350,754 citations, with a mean relative citation ratio of 3.30 {+/-} 0.47, approximately three times the field average and sustained across three decades of programme entry. Graduates secured an estimated $157.55 million across 99 grants, released 465 public datasets, and were named investigators on 31 clinical trials across five continents. Among the 99 survey respondents, 49.5% held consultant-grade posts, 72.7% remained research-active, and 25.3% had reached senior academic grade. Open-ended responses were coded into five recurring structural barriers, subsequently confirmed by the Study Group: insufficient protected research time (72.2% of responses), unsupportive training structures and limited career opportunities (36.7%, 24.4% of responses), funding and pay barriers (22.2% of responses), and lack of mentorship or geographical/family constraints (14.4%, 13.3% of responses). Conclusions: Integrated MB-PhD training generates sustained academic productivity and leadership, but structural barriers threaten retention of graduates within clinical-academic careers. Protecting research time, stabilising funding and pay, and reducing geographic instability are needed to retain the clinician-scientists that health systems have already invested in training.

Background Ambient AI documentation tools, known as scribes, are entering routine clinical practice at scale, but the evidence comparing the notes they produce against clinician-written notes is dominated by single-site, single-language studies that rely on human review to find errors, a method known to miss most documentation errors. Methods We conducted a paired simulation across five countries and languages (Cambridge/English, Barcelona/Spanish, Milan/Italian, Paris/French, Cologne/German; 385 paired consultations, 770 notes). From each actor-performed consultation, an AI scribe (Heidi) and a junior-to-middle-grade clinician independently produced a note. Notes were scored on the PDQI-9 by evaluators blinded to authorship. Documentation errors were identified by two methods of deliberately different sensitivity - clinician adjudication, and a calibrated automated reviewer externally validated against a blinded ten-clinician panel - then graded for clinical risk by a three-model panel. The co-primary outcomes were PDQI-9 total and Critical+High error burden, the latter reported under both detection arms. The analysis plan was registered before any pooling across sites. Results AI notes scored higher than clinician notes on the PDQI-9 (40.6 vs 35.6; difference +5.08, 95% CI 4.6-5.6; Cohen dz=0.55), consistently across all five sites (dz 0.41-0.75), and were less dispersed (5.7% of AI vs 27.8% of clinician notes fell below the study pre-specified low-score threshold (<32)). On the principal safety outcome - the paired probability that a note carried [&ge;]Critical+High error - clinician notes were affected more often under both detection arms: 61.0% versus 24.4% by the calibrated reviewer (relative risk 2.50, 95% CI 2.09-3.00) and 21.8% versus 6.2% by clinician adjudication (relative risk 3.50, 95% CI 2.32-5.27). The difference was largest for omissions. Unaided clinician review identified roughly 12% of the errors the calibrated reviewer retained, and a smaller fraction in AI notes than in clinician notes. Conclusions In this simulation, AI-generated notes scored higher on documentation quality, varied less, and carried fewer clinically significant errors than notes written on the same consultations by junior-to-middle-grade clinicians. The magnitude of the safety difference depends on the sensitivity of error detection, so we report both detection regimes and bound rather than point-estimate the absolute error rate. Extension to live practice, consultant-authored documentation, and notes as filed after clinician editing remains to be established.

Purpose Aging in place has become a central objective of health and social policies across the world, yet frailty and multimorbidity significantly undermine individuals capacity to remain safely at home. The aim was to identify the potential components of a home visit intervention led by nurse practitioners for frail populations. Design A consensus study using a two-round Delphi method Methods A two-round Delphi study was conducted in summer 2024 with 15 experts from four French-speaking countries (French Canada, Switzerland, Belgium, and France). The questionnaire was based on documented needs of frail patients and their caregivers. Results Experts identified the target population as older adults needing home care, people with physical or cognitive impairments, those requiring end-of-life care, and individuals experiencing difficulties remaining at home. Eligibility criteria included frailty, multiple chronic conditions, mobility issues, social isolation, and low socio-economic status. The nurse practitioner s role should include clinical assessment, treatment adjustments, care coordination, therapeutic education, support for patients and families, and promotion of self-care. Nurse practitioners may also serve as a reference for other healthcare professionals. Home visits should be initiated by healthcare providers, patients, or family members, with visit frequency and duration adapted to individual needs. Conclusions This study identified components of a nurse practitioner-led home visit intervention for frail individuals that achieved expert consensus, while highlighting areas where consensus was not reached. Clinical Relevance These findings will inform the development and future evaluation of such an intervention in real-world settings.

Background: Digital reminders reduce outpatient no-shows, but the optimal timing and frequency of messages remain unclear, particularly in Latin American public health systems. We emulated a target trial to evaluate the comparative effectiveness of four WhatsApp reminder strategies on appointment absenteeism and patient-initiated cancellations. Methods: We analyzed administrative and electronic health-record data from the public health system of the Autonomous City of Buenos Aires, Argentina (June 2023-May 2024). Eligible individuals had scheduled an in-person outpatient appointment in one of 15 prioritized specialties at least 75 hours in advance and had a mobile phone on record. We compared four strategies: (1) dual reminders at ~72 and ~24 hours before the appointment; (2) a single reminder at ~72 hours; (3) a single reminder at ~24 hours; and (4) no reminders. The primary outcome was the proportion of no-shows by the end of follow-up. Secondary outcomes were the cumulative incidence of patient-initiated cancellations overall, within 12 hours of the appointment, and followed by rebooking. We emulated the target trial using a cloning-censoring-weighting approach to estimate per-protocol controlled direct effects, with inverse-probability weights to address time-varying confounding and selection bias. Cumulative incidence of secondary outcomes was estimated using weighted Kaplan-Meier curves. Three pre-specified sensitivity analyses and standardized mean differences assessed robustness and covariate balance. Results: A total of 475,214 first eligible person-appointments were included; baseline no-show risk in the control arm was 34.6%. All three active strategies reduced no-shows compared with no reminders. The single 24-hour reminder produced the largest reduction (Risk Ratio [RR] 0.76, 95% CI 0.72, 0.81; Risk Difference [RD] -8.21 percentage points [pp], 95% CI -9.68, -6.54), followed by the dual-reminder strategy (RR 0.80, 95% CI 0.79,0.81; RD -7.05 pp, 95% CI -7.41, -6.71) and the single 72-hour reminder (RR 0.91, 95% CI 0.84,0.99; RD -3.16 pp, 95% CI -5.69, -0.49). All active strategies increased patient-initiated cancellations relative to control, with the dual-reminder strategy producing the largest increase. Sensitivity analyses preserved the qualitative ranking of strategies across all specifications. Conclusions: In this large target trial emulation, a single just-in-time WhatsApp reminder sent ~24 hours before the appointment was as effective as a dual-reminder schedule in preventing no-shows and superior to a distal 72-hour reminder alone. Adding a second, distal reminder provided no measurable benefit for attendance but substantially increased patient-initiated cancellations, which may be operationally valuable when active slot reallocation is a goal. These findings support timing, rather than frequency, as the primary lever of digital-reminder effectiveness, and favor the deployment of a single proximal reminder as the default strategy in resource-constrained outpatient settings.

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: Maternal postpartum checks with a general practitioner (GP) are recognised as an essential service in England and vital for recovery after pregnancy and reducing risk of long-term morbidity. Despite this, its reported fewer than of women have a record of the examination in the recommended 6-8 weeks, with observed disparities in uptake nationally. The impact of the COVID-19 pandemic disrupted delivery of these checks nationally, but there is limited data on the impact of the pandemic and its recovery for regional populations representing diversity and areas of dense poverty and ethnic minority populations. This study utilised region level data to assess the impact of COVID-19 on postnatal care. Methods: Anonymised electronic health records with clinical coded birth events for females, aged 16-49 years, were analysed for patients registered with a GP using the Greater Manchester Care Record (GMCR) between January 2018 and August 2023. Unique delivery episodes were defined and monthly rates calculated separately for women with a postnatal-related code within 4-, 6-, 8-, or 12-weeks or 1 year follow-up. Rates were also generated by key maternal demographics to assess any differences in postpartum care. Interrupted time series, modelling the onset of the pandemic estimated the IRR of 0.49 (95% CI 0.40-0.58). To assess the impact of maternal characteristics on the odds of non-attendance at examination, a logistic regression adjusting for various maternal characteristics was fitted. Results: There were 114,874 unique delivery episodes, relating to 85,076 women in the 12-week follow up cohort; 72,595 episodes to 55,784 women in 8-weeks and 28,846 episodes to 24,018 women in 6-weeks. The rate of postpartum checks was greater the longer the follow-up period. For checks within 8 weeks the first lockdown reduced from ~325 per 1000 delivery episodes in 2019 to 225 per 1000 by April 2020 (30.8%), which remained low, before returning to pre-pandemic rates by rates by October 2022. Rates remained lower overall for Black, or Asian women compared to White. Conclusion: The COVID-19 pandemic reduced postnatal follow-up in primary care across Greater Manchester, with rates frequently falling outside the recommended 6-8 week window. Significant disparities exist in the provision and uptake of these services. Improved integration of data across care sites, combined with enhanced risk management, could increase equity in access and support the timely delivery of care for those at greatest risk of postnatal complications and longer-term health issues.

Objectives To assess the concurrent and lagged associations between quality of primary care and planned and unplanned secondary care use for patients with multimorbidity, examining the modifying role of frailty. Design A retrospective cohort study Setting This population-level analysis included 468,172 patients with multimorbidity in England from the Discover research platform (April 2022-March 2024). Participants Patients with multimorbidity Main outcome measures We used principal component analysis to combine a set of quality indicators (QIs) and assessed the impacts of QIs on both planned and unplanned care. Results Generally, patients with higher QI attainment also had higher likelihood of planned (outpatient visits) and unplanned care (emergency admissions and ED visits) utilisation. There was a lower lagged odds of elective hospital admissions in the following 12 months among those with higher attainment of multimorbidity-specific QIs (OR=0.94, 95%CI 0.93-0.95). In the complex multimorbidity cohort ([&ge;]3 conditions), multimorbidity-specific QIs were longitudinally associated with lower odds of elective admissions (OR=0.94, 95%CI 0.92-0.95) and outpatient visits (OR=0.96, 95%CI 0.95-0.98), while generic QIs were related to lower odds of outpatient non-attendance (OR=0.95, 95%CI 0.91-0.99). In non-frail patients with multimorbidity, multimorbidity-specific QIs were longitudinally associated with reduced odds of outpatient visits (OR=0.98, 95%CI 0.97-0.99), elective admissions (OR=0.92, 95%CI 0.90-0.94) and prolonged elective hospital stay (IRR=0.94, 95%CI 0.89-0.99). Conclusions Attainment of generic and multimorbidity QIs was generally associated with slightly increased planned and unplanned care. However, patients for whom we identified higher attainment of multimorbidity-specific QIs had lower odds of elective admissions and outpatient visits, especially for those with complex multimorbidity. Our research suggests that the quality of primary care may influence patients' use of secondary care, with the potential to improve care for people with multimorbidity and warrant further investigation into management strategies.

Background: South Africa adopted evidence-based antenatal care (ANC) frameworks to improve maternal health outcomes. However, the maternal mortality ratio remains above Sustainable Development Goal target 3.1 and routine data indicate declining ANC first-visit coverage. Aim: This study sought to explore implementation gaps, barriers and facilitators in the delivery and uptake of ANC. Setting: Ugu and uMzinyathi districts in KwaZulu-Natal, and Capricorn and Waterberg districts in Limpopo, South Africa. Methods: A qualitative descriptive design was utilised. Semi-structured interviews were conducted with 70 purposively sampled participants, comprising 30 health system providers and 40 service users. Data were analysed thematically using NVivo. Results: Health system providers attributed declining ANC coverage to fertility decline rather than reduced access alone. Providers identified mentorship, community outreach and enhanced screening as key strengths. Implementation was constrained by staffing and equipment shortages. While service users recognised the benefits of ANC, they reported that long waiting times, negative provider attitudes and limited privacy during consultations undermined the quality of service delivery. Providers and service users linked delayed ANC initiation to financial constraints, stigma and pregnancy concealment. Conclusion: Improving early ANC initiation requires an approach that addresses health system, socioeconomic and cultural barriers. Concerns about declining fertility as a driver of declining coverage warrant further investigation into coverage calculation methodologies. Contribution: The study provides insights into the interconnected factors influencing ANC delivery and uptake in primary healthcare settings. It further highlights the need to consider changing fertility patterns when interpreting ANC coverage. The findings can inform targeted interventions and strengthen maternal health planning, monitoring, and service delivery.

Objectives To explore the acceptability and tolerability of cranial electrotherapy stimulation (CES) using Alpha-Stim AID as a potential intervention for anxiety associated with breathlessness in people with advanced chronic respiratory disease. Methods A multicentre, mixed-methods, non-randomised interventional feasibility study with a parallel usual-care control group. Participants were adults with chronic respiratory disease and significant anxiety and breathlessness symptoms (assessed via Integrated Palliative Outcome Scale) receiving care from hospice services. The intervention groups used Alpha-Stim AID for eight weeks either at a fixed or personalised dose, followed by a four-week follow-up period. This feasibility study was not powered to assess clinical efficacy. Results 12.5% of screened patients at the primary site were eligible, and 29 unique participants were recruited. Three participants withdrew from the study (10.3%), none of which were attributable to CES. Most adverse events were mild, with headache reported frequently across control and intervention groups. Outcome measure completion was high, with data missingness below 6.4%. Numerical rating scales of anxiety and breathlessness fluctuated daily and remained broadly static, whereas GAD-7 scores assessing anxiety improved over time across all groups. This feasibility study was not powered to assess clinical efficacy. Conclusion CES using Alpha-Stim AID was deliverable within hospice services and was generally acceptable and tolerable among participants who enrolled. Our findings support further evaluation which should involve a fully-powered randomised controlled trial against a sham device to determine whether CES provides clinically meaningful improvements in anxiety for this patient population.

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.

Ambient artificial intelligence scribes are being increasingly used in healthcare to improve efficiency and reduce provider clinical documentation burden, yet their performance across linguistically diverse patient populations is not well characterized. We conducted a retrospective analysis of 54,160 outpatient encounters within a U.S. safety net health system to evaluate the performance of an artificial intelligence documentation tool in English and non-English clinical encounters, and in encounters where an interpreter or bilingual provider was present. Documentation performance was measured by the percentage of words in the final note that were generated by the ambient AI documentation tool and not edited by the provider. Associations between language factors and documentation performance were measured using Generalized Estimating Equations with exchangeable correlation structures to account for clustering of multiple encounters within unique patients. Univariable models were fitted to estimate the odds of adequate performance by language and interpreter modality, and a multivariable interaction model was used to evaluate within-language differences between bilingual providers and interpreter-mediated encounters. Non-English encounters were 21% to 25% less likely than English encounters to achieve the same performance threshold. There was no significant difference in generative documentation performance between interpreter-mediated and bilingual provider encounters. These findings underscore the importance of equity-focused evaluation and multilingual model refinement to ensure that artificial intelligence documentation benefits are distributed fairly across diverse patient populations.

High-alert medications are a leading cause of preventable patient harm worldwide, but there was no any high alert medicine list or error prevention strategy for Sri Lankan hospitals. This study addresses that gap by using interviewer administered questionnaire [n=315], five stakeholder consultative meetings [n=62] including multidisciplinary clinicians to reach consensus, followed by interviewer administered questionnaire [n=45], semi-structured three focus group discussions [n=45] to explore implementation barriers. Our findings identified [n=100] medicines as high-alert for acute care settings, and [n=40] medicines for community settings. I believe this article will be of interest and benefit to the readers of your journal. I declare that this manuscript is original, has not been published before and is not currently being considered for publication elsewhere.No conflicts of interest exist. Ethical approval was obtained from the Ethics Review Committee of Faculty of Medicine, University of Colombo (Reference number: 18-008) and approval were renewed annually as required and Ethical Review Committees of National Hospital of Sri Lanka (Reference number: AAj/ETH/COM/2017) and Colombo South Teaching Hospital (Reference number: PL/MO/2018-2019).All approval covered the full data collection period. Permission to photograph hospital pharmacies were obtained from chief pharmacist of participating hospital and no patient-identifiable information is shown.Written informed consent was obtained from all participants. The high alert medicine lists for acute and community settings are provided as S1 and S2 appendices.As corresponding author, I confirm that the manuscript has been read and approved for submission by all the named authors.