The study, published in BMC Health Services Research, drew on five waves of the China Health and Retirement Longitudinal Study, or CHARLS, collected in 2011, 2013, 2015, 2018, and 2020. The research team, led by Lingjie Wang and Junjie Jiang of Fujian Medical University together with collaborators at Georgetown University and the University of Georgia, focused on a population that health economists consider especially vulnerable: people aged 45 and older who reported living with multiple chronic conditions, often abbreviated as MCCs. These are individuals whose illnesses, such as hypertension, diabetes, heart disease, and chronic lung disease, accumulate over time and who typically need more hospital care than healthier peers, making any income-based barrier to admission a matter of serious equity concern.

To measure inequality, the researchers used a pair of well-established econometric tools. The first is the concentration curve, which plots the cumulative share of hospital admissions against the cumulative share of the population ranked from poorest to richest. If hospital use were distributed equally across income groups, the curve would trace a perfect diagonal line. Deviations above or below that line reveal whether care is concentrated among the poor or the wealthy. The second tool, the standard concentration index, condenses that visual picture into a single number, where a positive value signals that care favors the better-off and a negative value signals a pro-poor distribution.

The headline result is a clear downward march in that index. Among middle-aged and older Chinese adults with multiple chronic conditions, the standard concentration index stood at 0.1235 in 2011, fell to 0.0721 in 2013, edged up slightly to 0.0780 in 2015, then dropped to 0.0447 in 2018 and again to 0.0357 in 2020. In plain terms, hospital care in this population was consistently tilted toward the richer half of society throughout the decade, but that tilt weakened by roughly seventy percent over the study period. The only interruption came between 2013 and 2015, when the gap widened modestly before resuming its decline.

What makes this study more than a trend report is its decomposition analysis, a technique that breaks the change in the concentration index into contributions from individual factors, such as income itself, medical expenditure, insurance coverage, smoking, and demographic characteristics. Each factor receives a percentage contribution to the change in inequality between two adjacent survey waves, allowing researchers to see which forces pushed the gap wider and which pulled it narrower. This is where the study reveals some genuinely surprising mechanics behind the headline numbers.

In the first transition, from 2011 to 2013, medical expenditure emerged as the dominant driver, contributing minus 90.74 percent to the change in inequality. The negative sign indicates that shifts in out-of-pocket spending patterns actually exacerbated the income-related disparity during those early years, even as the overall index was falling. In other words, the initial narrowing of the gap happened despite, not because of, the way medical costs were distributed across income groups, suggesting that other forces, including broader economic growth and expanding insurance enrollment, were doing the heavy lifting.

The 2013 to 2015 period, the one interval in which inequality worsened, produced perhaps the most striking finding of the entire analysis: smoking contributed 512.50 percent to the increase in the concentration index. The researchers’ interpretation is that smoking behavior, which is strongly patterned by income and education in China, interacted with hospital use in a way that disproportionately benefited wealthier smokers or disadvantaged poorer ones during this window. The magnitude of the contribution underscores how a seemingly unrelated behavioral risk factor can become a powerful engine of health care inequity when it clusters along socioeconomic lines.

The final two transitions turned the spotlight on insurance, and the results form a cautionary tale about the design of coverage schemes. Between 2015 and 2018, commercial insurance contributed 273.91 percent toward alleviating inequality, while the New Rural Cooperative Medical Insurance, the flagship scheme covering China’s rural population, contributed minus 117.39 percent toward exacerbating it. Then, between 2018 and 2020, the roles reversed dramatically: commercial insurance contributed minus 522.73 percent, worsening the disparity, while the rural cooperative scheme contributed 263.64 percent, helping to reduce it. The authors suggest that these swings reflect how the two insurance types reached different populations at different times, with commercial plans initially covering better-off urban residents and later expanding in ways that deepened stratification, while the rural scheme matured into a more effective equalizer as its reimbursement levels improved.

For readers unfamiliar with China’s health insurance landscape, the stakes of these findings are considerable. The country built the world’s largest health insurance system in roughly a decade, enrolling more than 95 percent of its 1.4 billion people through three main schemes: Urban Employee Basic Medical Insurance for formal-sector workers, Urban Resident Basic Medical Insurance for other urban dwellers, and the New Rural Cooperative Medical Insurance for the rural majority. Because reimbursement rates, benefit packages, and the underlying health of enrollees differ sharply across these schemes, insurance design has become one of the most consequential levers for health equity in the country. The new study provides rare longitudinal evidence on how those design choices translated into real hospital access for the chronically ill.

The study’s conclusions come with a note of guarded optimism. The authors write that income-related inequality in inpatient care utilization among Chinese middle-aged and older adults with multiple chronic conditions declined over the decade, showing a pro-poor change trend, and they emphasize that despite the impressive reductions, it remains important to maintain and improve equal access to hospital care. They point toward future interventions and policies that could target the economic circumstances of socially and economically vulnerable individuals and strengthen their ability to cope with the mounting burden of chronic disease. As populations age across Asia, Europe, and North America, and as multimorbidity becomes the norm rather than the exception in later life, the Chinese experience documented here offers a template, and a warning, for any health system hoping to measure, understand, and ultimately close the gap between the hospital care that the rich receive and the care that everyone else needs.

Subject of Research: Income-related inequality trends in inpatient care utilization among Chinese middle-aged and older adults with multiple chronic conditions

Article Title: Trend in income-related inequalities in inpatient care utilization among Chinese middle-aged and older adults with multiple chronic conditions, 2011–2020

Article References: Wang, L., Jiang, J., Zeng, W., Khan, M. M., Li, C., & Liu, W. (2026). Trend in income-related inequalities in inpatient care utilization among Chinese middle-aged and older adults with multiple chronic conditions, 2011–2020. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15791-6

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15791-6

Keywords: health inequality, inpatient care, multiple chronic conditions, China, CHARLS, concentration index, health insurance, aging, health economics, health policy, multimorbidity, health services research

The trial, led by Sinead McLernon and colleagues, set out to answer a question that sounds procedural but carries real clinical weight: is it actually possible to embed DIALOG and DIALOG+ in inpatient rehabilitation settings, where patients often have complex and enduring mental health difficulties and where care is delivered by multidisciplinary teams under constant operational pressure? The study was designed not as a test of effectiveness but as a feasibility and acceptability trial, the crucial first step in the pipeline of implementation science. Before a large-scale evaluation can be justified, researchers must establish whether the intervention can be delivered as intended, whether patients and staff will engage with it, and what practical barriers stand in the way. To that end, the team registered their protocol prospectively on ClinicalTrials.gov in May 2024 and received ethical approval from the Health Research Authority in July 2024, following the UK Policy Framework for Health and Social Care research with informed consent from all participants.

Methodologically, the study used a cluster allocation design, meaning that whole wards rather than individual patients were assigned to the implementation conditions. Feasibility data were collected over a five-month intervention period using a deliberately adapted, paper-based format of DIALOG and DIALOG+, a pragmatic choice reflecting the realities of inpatient wards where access to tablets or shared digital devices cannot be assumed. The researchers set pre-established progression criteria, thresholds that would determine whether the study could reasonably advance to a full trial. Staff recruitment and training proved achievable: seventeen staff members were recruited and trained, demonstrating that the service was willing to engage with the research at the organizational level. The patient side of the equation, however, told a different story.

Patient recruitment fell short of the pre-defined progression criteria, and engagement once enrolled was strikingly low. Across the five-month period, the mean number of DIALOG+ sessions completed per patient was just 1.9 out of a planned 10 sessions. Of the eight patients who participated, only four completed more than a single outcome measure. In implementation science terms, these adherence figures signal that the intervention could not be delivered with anything approaching fidelity in this context. The authors are careful to frame these numbers cautiously given the very small sample size, but the pattern is difficult to ignore: a structured monitoring and solution-focused intervention designed to be delivered repeatedly over months was, in practice, delivered once or twice.

To understand why, the researchers turned to qualitative methods. Patient participants completed qualitative surveys about their experiences, while staff participants took part in focus groups and interviews. Thematic analysis of this material identified four overarching themes that shaped whether DIALOG+ could take root. The first concerned staff and stakeholders’ affective attitude towards the feasibility objectives themselves, that is, their emotional responses to what the research was asking of them. The second theme captured affective attitudes towards the intervention, including how staff and patients felt about the DIALOG+ approach on its own merits. The third theme, alignment with current practice, examined whether the tool fitted the existing rhythms and routines of ward life. The fourth and perhaps most revealing theme was the inpatient setting itself, recognizing that the environment imposes constraints that outpatient or community services do not face.

These themes converge on a central insight: the failure was not necessarily one of the intervention’s design but of its integration. The authors identify insufficient adherence and limited integration within multidisciplinary team meetings as key implementation barriers. DIALOG+ is built around the premise that patient-rated outcomes feed directly into care planning conversations, ideally surfacing in the regular reviews where decisions about support are made. When the ratings remain isolated, completed sporadically and discussed outside the team’s main decision-making forums, the mechanism of action is broken. The tool becomes paperwork rather than practice. This finding echoes a broader lesson from implementation research across healthcare: innovations that require changes to team routines need active, sustained support to alter those routines, and simply training individual staff members is rarely enough.

The implications for the wider field of routine outcome monitoring are significant. DIALOG+ has accumulated encouraging evidence in community mental health settings, where structured quality-of-life assessments paired with solution-focused discussions have been associated with improved outcomes. Rehabilitation inpatient wards, however, serve patients with some of the most complex needs in the system, often involving long stays, fluctuating engagement, cognitive and motivational difficulties, and care delivered by shifting combinations of nurses, occupational therapists, psychologists and psychiatrists. The trial suggests that the assumptions about patient throughput and staff continuity that work in community settings may simply not transfer. A patient who is acutely unwell or ambivalent about their care may not reliably complete a ten-session monitoring schedule, however well intentioned the design.

Importantly, the authors do not conclude that DIALOG+ is unsuitable for this population. Instead, they offer concrete directions for future implementation trials: providing dedicated implementation support, additional training, and ongoing supervision to facilitate intervention fidelity and integration into routine multidisciplinary team practice. This recommendation aligns with contemporary implementation frameworks that distinguish between the effort of introducing an intervention and the effort of sustaining it. Dedicated implementation support might include embedding the tool into ward meeting agendas, assigning named staff champions, building completion into care pathways, and providing regular supervision to troubleshoot barriers as they emerge, rather than discovering them at the end of a five-month window.

The study also demonstrates the value of rigorous feasibility methodology itself. By setting progression criteria in advance, registering the trial prospectively, and combining quantitative adherence data with qualitative thematic analysis, the researchers produced a result that is honest and actionable rather than simply disappointing. Many interventions that fail quietly in routine services are never reported, leaving the field to repeat the same mistakes. Publishing a negative feasibility result, with a clear account of the four barrier themes, gives future teams a map of the specific obstacles they must address before investing in a full-scale trial of outcome monitoring in inpatient rehabilitation.

For patients on psychiatric rehabilitation wards, the stakes of getting this right are considerable. Structured monitoring of quality of life has the potential to give voice to people whose preferences are often overlooked in institutional settings, and to convert vague dissatisfaction into specific, solvable problems. The Sheffield-led trial shows that the technology and the clinical logic are portable only up to a point; the surrounding system must carry the intervention, and in this setting it did not. Whether a better-supported, perhaps digitally enabled version of DIALOG+ can succeed where the paper-based approach faltered remains an open question, one that the authors’ recommendations now make possible to test properly. The study, published open access under a Creative Commons licence with support from the University of Sheffield Institutional Open Access Fund, stands as a candid data point in the ongoing effort to make measurement-based mental health care a reality for the patients who need it most.

Subject of Research: Feasibility of implementing the DIALOG+ routine outcome monitoring system in psychiatric rehabilitation inpatient care

Article Title: Is it possible to implement the DIALOG+ routine outcome monitoring system in a psychiatric rehabilitation inpatient setting? A mixed methods feasibility trial in the UK National Health Service

Article References: McLernon, S., Bone, C., Fergusson, A., & Delgadillo, J. (2026). Is it possible to implement the DIALOG+ routine outcome monitoring system in a psychiatric rehabilitation inpatient setting? A mixed methods feasibility trial in the UK National Health Service. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08669-8

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08669-8

Keywords: DIALOG+, routine outcome monitoring, psychiatric rehabilitation, inpatient care, feasibility trial, mixed methods, NHS, implementation science, mental health, quality of life, multidisciplinary team, BMC Psychiatry

The clinical stakes are considerable. Rates of trauma exposure among people with eating disorders are high, and trauma is known to influence both the severity of the illness and how well treatment works. Inpatient care itself carries a paradoxical risk. The very environment designed to restore physical health can become a source of what researchers call treatment-related trauma, or it can re-traumatise patients who arrive with pre-existing histories of abuse, neglect or other adverse experiences. The risk of traumatisation or re-traumatisation rises sharply when treatment is coercive or restrictive, which in eating disorder units is often unavoidable: enforced bed rest, supervised meals, restriction of physical activity and, in severe cases, feeding under duress are all standard tools for managing medically unstable patients.

Trauma-informed care emerged as a response to precisely this tension. At its core, the framework asks services to recognise the prevalence of trauma among the people they treat and to organise care around principles of safety, trustworthiness, choice, collaboration and empowerment. In Australian mental health policy, these ideas have been prioritised for roughly the past ten years, appearing in state and national strategies as a marker of humane, modern practice. Yet policy endorsement does not automatically translate into clinical guidance, and it was this gap between aspiration and operational detail that the review set out to measure systematically.

Methodologically, the team conducted a systematic review following established reporting standards, searching PubMed, PsycINFO and Embase for published guidelines, supplementing these with grey literature searches and direct correspondence with health services across Australia. Eligible documents covered adult inpatient eating disorder treatment in public hospitals. Rather than simply counting mentions of trauma, the researchers applied qualitative thematic analysis, using both deductive coding, in which the five established trauma-informed care principles served as predetermined categories, and inductive coding, in which new themes were allowed to emerge from the material itself. This dual approach allowed them to capture not only whether guidelines addressed trauma but how the concept was being framed when it appeared.

The deductive analysis revealed a striking imbalance. Physical safety dominated the guidelines, and the prevailing logic was that protecting a patient’s medical stability justified restricting their freedom. Choice, collaboration and empowerment, the principles that give trauma-informed care its transformative potential, appeared far less often and were rarely connected to concrete clinical decisions. Some guidelines mentioned trauma or trauma-informed care by name, but most did not consider an individual patient’s trauma history or personal preferences when describing how treatment should be planned and delivered. In effect, the framework’s vocabulary had entered the guidelines without its substance.

The inductive analysis added three themes that sharpen the picture. The first, recognising trauma and trauma-informed care, reflected the simple fact that many documents failed to acknowledge high rates of trauma among eating disorder populations at all. The second, respect for inclusion and diversity, pointed to concerns about invalidating, judgemental or culturally unsafe treatment, which the authors note can itself contribute to treatment-related trauma. The third and perhaps most consequential theme was the balancing of coercive care with trauma-informed care, exposing an unresolved tension at the heart of inpatient eating disorder treatment: how to deliver genuinely necessary restrictive interventions without inflicting psychological harm.

Here the review uncovered its most important finding. When trauma-informed care did appear in the guidelines, it was commonly conceptualised as a style of delivering restrictive interventions more sensitively and supportively, rather than as a framework for minimising or critically examining coercive practices themselves. In other words, the guidelines tended to treat trauma-informed care as a communication technique layered on top of unchanged treatment, softening the tone of enforced feeding or supervised rest without asking whether the restriction was proportionate, whether less coercive alternatives existed, or how the patient’s own perspective might reshape the plan. The researchers warn that without clearer guidance on proportionality and the inclusion of patient perspectives, trauma-informed care risks remaining primarily a style of delivering coercive interventions rather than a framework that genuinely shapes clinical decision-making in inpatient settings.

This distinction matters because the two interpretations lead to very different clinical realities. A service that treats trauma-informed care as a delivery style might train nurses to explain procedures calmly and offer small choices within a rigid regime, changes that are worthwhile but leave the underlying power structure intact. A service that treats it as a decision-making framework would instead interrogate each restrictive practice at the level of the multidisciplinary team, weighing the therapeutic necessity of coercion against its psychological cost, documenting the reasoning, and involving the patient wherever medically feasible. The review suggests that Australian guidelines, taken as a whole, have not yet made this second, harder shift, and that clinicians are therefore left to navigate the tension between safety and autonomy largely on their own.

The findings arrive at a moment of growing international scrutiny of iatrogenic harm in psychiatry, and they carry implications well beyond Australia. Eating disorder inpatient units worldwide rely on restrictive practices that would be unthinkable in most other medical settings, justified by the life-threatening nature of illnesses such as anorexia nervosa. The Australian review does not argue that these practices should be abandoned; the authors acknowledge that prioritising physical safety is legitimate and often necessary. What the analysis exposes is the absence of guidance on where the balance should lie, how it should be struck, and whose voice should be heard in striking it. Guidelines that mandate restriction without addressing its traumatic potential, the study implies, are only telling half of the clinical story.

For the field, the path forward suggested by the review is one of clearer, more explicit operational guidance: guidelines that name trauma prevalence, define proportionality in coercive care, incorporate patient perspectives into treatment planning, and treat safety, trustworthiness, choice, collaboration and empowerment as inputs to clinical decisions rather than as decorative language. Until that happens, the authors conclude, a decade of Australian policy commitment to trauma-informed care has not fully reached the hospital wards where eating disorders are treated, and patients with trauma histories continue to enter units whose own rulebooks are largely silent on the harm those units can cause. The full open-access analysis is available in the Journal of Eating Disorders.

Subject of Research: Integration of trauma-informed care principles in Australian inpatient eating disorder treatment guidelines

Article Title: Trauma-informed care in Australian inpatient eating disorder guidelines: a systematic review and thematic analysis

Article References: Roome, S., Fallander, K., & James, S. (2026). Trauma-informed care in Australian inpatient eating disorder guidelines: a systematic review and thematic analysis. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01767-8

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01767-8

Keywords: trauma-informed care, eating disorders, inpatient care, clinical guidelines, coercive practices, restrictive interventions, re-traumatisation, Australia, systematic review, thematic analysis, mental health policy, patient safety

The urgency behind the guideline is grounded in stark epidemiology. Cigarette smoking remains the leading cause of preventable death in the United States, contributing to hundreds of thousands of deaths each year through lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, and stroke. Smoking rates are not evenly distributed across the population. They are especially high among individuals of lower socioeconomic status, groups that also tend to face greater barriers to accessing outpatient cessation services, and among hospitalized populations, where smoking-related illness is frequently the very reason for admission. For many patients, a hospital stay represents one of the few sustained contacts they will have with the health care system, making it a uniquely valuable window for intervention.

Despite that opportunity, tobacco treatment interventions remain chronically underutilized in hospitals, even though they rank among the most cost-effective strategies in all of health care. Studies of cessation pharmacotherapy and counseling have repeatedly shown favorable cost-effectiveness profiles compared with many other preventive services, yet the practical machinery of inpatient care, with its emphasis on treating the acute presenting illness, often leaves smoking unaddressed. The new guideline aims to close that gap by giving clinicians a clear, standardized protocol rather than leaving cessation decisions to individual habit or institutional variation.

Lead author Hasmeena Kathuria, MD, framed the guideline as a response to that inconsistency. When a patient is hospitalized, she noted, there is a real opportunity to initiate tobacco treatment. Her hope, she said, is that a standardized approach will help more clinicians feel comfortable providing counseling and pharmacotherapy to all hospitalized patients who smoke unless they explicitly decline, and will support continued treatment after discharge. Implementing these approaches, she added, is likely to improve smoking-cessation outcomes and reduce hospital readmissions, a dual benefit that speaks directly to both public health goals and the financial pressures hospitals face under value-based purchasing programs that penalize excess readmissions.

Among the six recommendations, several stand out for their specificity. The guideline recommends that, in hospitalized adults who smoke cigarettes, clinicians initiate varenicline during hospitalization to promote smoking cessation following discharge. Varenicline, a partial agonist at the nicotinic acetylcholine receptor, works by reducing both the reward associated with smoking and the withdrawal symptoms that drive relapse. It has consistently ranked among the most effective single-agent pharmacotherapies for cessation in randomized trials, and starting it in the hospital, rather than waiting for an outpatient visit that may never happen, ensures that patients leave with active treatment already underway.

The guideline also addresses the intensity and continuity of counseling, an area where inpatient practice varies enormously. For hospitalized adults who currently smoke cigarettes, the panel recommends inpatient tobacco treatment counseling lasting fifteen or more minutes over brief advice of less than fifteen minutes. The distinction matters because brief advice, while better than nothing, has modest effect sizes, whereas more substantial counseling sessions allow clinicians to assess dependence, discuss triggers, set quit plans, and address ambivalence using established behavioral techniques such as motivational interviewing. Requiring a minimum duration pushes institutions to allocate real staff time, whether through trained nurses, pharmacists, respiratory therapists, or dedicated cessation counselors, rather than treating a sentence about quitting as sufficient intervention.

Continuity of care forms the third highlighted pillar. The guideline recommends that inpatient counseling for hospitalized adults who smoke include a referral to postdischarge tobacco treatment counseling, with examples including scheduled follow-up contact and direct or electronic health record referral to a quitline or an outpatient program. The postdischarge period is where many inpatient cessation efforts collapse. Withdrawal symptoms intensify as patients return to environments saturated with smoking cues, and without structured follow-up, the momentum built during admission dissipates quickly. Quitlines, which provide free telephone-based coaching and in many jurisdictions medication support, offer a scalable bridge, and electronic health record-based referral systems can automate the connection, reducing the burden on bedside clinicians.

The logic of linking cessation to readmission reduction deserves emphasis. Patients admitted with exacerbations of COPD, acute coronary syndromes, pneumonia, or heart failure who continue smoking face elevated risks of returning to the hospital, and smoking cessation after such diagnoses measurably improves survival and reduces recurrent events. By embedding cessation into the inpatient workflow, hospitals can address a modifiable risk factor at the moment of maximal patient receptivity. The guideline’s authors argue that a standardized approach, applied to every hospitalized patient who smokes unless the patient explicitly declines, transforms cessation from an optional add-on into a default standard of care, analogous to venous thromboembolism prophylaxis or medication reconciliation.

The full set of six recommendations, including those not highlighted in the release, is available through the CHEST journal website in the article titled Tobacco Treatment in the Inpatient Setting: An American College of Chest Physicians Clinical Practice Guideline. As with other CHEST clinical practice guidelines, the recommendations synthesize the available literature using structured methodology, grading both the quality of evidence and the strength of each recommendation so that clinicians can understand how firmly each statement is supported. Guideline panels of this kind typically weigh randomized trial data, observational evidence, and patient values and preferences, and the published document details the rationale behind each recommendation for readers who need to adapt the guidance to local resources and populations.

For hospitals and health systems, the practical implications are significant. Implementing the guideline will require mechanisms to identify every admitted patient who smokes, typically through admission screening embedded in the electronic health record; protocols to prescribe varenicline where clinically appropriate, with attention to contraindications and drug interactions; staffing or consult services capable of delivering counseling sessions of at least fifteen minutes; and referral pathways that reliably connect patients to quitlines or outpatient programs before discharge. None of these components is technically difficult, but each requires institutional commitment, and the guideline’s standardization is intended to make that commitment easier to justify and audit. For the roughly one in eight American adults who smoke, many of whom will pass through a hospital bed in any given year, the guideline converts a fleeting admission into a structured pathway toward quitting, one that begins at the bedside and continues long after discharge.

Subject of Research: Evidence-based tobacco treatment recommendations for hospitalized adult patients

Article Title: CHEST releases guideline on tobacco treatment in the inpatient setting

Article References: CHEST releases guideline on tobacco treatment in the inpatient setting. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: tobacco treatment, smoking cessation, hospitalized patients, clinical practice guideline, varenicline, counseling, quitline, hospital readmissions, American College of Chest Physicians, inpatient care, preventable death, postdischarge follow-up

The study, published in BMC Nursing by Joo Yun Lee of Gachon University and colleagues, addresses a deceptively simple measurement problem. Patient experience is widely regarded as a key indicator of healthcare quality, and health systems around the world routinely survey patients about their stays. But the existing instruments were designed for conventional wards, where family members shoulder much of the daily care. In a nurse-led model, the entire texture of the hospital experience changes: who helps you to the bathroom, who explains your medication, who notices when you have not eaten. A generic questionnaire, the researchers argued, may simply not capture the features that matter most in this new arrangement.

To close that gap, the team carried out a methodological study that followed the classic sequence of instrument development. First, they mined the published literature for the dimensions of patient experience relevant to inpatient care. Then they conducted focus group interviews with nurses who work directly within the INCS model, an approach that grounds the questionnaire in the lived reality of the wards rather than in abstract theory. Items drafted from these sources were then subjected to expert content validation, in which specialists judged whether each item was clear, relevant, and representative of the construct it was meant to measure. Only after this multi-stage vetting did the candidate items advance to formal psychometric testing.

That testing drew on survey data from 237 recently discharged patients recruited across 126 hospitals, a notably broad sampling frame that spans a large share of the institutions delivering the INCS model. Because the respondents had all experienced nurse-led inpatient care firsthand, their ratings could be used to interrogate the internal structure of the draft scale. The researchers assessed construct validity, which asks whether the statistical pattern of patient responses matches the theoretical domains the questionnaire was designed around, as well as concurrent validity, which checks that scores on the new instrument behave as expected when compared against established measures of the same underlying concept.

The results were strikingly clean for an instrument at this stage of development. The final INCS Patient Experience Scale, abbreviated INCS-PES, settled at just 12 items organized into four domains: personalized care, information and communication, support for activities of daily living, and facilities and environment. Each domain maps onto a distinct question about the nurse-led ward. Personalized care probes whether treatment felt tailored to the individual. Information and communication examines whether patients understood what was happening to them and could converse effectively with staff. Support for activities of daily living captures the hands-on help with eating, hygiene, and mobility that families would traditionally have provided. Facilities and environment rounds out the picture with the physical conditions of the stay.

The statistical evidence for this four-factor structure was strong. Confirmatory analysis yielded a comparative fit index of 0.966 and a Tucker-Lewis index of 0.953, both comfortably above the conventional 0.95 threshold that psychometricians treat as indicating good model fit. The root mean square error of approximation, a measure of how far the model deviates from perfect fit, came in at 0.069, within the acceptable range. Internal consistency, which reflects how coherently the items within the scale hang together, was measured by Cronbach’s alpha at 0.90, a value generally interpreted as excellent for a multi-domain experience scale. Concurrent validity was also supported, meaning the new scale tracks with established measures of patient experience rather than diverging from them.

The 12-item scale does not stand alone. The researchers packaged it with three contextual items, which gather background about the patient’s hospitalization, and two global evaluation items, which ask for overall judgments of the care received. Together these components form the 17-item INCS Patient Experience Questionnaire, or INCS-PEQ. This architecture reflects a practical design philosophy: the core scale measures specific, actionable dimensions of the nurse-led care experience, while the contextual and global items allow administrators to interpret those scores and to benchmark overall satisfaction. A hospital can administer the full questionnaire in minutes, yet obtain a granular map of where its inpatient experience excels and where it falls short.

Why does this matter beyond South Korea? The INCS model emerged from a genuine systemic crisis. With one of the world’s lowest birth rates and a rapidly aging population, South Korea cannot rely indefinitely on family members, often adult children balancing jobs of their own, to provide unpaid bedside care. The nurse-led model professionalizes that work, and its expansion has been supported by the National Health Insurance Service of Korea, which supported the present research. But any large-scale service transformation needs feedback loops. Without a validated way to ask patients whether the new model is actually working for them, policymakers are steering by instruments that were built for a different ship. The INCS-PEQ supplies that instrument, and its development path, from nurse focus groups through expert review to a 237-patient validation sample, offers a template other countries could follow as they experiment with similar shifts away from family-dependent caregiving.

The study also carries a broader lesson for the science of measurement in healthcare. Instruments are not neutral rulers; they encode assumptions about what care looks like. When the structure of care changes fundamentally, as it does when informal caregivers are removed from the equation, the old rulers can silently mislead, undercounting the dimensions that matter and overweighting those that no longer apply. The four domains identified here, particularly the explicit attention to support for activities of daily living, would likely have been framed differently in a questionnaire intended for wards where families handle those tasks. In that sense, the INCS-PEQ is less a minor technical refinement than a recalibration of the yardstick to match a new reality of hospital care.

Limitations, as always, temper the enthusiasm. The validation rests on a single cross-sectional survey of 237 patients, and further work will be needed to confirm the instrument’s performance over time, across different hospital types, and in translated versions for international use. The authors themselves frame the questionnaire as a tool to support quality improvement and patient-centered care rather than a finished verdict on the INCS model. Still, the publication arrives at a moment when health systems worldwide are searching for ways to deliver more with fewer informal caregivers, and a rigorously validated, context-specific measure of patient experience is a small but consequential piece of that puzzle. Funded by a National Research Foundation of Korea grant from the Ministry of Science and ICT and approved by the Institutional Review Board of Sungshin Women’s University, the study was conducted with participants giving informed consent through a mobile-based survey system, in line with the Declaration of Helsinki. As nurse-led care models spread, the quiet work of asking patients what they experienced, and measuring the answers properly, may prove as important as the clinical reforms themselves.

Subject of Research: Development and validation of a patient experience questionnaire for nurse-led inpatient care in South Korea's Integrated Nursing and Care Service model

Article Title: Patient experiences in nurse-led inpatient care: development and validation of a questionnaire to support the shift toward patient-centered services

Article References: Lee, J. Y., Kim, S.-A., Park, J., Kwon, H., Kim, K., & Lee, E. (2026). Patient experiences in nurse-led inpatient care: development and validation of a questionnaire to support the shift toward patient-centered services. BMC Nursing. https://doi.org/10.1186/s12912-026-05458-2

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05458-2

Keywords: patient experience, nurse-led care, Integrated Nursing and Care Service, questionnaire validation, psychometrics, patient-centered care, inpatient care, South Korea, nursing research, instrument development, healthcare quality, BMC Nursing

The scale of the question is enormous. Between 50 and 72 percent of hospitalized patients carry a hypertension diagnosis, and roughly three-quarters experience at least one elevated blood pressure reading during their stay. Acute, symptomatic spikes that cause end-organ damage, known as hypertensive emergencies, demand rapid, high-intensity treatment. But for readings that fall well short of emergency territory and produce no symptoms, the evidence for intervening is remarkably thin, and what observational data exist point in a troubling direction: intensifying antihypertensive medications in the hospital may actually harm patients.

Those signals of harm are not subtle. In a propensity-matched cohort study, hospitalized patients who received antihypertensive medication on an as-needed basis had 24 percent higher odds of acute kidney injury, more than eight times the odds of ischemic stroke, and more than triple the odds of inpatient mortality. Intravenous antihypertensives, in particular, have been linked to prolonged hospital stays, while even oral intensification has been associated with kidney and myocardial injury. Worse, treating elevated blood pressure in the hospital does not appear to improve long-term blood pressure control and may raise the risk of adverse outcomes in the 30 days after discharge.

Recognizing this uncertainty, the American Heart Association issued a Scientific Statement in May 2024 concluding that the risk-benefit ratio of prescribing antihypertensives for asymptomatic elevated inpatient readings is unclear. Blood pressure can rise transiently because of pain, nausea, temperature, or stress, and in those cases the underlying cause, not the number on the monitor, is the appropriate target. But at some threshold, presumably, treatment becomes worthwhile. Where that threshold lies has never been established, which is precisely why a team led by Elizabeth R. Pfoh of the Cleveland Clinic set out to map what physicians actually think.

Between February and October 2024, the researchers emailed anonymous surveys to hospitalists at five academic medical centers: the Cleveland Clinic, Johns Hopkins School of Medicine, the University of Utah School of Medicine, the University of Nebraska Medical Center, and the University of Wisconsin-Madison. They defined elevated blood pressure as readings between 140/90 and 210/120 mmHg without symptoms of hypertensive emergency, deliberately excluding crises from the picture. Of 397 potential respondents, 166 physicians replied, an overall response rate of 42 percent that ranged from 24 to 64 percent across sites. Because the survey straddled the release of the AHA statement, the team also ran a sensitivity analysis comparing sites surveyed before and after May 2024.

The headline finding was a near-even split of professional opinion. When asked whether it is important to treat patients with an elevated blood pressure, 27 percent of hospitalists agreed while 47 percent disagreed, and the remaining quarter were neutral. On average, respondents leaned neutral overall, with a mean score of 3.3 on a five-point scale, but that average concealed a polarized profession: 8 percent strongly agreed treatment was warranted, 19 percent agreed, 30 percent disagreed, and 17 percent strongly disagreed. These attitudes were remarkably consistent across all five institutions, suggesting the divide is not a local quirk but a national pattern.

When it came to numbers, physicians converged loosely around a threshold but disagreed on the details. The median systolic trigger for intensifying medication was 170 to 179 mmHg, yet 38 percent of physicians said they would intensify below 169 mmHg, while 24 percent would hold off until readings reached at least 180 to 189 mmHg. Patience, however, was nearly universal: 79 percent of physicians would wait at least 12 hours before acting on an elevated reading. Patient characteristics mattered even more than the raw numbers. Physicians reported being more likely to treat patients with a history of heart failure (73 percent), stroke (73 percent), myocardial infarction (64 percent), or coronary disease (57 percent), and markedly less likely to treat patients whose elevated readings plausibly stemmed from withdrawal symptoms (81 percent less likely), pain (79 percent), fall risk (77 percent), substance use (61 percent), or nausea (53 percent).

Perhaps the most provocative finding concerned who, in practice, drives treatment. Sixty percent of physicians agreed that treatment is driven by nurses calling physicians, and an overwhelming 89 percent agreed they would prefer not to be contacted by a nurse about an asymptomatic systolic reading below 170 mmHg. Physicians who were least inclined to treat agreed most strongly that nursing calls were pushing them to prescribe, and they expressed the strongest preference for silence below both 170 and even 200 mmHg. The free-text responses laid bare the mechanism: repeated nursing calls create pressure to do something, and for many physicians, the perceived risk of prescribing feels smaller than the discomfort of ignoring an alarm. The AHA’s own framework, which urges hospitals to modify the culture of unnecessary treatment cascades, including default nurse-notification orders, appears aimed squarely at this dynamic.

Qualitative analysis of 133 open-ended responses revealed three broad rationales. Some physicians rejected routine treatment outright, with comments such as increasing medications without symptoms or clear indications puts the patient at higher risk for damage than benefit. Others would treat only when readings remained persistently elevated, for example beyond 24 hours, without another explanation. A third group would act only at very high values, though what counted as very high ranged from above 170 to over 200 mmHg. Underlying it all were two cross-cutting concerns: patient-specific conditions such as heart failure, and process worries such as poor outpatient follow-up after discharge. Meanwhile, only about a quarter of physicians felt there was clear guidance on when to prescribe, and 79 percent strongly disagreed that intravenous medication should ever be used for asymptomatic elevations, a view that hardened further among sites surveyed after the AHA statement.

The survey’s limitations are worth noting. It captured only academic medical centers in five states, response rates were moderate, and anonymity precluded comparisons between responders and non-responders, raising the possibility that physicians with strong opinions were more likely to reply. It is also possible that respondents imagined intensification as a permanent regimen change rather than a single dose, which could have shaped their answers. Still, the picture that emerges is of a profession practicing without a map. A 2024 systematic review found no guidelines at all for asymptomatic elevated inpatient blood pressure, only ten for hypertensive urgencies and eleven for emergencies. Compared with a 2010 survey in which 80 percent of residents called inpatient blood pressure control a high priority, the finding that just 27 percent of today’s hospitalists agree treatment is important suggests opinion has shifted as evidence of harm has accumulated. The authors conclude that randomized trial evidence is urgently needed to inform evidence-based guidelines, which in turn could reduce the wide practice variation that currently governs one of the most common decisions in hospital medicine. Until then, the most defensible approach, the researchers suggest, is the one the evidence already supports: treat the pain, the nausea, the stress, and the underlying illness, and let a truly asymptomatic number wait.

Subject of Research: Hospitalist attitudes toward treating asymptomatic elevated blood pressure readings in hospitalized patients

Article Title: Physicians’ Beliefs About Treating Asymptomatic Elevated Blood Pressure Readings Among Hospitalized Patients

Article References: Pfoh, E. R., Harris, C. M., Singh, M., Pappas, M. A., Ellenbogen, M. I., Shiffermiller, J., Kaiksow, F. A. A., Vaughn, V. M., & Rothberg, M. B. (2026). Physicians’ Beliefs About Treating Asymptomatic Elevated Blood Pressure Readings Among Hospitalized Patients. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10708-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10708-9

Keywords: hypertension, hospitalized patients, hospital medicine, antihypertensive medication, blood pressure, American Heart Association, inpatient care, physician survey, overtreatment, clinical guidelines, nursing calls, patient safety