Background Private equity (PE) investment in U.S. nursing homes has increased significantly over the past two decades. The emergence of this novel ownership model has prompted concerns regarding its effects on nursing home performance, especially quality. Objective This systematic review examined the impact of PE ownership on U.S. nursing homes, focusing on quality of care and financial performance. The review was conceptually informed by agency theory and the structure-process-outcome (SPO) framework. Methods Following PRISMA guidelines, a systematic search across five databases identified 12 studies published between 2000 and 2024. Eligible studies examined the effects of PE ownership on nursing home quality or financial performance. Data were extracted and synthesized across these two dimensions. Results Across studies, PE ownership was linked to higher number of deficiencies, increased hospitalization rates, and higher mortality, although some improvements in care processes were noted. Financial outcomes showed initial financial gains but long-term challenges, primarily due to high debt loads. Conclusions Findings suggest that PE strategies may prioritize short-term profitability, which may compromise quality of care in some instances. These findings highlight the need for financial transparency, and reimbursement models that incentivize long-term quality.

Objectives: The relationship between the volume of medical procedures conducted in hospitals and the resulting health outcomes has been described for various surgical and non-surgical medical interventions. As a policy response to this, several countries have implemented minimum volume standards. However, there is currently a lack of systematically compiled evidence assessing their impact. To close this research gap, we conducted a systematic review on the effects of minimum volume standards in hospitals. Design: Systematic review using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Data sources: MEDLINE, PubMed Central and Bookshelf (PubMed), EMBASE (Elsevier), CENTRAL (Cochrane Library), CINHAL (EBSCO), EconLIT (EBSCO), PDQ-Evidence for Informed Health Policymaking, Health Systems Evidence and three trial registries were searched until June 2023. Additionally, manual searches were conducted. Eligibility criteria for selecting studies: For inclusion in this review, studies must investigate the effects of minimum volume standards. We accepted all categories of outcomes. Following the Cochrane Effective Practice and Organisation of Care (EPOC) criteria, only a strict set of study designs, namely randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted time series studies, were included. No restrictions were placed on language, publication date or publication status. Data extraction and synthesis: Two reviewers independently screened titles and abstracts for eligibility, reviewed the full texts and performed data extraction of the included articles. Risk of bias was assessed using the 'Risk Of Bias In Non-Randomised Studies-of Interventions' (ROBINS-I) tool. Certainty of evidence was rated using the GRADE approach. For data synthesis and statistical analyses, we adhered to the EPOC guidance. Results: We included nine studies into our systematic review. Overall, the outcomes reported in the studies are heterogeneous, which did not allow for a meta-analysis, resulting in a narrative analysis of the found evidence. While travel distance increased and length of stay decreased, other reported outcomes such as complications or reoperations were not affected by the introduction of minimum volume standards. Overall, the risk of bias was considered serious for results on outcomes of seven out of the nine included studies and moderate for the remaining two. The certainty of evidence was rated low for complications, reoperations, length of stay and travel distance and very low for mortality (in-hospital; 30 days). Conclusion: This systematic review does not provide conclusive evidence on the effects of minimum volume standards in hospitals regarding any outcomes. The certainty of evidence for mortality (in-hospital; 30 days) is very low and low for complications, reoperations and travel distance. The results are based on a relatively small number of studies for most outcomes. There is a need for studies researching the effects of minimum volume standards based on a robust study design. Prospero registration number: CRD42022318883.

Background: Essential services ensure the health, safety, and well-being of individuals and their communities. However, there is currently a lack of consensus on what constitutes an essential service in Australia. This gap hinders a detailed spatial understanding of essential service provision, access, and influence on populations. This systematic review critically assessed the literature on essential services and their impact on quality of life to understand service definitions and their relative contributions to quality of life. Methods: A systematic search of ten databases was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Five criteria were established for the inclusion of studies: (i) major developed economies, (ii) defined essential service and focus on spatial access, (iii) quality of life outcome, (iv) peer-reviewed, and (v) published between 2000 and 2024. Results: From 1,473 unique records, seven studies met the inclusion criteria, with studies from Europe, Asia-Pacific, and North America. Across the studies, services were characterised based on their primary function and contributions to quality of life. Service categories included food, retail, personal services, health, education, culture and recreation, and faith-based services. Despite demographic and scale variations, services that fostered social connection and a sense of place showed the highest positive impact on quality of life. Conclusions: Findings indicate limited and inconsistent evidence on essential service measures and their relationship with quality of life. The persistent lack of justification for classifying services as essential in research hinders definitive conclusions about which services most effectively enhance quality of life. Future research should adopt standardised, validated measures, and address representation gaps across diverse populations and regions. This work is fundamental for developing a validated set of essential services, to improve national modelling of geographic access and inform policy, decision-making, and understanding of how access to services influences quality of life.

Accreditation of health services is one of the criteria for achieving the predetermined standards for health organizations. Therefore, the purpose of this systematic study was to investigate the primary health care (PHC) accreditation programs in the world and compile a summary of these programs in order to identify the areas and dimensions of these standards. This systematic review was conducted on online database studies, including PubMed, Scopus, Web of Science, and Google Scholar, using comprehensive terms. The inclusion criteria included all qualitative, quantitative, and mixed-method studies published in any language from 1990 to December 2022. The studies were evaluated with Joanna Briggs Institute Critical Appraisal Tools (JBI) critical appraisal tools checklist, and finally, the data were analyzed using the framework analysis method. The findings of 10 studies that were included in this study cover four main topics regarding the functions of the health system: stewardship, resource production, financing, and service delivery, as well as 10 sub-topics: policy making, interdepartmental leadership, monitoring and evaluation, human resources, equipment and medicine, information management, gathering of financial resources, capacity to provide services, access, and quality of services. In the accreditation of PHC, in addition to paying attention to performance indicators, indicators such as satisfaction and rights of clients and employees, access, information technology, coordination, integration of care, financing, and management of resources and equipment should also be considered.

Billionaire wealth has risen three times faster in 2024 than in 2023. Five trillionaires are now expected within a decade. Meanwhile, crises of economy, climate and conflict mean the number of people living in poverty has barely changed since 1990. Most billionaire wealth is taken, not earned- 60% comes from either inheritance, cronyism, corruption or monopoly power. Our deeply unequal world has a long history of colonial domination which has largely benefited the richest people. The poorest, racialized people, women and marginalized groups have been and continue to be systematically exploited at huge human costs. Today’s world remains colonial in many ways. This must be reversed. Reparations must be made to those who were brutally enslaved and colonised. Our modern-day colonial economic system must be made radically more equal to end poverty. The cost should be borne by the richest people who benefit the most.

INTRODUCTION: The COVID-19 pandemic has instigated the development of telemedicine-mediated provision of medications for opioid use disorder such as buprenorphine and methadone, referred to as TMOUD in this study. As services start to return to pre-pandemic norms, there is a debate around the role of TMOUD as addition to or replacement of the conventional cascade of care for people with opioid use disorder (PWOUD). This scoping review is designed to characterize existing TMOUD services and provide insights to enable a more nuanced discussion on the role of telemedicine in the care of PWOUD. METHODS: The literature search was conducted in OVID Medline, CINAHL, and PsycINFO, from inception up to and including April 2023, using the Joanna Briggs Institute methodology for scoping reviews. The review considered any study design that detailed sufficient descriptive information on a given TMOUD service. A data extraction form was developed to collect and categorize a range of descriptive characteristics of each discrete TMOUD model identified from the obtained articles. RESULTS: A total of 45 articles met the inclusion criteria, and from this, 40 discrete TMOUD services were identified. In total, 33 services were US-based, three from Canada, and one each from India, Ireland, the UK, and Norway. Through a detailed analysis of TMOUD service characteristics, four models of care were identified. These were TMOUD to facilitate inclusion health, to facilitate transitions in care, to meet complex healthcare needs, and to maintain opioid use disorder (OUD) service resilience. CONCLUSIONS: Characterizing TMOUD according to its functional benefits to PWOUD and OUD services will help support evidence-based policy and practice. Additionally, particular attention is given to how digital exclusion of PWOUD can be mitigated against.

The narrative framings of partnerships and interventions in global health shed light on actors' conceptualisations of international development. Ideas of equity and justice in North-South partnerships are increasingly centred in international development and global health policy approaches. However, the extent to which these are evident within practice requires further investigation. This paper critically examines published work from health actors based in Scotland conducted within low - and middle-income countries (LMICs), under a Scottish government policy context currently promoted as engaging in a novel approach to international development. The paper uses a scoping review to analyse Scottish actors' engagement and framing of global health interventions and partnerships with LMIC actors. A majority of the texts discussed Scottish-affiliated global health partnerships and/or interventions in the Malawian medical education and clinical medicine context and focused on capacity building and knowledge transfer. Authors of included documents characterised the 'Scottish approach' to partnership as rejecting the traditional donor-aid model and championing ideas of collaboration, reciprocity and equity in partnership. Yet simultaneously, most works described partnerships that positioned Scottish actors as the sources of expertise with partner country actors as beneficiaries, replicating the donor-recipient aid model. Additionally, the framing of partnership activities frequently deployed historical narrative frames.

Objectives: This systematic review aimed to identify the nature and effects of implementation strategies used to improve the care of older people with frailty in hospital settings. Methods: We included randomised controlled trials (RCTs), non-RCTs, before-after studies and interrupted time series describing clinical frailty-focussed interventions and implementation strategies aimed at improving outcomes for older people with frailty in hospital settings. We included peer-review articles and PhD theses published from the Year 2000 onwards. We excluded publications not in English and conference abstracts. Four electronic databases (Medline, PsycInfo, CINAHL and Scopus) were searched, alongside grey literature, in April 2024. Risk of bias was analysed using the NIH Quality Assessment Tool. A narrative synthesis approach was undertaken, with the RE-AIM framework used to present data for implementation outcomes and the Expert Recommendations for Implementing Change (ERIC) taxonomy used to categorise implementation strategies. Results: Fifteen studies were included; all were pre-/postdesigns and published post-2014. Most studies involved implementing frailty assessments to trigger care planning and pathways for people with frailty. Twelve studies reported positive improvements in one or more primary outcomes. Common implementation strategies included developing quality monitoring tools, mandating change, promoting adaptability of the intervention and distributing educational materials. Conclusions: Frailty interventions in hospital settings are usually multicomponent and highly influenced by context. This review confirms the feasibility of frailty screening and intervention in hospital settings, but implementation strategies are not well-reported. Future research should prioritise rigorous study designs and reporting to optimise the transferability of successful implementation strategies for frailty interventions to other health-care settings.

This paper shares stories from six countries—Bangladesh, Nepal, Kenya, Somalia, Syria, and Iraq—highlighting the challenges communities face in accessing water. It seeks to bring forward the unique perspectives of communities from diverse backgrounds, each experiencing water crises in distinct ways. While climate change intensifies their crises, many communities also face marginalization due to exclusionary water governance. The impacts are further compounded by factors such as gender, poverty, ethnicity, and race. However, the voices and perspectives of these communities are often overlooked in global climate discussions.The paper aims to highlight these diverse community experiences and advocate for the inclusion of local voices and leadership in climate actions and interventions to ensure fairer access to water. As global climate events like COP-29 unfold, it calls on governments to create inclusive climate policies, integrate water issues into loss and damage discussions, actively involve women and local voices, and urge rich, polluting nations to compensate those most affected by historic and ongoing carbon emissions.

Background: Cost-effectiveness analyses of preventive screening strategies are paramount for public health to ensure effective resource use, especially for sexually transmitted infections such as Chlamydia, which lead to significant quality-adjusted life years (QALY) loss. Summary: This study systematically reviewed EMBASE, PubMed, and SCOPUS databases, from inception to October 2022, Chlamydia infection screening strategies' cost-effectiveness studies analyzing Incremental Cost Effectiveness Ratio (ICER) of QALYs versus no screening. Out of 487 studies, six were included, each employing distinct screening approaches, assumptions, and prevalence and incidence rates. The ICERs varied from USD 2,350/QALY gained with annual screening of women aged 15-24 years to EUR 117,529/QALY gained with women and men screening (age 16-29). Key messages: The results underscore the impact of the different assumptions on ICERs and highlight the importance of precise epidemiology on Chlamydia infections. Studies characterizing the local population are crucial for accurate cost-effectiveness analysis and public health policy formulation.

Background: In the context of a broader vision for primary healthcare (PHC) informed health systems, Sweden is following international trends by introducing the national Good Quality and Local Health Care reform. This reform seeks to establish a health system with primary care (PC) at the centre by emphasising aspects such as interorganisational collaboration and e-Health innovation. Since translating policy into practice may be challenging in rural areas due to resource constrains and normatively urban perspectives in national policy-making, this study explores how rural PC actors navigate the PHC vision in the context of a sparsely populated area of the Swedish north. Methods: This was a single case study, focusing on a rural municipality in northern Sweden. Thematic analysis was applied to data collected through interviews and observations, resulting in the development of three themes. Results: The results indicate that the policies were suboptimally aligned with the needs of the rural municipality. The results highlighted enduring collaborations that predated the reform. These local alliances led to a resource allocation challenge, rendering the existing networks and reform efforts concurrently understaffed. Moreover, the reform's efforts to digitise healthcare faced impediments due to challenges associated with scaling up e-Health technology. Although key reform concepts such as person-centeredness and integrated care had already been put into practice, they were insufficiently acknowledged as such by external stakeholders. Conclusion: Subjecting national health policy-making to scrutiny by different stakeholders through the use of rural proofing can lead to a more deliberate and impactful implementation of policies. Rural proofing facilitates the preemptive identification of potential shortcomings, thereby enabling the formulation of necessary adjustments that resonate with local needs. This study shows apparent misalignments between the national vision and the practical reality in rural areas, therefore calling for greater efforts to include rural perspectives in national policy-making.

A Private Sector Rapid Care Analysis toolkit (PS RCA) is a rapid process for businesses and workers to understand the heavy responsibility and long hours of unpaid care and domestic work (UCDW), usually done by women workers. The guide also makes the case for why private sector companies should address UCDW as part of workers’ rights and human rights, and it outlines the benefits to businesses of taking action. PS RCA discussions clarify how employment policies, workplace culture and practices may make unpaid care and domestic work more challenging for workers, with hidden costs for company operations. The PS RCA process helps identify opportunities for company action and builds commitment to change. The step-by-step guide is easy to follow for businesses, women’s rights and feminist organisations, civil society organisations, trade unions and other interested parties. The two accompanying webinars provide training and guidance for managers, champions and advocates on how to conduct a PS RCA (Webinar 1), and for facilitators on how to conduct the focus group exercises with workers (Webinar 2). This PS RCA Toolkit complements the original Participatory Methodology: Rapid Care Analysis that focuses on community and local government roles in addressing women’s heavy and unequal share of unpaid care and domestic work. The toolkit also complements broader gender equity audits and strategies for business. Get in touch: If you would like to make use of the toolkit, have any questions on the process; and/or would like a PowerPoint/ open version of the webinars, please contact policyandpractice@oxfam.org.uk’

Digital technologies have the potential to either ameliorate or worsen the dynamics underlying poverty and inequality, depending on how those technologies are designed, developed, deployed, and used, as well as on the degree to which the businesses, and business models behind them, respect the rights of users and workers. This paper recommends changes in corporate and government policies and practices to ensure that the information and communication technology (ICT) industry respects human rights and does not exacerbate poverty and economic inequality across five pillars: access and equity, digital civic space, data use and privacy, automation and the future of work, and governance.

Background The uptake of guidelines in care is inconsistent. This review focuses on guideline implementation strategies used by guideline organizations (governmental agencies, scientific/professional societies and other umbrella organizations), experienced implementation barriers and facilitators and impact of their implementation efforts. Methods We searched PUBMED, EMBASE and CINAHL and conducted snowballing. Eligibility criteria included guidelines focused on hospital care and OECD countries. Study quality was assessed using the Mixed Methods Appraisal Tool. We used framework analysis, narrative synthesis and summary statistics. Results Twenty-six articles were included. Sixty-two implementation strategies were reported, used in different combinations and ranged between 1 and 16 strategies per initiative. Most frequently reported strategies were educational session(s) and implementation supporting materials. The most commonly reported barrier and facilitator were respectively insufficient healthcare professionals’ time and resources; and guideline's credibility, evidence base and relevance. Eighty-five percent of initiatives that measured impact achieved improvements in adoption, knowledge, behavior and/or clinical outcomes. No clear optimal approach for improving guideline uptake and impact was found. However, we found indications that employing multiple active implementation strategies and involving external organizations and hospital staff were associated with improvements. Conclusion Guideline organizations employ diverse implementation strategies and encounter multiple barriers and facilitators. Our study uncovered potential effective implementation practices. However, further research is needed on effective tailoring of implementation approaches to increase uptake and impact of guidelines.

Background: Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes. Methods: A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE. Results: Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses' attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes. Conclusions: Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes. Trial registration: PROSPERO CRD42019130446.

Background: Antimicrobial resistance (AMR) is a global public health concern that is fueled by the overuse of antimicrobial agents. Low- and middle-income countries, including those in Africa,. Point prevalence surveys (PPS) have been recognized as valuable tools for assessing antimicrobial utilization and guiding quality improvement initiatives. This systematic review and meta-analysis aimed to evaluate the prescription rates, indications, and quality of antimicrobial use in African health facilities. Methods: A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Embase, Hinari (Research4Life) and Google Scholar. Studies reporting the point prevalence of antimicrobial prescription or use in healthcare settings using validated PPS tools were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A random-effects meta-analysis was conducted to combine the estimates. Heterogeneity was evaluated using Q statistics, I² statistics, meta-regression, and sensitivity analysis. Publication bias was assessed using a funnel plot and Egger's regression test, with a p-value of < 0.05 indicating the presence of bias. Results: Out of 1790 potential studies identified, 32 articles were included in the meta-analysis. The pooled prescription rate in acute care hospitals was 60%, with significant heterogeneity (I2 = 99%, p < 0.001). Therapeutic prescriptions constituted 62% of all the prescribed antimicrobials. Prescription quality varied: documentation of reasons in notes was 64%, targeted therapy was 10%, and parenteral prescriptions were 65%, with guideline compliance at 48%. Hospital-acquired infections comprised 20% of all prescriptions. Subgroup analyses revealed regional disparities in antimicrobial prescription prevalence, with Western Africa showing a prevalence of 65% and 44% in Southern Africa. Publication bias adjustment estimated the prescription rate at 54.8%, with sensitivity analysis confirming minor variances among studies. Conclusion: This systematic review and meta-analysis provide valuable insights into antimicrobial utilization in African health facilities. The findings highlight the need for improved antimicrobial stewardship and infection control programs to address the high prevalence of irrational antimicrobial prescribing. The study emphasizes the importance of conducting regular surveillance through PPS to gather reliable data on antimicrobial usage, inform policy development, and monitor the effectiveness of interventions aimed at mitigating AMR.

Background: Despite increasing interest in quality end-of-life care (EOLC), critically ill patients often receive suboptimal care. Critical care nurses play a crucial role in EOLC, but face numerous barriers that hinder their ability to provide compassionate and effective care. Methods: An integrative literature review was conducted to investigate barriers impacting the quality of end-of-life care. This review process involved searching database like MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, and ScienceDirect up to November 2023. Search strategies focused on keywords related to barriers in end-of-life care and critical care nurses from October 30th to November 10th, 2023. The inclusion criteria specified full-text English articles published between 2010 and 2023 that addressed barriers perceived by critical care nurses. This integrative review employs an integrated thematic analysis approach, which combines elements of deductive and inductive analysis, to explore the identified barriers, with coding and theme development overseen by the primary and secondary authors. Results: Out of 103 articles published, 11 articles were included in the review. There were eight cross-sectional descriptive studies and three qualitative studies, which demonstrated barriers affecting end-of-life care quality. Quality appraisal using the Mixed Method Appraisal Tool was completed by two authors confirmed the high credibility of the selected studies, indicating the presence of high-quality evidence across the reviewed articles. Thematic analysis led to the three main themes (1) barriers related to patients and their families, (2) barriers related to nurses and their demographic characteristics, and (3) barriers related to health care environment and institutions. Conclusion: This review highlights barriers influencing the quality of end of life care perceived by critical care nurses and the gaps that need attention to improve the quality of care provided for patients in their final stages and their fsmilies within the context of critical care. This review also notes the need for additional research to investigate the uncover patterns and insights that have not been fully explored in the existing literature to enhance understanding of these barriers. This can help to inform future research, care provision, and policy-making. Specifically, this review examines how these barriers interact, their cumulative impact on care quality, and potential strategies to overcome.

Payment reforms are frequently implemented alongside service delivery reforms, thus rendering it difficult to disentangle their impact. This scoping review aims to link alternative payment arrangements within their context of service delivery, to assess their impact on quality of chronic care, and to disentangle, where possible, the impact of payment reforms from changes to service delivery. A search of literature published between 2013 and 2022 resulted in 34 relevant articles across five types of payment models: capitation/global budget (n = 13), pay-for-coordination (n = 10), shared savings/shared risk (n = 6), blended capitation (n = 3), and bundled payments (n = 1). The certainty of evidence was generally low due to biases associated with voluntary participation in reforms. This scoping review finds that population-based payment reforms are better suited for collaborative, person-centred approaches of service delivery spanning settings and providers, but also highlights the need for a wider evidence base of studies disentangling the impact of financing from service delivery reforms. Limited evidence disentangling the two suggests that transforming service delivery to a team-based model of care alongside a purchasing reform shifting to blended capitation was more impactful in improving quality of chronic care, than the individual components of payment and service delivery. Further comparative studies employing causal inference methods, accounting for biases and quantifying aspects of service delivery, are needed to better disentangle the mechanisms impacting quality of care.

Objectives: Health-related quality-of-life (HRQoL) instruments for cardiovascular diseases (CVD) have been commonly used to measure important patient-reported outcomes (PROs) in clinical trials and practices. This study aimed at systematically identifying and assessing the content validity of CVD-specific HRQoL instruments in clinical studies. Methods: The research team searched Cumulative Index to Nursing and Allied Health Literature, Embase, and PubMed from inception to January 20, 2022. The research team included studies that reported the development and content validity for CVD-specific instruments. Two reviewers independently assessed the methodological quality using the Consensus-based Standards for the Selection of Health Measurement Instruments methods on evaluating content validity of PROs. Content analysis was used to categorize the items included in the instruments. Results: The research team found 69 studies reporting the content validity of 40 instruments specifically developed for CVD. Fourteen (35.0%) were rated "sufficient" with very low to moderate quality of evidence. For PRO development, all instruments were rated "doubtful" or "inadequate." Twenty-eight (70.0%) instruments cover the core concepts of HRQoL. Conclusions: The quality of development and content validity vary among existing CVD-specific instruments. The evidence on the content validity should be considered when choosing HRQoL instrument in CVD clinical studies and health economic evaluations.

Objectives: China Health -Related Outcomes Measures (CHROME) was an initiative aimed at developing a system of preference -based health -related quality of life instruments for China. CHROME -cardiovascular disease (CVD) is a CVD-specific instrument with 14 items developed under this initiative. This study aimed to test the psychometric properties of CHROME-CVD. Methods: This validation study was conducted using cross-sectional questionnaire survey in China. Eligible patients with CVD were recruited and asked to complete the CHROME-CVD, the EQ-5D-5L, and a CVD-specific nonpreference-based healthrelated quality of life instrument selected according to the confirmed diagnosis of the patients. Item evaluation, internal consistency, measurement invariance, test -retest reliability, structural validity, and construct validity were tested using classic test theory. Item response theory was used to evaluate item -level performance. Results: A total of 444 patients with CVD (coronary artery disease, n = 276, heart failure, n = 104, angina, n = 33, and atrial fibrillation, n =16) from 6 provinces in China were enrolled for the validation. Exploratory factor analysis identified 4 factors: chest pain, other symptoms, physical health, and mental and social health. Cronbach 's alpha and intraclass correlation coefficient were .0.8. A total of 20 of 26 (76.9%), and 90 of 95 (94.7%) predefined hypotheses were met for convergent and discriminant validities, respectively. No important difference was identified between subgroups of gender and residency. Response options of 10 items were found overlapped based on categorical response curves, which led to modification to 4 -level response options. Wording of 3 items were modified by referring wordings of reference instruments. Conclusion: The validation of the CHROME-CVD demonstrated generally good psychometric properties. Further validation on the modified CHROME-CVD is needed.