Explore the vast range of titles available.

•Patients were extremely satisfied with COVID-19 vaccination in pharmacies.•Accessibility, proximity and short waiting times were some of the reasons.•Patients’ motivation for vaccination was primarily to protect themselves from severe COVID-19.•Pharmacists stated difficulties to provide this service due to personnel shortage.•Physicians rather appreciated the relief on their workload. COVID-19 vaccinations applied in pharmacies can facilitate accessibility and potentially increase the vaccination rate but remain controversial in many countries. This study aimed to explore the patients’ motivation to receive their COVID-19 vaccination in a pharmacy and examine patient and provider satisfaction with this novel service. The study was designed as an explorative cross-sectional multicenter in-house quantitative survey and was conducted during the first weeks of COVID-19 vaccinations in German pharmacies from February to April 2022. The survey consisted of a paper-based questionnaire with scaling questions, multiple choice questions and open questions. Patients were recruited consecutively before their vaccination and completed the survey directly after the service. Vaccinating pharmacists were also invited to answer a questionnaire on their experiences, motivation and expectations. A total of 427 questionnaires out of 11 pharmacies were be included. The overall patient satisfaction with vaccinations in pharmacies was rated with the highest remarks by 91.5% of the participants, another 7.8% were fairly satisfied. Patient satisfaction with scheduling, waiting time, information, hygiene, vaccination technique and a feeling of safety was very high (96.5–97.9%). Patients’ motivation on COVID-19 vaccination was to prevent severe COVID-19 symptoms (88.9%) and to protect others (72.3%). Easy accessibility, low barriers and proximity were other reasons for utilizing this service, mentioned by 61.8% of the patients. Pharmacists were highly motivated and found the task meaningful but experienced considerable personnel shortage. General practitioners rather expressed relief on their workload. Data of this study strongly supports to include pharmacies as additional providers of COVID-19 vaccinations. Patients stated marked satisfaction with this setting and expressed a feeling of safety and trust. Whereas most patients may have utilized the service for convenience, easy accessibility and low barriers were appreciated and can potentially contribute to higher vaccination rates.

Background Conversational agents (CAs) have become an emerging field of research in healthcare, driven by their potential to support medical workflows, improve efficiency and enhance access to health services. However, despite growing technological development, their actual implementation in healthcare remains limited. In particular, little is known about physicians’ expectations regarding the potential use of CAs in healthcare. This study therefore investigates physicians’ expectations toward CAs and identifies expected barriers and facilitating factors for a possible future implementation. Methods We conducted semi-structured interviews with 16 physicians from various specialties and care settings (inpatient and outpatient) across Germany. Maximum variation sampling was applied to ensure diversity in gender, age, prior experience with CAs, and medical discipline. The interviewees were encouraged to share their expectations regarding the potential use of CAs, their preferred characteristics, and expected barriers and facilitators for future implementation. Interview data were analyzed based on the concept of the Framework Method. Results Five main topics were identified regarding how physicians expect the potential use of CAs in healthcare. Only one of sixteen physicians reported practical experience with a medical CA, highlighting a critical gap between expected potential and real-world application. Physicians viewed CAs as promising tools for maintaining the quality of care in the face of increasing workloads and staff shortages. Expected benefits included time savings, efficiency gains, and improved patient access, particularly through administrative support, symptom assessment, and patient empowerment. At the same time, substantial expected barriers were reported, including legal uncertainties, lack of interoperability, data privacy concerns, and limited real-world experience. Physicians emphasized that the true potential of CAs becomes apparent only through practical application. Conclusion This study provides insights into physicians’ expectations regarding the potential use of CAs in healthcare and key factors for future implementation. According to physicians, successful implementation requires consideration of technical performance, regulatory frameworks, integration into clinical workflows, and human factors such as acceptance, trust, and user competence. CAs should support decision making without undermining clinical judgment. Practical trials and pilot programs are essential to foster trust through transparency and real-world experience, providing an orientation for evidence-based implementation initiatives.

Background Despite the potential of eHealth solutions to enhance medication management and patient safety, the integration of clinical decision support systems (CDSSs) into primary care remains challenging for healthcare systems worldwide. In Germany, the Digital Healthcare Act created a legal framework to accelerate eHealth adoption, but implementation lags behind international standards. We reanalysed data from a completed cluster-randomised stepped wedge trial (SW-CRT) that implemented a CDSS for medication management in German primary care to identify and characterise distinct implementation patterns and their predictive factors. Methods We linked routine health insurance records, practice structural data, pseudonymised CDSS logbook entries, and cross-sectional postal survey data from general practitioners (GPs) participating in the SW-CRT ( n  = 736 practices). We used hierarchical cluster analysis (Ward’s method) on five implementation outcomes to identify distinct adoption patterns. Random Forest models were developed to assess how well structural, patient-level, and attitudinal variables could classify practices into these patterns. Results Of 736 participating practices, 356 (48%) performed at least one medication review. Hierarchical cluster analysis of these practices based on five implementation outcomes identified three distinct adoption patterns. The remaining 380 practices that did not perform medication reviews constituted a fourth pattern. CDSS usage intensity did not align with cluster-specific intervention effect across patterns. The pattern with the lowest usage intensity and fidelity showed the largest cluster-specific intervention effect on the combined endpoint of hospitalisation and mortality. Practices in this pattern reported significantly higher change commitment, change efficacy, and cognitive participation. Random Forest models using structural variables alone showed limited discrimination (AUC 0.56–0.66). Including a binary indicator of GP survey participation improved discrimination (AUC 0.61–0.82). Conclusions Within this single trial context, higher CDSS usage intensity did not correspond to larger cluster-specific intervention effects, and adoption behaviour was heterogeneous across practices. Structural variables alone were insufficient to distinguish adoption patterns; differences were instead associated with attitudinal factors such as change commitment, change efficacy, and willingness to engage with the intervention. Because these attitudinal measures were collected after practices had reached intervention status, they cannot be interpreted as antecedents of adoption. These findings nonetheless underscore the value of assessing implementer engagement during implementation and of tailoring implementation strategies to distinct adoption patterns rather than pursuing uniform approaches. Trial registration AdAM: ClinicalTrials.gov (NCT03430336), 6 February 2018; eHealth COMPATH: Open Science Framework (osf.io/gau5w), 29 December 2023.

IntroductionSocial prescribing is an approach to addressing non-medical issues affecting people’s health and well-being (eg, loneliness, housing or financial problems). It has gained international traction over recent years as complementary to medical care. A larger research project, comparing social prescribing across European countries, is considering how to tailor provision for the following groups: (a) LGBTIQ+persons, (b) refugees and first-generation immigrants and (c) older adults living alone. As part of this research, a qualitative study will address the question: What are the enabling and limiting factors associated with implementing social prescribing, across different European countries, from the perspective of key stakeholders?Methods and analysisFive European countries (Austria, England, Germany, Poland, Portugal) will be involved. Researchers from each country will conduct approximately 20 semi-structured interviews (total number will be 100). Interviewees will be people receiving, delivering, managing and funding/commissioning social prescribing. Interviews will be audio-recorded and transcribed. A cross-country analysis will be undertaken; framework analysis will support this process, with a chart developed in Excel in which data from across the five countries is summarised by the researchers involved. Summaries will be based on a thematic framework that researchers from the five countries develop together after initially analysing their own data.Ethics and disseminationEthical approval was initially secured through the University of Oxford’s Medical Sciences Interdivisional Research Ethics Committee (IDREC 1806086) for data collection in England. This approved application was then used to secure ethics approval in Austria (through Ludwig Boltzmann Gesellschaft), Germany (through Bergische Universität Wuppertal), Poland (through Wroclaw Medical University) and Portugal (through NOVA University of Lisbon). Dissemination will include an academic journal article and presentation at relevant conferences. It will also include short videos, written summaries/policy briefs and an infographic.This project has received funding from the European Union’s Horizon Europe Research and Innovation Programme under grant agreement No 101155873. Views and opinions expressed are, however, those of the author(s) only and do not necessarily reflect those of the European Union or the European Health and Digital Executive Agency (HADEA). Neither the European Union nor the granting authority can be held responsible for them.

Background Visual impairment and blindness cause a considerable and increasing economic burden affecting not only persons with vision loss and their families, but also societies. For the majority of countries, there is no solid database that would allow a comprehensive assessment of costs from a societal perspective. The present study was conducted to fill this gap. Objectives To investigate resource utilization of blind or visually impaired people and to assess the economic burden of blindness and visual impairment in Germany. Methods This cross-sectional cost-of-illness study measures the economic burden of blindness and visual impairment bottom-up and from a societal perspective. Therefore, blind and visually impaired persons were recruited via national self-help organizations (prevalence-based approach) and interviewed regarding their utilized resources using various survey modes (mixed-mode approach). The observation period was 6 months retrospectively. Utilized resources were valued applying standardized unit costs (macro-costing).Calculations for the study population provided direct and indirect costs per person for a period of 6 months. Further cost per category was extrapolated to 1 year for the general population of Germany. Uncertainty of results was addressed applying uni variate deterministic sensitivity analyses. Results Complete data were collected from 683 participants (54.84% women; average age: 60.28 ± 17.02 years). Decreasing vision was associated with increasing costs (p < 0.001). Most costs were incurred by informal support from relatives, which was the most important resource for coping with everyday life for people with visual loss. Together with assistive/medical devices and loss of productivity due to disability, informal support accounted for 80% of total costs. Extrapolated to Germany, the annual costs of blindness and visual impairment from a societal perspective amounted to ϵ49.6 billion. Results of the sensitivity analyses and 95% confidence intervals showed a considerable degree of uncertainty. Conclusion Visual impairment and blindness may cause enormous overall costs from a societal point of view, as shown here for Germany. Our findings on the costs of blindness and visual impairment in Germany add in a number of different ways to the international evidence. In particular, results show that a large proportion of the costs are not obvious per se as it is caused by self-paid deductibles, productivity loss, early retirement and informal support/care by relatives. Further research should make special efforts to investigate these costs precisely as well as their influence factors.

Background Vertigo, dizziness and balance disorders affect over half of adults aged 65 and older. The MobilE-PHY2 study, conducted in Germany, evaluated the effectiveness of an evidence-based, multidisciplinary care pathway for this population. From a health economic perspective, the intervention was expected to increase outpatient and physiotherapy costs while reducing resource utilisation in other healthcare areas and improving patient-relevant outcomes. Objective This health economic evaluation examined the cost-effectiveness of the care pathway compared to optimised routine care. Incremental costs were related to incremental changes in both quality-adjusted life years (QALYs) and the Dizziness Handicap Inventory (DHI) as a disease-specific outcome; expressed as incremental cost-effectiveness ratios (ICER). Methods The study was a multicentre, cluster-randomised controlled trial with six -month follow-up. The health economic evaluation was conducted from a societal perspective. Cost-effectiveness was determined via incremental cost-utility ratios (ICURs) and incremental cost-effectiveness ratios (ICERs). Uncertainty was addressed using cost-effectiveness acceptability and net-monetary-benefit curves. Missing data were handled using Multiple Imputation by Chained Equations. Sensitivity analyses excluded informal care costs and focused on a subgroup with reduced imputation uncertainty. Results The ICER was 81,246.85€ per additional patient achieving a clinically relevant DHI improvement. Indicating that if the willingness-to-pay threshold were €50,000 per additional patient achieving a clinically relevant DHI improvement, the intervention would be cost-effective with 71% probability. The ICUR was negative (-121,847.54€/QALY), meaning optimised routine care dominated the intervention. From a payer perspective, the intervention was less costly, though with lower QALYs. Findings were robust in sensitivity analyses. Conclusion The care pathway shows potential for cost-effectiveness among patients achieving DHI improvements, supporting cautious, targeted implementation in routine care. Future research should address the economic burden on informal caregivers. Trial registration DRKS00028524 retrospectively registered on March 24, 2022.

Conversational agents (CAs), also known as chatbots, are digital dialog systems that enable people to have a text-based, speech-based, or nonverbal conversation with a computer or another machine based on natural language via an interface. The use of CAs offers new opportunities and various benefits for health care. However, they are not yet ubiquitous in daily practice. Nevertheless, research regarding the implementation of CAs in health care has grown tremendously in recent years. This review aims to present a synthesis of the factors that facilitate or hinder the implementation of CAs from the perspectives of patients and health care professionals. Specifically, it focuses on the early implementation outcomes of acceptability, acceptance, and adoption as cornerstones of later implementation success. We performed an integrative review. To identify relevant literature, a broad literature search was conducted in June 2021 with no date limits and using all fields in PubMed, Cochrane Library, Web of Science, LIVIVO, and PsycINFO. To keep the review current, another search was conducted in March 2022. To identify as many eligible primary sources as possible, we used a snowballing approach by searching reference lists and conducted a hand search. Factors influencing the acceptability, acceptance, and adoption of CAs in health care were coded through parallel deductive and inductive approaches, which were informed by current technology acceptance and adoption models. Finally, the factors were synthesized in a thematic map. Overall, 76 studies were included in this review. We identified influencing factors related to 4 core Unified Theory of Acceptance and Use of Technology (UTAUT) and Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) factors (performance expectancy, effort expectancy, facilitating conditions, and hedonic motivation), with most studies underlining the relevance of performance and effort expectancy. To meet the particularities of the health care context, we redefined the UTAUT2 factors social influence, habit, and price value. We identified 6 other influencing factors: perceived risk, trust, anthropomorphism, health issue, working alliance, and user characteristics. Overall, we identified 10 factors influencing acceptability, acceptance, and adoption among health care professionals (performance expectancy, effort expectancy, facilitating conditions, social influence, price value, perceived risk, trust, anthropomorphism, working alliance, and user characteristics) and 13 factors influencing acceptability, acceptance, and adoption among patients (additionally hedonic motivation, habit, and health issue). This review shows manifold factors influencing the acceptability, acceptance, and adoption of CAs in health care. Knowledge of these factors is fundamental for implementation planning. Therefore, the findings of this review can serve as a basis for future studies to develop appropriate implementation strategies. Furthermore, this review provides an empirical test of current technology acceptance and adoption models and identifies areas where additional research is necessary.

Background Participatory approaches are crucial for identifying the determinants of successful implementation and informing the development of implementation strategies. However, systematic knowledge regarding the nature of participatory approaches for tailoring implementation strategies in healthcare remains limited. Therefore, we explored and mapped participatory approaches used in tailoring implementation strategies, characterized them, and conducted an exploratory analysis of their reported links to implementation outcomes. Methods A scoping review of contemporary literature was conducted using MEDLINE via PubMed, PsycINFO and CINAHL via EBSCOhost that included literature published between January 2019 and December 2023. The search was updated for 2024. Backward and forward citation tracking was applied for studies that included labeled participatory approaches and quantitative outcomes. Two raters independently screened the literature. An adapted Intervention Component Analysis (ICA) was conducted as an exploratory approach to analyze reported characteristics. Results Based on 24,240 citations, 129 studies were identified. Among them, 71 studies reported labeled participatory approaches, summarized in seven main categories: co-approaches, design, research, engagement, mapping, knowledge translation and other approaches. Nearly two-thirds were common approaches such as co-design, while slightly more than one-third were specific, such as the Person-Based Approach. More than half of these were implementation-specific, e.g., implementation mapping. Among these approaches, the linking of determinants to implementation strategies was based primarily on interest-holder theory (experience-based). Empirically measured quantitative outcomes were identified in 12 studies, six of which were eligible for ICA. All six studies reported positive findings of participatory approaches applied to the tailoring of implementation strategies. Among them, three studies reported results for each tailoring step and linked them to the participatory approach used. Three studies reported significant quantitative outcomes. However, no method showed a notable link to the success of participatory approaches for tailoring implementation strategies. Conclusion This scoping review identified diverse participatory approaches that were applied for tailoring implementation strategies in healthcare. The emergence of implementation-specific participatory approaches highlights the need to consider specialized methods in implementation science. The lack of rigorously evaluated studies across all tailoring phases emphasizes the need for further research to facilitate a comprehensive understanding of effective participatory approaches for tailoring implementation strategies. Trial Registration Protocol registered on Open Science Framework (24 April 2024, https://doi.org/10.17605/OSF.IO/RQKTP ).

Increased life expectancy is associated with increasing multimorbidity and polypharmacy, leading to a heightened risk of drug-drug interactions and adverse events, especially when multiple health care providers are involved. To address the urgent need for safer medication management in this population, tools such as medication plans (MP), electronic prescriptions (e-prescriptions), and clinical decision support systems (CDSS) offer valuable support. These instruments have the potential to enhance medication safety by providing physicians and pharmacists with a comprehensive overview of a patient's overall medication regimen and by assisting health care professionals in making informed prescribing decisions. This study aims to improve medication therapy safety by combining e-prescriptions, the use of claims data, MPs, CDSS, and interprofessional communication. To comprehensively evaluate this complex intervention, a holistic multiphase study will be conducted, examining (1) the effectiveness of the intervention and (2) health-economic and (3) implementation-related aspects. A multiphase study design is used. In the first phase, the intervention is implemented in selected outpatient practices (n=10) and pharmacies (n=10) in 2 regions in Germany as part of a cluster-randomized controlled trial to assess process-related outcomes. The primary outcome is the congruence between the MP and claims data. In phase 2, the intervention is scaled up in 3 regions and evaluated in a quasi-experimental study. The required sample size for the intervention group is 3528 patients, with a synthetic control group matched from existing claims data. The primary outcome is a combined end point of all-cause mortality and hospitalization within 3 months of an index prescription. Quantitative methods (descriptive, regression-based methods using claims data, calculation of the incremental cost-effectiveness ratio, and survey-based analyses of implementation-related aspects) and qualitative methods (interviews and focus groups to capture experiences of health care professionals and patients) are used. In phase 1, a total of 187 patients were recruited (74 in the intervention group and 113 in the control group) by June 2025. Phase 2 is currently ongoing, with data collection continuing through December 31, 2025. Final analyses are planned by March 2027. Medication safety in polypharmacy remains a critical challenge in Germany. This study provides multiperspective evidence supporting the nationwide implementation of the eRIKA (e-prescription as an element of interprofessional care pathways for continuous medication therapy management [eRezept als Element interprofessioneller Versorgungspfade für kontinuierliche AMTS]) intervention.

Background: Interventional studies on polypharmacy often fail to significantly improve patient-relevant outcomes, or confine themselves to measuring surrogate parameters. Interventions and settings are complex, with many factors affecting results. The AdAM study’s aim is to reduce hospitalization and death by requiring general practitioners (GPs) to use a computerized decision-support system (CDSS). The study will undergo a process evaluation to identify factors for successful implementation and to assess whether the intervention was implemented as intended. Objective: To evaluate our complex intervention, based on the Medical Research Council’s guideline dimensions. Research Questions: We will assess implementation (reach, fidelity, dose, tailoring) by asking: (1) Who took part in the intervention (proportion of GPs using the CDSS, proportion of patients enrolled in them)? Information on GPs’ and patients’ characteristics will also be collected. (2) How many and which medication alerts were dealt with? (3) Was the intervention implemented as intended? (4) On what days did GPs use the intervention tool? Methods: The process evaluation is part of a stepped-wedge cluster-randomized controlled trial. Characteristics of practices, GPs and patients using the CDSS will be compared with the non-participating population. CDSS log data will be analyzed to evaluate how the number of medication alerts changed between baseline and 2 months later, and to identify the kind of alerts that were dealt with. Comparison of enrolled patients on weekdays versus weekends will shed light on GPs’ use of the CDSS in the absence or presence of patients. Outcomes will be presented using descriptive statistics, and significance tests will be used to identify associations between them. We will conduct subgroup analyses, including time effects to account for software improvements. Discussion: This study protocol is the basis for conducting analyses of the quantitative process evaluation. By providing insight into how GPs conduct medication reviews, the evaluation will provide context to the trial results and support their interpretation. The evaluation relies on the proper documentation by GPs, potentially limiting its explanatory power.