BMJ Open Quality

Context/Objective: Demonstrating real-world impact is increasingly important for prehospital researchers. While biomedical sciences show high altmetric coverage, policy citation density in paramedicine remains largely unknown. This study evaluates the policy citation rate of UK ambulance service research, measures uptake differences between clinical practice guidelines and broader health policies and maps its geographic dissemination. Methods: Following the BiBLio reporting guidelines, all publications with a Digital Object Identifier (DOI) where at least one author was working in an NHS ambulance service were extracted from the amber repository covering 2006 to 2026 (N=2,095). Policy and clinical guideline citations were tracked using BMJ Impact Analytics. Document classifications and issuing organisation metadata were analysed in Microsoft Excel using descriptive bibliometrics. Key Findings: The overall policy citation rate was 23.48% (n=492/2,095), with 53.66% of cited papers cited once and 1.63% achieving 10 or more citations. A total of 1,143 citations were identified across 760 clinical practice guidelines (66.49%) and 383 health policies (33.51%), producing a guideline-to-policy ratio of 1.98:1. Multicentre clinical trials accrued high scholarly and policy citation volumes, whereas service design and workforce studies achieved high policy translation despite modest scholarly citations. Of 704 citations with resolvable geographic metadata, 46.45% (n=327) were domestic UK citations, 32.67% (n=230) originated from international Anglophone jurisdictions, 13.07% (n=92) from non-Anglophone European nations, and 4.83% (n=34) from international bodies. Conclusion/Significance: UK paramedic and ambulance service research demonstrates measurable translation into clinical practice guidelines and health policy, although its 23.48% policy citation rate places it towards the lower end of comparable empirical healthcare portfolios. The disproportionate uptake in clinical guidelines highlights the reliance of guideline panels on high-quality prehospital evidence. Maximising translational reach requires active dissemination by embedded researchers, explicit practice recommendations within publications, and systematic green open access preservation via sector repositories such as amber.

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.

Introduction Medicines account for 20% of the National Health Service (NHS) carbon footprint, but it is unclear how consistently they are measured by individual NHS trusts. This study assessed medicine carbon footprint (MCF) practices across NHS trusts in England and whether these changed between 2021 and 2024. Methods Freedom of Information requests were sent to NHS trusts about MCF practices in 2021 and 2024. Responses were analysed to determine the proportion of trusts calculating MCFs, the medicines included and the emission factors used for spend-based calculations. Reported spend-based factors were compared with the median factor for each year to assess the effect of factor choice on MCFs. Results Of 196 trusts included in analysis, 178 (91%) responded for 2021 and 182 (93%) for 2024. Among responding trusts, 30 of 178 calculated MCFs in 2021 compared with 46 of 182 in 2024. Spend-based medicine footprinting increased from 19 trusts in 2021 to 31 in 2024. Ten different factors were used by 15 trusts in 2021 and 13 by 21 trusts in 2024. Reported factors ranged from 31% below to 258% above the median in 2024. Conclusions Medicine carbon footprinting remained uncommon, with only one-quarter of responding NHS trusts calculating a footprint in 2024. Among trusts using spend-based methods, wide variation in emission factors produced substantially different estimated MCFs. Clear national guidance on spend-based methodology could improve consistency in the short term, while greater use of standardised product-level approaches may better support medicine decarbonisation over time.

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.

Background: Breaking bad news (BBN) is an essential part of healthcare communication especially in the fields of oncology. palliative care and life threatening illness. Objective: This study aims to analyze the global research trends, publication patterns and the intellectual structure of BBN literature from 2000 to 2025. Methods: Bibliometric study was performed on Scopus database. A total of 843 publications were retrieved and analyzed by bibliometric techniques. Visualization tools such as VOSviewer and R Studio were employed, along with Lotkas and Bradford laws. Results: The findings indicate that there is a steady growth of publications. The United States emerged as the leading contributor. Journals including Patient Education and Counseling were dominant in the field. Key areas of focus identified through thematic analysis included oncology, palliative care and communication, while emerging themes included empathy and telemedicine. Conclusion: BBN research has evolved into a mature, interdisciplinary field with increasing emphasis on patient centered communication.

Background: Patient satisfaction is a key measure of healthcare quality among people experiencing homelessness. Student-run free clinics (SRFCs) provide care to underserved populations, but the role of student involvement in patient satisfaction remains unclear. Methods: We conducted a cross-sectional study of patients receiving care at an SRFC. From February 2024 to February 2025, patients completed post-visit surveys assessing satisfaction that were evaluated using regression analyses. Results: Eighty-eight patients completed surveys, reporting high overall satisfaction (mean 9.26/10). In separate linear regression models adjusted for age, gender, and race, greater perceived benefit of student involvement was associated with higher satisfaction ({beta} = .298, p = .037), whereas perceiving the visit as too long was associated with lower satisfaction ({beta} = -.285, p = .019). Conclusion: Greater perceived benefit of student involvement was associated with higher patient satisfaction, whereas longer perceived visit duration was associated with lower satisfaction. These findings highlight the importance of balancing educational opportunities with efficient workflows in SRFCs.

A. Rationale: Medication-related incidents are an important patient-safety concern, particularly in critical-care and inpatient settings where polypharmacy, clinical complexity, frequent therapeutic modifications, and transitions of care increase the risk of medication errors. Systematic analysis of reported incidents can help identify predominant error patterns, potential contributing factors, and priority areas for quality improvement. The present study was undertaken to characterize medication-related incidents and identify areas requiring targeted patient-safety interventions. B. Research Question What are the predominant patterns and distribution of medication-related incidents across critical-care and inpatient units, what patient-care, process, communication, documentation, and system-level factors potentially contribute to their occurrence, and how can these findings be systematically translated into prioritized, evidence-based quality-improvement interventions to strengthen medication safety and reduce preventable medication-related harm? C. Study Design and Methods A retrospective descriptive observational study was conducted to assess the pattern of medication-related errors identified through medication audits conducted in inpatient and critical-care settings. A total of 74 medication audit records were retrospectively reviewed. Each record was evaluated for the presence and type of medication-related error, including transcription, administration, documentation, and dispensing errors. The identified medication errors were categorized based on the nature of the error documented in the audit records. As individual records could contain more than one type of medication-related error, the error categories were considered non-mutually exclusive. Consequently, the total number of error occurrences could exceed the number of records reviewed. Descriptive statistical analysis was performed using frequency distributions and percentages to determine the relative occurrence of each medication-error category. Pareto analysis was subsequently performed to identify the predominant error categories and establish priorities for quality-improvement interventions. The Pareto analysis demonstrated that transcription and administration errors constituted the major contributors to the observed medication-related errors. The identified error patterns were further evaluated using a process-based patient-safety approach to determine potential failure points within the medication-use process. Poka-Yoke (error-proofing) principles were applied to identify opportunities for preventing or detecting errors at the point of occurrence. Based on the findings, potential interventions included standardization of medication-ordering and transcription processes, mandatory verification of medication details, strengthening of independent verification for high-alert medications, and incorporation of technology-enabled safeguards such as electronic medication administration records and barcode-based medication administration. The findings were used to identify priority areas for targeted quality-improvement interventions aimed at reducing medication-related errors and strengthening the safety and reliability of the medication-use process. D. Results: A total of 91 medication-related error occurrences were identified across the 74 audit records reviewed. Transcription errors constituted the predominant error category (46; 50.5%), followed by administration-related errors (41; 45.1%). Documentation-related and dispensing-related errors accounted for 3 (3.3%) and 1 (1.1%) occurrences, respectively. Pareto analysis demonstrated that transcription and administration-related errors collectively accounted for 87 of the 91 identified occurrences (95.6%), indicating a substantial concentration of medication-related errors within these two categories. The cumulative frequency increased from 50.5% for transcription errors to 95.6% following inclusion of administration-related errors, while the remaining categories contributed only 4.4% of the total error occurrences. Accordingly, transcription and administration-related errors were identified as the principal priority areas for subsequent root cause analysis and quality-improvement interventions. Interpretation: The findings demonstrate that transcription errors (50.5%) and administration-related errors (45.1%) were the predominant medication-related errors, collectively accounting for 87 of the 91 identified error occurrences (95.6%). Documentation-related errors constituted 3.3%, while dispensing-related errors accounted for 1.1% of the observed occurrences. Pareto analysis revealed a marked concentration of medication-related errors within the transcription and administration domains, indicating that these two categories represented the principal areas requiring focused quality-improvement interventions. Subsequent Root Cause Analysis (RCA) and Poka-Yoke-based error-proofing approaches were therefore directed toward identifying and mitigating process vulnerabilities within these high-frequency error domains. Keywords: Medication-related incidents, Medication errors, Patient safety, Critical care, Inpatient care, Medication transcription errors, Medication omission, Medication administration, Root Cause Analysis, Pareto analysis, Poka-Yoke, Error-proofing, Quality improvement, Medication safety, PDSA.

Background. Dedicated allied health professions (AHP) informatics posts remain rare and largely unevaluated: one NHS trust in ten reports a formal AHP informatics lead. Objectives. To evaluate stakeholder-perceived value and experience of a dedicated AHP Information Officer (AHPIO) role supporting an organisation-wide electronic health record (EHR), and to derive a working framework of the role's practice. Methods. Cross-sectional online survey within a registered service evaluation at a specialist cancer centre in England. A purposive census of 40 stakeholders (clinical and operational AHP staff, digital champions and EHR programme colleagues) rated six agreement items with four free-text questions. Analysis led with distributions, medians and Wilson intervals; inference was exploratory; free-text coding is fully audit-trailed. Results. Twenty-seven stakeholders responded (68%). Five items sat at a ceiling (medians 4 to 5; agreement 95% to 100%); all 25 answering the overall item agreed the role adds value, 80% strongly. Data and reporting access was the outlier (median 3.0; 52% neutral or below; agreement 48%, 95% CI 28% to 68%), ranking below every other item (Friedman chi-squared 36.3, df 5, 20 complete cases; Holm-adjusted post-hoc comparisons, rank-biserial -0.73 to -1.00). Nine themes located value in brokerage and routing (18/26), concrete outcome accounts (16/26) and a clinician who understands AHP work (12/26). Conclusions. Stakeholders located the role's value in brokerage, clinical-digital translation, representation and outcome response, resting on a named trusted contact; self-service data is the part-built pillar and development priority. The framework and method offer a replicable template for evaluating AHP informatics roles.

Background: The Greater Manchester Care Record (GMCR) integrates health and social care data for 2.8 million individuals. While it contains maternity information, identifying individual pregnancies, including timing and outcomes, is complex due to variations in healthcare interactions and recording practices. This study develops open-source code to create a pregnancy register within the GMCR using diagnosis- and procedure-based algorithm established in other databases. Methods: 1,448 maternity SNOMED clinical codes identified pregnancy-related primary care records among women aged 14-49 years between March 2012 and August 2023. Codes were grouped by pregnancy outcome, with a hierarchical ruling approach where multiple outcomes appeared within one episode. Pregnancy start dates were derived from hierarchical coded events or imputed using biologically plausible duration based on outcome type. Internal validation compared GMCR register episodes against Hospital Episode Statistics (HES) hospital maternity admissions; external validation compared outcome rates against published UK estimates. Results: The algorithm was developed across 379,832 women, identifying 880,926 pregnancies. Internal validation showed nearly half of register deliveries had a corresponding HES record, with a positive predictive value (PPV) of 48.1%and a median date difference of 17 days (IQR 1-30). External comparison revealed live birth (927.8 vs. 995.6 per 1,000 deliveries) and stillbirth (2.12 vs. 3.9 per 1,000 births) rates close to national estimates but a notable discrepancy for miscarriage (8.00 vs. 15.3 per 100 pregnancies) and termination of pregnancy (5.36 vs. 25.1 per 1,000 women). Demographic alignment was strong for maternal age (31 vs. 29.8 years) and deprivation (IMD10 median: 3 vs. 2.6), though ethnic minority representation was expectedly higher in the GMCR (37.0% vs. 28.7%). Conclusions: This pregnancy register enriches the GMCR for maternal health research, enabling more comprehensive and regionally tailored studies to inform healthcare delivery and policy. This work represents an important first step in developing a scalable, open-source algorithmic tool to support pregnancy research across diverse populations. By making the code openly available, it can be adapted for use in federated data environments, enhancing reproducibility and collaboration.

Abstract Background. Outcomes for low-birth-weight (LBW) neonates depend not only on biology but on the timeliness of the care pathway. The Three Delays Model--deciding to seek care (Delay 1), reaching the hospital (Delay 2), and receiving adequate care after arrival (Delay 3)--offers a validated lens for locating where that pathway fails. We applied the model to characterise care-pathway barriers affecting LBW neonates admitted to a Kenyan county referral hospital and to relate them to severe adverse outcomes. Methods. Facility-based mixed-methods cross-sectional study of 169 LBW neonate-mother pairs admitted to the newborn unit of Kericho County Referral Hospital, complemented by nine key-informant interviews with providers. Delay indicators were derived for each of the three delays, with denominators defined explicitly. Descriptive statistics summarised each indicator; associations with severe adverse outcome were tested with the chi-square or Fisher exact test (kept descriptive, not modelled). Provider interviews were analysed thematically and coded directly to the three delays; quantitative and qualitative findings were integrated in a delay-structured joint matrix. Results. A severe adverse outcome occurred in 136/169 neonates (80.5%). Pathway barriers clustered before arrival: decision-to-seek-care delay >6 h in 13.6%, a transport-access problem in 32.5%, and residence >10 km from a facility in 34.3%; nearly half (49.1%) were referred/outborn, and among referred neonates 26.5% arrived without a referral note. After arrival, care began within 30 minutes in 66.3%. Referral/outborn status was associated with higher odds of a severe outcome (crude OR 2.25, 95% CI 1.01-5.00; p = 0.043), as was essential drug/feed shortage (OR 2.26, 95% CI 1.04-4.90; p = 0.036). Paradoxically, decision delay, transport problems, and any pathway delay were each associated with a lower proportion of severe outcomes (all p < 0.01); these inverse associations most plausibly reflect confounding by indication and reverse causation--the sickest neonates were prioritised for rapid transfer and care--and should not be read as protective effects of delay. Provider narratives, coded to the three delays, described caregiver danger-sign recognition gaps, transport and referral-coordination barriers (cold, poorly documented arrivals), and first-hour stabilisation, staffing, warm-chain, supply, and monitoring constraints. Conclusions. Barriers for the smallest neonates accumulate along the pre-hospital pathway, and referral status signals more than a transport category--it marks accumulated vulnerability from delayed decision-making, transport constraints, incomplete pre-referral stabilisation, and facility-response gaps. Reducing severe outcomes requires shortening specific, identifiable delays, especially strengthening referral coordination and the fragile first hour after arrival, rather than reproducing a full determinants model.

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 Owing to a growing body of evidence, clinical guidelines now recommend exercise for stroke survivors. However, many stroke survivors are physically inactive and may need more support to engage with exercise in the community. There are between 600-800 exercise referral schemes in the United Kingdom, but engagement from stroke survivors is very low. This study aimed to evaluate the accessibility of exercise referral schemes in England to stroke survivors. Methods A cross-sectional, online survey was conducted throughout England. All 317 local authorities in England were invited to participate. Geospatial mapping was used to visualise the accessibility of exercise referral schemes across England. Data on scheme design and delivery parameters were analysed descriptively. Results Data were collected from 147 local authorities. Exercise referral schemes were offered in 134 local authorities, of which, stroke survivors were able to access 128. However, stroke-specific schemes were available in only 17 local authorities. Significant variations in exercise referral scheme design and delivery were identified across the country. Only two consistencies were found between schemes: the involvement of fitness instructors, and the lack of transport provision. The capacity of exercise referral schemes did not correlate with the general population, stroke population, or stroke prevalence within a local authority. Conclusions Exercise referral schemes are widely available across England, and the majority are open to stroke survivors. However, stroke-specific services are very limited and there is substantial variation in scheme eligibility, capacity, costs, and referral pathways. These inconsistencies, paired with the lack of transport provision, may explain the low uptake of exercise referral schemes within the stroke population.

Background: Patient-facing AI intake chatbots can enter clinical use without regulatory review, so their errors may first surface with actual patients. Objective: To develop and pilot a remote, voice-based standardized patient (SP) method for evaluating an intake chatbot's history-taking, documentation, and patient-centeredness. Methods: Four primary care cases had Easy and Difficult variants. In Phase 1, five SPs completed 40 encounters with internal medicine residents rating portrayal fidelity. In Phase 2, SPs completed 80 encounters with a ChatGPT 4o chatbot, recorded whether critical elements were asked about and addressed satisfactorily, and rated summaries; four debriefing interviews were analyzed. In Phase 3, two blinded clinicians rated transcripts and summaries from 101 encounters (32 resident-led, 69 chatbot-led). Results: Portrayal fidelity averaged 4.52 of 5. The chatbot asked about 59.3% of critical elements in Easy versus 50.2% in Difficult variants (adjusted OR 1.49; 95% CI, 1.15 to 1.93) and addressed 73.3% versus 64.6% (OR 1.47; 1.12 to 1.93); near-ceiling summary quality did not differ. SPs reported missed information and rushed pacing. Reviewer agreement was moderate to substantial for element judgments (AC1 0.49 to 0.70) but poor for totals (ICC 0.10 and 0.21). In exploratory comparisons, residents asked about more elements (adjusted difference 12.5 percentage points; 95% CI, 7.0 to 18.1) and satisfactorily addressed more (9.2 points; 3.8 to 14.6); totals did not differ. Conclusions: SP portrayal was consistent enough for pre-clinical chatbot evaluation, and the method detected lower coverage in harder cases. Documentation ratings alone may miss conversational gaps, which require direct measurement.

Abstract Objectives To conduct a Delphi process to inform an international, consensus definition of manuscript peer review. Design Three-round Delphi consensus study including two surveys and one virtual consensus meeting. Peer review features identified through a prior scoping review were rated on a 5-point Likert scale in Rounds 1 and 2 and voted on using include, exclude, and abstain options in Round 3. Consensus was defined as [&ge;]80% agreement. Setting International experts representing interest holders affected by manuscript peer review across the fields of biomedical, health, and social sciences, economics, and healthcare-related industries. Participants Round 1 participants were purposively recruited via email from corresponding authors of articles included in the preceding scoping review. Round 2 participants were those who completed Round 1. Round 3 participants were purposely selected to address gaps in representation from earlier rounds, with attention to diversity of perspectives and equity-relevant characteristics informed by PROGRESS-Plus (e.g., geographic location, gender, race/ethnicity, occupation, and socioeconomic context). Participants were required to communicate in English. Main outcome measures Consensus on the terminology, scope, characteristics, functions, processes, and reviewer characteristics that should inform a definition of manuscript peer review. Results Across the three rounds (N=143, 109, and 16 participants, respectively), 44 peer review features across six domains (Characteristics, Function, Motivation, Assessment, Process, and Challenges) and six peer reviewer characteristics met the consensus threshold for inclusion. Consensus was also reached on terminology to describe manuscript peer review and the peer review workflow. Results were synthesized into a final conceptualization of manuscript peer review, consisting of one definition and eight pillars.The consensus definition is: Manuscript peer review is a structured process by which human reviewers assess scholarly manuscripts, with the aim of improving the quality and trustworthiness of published research in line with norms of reciprocity to the research community. The eight pillars characterize manuscript peer review and are as follows: Principled, Constructive, Timely, Transparent, Professional, Quality, Confidential, and Pluralistic. Conclusions This three-round international Delphi established a consensus-based, normative conceptualization of manuscript peer review as a distinct, human-led process to improve the quality and trustworthiness of scholarly research. The resulting definition and eight pillars may provide a shared foundation for research, evaluation, education, and improvement across publishing contexts while allowing operational features to remain adaptable.

Background: Patient-generated online reviews contain detailed accounts of physician communication that remain systematically underused in health services research. Prior computational analyses have either applied service quality frameworks without grounding in clinical communication theory, or have been geographically and specialty-restricted. Objective: To examine which physician communication dimensions predict patient recommendation, switching intent, and retention across specialties and cities in India. Methods: We analyzed 62,319 patient reviews from the Practo platform (10 cities, 8 specialties) coded against established clinical communication frameworks, the Kalamazoo Consensus Statement, Calgary-Cambridge Guide, and SPIKES protocol, adapted into a 12-dimension codebook. Expert confirmatory review on 200 stratified reviews yielded 98.5% agreement between reviewer and model labels across 11 communication dimensions. Binary recommendation was designated the primary outcome; recommendation intensity is reported as secondary. Logistic regression with 1,000 bootstrap iterations examined associations between communication dimensions and recommendation and switching intent, adjusting for treatment outcome, cost, wait time, and specialty. Results: Reassurance (OR 2.07, 95% CI 1.86-2.42) and empathy (OR 1.89, 95% CI 1.79-2.00) were the strongest positive predictors of recommendation. Excessive directiveness (OR 0.62, 95% CI 0.60-0.64) and rushedness (OR 0.65, 95% CI 0.64-0.67) were the dominant negative predictors; directiveness was present in 33.3% of switching-intent reviews. Cost asymmetry was pronounced: cost concerns reduced recommendation rates by 54.2 percentage points; positive cost comments increased recommendation by 6.2 points. Specialty variance in recommendation intensity exceeded city variance (ratio 2.63). Conclusions: Excessive directiveness and rushedness were the communication behaviors most strongly associated with adverse behavioral outcomes in this corpus; reassurance and empathy are the strongest drivers of recommendation. These effects are modified by specialty context in ways that align with Kalamazoo, Calgary-Cambridge, and SPIKES theoretical predictions. The specialty-stratified findings provide a direct empirical basis for competency-based communication curricula in undergraduate and postgraduate medical education.

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.

Abstract Background Community-based exercise may support physical and cognitive recovery after stroke, but the preferences of stakeholders involved in receiving, supporting and delivering these programmes are poorly understood. This study piloted a discrete choice experiment (DCE) that aimed to evaluate stroke survivors, carers, clinicians, and fitness instructors preferences for community-based exercise programmes for stroke survivors. The pilot aimed to assess the feasibility of conducting and analysing data for a larger-scale study and inform the sample size for a definitive DCE. Methods A DCE design was developed using literature reviews, stakeholder consultations, and evaluations of current services. Six attributes were included in the design: location, price, session frequency, individualisation, carer involvement, and recovery. Sixteen Bayesian D-optimal choice sets were developed, then blocked into two sets of eight to reduce cognitive burden. Main-effects were analysed using a mixed logit model, and stakeholder differences were explored using a conditional logit interaction model. Willingness to pay was also calculated. Results Overall, 161 respondents started the survey and 106 (66%) fully completed it. Stakeholders significantly preferred programmes that were delivered at a leisure centre, lower priced, individualised, had carer-specific sessions and offered greater chances of recovery. The largest willingness-to-pay estimates were {pound}49.41/ month for 80% chance of meaningful recovery vs 20%, and {pound}18.61/ month for leisure centre delivery vs online. Significant preference heterogeneity was identified in the main-effects model. Exploratory stakeholder interactions suggested clinicians were more price sensitive and placed greater importance on recovery and carer-specific sessions than stroke survivors, while fitness instructors placed greater importance on programme location and recovery. Carer interaction estimates were unstable due to the small subgroup sample. Conclusions The pilot supported the feasibility of the DCE design and analytical approach but identified limitations in the recruitment methods and survey completion. Addition of face-to-face recruitment methods are recommended for a larger-scale study. A larger sample size is required to investigate differences in preferences between stakeholder groups.

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: Multidisciplinary tumor boards (MTBs) are a standard part of cancer care, yet India has no national measure of how many cancer patients are discussed at one. A national survey of hospitals in the National Cancer Registry Programme (NCRP), published in 2026, gives the first structured look at board presence and functioning. Objective: To describe how far hospital-level tumor board presence translates into all-case review, documentation and follow-up, and to define the data needed to measure patient-level coverage. Methods: Secondary analysis of published aggregate data: the ICMR-NCDIR survey of 229 hospitals in the NCRP hospital-based cancer registry (HBCR) network (October 2024), the HBCR 2021 report, national incidence estimates (ICMR-NCDIR 2022; GLOBOCAN 2024) and two published single-center MTB audits. We calculated proportions with Wilson 95% confidence intervals, non-response bounds across all 229 hospitals, and logical bounds for joint conditions. No individual-level data were used. Results: A total of 229 hospitals were invited and 172 responded (75.1%). Among the respondents, 137 (79.7%; 59.8% to 84.7% across all hospitals) reported a functional tumor board. Only 65 respondents (37.8%; 28.4% to 53.3%) reported boards that review all cases, 71 (41.3%) had a follow-up system, 50 (29.1%) used any electronic documentation and 7 (4.1%) always took part in cross-hospital reviews. The share of hospitals with both all-case review and a follow-up system could lie anywhere from 0% to 37.8% of respondents. Boards were reported more often in private (86.6%) than in public hospitals (72.5%). Two single-center audits reported about 800 case discussions (573 new patients) and 1,260 case discussions (about 917 patients) a year, but neither reported new registrations at the same hospital, so coverage could not be calculated. Conclusions: Tumor board presence is common in India, but evidence of all-case review, documentation and follow-up is much thinner, and the share of patients reviewed nationally is unknown. We propose six indicators that hospital-based registries could report to measure coverage directly.

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.