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What impact has the Centre of Research Excellence in Digestive Health made in the field of gastrointestinal health in Australia and internationally? Study protocol for impact evaluation using the FAIT framework

Por: Koloski · N. · Duncanson · K. · Ramanathan · S. A. · Rao · M. · Holtmann · G. · Talley · N. J.
Introduction

The need for public research funding to be more accountable and demonstrate impact beyond typical academic outputs is increasing. This is particularly challenging and the science behind this form of research is in its infancy when applied to collaborative research funding such as that provided by the Australian National Health and Medical Research Council to the Centre for Research Excellence in Digestive Health (CRE-DH).

Methods and analysis

In this paper, we describe the protocol for applying the Framework to Assess the Impact from Translational health research to the CRE-DH. The study design involves a five-stage sequential mixed-method approach. In phase I, we developed an impact programme logic model to map the pathway to impact and establish key domains of benefit such as knowledge advancement, capacity building, clinical implementation, policy and legislation, community and economic impacts. In phase 2, we have identified and selected appropriate, measurable and timely impact indicators for each of these domains and established a data plan to capture the necessary data. Phase 3 will develop a model for cost–consequence analysis and identification of relevant data for microcosting and valuation of consequences. In phase 4, we will determine selected case studies to include in the narrative whereas phase 5 involves collation, data analysis and completion of the reporting of impact.

We expect this impact evaluation to comprehensively describe the contribution of the CRE-DH for intentional activity over the CRE-DH lifespan and beyond to improve outcomes for people suffering with chronic and debilitating digestive disorders.

Ethics and dissemination

This impact evaluation study has been registered with the Hunter New England Human Research Ethics Committee as project 2024/PID00336 and ethics application 2024/ETH00290. Results of this study will be disseminated via medical conferences, peer-reviewed publications, policy submissions, direct communication with relevant stakeholders, media and social media channels such as X (formely Twitter).

Experiences of the clinical academic pathway: a qualitative study in Greater Manchester to improve the opportunities of minoritised clinical academics

Por: Lin · C.-Y. · Greco · C. · Radhakrishnan · H. · Finn · G. M. · Cowen · R. L. · Gardiner · N. J.
Objectives

The aim of this study was to explore the barriers and facilitators faced by clinical academics (CAs) in the Greater Manchester region, with particular attention to the experiences of minoritised groups.

Design

A qualitative study using semistructured interviews and focus groups was conducted. A reflexive thematic analysis was applied to identify key themes.

Setting

University of Manchester and National Health Service Trusts in the Greater Manchester region.

Participants

The sample of this study was composed of 43 participants, including CAs, senior stakeholders, clinicians and medical and dental students.

Results

Six themes were identified. CAs face several barriers and facilitators, some of which—(1) funding insecurity and (2) high workload between the clinic and academia—are common to all the CAs. Other barriers, including (3) discrimination that translates into struggles with self-worth and feeling of not belonging, (4) being or being perceived as foreign and (5) unequal distribution of care duties, particularly affect people from minoritised groups. In contrast, (6) mentorship was commonly identified as one of the most important facilitators.

Conclusions

Cultural and structural interventions are needed, such as introducing financial support for early career CAs and intercalating healthcare students to promote wider social and cultural change and increase the feelings of belonging and representation across the entire CA pipeline.

Protocol for the development of a tool (INSPECT-SR) to identify problematic randomised controlled trials in systematic reviews of health interventions

Por: Wilkinson · J. · Heal · C. · Antoniou · G. A. · Flemyng · E. · Alfirevic · Z. · Avenell · A. · Barbour · G. · Brown · N. J. L. · Carlisle · J. · Clarke · M. · Dicker · P. · Dumville · J. C. · Grey · A. · Grohmann · S. · Gurrin · L. · Hayden · J. A. · Heathers · J. · Hunter · K. E. · Lasser
Introduction

Randomised controlled trials (RCTs) inform healthcare decisions. It is now apparent that some published RCTs contain false data and some appear to have been entirely fabricated. Systematic reviews are performed to identify and synthesise all RCTs that have been conducted on a given topic. While it is usual to assess methodological features of the RCTs in the process of undertaking a systematic review, it is not usual to consider whether the RCTs contain false data. Studies containing false data therefore go unnoticed and contribute to systematic review conclusions. The INveStigating ProblEmatic Clinical Trials in Systematic Reviews (INSPECT-SR) project will develop a tool to assess the trustworthiness of RCTs in systematic reviews of healthcare-related interventions.

Methods and analysis

The INSPECT-SR tool will be developed using expert consensus in combination with empirical evidence, over five stages: (1) a survey of experts to assemble a comprehensive list of checks for detecting problematic RCTs, (2) an evaluation of the feasibility and impact of applying the checks to systematic reviews, (3) a Delphi survey to determine which of the checks are supported by expert consensus, culminating in, (4) a consensus meeting to select checks to be included in a draft tool and to determine its format and (5) prospective testing of the draft tool in the production of new health systematic reviews, to allow refinement based on user feedback. We anticipate that the INSPECT-SR tool will help researchers to identify problematic studies and will help patients by protecting them from the influence of false data on their healthcare.

Ethics and dissemination

The University of Manchester ethics decision tool was used, and this returned the result that ethical approval was not required for this project (30 September 2022), which incorporates secondary research and surveys of professionals about subjects relating to their expertise. Informed consent will be obtained from all survey participants. All results will be published as open-access articles. The final tool will be made freely available.

DEcreased Cognitive functiON, NEurovascular CorrelaTes and myocardial changes in women with a history of pre-eclampsia (DECONNECT): research protocol for a cross-sectional pilot study

Por: Brandt · Y. · Alers · R.-J. · Canjels · L. P. W. · Jorissen · L. M. · Jansen · G. · Janssen · E. B. N. J. · van Kuijk · S. M. · Went · T. M. · Koehn · D. · Gerretsen · S. C. · Jansen · J. F. · Backes · W. H. · Hurks · P. P. M. · van de Ven · V. · Kooi · M. E. · Spaanderman · M. E. A.
Introduction

Pre-eclampsia is a hypertensive disorder affecting up to 8% of pregnancies. After pre-eclampsia, women are at increased risk of cognitive problems, and cerebrovascular and cardiovascular disorders. These sequelae could result from microvascular dysfunction persisting after pre-eclampsia. This study will explore differences in cerebral and myocardial microvascular function between women after pre-eclampsia and women after normotensive gestation. We hypothesise that pre-eclampsia alters cerebral and myocardial microvascular functions, which in turn are related to diminished cognitive and cardiac performance.

Methods and analysis

The cross-sectional ‘DEcreased Cognitive functiON, NEurovascular CorrelaTes and myocardial changes in women with a history of pre-eclampsia’ (DECONNECT) pilot study includes women after pre-eclampsia and controls after normotensive pregnancy between 6 months and 20 years after gestation. We recruit women from the Queen of Hearts study, a study investigating subclinical heart failure after pre-eclampsia. Neuropsychological tests are employed to assess different cognitive domains, including attention, processing speed, and cognitive control. Cerebral images are recorded using a 7 Tesla MRI to assess blood–brain barrier integrity, perfusion, blood flow, functional and structural networks, and anatomical dimensions. Cardiac images are recorded using a 3 Tesla MRI to assess cardiac perfusion, strain, dimensions, mass, and degree of fibrosis. We assess the effect of a history of pre-eclampsia using multivariable regression analyses.

Ethics and dissemination

This study is approved by the Ethics Committee of Maastricht University Medical Centre (METC azM/UM, NL47252.068.14). Knowledge dissemination will include scientific publications, presentations at conferences and public forums, and social media.

Trial registration number

NCT02347540.

Perceptions on artificial intelligence-based decision-making for coexisting multiple long-term health conditions: protocol for a qualitative study with patients and healthcare professionals

Por: Gunathilaka · N. J. · Gooden · T. E. · Cooper · J. · Flanagan · S. · Marshall · T. · Haroon · S. · DElia · A. · Crowe · F. · Jackson · T. · Nirantharakumar · K. · Greenfield · S.
Introduction

Coexisting multiple health conditions is common among older people, a population that is increasing globally. The potential for polypharmacy, adverse events, drug interactions and development of additional health conditions complicates prescribing decisions for these patients. Artificial intelligence (AI)-generated decision-making tools may help guide clinical decisions in the context of multiple health conditions, by determining which of the multiple medication options is best. This study aims to explore the perceptions of healthcare professionals (HCPs) and patients on the use of AI in the management of multiple health conditions.

Methods and analysis

A qualitative study will be conducted using semistructured interviews. Adults (≥18 years) with multiple health conditions living in the West Midlands of England and HCPs with experience in caring for patients with multiple health conditions will be eligible and purposively sampled. Patients will be identified from Clinical Practice Research Datalink (CPRD) Aurum; CPRD will contact general practitioners who will in turn, send a letter to patients inviting them to take part. Eligible HCPs will be recruited through British HCP bodies and known contacts. Up to 30 patients and 30 HCPs will be recruited, until data saturation is achieved. Interviews will be in-person or virtual, audio recorded and transcribed verbatim. The topic guide is designed to explore participants’ attitudes towards AI-informed clinical decision-making to augment clinician-directed decision-making, the perceived advantages and disadvantages of both methods and attitudes towards risk management. Case vignettes comprising a common decision pathway for patients with multiple health conditions will be presented during each interview to invite participants’ opinions on how their experiences compare. Data will be analysed thematically using the Framework Method.

Ethics and dissemination

This study has been approved by the National Health Service Research Ethics Committee (Reference: 22/SC/0210). Written informed consent or verbal consent will be obtained prior to each interview. The findings from this study will be disseminated through peer-reviewed publications, conferences and lay summaries.

Patient experiences during the planned perioperative care pathway: An integrative review

Abstract

Aims

This integrative review aimed to synthesize evidence about the patients' experiences during the planned perioperative care pathway.

Design

Integrative review.

Data Sources

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline Ovid, Scopus, and American Psychological Association (APA) PsychINFO. Original, peer-reviewed studies published in English between 2012 and 2023 exploring patient experiences during the planned perioperative care pathway were reviewed.

Methods

This review was guided by the Whittemore and Knafl method and followed PRISMA guidelines to search the literature. Twenty-two articles were selected for the final study.

Results

Three themes emerged: Sharing of information is empowering; interpersonal relationships are valued by patients, and hospital systems and care co-ordination influence the patient experience.

Conclusions

The quality and consistency of the information patients receive can both support and undermine patient confidence in health professionals. The quality of relationships that participants experience and effective communication with health professionals can support or compromise the quality of the patients' perioperative experience. The nature of the hospital systems and care co-ordination in hospital has implications for the quality of recovery from surgery.

Impact

This review evaluates whether national and international health services and organizations, adhering to the WHO guidelines, have developed and implemented intentionally focused perioperative care with the aims to achieving effective and sustainable surgical outcomes through increased patient satisfaction.

No Patient or Public Contribution

This article is an integrative review and does not include patient or public contribution.

Five-year cross-sectional study to determine the burden of Candida spp. infections of the urinary tract system among patients attending tertiary hospital in Northwestern Tanzania

Por: Konje · E. T. · Kizenga · O. · Charco · N. J. · Kibwana · U. O. · Shango · N. · Tarimo · F. · Mushi · M. F.
Objective

Urinary tract infections (UTIs) stand as a prominent global health concern. This study entails a 5-year retrospective analysis, using a cross-sectional study design to examine microbiology laboratory data of individuals clinically diagnosed with UTIs at Bugando Medical Centre to gain insights into the prevalence and factors linked to candiduria.

Methodology

Data extracted were meticulously cleaned and coded in an MS Excel sheet, subsequently transferred to STATA V.15 for analysis. Binary logistic regression analysis was used to identify factors associated with candiduria. A probability value below 0.05 at a 95% CI was considered statistically significant.

Results

Urine samples for culture and sensitivity comprised 33.4% (20755) of the total biological samples (62335). The median age of the patients stood at 19 years. A slight majority were female, accounting for 52.8% (10051), and two-thirds sought treatment at outpatient departments (67.5%, 12843). Among patients with significant pathogenic growth, the prevalence of candiduria was 4.6% (221 out of 4772). Notably, inpatients exhibited a higher incidence of candiduria compared with outpatients, with rates of 9.4% (1882) versus 1.6% (2890), p value of 0.000. Non-albicans Candida spp. (NAC) remained the most prevalent pathogen. Factors significantly associated with candiduria included being female (OR=1.7, 95% CI 1.3 to 2.3) and hospital admission (OR=6.6, 95% CI 4.7 to 9.2). In conclusion, candiduria affect 5 out of every 100 UTI-diagnosed patients, predominantly among females and those admitted to the hospital. Clinicians at tertiary hospitals should consider urinary candidiasis as a potential diagnosis for patients at risk who present with UTI-like symptoms.

Research priorities for childrens cancer: a James Lind Alliance Priority Setting Partnership in the UK

Por: Aldiss · S. · Hollis · R. · Phillips · B. · Ball-Gamble · A. · Brownsdon · A. · Chisholm · J. · Crowther · S. · Dommett · R. · Gower · J. · Hall · N. J. · Hartley · H. · Hatton · J. · Henry · L. · Langton · L. · Maddock · K. · Malik · S. · McEvoy · K. · Morgan · J. E. · Morris · H. · Parke
Objectives

To engage children who have experienced cancer, childhood cancer survivors, their families and professionals to systematically identify and prioritise research questions about childhood cancer to inform the future research agenda.

Design

James Lind Alliance Priority Setting Partnership.

Setting

UK health service and community.

Methods

A steering group oversaw the initiative. Potential research questions were collected in an online survey, then checked to ensure they were unanswered. Shortlisting via a second online survey identified the highest priority questions. A parallel process with children was undertaken. A final consensus workshop was held to determine the Top 10 priorities.

Participants

Children and survivors of childhood cancer, diagnosed before age 16, their families, friends and professionals who work with this population.

Results

Four hundred and eighty-eight people submitted 1299 potential questions. These were refined into 108 unique questions; 4 were already answered and 3 were under active study, therefore, removed. Three hundred and twenty-seven respondents completed the shortlisting survey. Seventy-one children submitted questions in the children’s surveys, eight children attended a workshop to prioritise these questions. The Top 5 questions from children were taken to the final workshop where 23 questions in total were discussed by 25 participants (young adults, carers and professionals). The top priority was ‘can we find effective and kinder (less burdensome, more tolerable, with fewer short and long-term effects) treatments for children with cancer, including relapsed cancer?’

Conclusions

We have identified research priorities for children’s cancer from the perspectives of children, survivors, their families and the professionals who care for them. Questions reflect the breadth of the cancer experience, including diagnosis, relapse, hospital experience, support during/after treatment and the long-term impact of cancer. These should inform funding of future research as they are the questions that matter most to the people who could benefit from research.

Development of an international core outcome set for treatment trials in paediatric inguinal hernia: protocol for a three-phase study including a systematic review and Delphi survey

Por: Maat · S. C. · Gorter · R. R. · van Heurn · E. L. W. · Rippen · H. · Butcher · N. J. · Offringa · M. · Derikx · J. P. M.
Introduction

In children, open inguinal hernia repair has been the gold standard for treatment, but with recent technical advancements in laparoscopy, laparoscopic hernia repair is gaining popularity. Despite available results from comparative studies, there is still no consensus regarding the superiority of open versus laparoscopic treatment strategy. An important reason for lack of consensus is the large heterogeneity in the trials’ reported outcomes and outcome definitions, which limits comparisons between studies and precludes conclusions regarding the superiority of treatment strategies. The development and implementation of a core outcome set (COS) is a solution for this heterogeneity in the selection, measurement and reporting of trial outcome measures across studies. Currently, there is no COS for the treatment of paediatric inguinal hernia.

Methods and analysis

The aim of this project is to reach international consensus on a minimal set of outcomes that should be measured and reported in all future clinical trials investigating inguinal hernia repair in children. The development process comprises three phases. First, we identify outcome domains associated with paediatric inguinal hernia repair from a patient perspective and through a systematic review of the literature using EMBASE, MEDLINE and the Cochrane Library databases. Second, we conduct a three-step Delphi study to identify and prioritise ‘core’ outcomes for the eventual minimal set. In the third phase, an expert meeting is held to establish the final COS and develop implementation strategies with participants from all stakeholder groups: healthcare professionals, parents and patients’ representatives. The final COS will be reported in accordance with the COS-Standards for Reporting statement.

Ethics and dissemination

The medical research ethics committee of the Amsterdam UMC confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) does not apply to this study and that full approval by the committee is not required. Electronic informed consent will be obtained from all participants. Results will be presented in peer-reviewed academic journals and at relevant conferences.

PROSPERO registration number

CRD42021281422.

Association between preterm delivery and subsequent maternal risk of hypertension and type 2 diabetes mellitus in a UK population-based retrospective cohort study

Por: Song · A. · Okoth · K. · Adderley · N. J.
Objectives

Women with a history of preterm delivery (PTD) are at higher risk of developing cardiovascular diseases (CVD) later in life. However, it is not well established whether PTD is associated with CVD risk factors, hypertension and type 2 diabetes mellitus (T2DM). Therefore, in this study, we examined the associations between PTD compared with term delivery and subsequent risk of hypertension and T2DM.

Design

Retrospective matched population-based open cohort study.

Setting

Clinical Practice Research Datalink GOLD data in the UK.

Participants

A total of 3335 18–49-year-old women with preterm delivery were matched by age and region to 12 634 without a record of preterm delivery.

Primary outcome measures

Outcomes of interest were newly diagnosed hypertension or T2DM at least 6 months after delivery. During the study period (January 2000–December 2019), hypertension or T2DM events in the medical records of women with (exposed) and without (unexposed) preterm delivery were compared. HR and 95% CI were estimated using Cox proportional hazards models adjusted for potential confounders.

Results

Over a median follow-up period of 5.11 (IQR 2.15–9.56) years, the HRs for hypertension in women who delivered preterm compared with women who delivered at term were 1.42 (95%CI 1.09 to 1.80) and 1.18 (95%CI 0.90 to 1.56) in the unadjusted and adjusted models, respectively. For T2DM, over a median follow-up period of 5.17 (IQR 2.18–9.67) years, the HRs in women who delivered preterm compared with those who delivered at term were 1.67 (95%CI 1.12 to 2.48) and 1.10 (95%CI 0.72 to 1.68) in the unadjusted and adjusted models, respectively.

Conclusion

We found no independent effect of preterm delivery on risk of hypertension or type 2 diabetes in this study. While significant associations were observed in unadjusted analyses, associations were lost after adjustment and may be attributable to other reproductive complications. Additional studies are needed to confirm these findings.

Clinical validation of the 'C-arm rotational view (CARV): study protocol of a prospective randomised controlled trial

Por: Bleeker · N. J. · Doornberg · J. N. · ten Duis · K. · El Moumni · M. · Jaarsma · R. L. · IJpma · F. F. A.
Introduction

Rotational malalignment occurs in up to 30% of cases after intramedullary nailing of tibial shaft fractures. The aim of this study is to assess the clinical feasibility of a newly introduced standardised intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ in order to reduce the risk of rotational malalignment during intramedullary nailing of tibial shaft fractures. The CARV includes predefined fluoroscopy landmark views of the uninjured side to obtain correct alignment of the injured side with use of the rotation of the C-arm.

Methods and analysis

This randomised controlled trial will be conducted in a level 1 trauma centre. Adult patients with an open or closed tibial fracture, eligible for intramedullary nailing, will be enrolled in the study. The interventional group will undergo intramedullary nailing guided by the CARV protocol to obtain accurate alignment. The control group is treated according to current clinical practice, in which alignment control of the tibia is based on clinical estimation of the treating surgeon. The primary endpoint is defined as the degree of rotation measured on low-dose postoperative CT scans.

Ethics and dissemination

The study protocol will be performed in line with local ethical guidelines and the Declaration of Helsinki. The results of this trial will be disseminated in a peer-reviewed manuscript. Future patients are likely to benefit from this trial as it aims to provide a clinically feasible and easy-to-use standardised fluoroscopy protocol to reduce the risk for rotational malalignment during intramedullary nailing of tibial shaft fractures.

Trial registration number

NCT05459038.

Qualitative exploration of the constraints on mothers and pregnant womens ability to turn available services into nutrition benefits in a low-resource urban setting, South Africa

Por: Erzse · A. · Desmond · C. · Hofman · K. · Barker · M. · Christofides · N. J.
Objectives

Despite free primary healthcare services and social protection system for mothers and children, significant nutrition inequalities occur across the globe, including in South Africa. This study aimed to explore what determines mothers’ ability to access and turn available services into nutrition benefits.

Design

An exploratory qualitative study was conducted including semistructured interviews with employees from community-based organisations and focus groups with pregnant women and mothers. Discussions focused on existing services perceived as important to nutrition, differences in mothers’ ability to benefit from these services, and the underlying unmet needs contributing to these disparities. Data were analysed thematically using a novel social needs framework developed for this study where social needs are defined as the requisites that can magnify (if unmet) or reduce (if met) variation in the degree to which individuals can benefit from existing services.

Setting

A resource-constrained urban township, Soweto in Johannesburg.

Participants

Thirty mothers of infants (

Results

Mothers identified social needs related to financial planning, personal income stability, appropriate and affordable housing, access to government services, social support and affordable healthier foods. The degree to which these needs were met determined mothers’ capabilities to benefit from eight services. These were clinic-based services including nutrition advice and social work support, social grants, food aid, community savings groups, poverty alleviation projects, skills training workshops, formal employment opportunities and crèches/school feeding schemes.

Conclusion

Findings demonstrate that while current social protection mechanisms and free health services are necessary, they are not sufficient to address nutrition inequalities. Women’s social needs must also be met to ensure that services are accessed and used to improve the nutrition of all mothers and their children.

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic

Por: Kennalley · A. L. · Fanelli · J. L. · Furst · J. A. · Mynarski · N. J. · Jarvis · M. A. · Nichols · S. D. · McCall · K. L. · Piper · B. J.
Objectives

Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic.

Design

Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases.

Setting

USA.

Participants

Patients who were dispensed methadone at US opioid treatment programmes (OTPs).

Primary and secondary outcome measures

The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone.

Results

Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p

Conclusions

There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.

Experiences with remote interpreting tools in primary care settings: a qualitative evaluation of the implementation and usage of remote interpreting tools during a feasibility trial in Germany

Por: Pruskil · S. · Fiedler · J. · Pohontsch · N. J. · Scherer · M.
Objective

This study aims to evaluate the usage and implementation of video remote (VR) interpreting and telephone remote (TR) interpreting in primary healthcare settings.

Design

This publication forms part of a larger three-pronged study in which we compared both remote interpreting modalities to each other and to a control group. This paper conveys the findings of the qualitative evaluation of the implementation and usage of both remote interpreting solutions. The quantitative evaluation of the 6-month intervention period (September 2018–February 2019) has been reported previously. After this period, we conducted focus groups with the healthcare professionals involved. The focus groups were recorded, transcribed verbatim and analysed using the structured qualitative content analysis.

Setting

We provided either VR or TR tools to 10 different primary healthcare practices (general medicine, gynaecology and paediatrics) in the city of Hamburg, Germany.

Participants

Three physicians and two physician’s assistants took part in the TR focus group. The VR focus group consisted of four physicians.

Results

The main topics identified were the importance of communication for diagnostic and therapeutic processes, previous solutions to language barriers, as well as advantages and disadvantages of the two remote interpreting solutions. Advantages included the possibility to adequately communicate with language discordant patients and the high quality of the interpreting. Disadvantages included the habituation time required for new technology as well as time constraints.

Conclusion

Our evaluation found that these solutions were highly appreciated, if not considered indispensable, for the delivery of appropriate medical care to language-discordant patients. Differences between the two modalities were named and concrete suggestions for improvement were made. Policy-makers should consider providing VR or TR as an adequate and safe interpreting service alternative when professional in-person interpreters are not available or too expensive.

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