Complex Health Care System Research Articles

Intensive Care Unit Capacity, Cancellation of Elective Surgery, and the US Pandemic Response.

Intensive Care Unit Capacity, Cancellation of Elective Surgery, and the US Pandemic Response.

Adoption of a Data-Driven Bayesian Belief Network Investigating Organizational Factors that Influence Patient Safety.

Medical errors pose high risks to patients. Several organizational factors may impact the high rate of medical errors in complex and dynamic healthcare systems. However, limited research is available regarding probabilistic interdependencies between the organizational factors and patient safety errors. To explore this, we adopt a data‐driven Bayesian Belief Network (BBN) model to represent a class of probabilistic models, using the hospital‐level aggregate survey data from U.K. hospitals. Leveraging the use of probabilistic dependence models and visual features in the BBN model, the results shed new light on relationships existing among eight organizational factors and patient safety errors. With the high prediction capability, the data‐driven approach results suggest that “health and well‐being” and “bullying and harassment in the work environment” are the two leading factors influencing the number of reported errors and near misses affecting patient safety. This study provides significant insights to understand organizational factors’ role and their relative importance in supporting decision‐making and safety improvements.

Lean implementation within healthcare: imaging as fertile ground

PurposeThe purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective.Design/methodology/approachAn in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme.FindingsImplementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean.Practical implicationsWhen introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean.Originality/valueThis ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system.

How vision and leadership shaped the U.S. National Cancer Institute's 50-year journey to advance the evidence base of cancer control and cancer care delivery research

In 1971, Congress passed the National Cancer Act, landmark legislation that reorganized the National Institutes of Health's National Cancer Institute (NCI). The Act included a new focus on cancer control, including the requirement that the NCI award research grants and contracts, in collaboration with other public agencies and private industry, to conduct cancer control activities related to the diagnosis, prevention, and treatment of cancer. The requirement placed the NCI at the nexus of a rapidly changing science and a complex and dynamic healthcare delivery system and involved an evolutionary transformation to advance cancer control and cancer care delivery research along the cancer care continuum. Analysis is based on a qualitative ethnographic approach using historical records, oral histories, and targeted interviews. The multimethod approach provided the opportunity to describe the vision, leadership, and struggle to build an infrastructure, expand expertise, and forge collaboration with the NCI and a complex and changing healthcare system. As the 50th anniversary of the National Cancer Act approaches in 2021, the process and these achievements are at risk of being taken for granted or lost in the flow of history. Documenting the process, milestones, and key players provides insight and guidance for continuing to improve cancer care, advance research, and reduce cancer incidence and mortality. Cancer care is a microcosm of the larger healthcare system providing insight and lessons on the importance of developing and maintaining a research infrastructure and the role of multi-level collaboration and partnerships involving both the private and public sectors.

Professional identity of allied health staff associated with a major health network organizational restructuring.

Maintenance of professional identity, particularly during periods of organizational restructuring, is critical within modern complex healthcare systems as professional identity contributes to the psychological well-being of staff and leaders. This study aimed to evaluate change in professional identity of allied health staff associated with a major health network organizational restructuring in Australia. Data were collected from allied health staff in 2017 and 2019, before (n = 226) and after (n = 197) the restructuring. An online questionnaire including the 10-question Brown's Group Identification Scale that considers the strength of professional identity of the individual with their own professional group was used. Professional identity of allied health staff was high before and after the organizational restructuring, although several individual statements, and overall professional identity, declined significantly post-restructuring. It was difficult to attribute these changes solely to the restructuring due to some differences in demographic characteristics between the two cohorts. Future studies should seek to understand the effect of other workplace factors on the professional identity of allied health staff. Further research could also investigate allied health professional identity to understand its importance within contemporary healthcare.

The Importance of Developing Athletic Training Leadership Behaviors

ContextHealth care professionals such as athletic trainers (ATs) and athletic training educators should embrace contemporary leadership theories and practice leadership behaviors essential to professional responsibility.ObjectiveThis commentary discusses leadership behavior trends and the need for leadership development in professional athletic training education curricula and continuing education.BackgroundTraditional leadership theories focused on trait-based and “Great Man” characteristics. These theories suggest that leaders arise only through inherent or inherited leader-like behaviors. In contrast, contemporary leadership theories suggest that leaders can be developed and better promote the collegial leader-follower exchange that is needed to motivate, encourage, and support followers as well as a profession.SynthesisContemporary leadership theories involve a leader-follower relationship that integrates a teamwork approach into the workplace setting. Athletic trainers practice leadership behaviors but are less likely to demonstrate leadership characteristics when not practicing in their AT roles. Existing evidence suggests that contemporary leadership development can be helpful in athletic training to identify and develop future leaders, to promote the profession, and to improve patient outcomes.ResultsTransformational, team-centered leadership styles provide a growing opportunity for practicing ATs and athletic training students to expand into greater organizational leadership and decision-maker roles.Recommendation(s)Athletic trainer leadership knowledge, skills, and abilities development and professional responsibility should be emphasized more in professional athletic training educational programs and continuing education.Conclusion(s)Leadership behaviors that are effectively integrated into athletic training educational programs early and often may promote the profession by concurrently improving clinical and professional practice behaviors. Athletic trainers should practice leadership behaviors with greater frequency in differing societal constructs, communities, and complex health care systems.

Medically Underserved Populations: The Athletic Trainer's Role

Context Health care cost continues to rise; the US continues to spend dramatically more money than other developed nations per individual without increased health outcomes. More individuals are finding it harder to get access to a health care provider, especially those in medically underserved areas and populations. Objective To increase the knowledge of the athletic training educator about medically underserved populations and the roles athletic trainers (ATs) play as leaders in health care delivery. Background Current and future physician shortages are known and are only going to increase as more than one-third of current primary care physicians are expected to retire in the next 10 years. Forty percent of the population lives in areas that are medically underserved and designated by the government as areas of professional medical shortage; patients in these areas are primarily served by primary care physicians. Synthesis As with access to physicians, access to ATs has been shown to be based upon socioeconomic status and presents more challenges for the medically underserved. Early access to health care providers has shown to be important in adolescents, as negative health behaviors can carry into adulthood, leading to poorer health-related outcomes throughout life. Recommendation(s) To ensure that athletic training educational programs include opportunities to provide service to the medically underserved, education on social determinates of health, and the means by which ATs can fill critical holes in providing care for these patients. More research is needed to validate ATs' roles in providing quality health care. Additionally, more research is needed around how AT education can help meet patient needs. Conclusion(s) As the athletic training profession continues to evolve and responds to the growing demands of the complex health care system, access to an AT may provide a vital bridge to overall health care for patients within medically underserved populations.

Outcomes for Somali immigrant kidney transplant recipients in a large-volume transplant center

IntroductionKidney transplantation (KT) demands that patients navigate a complex healthcare system and adhere to lifelong therapy and surveillance. Cultural and linguistic discordance between patients and providers has been identified as a barrier to successful KT. We studied KT outcomes and disparities among a native Somali population living in Minnesota. MethodsBetween 1995 and 2015, 2,385 patients underwent KT at our institution; 22 were self-designated Somali nationals. Patient and graft survival and time to first rejection were analyzed. Utilization of interpreter services was evaluated. ResultsPatient survival for the Somali cohort at 1 year was 100% and 95.5% at 5 years; compared to 97.2% at 1 year and 89.1% at 5 years for the Caucasian cohort (p = 0.40). Graft survival for the Somali cohort at 1 year was 100% and 95.5% at 5 years; for the Caucasian cohort 94.8% and 81.6% (p = 0.35). Rejection-free survival in the Somali cohort was 100% at 1 and 5 years, for the Caucasian cohort 86.2% and 82.1 (p = 0.41). Among 22 adult Somali KT recipients, 15 (68%) patients frequently utilized interpreter services in their KT-related clinical encounters. ConclusionImmigrant Somali KT recipients, appear to have comparable KT outcomes compared to a contemporaneous Caucasian cohort.

Emerging roles for research intensive PhD prepared nurses: Beyond faculty positions.

Research-intensive PhD programs need to prepare nurse scientists to bridge the chasms between research, and practice and policy in an increasingly complex healthcare system. In practice, nurse scientists are critical to building capacity for research, promoting excellence in patient-centered care, and achieving or exceeding national quality benchmarks. Moreover, they provide methodological expertise and insight to address pressing clinical questions. PhD-prepared nurses also leverage their research expertise and practice knowledge to transform health policy in roles as organizational executives and leaders, advocates, and communicators. Re-envisioning nursing PhD curricula is required to ensure that PhD students are capable of not only conducting rigorous and impactful science, but launching careers across sectors of healthcare. Here, we summarize viewpoints of a special session from the October 2019 PhD Summit "Re-Envisioning PhD Programs of the Future" sponsored by the University of Pennsylvania School of Nursing and literature to invigorate thinking about ways to promote career transitions into nontraditional vital positions for nurse scientists. Advancing the health of patients and communities depends on preparing the next generation of nurse scientist to pursue career trajectories outside of traditional academic institutions.

Systems Thinking for Managing COVID-19 in Health Care Systems: Seven Key Messages.

This article provides the most current guidelines for nurse educators and nurses to use systems thinking to manage COVID-19 in health systems. A working definition of systems thinking is offered, with a review of basic knowledge and care in the context of the system awareness model (SAM). Seven key messages assist nurse educators and nurses in the management of COVID-19 patients culminating in leadership of complex health care systems using systems thinking. [J Contin Educ Nurs. 2020;51(9):402-411.].

Abstract 1186: Relationships between health literacy, having a cancer care coordinator, and long-term health-related quality of life among cancer survivors

Abstract Care coordination has been identified as a strategy to reduce challenges navigating the healthcare system for cancer patients. The objective of this study was to assess the association between cancer patients having a cancer care coordinator during their treatment and their long-term health-related quality of life (HRQoL) after treatment, and whether this association differs by level of health literacy. A population-based sample of patients diagnosed with breast, prostate, or colorectal cancer in 2015 were recruited from the Iowa Cancer Registry and invited by mail to participate in an online survey conducted in 2017-2018 (N=369). Survey and Registry data were analyzed using linear regression to model the association between having a cancer care coordinator during active treatment with post-treatment physical or mental HRQoL, a mean of 2.7 years later, by varying levels of health literacy while controlling for sociodemographic and clinical factors.Most patients (81%) reported having one individual coordinating their cancer care. Overall, having a care coordinator was not significantly associated with physical HRQoL (p=0.113). However, patients (20%) with low health literacy, who had a care coordinator, had significantly higher physical HRQoL scores (mean difference 5.0, p=0.022), while those with medium (29%) and high (51%) health literacy, did not (p=0.223, and p=0.864, respectively). Mental HRQoL scores were not associated with the presence of a care coordinator overall or when stratified by health literacy level. Findings suggested care coordinators improved post-treatment physical HRQoL, particularly for patients with low health literacy. Care coordinators may be beneficial to patients struggling to navigate the complex healthcare system during cancer treatment. Future research should focus on the mechanisms by which care coordination affects post-treatment HRQoL. PROMIS Physical HRQoL and CCC by Health Literacy LevelPROMIS Physical HRQoLMultivariable-Adjusted means (95% CI)Cancer Care CoordinatorLow Health LiteracyMedium Health LiteracyHigh Health LiteracyYes49.4 (42.7-56.1)48.9 (43.5-54.3)52.5 (46.1-58.8)No or I Don't Know44.4 (36.2-52.5)46.6 (39.3-53.8)52.1 (45.9-58.4p-valuep=0.0223p=0.2231p=0.8640PROMIS Mental HRQoLMultivariable-Adjusted means (95% CI)Cancer Care CoordinatorLow Health LiteracyMedium Health LiteracyHigh Health LiteracyYes49.7 (44.2-55.1)49.0 (45.5-52.5)55.3 (50.1-60.4)No or I Don't Know47.5 (39.9-55.2)48.1 (43.0-53.3)53.3 (48.3-58.2)p-valuep=0.4099p=0.6168p=0.3360 Citation Format: Natalie J. Del Vecchio, Mary Charlton, Natoshia Askelson, Knute Carter, Elizabeth Chrischilles, Charles Lynch. Relationships between health literacy, having a cancer care coordinator, and long-term health-related quality of life among cancer survivors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1186.

Free-text patient experience data inform service development.

Understanding patients' experiences of treatment and care is essential to effective service development, and is therefore a common topic of investigation for clinicians and health-service researchers. For service development, different kinds of investigation may be useful for a different purpose. Closed measures of patient satisfaction (e.g. rating scales) are useful in providing reproducible measures in specified domains; however, they are often limited both by the scope of predefined questions and by the level of detail that they provide on processes affecting reported outcomes. Free-text data are therefore often collected alongside such measures, to provide further descriptive detail on patient experience and identify emergent issues that are not covered by closed questions (Bracher et al. BMJ Open 2016;6:e011830). Izzet-Kay et al. present a rigorous and systematic exploration of women's experiences and concerns following mesh-augmented prolapse surgery (BJOG 2021; 128:131–139). The study also provides an exemplar of how free-text analysis can inform service development in more general ways: first, by exploring how patients evaluate treatment success in the context of everyday life; second, by investigating how patients understand costs/risks and benefits of treatment; and third, by identifying issues for further investigation. Findings from the study give us descriptions of experiences as both outcomes (i.e. what happened) and processes (i.e. what factors affected the outcome). This distinction is important, because different types of knowledge can serve distinct but complementary functions in service development: the former identifying areas of concern (e.g. postoperative uncertainty, decision regret), the latter describing mechanisms contributing to the outcome and hence potential points of intervention (e.g. improved information provision, communication and shared decision-making processes) (Elwyn et al. BMJ 2010;341:c5146). Navigating complex healthcare systems (such as treatment pathways involving multidisciplinary teams) involves patients, clinicians and (often) carers in varied kinds of physical, emotional and cognitive work that includes making sense of information, identifying preferences and appraising risk (May et al. BMC Health Serv Res 2014;14(281)). Free-text data can provide important insights into both processes and outcomes that may not be visible through other means such as clinical audit. Findings can be used to complement those from closed measures (as Izzett-Kay et al. have done), inform development of new questions for wider systematic exploration (e.g. through a population-level survey) or identify areas for more detailed qualitative investigation (e.g. through in-depth interviews or longitudinal diaries exploring experiences over time). More detailed qualitative studies may, for example, focus on key points of communication or information provision within treatment pathways, to better understand how presentation and discussion of information affect risk perception and decision-making (Mills et al. J Clin Epidemiol 2011;64:1127–36). Readers of this journal undertaking service evaluation and development activity may wish to consider using free-text data as one additional tool to inform this work, a helpful demonstration of which has been provided by Izzett-Kay et al. None declared. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

How Do Caregivers of Children with Congenital Heart Disease Navigate the Health Care System in Ethiopia?

Research ObjectiveGlobal surgery is becoming an increasingly important global health agenda. Cardiovascular disease is the major cause of mortality around the world, and congenital heart disease is the leading cause of morbidity in children. This study aimed to investigate and illustrate the caregivers’ experiences of accessing the health care system and undergoing pediatric cardiac surgery for children with congenital heart disease (CHD).Study DesignA qualitative study was conducted. Interviews were conducted in December 2019 in Amharic, then translated into English using trained local interpreters. Data were transcribed verbatim and analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework, using NVivo. The candidacy framework explores the access to health care utilization by seven elements: candidacy, navigation, the permeability of services, appearances at health services, adjudications, offers and resistance, and operating conditions and the local production of candidacy.Population StudiedInterviews were conducted with 13 caregivers of 10 patients with congenital heart disease that received cardiac surgery during the week of the interview.Principal FindingsThe following three themes emerged from the interviews: (a) Recognition of CHD mostly took place at birth, but for those born at home, they found out much later (max 14 years); (b) CHD was misdiagnosed multiple times prior to seeking care at a large hospital; and (c) patients were waiting for the surgery for more than a year, (d) being scheduled for surgery induced both anxiety and hopefulness. In the discussion, caregivers had financial difficulties and struggled in a fragmented delivery system and experienced poor service quality such as the inaccuracy of diagnosis while navigating the Ethiopian health care system.ConclusionsMajor care‐seeking delays were related to the inefficient and complex health care system, largely due to lack of early CHD recognition and financial hardships. Financial protection is low despite the availability of fee waivers for medications. Low education attainment and distance to hospitals are contributing to this challenge.Implications for Policy or PracticeOverall, Ethiopia needs to prioritize policies that protect the financial status of low‐income households that need health care services. Along with increasing health care workforce capacity for pediatric cardiac surgeries in Ethiopia, there is a need to strengthen the district‐level screening capacity to facilitate earlier diagnosis at easily accessible health care settings.Primary Funding SourceSearch Results Web results Korea International Cooperation Agency.

Novice OTs’ Perceptions of Competency

Abstract Date Presented 03/28/20 Research within the self-perceived state of workplace competence provides areas of necessary growth in the journey of novice OT competency. Continual self-assessment is essential for attaining OT competency and impacts the profession’s role as effective leaders in the complex healthcare system. Analysis of fluctuating competence of current novice OTs provides necessary development tools in the novice OT’s transition to competent practitioner. Primary Author and Speaker: Kaitlin Rotella Additional Authors and Speakers: Betsey Smith

Measuring the Scale of Hospital Health Record System Fragmentation in England

Many patients experience a fragmented health care journey that involves transitions of care between different hospitals. Ineffective sharing of health data between hospitals can impair the delivery of safe, high‐quality care. This study aimed to identify the unmet need for interhospital data sharing by quantifying the movement of patients between acute hospital trusts and health record systems in the NHS in England.This retrospective observational review examined Hospital Episode Statistics (HES), a national hospital administrative dataset relating to patient encounters with the NHS in England. Outcome measures included the frequency of patient encounters with multiple hospital trusts and the frequency of consecutive encounters with hospitals using different health record systems.All adult patients with inpatient, emergency department, or outpatient encounters at acute hospitals in the NHS in England during the 12‐month period from April 2017 to April 2018 were included.21,286,873 patients were involved in 121,351,837 encounters at 152 included NHS trusts over the one‐year period. There was limited regional alignment of electronic health record (EHR) systems in the 117 (77.0%) hospital trusts that were using EHR systems. 15,736,863 (73.9%) patients had two or more encounters with the included trusts and 3,931,255 (25.0%) of those attended two or more trusts. Over half (53.6%) of these patients had encounters shared between just 20 pairs of hospitals. Only two of these pairs of trusts used the same EHR system. On 11,017,767 (9.1%) occasions, patients presented to a hospital using a different EHR, or paper record system, to their previous hospital attendance.This study found that nearly four million patients accessed care at two or more different NHS hospital trusts over the one‐year study period, highlighting the demand for effective interhospital data sharing. Most of the pairs of hospital trusts that commonly share patients do not use the same health record systems. The fragmented distribution of health record systems that exists in the NHS in England represents a significant barrier to interhospital data sharing and interoperability.To make informed and safe decisions for patients negotiating increasingly complex health care systems, clinicians need the right information about the right patient in the right place at the right time. The findings from this study provide guidance for policy makers, clinicians, service managers, researchers, software providers, and patients to better understand and improve how data may be shared between hospitals. The methods used in this research could be applied to health care systems in other settings to guide the procurement and coordination of EHR systems to promote interoperability and effective data sharing.National Institute for Health Research (UK).

An Integrated Review of Hypertrophic Cardiomyopathy in Black Populations

Background Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disorder globally, affecting 0.2% to 0.5% of individuals. Existing clinical HCM guidelines do not address diverse populations, specifically minority groups who often experience health disparities. Objective The aim of this study was to describe the state of the science of HCM in black populations. Methods This integrated review guided by Whittemore and Knafl's methodology included literature search of multiple databases, data evaluation, and analysis. Publications between 2000 and 2020 were included if they addressed HCM cardiac anatomic manifestations, disease course, symptoms, quality of life, or outcomes in black populations. Results Six articles met the inclusion criteria. Overall, blacks are underrepresented in HCM research. Certain HCM structural phenotypes are more commonly exhibited in blacks, and physiology drives HCM treatment. Sudden death events and all-cause mortality do not differ between blacks and whites with HCM. Fewer blacks with HCM undergo genetic testing than whites with HCM. The lack of diversity in general genomic databases has resulted in reclassification of several genetic variants identified as more common in blacks. Conclusions Blacks are underrepresented in HCM research, even those focused on elucidating HCM manifestations, disease course, and outcomes in black populations. This may be due in part to HCM research that is largely generated from specialty centers that can require patients to navigate complex healthcare systems to reach expert HCM care. Longitudinal studies with large samples of blacks with HCM are necessary to elucidate how HCM affects this population.

Caring for the Deaf: Nursing Students' Knowledge and Awareness.

Navigating an increasingly complex health care system is challenging for marginalized populations, including the Deaf and hard of hearing who rely heavily on nurses' and hospital-provided interpreters' knowledge of the American Sign Language. This study examined Deaf culture knowledge and awareness among undergraduate and graduate nursing students in the United States. Study findings indicated low knowledge regarding cochlear implants, use of interpreters, and parental newborn hearing test rights. Integrating care of the deaf into all levels of nursing education will serve to promote patient health literacy and health outcomes while advancing the science of nursing education.

Exploring Family Caregiver Communication Difficulties and Caregiver Quality of Life and Anxiety.

When family caregivers are involved in patient care, both patients and caregivers experience better clinical outcomes. However, caregivers experience communication difficulties as they navigate a complex health care system and interact with health care providers. Research indicates that caregivers experience a communication burden that can result in topic avoidance and distress; however, little is known about how burden stemming from communication difficulties with health care providers relates to caregiving outcomes. To investigate how family caregiver communication difficulties with health care providers influence caregiver quality of life and anxiety. Data were collected in a cross-sectional online survey of 220 caregivers with communication difficulties resulting from caregiver avoidance of caregiving-related topics, inadequate reading and question-asking health literacy, and low communication self-efficacy. Caregiver outcomes were not affected by reading health literacy level but did differ based on question-asking health literacy level. Adequate question-asking health literacy was associated with lower anxiety and a higher quality of life. Caregivers who avoided discussing caregiving topics reported higher anxiety and lower quality of life and caregivers with increased communication self-efficacy reported a higher quality of life. Involvement of family caregivers in care is likely to require tailored approaches that address caregiver communication and health literacy skills. Findings from this study suggest that hospice and palliative care providers should identify and provide support for caregiver communication difficulties in order to positively influence caregiver quality of life and anxiety.

Ultrastretchable, Self‐Healable, and Wearable Epidermal Sensors Based on Ultralong Ag Nanowires Composited Binary‐Networked Hydrogels

AbstractStretchable and biocompatible flexible electronic devices are essential to meet the increasing demands of complex and multifunctional personal healthcare systems. To detect various external stimuli, noninvasively epidermal sensors with reliable and sustainable performances are desirable. Herein, ultrastretchable, self‐healable, and wearable epidermal sensors based on ultralong Ag nanowires (AgNWs) composited binary‐networked hydrogels are fabricated. The flexible hydrogel sensors can monitor dynamic strains in a wide range (4–3000%), realize high healing efficiency (94.3%) and strong adhesiveness, which is attributed to the strong covalent bond and reversible physical interaction structured binary‐network. The ultralong AgNWs network remains in direct contact under strain, ensures a rapid response to external stimuli. The strong interactions between polymer matrix and the nanowires endow the hydrogel sensors excellent sensitivity (gauge factor of 4.59) within a wide sensing range (0–850%). The cycling stability of the hydrogel sensors is further improved by the composition of AgNWs, presenting negligible degradation both on tension and compression. Based on the advantageous performances, the flexible stain sensors can differentiate complicated human motions and realize phonation recognition precisely, showing promising application in next‐generation wearable epidermal sensors with ultrabroad working range and high sensitivity.

Dynamics of a specialized and complex health care system: Exploring general practitioners' management of multimorbidity.

To explore general practitioners' (GPs') experiences of cooperation with hospital-based physicians regarding multimorbid patients and to identify challenges as well as strategies in managing such challenges.Study setting: Three medical practices in a provincial town in Denmark. A qualitative methodological design was used with explorative data collection among GPs.Data collection/Extraction methods: Participant observation, qualitative interviews and a focus group interview were conducted. Interpretive description was used as the analytical framework.Principal findings: The GPs appreciated cooperating with physicians in optimizing treatment of multimorbid patients. However, three main challenges were experienced: insufficient communication and coordination; unclear divisions of roles and responsibilities; and differences in the way of approaching patients. The GPs navigated these challenges and complexities by taking advantage of their personal relationships and by developing creative and patient-centred ad hoc solutions to difficulties in cross-sectorial cooperation. A hospital initiative to support care for multimorbid patients has not been adopted by the GPs as a preferred strategy. The structures of the health care system severely challenged cooperation regarding multimorbid patients; nevertheless, these GPs were aware of the advantages of cooperation, and their mainstay strategy in this involved personalized solutions and flexibility.