Health Policy

Objectives: Women's empowerment is a key determinant of health and well-being and may shape how women access and benefit from publicly-funded health insurance (PFHI). We aimed to examine whether different levels of women's empowerment were associated with 1) verification in India's PFHI Pradhan Mantri Jan Arogya Yojana (PM-JAY), 2) outpatient care utilization, and 3) resultant out-of-pocket expenditure. Design: We conducted a cross-sectional observational study. We analyzed data from a household survey, created a composite empowerment index using structural equation models, and used multivariate regression models to test associations between women's empowerment and the outcome variables. Setting: The study was conducted between December 2019 and February 2020 among PM-JAY eligible households in six Indian states (Bihar, Chhattisgarh, Gujarat, Meghalaya, Tamil Nadu, and Uttar Pradesh). Participants: 14,378 women across the six states. Results: Three main findings emerged: First, high levels of women's empowerment were associated with higher odds of completing PM-JAY verification (AOR: 1.22, 95% CI: 1.09-1.36). Second, women's empowerment was not associated with outpatient service utilization. And third, either medium levels of empowerment (coef = -0.49, p = 0.020) or PM-JAY verification (coef = -0.37, p = 0.034) was associated with lower OOPE for outpatient services. Women who had both, PM-JAY verification and medium levels of empowerment, experienced higher OOPE (coef = 0.45, p = 0.058). Conclusions: Women's empowerment is an important factor related with PM-JAY verification, but not with outpatient service use. OOPE varied depending on whether women were both empowered and PM-JAY verified or not. Our results suggest that institutional and structural barriers may play a greater role in healthcare access than individual factors pertaining to empowerment alone. Achieving equitable access therefore requires gender-responsive systems that reduce administrative barriers and support women in navigating the healthcare pathway. Our findings highlight the importance of integrating outpatient care into PM-JAY to increase financial protection, streamlining verification processes to improve women's engagement with PM-JAY and the broader health system, and advancing health financing reforms that better support women.

Background: While health system costs of COVID-19 are well documented, evidence on out-of-pocket costs to patients and families, including non-medical and time burden, is limited. This study aimed to estimate out-of-pocket medical, non-medical, and time burden of COVID-19 illness directly from patients and caregivers. Methods: Two cross-sectional surveys were fielded to national nonprobability samples of U.S. adults in Fall 2023: a personal burden survey (adult sample) and a caregiver burden survey (child sample). Surveys collected data on care setting, visit duration including travel and wait time, and medical and non-medical out-of-pocket costs. After applying quality-based exclusion criteria, 409 adult sample and 52 child sample responses were analyzed. Results: Over 87% of respondents were insured. Median out-of-pocket medical costs per visit were low, ranging from $5 (emergency department) to $10 (urgent care) in the adult sample, and from $0 (emergency department) to $75 (hospitalization) in the child sample. Median non-medical costs were $28 or less across care settings. Median time spent receiving care ranged from 90 minutes (primary care, child sample) to 300 minutes (emergency department, adult sample). Despite the relatively low reported out-of-pocket costs, COVID-related financial challenges were reported by 34% of the adult sample and 29% of the child sample, with the most common difficulty being paying non-medical bills (11% and 15%, respectively). Twelve percent in both groups reported problems paying COVID-19-related medical bills. Conclusions: In this post-pandemic non-probability sample, individual out-of-pocket costs for COVID-19 illness were relatively modest. However, time burden was substantial and one-third of respondents reported financial hardship. These estimates, including non-medical and time burden not captured in administrative data, can support more robust economic evaluations of COVID-19 prevention and treatment interventions.

Background: Lean Healthcare has been adopted as an approach to reducing waste, enhancing process efficiency, and optimizing clinical and administrative workflows. However, empirical evaluations aimed at establishing a causal relationship between Lean Healthcare interventions and outcomes remain limited. This evidence gap is particularly pronounced in the context of large-scale implementations in low- and middle-income countries, where more efficient allocation could yield substantial improvements in population health. Methods: We conducted an impact evaluation study employing a staggered difference-in-differences approach to estimate the effects of the Lean Healthcare in Emergency Departments (ED) initiative in the Brazilian context. The intervention was implemented between January 2017 and December 2025 across 309 hospitals. We analyzed hospital-level indicators of the number of hospitalizations and the average length of stay (in days) among patients admitted through urgent or emergency pathways. Results: Our estimates suggest that the intervention was associated with an average increase of 38.6 admissions per hospital per month (p = 0.033), corresponding to approximately a 5.9% increase relative to the monthly admission volume. We also observed a reduction of 0.184 days in the average length of stay (p = 0.058), equivalent to an approximately 3.0% decrease in hospitalization time. These effects exhibited distinct temporal dynamics: the effect on the number of hospitalizations emerged gradually and increased with the duration of the intervention, whereas the reduction in length of stay became evident earlier. Conclusion: This study provides evidence of a causal effect of Lean Healthcare implementation in emergency departments on operational performance. The simultaneous increase in admissions and reduction in length of stay suggests improved bed productivity and effective capacity without expanding physical infrastructure. These findings support the use of flow-management methodologies as an effective strategy for mitigating emergency department overcrowding while increasing service capacity.

This paper examines the impact of Cancer Care Ontario's regionalization of lung cancer surgery on blood transfusion use for thoracic surgery at The Ottawa Hospital. Using aggregate data scraped from the paper ''Changing trends in blood transfusion: an analysis of 244,013 hospitalizations'' by Shehata et al. (2014) we estimated the effect regionalization on the log mean number of blood transfusions among thoracic surgeons (who treat lung cancer), utilizing other surgical specialties as controls. We found that the average number of blood transfusions increased significantly among thoracic surgeons following the opening of a new cancer care centre at the hospital in December 2009, while control specialties showed no parallel change. Contextualizing these results in a modified ''population level'' treatment threshold model, it is argued that the main driver of this increase in blood transfusions among thoracic surgeons was due to the influx of less skilled thoracic surgeons to The Ottawa Hospital, and the closing of thoracic surgery units at smaller hospitals which was part of the broader regionalization process.

Health systems increasingly record ICD-10 Z59 social-needs codes for housing, food, transportation, and related hardship to trigger referrals, report quality, and adjust risk. However code documentation occurs at varying rates and no study has separated what the code says about a patient's hardship from what it says about being documented at all. Using a linked electronic health record and claims corpus covering 4.95 million patients in 21 identifiable health systems, we matched 26,153 adults with a first outpatient Z59 code to similar uncoded patients and, as a negative control, repeated the entire design around an administrative code. Coding ranged from 1 percent to 24 percent of patients across systems and remained highly variable after adjustment for patient mix. A hardship code was associated with 67% (95% CI=1.61, 1.74) more emergency department (ED) visits and 43% ( 95% CI=1.38, 1.49) more hospital admissions in the next year (62 versus 49 of every 100 patients with any acute event). The administrative-code reproduced 46 percent of the Z59 association for ED visits and 70 percent for admissions. In the five systems with the most complete stay dates, no hardship-specific admission excess was detectable. Homelessness codes forecast two and a half times the ED visit rate. At national planning prices, excess emergency and preventable hospital care totaled roughly $2,000 to $2,500 per coded patient-year ($2,516 base scenario; about $1,100 under an exploratory assumed-discount scenario (not an estimate of hardship-attributable spending)), with the largest emergency burden among Medicaid patients. The Z code added no increment to clinical and utilization-based risk prediction models in any system.

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.

Abstract Many women experience menopausal symptoms after stopping hormone replacement therapy (HRT). An evidence gap remains regarding how women and healthcare professionals (HCPs) make decisions about discontinuing and restarting HRT. Aim To explore experiences of HCPs that support women when they discontinue and restart HRT. Design and setting Qualitative study with HCPs working in NHS primary care. Method Semi-structured interviews with HCPs (n = 15) conducted between October 2025 and March 2026. A preliminary coding template was created using the discussion guide as a framework. Each interview was then coded inductively against the template which developed iteratively. Team based discussion helped refine codes into themes and sub-themes, and a subsequent conceptual model was created. Results The model describes HCPs experiences of supporting women to discontinue HRT as an iterative process characterised by uncertainty. Discussions about discontinuation were commonly prompted by changes in clinical risk or annual HRT review, but decisions about whether and when to stop also depended on womens symptoms, side effects, life stage and readiness. HCPs described agreeing an individualised discontinuation strategy, providing support during the process, and reviewing women after discontinuation to consider alternative treatments or, where appropriate, restarting HRT. Conclusion HCPs recognise the importance of readiness to discontinue and that decision making should be woman led, with HCP support, clear practice guidance and opportunities to revisit treatment. Further research is needed to support women weigh up their personalised risk and benefit of continuing/discontinuing and identify discontinuation strategies that limit resurgent symptoms.

People experiencing homelessness (PEH) have substantially lower quality-adjusted life expectancy and substantially higher healthcare spending compared to housed populations. California has the largest population of PEH in the United States, and an estimated ten percent of PEH have co-occurring opioid use disorder (OUD). We developed a lifetime, individual-level microsimulation of the 18,928 PEH with OUD in California to evaluate the health and economic effects of expanding access to housing through a Housing First approach, which does not require OUD treatment or abstinence. Increases in permanent housing and shelter access were based on Los Angeles County's Measure A goals, and we accounted for both housing and healthcare costs. Expanding housing access increased mean age at death by 0.34 years, reduced fatal overdoses for the cohort by 39, and produced an incremental cost-effectiveness ratio of $31,083 per quality-adjusted life-year gained, well below conventional willingness-to-pay thresholds. We provide evidence that housing is a high-value health intervention for PEH with OUD in California. Policymakers should support Housing First programs as part of integrated responses to the intertwined crises of homelessness and opioid use.

Purpose Prescribing to lactating women is constrained by limited evidence. Published compatibility classifications provide clinical guidance and a discrete research comparator. How often prescribing diverges from that guidance, and what characteristics are associated with divergence, is unknown at national scale. Methods Retrospective analysis of prescriptions filled during lactation, identified in the 2012-2014 MarketScan Commercial Claims Database. Prescriptions were classified as concordant (Hale's lactation risk category L1-L3) or discordant (L4-L5). Multivariable logistic regression identified factors associated with concordance. Results Of 96,484 new prescriptions, 95,710 (99.2%) were concordant and 774 (0.8%) were discordant. Discordant prescriptions were filled later after delivery (median 59 vs 33 days) and had a day supply three times longer (30 vs 10 days). In multivariable analysis (N=28,732), concordant prescriptions were associated with maternal age under 35 (adjusted odds ratio (aOR)=1.34, 95% confidence interval (CI): 1.02-1.75) and chronic-condition medications (aOR=10.94, 95% CI: 6.47-18.50), and were less likely within 14 days of delivery (aOR=0.53, 95% CI: 0.38-0.73) and with each additional day of supply (aOR=0.96, 95% CI: 0.96-0.96). Compared with family practice, concordance did not differ for obstetric, internal medicine, or emergency medicine prescriptions, but prescriptions from other provider types had lower odds of concordance (aOR=0.57, 95% CI: 0.41-0.79). Conclusions Prescribing during lactation was overwhelmingly concordant with published compatibility guidance; the rare divergence was patterned by prescription and prescriber characteristics. Because the categories are an expert classification rather than consensus guidance, divergence should not be read as inappropriate prescribing.

Background Chemsex, drug use before/during sex to facilitate and enhance the experience, is undertaken by a minority of gay, bisexual and other men who have sex with men (GBMSM), but evidence of chemsex prevalence in England is limited. This study describes trends in chemsex prevalence between 2022-2025 and identifies factors associated with chemsex amongst GBMSM in England. Methods Data from the RiiSH study (2022-2025), an annual online cross-sectional survey of GBMSM recruited through social networking/dating apps and community partners, were analysed. Trends in chemsex prevalence and adjusted prevalence were estimated using log-binomial regression models. The following seven variables were candidate factors associated with chemsex and were assessed through logistic regression: age, sexual orientation, education, employment, HIV status, HIV PrEP use, and sexual health service (SHS) use. Results 5728 GBMSM were included in this study. Adjusted chemsex prevalence varied from 6.1% in 2022 to 4.2% in 2023, 5.1% in 2024 and 6.8% in 2025. Chemsex was more likely in GBMSM who were: gay (aOR=1.57 versus other sexual orientations; 95%CI 1.11-2.29, p=0.01), unemployed (aOR=3.08 versus employed full-time; 95%CI 2.19-4.26, p<0.001); aged 35-59 versus 16-34 years (p<0.001), with recent HIV PrEP use (aOR=3.79 versus no recent use; 95%CI 2.63-5.56, p<0.001), SHS use (aOR=2.23 versus no recent use; 95%CI 1.76-2.83, p<0.001), and living with HIV (aOR=3.16 versus negative/unknown HIV status; 95%CI 2.43-4.09, p<0.001). Conclusions Chemsex prevalence was low and stable between 2022-2025. PrEP and SHS use were associated with chemsex, supporting integration of specialist support services within SHS.

Background: Cost-effectiveness analyses (CEA) built on simulation models are usually delivered through project-specific scripts. Each new model, and often each new question, rebuilds the same scaffolding: parameter management, calibration, base-case analysis, sensitivity analysis and export. This is costly, and is where traceability between an estimate and the model version producing it is lost. We present THALASSA, a web application providing this infrastructure once, for any model satisfying a small programming contract. Methods: A simulation model is connected by one file implementing a fixed contract of R functions that determine its behaviour. THALASSA exposes the complete CEA workflow in a browser: a generated overview of the connected model, parameter editing, calibration, base-case comparison with the efficiency curve, and deterministic and probabilistic sensitivity analysis at a willingness-to-pay threshold, each with timestamped file export carrying the parameter values it was run with. Every session is bound to a repository version, so results carry their generating model version. Results: We demonstrate THALASSA on two public models of contrasting difficulty: a simple tutorial model and a generic cancer screening model with two competing natural-history pathways and a 21-dimensional calibration deliberately built to be more complex. Both ran on the same unmodified setup, implementing the same contract, with no code changes. Conclusions: Separating analysis infrastructure from model logic makes the CEA workflow reusable across projects and reproducible by construction. A modelling team can move from a versioned repository to audit-ready, exportable CEA outputs without writing analysis code. The integration effort does not grow with model size and one installation serves unrelated projects.

Introduction: Primary care electronic health records (EHRs) are an important resource for health research, but death recording in primary care EHRs may be incomplete or differ from Office for National Statistics (ONS) death registrations. We used OpenSAFELY-TPP to assess the completeness and concordance of death recording and provide recommendations for using date-of-death information. Methods: Using linked primary care EHRs and ONS death registrations, we assessed whether ONS-registered deaths from 2020-2025 had a primary care date of death and, where present, calculated the difference between dates. Where a primary care date was absent, we assessed death-related SNOMED CT codes. Analyses were conducted overall and by year, population subgroup, and general practice. We also examined GP registration end dates and primary-care-recorded deaths without a corresponding ONS record, including monthly patterns near the data extraction date. Results: Among 1,409,275 ONS-registered deaths, 88% had the same date recorded in primary care and 8% had no corresponding primary care date. Among 1,324,995 deaths recorded in primary care, <2% had no corresponding ONS record. Deaths recorded in only one source were more frequent among people aged <45 years and those from Mixed, Asian or Asian British, Black or Black British, and Chinese or Other ethnic groups. ONS-only dates were also more frequent in London and the West Midlands. Primary-care-only deaths increased close to date of data extraction, reaching 7% in February 2026. Same-day GP deregistration increased from 9% in 2020 to 85% in 2025. Conclusions: Death recording in primary care EHRs showed high completeness and concordance with ONS registrations, but discrepancies remained for recent deaths and some population groups. Data recency and population-specific completeness should therefore be considered when using linked mortality data for research.

Background: Workplace discrimination and violence against health workers including sexual harassment is a societal problem worldwide. We aimed to assess the frequency, predictive factors, and effects of sexual harassment using a nationwide survey of physicians working in Switzerland. Materials and Methods: We conducted a self-administered questionnaire survey of physicians working in Swiss healthcare institutions. The questionnaire assessed experiences of sexual harassment at work, including frequency, types, and sources of harassment. It also asked about the impact of sexual harassment, whether incidents were reported, and what actions were taken following a report. Results: Among the 1837 physicians that participated in the survey, 575 (31.3%) had experienced sexual harassment at least once during their career. Among those reporting sexual harassment, 39.1% of women and 13.2% of men had experienced harassment at least once in their job. Women reported more verbal harassment, while men reported more physical harassment. Women were also more likely to face both forms combined. The main sources of harassment were colleagues of the same profession (46.7%), patients (42.3%), and superiors (41.0%). The most frequently reported impacts included stress (60.1%), emotional exhaustion (34.7%), reduced motivation at work (30%), and considering leaving the job (7.5%). Gender-men was associated with a lower likelihood of experiencing harassment 0.24 (0.18 to 0.31), whereas working in the German-speaking region was associated with a slightly higher likelihood of having experienced sexual harassment at least once (OR 1.35, 95% CI:1.02-1.81). Conclusions: Sexual harassment is common among physicians in Swiss healthcare institutions. It adversely affects the mental health and career trajectories of both men and women yet remains widely underreported due to fears of reprisals and inaction. Institutions should effectively intervene to ensure that reported incidents result in appropriate actions, and that those who report them receive adequate protection from reprisals.

Purpose: Accurately capturing a patient's health journey is essential for ensuring the validity of scientific and public health studies. Electronic health records (EHR) and administrative claims are commonly used in healthcare research, albeit separately. Previous research has demonstrated that EHR and claims capture different aspects of patient history and care, potentially introducing bias when used alone. In this study, we leveraged the largest public US EHR resource, the National Clinical Cohort Collaborative (N3C), alongside Centers for Medicare & Medicaid Services (CMS) claims data to compare their information coverage and agreement. Methods: We integrated N3C EHR and CMS data to create one cohesive dataset and quantified the proportion of key variables present in EHR alone, CMS alone, and the overlap present in both data sources. Overlap in information coverage was quantified pre- and post-landmark diagnosis of COVID-19. To evaluate the impact of data coverage differences, we conducted a case study evaluating the effect of COVID-19 vaccination on ischemic stroke using both data sources alone and in combination. Results: CMS data helped identify many individuals that were duplicated among EHR identifiers. Examination of the overlap showed that CMS data more completely captured conditions, while EHR data more completely captured medications after COVID-19 diagnosis. Some variables exhibited marked differences over time after landmark COVID-19 diagnosis. Using target trial emulation and self-controlled case series methods, we found that data capture variations altered effect estimates: EHR data alone yielded lower risk of ischemic stroke after vaccination in the target trial emulation (odds ratio 0.47, 95% CI 0.28-0.79), with a smaller, non-significant reduction in the self-controlled case series (incidence rate ratio 0.81, 95% CI 0.64-1.02), whereas analyses using CMS data alone or both sources combined yielded estimates close to the null in both designs. Conclusions: Results indicated that when using either a national database combining multiple EHR sources, or CMS claims data alone, patients' medical histories are less completely captured compared to when these data sources are combined. Case study results highlighted the value of combining data sources for not only yielding fuller patient health histories and valid scientific results, but for identifying and explaining biases that may emerge in research studies that rely on a single data source.

Background Interruptions are common in hospital outpatient departments (OPDs) and are linked to error. Many are clinically necessary, so the aim is to regulate them. Most interventions target the individual clinician. Little is known about how doctors manage interruptions in practice or what makes their strategies work. Methods Qualitative study using focus groups and interviews with 42 doctors working in UK National Health Service OPDs (19 sessions, September to November 2025). Participants were purposively sampled by clinical experience and self-reported patient complexity. Data were analysed using Framework Analysis, informed by Cognitive Load Theory and Social Identity Theory. Results We developed four themes. (1) Pre-emptive protection of attention. Doctors withdrew, signalled unavailability and set thresholds for interrupting. These depended on colleagues learning and sharing the norm, which staff rotation eroded. (2) Sharing the burden through team coordination. Designated roles and time-limited rotas moved interruptions to colleagues with capacity set aside for them and made interrupting legitimate. (3) Real-time cognitive repair. Doctors asked interrupters to wait while they secured the task, and rebuilt the consultation on return, sometimes with the patient's help. Asking a colleague to wait depended on seniority or team membership; some trainees described difficulty doing this with senior colleagues. (4) Organisational recognition as the precondition for sustainable regulation. Where supervision was built into job plans, the interruptions it generated were expected and doctors held capacity in reserve for them. Advice, vetting and telephone queries were rarely counted as work. Conclusions Each strategy served a cognitive purpose, and social and organisational conditions decided whether it was perceived to work. Interventions could make norms shared and roles explicit, count interruption work in job plans and keep routes open for junior staff to raise concerns. Evaluations should ask who is able to use them.

Introduction Cancer incidence is rising rapidly in low- and middle-income countries (LMICs), where diagnostic pathology capacity is constrained. AI applied to routine histopathology could strengthen diagnostic capacity and offer leapfrogging potential by embedding AI into diagnostic systems as they are built up. However, without empirically identifying implementation determinants in LMIC cancer-diagnostic settings, AI solutions risk being poorly aligned with local constraints, limiting impact or exacerbating existing disparities. Methods We conducted an exploratory mixed-methods pilot study across three phases: 1) a structured survey characterising the diagnostic and technical landscape and AI priorities; 2) focus group discussions (FGDs) to inductively identify implementation determinants and 3) a second survey quantifying FGD-derived themes. Twelve physicians were purposively recruited (10 from LMIC, 2 from high-income countries for reference) and findings integrated through narrative triangulation. Results There was substantial heterogeneity in diagnostic and AI infrastructure that did not track consistently with country income classification. H&E staining was universally available, immunohistochemistry capacity was rudimentary at 7 of 10 sites and molecular testing absent or minimal at 6 of 10 sites. Whole-slide-imaging scanners were available at 8 of 10 sites, while graphical processing units, required for efficient AI inference, were available at only 4 of 10 sites. The participants would prioritise use of AI for cancer screening, cancer diagnosis, and biomarker prediction from H&E slides. Six implementation determinants were identified: AI literacy, governance frameworks, funding, evidence generation, clinical deployment, and collaboration. Financial constraints emerged as the dominant barrier across all determinants, and collaboration as an important enabling mechanism. Conclusion AI implementation readiness in LMIC cancer-diagnostic settings is highly heterogeneous and cannot be inferred from income classification, underscoring the need for institution-level assessment. Realising the leapfrogging potential of AI in this context requires coordinated progress across all determinants, with sustainable financing, and collaboration enabling the remaining determinants.

Background Emergency Department (ED) overcrowding is associated with adverse outcomes including delays to treatment, patients leaving without being seen and increased mortality. Increasingly, evidence suggests that crowding may disproportionately affect those of lower socioeconomic status, worsening health inequalities. This study investigates the relationship between prolonged ED length of stay and vulnerable patient groups choosing not to wait to be seen. Methods A retrospective cohort study analysed monthly ED attendance data from a large district general hospital between January 2020 and July 2025. Patients who did not wait to be seen (DNW) were assessed for vulnerability based on age, presenting complaint and inferred frailty. Associations were explored using generalised estimation equation model with binary outcome. Results During the 66-month study period, 317,978 patients attended the ED, of whom 35,403 (11.1%) did not wait to be seen. Of these, just under one third met vulnerability criteria. As the percentage of patients staying in the ED for more than 8-hours increased, so did the proportion of patients leaving the department without being seen. With each 10% increase in LOS>8h percentage, the odds of any patient choosing not to wait increases by 48% (OR=1.48, 95% CI(1.47 to 1.49), p<0.001). Of the three vulnerability groups assessed, paediatric patients, those presenting with mental health complaints and frailty, frail patients were the most affected when lengths of stay in the ED increased and crowding became a problem (OR=1.73, 95% CI(1.72 to 1.74), p<0.001). Conclusion These findings demonstrate that while all patient groups are more likely to leave without being seen as crowding worsens, elderly and paediatric patient cohorts are significantly more likely to leave without being seen as crowding worsens. This raises genuine concerns about the accessibility of healthcare, in the presence of crowding, in these vulnerable groups.

Abstract Importance Patients with behavioral health presentations leave the emergency department (ED) before evaluation more often than other patients, but outcomes after leaving without being seen (LWBS) have not been described in this population. Objective To compare return visits, admission, and mortality after LWBS vs completed care among behavioral health ED episodes. Design, Setting, and Participants This retrospective episode-level cohort study used a multisystem deidentified electronic health record database of US health systems (data snapshot June 4, 2026). Participants were patients of all ages with an ED visit and same-day behavioral health diagnosis. Index visits (recorded January 26, 2001 to April 13, 2025) each opened a 30-day episode window; in-window were counted as outcomes, and patients could contribute episodes to either group. Data were analyzed in October 2026. Exposure LWBS (diagnosis code Z53.21 on a date with an ED encounter) vs completed care ending in discharge home. Main Outcomes and Measures The primary outcome was ED return visit within 7 days. Secondary outcomes were return visit within 3 and 30 days; admission on day 0, on days 1-7 (principal measure), and within 30 days; and all-cause death within 7 and 30 days, assessed among episodes from 2017 through 2023 using a verified death-record definition. Results The analysis included 1,305,812 episodes (12,248 LWBS; 1,293,564 completed care) from 525,490 patients; 666,930 episodes (51.1%) involved female patients and 66,733 (5.1%) involved patients younger than 18 years. Return visit within 7 days followed 24.5% of LWBS episodes vs 13.2% of completed-care episodes (risk ratio [RR], 1.86; 95% CI, 1.81-1.92), and admission on days 1-7 followed 17.1% vs 3.9% (RR, 4.41; 95% CI, 4.24-4.59). Among 2017-2023 episodes, 30-day mortality was 0.69% (70 of 10,141) after LWBS vs 0.32% (2,426 of 756,140) after completed care (RR, 2.15; 95% CI, 1.70-2.73). Results were similar under alternative episode definitions. Conclusions and Relevance Among patients with behavioral health ED presentations, LWBS was followed by higher rates of return visits, admission, and short-term mortality than completed care. These unadjusted findings describe outcome burden, not causal effects, and highlight patients who leave as a target for rapid follow-up.

PURPOSE: Women with metastatic breast cancer (MBC) are at risk of developing financial toxicity due to prolonged treatment. Resilience has been identified as a key protective factor associated with better quality of life among cancer populations. However, it is unknown if resilience is associated with financial toxicity. We sought to examine the relationship between resilience and financial toxicity among women with MBC and explore whether socioeconomic factors moderate this association. PATIENTS AND METHODS: Our sample included 209 women with MBC who completed self-reported questionnaires of the Resilience Scale Specific to Cancer (RS-SC) and the Comprehensive Score for Financial Toxicity (COST). Participants (n=2) with missing data were excluded from analysis. We conducted multiple linear regression to examine the association of resilience with financial toxicity. Interaction terms were used to test moderating effects of age (18-39, 40-64 and > =65 years), race, education, health insurance, household income and employment status. RESULTS: Of the sample, 56.5% were aged 40-64 years, 76.6% were White, and 79.9% had a college or master degree or above. Women reported moderately high resilience with mean RS-SC score of 34.49 (SD = 6.67), and moderate financial toxicity (mean COST score =21.01 [SD = 10.51]). Adjusting for covariates, higher resilience was linked to better financial well-being (b = 0.37, SE= 0.11, 95% CI [0.14, 0.59], P < 0.01). Age, education and health insurance moderated this relationship, with resilience more strongly associated with better financial well-being among those aged 40-64 years, with college/master degree or above and private insurance. Race, household income, and employment status did not moderate the association between resilience and financial toxicity. CONCLUSION: Women with MBC who reported higher resilience are more likely to experience better financial well-being, but the strength of this association varied by socioeconomic factors. Further research is needed to confirm these findings. Our results have important implications for incorporating resilience into financial toxicity interventions and tailoring such interventions based on individual socioeconomic characteristics.

Background. Regulatory pressure to avoid confusingly similar drug names appears to have pushed manufacturers to coin more distinctive proprietary names, but no one has quantitatively analyzed this trend. Objective. To determine whether proprietary drug names became more orthographically distinctive (unusual in spelling) over time. Methods. We examined 1,321 US Food and Drug Administration (FDA) new molecular entity (NME) names (1985-2024), 2,769 FDA Orange Book trade names (1982-2026), 177,337 US pharmaceutical trademarks (1980-2026), and 1,273 generic names (1982-2025). Compared to prior names (including those already marketed) and ordinary English, we scored each name's character trigram (three-letter sequence) surprisal (statistical unexpectedness) and its edit-distance similarity to the closest existing names. Linear regression tested time trends, controlling for name length. Results. Mean NME trigram surprisal rose in every decade between the 1980s and 2020s, from 7.21 to 8.50 nats (natural-logarithm units, higher meaning less predictable), an 18% increase (b = 0.038, p < .001, R2 = 0.34). Half of 2020s names (7% in the 1980s) contained a letter sequence found in no common English word (e.g., Jesduvroq, Omvoh). Nearest-neighbor similarity fell after the early 1990s. Trademark data showed the same trend (b = 0.016, p < .001). Generic names showed a weaker trend (b = 0.011, R2 = 0.063). Conclusions. Over four decades, drug names became more orthographically distinctive, consistent with namespace crowding, deliberate efforts to avoid confusing names, and branding strategy. Because unfamiliar letter sequences can introduce other error pathways, increased distinctiveness does not necessarily imply improved safety.