• Research article
  • Open access
  • Published: 24 April 2019

Priorities and challenges for health leadership and workforce management globally: a rapid review

  • Carah Alyssa Figueroa   ORCID: orcid.org/0000-0002-8825-7796 1 ,
  • Reema Harrison 1 ,
  • Ashfaq Chauhan 1 &
  • Lois Meyer 1  

BMC Health Services Research volume  19 , Article number:  239 ( 2019 ) Cite this article

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Health systems are complex and continually changing across a variety of contexts and health service levels. The capacities needed by health managers and leaders to respond to current and emerging issues are not yet well understood. Studies to date have been country-specific and have not integrated different international and multi-level insights. This review examines the current and emerging challenges for health leadership and workforce management in diverse contexts and health systems at three structural levels, from the overarching macro (international, national) context to the meso context of organisations through to the micro context of individual healthcare managers.

A rapid review of evidence was undertaken using a systematic search of a selected segment of the diverse literature related to health leadership and management. A range of text words, synonyms and subject headings were developed for the major concepts of global health, health service management and health leadership. An explorative review of three electronic databases (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content between January 2010 to July 2018. A search strategy was then applied to the key journals identified, in addition to hand searching the journals and reference list of relevant papers identified. Inclusion criteria were independently applied to potentially relevant articles by three reviewers. Data were subject to a narrative synthesis to highlight key concepts identified.

Sixty-three articles were included. A set of consistent challenges and emerging trends within healthcare sectors internationally for health leadership and management were represented at the three structural levels. At the macro level these included societal, demographic, historical and cultural factors; at the meso level, human resource management challenges, changing structures and performance measures and intensified management; and at the micro level shifting roles and expectations in the workplace for health care managers.

Contemporary challenges and emerging needs of the global health management workforce orient around efficiency-saving, change and human resource management. The role of health managers is evolving and expanding to meet these new priorities. Ensuring contemporary health leaders and managers have the capabilities to respond to the current landscape is critical.

Peer Review reports

Health systems are increasingly complex; encompassing the provision of public and private health services, primary healthcare, acute, chronic and aged care, in a variety of contexts. Health systems are continually evolving to adapt to epidemiological, demographic and societal shifts. Emerging technologies and political, economic, social, and environmental realities create a complex agenda for global health [ 1 ]. In response, there has been increased recognition of the role of non-state actors to manage population needs and drive innovation. The concept of ‘collaborative governance,’ in which non-health actors and health actors work together, has come to underpin health systems and service delivery internationally [ 1 ] in order to meet changing expectations and new priorities. Seeking the achievement of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), particularly in low- and middle-income countries, have been pivotal driving forces [ 2 ]. Agendas for change have been encapsulated in reforms intended to improve the efficiency, equity of access, and the quality of public services more broadly [ 1 , 3 ].

The profound shortage of human resources for health to address current and emerging population health needs across the globe was identified in the World Health Organization (WHO) landmark publication ‘Working together for health’ and continues to impede progress towards the SDGs [ 4 ]. Despite some improvements overall in health workforce aggregates globally, the human resources for health challenges confronting health systems are highly complex and varied. These include not only numerical workforce shortages but imbalances in skill mix, geographical maldistribution, difficulty in inter-professional collaboration, inefficient use of resources, and burnout [ 2 , 5 , 6 ]. Effective health leadership and workforce management is therefore critical to addressing the needs of human resources within health systems and strengthening capacities at regional and global levels [ 4 , 6 , 7 , 8 ].

While there is no standard definition, health leadership is centred on the ability to identify priorities, provide strategic direction to multiple actors within the health system, and create commitment across the health sector to address those priorities for improved health services [ 7 , 8 ]. Effective management is required to facilitate change and achieve results through ensuring the efficient mobilisation and utilisation of the health workforce and other resources [ 8 ]. As contemporary health systems operate through networks within which are ranging levels of responsibilities, they require cooperation and coordination through effective health leadership and workforce management to provide high quality care that is effective, efficient, accessible, patient-centred, equitable, and safe [ 9 ]. In this regard, health leadership and workforce management are interlinked and play critical roles in health services management [ 7 , 8 ].

Along with health systems, the role of leaders and managers in health is evolving. Strategic management that is responsive to political, technological, societal and economic change is essential for health system strengthening [ 10 ]. Despite the pivotal role of health service management in the health sector, the priorities for health service management in the global health context are not well understood. This rapid review was conducted to identify the current challenges and priorities for health leadership and workforce management globally.

This review utilised a rapid evidence assessment (REA) methodology structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [ 11 ]. An REA uses the same methods and principles as a systematic review but makes concessions to the breadth or depth of the process to address key issues about the topic under investigation [ 12 , 13 , 14 ]. An REA provides a balanced assessment of what is already known about an issue, and the strength of evidence. The narrower research focus, relative to full systematic reviews, make REAs helpful for systematically exploring the evidence around a particular issue when there is a broad evidence base to explore [ 14 ]. In the present review, the search was limited to contemporary literature (post 2010) selected from leading health service management and global health journals identified from exploring major electronic databases.

Search strategy

An explorative review of three core databases in the area of public health and health services (MEDLINE®, Pubmed and Scopus) was undertaken to identify the key publication outlets for relevant content. These databases were selected as those that would be most relevant to the focus of the review and have the broadest range of relevant content. A range of text words, synonyms and subject headings were developed for the major constructs: global health, health service management and health leadership, priorities and challenges. Regarding health service management and health leadership, the following search terms were used: “healthcare manag*” OR “health manag*” OR “health services manag*” OR “health leader*”. Due to the large volume of diverse literature generated, a systematic search was then undertaken on the key journals that produced the largest number of relevant articles. The journals were selected as those identified as likely to contain highly relevant material based on an initial scoping of the literature.

Based on the initial database search, a systematic search for articles published in English between 1 January 2010 and 31 July 2018 was undertaken of the current issues and archives of the following journals: Asia-Pacific Journal of Health Management; BMC Health Services Research; Healthcare Management Review; International Journal of Healthcare Management; International Journal of Health Planning and Management; Journal of Healthcare Management; Journal of Health Organisation and Management; and, Journal of Health Management. Hand-searching of reference lists of identified papers were also used to ensure that major relevant material was captured.

Study selection and data extraction

Results were merged using reference-management software (Endnote) and any duplicates removed. The first author (CF) screened the titles and abstracts of articles meeting the eligibility criteria (Table 1 ). Full-text publications were requested for those identified as potentially relevant. The inclusion and exclusion criteria were then independently applied by two authors. Disagreements were resolved by consensus or consultation with a third person, and the following data were extracted from each publication: author(s), publication year, location, primary focus and main findings in relation to the research objective. Sixty-three articles were included in the final review. The selection process followed the PRISMA checklist [ 11 ] as shown in Fig. 1 .

figure 1

PRISMA flow chart of the literature search, identification, and inclusion for the review

Data extraction and analysis

A narrative synthesis was used to explore the literature against the review objective. A narrative synthesis refers to “an approach to the systematic review and synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the findings of the synthesis” [ 15 ]. Firstly, an initial description of the key findings of included studies was drafted. Findings were then organised, mapped and synthesised to explore patterns in the data.

Search results

A total of 63 articles were included; Table 2 summarizes the data extraction results by region and country. Nineteen were undertaken in Europe, 16 in North America, and one in Australia, with relatively fewer studies from Asia, the Middle East, and small island developing countries. Eighteen qualitative studies that used interviews and/or focus group studies [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ] were identified. Other studies were quantitative [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ] including the use of questionnaires or survey data, or used a mixed-method approach [ 40 , 41 , 42 , 43 , 44 ]. Other articles combined different types of primary and secondary data (key informant interviews, observations, focus groups, questionnaire/survey data, and government reports). The included literature also comprised 28 review articles of various types that used mixed data and bibliographic evidence.

Key challenges and emerging trends

A set of challenges and emerging trends were identified across healthcare sectors internationally. These were grouped at three levels: 1) macro, system context (society, demography, technology, political economy, legal framework, history, culture), 2) meso, organisational context (infrastructure, resources, governance, clinical processes, management processes, suppliers, patients), and 3) micro context related to the individual healthcare manager (Table 3 ). This multi-levelled approach has been used in previous research to demonstrate the interplay between different factors across different levels, and their direct and indirect reciprocal influences on healthcare management policies and practices [ 45 ].

Societal and system-wide (macro)

Population growth, ageing populations, and increased disease burdens are some of the common trends health systems are facing globally. Developing and developed countries are going through demographic and epidemiological transitions; people are living longer with increasing prevalence of chronic diseases requiring health managers and leaders to adjust to shifting healthcare needs at the population level, delivering preventative and long-term care beyond acute care. Countries in Africa, Europe, the Pacific Islands, Middle East, Asia and Caribbean are seeing an increase in number of patients with non-communicable diseases and communicable diseases [ 21 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ].

Although many countries have similar emerging health system concerns, there are some differences in the complexities each country faces. For many small countries, outmigration, capacity building and funding from international aid agencies are affecting how their health systems operate, while in many larger countries, funding cuts, rise in private health insurance, innovations, and health system restructuring are major influences [ 21 , 34 , 50 , 53 , 54 ]. In addition, patients are increasingly health literate and, as consumers, expect high-quality healthcare [ 34 , 53 , 54 ]. However, hospitals and healthcare systems are lacking capacity to meet the increased demand [ 16 , 34 , 43 ].

Scientific advances have meant more patients are receiving care across the health system. It is imperative to have processes for communication and collaboration between different health professionals for high-quality care. However, health systems are fragmented; increasing specialisation is leading to further fragmentation and disassociation [ 31 , 54 , 55 ]. Adoption of technological innovations also require change management, hospital restructure, and capacity building [ 56 , 57 , 58 ].

Changes in health policies and regulations compound the challenge faced by healthcare managers and leaders to deliver high quality care [ 53 , 54 , 59 ]. Political reforms often lead to health system restructuring requiring change in the values, structures, processes and systems that can constrain how health managers and leaders align their organisations to new agendas [ 24 , 28 , 31 , 60 ]. For example, the distribution of health services management to local authorities through decentralisation has a variable impact on the efficacy and efficiency of healthcare delivery [ 24 , 27 , 35 , 59 ].

Governments’ decisions are often made focusing on cost savings, resulting in budgetary constraints within which health systems must operate [ 16 , 19 , 53 , 61 ]. Although some health systems have delivered positive results under such constraint [ 53 ], often financial resource constraints can lead to poor human and technical resource allocation, creating a disconnect between demand and supply [ 23 , 27 , 40 , 47 , 57 ]. To reduce spending in acute care, there is also a push to deliver health services in the community and focus on social determinants of health, though this brings further complexities related to managing multiple stakeholder collaborations [ 27 , 32 , 34 , 38 , 40 , 49 , 55 ].

Due to an increase in demand and cost constraints, new business models are emerging, and some health systems are resorting to privatisation and corporatisation [ 22 , 48 , 62 ]. This has created competition in the market, increased uptake of private health insurance and increased movement of consumers between various organisations [ 22 , 48 ]. Health managers and leaders need to keep abreast with continuously changing business models of care delivery and assess their impact [ 59 , 62 ]. The evolving international health workforce, insufficient numbers of trained health personnel, and maintaining and improving appropriate skill mixes comprise other important challenges for managers in meeting population health needs and demands (Table 3 ).

Organisational level (meso)

At the organisation level, human resource management issues were a central concern. This can be understood in part within the wider global human resources for health crisis which has placed healthcare organisations under intense pressure to perform. The evidence suggests healthcare organisations are evolving to strengthen coordination between primary and secondary care; there is greater attention to population-based perspectives in disease prevention, interdisciplinary collaboration, and clinical governance. These trends are challenged by the persistence of bureaucratic and hierarchical cultures, emphasis on targets over care quality, and the intensification of front-line and middle-management work that is limiting capacity.

Healthcare managers and leaders also face operational inefficiencies in providing primary health and referral services to address highly complex and shifting needs which often result in the waste of resources [ 49 , 63 , 64 ]. Considering the pace of change, organisations are required to be flexible and deliver higher quality care at lower cost [ 21 , 53 , 65 ]. To achieve this, many organisations in developing and developed countries alike are adopting a lean model [ 17 , 21 ]. However, there are challenges associated with ensuring sustainability of the lean system, adjusting organisational hierarchies, and improving knowledge of the lean model, especially in developing countries [ 17 , 21 ].

Healthcare organisations require various actors with different capabilities to deliver high quality care. However, a dominant hierarchical culture and lack of collaborative and distributed culture can limit the performance of healthcare organisations [ 22 , 36 , 54 ]. In addition, considering high turnover of executive leadership, healthcare organisations often rely on external talent for succession management which can reduce hospital efficiency [ 44 , 66 ]. Other contributors to weakened hospital performance include: the lack of allocative efficiency and transparency [ 24 , 30 , 64 , 67 ]; poor hospital processes that hamper the development of effective systems for the prevention and control of hospital acquired infections (HAIs) [ 53 , 68 ]; and, payment reforms such as value-based funding and fee-for-service that encourage volume [ 18 , 23 , 24 , 61 , 62 , 69 , 70 ].

Managerial work distribution within organisations is often not clearly defined, leading to extra or extreme work conditions for middle and front-line managers [ 29 , 42 , 53 , 70 ]. Unregulated and undefined expectations at the organisation level leads to negative effects such as stress, reduced productivity, and unpredictable work hours, and long-term effects on organisational efficiency and delivery of high quality care [ 22 , 28 , 29 , 37 , 42 , 51 , 71 ]. Furthermore, often times front-line clinicians are also required to take the leadership role in the absence of managers without proper training [ 20 ]. Despite this, included studies indicate that the involvement of middle and front-line managers in strategic decision-making can be limited due to various reasons including lack of support from the organisation itself and misalignment of individual and organisational goals [ 16 , 26 , 31 , 72 ].

Individual level (micro)

Worldwide, middle and front-line health managers and leaders are disproportionately affected by challenges at the system and organisational level, which has contributed to increasing and often conflicting responsibilities. Some countries are experiencing a growth in senior health managers with a clinical background, while in other countries, the converse is apparent. Indistinct organisational boundaries, increasing scope of practice, and lack of systemic support at policy level are leaving healthcare managers with undefined roles [ 28 , 59 ]. Poorly defined roles contribute to reduced accountability, transparency, autonomy, and understanding of responsibilities [ 24 , 30 , 31 , 67 ]. Studies also indicate a lack of recognition of clinical leaders in health organisations and inadequate training opportunities for them as such [ 20 , 67 ].

The number of hybrid managers (performing clinical and managerial work concurrently) in developed countries is increasing, with the perception that such managers improve the clinical governance of an organization. In contrast, the number of non-clinical managers in many developing countries appears to be increasing [ 63 , 73 , 74 , 75 ]. Included studies suggest this approach does not necessarily improve manager-clinical professional relationships or the willingness of clinicians becoming managers, limiting their participation in strategic decisions [ 28 , 70 , 71 , 74 ].

This rapid review highlights the current global climate in health service management, the key priority areas, and current health management approaches being utilised to address these. The multitude of issues emerging demonstrate the complex and evolving role of health service management in the wider complex functioning of health systems globally in a changing healthcare landscape. Key themes of achieving high quality care and sustainable service delivery were apparent, often evidenced through health reforms [ 5 ]. The influence of technological innovation in both its opportunities and complexities is evident worldwide. In the context of changing healthcare goals and delivery approaches, health management is seeking to professionalise as a strategy to build strength and capacity. In doing so, health managers are questioning role scope and the skills and knowledge they need to meet the requirements of the role.

Global challenges facing health management

Understanding how the features of the macro, meso and micro systems can create challenges for managers is critical [ 19 ]. With continual healthcare reform and increasing health expenditure as a proportion of GDP, distinct challenges are facing high-income Organisation for Economic Co-operation and Development (OECD) countries, middle-income rapidly-developing economies, and low-income, resource-limited countries. Reforms, especially in OECD countries, have been aimed at controlling costs, consolidating hospitals for greater efficiencies, and reconfiguring primary healthcare [ 1 , 76 ]. The changing business models for the delivery of care have wider implications for the way in which health managers conceptualise healthcare delivery and the key stakeholders [ 59 ], for example, the emerging role of private healthcare providers and non-health actors in public health. Changes to the business model of healthcare delivery also has implications for the distribution of power amongst key actors within the system. This is evident in the evolved role of general practitioners (GPs) in the UK National Health Service as leaders of Clinical Commissioning Groups (CCGs). Commissioning requires a different skill set to clinical work, in terms of assessing financial data, the nature of statutory responsibilities, and the need to engage with a wider stakeholder group across a region to plan services [ 77 ]. With new responsibilities, GPs have been required to quickly equip themselves with new management capabilities, reflecting the range of studies included in this review around clinician managers and the associated challenges [ 18 , 28 , 53 , 63 , 70 , 71 , 74 , 75 ].

Central to the role of healthcare managers is the ability to transition between existing and new cultures and practices within healthcare delivery [ 59 ]. Bridging this space is particularly important in the context of increasingly personalized and technologically-driven healthcare delivery [ 54 ]. While advances in knowledge and medical technologies have increased capability to tackle complex health needs, the integration of innovations into existing healthcare management practices requires strong change management [ 73 ]. Health leaders and managers need to be able to rapidly and continually assess the changes required or upon them, the implications, and to transform their analysis into a workable plan to realise change [ 10 ]. Focusing only on the clinical training of health professionals rather than incorporating managerial and leadership roles, and specifically, change management capability may limit the speed and success of innovation uptake [ 22 ].

Implications

Our findings highlight the implications of current priorities within the health sector for health management practice internationally; key issues are efficiency savings, change management and human resource management. In the context of efficiency approaches, health system and service managers are facing instances of poor human and technical resource allocation, creating a disconnect between demand and supply. At the service delivery level, this has intensified and varied the role of middle managers mediating at two main levels. The first level of middle-management is positioned between the front-line and C-suite management of an organisation. The second level of middle-management being the C-suite managers who translate regional and/or national funding decisions and policies into their organisations. Faced with increasing pace of change, and economic and resource constraints, middle managers across both levels are now more than ever exposed to high levels of stress, low morale, and unsustainable working patterns [ 29 ]. Emphasis on cost-saving has brought with it increased attention to the health services that can be delivered in the community and the social determinants of health. Connecting disparate services in order to meet efficiency goals is a now a core feature of the work of many health managers mediating this process.

Our findings also have implications for the conceptualisation of healthcare management as a profession. The scale and increasing breadth of the role of health leaders and managers is evident in the review. Clarifying the professional identity of ‘health manager’ may therefore be a critical part of building and maintaining a robust health management workforce that can fulfil these diverse roles [ 59 ]. Increasing migration of the healthcare workforce and of population, products and services between countries also brings new challenges for healthcare. In response, the notion of transnational competence among healthcare professionals has been identified [ 78 ]. Transnational competence progresses cultural competence by considering the interpersonal skills required for engaging with those from diverse cultural and social backgrounds. Thus, transnational competence may be important for health managers working across national borders. A key aspect of professionalisation is the education and training of health managers. Our findings provide a unique and useful theoretical contribution that is globally-focused and multi-level to stimulate new thinking in health management educators, and for current health leaders and managers. These findings have considerable practical utility for managers and practitioners designing graduate health management programs.

Limitations

Most of the studies in the field have focused on the Anglo-American context and health systems. Notwithstanding the importance of lessons drawn from these health systems, further research is needed in other regions, and in low- and middle-income countries in particular [ 79 ]. We acknowledge the nuanced interplay between evidence, culture, organisational factors, stakeholder interests, and population health outcomes. Terminologies and definitions to express global health, management and leadership vary across countries and cultures, creating potential for bias in the interpretation of findings. We also recognise that there is fluidity in the categorisations, and challenges arising may span multiple domains. This review considers challenges facing all types of healthcare managers and thus lacks discrete analysis of senior, middle and front-line managers. That said, managers at different levels can learn from one another. Senior managers and executives may gain an appreciation for the operational challenges that middle and front-line managers may face. Middle and front-line managers may have a heightened awareness of the more strategic decision-making of senior health managers. Whilst the findings indicate consistent challenges and needs for health managers across a range of international contexts, the study does not capture country-specific issues which may have consequences at the local level. Whilst a systematic approach was taken to the literature in undertaking this review, relevant material may have been omitted due to the limits placed on the rapid review of the vast and diverse health management literature. The inclusion of only materials in English language may have led to further omissions of relevant work.

Health managers within both international and national settings face complex challenges given the shortage of human resources for health worldwide and the rapid evolution of national and transnational healthcare systems. This review addresses the lack of studies taking a global perspective of the challenges and emerging needs at macro (international, national and societal), meso (organisational), and micro (individual health manager) levels. Contemporary challenges of the global health management workforce orient around demographic and epidemiological change, efficiency-saving, human resource management, changing structures, intensified management, and shifting roles and expectations. In recognising these challenges, researchers, management educators, and policy makers can establish global health service management priorities and enhance health leadership and capacities to meet these. Health managers and leaders with adaptable and relevant capabilities are critical to high quality systems of healthcare delivery.

Abbreviations

Clinical Commissioning Groups

General practitioners

Hospital acquired infections

Organisation for Economic Co-operation and Development

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Rapid evidence assessment

Sustainable Development Goals

Universal health coverage

World Health Organization

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Acknowledgements

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The rapid review is part of a larger study on global health management priorities and qualities, supported by the University of New South Wales, Sydney.

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Carah Alyssa Figueroa, Reema Harrison, Ashfaq Chauhan & Lois Meyer

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CF conducted the database searches and identification of relevant literature. RH and AC assessed the selected literature. RH and LM conceived the design of the review and contributed to the interpretation of the review results. CF drafted the initial manuscript while RH, AC and LM reviewed and revised subsequent drafts of the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

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Correspondence to Carah Alyssa Figueroa .

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Figueroa, C.A., Harrison, R., Chauhan, A. et al. Priorities and challenges for health leadership and workforce management globally: a rapid review. BMC Health Serv Res 19 , 239 (2019). https://doi.org/10.1186/s12913-019-4080-7

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  • Health service management
  • Health leadership
  • Global health

BMC Health Services Research

ISSN: 1472-6963

literature review healthcare management

Learning to lead: a review and synthesis of literature examining health care managers' use of knowledge

Affiliations.

  • 1 1 PhD Student, Faculty of Nursing, University of Alberta, CA.
  • 2 2 Research Associate, Faculty of Nursing, University of Alberta, CA.
  • 3 3 Assistant Scientific Director, Emergency Strategic Clinical Network, Alberta Health Services, CA.
  • 4 4 Dean and Professor, School of Nursing, McMaster University, CA.
  • 5 5 Manager Systemic Therapy, Southlake Regional Health Centre, CA.
  • 6 6 Principal Research Lead, Institute for Health Economics, CA.
  • 7 7 Professor, Faculty of Nursing, School of Public Health, University of Alberta, CA.
  • 8 8 Vice President & Chief Health Operations Officer Northern Alberta, CA.
  • 9 9 Dean and Professor, Faculty of Nursing, University of Alberta, CA.
  • PMID: 30044150
  • DOI: 10.1177/1355819618786764

Background: Scholarship cites health care managers (HCMs) as not using research evidence in their management practice. The purpose of this review was to evaluate the effectiveness of interventions to enhance HCMs use of research evidence in practice.

Methods: We carried out a systematic review and focus groups to validate the review findings. We searched 10 electronic databases for studies reporting on interventions for HCMs to enhance research utilization in their practice. Qualitative studies were analysed using Hoon's approach to meta-synthesis.

Results: Seven, primarily qualitative, studies of varying quality (reported in 11 articles) met our inclusion criteria. Interventions to enhance research use by HCMs included: informal and formal training, computer-based application, executive-level knowledge translation activities and residency programmes. Studies did not report efficacy of interventions or impacts of increasing managers' use of research on staff or patient outcomes. Meta-synthesis yielded four contextual factors influencing the perceived effectiveness of interventions to enhance research use by HCMs: organizational culture, competing priorities, time as a resource and capacity building. Included studies differed in how they defined research and demonstrated varying understandings of research among HCMs, limiting the generalizability of work in this field.

Conclusions: Healthcare managers are increasingly called upon to make evidence-based decisions in practice, but the small number of studies and diverse strategies employed hinder our ability to identify any intervention to increase use of evidence as superior. Future studies in this area should clearly articulate the definition of research evidence they base their decisions on. Registration: PROSPERO (CRD42014006256).

Keywords: healthcare management; research priority setting; systematic reviews.

Publication types

  • Research Support, Non-U.S. Gov't
  • Capacity Building
  • Decision Making*
  • Evidence-Based Practice
  • Focus Groups
  • Health Services Administration*
  • Leadership*
  • Translational Research, Biomedical*

Health Care Administration and Management

  • Find Articles/Databases
  • Reference Resources
  • Evidence Summaries & Clinical Guidelines
  • Health Data & Statistics
  • Grey Literature & Reports
  • Framing Research Questions
  • Selecting Databases
  • Crafting a Search
  • Narrowing / Filtering a Search
  • Expanding a Search
  • Cited Reference Searching
  • Saving Searches
  • Citing/Managing References
  • What are Literature Reviews?
  • Conducting & Reporting Systematic Reviews
  • Finding Systematic Reviews
  • Tutorials & Tools for Literature Reviews
  • Critical Appraisal Resources
  • Finding Full Text

What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

Systematic Literature Reviews: Steps & Resources

literature review healthcare management

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

  • The different types of literature reviews, including systematic reviews and other evidence synthesis methods
  • Tools & Tutorials

Literature Review & Systematic Review Steps

  • Develop a Focused Question
  • Scope the Literature  (Initial Search)
  • Refine & Expand the Search
  • Limit the Results
  • Download Citations
  • Abstract & Analyze
  • Create Flow Diagram
  • Synthesize & Report Results

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

  • PICO Question Help
  • Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

  • Background sources (books, point-of-care tools)
  • Article databases
  • Trial registries
  • Grey literature
  • Cited references
  • Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

  • Combine separate concepts with AND  (resulting in a narrower search)
  • Connecting synonyms with OR  (resulting in an expanded search)

Search:  pilates AND ("low back pain"  OR  backache )

Video Tutorials - Translating PICO Questions into Search Queries

  • Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11) 
  • Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

  • database thesauri
  • reference lists
  • relevant studies

Example: 

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

  • a personal database account (e.g., MyNCBI for PubMed)
  • Log in with your NYU credentials
  • Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

  • Limit to Article type, e.g.,:  "randomized controlled trial" OR multicenter study
  • Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

  • Filters in PubMed
  • CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

File structure of a Zotero library, showing a combined pooled set, and sub folders representing results from individual databases.

  • Citation Managers - General Guide

6. Abstract and Analyze

  • Migrate citations to data collection/extraction tool
  • Screen Title/Abstracts for inclusion/exclusion
  • Screen and appraise full text for relevance, methods, 
  • Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

Screenshot of the Covidence interface, showing Title and abstract screening phase.

  • Covidence Support
  • Critical Appraisal Tools
  • Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example PRISMA diagram showing number of records identified, duplicates removed, and records excluded.

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

  • PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
  • PRISMA Diagram Templates  (Word and PDF)
  • Make a copy of the file to fill out the template
  • Image can be downloaded as PDF, PNG, JPG, or SVG
  • Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

Example of a review matrix, using Microsoft Excel, showing the results of a systematic literature review.

  • Reporting Guidelines for Systematic Reviews
  • Download a sample template of a health sciences review matrix  (GoogleSheets)

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

  • << Previous: Citing/Managing References
  • Next: What are Literature Reviews? >>
  • Last Updated: Jan 9, 2024 12:57 PM
  • URL: https://guides.nyu.edu/healthcaremanagement

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International Conference on Production Research

Proceedings of the International Symposium for Production Research

ISPR 2019, ISPR 2019: Proceedings of the International Symposium for Production Research 2019 pp 570–579 Cite as

Supply Chain Management in Healthcare: A Literature Review

  • Tuğçe Beldek 3 ,
  • Aziz Kemal Konyalıoğlu 3 &
  • Hatice Camgöz Akdağ 3  
  • Conference paper
  • First Online: 25 October 2019

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Part of the Lecture Notes in Mechanical Engineering book series (LNME)

Supply chain management becomes more important in the developing world in order to provide a material flow with an optimum cost and time generally. Many sectors focus on supply chain management optimization and qualifications to construct a better network of suppliers for their end consumers. Especially in healthcare sector, not only for pharmaceutical products but also for hospital materials, supply chain management gets importance for service quality and patient satisfaction. Thus, there are many studies about supply chain management in healthcare to emphasize its importance. In this study, it is aimed to put forward a literature review of supply chain management in healthcare in order to give a perspective by expressing the important cases and researches which are parallel to the latest studies. Furthermore, this literature review will assess a perspective in order to understand how to manage a complex supply chain in healthcare sector by investigating studies in the literature.

  • Supply chain management
  • Pharmaceutical companies
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  • Healthcare sector

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Tuğçe Beldek, Aziz Kemal Konyalıoğlu & Hatice Camgöz Akdağ

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Beldek, T., Konyalıoğlu, A.K., Akdağ, H.C. (2020). Supply Chain Management in Healthcare: A Literature Review. In: Durakbasa, N., Gençyılmaz, M. (eds) Proceedings of the International Symposium for Production Research 2019. ISPR ISPR 2019 2019. Lecture Notes in Mechanical Engineering. Springer, Cham. https://doi.org/10.1007/978-3-030-31343-2_50

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Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity.

We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists).

One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system’s ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user’s professional status and expertise and is improved over the course of implementation.

This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.

Peer Review reports

Contributions to the literature

We provide a comprehensive literature review and narrative synthesis of the role of professional identity in CDSS implementation among diverse health care professionals and identify human, technological, and organizational determinants that influence professional identity and implementation.

The review shows that a perceived threat to professional identity plays a significant role in explaining failures of CDSS implementation. As such, our study highlights the need to recognize significant challenges related to professional identity in the implementation of CDSS and similar technologies. A better understanding and awareness of individual barriers to CDSS implementation among health professionals can promote the diffusion of such data-driven tools in health care.

This narrative synthesis maps, interconnects, and reinterprets existing empirical research and provides a foundation for further research to explore the complex interrelationships and influences of perceived professional identity-related mechanisms among health care professionals in the context of CDSS implementations.

Health care organizations increasingly implement clinical decision support systems (CDSSs) due to rising treatment costs and health care professional staff shortages [ 1 , 2 ]. CDSSs provide passive and active referential information, computer-based order sets, reminders, alerts, and patient-specific data to health care professionals at the point of care by matching patient characteristics to a computerized knowledge base [ 1 , 3 , 4 ]. These systems complement existing electronic health record (EHR) systems [ 5 ] and support various functional areas of medical care, such as preventative health, diagnosis, therapy, and medication [ 6 , 7 ]. Research has shown that CDSSs can improve patient safety and quality of care [ 8 , 9 , 10 ] by preventing medication errors and enhancing decision-making quality [ 11 ]. However, despite their potential benefits, their successful implementation into the clinical workflow remains low [ 1 , 12 ]. To facilitate CDSS acceptance and minimize user resistance, it is crucial to understand the factors affecting implementation success and identify the sources of resistance among the users [ 1 , 13 , 14 ].

In the health care innovation management and implementation science literature, a range of theoretical approaches have been used to examine the implementation and diffusion of health care information technologies. Technology acceptance theories focus on key determinants of individual technology adoption, such as ease of use , perceived usefulness or performance expectancy of the technology itself [ 15 , 16 , 17 ]. Organizational theories emphasize the importance of moving beyond an exclusive focus on the acceptance of technology by individuals. Instead, they advocate for examining behaviors and decisions with a focus on organizational structures and processes, cultural and professional norms, and social and political factors such as policies, laws, and regulations [ 18 , 19 ]. Other studies analyze the implementation of new technologies in health care from a behavioral theory perspective [ 20 ] and propose frameworks to explain how and why resistances emerge among users, which may have cognitive, affective, social, or environmental origins [ 13 , 21 , 22 ]. For example, the Theoretical Domains Framework has been applied to the behavior of health care professionals and serve as the basis for studies identifying influences on the implementation of new medical technologies, processes, or guidelines [ 21 , 23 ]. Other, more holistic, implementation frameworks, such as the Nonadoption, Abandonment, Scale-up, Spread and Sustainability framework , identify determinants as part of a complex system to facilitate CDSS implementation efforts across health care settings [ 13 ].

However, these theoretical approaches do not sufficiently take into account the unique organizational and social system in hospitals, which is characterized by strong hierarchies and the socialization of physicians into isolated structures and processes, making CDSS implementation particularly difficult [ 5 , 24 , 25 ]. Health care professionals are considered to have an entrenched professional identity characterized by the acquisition of a high level of expertise and knowledge over a long period of time, as well as by their decision-making authority and autonomy in clinical interventions. Defined roles and structures of different professional groups in medical organizations help to manage the multitude of tasks under high time pressure [ 26 ]. In addition, heath care professionals bear a high degree of responsibility in terms of ensuring medical quality and patient well-being [ 27 ]. Changing their professional identity is particularly difficult as they work in organizational contexts with high levels of inertia and long-lived core values based on established practices and routines [ 27 ]. This resilience of health care professionals’ identity makes it particularly difficult to implement new technologies into everyday medical practice [ 28 ].

By integrating existing evidence into an individual physician’s decision-making processes, CDSSs carry the disruptive potential to undermine existing, highly formalized clinical knowledge and expertise and professional decision-making autonomy [ 5 , 24 , 29 , 30 ]. Research has shown that health professionals may perceive new technologies, such as CDSSs, as a threat to their professional identity and draw potential consequences for themselves and their professional community, such as the change of established organizational hierarchies, loss of control, power, status, and prestige [ 31 , 32 , 33 ]. Nevertheless, other studies have shown that health professionals view CDSSs as tools that increase their autonomy over clinical decisions and improve their relationship with patients [ 34 , 35 ]. In addition, these consequences may vary widely by country, professional status, and medical setting. As a result, the use and efficacy of CDSSs differ around the world [ 24 ]. We therefore suggest that a better understanding of the identity-undermining or identity-enhancing consequences of CDSSs is needed. Despite growing academic interest, there is surprisingly scant research on the role of perceived identity threats and enhancements across different professional hierarchies during CDSS implementation and how they relate to other human, technological, and organizational influencing factors [ 5 , 36 , 37 ].

Therefore, the purpose of this narrative review is to analyze the state of knowledge on the individual, technological, and organizational circumstances that lead various health professionals to perceive CDSSs as a threat or enhancement of their professional identity. In doing so, this study takes an exploratory approach and determines human , organizational , and technological factors for the successful implementation of CDSSs. Our study extends the current knowledge of CDSS implementation by deconstructing professional identity related mechanisms and identifying the antecedents of these perceived threats and enhancements. It addresses calls for research to explore identity theory and social evaluations in the context of new system implementation [ 5 , 38 , 39 ] by aiming to answer the following research questions: What are the human, technological, and organizational factors that lead different health care professionals to perceive a CDSS as a threat or an enhancement of their professional identity? And, how do perceptions of threat and enhancement of professional identity influence CDSS implementation?

This study is designed to guide medical practice, health IT providers, and health policy in their understanding of the mechanisms that lead to conflicts between health professionals’ identity and CDSS implementation. It is intended to identify practices that may support the implementation and long-term use of CDSSs. By narratively merging insights and underlying concepts from existing literature on innovation management, implementation science, and identity theory with the findings of the empirical studies included in this review, we aim to provide a comprehensive framework that can effectively guide further research on the implementation of CDSSs.

Understanding professional identity

Following recent literature, professional identity refers to an individual’s self-perception and experiences as a member of a profession and plays a central role in how professionals interpret and act in their work situations [ 25 , 37 , 40 , 41 , 42 ]. It is closely tied to a sense of belonging to a professional group and the identification with the roles and responsibilities associated with that occupation. Professionals typically adhere to a set of ethical principles and values that are integral to their professional identity and guide their behavior and decision-making. They are expected to have specialized knowledge and expertise in their field. In return, they are granted a high degree of self-efficacy, autonomy, and ability to act in carrying out these tasks [ 25 , 43 ]. In addition, professionals make active use of their identities in order to define and change situations. Self-continuity and self-esteem encourages these professionals to align their standards of identification with the perceptions of others and themselves [ 44 ]. Many professions have formal organizations or associations that promote and regulate their shared professional identity [ 45 ]. Membership in these associations, adherence to their standards and to a shared culture within their field, including common rituals, practices, and traditions, may reinforce their professional identity [ 33 , 36 , 45 ].

Studies in the field of health care innovation management and implementation science reported a number of professional identity conflicts that shape individual behavioral responses to change and innovation [ 5 , 24 , 33 , 36 , 45 , 46 ]. The first set of conflicts relates to individual factors and expectations, such as their personality traits, cognitive style, demographics, and education. For example, user perception of a new technology can be influenced by professional self-efficacy, which can be described as perceived feeling of competence, control and ability to perform [ 47 ]. Studies have shown that innovations with a negative impact on individual’s sense of efficacy tend to be perceived as threatening, resulting in a lower likelihood of successful implementation. Users who do not believe in their ability to use the new system felt uncomfortable and unconfident in the workplace and were more likely to resist the new system [ 48 , 49 ].

The second set of studies relates professional identity to sense-making, which involves the active process of acquiring knowledge and comprehending change based on existing professional identities as frames of references [ 50 ]. For example, Jensen and Aanestad [ 51 ] showed that health care professionals endorsed the implementation of an EHR system only if it was perceived to be congruent with their own role and the physician’s practice, rather than focusing on functional improvements that the system could have provided. Bernardi and Exworthy [ 52 ] found that health care professionals with hybrid roles, bearing both clinical and managerial responsibilities, use their social position to convince health care professionals to adopt medical technologies only when they address the concerns of health care professionals.

The final set of studies address struggles related to a disruption of structures and processes that lead to the reorganization of the health professions [ 53 , 54 ] and the introduction of new professional logics [ 55 ]. These can result in threat perceptions from the perspective of health professionals regarding their competence, autonomy, and control over clinical decisions and outcomes. Accordingly, the perception of new systems not only influences their use or non-use, but implies a dynamic interaction with the professional identity of the users [ 56 ]. CDSSs may be perceived as deskilling or as a skill enhancement by reducing or empowering the responsibilities of users and thereby as compromising or enhancing the professional role, autonomy and status.

Taking the classical theoretical frameworks for the evaluation of health information systems [ 57 ] and this understanding of professional identity as a starting point, our narrative review identifies, reinterprets, and interconnects the key factors to CDSS implementation related to threats or enhancement of health professionals’ identity in different health care settings.

We conducted a comprehensive search of the Web of Science and PubMed databases to identify peer-reviewed studies on CDSS implementations published between January 2010 and September 2023. An initial review of the literature, including previous related literature reviews, yielded the key terms to be used in designing the search strings [ 1 , 49 ]. We searched for English articles whose titles, abstracts, or keywords contained at least one of the search terms, such as “clinical decision support system,” “computer physician order entry,” “electronic prescribing,” or “expert system.” To ensure that the identified studies relate to CDSS implementation, usage, or adoption from the perspective of health care organizations and health care professionals, we included, for example, the words “hospital,” “clinic,” “medical,” and “health.” The final search strings are provided in Table S 1 (Additional file 1). We obtained a total of 6212 articles. From this initial list, we removed 1461 duplicates, 6 non-retrievable studies, and 1 non-English articles. This left us with a total of 4744 articles for the screening of the titles, abstracts, and full texts. Three authors independently reviewed these articles to identify empirical papers which met the following inclusion criteria: (a) evaluated a CDSS as a study object, (b) examined facilitating factors or barriers impacting either CDSS adoption, use or implementation, (c) were examined from the perspective of health care professionals or medical facilities, and (d) represented an empirical study. We identified 220 studies that met our inclusion criteria. The three authors independently assessed the methodological quality of these 220 selected studies using the Mixed Methods Appraisal tool (MMAT), version 2018 [ 58 ]. The MMAT can be used for the qualitative evaluation of five different study designs, i.e., qualitative, quantitative, and mixed methods approaches. It is a qualitative scale that evaluates the aim of a study, its adequacy to the research question, the methodology used, the study design, participant recruitment, data collection, data analysis, presentation of findings, and the discussion and conclusion sections of the article [ 59 ]. One hundred thirty-one studies were included in the review after excluding studies based on the MMAT criteria, primarily due to a lack of a defined research question or a mismatch between the research question and the data collected [ 58 ]. Any disagreement about the inclusion of a publication between was resolved through internal discussion. Figure  1 summarizes our complete screening process.

figure 1

Overview of article screening process

The studies included in the review were then subject to a qualitative content analysis procedure [ 60 , 61 ] using MAXQDA, version 2020. For data analysis, we initially followed the principle of “open coding” [ 62 ]. We divided the studies equally among the three authors, and through an initial, first-order exploratory analysis, we identified numerous codes, which were labeled with key terms from the studies. Based on a preliminary literature review, we then developed a reference guide with the main categories of classic theoretical frameworks for health information systems implementation (human, technology, organization) [ 57 ] and further characteristics of the study. Second-order categories were obtained through axial coding [ 62 ], which reduced the number of initial codes but also revealed concepts that could not be mapped to these three categories (i.e., perceived threat to professional autonomy and control). This allowed us to identify concepts related to professional identity. Subsequently, a subset of 10% of the studies was randomly selected and coded by a second coder independently of the first coder [ 63 ]. Then, an inter-coder reliability analysis was performed between the samples of coder 1 and coder 2. For this purpose, Cohen’s kappa, a measure of agreement between two independent categorical samples, was calculated. Cohen’s kappa showed that there was a high agreement in coding ( k  = 0.8) [ 64 ]. We coded for the following aspects: human, organizational, technological, professional identity factor conceptualizations, dependent variables, study type and type of data, time-frame, clinician type sample, description of the CDSS, implementation phase [ 65 ], target area of medical care [ 7 ], and applied medical specialty. Tables 2 , 3 , 4 , 5 , 6  and 7 and Table S 2 provide detailed data as per the key coding categories.

Descriptive analysis

A total of 131 studies were included in our review. In line with recent reviews of CDSS implementation research [ 6 , 14 , 57 ], the reviewed articles are distributed widely across journals (Table  1 ).

The examined articles were drawn from 69 journals, 55 of which provide only one article. The BMC Medical Informatics and Decision Making and International Journal of Medical Informatics published nearly a third of the included studies, with 67 articles overall in medical informatics journals. There are additional clusters in medical specialty-related (33), health services, public health, or health care management-related (12), and implementation science-related (2) journals. The journals’ 5-year impact factor measured in 2022 ranged between 2.9 and 9.7. Of our included articles, 67 were published between 2010 and 2016, while 64 were published between 2017 and 2023.

The review includes a mixture of qualitative ( n  = 61), quantitative ( n  = 40), and mixed methods ( n  = 30) studies. Unless otherwise noted, studies indicated as qualitative studies in Table S 2 involved interviews and quantitative studies involved surveys. Interviews with individual health care professionals were the most common data collection method used ( n  = 38), followed by surveys ( n  = 58), and focus group interviews ( n  = 25). Most of the interviews were conducted with physicians ( n  = 60) and nursing professionals ( n  = 23). The studies were performed at various sites and specialties, with primary care settings ( n  = 35), emergency ( n  = 11), and pediatric ( n  = 6) departments being represented most frequently. Forty-five articles researched exclusively physicians and 10 covered nurse practitioners as respondents in their sample. Four studies surveyed pharmacists, one study surveyed medical residents as a single target group, and 20 articles included clinical leaders in addition to clinicians to their sample. Twenty-eight studies were longitudinal, although studying system implementation at one point in time will insufficiently explain the expected impact of the novel system on, e.g., the organizational performance outcomes over time [ 67 ]. The studies collected data in 29 different countries, with the most common being the USA ( n  = 41), the UK ( n  = 18), and the Netherlands ( n  = 11).

Included studies were additionally coded according to the implementation phase in which the study was conducted (i.e., exploration, adoption/preparation, implementation, sustainment phase) [ 65 ]. In 43 of the included studies, the analysis was conducted during the exploration phase, i.e., during a clinical trial or an exploration of the functionality and applicability of a CDSS. Nineteen studies were conducted in the active implementation phase, 15 studies in an implementation adoption or preparation phase, and 46 studies in a sustainment phase (i.e., implementation completed and long-term system use). The revealing studies involved an investigation in multiple implementation phases.

Following Berner’s study [ 7 ], we classified the examined CDSSs of the included studies according to specific target areas of care. As such, in 93 articles, CDSSs for planning or implementing treatment were studied. Thirty-seven studies examined CDSSs whose goal was prevention or preventive care screening. In 31 studies, the functional focus of the CDSSs was to provide specific suggestions for potential diagnoses that match a patient’s symptoms. Seventeen CDSSs of the included studies focused on follow-up management , 15 studies studied CDSSs for hospital and provider efficiency care plans and 12 focused on cost reduction and improved patient convenience (i.e., through duplicate testing alerts). Most CDSSs supported medication-related decisions and processes, such as prescribing, administration, and monitoring for effectiveness and adverse effects ( n  = 30). An overview of the characteristics of the included studies can be found in Table S 2 .

In the 131 included studies, we identified 1219 factors, which we categorized into human, technological, organizational, and professional identity threat and enhancement-related factors to implementation (Table  2 ). The total amount of factors is reported in Table  2 for each of our framework’s dimension and for each of our inferred factor sub-categories. The following section delves into the elements of our framework (Fig.  1 ), starting with the most commonly identified factors. Finally, the CDSS implementation outcomes are described.

Technological factors

At the technological level, perceptions of threat to professional identity were associated with factors related to the nature of the clinical purpose of the CDSS and system quality, such as compatibility of the CDSS with current clinical workflows [ 68 , 69 , 70 ], customization flexibility, intuitive navigation [ 71 , 72 , 126 ], and scientific evidence and transparency of the decision-outcome [ 73 , 74 , 191 ] . A total of 532 technological factors in 125 included studies were identified. In 21 studies, technological factors were related to study participants’ perceptions of professional identity threat, while in 9 studies these factors were related to perceived professional identity enhancements (Table  3 ). The exemplary quotes are chosen based on their clarity and representativeness related to the overall themes.

The reviewed studies focused primarily on medication-oriented CDSSs. Relevance, accuracy, and transparency of the recommendations’ quality and scientific evidence were found to be crucial for their acceptance and use. “ Irrelevant, inaccurate, excessive, and misleading alerts ” were associated with alert fatigue and lack of trust [ 72 , 75 , 76 , 127 , 144 ]. Some senior physicians preferred the provision of evidence-based guidelines that would reinforce their knowledge, while others advised junior physicians to override the CDSS recommendations in favor of their own instructions. However, residents tended to follow CDSS recommendations and used them to enhance their confidence about a clinical decision [ 69 , 77 , 128 ]. Physicians had diverse perceptions of the scientific evidence supporting the CDSS recommendations. Some regarded it as abstract or useless information that was not applicable to clinical decision making in practice. These physicians preferred a more conventional approach to learning from the “eminences” of their discipline while pragmatically engaging in the “art and craft” of medicine. CDSSs were perceived as increasingly undermining clinical work and expertise among health professionals [ 24 ]. In some studies examining AI (artificial intelligence)-based CDSS, explainability and transparency of the CDSS recommendations played a major role in maintaining control over the therapeutic process [ 78 , 129 ].

Many studies indicated that the introduction of a CDSS was perceived as a disruptive change to established clinical workflows and practices [ 12 , 79 , 80 , 81 , 167 ]. The fit of CDSS with standardized clinical workflows was seen as critical to the CDSS implementation. Senior clinicians preferred their own workflows and protocols for complex patient cases [ 82 ]. Geriatricians, for example, considered CDSS recommendations inappropriate for their clinical workflows because geriatric patients are typically multi-morbid and require individualized care [ 77 ]. Intuitiveness and interactivity of the CDSS were found to reduce the perceived threat to professional identity [ 5 ], and customization and adjustment of alerts based on specialties’ and individual preferences were perceived to increase competence [ 10 , 127 , 130 ]. Physicians considered that successful implementation of the CDSS depends on the integration of existing clinical processes and routine activities and requires collaboration as well as knowledge sharing among experienced professionals [ 24 ].

Organizational factors

A total of 287 organizational factors in 104 included studies were identified. In 17 studies, organizational factors were related to study participants’ perceptions of professional identity threat, while in 7 studies these factors were related to perceived professional identity enhancements (Table  4 ). In the included studies, organizational factors influencing professionals’ perceived threat to their identity have been studied from multiple perspectives, such as internal collaboration and communication [ 145 , 178 ], (top) managers’ leadership and support [ 79 , 83 ], innovation culture and psychological safety [ 24 ], organizational silos and hierarchical boundaries [ 69 , 70 ], and the relevance of social norms and endorsement of professional peers [ 161 ].

The empirical studies showed that the innovation culture plays a critical role in driving change in health care organizations. In this regard, resistance to the implementation of CDSSs may be due to a lack of organizational support as well as physicians’ desire to maintain the status quo in health care delivery [ 24 , 70 , 75 ]. Several key factors influenced the implementation in this regard. These included appropriate timing of the implementation project, user involvement, and dissemination of understandable information through appropriate communication channels [ 70 ]. Some studies showed that an innovation culture characterized by interdependence and cooperation promotes social interaction (i.e., a psychologically safe environment ), which in turn facilitates problem-solving and learning related to CDSS use [ 193 , 194 ]. For example, nursing practitioners recognized the potential of CDSSs for collaboration in complex cases, which had a positive impact on team and organizational culture development [ 24 ].

S upportive leadership (e.g., by department leaders) was found to be critical to successful CDSS implementation. This includes providing the necessary resources, such as time and space for training, technical support, and user involvement in the implementation process, which were negatively associated with perceived loss of control and autonomy [ 11 , 69 , 79 , 83 , 84 , 145 , 174 ]. Involving not only senior physicians but also nursing and paramedical leaders increased the legitimacy of CDSSs throughout the professional hierarchy and helped to overcome the negative effect of low status on psychological safety by flattening hierarchical distances [ 24 , 70 , 72 ]. In contrast, imposing a CDSS on users, led to resistance. Some physicians and nurses felt that the use of the CDSS was not under their voluntary control (i.e., “we have no choice”, “it’s not an option to not use it”) because these systems have become “as essential as … carrying a pen and a stethoscope,” with physicians feeling that they now “are reliant on the CDSS” [ 10 ]. In other cases, top-down decisions led to the resolution of initial resistance toward the CDSS [ 167 ]. Overall, committed leadership that involved users and transcended professional silos and hierarchies was critical to successful CDSS implementation. In this context, an established hierarchy and culture of physician autonomy impeded communication, collaboration, and learning across professional and disciplinary boundaries [ 54 , 195 , 196 ]. A well-designed CDSS minimized professional boundaries by, for example, empowering nurses and paramedics to make independent treatment decisions [ 8 , 180 ]. CDSSs thus provided structured means for nonmedical professionals to receive support in their clinical decision-making that was otherwise reserved for professionals with higher authority [ 34 ]. Since CDSSs allow widespread access to scientific evidence, they often led to nursing practitioners’ control or oversight of medical decisions, putting junior physicians in an inferior position, and thus providing an occasion to renegotiate professional boundaries and to dispute the distribution of power [ 24 , 77 ].

In addition, the provision of sufficient training and technical support were essential to ensure that physicians and nursing practitioners felt confident in using the CDSS and increased their satisfaction with the system [ 77 , 85 ]. Embedding new CDSSs into routine practice required communication and collaboration among professionals with clinical expertise and those with IT expertise [ 86 , 145 , 178 ]. Involving physicians and nursing practitioners in decision-making processes increased their willingness to change their long-standing practice patterns and embrace the newly introduced CDSS [ 5 , 10 ]. Facilitating the CDSS uptake therefore required legitimization of the system’s designers and exploited data sources [ 24 ]. Similarly, the success or failure of CDSSs implementation depended on the ability of the new system to align with existing clinical processes and routine activities. Often, successful adoption was at risk when the implementation was too far away from the reality of clinical practice because those responsible for designing the CDSS poorly understood the rationale for designing the system in a particular way [ 145 ].

In addition, some studies indicated that resistance was overcome by communicating the benefits of the CDSS through contextual activities and providing opportunities to experience the system firsthand. Sharing positive implementation experiences and fostering discussions among actual and potential users could bridge the gap between perceptions and actual use [ 145 , 146 ]. In this regard, endorsement from “ respected ” and “ passionate ” internal change promoters , such as expert peers, was seen as key to overcoming user resistance [ 82 ]. Confirmation from clinical experts that the new system improves efficiency and quality of care was essential for the general system acceptance [ 154 ]. Thus, social influence played an important role, especially in the initial phase of system use, while this influence decreased as users gained experience with the CDSS [ 182 ].

Human factors

A total of 197 human factors in 99 included studies were identified. In 17 studies, human factors were related to study participants’ perceptions of professional identity threat, while in 6 studies these factors were related to perceived professional identity enhancements. Table 5 summarizes the key findings from the included articles, which relate to three factors: individual attitudes and emotional responses, experience and familiarization with the CDSS , and trust in the CDSS and its underlying source.

It is reported in the empirical studies that physicians often failed to fully utilize the features of CDSSs, such as protocols, reminders, and charting templates, because they often lacked experience and familiarization with the CDSS [ 3 , 79 , 87 , 127 ]. In addition to insufficient training and time constraints, limited IT skills were reported as the main reasons [ 83 , 87 , 147 , 185 ]. As a result, users interacted with the CDSS in unintended ways, leading to data entry errors and potential security concerns [ 88 ]. According to Mozaffar et al. [ 131 ], this includes physicians’ tendency to enter incorrect data or select the wrong medication due to misleading data presentations in the system. Inadequate IT skills and lack of user training also contributed to limited understanding of the full functionality of CDSSs. As such, physicians interviewed in one study expressed the lack of knowledge about basic features of a CDSS, including alerts, feedback, and customization options, as a major implementation barrier [ 127 ]. Some studies reported that the lack of system customization to meet the personal preferences of users and the lack of system training weakened their confidence in the system and compromised their clinical decision-making autonomy [ 10 , 83 , 89 , 90 , 127 , 183 ].

Some studies indicated that there were trust issues among physicians and nursing practitioners regarding the credibility of the decision-making outcome [ 132 , 154 ], the accuracy of the CDSS recommendations’ algorithm [ 146 ], and the timeliness of medical guidelines in the CDSS [ 127 ]. Seniors appreciated medication-related alerts but felt that their own decision-making autonomy regarding drug selection and dosing was compromised by the CDSS [ 74 ]. However, they tended to use the CDSS as a teaching tool for their junior colleagues, advising them to consult it when in doubt [ 77 , 128 ]. In some cases, this led to junior physicians accepting CDSS suggestions, such as computer-generated dosages, without independent verification [ 128 , 144 , 154 ].

Several studies indicated that the CDSS introduction elicited different individual attitudes and emotional responses . More tenured health care professionals were “ frightened ” when confronted with a new CDSS. Others perceived the CDSS as a “ necessary evil ” or “ unwelcome disruption ” [ 81 ], leading to skepticism, despair, and anxiety [ 3 , 145 , 167 ]. Younger physicians, on the other hand, tended to be “ thrilled ” and embraced the technology’s benefits [ 84 , 147 , 167 ]. Motivation, enthusiasm, and a “can do” attitude toward learning orientation and skill development positively influenced engagement in CDSS [ 11 , 83 , 84 , 145 , 184 ].

The role of professional identity threat and enhancement perceptions in CDSS implementation

Overall, we found 90 factors in 65 included studies related to perceptions of professional identity threat among the study participants. Forty-four factors in 34 included studies were associated with perceived professional identity enhancements. We identified three key dimensions of professional identity threat and enhancement perceptions among health care professionals impacting CDSS implementation along different implementation phases [ 197 ]. Table 6 contains exemplary quotes illustrating the findings.

A number of physicians perceived CDSSs as an ultimate threat to professional control and autonomy , leading to a potential deterioration of professional clinical judgment [ 30 , 69 , 77 , 154 , 155 ]. Most nurse practitioners, on the other hand, experienced a shift in decision-making power, providing an occasion to renegotiate professional boundaries in favor of health care professionals with lower levels of expertise [ 24 ]. Thus, nurses associated the implementation of a CDSS with enhanced professional control and autonomy in the performance of tasks [ 34 , 155 , 169 ]. Pharmacists often advocated for medication-related CDSSs, which in turn increased physician dependency and resistance to new tasks [ 12 , 84 , 178 ]. The latter was a consequence of physicians’ increasing reliance on pharmacists for complex drug therapies, as physicians had to relinquish some decision-making authority to pharmacists by restructuring of decision-making processes [ 74 ].

Senior physicians frequently expressed concerns about overreliance on CDSS and potential erosion of expertise , which they believed led to patient safety risks [ 10 , 24 , 75 , 89 , 155 ]. They complained that overreliance on CDSS recommendations interfered with their cognition processes. For example, in medication-related CDSSs, clinical data such as treatment duration, units of measure, or usual doses are often based on pharmacy defaults that may not be appropriate for certain patients. According to these physicians, their junior colleagues might not double-check recommended medication doses and treatment activities, leading to increased patient safety risk [ 131 ]. In another study, general practitioners expressed concerns about the deskilling of future physicians through CDSSs. Some CDSSs required a high level of clinical expertise, skill, and knowledge regarding the correct entry of clinical information (e.g., symptoms) for proper support in clinical decisions. Many physicians feared that the use of CDSSs would erode this knowledge and thus allow the CDSS recommendations to lead to incorrect decisions [ 30 ]. This potential loss of skills and expertise was seen as particularly problematic in situations where decision support for medications and e-prescriptions varied from facility to facility. Physicians working at different institutions who relied on the CDSS for medication treatment support used at one institution reported that they had difficulties making the correct clinical decisions at the other institution [ 154 ]. From the reviewed articles, it appeared that senior physicians perceived CDSSs as an intrusion into their professional role and object to their expertise and time being misused for “ data entry work ” [ 10 ]. They enjoyed the freedom to decide what to prescribe, when to prescribe it, and whether or not to receive more information about it [ 77 ] and were determined not to “ surrender ” and “ be made to use [the CDSS] ” [ 82 ].

In line with the increasing dependence of physicians on pharmacists when using CDSS for medication treatment, pharmacists used the CDSS to demonstrate their professional skills and to further develop their professional role [ 178 ]. Nurse practitioners were empowered by CDSSs guidance to systematically update medications and measurements during their hectic daily clinic routine [ 24 , 91 ], to independently manage more complicated scenarios [ 8 ], and to facilitate their decision-making [ 92 ]. Some physicians stated that CDSS recommendations facilitated their critical thinking to critically reflect on the medication more than usual and facilitated more conscious decisions [ 133 ]. Increased professional identity enhancement in terms of skills and expertise were thus often associated with technological factors such as enhanced patient safety, improved efficiency, and quality of care [ 9 ].

Furthermore, physicians strongly associated their professional identity with their central role in the quality of patient care based on a high level of empathy and trust between physician and patient [ 45 , 195 ]. Their perceived threat to professional identity lead to a sense of loss in clinical professionalism and control over patient relationships [ 162 , 170 ] . CDSS usage was perceived as unprofessional or disrupting to the power dynamic between them and their patients [ 89 , 93 , 171 ]. As a result, they indicated that established personal patient relationships were affected by imposed CDSS use [ 81 ]. Other physicians saw CDSSs as having potential to enhance patient relationships providing them with more control over the system and treatment time, facilitating information and knowledge sharing with patients and building trust between patients and physicians [ 35 , 94 ].

Mapping the perceptions of threat and enhancement of professional identity among physicians and other health care professionals identified in each study to implementation phases allowed for an examination of the evolution of identity perceptions in CDSS implementations. Table 7 assigns the identity perceptions among physicians and other health care professionals to the different implementation phases. The findings illustrate that threat perceptions were predominantly perceived before and at the beginning of implementation. With steady training, use and familiarization with the CDSS, the perceived threat to professional identity slightly decreased in the sustainment phase, compared to the pre-implementation phase, while perceptions of enhancement of professional identity increased. During the exploration phase, physicians in particular perceived the CDSS as undermining their professional identity, and this perception remained relatively constant through the sustainment phase. Other health care professionals, such as nurse practitioners and pharmacists often changed their perspective over the course of the implementation phases and perceived the CDSS as supporting their control, autonomy, and skill enhancement at work.

CDSS implementation outcomes

In total, we identified 93 benefits related to CDSS implementation in the reviewed studies (Table  2 ). The most commonly evaluated benefits were improvements in work efficiency and effectiveness through the use of CDSSs, improvements in patient safety, and improvements in the quality of care . Prevention of prescription and treatment errors was also frequently mentioned. The included studies measured CDSS implementation in various ways, which we classified into seven groups (Table  8 ). Most studies measured or evaluated self-reported interest in using the system or intention, willingness to use, or adoption , followed by self-reported attitude toward CDSSs , and both self-reported and objective measure of implementation success . Objective actual use measurement was evaluated in only 10 studies, while self-reported use was measured in seven studies, and self-reported satisfaction and performance of the system was measured in five studies. Both self-reported and objective measure of usefulness and usability was measured in one study.

Although we included 40 quantitative studies in our review, only a few of these empirically measured the direct effect of professional identity threat or related organizational consequences on implementation, adoption, or use of CDSSs. Two studies empirically demonstrated a direct significant negative relationship between perceived professional autonomy and intention to CDSS use [ 5 , 48 ]. Another four studies found empirical evidence of an indirect negative association between threats to professional identity and actual CDSS use. Physicians disagreed with the CDSS recommendation because they perceived insufficient control and autonomy over clinical decision making [ 79 , 88 ] and lacked confidence in the quality of the CDSS and its scientific evidence [ 154 ].

Main findings

The purpose of this narrative review was to identify, reinterpret, and interconnect existing empirical evidence to highlight individual, technological, and organizational factors that contribute to professional identity threat and enhancement perceptions among clinicians and its implications for CDSS implementation in health care organizations. Using evidence from 131 reviewed empirical studies, we develop a framework for the engagement of health care professionals by deconstructing the antecedents of professional identity threats and enhancements (Fig. 2 ). Our proposed framework highlights the role of cognitive perceptions and response mechanisms due to professional identity struggles or reinforcements of different individual health care professionals in the implementation of CDSSs. Our work therefore contributes to the growing literature on perceived identity deteriorations with insights into how knowledge-intensive organizations may cope with these threats [ 37 , 45 , 46 ]. We categorized clinicians’ professional identity perceptions into three dimensions: (1) perceived threat and enhancement of professional control and autonomy , (2) perceived threat and enhancement of professional skills and expertise , and (3) perceived loss and gain of control over patient relationships . These dimensions influenced CDSS implementation depending on the end user’s change of status and expertise over the course of different implementation phases. While senior physicians tended to perceive CDSSs as undermining their professional identity across all implementation stages, nurse practitioners, pharmacists, and junior physicians increasingly perceived CDSS as enhancing their control, autonomy, and clinical expertise. Physicians, on the other hand, were positive about the support provided by the CDSS in terms of better control of the physician–patient relationship. In most studies, professional identity incongruence was associated with technological factors, particularly the lack of adaption of the system to existing clinical workflows and organizational structures (i.e., process routines), and the fact that CDSS functionalities have to meet the needs of users. The lack or presence of system usability and intuitive workflow design were also frequently associated as antecedents of professional identity loss. The other dimensions (i.e., human and organizational factors) were encountered less often in relation to professional identity mechanisms among health care professionals. Only six studies found empirical evidence of an indirect or direct negative relationship between health professionals’ perceived threats to professional identity and outcomes of CDSS implementation, whereas no study explicitly analyzed the relationship between dimensions of professional identity enhancement and outcomes of CDSS adoption and implementation.

figure 2

A framework for the role of professional identity in CDSS implementation

Interpretations, implications and applicability to implementation strategies

The results indicate that healthcare professionals may perceive CDSSs as valuable tools for their daily clinical decision-making, which can improve their competence, autonomy, and control over the relationship with the patient and their course of treatment. These benefits are realized when the system is optimally integrated into the clinical workflow, meets users’ needs, and delivers high quality results. Involving users in design processes, usability testing, and pre-implementation training and monitoring can increase user confidence and trust in the system early in implementation and lead to greater adoption of the CDSS [ 146 ]. To address trust issues in the underlying algorithm of the CDSS, direct and open communication, transparency in decision-making values, and clinical evidence validation of the CDSS are crucial [ 154 ]. CDSS reminders and alerts should be designed to be unobtrusive to minimize the perceived loss of autonomy over clinical decisions [ 77 ].

Contrary, the implementation of a CDSS often lead to substantial changes of professional identity and thereby often associated with fear and anxiety. A sense of a loss of autonomy and control was linked to lower adoption rates and thus implementation failure. Cognitive styles, which may be expressed in emotional reactions of users toward the CDSS, reinforced reluctance to implement and use the system [ 145 , 167 ]. This underscores the importance of finding expert peers and professionals who are motivated and positive toward CDSS adoption and use, and who can communicate and promote the professional appropriateness and benefits of the CDSS to their colleagues [ 82 , 83 , 184 ]. This promotes a focus on the improvement and benefits of the CDSS while maintaining the integrity, perceived autonomy, control, and expertise of physicians and nurses.

Accordingly, the included studies show that health professionals respond to the professional identity threat triggered by the CDSS implementation by actively maintaining, claiming, or completely changing their identity [ 39 ], which is consistent with previous studies elaborating on the self-verification of professionals [ 44 ]. For example, physicians delegated routine tasks to other actors to maintain control over the delivery of services and thereby enhance their professional status [ 201 ]. Pharmacists used the introduction of CDSS for drug treatment to demonstrate their skills to physicians and to further develop their professional role [ 178 ]. Maintaining authority over the clinical workflow without the need for additional relational work with lower-status professionals was seen as one of the main factors for health care professionals’ CDSS acceptance in our findings [ 10 , 12 , 84 , 178 ]. Physicians influence change processes, such as the implementation of CDSS, in a way that preserves the status quo of physicians’ responsibilities and practices. They often stated their objective to avoid increasing dependence on lower-status professionals such as nurses or pharmacists who were gaining control by using the new CDSS. In addition, CDSS users frequently criticized the system’s lack of fit with clinical work processes and that the systems were not able to replace the clinical expertise and knowledge [ 12 , 34 , 77 , 82 ]. The loss of control over the patient-physician relationship also represented a key component of identity undermining through the introduction of CDSSs. Many physicians expressed that their trust-building interaction with patients was eroded by the functionalities of the CDSS [ 81 , 170 ]. The fact that the use of CDSSs saves time in patient therapy and treatment, freeing up time for their patients, was rarely expressed [ 12 , 147 ]. This underscores the need to cope with the physician’s strong identification with their professional role, their tendency to preserve the status quo, and self-defense against technological change during the implementation of CDSSs.

Furthermore, the reviewed studies emphasized the importance of both inter- and intra-professional involvement, collaboration, and communication in health care organizations, during the CDSS implementation, suggesting that these mechanisms influence the extent and quality of cooperative behavior, psychologically safe environments, and role adaptation of different professional groups [ 26 , 54 , 55 , 202 ]. Among the studies we reviewed, managerial support and collaboration influenced coordination during CDSS implementation [ 82 , 83 , 174 ], such as by providing usability testing and time for efforts to change the understanding of why and how health care professionals should modify their routine practices [ 74 , 95 ].

Overall, the review shows that the consideration of perceived professional identity mechanisms among health care professionals plays an important role when implementing new CDSSs in health care organizations. Additionally, perceived threats and enhancements of professional identity should be considered and regularly assessed in long-term oriented implementation strategies. These strategies often include methods or techniques to improve the adoption, implementation, and sustainability of a clinical program or practices [ 203 ] and may span from planning (i.e., conducting a local needs assessment, developing a formal implementation plan) to educating (i.e., conduct educational meetings, distribute educational materials) to restructuring professional roles to managing quality (i.e., provide clinical supervision, audit, and feedback) [ 204 , 205 ]. To ensure implementation, health care professionals of all hierarchies should be involved in the planning and decision-making processes related to CDSS implementation. Continuous feedback loops between health care professionals, IT staff, and implementation managers can help identify unforeseen threats to professional identity and necessary adjustments to the implementation plan. The review found that perceived identity threats particularly need to be addressed among highly specialized physicians to account for their knowledge-intensive skills, expertise, and clinical workflows [ 24 , 96 ]. In addition, the purpose of CDSS implementation and information about how it aligns with organizational strategic goals and individual professional development should be clearly and continuously communicated at all stages of implementation.

Our review also confirms that health care professionals’ perceptions of the effectiveness of CDSSs reinforce the impact of organizational readiness for the ongoing and required transformation of healthcare [ 17 ]. Comprehensive assessments of the suitability of the system for established or changing clinical workflows and the technical quality of the CDSS should be prioritized at the beginning of the implementation. Training programs should be developed to help professionals adapt to the new medical systems and allay fears of a loss of competence or relevance. To mitigate threats to professional identity in the long term, it is necessary to foster an organizational culture of adaptability, learning, and psychological safety, in which it is acceptable to make mistakes and learn from them. In addition, ongoing leadership support and professional development opportunities are critical to ensure that health care professionals continue to adapt their roles and keep pace with technological developments [ 79 , 84 ].

Limitations

A literature review of a large sample of empirical studies has many advantages [ 206 ]. However, some limitations arise from the study design. First, our included studies were mainly conducted in the USA or UK (see Table S 2 ). The dominance of these two countries may pose a potential bias, as different cultures may have different implications for CDSS implementation and threat perceptions among health care professionals. Therefore, there is a need for caution in generalizing the findings on the impact of human, technological, and organizational factors on professional identity perceptions among professionals across different cultures. More studies are needed to provide a nuanced understanding of professional identity mechanisms among health care professionals across a broader range of cultures and countries.

Second, broad search terms were used to identify a larger number of articles in the literature review and to identify professional identity based on implementation and adoption factors mentioned in the included studies from the perspective of health professionals who were not specifically identified as threats to or enhancements of professional identity. This could also be considered a methodological strength, as this review combines findings from qualitative, quantitative, and mixed methods studies on this construct from a large and diverse field of research on CDSS implementation. However, non-English language articles or articles that did not pass the MMAT assessment may have been overlooked, which would have provided valuable information on further barriers and facilitators (i.e., threats to professional identity in different cultures), affecting the rigor of this study.

Third, most of the studies reviewed captured CDSSs for use in primary care settings. CDSSs in highly specialized specialties or those that frequently treat multi-morbid patients, such as cardiology and geriatrics, require features that allow for detailed workflow customization. In such specialties, even more attention needs to be paid to balancing provider autonomy and workflow standardization [ 97 ]. As such, future research should provide the missing evidence in such complex settings.

Fourth, we were only able to identify a limited number of studies that empirically analyzed the causal relationships included in our framework. There is a lack of studies that use longitudinal research designs, quantitative data, or experimental study designs. Therefore, the identified effects of technological, organizational, and human factors on professional identity and consequently on implementation success need to be interpreted with caution. Future research should test whether the determinants and effects of professional identity mechanisms among healthcare professionals can be observed in real-world settings.

Professional identity threat is a key cognitive state that impedes CDSS implementation among various health care professionals and along all implementation phases [ 31 , 45 ]. Health care managers need to engage in supportive leadership behaviors, communicate the benefits of CDSSs, and leverage supportive organizational practices to mitigate the perception and effect of professional identity threat. An innovation culture needs to support the use of CDSSs and top management commitment should reduce uncertainty about why a new CDSS is needed [ 24 ]. Therefore, leaders should raise awareness of the relevant CDSS functionalities and communicate the terms and conditions of use. It is crucial to involve clinicians in updating CDSS features and developing new ones to ensure that CDSSs can be quickly updated to reflect rapid developments in guideline development [ 195 ]. One way to achieve this is to engage proactive, respected, and passionate individuals who can train colleagues to use the CDSS and promote the potential benefits of the system [ 70 , 82 ].

Our framework presented in this study provides a relevant foundation for further research on the complex relationship between human, technological, and organizational implementation factors and professional identity among different health care professionals. The findings also guide health care management experts and IT system developers in designing new CDSSs and implementation strategies by considering the ingrained norms and cognitions of health care professionals. As suggested above, more research is needed to determine whether some barriers or facilitators are universal across all types of CDSSs or whether there are domain-dependent patterns. In this context, research that explicitly focuses on AI-based CDSSs becomes increasingly important as they become more relevant in medical practice. In fact, five of the studies included in our research, conducted over the last 3 years, examined factors related to the adoption and implementation of AI-based CDSS [ 73 , 74 , 96 , 205 , 206 ]. AI-based CDSSs extend to full automation and can discover new relationships and make predictions based on learned patterns [ 97 ]. However, with their opaque and automated decision-making processes, AI-based systems may increasingly challenge professional identity as they increasingly disrupt traditional practices and hierarchies within healthcare organizations, posing a threat to professional expertise and autonomy [ 156 ]. This may further hinder the implementation and sustainable use of these systems compared to non-AI-based systems. Future research could examine overlaps in barriers and facilitators between CDSSs and AI-based systems, which are of relevance for professional identity threat perceptions among health care professionals, and assess the reasons behind these differences. In addition, translating the findings for different medical contexts may provide valuable insights. This can eventually lead to guidelines for the development of CDSS for different specialties.

Some factors were found less frequently during our analysis; in particular, communication of the benefits of a CDSS to users, the importance of trust across different hierarchies and among staff involved in implementation, and government-level factors related to the environment. While the former factors represent important psychological safety and acceptance of the CDSS, the level of the environment represents a minor role in the perception of professional identity. Future research is needed, however, to determine whether all of these factors play an important role in CDSS implementation. Furthermore, future research could explore the role of middle managers and team managers in health care organizations rather than the role of senior management in managing professional identity threats when leading change. Our narrative review found that clinical middle managers may have a special role in legitimizing CDSSs [ 156 ]. In addition, a future research opportunity arises from the perceived role and identity enhancement through new technologies and their consequences for social evaluation in hierarchical healthcare organizations [ 35 , 132 , 155 ].

Overall, the findings of this review are particularly relevant for managers of CDSS implementation projects. Thoughtful management of professional identity threat factors identified in this review can help overcome barriers and facilitate the implementation of CDSSs. By addressing practical implications and research gaps, future studies can contribute to a deeper understanding of the threat to professional identity and provide evidence for effective implementation strategies of CDSSs and thus for a higher quality and efficiency in the increasingly overburdened health care system.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Abbreviations

Artificial intelligence

  • Clinical decision support system

Electronic health record

Mixed Methods Appraisal tool

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Open Access funding enabled and organized by Projekt DEAL. Parts of the study are supported by the research grand by the German Bundesministerium für Bildung und Forschung (BMBF) Augmented Auditive Intelligence (A2I). Reference: 16SV8599.

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Sophia Ackerhans, Thomas Huynh, Carsten Kaiser & Carsten Schultz

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SA conceived the study, developed the literature search, screened citation titles, abstracts, and full-text articles, conducted the MMAT screening, cleaned, coded, analyzed, and interpreted one third of the data, and conceptualized and wrote the sections of the manuscript. TH conceived the study, developed the literature search, screened citation titles, abstracts, and full-text articles, conducted the MMAT screening, cleaned, coded, analyzed, and interpreted one third of the data, and edited the sections of the manuscript. CK screened citation titles, abstracts, and full-text articles, conducted the MMAT screening, cleaned, coded, analyzed, and interpreted one third of the data, and revised the manuscript. CS planned and coordinated the study and edited the manuscript. All authors read and approved the final manuscript.

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Supplementary Information

Additional file 1: table s1..

Final search strings used to identify articles for the review. Table S2. Characteristics of included studies.

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Ackerhans, S., Huynh, T., Kaiser, C. et al. Exploring the role of professional identity in the implementation of clinical decision support systems—a narrative review. Implementation Sci 19 , 11 (2024). https://doi.org/10.1186/s13012-024-01339-x

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Random-effects restricted maximum likelihood model. Squares indicate mean SBPs, with horizontal lines indicating 95% CIs and the size of the squares representing weight; diamonds indicate pooled estimates, with outer points of the diamonds indicating 95% CIs.

eTable 1. Search Strategies and Additional Methods

eTable 2. Additional Study Characteristics for the 28 Included Studies Meeting Eligibility Criteria

eTable 3. Baseline Demographic and Socioeconomic Characteristics of Participants in the 28 Included Studies

eTable 4. Excluded Studies From the Original Search With Reasons for Exclusion

eTable 5. Excluded Studies That Were Eliminated From the Citation Chasing With Corresponding Rationale

eTable 6. Subgroup Analysis Showing Change in SBP at 6 Months

eTable 7. Subgroup Analysis Showing Change in DBP at 6 Months

eTable 8. Subgroup Analysis Showing SBP Values at 6 Months

eTable 9. Subgroup Analysis Showing DBP Values at 6 Months

eFigure 1. Differences in Diastolic Blood Pressure Changes From Baseline to Follow-Up Time Points Between Digital Health Intervention and Control Groups

eFigure 2. Differences in Follow-Up Diastolic Blood Pressures Between Digital Health Intervention and Control Groups at Different Time Points

eFigure 3. Sensitivity Analysis for Presence of Publication Bias Using Change in SBP Outcome at 6-Month Follow-Up and Leave-One-Out Meta-Analysis Results for Same Outcome

eFigure 4. Sensitivity Analysis for Presence of Publication Bias Using Follow-Up SBP Value Outcome at 6-Month Follow-Up and Leave-One-Out Meta-Analysis Results for Same Outcome

eFigure 5. Sensitivity Analysis for Presence of Publication Bias Using Change in DBP Outcome at 6-Month Follow-Up and Leave-One-Out Meta-Analysis Results for Same Outcome

eFigure 6. Sensitivity Analysis for Presence of Publication Bias Using Follow-Up DBP Value Outcome at 6-Month Follow-Up and Leave-One-Out Meta-Analysis Results for Same Outcome

eFigure 7. Risk of Bias Assessment for Included Studies

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Katz ME , Mszar R , Grimshaw AA, et al. Digital Health Interventions for Hypertension Management in US Populations Experiencing Health Disparities : A Systematic Review and Meta-Analysis . JAMA Netw Open. 2024;7(2):e2356070. doi:10.1001/jamanetworkopen.2023.56070

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Digital Health Interventions for Hypertension Management in US Populations Experiencing Health Disparities : A Systematic Review and Meta-Analysis

  • 1 New York Medical College School of Medicine, Valhalla
  • 2 Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 3 Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
  • 4 Department of Medicine, Yale School of Medicine, New Haven, Connecticut
  • 5 VA Connecticut Healthcare System, West Haven
  • 6 Division of Cardiology, Massachusetts General Hospital, Boston
  • 7 Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
  • 8 Yale Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut

Question   Are digital health interventions associated with reducing blood pressure (BP) levels in US populations experiencing health disparities, and what types of tailored modalities have been used to manage hypertension in demographically and socioeconomically diverse subgroups?

Findings   In this systematic review and meta-analysis of 28 studies, patients with health disparities receiving a digital health intervention compared with standard care had greater reductions in systolic BP at 6 and 12 months. Most studies involved multicomponent interventions, primarily remote BP monitoring.

Meaning   These findings suggest that digital health interventions are associated with improved BP levels in populations experiencing health disparities.

Importance   Hypertension remains a leading factor associated with cardiovascular disease, and demographic and socioeconomic disparities in blood pressure (BP) control persist. While advances in digital health technologies have increased individuals’ access to care for hypertension, few studies have analyzed the use of digital health interventions in vulnerable populations.

Objective   To assess the association between digital health interventions and changes in BP and to characterize tailored strategies for populations experiencing health disparities.

Data Sources   In this systematic review and meta-analysis, a systematic search identified studies evaluating digital health interventions for BP management in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases from inception until October 30, 2023.

Study Selection   Included studies were randomized clinical trials or cohort studies that investigated digital health interventions for managing hypertension in adults; presented change in systolic BP (SBP) or baseline and follow-up SBP levels; and emphasized social determinants of health and/or health disparities, including a focus on marginalized populations that have historically been underserved or digital health interventions that were culturally or linguistically tailored to a population with health disparities. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Data Extraction and Synthesis   Two reviewers extracted and verified data. Mean differences in BP between treatment and control groups were analyzed using a random-effects model.

Main Outcomes and Measures   Primary outcomes included mean differences (95% CIs) in SBP and diastolic BP (DBP) from baseline to 6 and 12 months of follow-up between digital health intervention and control groups. Shorter- and longer-term follow-up durations were also assessed, and sensitivity analyses accounted for baseline BP levels.

Results   A total of 28 studies (representing 8257 participants) were included (overall mean participant age, 57.4 years [range, 46-71 years]; 4962 [60.1%], female). Most studies examined multicomponent digital health interventions incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). Sociodemographic characteristics were similar between intervention and control groups. Between the intervention and control groups, there were statistically significant mean differences in SBP at 6 months (−4.24 mm Hg; 95% CI, −7.33 to −1.14 mm Hg; P  = .01) and SBP changes at 12 months (−4.30 mm Hg; 95% CI, −8.38 to −0.23 mm Hg; P  = .04). Few studies (4 [14.3%]) reported BP changes and hypertension control beyond 1 year.

Conclusions and Relevance   In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, BP reductions were greater in the intervention groups compared with the standard care groups. The findings suggest that tailored initiatives that leverage digital health may have the potential to advance equity in hypertension outcomes.

Hypertension is an important risk factor for cardiovascular disease (CVD), which accounts for approximately 1 in 5 deaths in the US. 1 Nearly half (47%) of all US adults, or 116 million individuals, have hypertension (defined as systolic blood pressure [SBP]≥130 mm Hg or diastolic blood pressure [DBP]≥80 mm Hg). Only 24% of those with hypertension have their condition under control. 2 , 3 Racial, ethnic, and socioeconomic disparities in hypertension prevalence, awareness, and treatment persist. Notably, population-based studies have shown that Black and Hispanic adults have lower BP awareness and control despite a higher overall burden of hypertension compared with non-Hispanic White individuals. 4 - 8

Emerging research has shown digital health technology to be a promising avenue for managing uncontrolled hypertension, particularly in underserved populations impacted by barriers to accessing care. Current digital health approaches for hypertension management typically involve text message reminders for medication adherence, 9 - 11 remote BP monitoring, 12 , 13 and virtual behavioral coaching. 14 , 15 There is also growing evidence for the value of tailored, multicomponent approaches for hypertension management. 16 , 17 Home monitoring can identify “white-coat hypertension” (BP measurements are high in the clinic but normal at home) and masked hypertension (BP measurements are normal in the clinic but high at home) and empower patients to take more control over their health. 12 , 18 When combined with a centralized medical team to respond to elevated home BP readings, home monitoring has potential to significantly improve BP control. Despite the intended benefits of home monitoring and other digital health interventions for hypertension control, there are varying effects on cardiovascular risk factor control, potentially because of the need for technology support and remote engagement. 19 - 22 Studies that incorporate a social determinants of health framework in the development and implementation of digital health interventions could prevent further widening of the digital divide and existing health disparities. 23

Accordingly, this systematic review and meta-analysis aimed to assess the association between digital health interventions and BP changes among populations experiencing health disparities. It also aimed to characterize the diversity of contemporary strategies used to meet the needs of populations experiencing health disparities.

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA ) reporting guideline. 24 The study protocol and methods were registered with PROSPERO a priori ( CRD42021257529 ).

A systematic search of the literature was conducted by a medical librarian (A.A.G.) in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science Core Collection databases to identify relevant articles published from the earliest record in the respective database to October 30, 2023. Databases were searched using a combination of controlled vocabulary and free-text terms for digital health, hypertension, social determinants of health, and demographic and/or socioeconomic disparities. The search was not limited by publication type, language, or year. The search was peer reviewed by a second medical librarian using Peer Review of Electronic Search Strategies. Details of the full search strategy are listed in eTable 1 in Supplement 1 . CitationChaser was used to search the reference lists of included studies and to retrieve articles that had cited the included studies to find additional relevant studies not retrieved by the database search.

Included studies were randomized clinical trials (RCTs) or cohort studies that investigated digital health interventions for managing hypertension and were conducted in adult populations (age ≥18 years). Studies were not excluded based on the type of digital health intervention used. Included studies presented change in SBP and/or baseline and follow-up SBP levels as primary or secondary outcomes. Studies were excluded if they possessed the following characteristics: review articles, abstracts, editorials or letters, animal studies, or case reports. Conference abstracts were excluded given that detailed information was required on follow-up BP levels, participants’ sociodemographic characteristics, and an in-depth description of the digital health intervention being assessed.

Additionally, given the objective of this systematic review and meta-analysis to assess the outcomes of digital health interventions in populations experiencing health disparities, the studies that were included at the full-text review stage were required to possess any of the following characteristics: (1) a clear emphasis on social determinants of health and/or health disparities, (2) study eligibility criteria focusing on the exclusive or predominant recruitment and enrollment of marginalized populations that have historically been underserved and underrepresented in medical and public health research, (3) study design and conduct approaches involving intentional community partnership and stakeholder engagement, and (4) digital health intervention strategies that were culturally and/or linguistically tailored to the populations they were meant to serve. It was not feasible to include these criteria as part of the first stage of eligibility determination because this information is frequently not included in a study’s title or abstract, thereby necessitating full review of the methods and results.

Citations from all databases were imported into an EndNote 20 library (Clarivate Analytics). Duplicate citations were removed using the Yale Reference Deduplicator. The deduplicated results were imported into Covidence for screening and data extraction. Two independent screeners (M.E.K., R.M.) performed a title and abstract review, and a third screener (E.S.S.) resolved disagreements. The full texts of the resulting studies were then reviewed for inclusion by 2 independent screeners (M.E.K., R.M.), with a third screener (E.S.S.) resolving disagreements.

Data were extracted and verified by 2 authors (M.E.K., R.M.). These data consisted of study characteristics including the following: study design (RCTs or cohort studies), study type (eg, pilot study status), study duration and location, type of digital health intervention(s), population characteristics and eligibility criteria, primary and secondary outcome measures, and type or level of cultural tailoring and community engagement. Additionally, we reported means and SDs or frequencies and proportions for the following sociodemographic characteristics for each study: age, sex, race and ethnicity (categories included non-Hispanic Black, non-Hispanic White, Hispanic, and other race [Asian and multiracial]), income, level of completed education, and insurance status and type. The outcomes of interest included baseline and follow-up SBP and DBP levels (in mm Hg) at 3, 6, 12, 18, or 24 months and SBP and DBP changes from baseline. In studies that either did not report the SD value for the BP outcomes or reported IQR or SE values instead, we used several algebraic conversions to produce the proper SD measure of variation to integrate into our meta-analysis. 25

The methods of the meta-analysis were established prior to data extraction. Mean differences in BP between treatment and control groups were analyzed with random-effects meta-analysis using the restricted maximum likelihood method. Analysis was stratified by follow-up duration in months. Study heterogeneity was evaluated using Higgins I 2 statistics with thresholds of 25%, 50%, and 75%, corresponding with low, moderate, and high levels of heterogeneity, respectively. 25 If the I 2 value was 50% or greater, we explored heterogeneity using leave-one-out sensitivity analysis, subgroup analysis, and metaregression for outcomes with at least 10 studies. Subgroups included studies that tested remote BP monitoring in the intervention arm, focused on Black or Hispanic individuals, were pilot studies, identified BP as the primary outcome, and were limited to patients with controlled BP at baseline. Metaregression included the same subgroup variables and the proportion of study participants who were female, were Black or Hispanic, and/or had a lower level of completed education. Statistical analysis was performed using Stata/BE, version 17.0 (StataCorp LLC). Two-sided P  < .05 was considered significant.

The quality of observational studies was assessed independently by 2 investigators (M.E.K., R.M.) and scored on the Newcastle-Ottawa Scale, and interobserver agreement was calculated using the Cohen k coefficient. 26 Discrepancies were resolved by the senior reviewer (E.S.S.). Publication bias was assessed visually by inspection of a funnel plot and through the Egger test of intercept. 27

Our initial literature search yielded 4091 studies after removing duplicate publications ( Figure 1 ). Of these, 308 full-text articles were evaluated, and 28 studies 28 - 55 (27 RCTs [96.4%] 29 - 55 and 1 cohort study [3.6%] 28 ) were ultimately included in this systematic review and meta-analysis ( Table 1 and Table 2 ). Among the included studies, the eligibility criteria for participant recruitment varied widely, although most used a diagnosis of hypertension and/or a history of taking antihypertensive medications (eTable 2 in Supplement 1 ). 28 , 30 - 33 , 36 , 37 , 41 - 44 , 46 - 54 Eighteen studies (64.3%) included remote BP monitoring, 28 , 30 - 34 , 37 , 41 , 43 , 44 , 46 , 48 , 49 , 51 - 55 and all studies incorporated multiple digital health components, including electronic health reminders, education, and behavioral support programs. Other interventions included the integration of community health workers (CHWs) or skilled nurses (13 studies [46.4%] 28 , 29 , 32 , 34 - 36 , 38 , 40 , 41 , 43 , 45 , 46 , 53 ), wearable or ingestible sensors (4 studies [14.3%] 40 , 43 , 50 , 54 ), and tailored messaging or reminders based on cultural, linguistic, behavioral, and/or psychosocial considerations (21 studies [75.0%] 29 , 31 - 36 , 38 - 43 , 45 - 48 , 52 - 55 ) (eTable 3 in Supplement 1 ). Additionally, 5 studies (17.9%) directly involved active medication management for hypertension control as part of the digital health intervention. 28 , 35 , 41 , 43 , 48 Studies excluded from this systematic review and meta-analysis and the corresponding rationales are presented in eTables 4 and 5 in Supplement 1 . Few studies (4 [14.3%]) reported the BP outcomes of interest beyond 1 year of follow-up.

Overall, 8257 individuals from the 28 studies were included in this systematic review and meta-analysis, of whom 3828 (46.4%) were assigned to an intervention group and 4429 (53.6%) were assigned to a control group. The mean pooled age of participants was 57.4 years (range, 46-71 years); 3295 (39.9%) were men, and 4962 (60.1%) were women (eTable 3 in Supplement 1 ). Overall, 1631 individuals (19.8%) were Hispanic; 3531 (42.8%), non-Hispanic Black; 2607 (31.6%), non-Hispanic White; and 488 (5.9%), other race. Regarding socioeconomic characteristics, 1471 individuals (17.8%) had a low level of completed education (often defined as less than high school), and 1884 (22.8%) were classified as having low income. Additionally, 1177 individuals (14.3%) had Medicaid, 2146 (26.0%) had Medicare, and 548 (6.6%) had no insurance coverage. In total, 17 studies (60.7%) focused on Black or Hispanic individuals or included a large proportion of individuals self-identifying as Black or Hispanic. 29 , 32 - 37 , 39 - 42 , 44 , 46 , 49 , 50 , 53 , 54 Regarding socioeconomic characteristics, 15 studies (53.6%) were specifically conducted in socioeconomically disadvantaged communities or among individuals with a low income or who were uninsured or underinsured. 28 - 30 , 35 - 39 , 41 , 43 , 45 , 47 , 50 , 52 , 55 Several studies were also conducted among veterans (2 [7.1%] 48 , 51 ) and rural populations (3 [10.7%] 28 , 47 , 54 ).

Across all studies included in the meta-analysis regardless of follow-up duration, the mean (SD) SBP at baseline for the digital health intervention and control groups was 138.6 (16.3) mm Hg and 139.2 (16.2) mm Hg, respectively. The mean (SD) follow-up SBP at the final follow-up time point was 131.8 (15.9) mm Hg in the intervention groups and 135.3 (16.5) mm Hg in the control groups.

Among the 10 studies that reported change in SBP at 6 months, 28 , 30 , 31 , 33 , 36 , 37 , 40 , 44 , 47 , 51 we found a mean difference of −2.74 mm Hg (95% CI, −6.43 to 0.95 mm Hg; P  = .15; I 2  = 80.32%) between the digital health intervention and control groups ( Figure 2 ). At 12 months’ follow-up, there was a statistically significant mean difference of −4.30 mm Hg (95% CI, −8.38 to −0.23 mm Hg; P  = .04; I 2  = 71.43%) in the 4 studies reporting SBP change. 30 , 31 , 36 , 47 For the SBP change outcome, 3 or fewer studies had complete information at the 3-month, 41 , 49 , 50 18-month, 30 , 36 and 24-month 36 follow-up. Among the 12 studies that presented follow-up SBP, we found a statistically significant mean difference of −4.24 mm Hg (95% CI, −7.33 to −1.14 mm Hg; P  = .01; I 2  = 77.36%) at 6 months ( Figure 3 ). 28 - 31 , 33 , 35 , 38 , 40 , 43 , 44 , 51 , 52 The greatest mean difference in 6-month SBP between intervention and control groups was −13.70 mm Hg (95% CI, −16.62 to −10.78 mm Hg), 28 while the smallest (most positive) mean difference was 1.90 mm Hg (95% CI, −4.66 to 8.46 mm Hg). 29

Across all included studies regardless of follow-up duration, the mean (SD) DBP at baseline for the digital health intervention and control groups was 81.4 (11.8) mm Hg and 81.7 (11.7) mm Hg, respectively. The mean follow-up DBP at the end of the included studies (time of last follow-up) was 77.8 (10.5) mm Hg in the intervention groups and 79.6 (11.2) mm Hg in the control groups.

Among 10 studies that reported 6-month DBP changes, we found a mean difference of −1.11 mm Hg (95% CI, −3.09 to 0.87 mm Hg; P  = .27; I 2  = 70.45%) (eFigure 1 in Supplement 1 ). 28 , 30 , 31 , 33 , 36 , 37 , 40 , 44 , 47 , 51 The most prominent mean difference in DBP changes between the intervention and control groups was −6.10 mm Hg (95% CI, −11.02 to −1.18 mm Hg). 28 Across the 12 studies with 6-month data on follow-up DBP (42.9%), we found a mean difference of −1.86 mm Hg (95% CI, −3.82 to 0.10 mm Hg; P  = .06; I 2  = 67.57%) (eFigure 2 in Supplement 1 ). 28 - 31 , 33 , 35 , 38 , 40 , 43 , 44 , 51 , 52 The largest mean difference was −6.70 mm Hg (95% CI, −9.98 to −3.42 mm Hg), 30 while the smallest (most positive) mean difference between the intervention and control groups was 1.50 mm Hg (95% CI, −1.53 to 4.53 mm Hg). 31

Among the studies with 6-month follow-up data for the BP outcomes of interest, 28 - 31 , 33 , 35 , 38 , 40 , 43 , 44 , 51 , 52 each of the 6-month outcomes had moderate-high heterogeneity ( I 2  = 67.57%-80.32%). On sensitivity analysis, removing individual studies had minimal effect on the pooled result (eFigures 3-6 in Supplement 1 ). Subgroup analyses based on whether studies included remote BP monitoring, were limited to specific racial or ethnic groups, were pilot studies, enrolled patients with controlled BP at baseline, or had BP as the primary outcome also found little effect on statistical heterogeneity (eTables 5-9 in Supplement 1 ). Metaregression using the proportion of study participants who were female, Black, or Hispanic and/or had a lower level of education had little effect on heterogeneity. Similarly, metaregression including the subgroup variables had little effect on heterogeneity except whether the mean baseline BP was controlled (SBP ≤140 mm Hg). For the outcome of change in SBP, 4 studies had a mean baseline SBP of 140 mm Hg or lower. 31 , 36 , 40 , 47 On metaregression, 50.3% of the heterogeneity was explained by this variable (β = 7.1; P  = .02). For the other 3 BP outcomes at 6 months, the studies with a mean baseline SBP of 140 mm Hg or lower 29 , 31 , 35 , 36 , 38 , 40 , 47 , 52 found less benefit of digital health interventions, but the differences were not statistically significant.

Among included studies presenting complete outcome information such as change in BP or follow-up BP, 28 - 38 , 40 - 44 , 47 , 49 - 53 , 55 inclusion of fewer than 10 studies limited formal assessment of publication bias (eFigures 3-6 in Supplement 1 ). Given that only the 6-month time point had 10 or more studies reporting BP changes or BP at follow-up, this was the only duration that we were able to assess for publication bias. The Egger regression intercept showed no significant publication bias among studies that reported change in SBP, 28 , 30 , 31 , 33 , 36 , 37 , 40 , 44 , 47 , 51 follow-up SBP, 28 - 31 , 33 , 35 , 38 , 40 , 43 , 44 , 51 , 52 change in DBP, 28 , 30 , 31 , 33 , 36 , 37 , 40 , 44 , 47 , 51 and follow-up DBP. 28 - 31 , 33 , 35 , 38 , 40 , 43 , 44 , 51 , 52

Overall, there were few concerns regarding the quality of included studies in our systematic review and meta-analysis. The domain-specific judgements on study quality ranged from low risk of bias to some concerns of potential bias. In total, 8 of the 28 studies (28.6%) had some concerns, most often attributed to bias due to missing outcome data (eFigure 7 in Supplement 1 ). 28 , 33 , 34 , 40 , 41 , 45 , 50 , 52 Only 1 study (3.6%) had an overall judgement score of “some concerns.” 34

To our knowledge, this was the first large-scale, contemporary analysis of more than 8257 participants from 28 studies to characterize existing evidence on the outcomes of digital health interventions for hypertension management in populations experiencing health disparities. Our systematic review and meta-analysis included a diverse sample of participants and a breadth of culturally tailored strategies seeking to integrate racial, ethnic, and socioeconomic determinants into the study design and intervention delivery. We found statistically significant and clinically relevant mean differences in SBP at 6 months (−4.24 mm Hg) and SBP changes at 12 months (−4.30 mm Hg). Only 3 studies 30 , 36 , 55 assessed BP changes beyond 1 year of follow-up.

This study found evidence of BP improvements in populations experiencing health disparities, strengthening the case for digital health as an efficient and effective tool for hypertension management in these groups. At 6 months of follow-up, individuals who received a digital health intervention had a 4.24 mm Hg greater reduction in SBP compared with those in a control group. Importantly, these results are consistent with findings from meta-analyses that focused on digital health interventions to lower BP levels in the general population. 17 , 56 - 58 One systematic review conducted among 4271 participants from 11 RCTs demonstrated net changes of −3.85 mm Hg in SBP and −2.19 mm Hg in DBP in the combined digital health intervention group, 56 which are similar to the mean differences observed in the current study.

The findings of our study can be evaluated in the context of the growing body of evidence linking health disparities with hypertension management and CVD. While this systematic review and meta-analysis focused on populations experiencing health disparities and assessed digital health interventions for culturally tailored components, we found that 17 studies were specifically focused on enrolling a large proportion of Black and Hispanic individuals. 29 , 32 - 37 , 39 - 42 , 44 , 46 , 49 , 50 , 53 , 54 However, subgroup analysis based on whether studies were limited to specific racial or ethnic groups had little effect on statistical heterogeneity. Black and Hispanic adults and individuals with low income and lower level of completed education experience a disproportionately higher burden of hypertension and have higher rates of morbidity and mortality associated with CVD. 2 , 59 , 60 Moreover, individuals without insurance have been shown to have worse CVD outcomes. 60 , 61 These inequities may be driven by individual-, relational-, and system-level inequities. For example, lifestyle behaviors (ie, physical activity, diet, and sleep quality), interpersonal and structural racism and implicit bias, and differences in access to high-quality care can impact BP control rates. 62 Black and Hispanic individuals face an increased level of discrimination, which has been associated with hypertension. 63 In recent years, Hispanic and non-Hispanic Black individuals in the US have shown a stagnation and even a decline in hypertension awareness, treatment, and control, with widening gaps in BP control. 5 , 6 , 64

Several of the included studies addressed these challenges. For example, we observed a diverse range of recruitment strategies and culturally tailored interventions, ranging from faith-based community partnerships to motivational coaching based on personal belief frameworks. While nearly all of the studies included a combination of home BP monitoring with synchronized digital cuffs, medication adherence messaging, or motivational reminders, 21 studies made these reminders linguistically and/or culturally tailored to their patient population. 29 , 31 - 36 , 38 - 43 , 45 - 48 , 52 - 55 In the Cholesterol, Hypertension, and Glucose Education (CHANGE) study focusing on non-Hispanic Black patients with diabetes, nurses underwent cultural sensitivity training that provided information on the unique challenges that non-Hispanic Black individuals face in their community. 34 Additionally, there was a diverse set of community-engaged aspects of the study design and conduct, including the integration of community health centers, involvement of local church leadership for faith-based recruitment and intervention delivery, and participation of community health educators and patient advisory councils. 29 , 31 - 33 , 35 - 39 Community-based interventions have been shown to ease the psychosocial stressors often associated with clinical settings, such as white coat syndrome, along with building trust between research staff and study participants. 17

Given our aim to characterize approaches to tailoring digital health intervention delivery for populations experiencing health disparities, we have provided several examples to help inform future work seeking to expand access to these strategies. The Reach Out Churches study by Skolarus et al 33 was conducted across community centers and places of worship. The community-based participatory research intervention was designed by community and academic leaders to address needs such as food insecurity, cost-related medication nonadherence, poverty, and health literacy in a majority Black neighborhood. Although BP reduction was not statistically significant in that pilot trial, high participation and engagement provided evidence for the feasibility of community-based programs to focus on high-risk groups that are otherwise difficult to reach via traditional medical avenues. Additionally, in the Fostering African American Improvement in Total Health (FAITH!) trial, Brewer and colleagues 40 developed and analyzed a community-informed mobile health intervention (FAITH! app) for promoting ideal cardiovascular health among African American individuals in faith communities. In addition to organizing an advisory board composed of diverse community stakeholders to provide study oversight and ensure community centeredness, the research team convened joint congregation community recruitment kickoff events and developed educational materials incorporating practical strategies to overcome barriers from social determinants of health.

In recent years, research has shown that hypertension management and control are low across all Hispanic and Latino groups, with rates lower than those among non-Hispanic White individuals and lowest among Hispanic adults without health insurance. 65 , 66 The integration of CHWs has been a well-studied and validated approach to increasing health care access in these groups. Previous evidence has shown that CHWs who provide technical support, engage in participant recruitment, and are knowledgeable about community resources collectively aid in improving the adoption and acceptability of a digital health intervention. 67 In this systematic review and meta-analysis, a subset of studies specified whether an intervention was available in the participants’ native or preferred language and whether culturally sensitive messaging was present, both of which would further enhance access to digital health interventions. In particular, Still et al 32 partnered with nurses from the Cleveland Council of Black Nurses, who, similar to CHWs, served as a bridge between underserved communities and their health care needs. While the intervention and control groups did not have significant differences in BP control at 3 months, clinically relevant BP reduction was observed in the intervention group. Additionally, in the TIME Study, Vaughan and colleagues 35 incorporated CHW-participant mobile health communication, CHW-led diabetes group visits, and CHW-physician diabetes training and support via telehealth in a population of Hispanic and Spanish-speaking individuals. Compared with control participants, those enrolled in TIME had significant BP improvement (SBP: −6.89 mm Hg vs 0.03 mm Hg; DBP: −3.36 mm Hg vs 0.2 mm Hg).

The findings from our systematic review and meta-analysis should be interpreted in the context of several limitations. First, this study was limited in its ability to examine comprehensive, patient-level data on BP changes beyond 1 year. With few studies reporting longer-term follow-up data and the proportion of individuals with controlled hypertension at the end of the study period, the outcomes that were sufficiently powered both overall and for subgroup analyses were limited. However, despite this limitation, statistically significant and clinically meaningful data for SBP changes at 6 and 12 months were identified. Second, since there was inconsistently reported information on sociodemographic characteristics and studies used different definitions for specific subpopulations experiencing health disparities, our literature search may not have captured all studies of digital health interventions conducted in these populations. For example, studies conducted in rural areas may not have been identified if not cataloged as such. To improve our capture of studies, we used a snowball approach, identifying studies referenced by articles that did meet our search criteria.

Third, several studies involved significant investment in community partnerships, patient engagement, and digital health interventions. While questions related to cost, sustainability, and scalability were beyond the scope of this study, they remain important challenges that should be considered in future interventions to address disparities in hypertension control. Last, given that many of the digital health interventions possessed multiple components, we were unable to isolate the effects of each component. Future scoping reviews may be particularly helpful in assessing the breadth of and heterogeneity in digital health intervention components. Relatedly, the control or standard care groups varied widely across included studies and may have impacted the observed effects accordingly.

In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, significant and clinically relevant differences in BP lowering between the intervention and control groups were detected. We also identified a breadth of interventions and community engagement strategies, such as participant recruitment and educational programming through faith-based organizations and community centers; however, few studies were conducted beyond 1 year. With the increased use of digital health technologies in medicine, it is important that researchers, clinicians, and public health professionals continue to adapt digital health interventions to meet the needs of demographically and socioeconomically diverse populations with different challenges to improving BP control. More personalized approaches to remote BP monitoring may help to eliminate inequities in hypertension management and outcomes.

Accepted for Publication: December 21, 2023.

Published: February 14, 2024. doi:10.1001/jamanetworkopen.2023.56070

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Katz ME et al. JAMA Network Open .

Corresponding Author: Erica S. Spatz, MD, MHS, Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Ave, PO Box 208017, New Haven, CT 06520-8017 ( [email protected] ).

Author Contributions: Mr Mszar and Dr Gunderson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ms Katz and Mr Mszar contributed equally to this manuscript.

Concept and design: Katz, Mszar, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Acquisition, analysis, or interpretation of data: Katz, Mszar, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Drafting of the manuscript: Katz, Mszar, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Critical review of the manuscript for important intellectual content: Katz, Mszar, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Statistical analysis: Katz, Mszar, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Obtained funding: Katz, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Administrative, technical, or material support: Katz, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Supervision: Katz, Grimshaw, Gunderson, Onuma, Lu, Spatz.

Conflict of Interest Disclosures: Dr Lu reported receiving grants from the Sentara Research Foundation; the National Heart, Lung, and Blood Institute, National Institutes of Health; and the Patient-Centered Outcomes Research Institute outside of the submitted work. Dr Spatz reported receiving grants from the US Food and Drug Administration to support projects within the Yale University–Mayo Clinic Center of Excellence in Regulatory Science and Innovation and from the Patient Centered Outcomes Research Institute; the National Heart, Lung, and Blood Institute; the Centers for Disease Control and Prevention; the National Institute of Biomedical Imaging and Bioengineering; and the National Institute on Minority Health and Health Disparities, all for work unrelated to this study. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Healthcare Management: A Bibliometric Analysis Based on the Citations of Research Articles Published between 1967 and 2020

Oana păduraru.

1 Doctoral School, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; moc.oohay@17tserofanao

Alina Moroșanu

2 Department of Social Sciences and Humanities, Institute of Interdisciplinary Research, Alexandru Ioan Cuza University, 700506 Iasi, Romania

Călin Ștefan Păduraru

3 Doctoral School of Biomedical Sciences, Dunărea de Jos University, 800008 Galati, Romania; moc.liamg@urarudapnafetsnilac

Elena Mihaela Cărăușu

4 Department of Public Health and Management, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; moc.oohay@usuaracaleahim

Associated Data

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to restrictions, e.g., privacy or ethical.

The purpose of this study is to analyse the trends manifested in research literature from the field of healthcare management, with emphasis on bibliometric features and different influencing factors. For this, a search was conducted of nine academic databases between January and May 2021. Article features were registered in our database after first applying the validation criteria used for their inclusion. Then, data regarding the publication of the included articles were collected. The analysis focused on trends over time, topic, and journals in which they were published. Moreover, the effect of some factors on the citation of articles was analysed. Our results showed that the 250 analysed articles were published in 139 journals, and many of were by researchers affiliated with universities in the United States. Over time, the publication of analysed articles and their number of citations registered a continuous increase. The most common topics of focus were healthcare management systems and their challenges. In our study, we identified factors that significantly affect citation number, such as number of years since publication, the number of words in the title, and the number of authors of an article. In addition, major gaps were identified, as were new unresolved challenges that can trigger new research ideas.

1. Introduction

In recent years, there has been constant concern in the field of healthcare, considering the risks to the health of the population caused by severe pandemics, the most recent example being the COVID-19 pandemic [ 1 , 2 ]. The COVID-19 pandemic has shown more than ever that the most valuable source for generating innovation in the healthcare management field is concern and not only information. To increase the chances of generating innovations, the amount of useful information must also increase [ 3 ]. Evidence of this is the provision and rapid sharing of scientific data and information. Since the beginning of the pandemic on platforms such as GISAID or Nextstrain, the amount of data shared has increased significantly. Moreover, 117 organisations (including journals, funding agencies, disease prevention centres) signed a statement entitled “Sharing relevant data and research findings for the new coronavirus outbreak (COVID-19)” [ 3 ]. Thus, a series of practices related to the elimination of payment for accessing scientific documents and the use of preprint servers were initiated [ 4 ]. Researchers and practitioners from all over the world have continued this initiative, encouraging people to make their work available to help in fighting the COVID-19 pandemic [ 3 ]. Programs, such as CORD-19 (CORD-19, 2020), MOBS Lab, MIDAS, ELIXIR, COVID-19 Data Portal, or COVID-19 High-Performance Computing Consortium, can provide a variety of resources as well for scientific research [ 4 ]. In addition to sharing data and research tools, the rapid dissemination of research results played an important role in building an objective dialogue that helped to facilitate the process of generating new research directions [ 3 ].

Thus, researchers and academia have a key role to play in developing and promoting the highest level of healthcare [ 5 , 6 ]. The results of research in several fields contribute significantly to the identification and adoption of important solutions that help to achieve future objectives. Many of the organisations that provide healthcare services face the existence of quite serious problems that can be solved through research and innovation [ 5 ]. In other words, researchers are best placed to propose genuine innovative solutions that actively contribute to solving national and international problems [ 5 ]. Given this context, local and international authorities are free to implement research results and academic recommendations. They could provide a practical agenda that would strengthen the partnership with all stakeholders and help to accelerate the steps towards its fulfilment. On the other hand, the plurivalence of the research field is a way of understanding the fact that there is a non-linearity, and behaviours are the factors that determine the set rules [ 7 ]. They have developed through academic customs in the fields of exact sciences and humanities. The diversity and complexity of systems can be understood by identifying common traits and behavioural patterns that are based on distinct units [ 8 ]. In the areas related to health and healthcare, this diversity is provided by the multitude of involved categories (health professionals, health authorities, beneficiaries, non-governmental organisations) and the interactions between them [ 9 ]. This approach was initiated with the dissemination and publication of the results of studies and research debating the application of scientific plurivalence in the healthcare [ 10 , 11 , 12 ] or education [ 13 ] domains.

Global warming also presents a risk to the population through the rapid transmission of infectious diseases [ 11 ]. Conflicts in different geographical areas of the world have also led to the mass migration of refugees, with this category of people benefiting from minimal healthcare services [ 12 , 13 ]. Lack of well-being, cleanliness, access to medicines and healthcare services has increased the risk of spreading diseases to the most exposed categories of the population (children, women, and the elderly) [ 13 ]. The global onset of health challenges, in general, and healthcare imposed by spontaneous and unpredictable pandemics, conflicts, climate change, and the lack of economic growth have impacted welfare and the fulfilment of development goals.

Taking in consideration this context, the ability of research to understand and address some of the biggest challenges in healthcare delivery was observed. An edifying example is provided by [ 14 ], in which complexity theory is used to highlight and analyse how nurses in the United States make decisions. Another team of researchers [ 15 ] conducted a case study evaluating how decisions were made regarding the financing of hospitals in Kenya.

Therefore, in the specialised literature, there are indications according to which the study of the field of healthcare reaches a certain depth. They come as a complement to what is already known, and an examination of the influence and extent of this literature is even more beneficial. Bibliometric analysis offers an objective image of the publications from a certain area of the specialised literature. On the other hand, as specified above, bibliometric analyses cannot escape the intellectual properties contexts whereby researchers and policymakers (and funders) strive for innovative solutions in healthcare management and beyond.

Background and Objectives

Bibliometric analysis can be used to identify many papers from the recent literature that provide a general overview regarding different aspects of healthcare management. For example, some authors [ 16 ] have presented a view of healthcare-related research and the directions of future work to benefit patients and healthcare providers. Others [ 16 , 17 , 18 , 19 ] highlight dynamic trends in publications and have identified the most influential authors, institutions, countries, and research teams for a certain journal case. However, those studies are limited to broad directions on the development of healthcare. Another limitation they have is in regard to the definitions of the healthcare management field. Because some additional terms (for example, “sustainability” or “artificial intelligence”) were used to identify papers that treat aspects of healthcare management, there was a high risk of including sample documents on topics related to other fields, such as innovation, environment, or sociology. For this reason, we consider it necessary to have a clearer definition of healthcare management. In addition, a limitation of some papers that present a bibliometric analysis of healthcare management is the data source used [ 20 , 21 ]. An article search can be performed using other additional databases (for example, Scopus or Google Scholar), as suggested in another study [ 22 ].

Given these limitations, which we found by consulting the research literature, the aim of our paper is to perform a bibliometric analysis of the literature dealing with healthcare management by analysing the effect of different factors such that other researchers can then use the results in further studies. Moreover, another part of our goal is to identify aspects of healthcare management research that require further attention from researchers. This would serve to encourage future research in the areas of need, which would benefit this field of research.

In achieving this goal, we attempt to provide answers to the following questions:

  • ▪ Is there variability between journals regarding the number of citations received by academic articles?
  • ▪ Does the number of citations of an article vary depending on the journal in which it is published?
  • ▪ Does the number of citations of an article vary depending on its topic?
  • ▪ Are discrepancies in the citations of articles between areas due to dissimilarities in the level of developed research infrastructure?

Taking into consideration the proposed goal and the research questions, the following research objectives were established:

  • O1: Analysis of the dynamics of scientific “production” related to healthcare management field.
  • O2: Highlighting scientific progress as well as identifying the most prolific researchers, institutions, and countries in which research in this field is carried out [ 23 ].
  • O3: The study of the influence of some factors upon which the citations of the articles dealing with this topic are dependent.

2. Materials and Methods

2.1. international literature search, 2.1.1. databases.

To identify articles dealing with the topic of healthcare management, international databases, such as JAMA Network, JSTOR, PMC, PubMed, SAGE, ScienceDirect, Springer, Taylor & Francis, and Clarivate, were consulted. This activity took place between January and May 2021. Our approach involved the use of keywords that relate to healthcare management. No limits have been imposed for identifying articles, research reports, reviews, or books. In addition, the number of citations was used in cases where it was necessary to identify papers of high scientific relevance. In total, by searching the nine international databases, 1594 articles were identified. They were downloaded into an Excel spreadsheet, and duplicates were then removed. After this stage, 943 articles remained, and their details were saved in another spreadsheet in Excel with the purpose being to examine them so that only those titles that met the requirements specified above are retained for analysis. For those 943 articles, the titles/abstracts were checked, and 651 of them were excluded on the basis that their content was strongly related to other fields. We wanted to ensure that we would only consider articles that are not related to other fields for analysis and that there were no other compelling reasons for exclusion. Thus, we obtained 292 articles for which another evaluation was conducted, and other reasons for exclusion were identified in the case of another 42 articles ( Table 1 ).

Other reasons for excluding articles from the analysis.

After this stage, 250 articles were retained and subjected to analysis, although another 1344 had already been excluded in earlier stages because they did not meet the inclusion criteria during verification.

Of the 250 articles considered eligible for analysis, the full text in English was accessed for 223 articles, thus making it possible to achieve a more detailed and clear classification of the content. In the case of an additional 20 articles that were included in the bibliometric analysis and were published in journals in English, their text was only partially accessible, and in the case of the final 7 articles, the text was not available in English. Figure 1 presents a summary of the details concerning the search strategy.

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Object name is healthcare-10-00555-g001.jpg

Research strategy applied for the selection of articles included in analysis.

2.1.2. Keywords

To identify the most appropriate keywords to use in identifying articles dealing with healthcare management topic, it was necessary to first define this concept. Thus, in some sources [ 24 ], healthcare management is defined as “the profession that provide leadership and direction to organizations that deliver personal health services, and to divisions, departments, units, or services within those organisations”. Based on this definition, we can consider that healthcare management involves the planning and coordination of nonclinical activities within healthcare systems, organisations, and networks.

Database searching was conducted using “healthcare management” OR “healthcare hospital” OR “health system” OR “primary care” OR “clinical management” OR “acute care” OR “healthcare practice” OR “medical practice” OR “healthcare networks” OR “nursing management”. Those keywords must occur in the article’s title.

References identified using these keywords were managed using EndNote. Thus, duplicates were much more easily found and then removed from our list. All references that met our criteria were retained for analysis. In the next step, all data were exported to an Excel spreadsheet in which variables represent each of the researched aspects were created. For example, to quantify the number of authors of an article, the variable “Author” was created. To include an article in a certain category that designates the research area, the variable “Topic” was created. To identify the journal in which the article was published, the variable “Journal” was created, or to see the country from which most articles came, the variable “Country” was created. After the database was created, the statistical program R was used to obtain the results.

2.1.3. Criteria Used to Include Articles in the Analysis

The analysis will include articles published in academic journals with impact factors indexed in international databases and referring to healthcare management. It was also intended that these articles include results obtained not only by specialists who provide medical assistance (nurses, doctors) or specialised websites of institutions (such as hospitals, retirement homes) but also people specialised in other fields related to health (for example, education, ethics, policies, research).

Articles that, through their published results, promote aspects of reference to healthcare management, in general, were initially included in our archive. Following this action, some were removed because it was later found that they did not refer to healthcare and care platforms, the profession, or issues related to the provision of medical care services. Those articles referring to interventions or health promotion issues carried out at the population level were not included.

Editorial works, books, chapters, and articles published in volumes of certain correlations were also excluded because it was considered that the information regarding them was either not available or incomplete. This includes articles that, although initially not published in English, have a summary in English based on which it can be verified that they meet our criteria.

2.2. Bibliometric Analysis

2.2.1. searching bibliometric data.

The bibliometric data (year of publication, number of authors, the journal in which it was published, the country of residence of the main author) of each article were recorded from the text of the paper, from the journal that published the article, or from the database in which the journal was indexed. In some cases, it was found that the full text was not available, was inaccessible to the public in its entirety, or was not written in English.

2.2.2. Articles Content Evaluation

At this stage, the articles were grouped together, considering their content, the type, and the topic. This involved classifying articles as empirical or non-empirical. The articles that, through the published results, refer to a certain conceptual framework, methods of data analysis, or ways of interpreting some results were considered empirical. Included in the category of non-empirical works were case studies, reviews, editorials, and debates on conceptual criteria.

Another important aspect refers to the analysis of the content of the registered articles. Thus, a code was assigned to each article and comparisons were conducted, and changes were then made to the codes to identify the most frequently encountered research topics. These details were identified from the title of the articles or their abstract. These were also identified for articles in which the summary did not provide sufficient detail. In those cases, the full verification of the article content was carried out where the text was available in English.

2.2.3. Determination of Articles Influence

To determine the influence that an article has in the literature of the healthcare management field, the number of citations received over time was considered. For this purpose, Google Scholar was consulted. In addition, the references of each article whose text could be accessed and viewed in full version were considered. An essential condition was that the reference should not be made by a publication evaluated by fellow authors, which allowed ensuring greater objectivity in terms of considering other types of academic results. It is also important to mention that no patients or other categories of the population were involved in this research.

2.3. Evaluation of Article Influence

It is known that the number of citations received by an article is associated with his scientific quality. The impact factor (IF), Hirsch index (H index), crown indicator, and other appropriate metrics that take the citation number into consideration were calculated. In addition, scientific search engines used for finding references (such as Google Scholar) show the list of results according to the number of citations [ 25 ]. For these reasons, the number of citations that a scientific paper in the field of healthcare management receives is an important element used to assess the impact of research. However, the number of citations of an article may be influenced by different factors. According to [ 26 , 27 , 28 ], the number of citations of an article is affected by factors such as their length, author number, number of institutions at which the authors are affiliated, number of words in the title, number of cited references, topic, or time since publication.

Articles length (the number of pages) could be a factor that can significantly affect the citations received. A large article can reflect a greater scientific complexity and a higher quality of used methodology; in addition, a lengthier article is expected to contain a greater amount of information, increasing the possibility that it can be appropriated to be cited by other researchers [ 29 ]. In other words, in articles with a larger number of pages compared to those with a smaller number, the research methodology and the obtained results could be presented and discussed more clearly and in detail. Therefore, their impact on citation number could be higher.

The number of authors attracts citation because it is considered that the higher number of authors of an article can determine more traffic for the paper, and so the chances of obtaining more citation are increased [ 30 , 31 ]. On the other hand, articles that cite more references and more publications referenced in different research platforms get a fairly large number of citations.

The number of institutions at which the authors of an article are affiliated is also important. Multiple affiliation is increasingly considered as stimulating knowledge exchange. An individual scientist may seek affiliations to obtain access to research resources, research infrastructure, or career opportunities. Co-authorship can be an efficient way of developing the competencies of a research group, and co-affiliation may be a way of forming stronger connections between researchers and institutions [ 32 ].

Articles title length is perceived as having an important role in the strategy of attracting audience and citations [ 33 ]. Longer titles contain more words and, therefore, more potential keywords, increasing the chances of an article being found easier. On the other hand, longer titles may be harder to digest and thus less attractive [ 34 ].

The number of references in healthcare management articles is another factor that can affect the citation. The reason may be related to the reason researchers from this field cite other’s work. From a theoretical perspective, a reference list of high quality is a comprehensive and well-balanced selection of papers, which can support the content presented in a certain article. Researchers usually reach this by performing a retrospective search and selection of papers with content that is pertinent to that of their article, to be read and cited. Well-chosen and mentioned bibliographic references can support the novelty, value, and visibility of an article. Citations can link a study to other studies, thus creating a network of knowledge that allows other researchers to identify studies that are relevant in general and relevant to them.

Commonly, articles published recently have a limited number of citations, an increase being seen after 3 or 5 years since publication [ 35 ]. Therefore, when analysing citation frequencies, the temporal dimension is important too.

Furthermore, the nationality of the authors is important. This can show that a specific research culture that is associated with a certain geographical area can influence the progress of research in a certain field and the number of citations received.

Giving this context, we want to consider those factors identified in the research literature and to verify if those results are also the same in our case. Therefore, one of our research objectives is to identify the factors associated with obtaining citations so that we can explain their effect and offer useful suggestions for increasing citations. To do this, the following variables will be considered for analysis: journal name, number of title words, number of authors, time since each article was published, the paper length (pages number), the number of references in each article, and the country of the affiliated institution of the first author. The characteristics of those variables are presented in Table 2 .

Studied variables and their characteristics.

Data Analysis Methods

A multilevel regression model was used to study the influence of factors, such as article author number, article topic, researcher affiliation, or the number of words in the title, on the number of citations of the considered articles. Multilevel models describe hierarchical structures referring to quantifications taken on the same unit at various moments, e.g., physical characteristics that are strongly correlated compared to previous assessments from different units. Multilevel models are used for the analysis of such dependency.

Multilevel modelling allows us to analyse the type of between-group variability and the outcomes of a group-level attribute on single outcomes. To offer an answer to our research questions, we opted for a two-level pattern with articles at level 1, nested with groups at level 2. Moreover, in a two-level model, residuals are divided into two parts, suitable for the two levels in the data frame. The random effects (group-level residuals) are noted by u i and the individual residuals group is noted by e ij . The two-level extensions that allow for group effects are given by

where β 0 is the gross average of Y (through all groups). The average of Y for group j is β 0 + u j . The residual u j is the difference between the average of group j and of the total. The individual-level residual e i j is the difference between the Y value for the i unit and that unit’s mean group e i j = Y i j − ( β 0 + u j ) . Residuals for both levels are assumed to be normally distributed with 0 means: u j ~ N ( 0 , σ u 2 ) and e i j ~ N ( 0 , σ e 2 ) . The simplest multilevel model with one explanatory variable is

In this model, the relationship between Y and X is expressed by a direct line with intercept β 0 and slope β 1 .

3.1. Results Regarding the Dynamic of Scientific Production Related to the Healthcare Management Field

The 250 articles included in the analysis come from 139 different journals in the field of healthcare management, and they have a varied impact. Table 3 presents the journals in which the most articles in this field were published.

The first 15 journals in which healthcare management articles have been published.

The results show that the journal in which the highest number of articles in the field of healthcare management was published is JAMA (n = 34), followed by Health System in Transition (n = 11) and Libyan Journal of Medicine (n = 7).

Regarding the affiliation of the main author, it was observed that the analysed articles are from 48 countries. The United States 47% (n = 117), the United Kingdom 6% (n = 16), Australia 0.5% (n = 13), and Canada 4% (n = 9) together accounted for 62% of the total items included in the analysis, as can be seen in Figure 2 . Other countries with a higher contribution are India, China, Iran, Italy, and Libya (all with six published articles. each with a contribution of 2%).

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Object name is healthcare-10-00555-g002.jpg

Distribution of published articles in the domain of healthcare management worldwide.

Although most of the articles have been published by authors who are affiliated with universities in only a few countries, the results show that there has been significant growth in recent years, especially in the early period of the pandemic ( Figure 3 ). This result can show an increasing speed regarding the dissemination of research findings, many journals prioritising the processing of articles involving COVID-19. Related to this aspect, an analysis of a limited number of journals showed that the number of days between an article submission and article publication during the pandemic was decreased by almost half compared to that before the pandemic.

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Object name is healthcare-10-00555-g003.jpg

The number of articles and number of citations according to year.

Before 2000, the only countries that published literature on healthcare management were the United States, the United Kingdom, or Germany; since 2015, the articles have come from 19 different countries. The published articles also come from authors affiliated with universities from Finland, Norway, the Netherlands, Denmark, Spain, Switzerland, Romania, China, the Philippines, Pakistan, and Nigeria.

3.2. Results Regarding Articles Topic

All articles included in the analysis could be classified with full and accessible text. Around 12.4% of them ( n = 31) treated the conceptual elements regarding healthcare management as well as elements of “literature review” ( Table 4 ).

Number articles and citations according to topic.

Around 44.5% of the articles deal with management systems in terms of healthcare and the encountered challenges and the quality of these services. Both topics are addressed mainly in works by researchers from the United States (n = 46), Canada (n = 7), Australia (n = 5), and the United Kingdom (n = 4).

The results of such studies were obtained by large groups of researchers, with the number of authors of the articles exceeding 10 (in the case of articles published by authors in the United States or Canada). This result shows that there are many researchers who also contributed to the article, and these results are often being obtained because of large research projects that require multidisciplinary teams.

Moreover, as the field of healthcare management develops, its magnitude is reflected in the number of authors who publish their scientific papers. Lately, more and more often, the research is based on the efforts of larger groups of researchers. There is also a disadvantage of having many authors since there have been cases in which the article cannot be reviewed because almost all the experts in a certain field were among its authors.

Another important aspect highlighted by the analysed articles is the fact that in the last 2 years, the number of articles that were published in the domain of healthcare management has greatly increased. Most of the articles published in these 2 years refer to healthcare management systems and their challenges, the quality of these services, or access to them.

This result is not accidental, as more and more countries are facing many problems caused by the COVID-19 pandemic. For decisions to be made about healthcare for individual patients and public health policies, the best confirmations available based on research are needed. This creates the framework for ensuring best practices and reducing variations in the provision of healthcare. For this reason, the large number of articles is justified, requiring the latest and most reliable information.

Going deeper into the content of the selected articles, it was possible to develop broader categories in terms of the addressed topic, with several topics being frequently prominent. These topics are listed in Table 3 and refer to “Characteristics of health systems in healthcare management”, “Impact of factors on healthcare management”, “Healthcare legislation”, or “Good management practices”.

Although health professionals have addressed various topics dealing with healthcare management since 1967, it was only in 2015 that articles began to focus on change, growth, and implementation, research, and policy.

3.3. Influential Articles and the Effect of Factors on Which the Citation of Analysed Articles Depend

The number of citations of an article in a certain period, regardless of the field, can show the importance and appreciation given to the results obtained by members of the medical, scientific community.

The number of citations of each article was used to highlight the influence of the analysed articles. In total, the average number of citations is 101, although the degree of asymmetry is high (median = 20.5, min. = 3, max. = 1752).

The most influential article in our database was published in Nursing Outlook, which was cited 1752 times. The article deals with the effect of exhaustion, the high degree of dissatisfaction with the workplace among nurses, and the organisational support they receive on the quality of healthcare. Another article with a high number of citations (1612) was published in JAMA. In this study, the authors aimed to identify issues related to the quality of healthcare in the United States, including measuring, evaluating, and improving it in healthcare facilities both in the public and private sectors.

Articles published in journals, such as Nursing Outlook, Journal of Service Research, Operations Research, Medical Care, The Lancet, or Environment and Behaviour, have a high number of citations. In addition, articles written by American, Greek, and Dutch authors recorded a high number of citations, while authors from countries such as Jamaica, Qatar, or Romania had a low number of citations.

The evolution over time of the distribution of the mean number of citations can be observed in Figure 3 . It can be easily seen that the articles that were most often cited are those published in the first half of the analysed period (between 1975–2013). This result may show that articles that have recorded more citations have a higher intensity of impact on the volume of knowledge. Furthermore, from Figure 3 , it can be observed that a high number of articles appeared in the early period of the pandemic. Comparing the number of published articles and the number of citations received, we can believe that research topics from the healthcare management field became more actual and diverse. Regarding this, some inherent risks can be identified. One of the highest risks can be the dissemination of poor-quality research and rapid scientific publication, the quantity of information and processing speed being at an impressive level in this period.

To evaluate the effects of some factors on article citation, a multilevel model was used. Initially, a multilevel model that allows for estimating the journal effects on citation number and with explanatory variables was used. The obtained results are presented in Table 5 .

The effect of different factors on article citations and a coefficient of random effects according to journal.

From Table 5 , article citation is strongly affected by the time since that article was published. This effect is statistically significant because the estimated coefficient is more than five times its standard error.

Another factor that has a high effect on article citations is the article topic. Our results show that, for topics such as “Impact of different factors on healthcare management” and “Challenges of healthcare management”, the obtained coefficients were higher than the standard error.

However, we have considered only the main effects of these variables, and the relationship between the number of article citations and the explanatory variables may depend on an interaction effect between some explanatory variables. We added those interactions to the model, with estimates presented in Table 6 . For the results presented in Table 6 , the estimated coefficients for the interaction between variables are higher than their standard errors. However, the addition of those interaction effects does little to explain the differences between journals: the journal-level variance has only increased from 10,643 to 10,752.

The effect of different factors on article citations with the interaction effect of explanatory variables and a coefficient for random effects according to journal.

To compare the two estimated models, the likelihood ratio test statistics were calculated ( Table 7 ).

Likelihood ration test statistics.

Signif. codes: 0 ‘***’ 0.001.

From the low Pr (>χ 2 ) value, we conclude that there is evidence that the second model (Model 2) can more adequately explain the data structure and the effect of interaction between variables, which differs across journals.

4. Limitations

The limitation of our study arises from the use of quantitative methods to review the papers published in the healthcare management field. The review relied on the analysis of bibliographic data associated with the documents rather than an examination of the research findings. Thus, the review’s implications are limited to the general directions of the studied field rather than the synthesis of article results. Thus, our results can be used as a starting point for future analyses aimed at the development of this field.

5. Discussions

In our study, we aimed to perform a bibliometric analysis of the research literature of articles that treated topics in the healthcare management field. We identified trends in the publication of analysed articles, with an evident global spreading of ideas and into specific topic themes. In addition, we found substantial evidence leading us to make the following statement: a responsible author will publish the results of high-quality research in a way that is easy to understand and attractive, guaranteeing that it will be widely read by several categories of audience and thus accumulating more citations.

Our study delivered additional types of results. Thus, from the results regarding article publication, we saw that the journals in which most of the analysed articles were published are JAMA, Health System in Transition, and Libyan Journal of Medicine.

Regarding the affiliation of the main author, we found that most of the analysed articles are written by researchers from the United States, United Kingdom, Australia, and Canada. This result shows that a high number of analysed articles were published by researchers from developed countries. Similar results were reported for studies in other branches of medicine, such as general medicine [ 36 ] and neurology [ 37 ]. Regarding the small number of articles published by authors from developing countries, it can be considered that both their quantity and quality may be affected by several barriers, such as poor funding, lack of facilities to support research activities, lack of government incentives, or inadequate support. These issues can contribute to maintaining a scientific environment and research conditions that do not meet the competitive standards of prestigious journals. Certainly, journals can publish research results that are of interest to their readers. However, where possible, journals could support the dissemination of healthcare research conducted in the developing world by setting up international advisory boards to help ensure a greater degree of diversity.

Another result of the study was that before 2000, the only countries that published articles on healthcare management were the United States, United Kingdom, or Germany, and since 2015, articles have come from 19 different countries. This result shows that researchers from different countries have started to be more active since 2000. One possible explanation is that international cooperation in healthcare research between different countries has varied significantly, with the interest in research being gradually spread across multiple aspects of this field. Moreover, after 2000, an increasing trend of scientific production on healthcare management topics can be observed. The geographical distribution of analysed articles reveals that in the last two decades, the research has spread in countries from continents, such as North America and Europe. This result is not surprising, taking into consideration that the developed countries in North America and Europe have a stronger academic research infrastructure in healthcare management than less developed nations since they have more research institutes, well-established data management systems, and more assets allocated for research. The number of authors who are affiliated with research institutions in regions such as Asia, South America, or Africa was lower, and the dissemination of the results of their inquiry manifested later (after 2000).

The interest shown in healthcare management research can, however, also be affected by the healthcare system model specific to each nation or region. Healthcare systems in developed nations (for example, Regional Health Systems (RHS) in Singapore, Managed Care in the United States, or National Health Services (NHS) in the United Kingdom) have implemented several systematised medical lines of action [ 38 , 39 , 40 ]. The requirement for high-quality healthcare services has elevated many inquiries about health systems. For example, about 10 years ago, China and India deployed health reformation, setting out a set of policies to integrate healthcare services to improve their quality [ 41 ]. The objectives of healthcare reformation have made research topics catchier, and research can be more substantially supported and for longer, including through data availability and funding. In addition, the ways for cooperation between academic institutions have also influenced local research productivity [ 42 , 43 ].

Given our results and the results of other studies [ 44 , 45 ], we consider that the degree of economic development of a country or region can influence the production of scientific articles, with our analysis reporting a high growth in scientific production in more developed countries. Regarding this result, we also found evidence of countries with a lower level of GDP per capita for which the scientific production is high ( Table 8 ). This can suggest that there is not a clear link between economic development and scientific production in this field. Instead, this may show an effort made by governments in those countries in terms of investments in healthcare or the interest manifested by their scientific community for this field.

Countries with the highest scientific production in our analysis in relation to GDP per capita and heath expenditure per capita.

Source: World Bank and OECD Health Statistics 2021, WHO Global Health Expenditure Database.

Further, these results suggest that there may be a dilemma between healthcare ethics and financial constraints. In the literature, many empirical studies describing health employees’ dilemmas and decision-making processes can be identified [ 46 , 47 , 48 , 49 ]. These studies have, however, focused on developed countries, with a limited number of studies presenting results for the case of low and middle-income countries. Furthermore, the available studies are small qualitative studies [ 50 , 51 , 52 , 53 , 54 , 55 ].

In our paper, we also aimed to analyse the relationship between the number of articles citations and several factors. Some of those factors were number of authors of an article and the country with which the principal author is affiliated. We assumed that we could identify a correlation between these factors and the number of citations, with a higher number of authors bringing more information as well as personal grid contacts or research infrastructure. Even if authors such as [ 56 , 57 ] reported such effects in their papers, our results showed that there is an effect of author number but not author affiliation. Statistically significant effects were identified regarding the time since an article was published, showing that the temporal dimension is important. Articles that were recently published have not yet been cited, and the number of citations grows with time. In other words, the older an article, the more likely it is to be cited more than once [ 58 ].

Another important factor that has a significant effect on the number of articles citations is the title length (number of words in the title). We found that this factor has a negative effect on article citations. Similar results were also found by other researchers [ 59 , 60 ], with their argument being that the shortest titles generate the most citations. However, this effect could depend on differences between fields or research topics. Regarding this, the authors of [ 61 ] showed that in medicine, shorter titles often have less citations. On the other hand, the authors of [ 62 ] argued that this relationship became inverted around the year 2000 from negative to positive. This situation is explained by the growing volume of online search engines (for example, Web of Knowledge was released in 2002, Scopus in 2004, and Clarivate in 2016). It seems that short titles perform better when the search is made manually, while longer titles produce more hits in online searches, ensuring a higher degree of discoverability and a higher number of citations.

Another important effect on article citations is due to the interaction between the number of pages in an article and the time since it was published. Considered alone, the variable representing the number of pages does not seem to influence the number of citations. Regarding those results, the authors of [ 63 , 64 , 65 , 66 , 67 , 68 ] showed that the pagination affects the number of article citations depending on the discipline. In general, in the field of medicine, longer articles have more content, and the readers have a greater opportunity to find and access important info, which is conducive to a higher number of citations.

6. Conclusions

This paper provides an overview of research tendencies, challenges in healthcare management research, and possible future research perspectives. Healthcare research has grown significantly since 2000. Our results show that there are regional disparities in scientific output that are related to some aspects of economic development, specificities of healthcare systems, and academic association models.

In the paper, we also evaluated the factors influencing the number of citations of the analysed articles published in journals from the healthcare management field. We assume that the significance of identified factors will be sensitive to the growth of other approaches regarding impact quantification.

Thus, our results are useful in providing evidence related to the researched issues. Moreover, they can be used before planning or deciding a strategy for researching various aspects related to healthcare management. Thus, the awareness of the existence of a solid fund of knowledge increases, and the existing gaps can be identified, or some conceptual and methodological inconveniences can be avoided. On the other hand, exploring these data sources can help pave the way for future knowledge management (including science policy), as well as social policy decisions. In addition, our analysis is helpful in identifying unsatisfied challenges in the studied field that can trigger new ideas for further research.

Acknowledgments

This research is part of the doctoral research project “Healthcare management in hospitals from the North-East Region of Romania”, endorsed by the Research Ethics Commission (Registration No. 128/24.11.2021) from Grigore T. Popa University of Medicine and Pharmacy, Iași, Romania.

Author Contributions

For this article, the following describes the contribution of each author: conceptualisation, O.P., E.M.C. and C.Ș.P.; methodology, A.M.; validation, E.M.C., O.P. and C.Ș.P.; formal analysis, A.M.; investigation, A.M.; resources, A.M.; data curation, A.M.; writing—original draft, A.M.; writing—review and editing, O.P. and C.Ș.P.; supervision, E.M.C. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

  • Open access
  • Published: 13 February 2024

Recommendations for optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases

  • Holm Graessner   ORCID: orcid.org/0000-0001-9803-7183 1 , 2   na1 ,
  • Carola Reinhard 1 , 2   na1 ,
  • Tobias Bäumer 3 , 4 ,
  • Annette Baumgärtner 5 ,
  • Knut Brockmann 6 ,
  • Norbert Brüggemann 7 , 8 , 4 ,
  • Eva Bültmann 9 ,
  • Jeanette Erdmann 10 ,
  • Kirstin Heise 11 , 12 ,
  • Günter Höglinger 13 , 14 , 15 ,
  • Irina Hüning 16 ,
  • Frank J. Kaiser 17 ,
  • Christine Klein 18 ,
  • Thomas Klopstock 19 , 20 , 21 ,
  • Ingeborg Krägeloh-Mann 22 ,
  • Markus Kraemer 23 , 24 ,
  • Kerstin Luedtke 25 ,
  • Martin Mücke 26 , 27 , 28 ,
  • Thomas Musacchio 29 , 30 ,
  • Andreas Nadke 31 ,
  • Alma Osmanovic 17 ,
  • Gabriele Ritter 32 ,
  • Katharina Röse 5 ,
  • Christopher Schippers 33 ,
  • Ludger Schöls 34 , 35 , 2 ,
  • Rebecca Schüle 36 , 37 , 38 ,
  • Jörg B. Schulz 39 ,
  • Joachim Sproß 40 ,
  • Eveline Stasch 41 ,
  • Gilbert Wunderlich 42 &
  • Alexander Münchau 3 , 4  

Orphanet Journal of Rare Diseases volume  19 , Article number:  62 ( 2024 ) Cite this article

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In 2017, the German Academy for Rare Neurological Diseases (Deutsche Akademie für Seltene Neurologische Erkrankungen; DASNE) was founded to pave the way for an optimized personalized management of patients with rare neurological diseases (RND) in all age groups. Since then a dynamic national network for rare neurological disorders has been established comprising renowned experts in neurology, pediatric neurology, (neuro-) genetics and neuroradiology. DASNE has successfully implemented case presentations and multidisciplinary discussions both at yearly symposia and monthly virtual case conferences, as well as further educational activities covering a broad spectrum of interdisciplinary expertise associated with RND. Here, we present recommendation statements for optimized personalized management of patients with RND, which have been developed and reviewed in a structured Delphi process by a group of experts.

An interdisciplinary group of 37 RND experts comprising DASNE experts, patient representatives, as well as healthcare professionals and managers was involved in the Delphi process. First, an online collection was performed of topics considered relevant for optimal patient care by the expert group. Second, a two-step Delphi process was carried out to rank the importance of the selected topics. Small interdisciplinary working groups then drafted recommendations. In two consensus meetings and one online review round these recommendations were finally consented.

38 statements were consented and grouped into 11 topics: health care structure, core neurological expertise and core mission, interdisciplinary team composition, diagnostics, continuous care and therapy development, case conferences, exchange / cooperation between Centers for Rare Diseases and other healthcare partners, patient advocacy group, databases, translation and health policy.

Conclusions

This German interdisciplinary Delphi expert panel developed consented recommendations for optimal care of patients with RND in a structured Delphi process. These represent a basis for further developments and adjustments in the health care system to improve care for patients with RND and their families.

Introduction

In Europe, a disease is considered “rare” when affecting < 1 person in 2000. Although rare diseases (RDs) have—per definition—a low prevalence, the total number of patients with a RD is high, affecting about 3.5–5.9% of the population equating to 263–446 million people affected globally at any point in time [ 1 ]. The majority of RD have neurological manifestations including the central and peripheral nervous system and muscles [ 2 ]. In Germany alone, we estimate the number of patients with rare neurological diseases (RND) to amount to approximately 150,000 cases with 7000–8000 new cases manifesting each year. Care of patients with RND concerns a considerable fraction of the healthcare service provided by a national healthcare system [ 3 ]. Thus, suboptimal management of RND patients causes major healthcare problems [ 4 ].

The German Academy for Rare Neurological Diseases (Deutsche Akademie für Seltene Neurologische Erkrankungen; DASNE) is a German initiative aiming at paving the way for an optimized personalized management of patients with RND in all age groups. Instigated by the Centers for Rare Diseases in Lübeck and Tübingen, a dynamic national network for RND has been constituted comprising renowned experts in the fields of neurology, pediatric neurology, pediatrics, (neuro-)genetics and neuroradiology. DASNE has successfully implemented case presentations and multidisciplinary discussions both at yearly symposia and monthly virtual case conferences, as well as further educational activities covering a broad spectrum of interdisciplinary expertise associated with RND. [ 5 ]. The DASNE is associated with the German Reference Network (Deutsches Referenznetzwerk; DRN) for Rare Neurological Diseases, founded in 2021.

Taking into account both the magnitude of the healthcare challenge to provide optimal care for RND patients as well as the ambition of the DASNE and the German Reference Network for RND, precisely determining what optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases mean is warranted. In the present study, following a structured Delphi process, we developed and reviewed 38 recommendation statements by an interdisciplinary expert group composed of patient representatives, DASNE experts, as well as other healthcare professionals and managers. The development of the recommendations has been undertaken by thematic groups of experts (e.g. continuous care and therapy development, health policy) followed by a consensus meeting with the whole group of experts. Colleagues with different fields of expertise and backgrounds were involved. The recommendations were finalized in November 2021 and endorsed by the entire interdisciplinary expert group. Some are specific for RND, some are generically applicable also to other rare diseases. Furthermore, the specific areas, for which statements were developed, have a direct connection to care services or cover care related overarching topics such as health policy.

The aim of the recommendation is to refer to care for RND patients in general. Hence, specific recommendations for particular diseases or disease groups such as ataxias or leukodystrophies, are not covered in these statement recommendations.

The recommendations are conceived as action statements for the management and provision of clinical care, they are not merely political or contemplative. They refer to the structure of the care facility, ensuring neurological core expertise and core mission, composition of the interdisciplinary team, diagnostics, case conferences, continuous care and therapy development, translation, patient advocate groups, health policy, exchange/cooperation between rare disease centers and other partners in the health sector, and to databases. Research of RND is not addressed specifically. However, for RD the boundaries of what relates to care and what to research are often hard to define.

37 experts, chosen for their involvement in DASNE, expertise in RND and representing the interdisciplinary team involved in RND care, collaborated to develop this recommendation. Involved expertise included neurology, pediatric neurology, human genetics, neuroradiology, neurorehabilitation, social counseling and patient advocacy groups as well as two directors of German rare disease centers. A Delphi-like consensus methodology was adopted. A systematic PubMed search yielded no results as to similar studies specifically addressing the topic of this study.

Topics of relevance for optimal care of RND patients

An online collection of topics considered relevant for optimal patient care of RND patients was performed by the expert group. Next, a two-step Delphi process was performed to rank the importance of the selected topics. The two Delphi rounds revealed that none of the topics were rated as not important, the lowest median voting received on a Likert scale from 1 (not important) to 6 (most important) was 4. Table 1 shows the main topics as well as those subtopics that reached a median score ≥ 5 and were, thus, included in the further development of the statements. The full ranking results are given as Appendix 1. The selected eleven main topics reflect the full spectrum of topics that influence the quality of care provided to RND patients and include infrastructural, care as well as policy topics.

Consensus recommendations for optimal interdisciplinary management and healthcare settings for patients with RND

Small interdisciplinary working groups comprising three to five experts were formed and tasked to draft recommendations for the eleven main topics taking particularly considering the selected subtopics. In two subsequent consensus meetings and one online review round these recommendations were finally consented. Table 2 shows the main points of the consensus recommendations for optimal interdisciplinary management and healthcare settings for patients with RND.

To the best of our knowledge, we have developed the first recommendations for optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases on the basis of an adapted Delphi procedure involving a large interprofessional expert group. The recommendations can be taken as a guidance as to how and in which setting care for patients with RND should be provided. All recommendations were fully consented by our interprofessional expert group, which also included patient representatives. This level of agreement suggests that our recommendations provide important guidance for the development and delivery of high-quality RND care and we strongly recommend their use in realizing and planning the RND care provision.

Our consensus recommendations offer broader generalizability to all rare diseases. As far as we are aware of, no comparable study has been performed as yet for any rare disease. The recommendations highlight that the focus of RND care is on interprofessional and interdisciplinary, patient-centered and expertise based informed care delivery. Common themes that were mentioned across more than one main topic and which could thus be deemed as the very essence for RND care provision were the following:

Interdisciplinary and interprofessional care provision

Continued medical education for RND experts and non-experts

Importance of neurologic and neurogenetic expertise and expertise based decisions

Empowered participation and contribution of patients and patient advocacy organizations

Networking/cooperation between different players in the field of RND

Digital infrastructure including digital patient records, which are accessible to the entire interdisciplinary and interprofessional team involved in the care of a RND patient as well as use of Orpha codes for coding of RND patients,

Development of standard operating procedures for all RND related activities

Adequate funding of care services and structures, and

Structured and validated public information on RND expertise centers.

This study has several strengths. First, the resulting recommendations owe their credibility to the use of a modified Delphi procedure [ 6 ]. The authors have set clear standards for the conducting and reporting of the Delphi study, including the appointment of independent researchers to coordinate the study, the presence of a clear consensus criterion, clear descriptions of how the synthesis of responses in one survey round was used to design the subsequent round, and the review and approval of the final draft by an external board before publication and dissemination.

Second, the Delphi method allowed the involvement of a network of 14 interprofessional experts. These participants had various professional backgrounds and work settings. In the expert group, we also included six patient representatives. Our response rate of more than 80% indicates that the risk of selection bias is low. Third, the high degree of consensus in the expert groups regarding topic selection as well as derived recommendations contributes to the validity of our findings.

We acknowledge the following limitations of our study. For the study we performed we could not find an appropriate literature basis. Secondly, as healthcare for RND patients in Germany is currently changing, our recommendations might need to be updated considering the effects of these changes. Finally, recommendations need validation in the actual healthcare setting. Whether the use of the recommendations will, in fact, improve care provision is a matter that warrants further study.

As future steps, we recommend the dissemination, and implementation of these recommendations for use in practice and policy making. We also suggest evaluating the use of these recommendations in clinical practice, and their usefulness to change the healthcare system.

Our large interprofessional expert group came to a consensus on recommendations for RND. These recommendations represent an important first step in providing instructions and orientation with a view to the care that should be provided for RND patients. We hope these recommendations will have a catalytic effect to benefit patients and their relatives by changing the provision of care in the German healthcare system, thus contributing to improved quality of life for RND patients and other patients with rare diseases in Germany. Future implementation of these recommendation in care practice depends to a large extent on the systematic integration of specific care pathways and expertise networks such as the ERN-RND in the healthcare system as well as on respective resource allocation.

Determination of the most important topics

In May 2020, after studying the literature and finding no review or publication addressing the question of optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases (RND), as a first step an interdisciplinary group of 34 experts including patient representatives was contacted and asked to propose topics that are important for optimal care of patients with rare neurological diseases.

Potential panel experts (including patient representatives) were identified through their involvement in DASNE or through the professional networks of the members of the taskforce. In the selection process, we aimed for an interdisciplinary group of RND experts. The invited panelists were experts in RND research, practice, and policy, with backgrounds in medicine, social counseling, physiotherapy, ergotherapy, speech therapy and policy. Invited panelists also included five patient representatives from German patient advocacy organizations like the German Heredo-Ataxia Society.

In the letter that was used to contact the experts we explained the goal and the process of the study and asked an open question for topics that are important for the care of RND patients. The online questionnaire was answered by 17 experts that formed the expert panel for the ranking of the topics (see below). Subsequently, we structured these replies into main topics and subtopics. This process yielded 11 main topics each containing a number of subtopics.

Delphi round 1 and 2—ranking of topics

In June and July 2020, in the first Delphi round the determined main topics and subtopics were sent to the same expert panel through an online questionnaire. For the ranking of the main topics and subtopics, panelists were asked to rank the perceived importance of both main topics and related subtopics on a 6-point Likert scale (1 = least important to 6 = most important). The panelists' responses were used to calculate the levels of importance. Importance was indicated by a median score, which represents the 50th percentile value of opinions.

In August and September 2020, panelists received the median score of all topics together with the score they had given in the first Delphi round and were requested to re-assess their respective scoring. To maintain conformity between rounds, only those panelists who responded to the online questionnaire in the first Delphi round (n = 14) were asked to respond to the ranked topics in the second Delphi round. Again, panelists could indicate the perceived importance of both main topics and related subtopics on the same 6-point scale. All 14 panelists who responded in the first Delphi round, also responded in Delphi round 2. As we observed no major rating differences, especially with regard to downgrading but rather a ceiling effect, from round 1 to round 2, we decided to terminate the Delphi process after round 2.

Main topics were included in the recommendation development after round 2 if median ratings were ≥ 5 or if a subtopic received a median rating ≥ 5. If a main topic did not receive a median rating ≥ 5 but a linked subtopic or different subtopics did, the recommendation development focused on the respective subtopic(s).

Formulation of recommendations on most important topics

The prioritized main topics were used to form small interdisciplinary working groups composed of three to five members of the expert group that were tasked to formulate draft recommendations relating to the identified topics. Working groups were formed on the following main topics: Structure of the care facility, ensuring neurological core expertise and core mission, composition of the interdisciplinary team, diagnostics, case conferences, continuous care and therapy development, translation, patient advocacy organizations, health policy, exchange and cooperation between rare disease centers and other partners in the health care sector and databases. We provided an example recommendation to inform the recommendation drafting and discussion in the working groups. To the working groups, we invited the initial larger expert group that we contacted in round 1. 37 experts contributed to the working groups and their respective drafting of recommendations and to the consensus process. All draft recommendations were received by May 2021 (Additional file 1 ).

Consensus on recommendations

In June and July 2021, we organized a consensus process consisting of three steps. All draft recommendations were presented, thoroughly discussed and adapted in two online consensus meetings, in which the entire expert panel participated.

After the two meetings we shared the current stage recommendations with the panel and accepted further comments for two weeks. The set of recommendations was then circulated and approved by the entire panel.

Availability of data and materials

The data that support the findings of this study are available in the supplementary material at the end of the manuscript.

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Acknowledgements

Not applicable.

Open Access funding enabled and organized by Projekt DEAL. European Reference Network—Rare Neurological Diseases (ERN—RND; Project ID No 739510); AM was supported by the Damp-Stiftung (Kiel, Germany); Bundesministerium für Bildung und Forschung (BMBF) through funding for the TreatHSP network (grant 01GM2209A to RS) European Joint Programme on Rare Diseases for the PROSPAX consortium (grant 441409627 to RS).

Author information

Holm Graessner and Carola Reinhard Contributed equally to this work.

Authors and Affiliations

Institute for Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany

Holm Graessner & Carola Reinhard

Centre for Rare Diseases, University Hospital Tübingen, Tübingen, Germany

Holm Graessner, Carola Reinhard & Ludger Schöls

Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany

Tobias Bäumer & Alexander Münchau

Center for Rare Diseases, University of Lübeck and University Hospital Medical Center, Schleswig-Holstein, Germany

Tobias Bäumer, Norbert Brüggemann & Alexander Münchau

Institute of Health Sciences, University of Lübeck, Lübeck, Germany

Annette Baumgärtner & Katharina Röse

Interdisciplinary Pediatric Center for Children With Developmental Disabilities and Severe Chronic Disorders, Department of Pediatrics and Adolescent Medicine, University Medical Center, Göttingen, Germany

Knut Brockmann

Department of Neurology, University Hospital Medical Center Schleswig-Holstein, Schleswig-Holstein, Germany

Norbert Brüggemann

Institute of Neurogenetics, University of Lübeck, Lübeck, Germany

Institute of Diagnostic Und Interventional Neuroradiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

Eva Bültmann

Institute for Cardiogenetics, DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, and University Heart Center Lübeck, University of Lübeck, Lübeck, Germany

Jeanette Erdmann

Department of Health Sciences and Research, Medical University of South Carolina, Charleston, USA

Kirstin Heise

Department of Movement Sciences, Movement Control and Neural Plasticity Research Group, KU Leuven, Louvain, Belgium

Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany

Günter Höglinger

Department of Neurology, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, Munich, Germany

German Center for Neurodegenerative Diseases (DZNE), Feodor-Lynen-Straße 17, 81377, Munich, Germany

Institute of Human Genetics, University of Lübeck, Lübeck, Germany

Irina Hüning

Essen Center for Rare Diseases (Essener Zentrum Für Seltene Erkrankungen, EZSE), University Hospital Essen, Essen, Germany

Frank J. Kaiser & Alma Osmanovic

Institute of Neurogenetics, University of Lübeck and University Hospital Medical Center , Schleswig-Holstein, Germany

Christine Klein

Friedrich Baur Institute at the Department of Neurology, University Hospital, LMU , Munich, Germany

Thomas Klopstock

Munich Cluster for Systems Neurology (SyNergy), Munich, Germany

German Center for Neurodegenerative Diseases (DZNE), Munich, Germany

Department of Pediatric and Developmental Neurology, Social Pediatrics, University of Tübingen, Tübingen, Germany

Ingeborg Krägeloh-Mann

Department of Neurology, Alfried Krupp Hospital Essen, Essen, Germany

Markus Kraemer

Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany

Department of Physiotherapy, Institute of Health Sciences, University of Lübeck, Lübeck, Germany

Kerstin Luedtke

Institute for Digitalization and General Medicine, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany

Martin Mücke

Center for Rare Diseases Aachen (ZSEA), RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany

Department of Neurology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany

Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany

Thomas Musacchio

Center for Rare Diseases, University Hospital of Würzburg, Josef-Schneider-Str. 2, 97080, Würzburg, Germany

Deutsche Heredo-Ataxie-Gesellschaft E.V., Stuttgart, Germany

Andreas Nadke

Klinikum Ameos, 23774 Heiligenhafen Friedrich Ebertstrrasse 100 Huntington Zentrum Nord, Heiligenhafen, Germany

Gabriele Ritter

Center for Rare Diseases Aachen (ZSEA), University Hospital Aachen, Aachen, Germany

Christopher Schippers

Department of Neurology and Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany

Ludger Schöls

German Center of Neurodegenerative Diseases (DZNE), Tübingen, Germany

Division of Neurodegenerative Diseases, Department of Neurology, Heidelberg University Hospital and Faculty of Medicine, Heidelberg, Germany

Rebecca Schüle

Center for Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany

German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany

Department of Neurology and Center for Rare Diseases, University Hospital, RWTH Aachen University, Aachen, Germany

Jörg B. Schulz

Deutsche Gesellschaft Für Muskelkranke e.V. Im Moos 4, 79112, Freiburg, Germany

Joachim Sproß

Deutsche PSP-Gesellschaft e.V. Weingartenstr. 28a, 61231, Bad Nauheim, Germany

Eveline Stasch

Faculty of Medicine and University Hospital, Department of Neurology, University of Cologne, Cologne, Germany

Gilbert Wunderlich

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Contributions

HG and AM initiated the drafting of the recommendations and organized the meetings. CR supervised the project. HG, CR and AM wrote the manuscript and compiled all comments. HG, CR, TB, AB, KB, NB, EB, JE, KH, GH, IH, FJK, CK, TK, IKM, MK, KL, MM, TM, AN, AO, GR, KR, CS, LS, RS, JBS, JS, ES, GW, and AM participated in the meetings, drafted the recommendations and reviewed the manuscript. All authors approved the final Manuscript.

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Correspondence to Holm Graessner .

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Markus Kraemer received honoraria for teaching activities from Roche Pharma and Chugai Pharma. Dr. Brüggemann received honaria from Abbott, Abbvie, Biogen, Biomarin, Bridgebio, Centogene and Zambon. He is funded by the DFG (BR4328.2–1, GRK1957), and the Michael J Fox Foundation. GH served as a consultant for Abbvie, Alzprotect, Aprineua, Asceneuron, Bial, Biogen, Biohaven, Kyowa Kirin, Lundbeck, Novartis, Retrotope, Roche, Sanofi, UCB; received honoraria for scientific presentations from Abbvie, Bayer Vital, Bial, Biogen, Bristol Myers Squibb, Kyowa Kirin, Roche, Teva, UCB, Zambon.

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Additional file 1..

Full formulation of recommendations for optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases.

Appendix 1: Results of the Delphi process used for the ranking of the topics relevant for RND care provision

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Graessner, H., Reinhard, C., Bäumer, T. et al. Recommendations for optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases. Orphanet J Rare Dis 19 , 62 (2024). https://doi.org/10.1186/s13023-024-03023-1

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Development of low back pain curriculum content standards for entry-level clinical training

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The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs.

The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group.

Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described.

We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

Peer Review reports

Low back pain (LBP) is a common condition and the leading cause of years lived with disability worldwide [ 1 ]. While individual episodes of LBP may resolve quickly with minimal intervention, LBP recurrence and the development of persistent pain are also common and contribute to the overall healthcare burden associated with LBP [ 2 , 3 ]. Clinical practice guidelines are available to guide the appropriate management of LBP and improve patient outcomes [ 4 , 5 ]. Despite these recommendations, however, the management of LBP is highly variable [ 6 ]. Many patients receive management that is not recommended in current guidelines (e.g., imaging, opioids) and/or miss out on the care that is recommended (e.g., education, exercise). Both these problems may lead to poorer patient outcomes [ 4 , 6 ].

Strategies to educate clinicians and implement best-evidence and guideline recommendations into clinical practice have been attempted, with little current evidence of success [ 7 ]. Researchers have identified that a clinician’s beliefs, perceptions and level of clinical knowledge may influence the uptake of LBP guideline recommendations into clinical practice [ 8 ]. In particular, the influence of formal entry-level clinical training has been highlighted as a potential barrier to the uptake of clinical practice guidelines for LBP [ 8 , 9 ], and conversely, that changing student beliefs and attitudes about LBP in clinical training programs may facilitate more guideline-adherent practice in future clinicians [ 10 ].

Entry-level clinical training programs refer to undergraduate or postgraduate programs that train clinicians to enter healthcare professions [ 11 ]. Education related to LBP is variable across training programs, both within and between different healthcare professions. The time spent delivering LBP or general pain management content varies considerably across different clinical training programs [ 9 , 12 , 13 , 14 , 15 , 16 ]. Furthermore, gaps have been identified in different clinical training programs with regards to student knowledge and competencies related to LBP [ 10 , 17 , 18 , 19 , 20 , 21 , 22 ], confidence in ability to manage LBP on graduation [ 23 , 24 , 25 ], and alignment with LBP clinical guideline recommendations [ 12 , 26 ].

Appropriate LBP curriculum content within entry-level clinical training programs is needed to ensure that healthcare professionals are graduating with the knowledge and skills needed to deliver high-quality evidence-based care in clinical practice. Curriculum content standards are defined as the curriculum needed to equip clinicians with the knowledge, skills and attitudes necessary at the time of graduation [ 27 ]. Currently, while core competencies for clinical training programs as a whole have been developed [ 28 ], there are no specific content standards to guide teaching for LBP. Therefore, we aimed to develop the first curriculum content standards for the teaching of LBP in entry-level clinical training programs worldwide.

Overview and scope of the development of the low back pain curriculum content standards

An international, interdisciplinary working group, led by a steering group (authors), was formed to develop the Low Back Pain Curriculum Content Standards (LBP-CCS) using an iterative process. An initial literature review was performed by the steering group to identify the range of content to be included in the LBP-CCS. The content and structure of the LBP-CCS was then modified through two rounds of group discussion and feedback from the working group. The final version of the LBP-CCS was approved by all members of the working group. Ethical approval was not required for the development of the LBP-CCS as no participants or participant data were recruited or collected. All members of the working group who contributed to the LBP-CCS are acknowledged in this publication.

The LBP-CCS were developed to include a complete list of content items necessary for comprehensive education on LBP epidemiology, diagnosis, and management. Input into the development was sought from a diverse range of healthcare professions involved in the management of LBP. The working group recognised that different healthcare professions may require different levels of knowledge related to the diagnosis and management of LBP. Therefore, the LBP-CCS were designed to provide guidance that can be implemented to the appropriate level for individual entry-level clinical training programs.

Formation of the working group

The steering group (authors) identified professional organisations, academics, researchers, clinicians, and consumers to invite to participate in the development of the LBP-CCS. International professional organisations with interest in the management of LBP in primary care were invited to be involved in the development of the LBP-CCS. Organisations agreeing to be involved were asked to nominate a representative to be part of the working group. Other potential working group members were purposively invited to achieve a spread of different occupational and clinical backgrounds, sex, and geographic location.

Of 15 organisations approached, seven agreed to participate in the LBP-CCS development and provide representatives to join the working group. Participating organisations included: International Society for the Study of the Lumbar Spine (ISSLS), International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) on behalf of World Physiotherapy (WP), World Federation of Chiropractic (WFC), European Pain Federation (EFIC), Musculoskeletal Association of Chartered Physiotherapists (MACP), and Council of Physiotherapy Deans Australia and New Zealand (CPDANZ). Responses were not received from the remaining organisations approached, which included invitations to medical and osteopathic organisations. A further 22 academics, researchers, clinicians, or healthcare consumers were invited to join the working group, with 19 accepting, leading to a final working group of 32 participants (including the steering group). The spread of occupational backgrounds, sex, and geographic locations represented within the working group is presented in Table  1 .

Literature review to inform development of the low back pain curriculum content standards

The steering group conducted an initial review of the literature to establish a draft list of content to be included in the LBP-CCS. Three search strategies were used to find relevant literature:

Medline (OVID), Embase (OVID), CINAHL, and PsycInfo were searched from inception to March, 2022 to identify current gaps in entry-level clinical education related to LBP. Search terms related to: (i) LBP; (ii) curriculum/knowledge; and (iii) healthcare students. Searches were developed for each database and are available in Additional file 1 . Articles were screened by one member of the steering group (HJ) and were included if the article assessed or discussed LBP or pain education in an entry-level clinical training program. ‘Education’ could relate to any of the following: required competencies, learning outcomes, identified gaps, student preparedness for clinical practice, or alignment with evidenced-based practice or clinical practice guidelines. Articles discussing clinical practice with respect to the required competencies or knowledge needed from entry-level clinical training were also included. Clinical training programs could relate to any healthcare profession that requires training in LBP epidemiology, diagnosis, or management.

Clinical practice guidelines and accreditation documents, identifying required competencies or knowledge for healthcare clinicians related to the management of LBP, were identified by the steering group. To be included, clinical practice guidelines needed to be related to the multidisciplinary management of LBP in primary care, be produced by a national organisation, and be informed by literature review. A published overview of clinical practice guidelines [ 5 ] meeting these criteria was used to identify guidelines for inclusion. A search was performed for updates to the guidelines identified in the overview, with the most recent version included. National and international accreditation documents were included if they related to entry-level clinical training programs in medicine, physiotherapy, or chiropractic, and were written in English. Summary documents, collating information across multiple clinical guidelines or accreditation documents, were used where available.

The working group was asked to recommend documents, including curriculum and policy documents and new or updated guidelines not captured by the above process, that they considered appropriate to inform the development of the LBP-CCS.

From each included article or document, one of the steering group (HJ, BB, MO, MH) extracted the key findings, gaps, or requirements related to LBP education that were identified and categorised as content/knowledge and skills/competencies required.

Iterative development of the low back pain curriculum content standards

The first iteration of the LBP-CCS was developed by the steering group. The extracted data from the literature review were collated by one of the steering group (HJ) under broad topic headings. These topic headings were then discussed with the members of the steering group to determine an initial topic structure. The extracted data were then collated into the topic structure, with consolidation of individual items where there was duplication of data. It was not considered within the scope of the development of the LBP-CCS to evaluate the strength of available evidence and provide specific recommendations on how the content should be taught. Instead, the aim of the LBP-CCS was to provide high-level guidance of the content topics to be included within curriculum for LBP and be taught within an evidenced-based framework.

Two rounds of review, including group discussion and written feedback, were held with the working group to determine any necessary changes to the draft LBP-CCS. For each review round, members of the working group were provided with the latest iteration of the LBP-CCS and a feedback document, including the questions to be reviewed within group discussion and opportunity to provide more specific written feedback on each element of the LBP-CCS. Multiple online discussion groups were held to accommodate time-zone differences and enable all working group members to attend a session. Each discussion group was recorded (with permission of the working group members in attendance) and had at least two of the steering group members in attendance, to moderate the group discussion and record notes. The review questions were discussed within each group. Key discussion points from groups were also presented at subsequent groups within the same round to encourage further discussion. After each of the review rounds, both the feedback from the discussion groups and feedback documents were collated, qualitatively summarised, and a list of potential changes developed and discussed within the steering group. Where feedback was conflicting, potential changes were suggested in alignment with the majority of opinions from the working group and flagged for discussion within the next working group review. For each new iteration of the LBP-CCS, a summary of the changes was provided to the working group and discussed within the following review round. In this way, the working group were able to provide feedback on the changes which were incorporated into the following review round.

Literature review

The database search returned 577 articles, of which 57 were screened for full-text and 34 were included for data extraction. A previously published paper summarising 15 clinical practice guidelines from Africa, Australia, Brazil, Belgium, Canada, Denmark, Finland, Germany, Malaysia, Mexico, the Netherlands, Philippine, Spain, the USA, and the UK was used to extract clinical guideline recommendations [ 5 ]. Updates to two of the 15 guidelines were identified and used to extract guideline recommendations [ 29 , 30 ]. Ten accreditation documents were sourced from international and regional (North America, Australasia, Europe) accrediting bodies for medical, physiotherapy, and chiropractic entry-level clinical training programs. On assessing these accreditation documents, we decided not to source accreditation documents from other healthcare professions, as no criteria or competencies specific to LBP were found within the sourced documents. Seventeen additional documents were identified by the working group including clinical care standards, a musculoskeletal education framework, curriculum documents, and LBP overview papers. No new or updated clinical practice guidelines were identified by the working group. The complete list of documents used to inform the development of the LBP-CCS is available in Additional file 2 .

First iteration

Data from the literature review were collated under 12 topic headings as described in Table  2 . The steering group determined the structure of the first iteration to include: (i) the overarching objectives of the LBP-CCS; and (ii) 10 topic headings outlining the content to be included (Table  2 ). The individual content items were listed under: (i) principles; (ii) knowledge; and (iii) skills. The sub-heading ‘principles’ was intended to capture context to clarify the intent of the required knowledge and skills for each topic. For example, under the topic ‘Investigations’ one of the principles was for clinicians to consider whether investigation findings will substantially alter patient management; whereas, the associated knowledge item required that clinicians know the risks and benefits of the proposed investigations. The related skills item in this example stated that clinicians should be able to order and interpret investigations appropriately.

Second iteration

The first round of review with the working group was used to inform the second iteration of the LBP-CCS. The first review round focused on: (i) the appropriateness of the topic structure; (ii) the level of detail included within the content items and whether more specific recommendations should be made; (iii) the inclusion of content items not specific to LBP education (e.g., communication skills, clinical reasoning); and (iv) specific feedback on the individual content items or suggestions for additional/missing content items. The general structure of the document was agreed to be appropriate; however, a preamble to provide context to the document was thought necessary and suggestions were made to integrate some of the existing topic headings to improve the flow of the document and reduce repetition (Table  2 ). While the separation of ‘Principles’, ‘Knowledge’, and ‘Skills’ under each topic heading was considered important, the working group thought that ‘Principles’ should be replaced with an explanatory statement under each topic heading to explain alignment within the current evidence-base. The working group preferred the term ‘Competency’ to ‘Skills’ to reflect the move of many academic programs to competency-based teaching and assessment.

The working group agreed that the LBP-CCS should provide the general topics of content to be included (e.g., the risks and benefits of management options for LBP) rather than provide the specific evidenced-based recommendations (e.g., opioids should not be used in the management of LBP). This was to ensure that the LBP-CCS would be appropriate to use across different entry-level training programs and that the LBP-CCS would not become out-dated as new evidence becomes available. It was considered important, however, that the preamble clearly outline the need to apply the LBP-CCS within an evidenced-based context as appropriate for the clinical training program and local context/culture. A ‘Suggested resource’ section was also recommended to provide current evidence-based resources that could be used to inform application of the LBP-CCS. Regular review and update of the LBP-CCS (e.g., every five-years) was recommended to ensure that the standards align with emerging research findings. The inclusion of items not specific to LBP education but important in the development of appropriate patient management (e.g., patient communication, clinical reasoning), were considered essential. However, it was suggested that these be integrated within the items specific to LBP rather than included as stand-alone content items (e.g., ‘Synthesise clinical assessment findings and communicate a meaningful explanation of their LBP to the patient’).

Finally, feedback related to the specific content items was incorporated into the second iteration of the LBP-CCS. This included the addition of new content items and the removal/rewording of some content items to limit repetition, increase the consistency of language throughout the document, and increase the focus on some content items.

Third iteration

The second round of review with the working group was used to inform the third, and final, iteration of the LBP-CCS. The second review round focused on: (i) the appropriateness of the new sections of the LBP-CCS (preamble, explanatory statements, suggested resources); (ii) the structure/flow of the topic headings and included content items; and (iii) specific feedback on the individual content items. Overall, there was support for the new sections of the LBP-CCS, with some minor changes or additional resources suggested. Within the discussion groups it was highlighted that there were some differences in the interpretation of terms/words between members of the working group. The addition of a glossary to define common terms within the document was recommended. The topic flow was considered improved from the first iteration; however, to further improve the flow, it was suggested that the ‘Clinical assessment’ and ‘Investigations’ topics be collapsed together, and to integrate the ‘Low back pain diagnosis and classification’ topic across the remaining topics. The final topic structure is presented in Table  2 . The third iteration of the LBP-CCS was approved for dissemination and implementation by all members of the working group. The final LBP-CCS is available in Additional file 3 .

Key findings

We have developed curriculum content standards for LBP education in entry-level clinical training programs. The content items included in the LBP-CCS were informed by current literature, clinical practice guidelines, accreditation requirements, and other policy documents. The structure and content of the LBP-CCS were reviewed through three iterations and approved by an interdisciplinary international working group. The developed LBP-CCS are ready to be implemented in entry-level clinical training programs to inform the development or review of LBP curriculum and ensure that graduates have the knowledge and competencies required to deliver high-quality care to patient with LBP in clinical practice. The LBP-CCS will be reviewed and updated periodically to ensure that it remains current.

Comparison to previous literature

To our knowledge, curriculum content standards for LBP entry-level clinical training have not been previously developed. Current clinical practice guidelines [ 5 ] and clinical care standards for LBP [ 6 ] that exist have been developed to inform clinical practice for qualified clinicians with existing knowledge about LBP. Instead, we developed the LBP-CCS to focus on the curriculum requirements for entry-level clinical students with no prior knowledge of LBP. For example, clinical guidelines tend to focus on the appropriate assessment and management of LBP [ 5 ] and do not provide details of required knowledge related to the epidemiology and course of LBP that underpins clinical reasoning and management decisions. A similar outline of recommended curriculum content in healthcare programs has been developed for pain education as a whole (IASP Interprofessional Pain Curriculum Outline) [ 31 ]; however, this does not include details specific to LBP that are important to highlight within entry-level clinical training. For example, imaging is rarely recommended in the assessment of LBP and inappropriate use has been associated with poorer patient outcomes [ 32 ]; details such as determining the appropriate use of imaging can be highlighted more specifically in the LBP-CCS rather than within curriculum content for general pain [ 31 ], where the concept may not be relevant for all pain presentation types.

Strengths and limitations

A systematic and rigorous approach was used to develop the LBP-CCS. The working group was selected to ensure representation across diverse healthcare professions involved in the management of LBP, geographic locations, and professional backgrounds with academic, clinician, and consumer involvement. Eleven countries across 5 continents were represented within the working group; however, there was an underrepresentation of developing countries (1/11, 9%). Similar concerns related to the implementation of best-practice care for LBP have been identified globally [ 4 ], and, therefore, similar education requirements are likely to be needed. However, curriculum content requirements for developing countries may not have been completely explored. We therefore recommend, in the preamble to the LBP-CCS, that the LBP-CCS be implemented with consideration of the local context and environment. Physiotherapists and chiropractors commonly manage patients with LBP in primary care, which is reflected in more hours on LBP education in entry-level clinical training programs [ 12 ]. Therefore, we included larger proportions of physiotherapists and chiropractors within the working group to ensure that the LBP-CCS reflected the content required by programs with a stronger focus on LBP education. Moving forward, we intend to develop modified versions of the LBP-CCS for healthcare professions that are involved in the management of LBP but have different educational needs, such as medicine, pharmacy, clinical psychology, clinical exercise physiology, occupational therapy, and nursing. The current version can still be used to inform the education of all health professionals who treat people with LBP, but individual programs will need to consider the level of detail required.

The first iteration of the LBP-CCS was informed by a review of the literature and other professional policy documents. The literature search was performed in March, 2022 and new literature or guideline documents may change the content of the LBP-CCS. To minimise this limitation, regular review of the literature is planned by the steering group to ensure that the LBP-CCS remain current. The working group did not identify any new or updated clinical practice guidelines during the development process; however, the World Health Organization have published new guidelines for the management of chronic LBP since the development process concluded (December, 2023) [ 33 ]. The new guidelines have been assessed by the steering committee, and the guideline messages are consistent with the LBP-CCS. A sparsity of literature related to LBP education was identified from healthcare professions other than medicine, physiotherapy, chiropractic, and osteopathy; potentially highlighting gaps in other professions in identifying educational requirements related to LBP. The second and third iterations of the LBP-CCS were informed by review from the working group and all members of the working group approved the final iteration.

The LBP-CCS provides LBP educational content that should be feasible to incorporate into entry-level clinical training. Achieving a balance between providing constructive guidelines without dictating how the content should be taught is challenging. Highly prescriptive content recommendations (e.g., do not prescribe opioids in the management of LBP) might hold benefits of greater consistency of content across clinical training programs without individual interpretation. However, the exact recommendations to be included would be difficult to agree upon, would likely be nuanced depending on healthcare profession or geographic region (as seen in clinical guidelines from different regions [ 5 ]), and would need to be more frequently updated as specific knowledge evolves. The working group agreed that the content included in the LBP-CCS be less prescriptive to maintain flexibility of use. However, the content of the LBP-CCS is, therefore, more open to individual interpretation. Strategies were included to minimise negative effects of individual interpretation, including: (i) explanation of the need to reflect on current evidence; (ii) the use of explanatory statements to provide context to each topic; and (iii) the provision of high-quality suggested resources to inform use of the LBP-CCS.

Implementation of the low back pain curriculum content standards

The LBP-CCS have been designed to be used in entry-level clinical training programs for future healthcare clinicians involved in the assessment or management of patients presenting with LBP. The LBP-CCS can be used to guide the development of content in new programs or revise/benchmark content in existing programs. It must be noted that the time available to teach content related to LBP in different clinical training programs may differ considerably, which will impact the degree of detail to which the LBP-CCS can be implemented. For example, in an Australian study the number of hours related to the teaching of spinal assessment and management ranged from 2 h in pharmacy training to 310 h in chiropractic training [ 12 ]. In addition, the level of detail required for each item within the LBP-CCS may differ between clinical training programs and healthcare professions. For example, pharmacy programs would need to teach more detail related to the use of pharmaceutical management options for LBP, whereas physiotherapy programs would need to teach more detail on exercise and manual therapy options. Therefore, the LBP-CCS has been designed to provide high-level guidance regarding the content that should be covered, while acknowledging that the implementation of the LBP-CCS within individual academic programs may vary depending upon numerous factors. Moving forward, the development of profession-specific versions of the LBP-CCS, informed by professional representatives, could be considered to identify the content of most importance for each profession, while recognising time restraints within training programs.

Wide-spread dissemination of the LBP-CCS is essential to facilitate global uptake and produce change in LBP education standards. The LBP-CCS and associated resources are freely available online [ 34 ] and these will be disseminated to entry-level clinical training programs worldwide. Dissemination will occur through endorsing organisations, including professional organisations with global reach, working group members, and directly to entry-level clinical training programs.

We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to develop or benchmark the content of curriculum related to LBP in new or existing entry-level clinical training programs. Use of the LBP-CCS will help to increase the consistency and quality of LBP education.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

  • Low back pain

Low Back Pain Curriculum Content Standards

International Society for the Study of the Lumbar Spine

International Federation of Orthopaedic Manipulative Physical Therapists

World Physiotherapy

World Federation of Chiropractic

European Pain Federation

Musculoskeletal Association of Chartered Physiotherapists

Council of Physiotherapy Deans Australia and New Zealand

International Association for the Study of Pain

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Acknowledgements

The authors wish to acknowledge and thank the members of the Low Back Pain Curriculum Content Standards working group for their involvement in the development of the Low Back Pain Curriculum Content Standards: Fiona Blyth (Medicine– general practice, Australia); Dawn Carnes (Osteopathy, England); Chad Cook (Physiotherapy, America); Ben Darlow (Physiotherapy, Primary health care, New Zealand); Renee de Ruijter (IFOMPT representative, Physiotherapy, Switzerland); Julie Fritz (Physiotherapy, America); Brona Fullen (EFIC representative, Physiotherapy, Ireland); Doug Gross (Physiotherapy, Canada); Jill Hayden (Chiropractic, Canada); Jonathan Hill (Physiotherapy, England); Jaro Karppinen (Medicine– physical and rehabilitation medicine, Finland); Greg Kawchuk (Chiropractic, Canada); Alice Kongsted (Chiropractic, Denmark); Deborah Kopansky-Giles (WFC representative, Chiropractic, Canada); Henrik Hein Lauridsen (Chiropractic, Denmark); Michael Lee (CPDANZ representative, Chiropractic, Physiotherapy, Australia); Quinette Louw (Physiotherapy, South Africa); Kerry Mace (Consumer, Australia); James McAuley (Psychology, Australia); Andrew McLachlan (Pharmacy, Australia); Chris Mercer (MACP representative, Physiotherapy, England); Peter O’Sullivan (Physiotherapy, Australia); Sue Reid (Physiotherapy, Australia); Anna Ryan (Medicine, Chiropractic, Australia); Paolo Sanzo (IFOMPT representative, Physiotherapy, Canada); Edward Vresilovic (ISSLS representative, Medicine– orthopaedic surgery, America); Arnold Wong (Physiotherapy, Hong Kong).

No funding was obtained to support the development of the LBP-CCS.

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HJ formed and led the steering group, was involved in the design of the development process, formed the working group, performed the literature review, extracted data, drafted each iteration of the LBP-CCS, led the review of the LBP-CCS by the working group, reviewed all iterations of the LBP-CCS, and approved the final version. MH was a member of the steering group, was involved in the design of the development process, formed the working group, extracted data, reviewed all iterations of the LBP-CCS, and approved the final version. BB was a member of the steering group, was involved in the design of the development process, formed the working group, extracted data, reviewed all iterations of the LBP-CCS, and approved the final version. MO was a member of the steering group, was involved in the design of the development process, formed the working group, extracted data, reviewed all iterations of the LBP-CCS, and approved the final version. CM was a member of the steering group, was involved in the design of the development process, formed the working group, reviewed all iterations of the LBP-CCS, and approved the final version. All authors read and approved the final manuscript.

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Jenkins, H.J., Brown, B.T., O’Keeffe, M. et al. Development of low back pain curriculum content standards for entry-level clinical training. BMC Med Educ 24 , 136 (2024). https://doi.org/10.1186/s12909-024-05086-x

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Retailers and Health Systems Can Improve Care Together

  • Robert S. Huckman,
  • Vivian S. Lee,
  • Bradley R. Staats

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Health systems are struggling to address the many shortcomings of health care delivery: rapidly growing costs, inconsistent quality, and inadequate and unequal access to primary and other types of care. However, if retailers and health systems were to form strong partnerships, they could play a major role in addressing these megachallenges.

While some partnerships do exist, they are rare and have only scratched the surface of their potential. Rather than focusing on the direct-to-consumer model that retailers have largely employed, the partnerships should offer much broader care.

Drawing on real-world examples, the authors outline four key actions that retailers and health systems should take: (1) They must move beyond convenience to offer comprehensive care. (2) They should move care from clinics into the home. (3) They should leverage data to improve clinical care and the customer experience. And (4) they should change how—and by whom—health care work is done. Implementing these four actions would generate improvements that would benefit not just patients but also the organizations that pay for their health care.

They should coordinate their complementary services to help consumers and better address the needs of employers and insurers.

Idea in Brief

The problem.

Health systems are struggling to address the megachallenges facing health care: rapidly growing costs, inconsistent quality, and inadequate and unequal access to primary and other types of care.

Forge partnerships with retailers, which have largely focused on providing consumers with a convenient way to obtain basic care for one-off services such as taking a throat culture, treating an ear infection, or administering a flu vaccine.

The Way Forward

Together, retailers and health systems can better provide comprehensive care for complex conditions, offer care in patients’ homes, leverage data to improve clinical care and the customer experience, and address the looming labor shortage in health care.

The Covid-19 pandemic and its aftermath have starkly highlighted the shortcomings of health care delivery in the United States and many other countries: rapidly growing costs, inconsistent quality, and inadequate and unequal access to primary and other types of care. However, if retailers and health systems were to forge strong partnerships, they could play a major role in addressing these megachallenges. While some retail–health care partnerships exist—for example, one between Target and Kaiser Permanente in Southern California began in 2014—they are rare and have only scratched the surface of their potential. To fundamentally change how health care is delivered, more of these partnerships are needed, and many of those that exist must be reoriented toward a different goal. Rather than focusing on the direct-to-consumer model that retailers have largely employed to provide a handful of basic services, the partnerships must offer much broader care. They should, of course, target the needs of consumers, but they must also help employers and insurers manage the overall health—and health care spending—of the populations they cover. In this article, we make the case for these partnerships and highlight four key actions that retailers and health systems must take to achieve this larger goal.

  • Robert S. Huckman is the Albert J. Weatherhead III Professor of Business Administration at Harvard Business School, where he is the Howard Cox Faculty Chair of the HBS Health Care Initiative and head of the Technology and Operations Management unit. robert_huckman
  • Vivian S. Lee , MD, is an executive fellow at Harvard Business School. She is the former president of Verily Health Platforms at Alphabet, the former CEO of University of Utah Health, and the author of The Long Fix: Solving America’s Health Care Crisis with Strategies That Work for Everyone (W.W. Norton, 2020).
  • Bradley R. Staats is Ellison Distinguished Professor of Operations at the University of North Carolina’s Kenan-Flagler Business School, where he is the faculty director of the UNC Center for the Business of Health and senior associate dean of strategy and academics. He is the author of Never Stop Learning: Stay Relevant, Reinvent Yourself and Thrive (Harvard Business Review Press, 2018). brstaats

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Published on 16.2.2024 in Vol 10 (2024)

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

Authors of this article:

Author Orcid Image

  • Jie Wang 1 * , BMed   ; 
  • Fangqin Tan 1 * , BMed   ; 
  • Zhenzhong Wang 1 , BM   ; 
  • Yiwen Yu 1 , MPH   ; 
  • Jingsong Yang 1 , BMed   ; 
  • Yueqing Wang 1 , MPH   ; 
  • Ruitai Shao 1 , PhD   ; 
  • Xuejun Yin 1, 2 , PhD  

1 School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China

2 The George Institute for Global Health, University of New South Wales, Sydney, Australia

*these authors contributed equally

Corresponding Author:

Xuejun Yin, PhD

School of Population Medicine and Public Health

Chinese Academy of Medical Sciences & Peking Union Medical College

31 Beijige San Tiao

Dongcheng District

Beijing, 100005

Phone: 86 18600988138

Email: [email protected]

Background: Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

Objective: This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

Methods: The method of this scoping review has been guided by the framework by Arksey and O’Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

Results: A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

Conclusions: This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

Introduction

Noncommunicable diseases (NCDs) constitute a formidable global health challenge, accounting for approximately 80% of NCD-related deaths, and they include cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes [ 1 ]. Hypertension is the most pivotal risk factor for cardiovascular diseases [ 2 ]. The prevalence of hypertension among adults aged 30-79 years worldwide is estimated to be 1.28 billion, with an alarming 700 million individuals unaware of their condition. Less than half of adults with hypertension are diagnosed and treated. Only approximately 1 in 5 adults with hypertension have their blood pressure controlled [ 3 ]. Similarly, the global prevalence of diabetes among adults has surged to 537 million in 2021, with nearly half of these cases (240 million) remaining undiagnosed. Moreover, the treatment rate for diabetes is suboptimal, with only 32.9% of patients receiving appropriate care and a mere 16.5% attaining treatment goals [ 4 ]. Evidence suggests that a substantial proportion of patients with hypertension and diabetes reside in low- and middle-income countries (LMICs), wherein the management of these conditions remains persistently low [ 3 , 5 ].

Hypertension and diabetes are often approached differently by distinct clinical subspecialties owing to their clinical complexities. However, it is essential to recognize that the management of these 2 conditions together can be highly beneficial owing to their shared risk factors and bidirectional interaction. The management of hypertension and diabetes also shares the same pathway, which includes early detection, appropriate treatment, and continuous monitoring. The health care systems and implementation strategies designed to ensure the continuity of care exhibit significant overlap and can be harnessed efficiently and effectively to support both hypertension and diabetes patients. The care cascade is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome [ 6 ]. This model has sequential stages, including awareness, screening, diagnosis, appropriate management, and disease control, that patients navigate while accessing health care services. Acknowledging potential lapses at each stage, the care cascade model identifies critical stages where patients may disengage, hindering them from attaining disease control [ 7 ]. The care cascade model was originally conceived for HIV care [ 8 ]. It has since been extended to monitor and manage infectious diseases, such as hepatitis C [ 9 ] and tuberculosis [ 6 ], and has been more recently applied to NCDs [ 10 ].

The utility of studying the care cascade of hypertension and diabetes goes beyond the mere exploration of their clinical pathways. It encompasses a broader holistic perspective that includes not only clinical aspects but also the impact on health systems, the quality of life of affected individuals, and the efficiency of health care delivery. Cascade analysis for hypertension and diabetes can help understand the common factors that affect the care model in order to identify appropriate strategies to improve health care for these 2 conditions. However, there is limited evidence synthesis regarding the care cascade of hypertension and diabetes. Therefore, we performed a systematic scoping review with the goal of mapping and describing the current state of evidence on a global scale. We sought to understand the process of hypertension and diabetes management, identify the factors that influence each stage of the care cascade, and explore potential interventions that hold promise for improving care continuity. By synthesizing existing evidence, our findings seek to inform future research endeavors, propelling the advancement of management strategies for hypertension and diabetes.

Study Design

This scoping review was conducted following the stages of a scoping review by Arksey and O’Malley [ 11 ] and was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 12 ].

Identifying the Research Questions

This scoping review focused on mapping the existing evidence on the care cascade of hypertension and diabetes. The specific research questions were as follows:

  • How the care cascade model has been applied in hypertension and diabetes research?
  • Which stage of the hypertension and diabetes care cascade has the current research in high-income countries (HICs) and LMICs primarily focused on?
  • What are the barriers and facilitators of hypertension and diabetes care cascade completion?
  • What strategies have been employed to improve retention in the hypertension and diabetes care cascade?
  • What are the key knowledge gaps that remain in the literature about the hypertension and diabetes care cascade?

Identifying Relevant Studies

To identify relevant studies, a systematic search was conducted in MEDLINE, Embase, and Web of Science, using terms pertinent to hypertension, diabetes, and the specific stages of the care cascade. The framework of population, concept, and context was used to identify core concepts related to the research question and inform the search strategy [ 13 ]. A complete overview of the search terms for each database is provided in Multimedia Appendix 1 . The population of interest in this review was adults aged 18 years or older who had been screened for or diagnosed with hypertension or type 2 diabetes, as well as patients with hypertension or type 2 diabetes undergoing treatment or management. The key concept of the review was the hypertension and diabetes care cascade, with a focus on studies explicitly applying the cascade care model to one or more stages of screening, diagnosis, treatment, and control. Articles describing interventions targeting specific stages of the cascade or factors influencing interventions or outcomes of at least one stage of the care cascade were included. The review aimed to explore a broad range of influencing factors involving both barriers and facilitators, with all pertinent descriptions included, regardless of statistical associations. The contextual scope of this review was in both HICs and LMICs, where hypertension and diabetes care was provided. The timeframe for database searches spanned from January 2011 to January 2023 since the concept of the care cascade was introduced in 2011 [ 8 ]. There was no restriction on publication language, allowing for an inclusive evaluation of relevant studies worldwide. The eligibility criteria are shown in Textbox 1 .

  • Population: Adults aged 18 years or older who had been screened for or diagnosed with hypertension or type 2 diabetes and patients with known hypertension or type 2 diabetes currently undergoing treatment or management.
  • Concept: Hypertension and diabetes care cascade, with a focus on studies explicitly applying the cascade care model to one or more stages from awareness to control. Interventions that impact patient outcomes and factors that influence implementation outcomes and service outcomes within at least one stage of the care cascade.
  • Context: No limitation. All clinical and primary care settings.
  • Language: No limitation.
  • Published between January 1, 2011, and January 17, 2023.
  • Article type: Original articles and protocol papers, including cross-sectional studies, cohort studies, trials, and implementation studies published in peer-reviewed journals.

Study Selection

All identified articles were imported into Covidence, and duplicates were removed. Screening proceeded through 2 distinct stages, where titles and abstracts were assessed independently by 4 researchers (JW, FT, XY, and ZW) in pairs, adhering to predefined inclusion and exclusion criteria to determine potential eligibility. In the event of disagreements, a collaborative discussion within the research team swiftly resolved any discrepancies. Subsequently, full-text screening followed a similar process, again involving 4 researchers (JW, FT, YY, and ZW) in pairs. Articles were excluded if they were (1) observing outcomes unrelated to hypertension and type 2 diabetes health care; (2) case reports, conference abstracts, editorials, commentaries, or reviews; and (3) unavailable in full text. Any unresolved discrepancies in article eligibility were resolved by group discussion until a consensus was reached. Notably, to glean insights into ongoing or planned projects and to identify potential interventions and relevant factors, study protocols were intentionally retained and not excluded in the scoping review.

Charting the Data

A data-charting form was created in Microsoft Excel and pilot tested with 15 articles to establish clarity and consistency in data extraction variables across reviewers. Data extraction was performed by 4 researchers (JW, FT, YY, and ZW). The extracted variables included title, author names, year of publication, study countries, disease of interest (hypertension, diabetes, or both), study method (quantitative, qualitative, or mixed method), study design (cross-sectional study, cohort study, trial, or implementation study), sample size, mean age of participants, stages of the care cascade involved, interventions aimed at improving retention, factors associated with stage completion, and reported outcomes. The care of hypertension and diabetes was divided into multiple stages of the cascade, including awareness, screening, diagnosis, linkage to care, treatment, medication adherence, and ultimately, disease control. The world’s economies were classified based on the World Bank classification as follows: low income, lower-middle income, upper-middle income, and high income [ 14 ]. The outcomes were categorized into implementation outcomes, service outcomes, and client outcomes. Implementation outcomes encompassed aspects pertaining to the process of implementing interventions and services for hypertension and diabetes care. This included factors such as acceptability, adoption, appropriateness, cost, feasibility, fidelity, and sustainability of interventions to health care providers or patients. Service outcomes were those related to the quality and effectiveness of the health care services provided to patients with hypertension and diabetes, such as access to health care services, continuity of care, appropriateness of care, equity of service, and health care provider adherence to clinical guidelines. Client outcomes, on the other hand, delved into the impact of health services on patients’ health and clinical conditions, such as blood pressure and blood glucose control, reductions in cardiovascular risk factors, and improvements in overall quality of life. To ensure data accuracy and consistency, a senior researcher (XY) reviewed all extracted data. Any disagreements were resolved by consensus.

Collating, Summarizing, and Reporting the Results

Interventions and influencing factors were analyzed by cascade stages and focused diseases. Studies that reported multiple stages of the care cascade were included in the synthesis of each relevant stage. The resulting information was subjected to rigorous quantitative analysis, employing frequencies and percentages to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management. The initial list of codes was grouped into categories and then themes against the supporting evidence. Throughout this process, subthemes and themes were discussed and refined within the research team.

Ethical Considerations

This review does not involve human subject information, primary data collection, or any form of experimentation on individuals.

Characteristics of the Included Studies

Of the 1321 unique articles identified for the title and abstract screening, 222 were retrieved for full-text review. Of these, 128 were included in the analysis after excluding 94 articles for various reasons ( Figure 1 ).

The 128 studies originated from 40 countries, with 42.2% (54/128) conducted in HICs ( Figure 2 ). Of the 128 studies, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and 18 (14.1%) reported on the care of both diseases. Most studies (104/128, 81.3%) employed quantitative methods. The majority were cross-sectional studies (70/128, 54.7%), followed by cohort studies (26/128, 20.3%). There were 24 (18.8%) trials evaluating interventions to promote retention in at least one cascade stage. Only 8 (6.3%) were implementation studies designed to systematically assess service delivery gaps and identify contextually appropriate solutions to address these bottlenecks. A total of 116 (90.6%) studies reported health receivers’ perspectives, and only 8 (6.3%) studies had health system perspectives. Most studies (83/128, 64.8%) reported client outcomes as primary outcomes, and they mainly focused on the measure of the effectiveness of disease control. Moreover, 16 (12.5%) studies reported service outcomes, and they mainly focused on the measure of satisfaction. Furthermore, 29 (22.7%) studies reported implementation outcomes, such as feasibility, cost, and adoption ( Table 1 ). Detailed characteristics of the 128 included studies are summarized in Multimedia Appendix 2 [ 10 , 15 - 131 ].

literature review healthcare management

Completion of the Hypertension and Diabetes Care Cascade

Only 3 studies documented all 7 cascade stages, with 2 of them focusing on hypertension management and 1 addressing both hypertension and diabetes [ 15 , 16 , 132 ]. They were all population-based cross-sectional surveys aimed to describe disease prevalence and quantify the unmet need for hypertension and diabetes care. The remaining studies included in our analysis examined specific stages of the care cascade. Among the studies focusing on hypertension, 13 highlighted increasing awareness and knowledge related to hypertension, 8 addressed the importance of screening through blood pressure measurements, 14 focused on the diagnosis of hypertension, 13 explored the linkage to care, 34 discussed the initiation of treatment, 16 emphasized medication adherence, and 26 explored blood pressure management and control. For diabetes care, 8 studies addressed the critical aspect of awareness, 16 concentrated on screening, 20 discussed the diagnosis of diabetes, 21 explored the linkage to care, 38 focused on treatment interventions, 23 examined medication adherence, and 37 investigated the factors impacting diabetes control. In addition, 18 studies adopted an integrated approach, encompassing care for both hypertension and diabetes. Among these studies, 6 addressed awareness, 1 addressed screening, 4 addressed diagnosis, 10 addressed linkage to care, 9 addressed treatment, 2 addressed medication adherence, and 10 addressed control ( Table 2 ).

Interventions of the Hypertension and Diabetes Care Cascade

Various interventions were identified to enhance the knowledge of disease prevention. Health education programs for hypertension and diabetes were emphasized as continuous efforts to support ongoing management and care [ 17 ]. The provision of comprehensive education was achieved through training classes and consulting at nutrition-based shared medical appointments [ 17 - 19 ]. Automated outreach call services with the integration of electronic health records emerged as effective approaches [ 20 ]. Out-of-hospital continuous nursing interventions and community awareness campaigns were used to augment the awareness [ 21 ]. Dissemination of awareness campaign information occurred through various channels, including the internet, public awareness events, and targeted home visits [ 22 ].

In the pursuit of enhancing the screening process for hypertension and diabetes, a diverse array of interventions has emerged. The Sustainable East Africa Research in Community Health (SEARCH) study implemented a community health campaign that offered universal adult screening, rendering screening services widely accessible [ 23 ]. Moreover, innovative approaches like home-based screening interventions empowered individuals by providing convenience and ease of access to early detection services [ 24 ]. Early diabetes detection was prioritized through specialized medical check-ups, facilitating timely intervention [ 22 ]. The Integrated Tracking, Referral, and Electronic Decision Support and Care Coordination (I-TREC) program incorporated cutting-edge technologies, including electronic case record forms and clinical decision support systems, streamlining patient information and offering guideline-based screening. Enhanced training for health care providers in NCD management and lifestyle interventions further fortified the screening process [ 25 ]. Lastly, efforts were made to strengthen health education and outreach services, particularly targeting individuals without symptoms, to foster a proactive approach to screening [ 26 ].

Effective interventions have been deployed to enhance the diagnosis of hypertension and diabetes. Continuous and coordinated care among multi-level health institutions was emphasized to enable timely diagnosis and consistent follow-up for hypertension and diabetes. Telephone peer coaching provided personalized support through weekly calls, aiding in timely diagnosis and empowering patients to engage in self-care [ 27 ]. Patient-centered integrated care with advanced technologies, such as electronic case record forms and clinical decision support systems, streamlined patient information and referrals to deliver tailored guideline-based care. Enhanced training for primary health care providers further strengthened timely diagnosis among patients [ 25 ].

Linkage to Care

Follow-up within 6 weeks at NCD clinics for participants with hypertension, coupled with the use of diabetes self-management record sheets and telephone reinforcement, has shown positive outcomes [ 133 ]. Additionally, 8-week training classes encompassing diverse self-care aspects have demonstrated effectiveness [ 18 ]. Mobile health applications [ 28 ], shared medical appointments [ 29 ], telephone peer coaching [ 27 ], and regular general practitioner contact [ 30 ] have proven to be successful strategies for ensuring a smooth connection to care. Furthermore, providing training in communication skills and self-care education to health providers, along with reduced workload and increased availability of competent diabetes specialist nurses, has contributed to enhancing the linkage to care [ 31 ]. Educational group programs, decision support tools, and feedback reports for primary care professionals further reinforced the process [ 32 ]. Institution-level continuity of ambulatory care [ 33 ], standardized “self-care” programs [ 22 ], and patient-held health records [ 34 ] have also played pivotal roles in promoting seamless linkage to essential health care services among patients diagnosed with hypertension and diabetes.

Various interventions have been explored to improve the treatment process for patients with hypertension and diabetes. Lifestyle interventions, including physical activity promotion and heart-healthy diets, have shown promise in improving treatment outcomes [ 35 ]. Collaborative care models involving pharmacists and physicians demonstrated positive effects on medication therapy management and overall patient care [ 36 ]. Self-monitoring of blood pressure is vital for facilitating appropriate treatment [ 37 ]. Additionally, interventions targeting medication affordability [ 38 ] and continuity of care [ 39 - 41 , 134 ] play crucial roles in ensuring optimal treatment adherence. Telehealth and digital interventions, such as continuous remote care and mobile health applications, are being explored for improved treatment accessibility and engagement [ 28 , 135 ]. Integrated care models, employing multidisciplinary teams and decision support tools, have yielded promising outcomes in coordinating comprehensive patient care [ 20 , 136 ]. Targeted education for patients and health care providers can effectively enhance communication and self-care skills [ 31 , 32 ]. Moreover, financial incentive programs, like pay-for-performance schemes, have encouraged optimal health care delivery and reimbursement [ 42 ].

Medication Adherence

A range of interventions has been investigated to optimize medication adherence in patients with hypertension and diabetes. Community-based interventions with patient education, recall services, and reduced out-of-pocket payments have shown promise in promoting adherence [ 43 ]. Self-measured blood pressure monitoring and chronic disease management programs in primary care settings facilitated continuous and comprehensive patient care [ 38 , 44 ]. Telephone peer coaching [ 27 ], regular general practitioner contact [ 30 ], and continuity of care initiatives [ 39 , 40 , 45 , 46 , 134 ] have also demonstrated positive effects on medication adherence. Collaborative care models, which involve patient-centered coordinated care, referral systems, and diabetes education, have yielded favorable results [ 47 ]. Additionally, interventions, such as medication co-payment schemes, enhanced counseling, and training for health care providers in communication skills, have reinforced medication adherence efforts [ 31 , 48 ]. Patient and provider engagement programs, along with pay-for-performance initiatives, have also incentivized optimal medication adherence [ 32 , 42 ]. Integrating pharmacists into multidisciplinary care teams has enhanced medication management and adherence [ 136 ].

Interventions, including multidisciplinary collaboration, patient education, and technology integration, were adopted to enhance hypertension and diabetes control. The integration of pharmacists into care teams and the transition to specialized diabetes physicians can optimize disease management [ 49 , 50 , 136 ]. For instance, pharmacist-physician collaborative practice models have shown promise through features like shared medical records, defined interprofessional roles, frequent follow-ups, and collaborative practice agreements [ 50 ]. Structured educational programs, both for patients and primary care professionals, offer essential knowledge and support, such as tailored SMS text message communication and telephone peer coaching [ 27 , 51 ]. Patient health records and electronic decision support were used to improve the continuity of care and enable tailored interventions [ 34 ]. Additionally, integrated interventions like the EMPOWER-PAR program, grounded in the Chronic Care Model, made contributions to advancing disease control, even in the face of challenges related to health care system constraints [ 137 ].

Barriers and Facilitators of Completing Different Stages of the Care Cascade

In the completion of the hypertension and diabetes care cascade, several barriers and facilitators were identified, encompassing patient-level and system-level factors ( Table 3 ). Patient-level barriers included factors like low socioeconomic status, unhealthy lifestyle choices, and limited health literacy, hindering effective management. Misconceptions about disease and treatment, high treatment costs, and fear of diagnosis also impeded the care progress. At the system level, inadequate resources, heavy workloads, limited capacity in primary care, and a fragmented health system were identified as significant obstacles to effective care.

a HIC: high-income country.

b LMIC: low- and middle-income country.

Conversely, various patient-level facilitators positively impacted the cascade. At the patient level, characteristics like high socioeconomic status, positive health behaviors, and strong belief in treatment efficacy played vital roles. Furthermore, timely monitoring of blood pressure and glucose levels, engagement in health programs, and partner involvement were found to be associated with improved outcomes. System-level facilitators included a well-trained health workforce, existing chronic disease management programs, and improved access to medications.

Notably, certain barriers and facilitators were context-specific, with diverse prominence in HICs and LMICs. For instance, lack of understanding and misconceptions were more prevalent in LMICs, while the influence of cultural beliefs and minority status was more pronounced in HICs. Physician density and adequate resources were often noted as facilitators in HICs, while social support and tailored diabetes education were emphasized in LMICs.

This scoping review identified a substantial body of literature investigating the hypertension and diabetes care cascade in both HICs and LMICs. While most studies provided descriptive snapshots of each cascade stage, only a limited number of studies applied implementation cascade analysis to explore the barriers and facilitators of patient retention. Furthermore, there was a paucity of studies evaluating the effects of interventions to bridge gaps between cascade stages. In addition to analyzing the characteristics of the included studies, this scoping review comprehensively summarized key interventions, facilitators, and barriers associated with completing cascade stages. These findings provide critical insights into the existing evidence on hypertension and diabetes management, offering valuable directions for enhancing health care delivery for these chronic conditions.

The results of this scoping review have revealed a notable gap in the existing literature concerning the entire continuum of all stages in the hypertension and diabetes care cascade. The majority of studies predominantly focused on treatment and control for both hypertension and diabetes care. There was a relative paucity of studies examining the stages before treatment initiation despite evidence suggesting that over 50% of patients with hypertension and diabetes who could benefit from treatment never start medication [ 3 , 72 ]. These pretreatment losses accounted for a much greater reduction in effective care than nonadherence to medication [ 101 ]. Modeling studies showed that treatment losses earlier on can result in a greater overall reduction in the public health benefit of hypertension management [ 142 , 143 ]. Potential gaps exist in identifying problems and developing strategies to improve awareness, screening, and diagnosis of the 2 diseases. Based on microsimulation modeling, it is estimated that scaling up diagnosis, treatment, and control of diabetes to achieve a hypothetical 80% target for each component of the care cascade would be highly cost-effective [ 143 , 144 ]. Regarding interventions to improve retention across cascade stages, the review emphasizes the importance of awareness campaigns and health education programs to improve patient retention in care and medication adherence. Moreover, interventions targeting the health system (ie, multidiscipline collaborative care, training for primary health care providers, and increasing access to medications) showed promise in improving diagnosis and treatment outcomes. Other innovations in hypertension and diabetes service delivery have been developed and could further enhance quality, but they require further study and proof of effectiveness at scale. Examples include electronic case record–based clinical decision support systems and telephone peer coaching [ 27 , 32 ]. There was a relative dearth of studies incorporating informatics, internet techniques, and mass media to capture public opinions and enhance patient engagement in the management of these conditions. These technologies and communication strategies have only recently gained prominence, and their full potential in the context of hypertension and diabetes care has not yet been comprehensively explored. Our findings parallel another review about the implementation of telemedicine interventions for hypertension and diabetes, indicating that successful implementation of these interventions necessitates comprehensive efforts at all stages of planning, execution, engagement, and reflection and evaluation [ 145 ]. The adaptation of interventions to diverse contexts, particularly in LMICs with fragile health systems, warrants future studies. Implementation studies are essential to develop context-specific strategies for incorporating evidence-based interventions effectively into practice [ 146 ].

The review also revealed several facilitators and barriers affecting different stages of the care cascade across different income contexts. These insights are of paramount importance, serving as a compass for forthcoming investigations. Future studies can harness these nuanced factors to craft precise context-specific strategies that seamlessly integrate evidence-based interventions into clinical practice. Tailored interventions that address specific patient characteristics, cultural beliefs, and health system constraints are pivotal to enhancing care delivery. The implementation of evidence-based strategies, coupled with the cultivation of patient-centered care, paves the way for health care systems to embark on a journey toward equitable and ameliorated outcomes in hypertension and diabetes management, thereby catering to the unique needs of diverse patient populations.

This review highlights that the provision of integrated care for individuals with both hypertension and diabetes within primary care settings has the potential to be a judicious and efficient approach. The rationale behind this integration lies in the substantial overlap between the risk factors and management pathways of these 2 prevalent chronic conditions. This shared etiological foundation emphasizes the importance of addressing common risk factors, such as dietary patterns, physical activity levels, smoking habits, and weight management, concurrently. By focusing on integrated interventions that aim to modify these shared risk factors, primary care providers can foster holistic and synergistic management. Moreover, primary care providers play a pivotal role in early diagnosis, timely initiation of treatment, and regular follow-up. This proactive approach is essential for mitigating the burden of hypertension and diabetes, as well as their associated complications.

Our study has several strengths. We identified studies from a wide range of geographic and care delivery settings. In addition, this review expands upon the evidence regarding interventions throughout the hypertension and diabetes care cascade, offering insights into diverse strategies to address each stage. By encompassing studies conducted in both HICs and LMICs, this review captures the global perspective on interventions for hypertension and diabetes care. This strengthens the generalizability of the findings and provides insights into the varying challenges and approaches across different health care settings. While this scoping review offers valuable insights into the extensive body of literature concerning the hypertension and diabetes care cascade, it is important to recognize the inherent limitations of this approach compared to systematic reviews and meta-analyses. This breadth of mapping key concepts across diverse domains and disciplines might come at the cost of depth. The interventions described in our review predominantly featured descriptive accounts in the included reports, with the absence of a quantitative assessment of intervention effects, which is important for informing designs in other settings but does not allow for inferences about their effectiveness. As is typical with scoping reviews, we did not assess the quality of the included articles. This inherent limitation underscores the need for further research, particularly systematic reviews and meta-analyses, to delve deeper into the efficacy of interventions across various stages of the hypertension and diabetes care cascade. Moreover, the focus of this review was on studies that explicitly applied the cascade care lens to one or more stages of hypertension and diabetes care, which may have inadvertently excluded studies that explored these critical stages without using the term “cascade” or its associated lexicon. While this search strategy enabled a more targeted examination of research aligned with the cascade model, it also introduced an inadvertent restriction, potentially omitting relevant investigations that did not employ the cascade framework explicitly. This limitation underscores the need for future studies to explore these care stages more comprehensively, even when the cascade terminology is not explicitly invoked, providing a more holistic view of hypertension and diabetes care. Despite this limitation, our scoping review offers valuable insights into a broad landscape of influencing factors and interventions across the care cascade.

In conclusion, this scoping review offers valuable insights into the evidence of the hypertension and diabetes care cascade, highlighting the importance of comprehensive interventions that address all stages of disease management. By identifying facilitators and barriers, the study emphasizes the need for tailored health care strategies to improve patient outcomes. Moving forward, integrating collaborative care models, tailored education programs, and health care system enhancements can potentially enhance disease control and improve the quality of life for individuals living with hypertension and diabetes. These findings have significant implications for clinical practice and health policy, serving as a foundation for future research and efforts to optimize the care cascade for chronic disease management.

Acknowledgments

The study was supported by the nonprofit Central Research Institute Fund of the Chinese Academy of Medical Sciences (grant number: 2021-RC330-004). RS ([email protected]) and XY are cocorresponding authors for this study.

Data Availability

The data sets generated during or analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

XY and RS conceived and designed the study. XY developed the search strategy. JW and FT ran the search. JW, FT, ZW, YY, and XY conducted the study selection processes (title and abstract screening followed by full-text screening). JW, FT, ZW, and YY extracted the data. XY verified the data extraction. JW, FT, and XY analyzed and interpreted the data. JW wrote the first draft of the manuscript with XY. All authors contributed to the writing of the manuscript. All authors critically revised the manuscript and approved the final version.

Conflicts of Interest

None declared.

Search strategy.

Details of the included studies.

PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist.

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Abbreviations

Edited by A Mavragani; submitted 15.08.23; peer-reviewed by S Wei, P Mathur; comments to author 11.10.23; revised version received 22.10.23; accepted 27.12.23; published 16.02.24

©Jie Wang, Fangqin Tan, Zhenzhong Wang, Yiwen Yu, Jingsong Yang, Yueqing Wang, Ruitai Shao, Xuejun Yin. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 16.02.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on https://publichealth.jmir.org, as well as this copyright and license information must be included.

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Management of vesicoenteric fistulas arising from perforated Meckel’s diverticulum: a report of a case and review of the literature

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Dimitrios Diamantidis, Nikolaos Papatheodorou, Panagiotis Kostoglou, Georgios Tsakaldimis, Sotirios Botaitis, Management of vesicoenteric fistulas arising from perforated Meckel’s diverticulum: a report of a case and review of the literature, Oxford Medical Case Reports , Volume 2024, Issue 2, February 2024, omad155, https://doi.org/10.1093/omcr/omad155

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Vesicoenteric fistulas are rare, with an incidence of 0.1%–0.2% in the general population, and Meckel’s diverticulum is a rare cause, accounting for less than 5% of cases with challenging diagnosis due to atypical symptoms at the admission. This article presents a case of a vesicoenteric fistula formation between Meckel’s diverticulum perforated by a foreign body and urinary bladder in a 38-years-old Caucasian male admitted to emergency department due to colicky abdominal pain located in the lower abdomen. An extensive review of the literature was conducted referring all the cases of vesicoenteric fistula incorporating Meckel’s diverticulum to elucidate the clinical characteristics, explore the diagnostic yield, and to summarize the therapeutic approach.

Meckel’s diverticulum is a rare entity that affects the gastrointestinal tract and characterized by a blind pouch protruding from the wall of the small intestine approximately two inches long. It is usually caused by failure of the omphalomesenteric duct to obliterate, and usually being found within two feet from ileocecal valve. Although it is usually asymptomatic, it can lead to complications such as ulceration, bleeding, and even vesicoenteric fistula formation. Vesicoenteric fistulas are abnormal connections between the urinary bladder and an intestinal (small bowel) segment that could cause the leakage of urine into the intestine [ 1–4 ]. They pose a scarce pathology throughout the literature, with an incidence rate of 0.1%–0.2% in general population. They develop between Meckel’s diverticulum and urinary bladder, in less than 5% of cases [ 2 ]. Symptoms of vesicoenteric fistulas can include abdominal pain, fever, urinary retention, and vomiting [ 5 ]. These conditions can be diagnosed further through a combination of clinical examination, laboratory, and imaging tests. Treatment of vesicoenteric fistulas due to Meckel’s diverticulum typically involves the resection of the affected intestinal portion and repair of the fistula [ 6 ]. In some cases, laparoscopic surgery can be used successfully to treat these fistulas [ 5 , 7 ]. This article reports a rare case of a male patient suffering from an unknown until the point of the admission vesicoenteric fistula developed between the perforated by foreign body Meckel’s diverticulum and urinary bladder. Additionally, an extensive review of the literature using PubMed library was conducted using the keywords ‘enterovesical AND fistula AND meckel AND diverticulum’, ‘foreign AND body AND fistula AND meckel AND diverticulum AND vesicoenteric OR enterovesical’, ‘foreign AND body AND fistula AND meckel AND diverticulum’ and ‘vesicoenteric AND fistula AND meckel AND diverticulum’ in the title and abstract on June 2023. Moreover, the reference lists of the eligible studies and relevant review articles were cross-checked to identify all prior reported case reports of vesicoenteric fistula from Meckel diverticulum, and to determine the set of symptoms, the different diagnostic tools, and the surgical approach.

A 38-year-old Caucasian male patient was admitted to the emergency department of the University Hospital of Alexandroupolis with colicky abdominal pain, ongoing for three weeks. The patient reported slight remission of the symptoms the last two weeks and exacerbation of them two days before his admission. No active bleeding, history of hematochezia, faecaluria or pneumaturia was reported by the patient. The patient was afebrile, without accompanying nausea or vomiting. Vital parameters were recorded: blood pressure measurement 125/80 mm Hg, oxygen saturation rate 97% and pulse rate of 87 beats per minute. During the clinical examination, the abdomen was distended and tympanic, with intense tenderness in the hypogastrium and right and left iliac fossa. Positive McBurney and Rovsing signs were found, as well as decreased bowel sounds during auscultation. The laboratory tests results revealed leukocytosis, with a polymorphonuclear type, and increased inflammation indices. Table 1 summarizes the results of the laboratory tests. The emergent abdominal computed tomography (CT) revealed a thin elongated radiopaque formation about 2 cm long, that could be a foreign body, protruding from a blind small bowel loop (attributed to Meckel’s diverticulum, Fig. 1 ) into the pelvic cavity ( Fig. 2 ). Focal thickening as well as edema of the intestinal wall and the surrounding mesenterial fat was revealed, without any extraluminal air bubbles or intra-abdominal fluid collections ( Fig. 1 ).

Laboratory test results

Computed Tomography of the abdomen: a blind intestinal loop (thin arrow) was attributed to Meckel’s diverticulum. Concomitant focal thickening as well as edema of the intestinal wall and the surrounding mesenterial fat (thick arrow).

Computed Tomography of the abdomen: a blind intestinal loop (thin arrow) was attributed to Meckel’s diverticulum. Concomitant focal thickening as well as edema of the intestinal wall and the surrounding mesenterial fat (thick arrow).

Computed Tomography of the abdomen: a thin elongated hyperdense nodule about 2 cm long perforating the intestinal wall, attributed to a foreign body (fish-bone).

Computed Tomography of the abdomen: a thin elongated hyperdense nodule about 2 cm long perforating the intestinal wall, attributed to a foreign body (fish-bone).

The patient underwent an emergent exploratory laparotomy. Intraoperatively, distended small bowel coils and a hypertrophic but non-inflammatory appendix vermiformis were discovered. During the small bowel examination, adhesions as well as a large about one and a half inches long, inflammatory, and perforated by a fishbone Meckel’s diverticulum was observed about 80 cm from the ileocecal valve ( Fig. 3 ), solidly attached to the urinary bladder. Adhesiolysis, segmental small bowel resection incorporating the Meckel’s diverticulum, and a side-to-side small bowel anastomosis were carried out ( Fig. 4 ). Urinary bladder leakage was discovered during the Douglas pouch examination, and the bladder wall deficit was then closed via a double-layer suture pattern. A drainage tube inserted and positioned in Douglas’s pouch to detect any early postoperative leakage. The patient’s postoperative course was uneventful and the patient discharged home on the sixth postoperative day, and the Foley catheter was removed on the tenth postoperative day.

Postoperative specimen from small bowel segmental resection including the perforated by a fish bone Meckel’s diverticulum.

Postoperative specimen from small bowel segmental resection including the perforated by a fish bone Meckel’s diverticulum.

Postoperative specimen from small bowel segmental resection including the perforated by a fish bone Meckel’s diverticulum.

Meckel’s diverticulum is the most common congenital anomaly of gastrointestinal tract characterized by a blind pouch protruding from the wall of the small intestine [ 2 , 4 ]. It is a rare condition, occurring in approximately 2% of the population [ 3 ]. While Meckel’s diverticulum is usually asymptomatic, it can cause various complications such as intussusception, intestinal obstruction, ulceration, bleeding, diverticulitis, perforation and, very rarely, neoplasms and vesicoenteric fistulas [ 1 , 4 ].

Vesicoenteric fistulas (VEFs) are abnormal connections between the urinary bladder and the intestine that can result in the leakage of urine into the intestinal lumen. These fistulas are rare complications, with an incidence of 0.1%–0.2% in the general population [ 2 ]. Meckel’s diverticulum is a rare cause of vesicoenteric fistulas, accounting for less than 5% of all cases while most commonly occur secondary to diverticulitis, Crohn’s disease, colon and bladder malignancies [ 6 ]. Recent literature has documented eleven similar cases, with Table 2 offering a comprehensive summary encompassing their symptoms, the diagnostic imaging techniques employed, and the surgical interventions performed. The cause of the formation of vesicointestinal fistulas to the reported cases included the following: unknown etiology—idiopathic in seven cases [ 2 , 3 , 5 , 7–10 ], Crohn disease [ 11 ], enterolith, adenocarcinoma of ectopic pancreatic tissue, and foreign body [ 12–14 ].

Eleven similar studies have been documented reporting vesicoenteric fistulas formation between Meckel’s diverticulum and urinary bladder

VEFs can be difficult to diagnose, as symptoms may be nonspecific and the condition is rare [ 5 ]. Symptoms of vesicoenteric fistulas can include abdominal pain, fever, lower urinary tract symptoms, urinary retention, and vomiting [ 6 , 7 ]. The diagnosis of these conditions can be made through a combination of clinical examination, laboratory tests, and imaging studies, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), cystoscopy, Tc-99 m DTPA or gastrointestinal (GI) contrast studies [ 6 ]. In some cases, including ours, laparotomy may be necessary to confirm the diagnosis [ 11 ]. In our case, a vesicoenteric fistula could not be seen in the emergent CT examination of the abdomen. The diagnosis was confirmed intraoperatively with the existence of a vesicoenteric fistula developed between the perforated by a foreign body (fishbone) Meckel’s diverticulum and the urinary bladder.

The surgical approach for the treatment of vesicoenteric fistulas incorporating Meckel’s diverticulum typically involves the removal of the affected portion of the intestine and the Meckel’s diverticulum, as well as repair of the fistula [ 7 ]. In some cases, additional procedures such as appendectomy may be necessary [ 2 ]. After surgery, the patient may need to undergo urinary catheterization and may require ongoing monitoring for any complications [ 5 ]. Laparoscopic surgery can successfully be used to treat vesicoenteric fistula due to Meckel’s diverticulum [ 7 ]. Operative management of vesicoenteric fistulas involves resection and reanastomosis of the bowel segment causing the fistula and closing of the bladder [ 6 ].

In conclusion, Meckel’s diverticulum is a rare cause of vesicoenteric fistula formation. It could lead to life-threatening complications due to foreign body ingestion or perforation. The diagnosis of vesicoenteric fistula poses a challenge even for an experienced radiologist. General surgeons should be aware of this scarcity because of the provocative treatment required. Treatment is mainly surgical and involves the removal of the affected portion of the intestine incorporating the Meckel’s diverticulum, as well as repair of the fistula. Further studies should be conducted to evaluate the safety and effectiveness of laparoscopic surgery for the treatment of vesicoenteric fistulas incorporated Meckel’s diverticulum.

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

None declared.

No funding source to declare.

A consent form completed and signed by the patient.

Dimitrios Diamantidis (Author), Nikolaos Papatheodorou (Co-author), Panagiotis Kostoglou (Reviewer), Georgios Tsakaldimis (Reviewer), and Sotirios Botaitis (Supervisor).

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