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Objective: To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions., Design: Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions., Data Sources: Eight databases and authoritative reports were searched from inception dates to November 2023., Eligibility Criteria for Selecting Studies: Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses)., Results: Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48)., Conclusions: Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems., Systematic Review Registration: PROSPERO: CRD42022383719., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: financial support from the National Health and Medical Research Council (NHMRC), Australia, for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aim: The evidence about the acceptability and effectiveness of innovative paediatric models of care for Type 1 diabetes is limited. To address this gap, we synthesised literature on implemented models of care, model components, outcomes, and determinants of implementation and sustainability., Methods: A systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Database searches of Medline, CINAHL, EMBASE and Scopus were conducted. Empirical studies focused on Type 1 diabetes paediatric models of care, published from 2010 to 2022 in English were included., Results: Nineteen extant studies reported on models and their associations with health and psychosocial outcomes, patient engagement with healthcare, and healthcare costs. Thirteen studies described multidisciplinary teamwork, education and capacity building that supported self-care. Four studies involved shared decision making between providers and patients, and two discussed outreach support where technology was an enabler. Fourteen studies reported improvements in health outcomes (e.g. glycaemic control), mostly for models that included multidisciplinary teams, education, and capacity building (11 studies), outreach support or shared care (3 studies). Four studies reported improvements in quality of life, three reported increased satisfaction for patients and carers and, and one reported improved communication. Four of five studies describing shared care and decision-making reported improvements in quality of life, support and motivation. Outreach models reported no negative outcomes, however, accessing some models was limited by technological and cost barriers. Eight studies reported on model sustainability, but only half reported implementation determinants; none reported applying a theoretical framework to guide their research., Conclusion: Some health and psychosocial benefits were associated with newer models. To address knowledge gaps about implementation determinants and model sustainability, longitudinal studies are needed to inform future adoption of innovative models of care for children with Type 1 diabetes., (© 2024. The Author(s).)

Background: This study examines the perceptions of the Australian public canvassed in 2021 during the COVID-19 pandemic about their health system compared to four previous surveys (2008, 2010, 2012 and 2018)., Methods: In 2021, a nationwide online survey was conducted with a representative sample of Australians (N = 5100) recruited via market research panels. The results were compared to previous nationwide Australian survey samples from 2018 (N = 1024), 2012 (N = 1200), 2010 (N = 1201) and 2008 (N = 1146). The survey included questions consistent with previous polls regarding self-reported health status and overall opinions of, and confidence in, the Australian health system., Results: There was an increase in the proportion of respondents reporting positive perceptions at each survey between 2008 and 2021, with a significantly higher proportion of respondents expressing a more positive view of the Australian healthcare system in 2021 compared to previous years (χ 2 (8, N = 9645) = 487.63, p < 0.001). In 2021, over two-thirds of respondents (n = 3949/5100, 77.4%) reported that following the COVID-19 pandemic, their confidence in the Australian healthcare system had either remained the same (n = 2433/5100, 47.7%) or increased (n = 1516/5100, 29.7%). Overall, respondents living in regional or remote regions, younger Australians (< 45 years) and women held less positive views in relation to the system. In 2021, the most frequently identified area for urgent improvement was the need for more healthcare workers (n = 1350/3576, 37.8%), an area of concern particularly for Australians residing in regional or remote areas (n = 590/1385, 42.6%)., Conclusions: Irrespective of disruptions to the Australian healthcare system caused by the COVID-19 pandemic, Australians' perceptions of their healthcare system were positive in 2021. However, concerns were raised about inadequate workforce capacity and the cost of healthcare, with differences identified by age groups and geographical location., Patient or Public Contribution: Health consumer representatives from the Consumers Health Forum of Australia contributed to the co-design, deployment, analysis and interpretation of the results of this survey. J.A. and L.W. from the Consumers Health Forum of Australia contributed to the development of the paper., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Background: An essential component of future-proofing health systems against future pandemics and climate change is strengthening the front lines of care: principally, emergency departments and primary care settings. To achieve this, these settings can adopt learning health system (LHS) principles, integrating data, evidence, and experience to continuously improve care delivery. This rapid review aimed to understand the ways in which LHS principles have been applied to primary care and emergency departments, the extent to which LHS approaches have been adopted in these key settings, and the factors that affect their adoption., Methods: Three academic databases (Embase, Scopus, and PubMed) were searched for full text articles reporting on LHSs in primary care and/or emergency departments published in the last five years. Articles were included if they had a primary focus on LHSs in primary care settings (general practice, allied health, multidisciplinary primary care, and community-based care) and/or emergency care settings. Data from included articles were catalogued and synthesised according to the modified Institute of Medicine's five-component framework for LHSs (science and informatics, patient-clinician partnerships, incentives, continuous learning culture, and structure and governance)., Results: Thirty-seven articles were included, 32 of which reported LHSs in primary care settings and seven of which reported LHSs in emergency departments. Science and informatics was the most commonly reported LHS component, followed closely by continuous learning culture and structure and governance. Most articles (n = 30) reported on LHSs that had been adopted, and many of the included articles (n = 17) were descriptive reports of LHS approaches., Conclusions: Developing LHSs at the front lines of care is essential for future-proofing against current and new threats to health system sustainability, such as pandemic- and climate change-induced events. Limited research has examined the application of LHS concepts to emergency care settings. Implementation science should be utilised to better understand the factors influencing adoption of LHS approaches on the front lines of care, so that all five LHS components can be progressed in these settings., (© 2024. The Author(s).)

Background: The learning health system (LHS) concept is a potential solution to the challenges currently faced by primary care. There are few descriptions of the barriers and facilitators to achieving an LHS in general practice, and even fewer that are underpinned by implementation science. This study aimed to describe the barriers and facilitators to achieving an LHS in primary care and provide practical recommendations for general practices on their journey towards an LHS., Methods: This study is a secondary data analysis from a qualitative investigation of an LHS in a university-based general practice in Sydney, Australia. A framework analysis was conducted using transcripts from semistructured interviews with clinic staff. Data were coded according to the theoretical domains framework, and then to an LHS framework., Results: 91% (n=32) of practice staff were interviewed, comprising general practitioners (n=15), practice nurses (n=3), administrative staff (n=13) and a psychologist. Participants reported that the practice alignment with LHS principles was influenced by many behavioural determinants, some of which were applicable to healthcare in general, for example, some staff lacked knowledge about practice policies and skills in using software. However, many were specific to the general practice environment, for example, the environmental context of general practice meant that administrative staff were an integral part of the LHS, particularly in facilitating partnerships with patients., Conclusions: The LHS journey in general practice is influenced by several factors. Mapping the LHS domains in relation to the theoretical domains framework can be used to generate a roadmap to hasten the journey towards LHS in primary care settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The cornerstone of obesity treatment is behavioural weight management, resulting in significant improvements in cardio-metabolic and psychosocial health. However, there is ongoing concern that dietary interventions used for weight management may precipitate the development of eating disorders. Systematic reviews demonstrate that, while for most participants medically supervised obesity treatment improves risk scores related to eating disorders, a subset of people who undergo obesity treatment may have poor outcomes for eating disorders. This review summarises the background and rationale for the formation of the Eating Disorders In weight-related Therapy (EDIT) Collaboration. The EDIT Collaboration will explore the complex risk factor interactions that precede changes to eating disorder risk following weight management. In this review, we also outline the programme of work and design of studies for the EDIT Collaboration, including expected knowledge gains. The EDIT studies explore risk factors and the interactions between them using individual-level data from international weight management trials. Combining all available data on eating disorder risk from weight management trials will allow sufficient sample size to interrogate our hypothesis: that individuals undertaking weight management interventions will vary in their eating disorder risk profile, on the basis of personal characteristics and intervention strategies available to them. The collaboration includes the integration of health consumers in project development and translation. An important knowledge gain from this project is a comprehensive understanding of the impact of weight management interventions on eating disorder risk.

Background: Pandemics and climate change each challenge health systems through increasing numbers and new types of patients. To adapt to these challenges, leading health systems have embraced a Learning Health System (LHS) approach, aiming to increase the efficiency with which data is translated into actionable knowledge. This rapid review sought to determine how these health systems have used LHS frameworks to both address the challenges posed by the COVID-19 pandemic and climate change, and to prepare for future disturbances, and thus transition towards the LHS2.0., Methods: Three databases (Embase, Scopus, and PubMed) were searched for peer-reviewed literature published in English in the five years to March 2023. Publications were included if they described a real-world LHS's response to one or more of the following: the COVID-19 pandemic, future pandemics, current climate events, future climate change events. Data were extracted and thematically analyzed using the five dimensions of the Institute of Medicine/Zurynski-Braithwaite's LHS framework: Science and Informatics, Patient-Clinician Partnerships, Continuous Learning Culture, Incentives, and Structure and Governance., Results: The search yielded 182 unique publications, four of which reported on LHSs and climate change. Backward citation tracking yielded 13 additional pandemic-related publications. None of the climate change-related papers met the inclusion criteria. Thirty-two publications were included after full-text review. Most were case studies (n = 12, 38%), narrative descriptions (n = 9, 28%) or empirical studies (n = 9, 28%). Science and Informatics (n = 31, 97%), Continuous Learning Culture (n = 26, 81%), Structure and Governance (n = 23, 72%) were the most frequently discussed LHS dimensions. Incentives (n = 21, 66%) and Patient-Clinician Partnerships (n = 18, 56%) received less attention. Twenty-nine papers (91%) discussed benefits or opportunities created by pandemics to furthering the development of an LHS, compared to 22 papers (69%) that discussed challenges., Conclusions: An LHS 2.0 approach appears well-suited to responding to the rapidly changing and uncertain conditions of a pandemic, and, by extension, to preparing health systems for the effects of climate change. LHSs that embrace a continuous learning culture can inform patient care, public policy, and public messaging, and those that wisely use IT systems for decision-making can more readily enact surveillance systems for future pandemics and climate change-related events., Trial Registration: PROSPERO pre-registration: CRD42023408896., (© 2024. The Author(s).)

Objective: To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems., Data Sources and Study Setting: Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability., Study Design: A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool., Data Collection/extraction Methods: A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies., Results: Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation., Conclusions: This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area., Trial Registration: https://bmjopen.bmj.com/content/7/11/e018568 ., (© 2023. The Author(s).)

Background: Managing the care regimen for Type 1 Diabetes is challenging for emerging adults, as they take on greater responsibility for self-management. A diverse range of models of care have been implemented to improve safety and quality of care during transition between paediatric and adult services. However, evidence about acceptability and effectiveness of these is limited. Our aim was to synthesise the evidence for transition models and their components, examine the health related and psychosocial outcomes, and to identify determinants associated with the implementation of person-centred models of transition care., Method: We searched Medline, CINAHL, EMBASE and Scopus. Peer reviewed empirical studies that focused on T1D models of care published from 2010 to 2021 in English, reporting experimental, qualitative, mixed methods, and observational studies were included., Results: Fourteen studies reported on health and psychosocial outcomes, and engagement with healthcare. Three key models of care emerged: structured transition education programs (6 studies), multidisciplinary team transition support (5 studies) and telehealth/virtual care (3 studies). Compared with usual practice, three of the six structured transition education programs led to improvements in maintenance of glycaemic control, psychological well-being, and engagement with health services. Four MDT transition care models reported improved health outcomes, and improved engagement with health services, however, three studies reported no benefit. Reduced diabetes related stress and increased patient satisfaction were reported by two studies, but three reported no benefit. Telehealth and virtual group appointments improved adherence to self-management and reduced diabetes distress but did not change health outcomes., Conclusions: Although some health and psychosocial benefits are reported, the results were mixed. No studies reported on T1D transition model implementation outcomes such as acceptability, adoption, and appropriateness among clinicians or managers implementing these models. This gap needs to be addressed to support future adoption of successful models., (© 2023. The Author(s).)

The Eating Disorders In weight-related Therapy (EDIT) Collaboration brings together data from randomised controlled trials of behavioural weight management interventions to identify individual participant risk factors and intervention strategies that contribute to eating disorder risk. We present a protocol for a systematic review and individual participant data (IPD) meta-analysis which aims to identify participants at risk of developing eating disorders, or related symptoms, during or after weight management interventions conducted in adolescents or adults with overweight or obesity. We systematically searched four databases up to March 2022 and clinical trials registries to May 2022 to identify randomised controlled trials of weight management interventions conducted in adolescents or adults with overweight or obesity that measured eating disorder risk at pre- and post-intervention or follow-up. Authors from eligible trials have been invited to share their deidentified IPD. Two IPD meta-analyses will be conducted. The first IPD meta-analysis aims to examine participant level factors associated with a change in eating disorder scores during and following a weight management intervention. To do this we will examine baseline variables that predict change in eating disorder risk within intervention arms. The second IPD meta-analysis aims to assess whether there are participant level factors that predict whether participation in an intervention is more or less likely than no intervention to lead to a change in eating disorder risk. To do this, we will examine if there are differences in predictors of eating disorder risk between intervention and no-treatment control arms. The primary outcome will be a standardised mean difference in global eating disorder score from baseline to immediately post-intervention and at 6- and 12- months follow-up. Identifying participant level risk factors predicting eating disorder risk will inform screening and monitoring protocols to allow early identification and intervention for those at risk., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: AS owns 50% of the shares in Zuman International, which receives royalties for books AS has written and payments for presentations. AS additionally reports receiving presentation fees and travel reimbursements from Eli Lilly and Co, the Pharmacy Guild of Australia, Novo Nordisk, the Dietitians Association of Australia, Shoalhaven Family Medical Centres, the Pharmaceutical Society of Australia, and Metagenics, and serving on the Nestlé Health Science Optifast VLCD advisory board from 2016 to 2018. ALA is Principal Investigator on two publicly funded trials where the intervention is provided by WW (formerly Weight Watchers) at no cost. KS has received in kind support as meals from ‘Lite and Easy’ for a clinical trial of weight stigma in young women in the last 5 years. ER has previously received research funding from Unilever and the American Beverage Association for unrelated work. JAY reports unrelated grant funds to NICHD supporting his research from Soleno Therapeutics, Rhythm Pharmaceuticals, and Hikma Pharmaceuticals. HFS has previously received a salary from Novo Nordisk unrelated to the present work. YSD has previously received a salary from Novo Nordisk unrelated to the present work. HAR has received funding from the National Institutes of Health in the area of adult and pediatric weight management. HAR is a committee member for the evidence-based practice guidelines for pediatric weight management for the American Psychological Association and for the Evidence Analysis Library for the Academy of Nutrition and Dietetics for the topic of adult weight management and the prevention of type 2 diabetes. MIC is an employee and shareholder at WW International, Inc. TKK has received professional fees from Novo Nordisk, Nutrisystem, Gelesis and Johnson & Johnson. CKM has received research grants and research agreements from Commission on Dietetic Registration, Academy of Nutrition and Dietetics, Ohio State University (InFACT), Novartis, University of Michigan’s Michigan Institute for Clinical and Health Research, Elizabeth Blackwell Institute for Health Research, Egg Board, PCORI, Department of Defense, Access Business Group International LLC, IDEA Public Schools, Louisiana LIFT Fund, WW, Pack Health, American Society for Nutrition, RAND Corporation, Richard King Mellon Foundation (RKMF), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Evidation Health, Leona M. and Harry B. Helmsley Charitable Trust, State of Louisiana- Federal American Rescue Plan (ARP), United States Department of Agriculture (USDA), National Institute for Health Research (NIHR), National Science Foundation (NSF), Lilly, National Institutes of Health (NIH). CKM has served on advisory boards for EHE Health, Wondr Health, and the Nutrition Obesity Research Center at the University of Alabama Birmingham and consulted to Kitchry, Metagenics, WW, Florida Hospital, Gila Therapeutics, Zafgen, OpenFit/MXCXM Health Inc. CKM developed intellectual property (IP) to quantify dietary adherence and his institution has licensed this IP, resulting in receiving royalties via the institution from the licensing fees. CKM is part of US and European patent applications for a weight loss approach called the Body weight Management and activity tracking system and also occasionally gives lectures and talks where he is provided with an honorarium, including talks to the Obesity Action Coalition and Indiana University Bloomington. Finally, CKM serves as a developer and facilitator for continuing education events sponsored by the Commission on Dietetic Registration, and is a Planning Committee Member for the Bray Course. The opinions and assertions expressed herein are those of the authors and are not to be construed as reflecting the views of the Public Health Service, the Department of Health and Human Services, USUHS, or the U.S. Department of Defense., (Copyright: © 2023 Jebeile et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This systematic review examined change in eating disorder risk during weight management interventions. Four databases and clinical trials registries were searched in March and May 2022, respectively, to identify behavioral weight management intervention trials in adults with overweight/obesity measuring eating disorder symptoms at pre- and post-intervention or follow-up. Random effects meta-analyses were conducted examining within group change in risk. Of 12,023 screened, 49 were eligible (n = 6337, mean age range 22.1 to 59.9 years, mean (SD) 81(20.4)% female). Interventions ranged from 4 weeks to 18 months, with follow-up of 10 weeks to 36 months post-intervention. There was a within group reduction in global eating disorder scores (20 intervention arms; Hedges' g = -0.27; 95% CI -0.36, -0.17; I 2 67.1%) and binge eating (49 intervention arms; -0.66; 95% CI -0.76, -0.56; I 2 82.7%) post-intervention, both maintained at follow-up. Of 14 studies reporting prevalence or episodes of binge eating, all reported a reduction. Four studies reported eating disorder symptoms, not present at baseline, in a subset of participants (0%-6.5%). Overall, behavioral weight management interventions do not increase eating disorder symptoms for most adults; indeed, a modest reduction is seen post-intervention and follow-up. A small subset of participants may experience disordered eating; therefore, monitoring for the emergence of symptoms is important., (© 2023 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Background: Preventative healthcare is crucial for improving individual patient outcomes and is integral to sustainable health systems. The effectiveness of prevention programs is enhanced by activated populations who are capable of managing their own health and are proactive to keep themselves well. However, little is known about the level of activation among people drawn from general populations. We used the Patient Activation Measure (PAM) to address this knowledge gap., Methods: A representative, population-based survey of Australian adults was conducted in October 2021 during the Delta strain outbreak of the COVID-19 pandemic. Comprehensive demographic information was collected, and the participants completed the Kessler-6 psychological distress scale (K6) and PAM. Multinomial and binomial logistic regression analyses were performed to determine the effect of demographic factors on PAM scores, which are categorised into four levels: 1-participants disengaged with their health; 2-becoming aware of how to manage their health; 3-acting on their health; and 4-engaging with preventative healthcare and advocating for themselves., Results: Of 5100 participants, 7.8% scored at PAM level 1; 13.7% level 2, 45.3% level 3, and 33.2% level 4. The mean score was 66.1, corresponding to PAM level 3. More than half of the participants (59.2%) reported having one or more chronic conditions. Respondents aged 18 to 24 years old were twice as likely to score PAM level 1 compared with people aged 25-44 (p < .001) or people aged over 65 years (p < .05). Speaking a language other than English at home was significantly associated with having low PAM (p < .05). Greater psychological distress scores (K6) were significantly predictive of low PAM scores (p < .001)., Conclusion: Overall, Australian adults showed high levels of patient activation in 2021. People with lower incomes, of younger age, and those experiencing psychological distress were more likely to have low activation. Understanding the level of activation enables targeting sociodemographic groups for extra support to increase the capacity to engage in prevention activities. Conducted during the COVID-19 pandemic, our study provides a baseline for comparison as we move out of the pandemic and associated restrictions and lockdowns., Patient or Public Contribution: The study and survey questions were co-designed with consumer researchers from the Consumers Health Forum of Australia (CHF) as equal partners. Researchers from CHF were involved in the analysis of data and production of all publications using data from the consumer sentiment survey., (© 2023 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Objective: To undertake a synthesis of evidence-based research for seven innovative models of care to inform the development of new hospitals., Design: Umbrella review., Setting: Interventions delivered inside and outside of acute care settings., Participants: Children and adults with one or more identified acute or chronic health conditions., Data Sources: PsycINFO, Ovid MEDLINE and CINAHL., Primary and Secondary Outcome Measures: Clinical indicators and mortality, healthcare utilisation, quality of life, self-management and self-care and patient knowledge., Results: A total of 66 reviews were included, synthesising evidence from 1272 primary studies across the 7 models of care. Virtual care was the most common model studied, addressed by 47 (73%) of the reviews. Common outcomes evaluated across reviews were clinical indicators and mortality, healthcare utilisation, self-care and self-management, patient knowledge, quality of life and cost-effectiveness. The findings indicate that the innovative models of healthcare we identified in this review may be effective in managing patients with a range of acute and chronic conditions. Most of the included reviews reported evidence of comparable or improved care., Conclusions: A consideration of local infrastructure and individual patient characteristics, such as health literacy, may be critical in determining the suitability of models of care for patients and their implementation in local health systems., Trial Registration Number: 10.17605/OSF.IO/PS6ZU., Competing Interests: Competing interests: There are no competing interests to declare between the authors and Health Infrastructure. The project was commissioned by Health Infrastructure NSW and Western Sydney LHD (WSLHD). KM works for WSLHD; however, this did not inform the evaluation of evidence or conclusions of the review., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This study aimed to understand clinician, researcher and consumer views regarding factors which influence eating disorder (ED) risk during behavioral weight management, including individual risk factors, intervention strategies and delivery features. Eighty-seven participants were recruited internationally through professional and consumer organizations and social media and completed an online survey. Individual characteristics, intervention strategies (5-point scale) and delivery features (important/unimportant/unsure) were rated. Participants were mostly women (n = 81), aged 35-49 y, from Australia or United States, were clinicians and/or reported lived experience of overweight/obesity and/or ED. There was agreement (64% to 99%) that individual characteristics were relevant to ED risk, with history of ED, weight-based teasing/stigma and weight bias internalization having the highest agreement. Intervention strategies most frequently rated as likely to increase ED risk included those with a focus on weight, prescription (structured diets, exercise plans) and monitoring strategies, e.g., calorie counting. Strategies most frequently rated as likely to decrease ED risk included having a health focus, flexibility and inclusion of psychosocial support. Delivery features considered most important were who delivered the intervention (profession, qualifications) and support (frequency, duration). Findings will inform future research to quantitatively assess which of these factors predict eating disorder risk, to inform screening and monitoring protocols.

Background: Healthcare systems may be resilient and adaptive, but they are not fit for purpose in their current state. Increasing threats to health system sustainability have underscored the need to move towards a learning health system in which research and data are used routinely in clinical practice to facilitate system improvement. This study aimed to establish which elements of the learning health system were being realised within a university-based general practice and determine acceptability from staff to embrace further the transition towards a learning health system., Methods: Semi-structured interviews were conducted with practice staff, including clinical and administrative staff, to determine the current state of the learning health system in the practice. An embedded researcher was placed within the general practice on a part-time basis to investigate the learning health system model. Interviews were transcribed and thematically analysed based on the National Academy of Medicine's framework of learning health systems., Results: In total, 32 (91%) practice staff were interviewed, comprising general practitioners (n = 15), nurses (n = 3), administrative staff (n = 13), and a psychologist (n = 1). Participants indicated that the practice was operating with several characteristics of a learning health system (e.g., emphasising science and informatics; focusing on patient-clinician partnerships; applying incentives; supporting a continuous learning culture; and establishing structures and governance for learning). These measures were supported by the university-based setting, and resultant culture of learning. Nevertheless, there were areas of the practice where the learning health system could be strengthened, specifically relating to the use of patient data and informatics. Staff generally expressed willingness to engage with the process of strengthening the learning health system within their practice., Conclusion: Although the idea of a learning health system has been gaining traction in recent years, there are comparatively few empirical studies presented in the literature. This research presents a case study of a general practice that is operating as a learning health system and highlights the utility of using the learning health system framework., (© 2023. The Author(s).)

Background: Previous research suggests that the COVID-19 pandemic caused significant disruption to the lives and mental health of Australians. In response, health services adapted rapidly to digital modes of treatment, prevention and care. Although a large amount of research emerged in the first year of the pandemic, the longer-term mental health impacts, contributing factors, and population-level utilization of digital health services are unknown., Methods: A population-based online survey of 5,100 Australians adults was conducted in October 2021. Psychological distress was assessed with the Kessler 6-item Psychological Distress Scale. Additional survey questions included use and satisfaction with digital health services. Where available, data were compared with our previous survey conducted in 2018, permitting an examination of pre- and post-pandemic digital health service utilization., Results: In 2021, almost a quarter ( n = 1203, 23.6%) of respondents reported serious levels of psychological distress; participants with pre-existing health related conditions, of younger age, lower educational attainment, those who lost their job or were paid fewer hours, or living in states with lockdown policies in place were at highest risk of serious psychological distress. Almost half of all respondents ( n = 2177, 42.7%) reported using digital health technologies in 2021, in contrast to just 10.0% in 2018. In 2021, respondents with serious psychological distress were significantly more likely to consult with a healthcare professional via telephone/videoconferencing ( P < 0.001), access healthcare via a telephone advice line ( P < 0.001), or via an email or webchat advice service ( P < 0.001) than those with no serious psychological distress. Those with and without psychological distress were highly satisfied with the care they received via digital health technologies in 2021., Conclusion: Rates of serious psychological distress during the second year of the pandemic remained high, providing further evidence for the serious impact of COVID-19 on the mental health of the general population. Those with psychological distress accessed digital mental health services and were satisfied with the care they received. The results highlight the continued need for mental health support and digital health services, particularly for people living with chronic conditions, younger adults and people most impacted by the COVID-19 pandemic, both in the short term and beyond., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ellis, Dammery, Wells, Ansell, Smith, Tran, Braithwaite and Zurynski.)

Objectives: To explore a macrolevel Learning Health System (LHS) and examine if an intentionally designed network can foster a collaborative learning community over time. The secondary aim was to demonstrate the application of social network research to the field of LHS., Design: Two longitudinal online questionnaires of the Australian Genomics learning community considering relationships between network members at three time points: 2016, 2018, 2019. The questionnaire included closed Likert response questions on collaborative learning patterns and open-response questions to capture general perceptions of the community. Social network data were analysed and visually constructed using Gephi V.0.9.2 software, Likert questions were analysed using SPSS, and open responses were analysed thematically using NVivo., Setting: Australian Genomic Health Alliance., Participants: Clinicians, scientists, researchers and community representatives., Results: Australian Genomics members highlighted the collaborative benefits of the network as a learning community to foster continuous learning in the ever-evolving field of clinical genomics. The learning community grew from 186 members (2016), to 384 (2018), to 439 (2019). Network density increased (2016=0.023, 2018=0.043), then decreased (2019=0.036). Key players remained consistent with potential for new members to achieve focal positions in the network. Informal learning was identified as the most influential learning method for genomic practice., Conclusions: This study shows that intentionally building a network provides a platform for continuous learning-a fundamental component for establishing an LHS. The Australian Genomics learning community shows evidence of maturity and sustainability in supporting the continuous learning culture of clinical genomics. The network provides a practical means to spread new knowledge and best practice across the entire field. We show that intentionally designed networks provide the opportunity and means for interdisciplinary learning between diverse agents over time and demonstrate the application of social network research to the LHS field., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic., Objectives: We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured., Design: Scoping review of peer-reviewed articles and editorials published from database inception to February 2021., Data Sources: PubMed and Ovid Medline, and snowballing techniques., Eligibility Criteria: We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS., Data Extraction and Synthesis: After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts., Results: Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible., Conclusions: To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The development and adoption of a learning health system (LHS) has been proposed as a means to address key challenges facing current and future health care systems. The first review of the LHS literature was conducted 5 years ago, identifying only a small number of published papers that had empirically examined the implementation or testing of an LHS. It is timely to look more closely at the published empirical research and to ask the question, Where are we now? 5 years on from that early LHS review., Objective: This study performed a scoping review of empirical research within the LHS domain. Taking an "implementation science" lens, the review aims to map out the empirical research that has been conducted to date, identify limitations, and identify future directions for the field., Methods: Two academic databases (PubMed and Scopus) were searched using the terms "learning health* system*" for papers published between January 1, 2016, to January 31, 2021, that had an explicit empirical focus on LHSs. Study information was extracted relevant to the review objective, including each study's publication details; primary concern or focus; context; design; data type; implementation framework, model, or theory used; and implementation determinants or outcomes examined., Results: A total of 76 studies were included in this review. Over two-thirds of the studies were concerned with implementing a particular program, system, or platform (53/76, 69.7%) designed to contribute to achieving an LHS. Most of these studies focused on a particular clinical context or patient population (37/53, 69.8%), with far fewer studies focusing on whole hospital systems (4/53, 7.5%) or on other broad health care systems encompassing multiple facilities (12/53, 22.6%). Over two-thirds of the program-specific studies utilized quantitative methods (37/53, 69.8%), with a smaller number utilizing qualitative methods (10/53, 18.9%) or mixed-methods designs (6/53, 11.3%). The remaining 23 studies were classified into 1 of 3 key areas: ethics, policies, and governance (10/76, 13.2%); stakeholder perspectives of LHSs (5/76, 6.6%); or LHS-specific research strategies and tools (8/76, 10.5%). Overall, relatively few studies were identified that incorporated an implementation science framework., Conclusions: Although there has been considerable growth in empirical applications of LHSs within the past 5 years, paralleling the recent emergence of LHS-specific research strategies and tools, there are few high-quality studies. Comprehensive reporting of implementation and evaluation efforts is an important step to moving the LHS field forward. In particular, the routine use of implementation determinant and outcome frameworks will improve the assessment and reporting of barriers, enablers, and implementation outcomes in this field and will enable comparison and identification of trends across studies., (©Louise A Ellis, Mitchell Sarkies, Kate Churruca, Genevieve Dammery, Isabelle Meulenbroeks, Carolynn L Smith, Chiara Pomare, Zeyad Mahmoud, Yvonne Zurynski, Jeffrey Braithwaite. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 23.02.2022.)