The objective of this study is to estimate the number of deaths attributable to cardiovascular diseases and diet-related cancers that could be prevented or delayed in the Nordic countries, i.e., Sweden, Denmark, Finland, Norway, and Iceland, if adults adhere to the Nordic Nutrition Recommendations (NNR). A sex- and age-group specific epidemiological macro-simulation model was used to estimate the preventable deaths due to the differences between country specific actual intake and recommended intake of changes in food components. Data included in the model are a baseline scenario , a counterfactual scenario (recommended intake), and age-and sex-specific mortality for cardiovascular and diet-related cancer diseases, together with the total population risk of a specific year. Monte Carlo analyses with 5000 iterations were performed to produce the 95% uncertainty intervals. The model predicts that Iceland would benefit the most by adhering to the NNR, followed by Finland. In all the Nordic countries, the highest benefit would be achieved by adhering to the fruits and vegetable intakes, except Denmark, where a lower recommended intake of salt would provide the highest benefit. For men, fruits and vegetables could have saved more lives compared to other dietary components for all the Nordic countries, while for women, dietary fiber was the most prominent factor, except in Iceland. The Nordic Council should consider policies for promoting healthy eating according to the needs of each country. For several decades, the Nordic countries have collaborated to establish dietary guidelines. The Nordic Nutrition Recommendations (NNRs) are based on research data from epidemiological studies and laboratory studies by a panel of experts. These recommendations are applicable to all the Nordic countries: Sweden, Denmark, Finland, Norway, and Iceland . The decThe latest NNR was developed in 2012, when about 100 scientists from all five Nordic countries were involved in developing recommendations . The SYSThe number of deaths from chronic diseases and/or the incidences of chronic diseases that could be prevented or avoided by changing the dietary intake of the Nordic population according to the recommendations of the NNR 2012 are still unidentified. Furthermore, the dietary components that could provide the highest beneficial health effects in the respective countries are unknown. Since most of the top determinants of the burden of disease are diet-related such, as CVDs, T2D, obesity, and numerous cancers , it is tSimulation models are suitable for integrating results from observational studies where different experimental studies, such as randomized controlled trials (RCTs), are difficult to conduct ,11. ThisThe aim of this study is firstly to quantify health benefits by means of deaths related to CVDs and cancer that could be prevented or delayed if the Nordic population could follow the Nordic nutrient recommendations using a simulation model. Secondly, the aim is to perform an inter-country comparison to identify which dietary components would provide the highest health benefits for each country population. Thirdly, this study aims to observe heterogeneity in the quantified benefits based on age and gender.We compared the recommended nutrient intake with the actual dietary intake of the country-specific Nordic population. A validated and transparent macrosimulation model, the PRIME (Preventable Risk Integrated ModEl) , was useThe NNR 2012 . The minThe diet in the Nordic countries is characterized by a higher consumption of animal, processed, and sweetened foods, including non-alcoholic beverages and soft drinks . The fooIt is not surprising to note that the national dietary surveys vary with respect to sample size, age group, participation rate, as well as the methodology to collect the dietary intakes. Except for Finland, all countries had invited sample representatives to the country. However, the participation rate varied from 36% to 68.8%, where Sweden had the lowest and Iceland had the highest rate of participation. The methods to collect the dietary information also varied. Only Norway and Iceland used a similar method . The food intake was converted into specific nutrient intakes using country-specific nutrient databases, which are also presented in The actual mean intakes of nutrients is presented in A comparative risk assessment macrosimulation model, PRIME (Preventable Risk Integrated ModEl)  has beenTo be included in the model, food components have to be recognized as statistically associated with CVD outcomes and cancer, or biological risk factors for these diseases. Meta-analyses obtained from prospective cohort studies and randomized controlled trials are used to parameterize changes in nutritional risk factors and mortality as a result of the change in the population’s intake of food items and nutrients . PRIME eThe counterfactuals are based on changing dietary variables that are continuous ), rather than binary exposures (meet recommendations for fruit (yes/no)). Therefore, a distribution of each variable within the population is used as a baseline for the model. For the counterfactuals, a shift of distribution is made so that the new mean level of consumption matches the recommendation, but the variance in the population remains the same as the baseline. This is equivalent to everyone in the population making the same changes to their diet, implying that approximately 50% of the population will still not meet the recommendations in the counterfactual scenario, but this is appropriate since population-level targets (such as dietary recommendations) are monitored by tracking a population’s mean consumption levels.Combined changes in the risks for individuals are multiplicative. For example, if one extra serving of fruits reduces the risk of CVD by 11% and reducing salt intake by 1 g per day reduces the risk by 10%, then both of these behavior changes jointly reduce the risk of CVD death by 19.9% (1 − (1 − 0.11) × (1 − 0.10)). The PRIME model accounts for competing risks by combining relative risks multiplicatively. However, the model is unable to account for interactions between risk factors .Another assumption is that changes in risk follow a log-linear, dose-response relationship, except for obesity, which follows a J-shaped curve. For example, a change in the consumption of fruits and vegetables from 3 to 4 servings has the same effect on relative risk as a change in consumption from 6 to 7 servings. However, an upper threshold was included, above which there are no additional health benefits. The upper thresholds are based on the range of data collected in the meta-analyses used to parameterize the models. It is unlikely that the effects of different food components are independent and additive. By combining parameters multiplicatively, the PRIME model estimates the overlap in estimated changes in the risk of cause-specific mortality as they relate to changes in different dietary components .The model is based on a number of key assumptions:We also assume that Nordic people are similar in all aspects other than food intake, for example in terms of other health-related behaviors, such as physical exercise, alcohol drinking, and smoking habits, although within-country differences do prevail in health behaviors . PRIME hThe model requires age- and sex-specific population mortality for specific diseases for a given year. The mortality data for diet-related cancers , coronary heart diseases (ICD-10: I20-25) and stroke (ICD-10: I60-69) were obtained from country specific national databases. This model also required the age- and sex-specific number of populations in that country for that specific year. The population statistics were obtained from the official statistical websites of each country. The latest population and mortality data (from 2016) were used for all the countries except Norway, where the population and death statistics are from 2013.A Monte Carlo simulation was conducted to estimate the Uncertainty Intervals (UI) around the results. Each of the estimates in the model were allowed to vary according to the distribution reported in the accompanying literature. The 95% UI estimates are based on the 2.5th and 97.5th percentiles of results obtained from 5000 iterations of the model.The reported intake of fruits and vegetables was lowest for Finish men and women among all Nordic countries . Women cThe model estimates that the highest number of deaths that could be prevented by following the recommendation intake is for Iceland, where 19.7% of the deaths can be prevented, followed by the Finish population (18.9%) . In termIn terms of gender, more deaths could be prevented or delayed among men than women . ModifyiMost of the deaths that could be prevented or delayed by improving dietary intake are related to coronary heart diseases, followed by stroke in all the Nordic countries . In termIn this model-based simulation study, we show that a considerable number of deaths could be prevented or delayed if the Nordic population adhere to the NNR. Among the Nordic Countries, Iceland would benefit the most by adhering to the NNR. We also find that the most lives could be saved by changes attributable to an increase in fruits and vegetable consumption except for Denmark, where most of the lives can be saved by reducing salt intake. Furthermore, it also revealed that more lives of men than women could be saved.The simulation model predicts that the highest benefit would be gained for Iceland. This result is reasonable since Icelanders had the lowest intake of fiber and the highest intake of total fat, saturated fat, and a low intake of fruits and vegetables . This reThe highest number of deaths could be prevented or delayed by increasing the intake of fruits and vegetables for most countries where Finland would gain the most benefit. These findings are consistent with the Global Burden of Disease study, which revealed that health benefits are higher for food categories that are consumed in an insufficient amount, such as fruits and vegetables, than for foods and nutrients which are consumed in excess . FindingThe benefits from following the recommended salt intake are the third highest except for Denmark where it is the highest, according to the simulation model. For Denmark, the major portion of the salt comes from processed or semi-processed food, such as bread, meat, meat products, and cheese. Finland had the lowest salt intake among the Nordic countries. Since the 1970s, Finland has aimed to reduce salt intake in its National Nutrition Policy  by reforThe health benefits from changing the intake of fats and fatty acids are fewer compared to other dietary components. The estimates from the simulation model report on both the strength of the association between dietary factors and its health outcomes. The actual intake of fat and fatty acids for the Nordic population are very close to the recommended intake. Moreover, the population of the Nordic countries consumes a considerable number of dairy products and fish. Fish consumption has been measured to be the highest in Norway, followed by Iceland and Finland . Fatty fIt is noteworthy that women could gain the most from increased fiber intake, except in Iceland and Finland, whereas men could gain higher health benefits from an increased intake of fruits and vegetables. The reason for this result may be that men consume fewer servings of fruits and vegetables than women, whereas women consume less fiber than men . Since aThe results from this study can be compared with studies that use the earlier version of the PRIME model to estimate the health impact of achieving dietary recommendations in Canada  and the The need for comparable data on nutrient intake across the Nordic countries is complicated due to diverse study methodologies. The methods used in the Nordic countries for the dietary surveys were different . The 4 oDifferences in dietary assessment methodologies present further limiting factors when making inter-country comparisons. For example, the mean energy intakes of Norwegian men aged 18–29 years were 3059 kcal per day , which iThe participation rates in the national dietary surveys vary to a large extent, and there is, in general, a low participation rate . The higThe lack of alignment and completeness of national nutrient databases and classification systems present further limitations. Nutrient databases are required to calculate energy and nutrient intakes from food consumption data and are prone to random and systematic dietary measurement errors, which can affect population means and the distribution of nutrient intakes . An inteThe strength of this study is that it uses the same simulation model, which facilitates cross-country comparison. The mortality statistics and population data were obtained from country-specific credible sources, and it is known that Nordic countries maintain good epidemiological data due to unique personal identification numbers and validated national registers . These rPRIME is a transparent model for which all the risk equations related to changes in diet and mortality come from high-quality meta-analyses . MoreoveNonetheless, we provide a comparative scenario in the Nordic countries in regard to discrepancies in terms of actual dietary intake and recommended dietary intake by NNR with a simulation model. This simulation model study has the potential for future research. We found that different countries require different areas for the policy implications of changes in dietary habits. Danes need to reduce their salt intake while Finns need to increase their fruit and vegetable intake. The next question would be to investigate how decision makers can intervene to modify the consumption of dietary components (e.g., increase fruit and vegetable intake or decrease salt intake by using taxes or subsidies ,73,74 orIn conclusion, this study shows that by modifying dietary intake, a considerable number of deaths could be prevented or delayed in the Nordic countries. Thus, policy makers should take the necessary steps to modify the dietary intake of the Nordic population.


Slip and fall incidents at work remain an important class of injury and fatality causing mechanisms. An extensive body of safety research has accumulated on this topic. This article presents an analysis of this research domain. Two bibliometric visualization tools are applied: VOSviewer and HistCite. Samples of 618 slip and fall related articles are obtained from the Web of Science database. Networks of institutions, authors, terms, and chronological citation relationships are established. Collaboration and research activities of the slip and fall research community show that most contributors are from the United States, with the (now closed) Liberty Mutual Research Institute for Safety the most influential research organization. The results of a term clustering analysis show that the slip and fall research can be grouped into three sub-domains: epidemiology, gait/biomechanics, and tribology. Of these, early research focused mainly on tribology, whereas research on gait/biomechanics and epidemiological studies are relatively more recent. Psychological aspects of slip and fall incident occurrence represent a relatively under-investigated research topic, in which future contributions may provide new insights and safety improvements. Better linking of this research domain with other principles and methods in safety science, such as safety management and resilience, may also present valuable future development paths. Slips and falls are one of the major sources of injuries and fatalities at work , at homeIt is not entirely clear when the very first scientific research on slips and falls was performed, but it appears that only a handful of studies was performed before 1970. Carlsöö was one of the pioneers in the study of gait . PerkinsBoth incident types are common but present complex topics for scientific inquiry, as they involve many factors traditionally studied in different scientific disciplines. From an interdisciplinary safety science perspective, and for reducing slip and fall related incidents and accidents in practice, it is thus important to obtain a holistic view on the research areas and topics which are involved in the study of these phenomena. Systematic literature reviews are useful for decision makers and safety practitioners to develop evidence-based safety assurance programs, and valuable for scientists to understand the state of the art and work on identified research gaps or uncertainties. Several review articles have been made, addressing specific issues or circumstances. Leclerq  reviewedWhile the above-mentioned review articles are insightful and useful to understand specific aspects of slip and fall research, these do not provide insights into the range of topics which are covered in the research domain, and in the structure of this scientific domain in terms of impactful journals, authors, and institutions, and its historic development and recent trends. This is not a shortcoming of these works per se, but a result of the focus, scope, and correspondingly applied methodologies in these review articles. For obtaining insights into the structure of a research domain and to identify high-level trends and gaps, a mapping review methodology is more appropriate . BibliomSafety Science journal 33], specThe remainder of this article is organized as follows. The scientific literature on slip and fall incidents and accidents was downloaded from the online version of Web of Science Core Collection, which is one of the leading citation databases and includes high-quality bibliographic information about publications in a wide range of scientific disciplines. Consequently, it has been widely used in bibliometric review research ,35. In sThe annual trend of research outputs is a simple but insightful way the to show the global activity and scientific attention to slips and falls. The time series of the published slip and fall papers is shown in Bibliometric mapping methods and tools were used in this study, where scientific data was visualized using various processes. Bibliometric mapping as a research method is the application of quantitative methods for visually representing scientific literature based on bibliographic data.https://www.vosviewer.com/publications), including topics addressing environment and public health [The VOSviewer software was applied in the research to visually represent the bibliometric map of the slip and fall research domain. As software for analysing bibliometric networks with text mining functionalities and advanced visualization options, it has been widely used for analysing various knowledge domains , who is also the father of the Web of Science database [In addition, the HistCite software tool was also applied to analyse the citation network for slip and fall studies. HistCite is a software implementation of database . It alloIn order to conduct and create the bibliometric analyses and visualizations of the slip and fall research domain, the steps presented in Authors active in the slip and fall research domain are knowledge providers, where especially the highly productive authors have a possibly influential role. An author’s collaboration analysis not only can display the core leading knowledge providers, but also the social networks among these authors. This is interesting knowledge, for instance, for early career researchers entering this research domain, or for external stakeholders seeking advice from world-class experts. In order to obtain a visually clear authors’ collaboration network, not all authors are included in the network. In the current research, authors who have published more than two articles on slip and fall incidents or accidents are included in the collaboration network in The productivity of authors in a given research domain is one of the most important indicators to measure their impact in that area. The results of the author outputs show that W.R. Chang of the Liberty Mutual Research Institute for Safety (LMRIS), published 58 papers and ranked first place in this area. He is followed by Li (38), Lockhart (31), Courtney (25), Gronqvist (25), Pai (24), Yang (22), Chang, C. C. (21), Hirvonen (18), and Huang (18). As listed in Authors can be divided into different groups based on the strength of their collaboration. Each group of authors shows the different sub-communities of the slip and fall research domain. For example, W. R. Chang has the largest node in his group, and has 42 collaborators in the global collaboration network. Li, Lockhart, Gronqvist, and Hirvonen also play leading roles in their group. Among these institutions, the LMRIS was the most productive, having published 69 papers. It was followed by the University of Illinois (36), Virginia Polytechnic Institute and State University (35), National Institute for Occupational Safety and Health of the United States , Chung Hua University (32), and University of Pittsburgh (31). As is known from the analysis of the slip and fall authors in The VOSviewer software was used to apply the so-called Automatic term identification method  to extraThe cluster of the terms for the slip and fall research domain is shown in The number of times a paper has been cited by other papers, either within the research domain under scrutiny, or in the entire scientific body of literature, has been widely adopted in bibliometric analyses to quantify the impact and influence of the paper ,31.In this section, not only are the highly cited articles in the slip and fall research domain identified. Rather, also the networks between these highly cited papers are determined, by using the HistCite software. HistCite distinguishes two types of citation scores: the local citation scores (LCS) and global citation scores (GCS). The local citation score of an article is the number of citations of this article within the local database being studied , with two published in Applied Ergonomics and the Journal of Biomechanics. In relative terms, 53.3% of the highly cited articles are published in Ergonomics, reflecting its status as the leading journal in the slip and fall research domain, and indicating that slips and falls are considered an important subdomain in ergonomics. The time distribution of the papers shows that seven (23.3%) highly cited papers were published in 2001, and 71.4% (5/7 = 71.4%) of these papers from 2001 were published in Ergonomics. Chang W. R. (4), Cham (3), Rosqvist (3), Strandberg (3), and Redfern (2) are influential authors who published more than one highly cited article in the slip and fall citation network.To obtain a more complete chronological network of the slip and fall research domain, papers which have been cited more than 20 times in the references of the citing articles were also included and used for constructing a citation network. This means that 27 papers were added to this network. Finally, the top 30 highly cited slip and fall papers were extracted and used to construct a citation network. The citation network also shows the evolution of slip and fall research from 1978 to 2004. Within this network, Perkins was the first highly cited article with 53 citations , with a In the collaboration network analysis, both authors and institutions publishing work in the slip and fall research domain were included. It should be noted that authors are associated with institutions. Therefore, there were significant correlations between the networks of authors and institutions. For example, the LMRIS was the most productive institution within the research domain. Most of the highly influential authors in The dominance of research performed in the United States is remarkable, and it may be questioned if the same clusters or trending topics would be found if only authors or institutions from the United States, or from other countries were considered. Focusing on the United States, given the dominance of the highly influential authors from that area, it is likely that the results would not change significantly if only work originating from the United States were included. Perhaps the centrality of some authors or institutions would shift somewhat, and the relative occurrence frequency of topics could change somewhat. For other countries, with fewer contributions, it may well be that significantly different patterns would be found. For instance, it may be hypothesized that authors from Finland or Sweden would be comparatively more focused on friction measurement in icy conditions, or the influence of snow or ice on biomechanics in the context of slips and falls. Such more detailed questions were however not further analysed in this paper, and were left for future research. A note is in place on the data collection method, and related limitations of the presented work. The slip and fall focus in this paper was the slip and fall of humans, which implied a subsequent contact with the ground, with likelihood of injury or fatality of the victim. In searching the articles in the literature, and in constructing the dataset using the keywords as described in n clusters, where n is greater than or equal to two. Here three clusters of slip and fall topics were identified. It appears that the slip and fall research community contains more physical ergonomists then psychologists. Hence, more focus by psychologists may be required to strengthen the scientific understanding of perceptual and psychophysical aspects of slip and fall incidences. It may also be worthwhile to explore and strengthen links between the slip and fall research community and other safety principles and approaches, for instance, safety management, risk analysis and uncertainty based decision analysis, and resilience engineering.Another point concerns the clustering of the research as presented in It should also be noted that all scientometric analyses use citations from all authors, i.e., also self-citations are counted. It is possible that in the local and global citation analyses of Ergonomics journal. The year 2001 is special, in the sense that it produced the most highly cited papers  Liberty Mutual Research Institute for Safety were amongst the most influential in the field, with Wen Ruey Chang the most impactful author overall. By far the most work originated from the United States, with Taiwan, Finland, and Sweden other significantly contributing countries. A terms analysis revealed three major clusters: epidemiology and slip and fall incidence, gait of biomechanics, and friction measurement and coefficient. An analysis of the average years in which these terms were found in the literature revealed that research recently has focused more on the gait and biomechanics cluster, indicating that more work is recently being performed on addressing the human factors in the slip and fall occurrence. The results also suggest that more work on the perceptual and psychological aspects of slip and fall occurrence would be beneficial. Another area of future research, which has not attracted significant attention, is the link between slips and falls, and other (more generic) safety principles such as safety management, risk analysis and uncertainty based decision analysis, and resilience engineering. A local and global citation analysis revealed which articles have been most influential within the slip and fall research community, and a chronological citation network showed how the field has evolved in light of the interconnection between these highly influential articles. Finally, a discussion has indicated how these results can be used by researchers and funding agencies, addressed some limitations of the current work, and made suggestions for future research.


Monitoring results regarding the effectiveness of knee and hip arthroplasties may be useful at the clinical, economic and patient level and help reduce the number of prosthesis revisions. In Spain, and specifically in Catalonia, there is currently no systematic monitoring of the different prosthesis models available on the market. Within this context, the aim of the project presented in this protocol is to evaluate the short- and medium-term effectiveness of knee and hip models implanted in Catalonia and to identify where the results could be better or worse than expected.A prospective observational design will be drawn up based on data from a population-based arthroplasty register for hip and knee replacements that includes data from 53 of the 61 public hospitals in Catalonia. The knee and hip prosthesis models used will be identified and classified according to the type of prosthesis, fixation and, in total hip replacements, the bearing surface. For the data analysis, two methodological approaches will be used sequentially: first, an approach based on a survival analysis, followed by an approach based on standardised revision ratios and funnel plots. Following the analyses, a panel of experts will evaluate the results to identify possible sources of bias. Lastly, those models with results better or worse than expected compared to those from the comparison group will be valued, and strengths and difficulties for routine implementation of this methodology within the Catalan Arthroplasty Register will be identified.The study presented in this protocol will allow us to identify the hip and knee prosthesis models whose results might be better or worse than expected. This information could have a potential impact at the patient, orthopaedic surgeon, healthcare manager, decision-making and industry levels, both in the short term and in the medium and long term. Currently, knee and hip arthroplasties are one of the most frequent elective surgeries worldwide . In SpaiIn the current context of continuous innovation and technological progress, the number of prosthesis models available on the market is constantly increasing –8. DespiSpain does not currently have a joint replacement registry covering the entire country, nor a repository of the different prosthetic models in place nationwide. Although there are regional registries, the only consolidated example is the Catalan Arthroplasty Register (RACat) . The RACAt the Catalan and Spanish level, all prosthesis models are authorised for commercialisation, but there is no systematic information to assess their post-market effectiveness and identify models with better or worse results. In general, the information available regarding efficacy and effectiveness of the different prosthetic models is provided by the manufacturers resulting from studies conducted with one or a few specific prosthetic models, or derived from studies combining different models –15. As sRegarding the methodology used in the past to compare prosthesis effectiveness, various approaches to the problem have been suggested, both from a clinical perspective and from a more statistical perspective –27. Two Within the context described, the main objective set for the project is to evaluate the short- and medium-term effectiveness of the models implanted and to identify those where the results could be better or worse than expected. Specifically, this study focuses on three specific objectives, which are (1) to describe the frequency of use and analyse the survival of the models used in Catalonia for knee and hip arthroplasties between 2005 and 2016 and (2) to detect specific prosthesis models with potentially better or worse than expected results. Furthermore, as a medium- and long-term objective, the proposal is (3) to identify relevant aspects for the incorporation of the methodology of this study on a routine basis within the RACat in order to identify prosthesis models that could have better or worse results.A prospective observational design will be drawn up based on data from the Catalan Arthroplasty Register (RACat) to describe and evaluate the functioning of the different prosthesis models used in Catalonia between 2005 and 2017. Since 2005, the RACat has systematically gathered information on knee and hip replacements implanted in publicly owned institutions in Catalonia. This information is further supplemented by data drawn from three additional sources: (1) the Central Insurance Registry (RCA) which provides information about patients’ vital records  and enables us to track them; (2) the Minimum Basic Data Set for Hospital Discharge (MBDS-HD), which serves to complete patient data, treatment episodes and diagnoses; and (3) the RACat Prosthesis Catalogue, a compendium of information regarding the specific prosthesis models that were implanted that allows us to see their characteristics based on information provided by the manufacturers.Firstly, the models of knee and hip prostheses used during the study period will be identified and classified according to the prosthesis group to which they belong . Subsequently, we will analyse the results and compare the behaviour of each of the models to their reference group. Lastly, aspects and limitations related to the described process will be evaluated and taken into account for the routine implementation of this methodology within the RACat Fig. .Fig. 1PrThe study population to be considered will comprise all patients undergoing knee or hip arthroplasty operations at hospitals belonging to the SISCAT  between January 2005 and December 2016. In the years following, after executing the study and verifying its utility, data analysis will continue on new cases and prosthesis models as they are added to the RACat.The RACat currently has information available on more than 46,000 primary hip arthroplasties and 5000 revisions, and over 60,000 primary knee arthroplasties and 6500 revisions . Since iConsideration will be given to all primary prosthesis models employed throughout the period studied. The analyses will exclude cases where it is impossible to identify the operated joint and their laterality (if the operated joint is in the left or the right side), the gender of the patient undergoing the operation, their age, the presence of prior comorbidity or the specific prosthesis model. We will also exclude prosthesis models whose volume of implantation during the study period would not have allowed us to establish valid and reliable conclusions regarding the survival and possible deviation between observed and expected values. Before starting, a minimum frequency of 10 prostheses corresponding to the model implanted throughout the period studied will be established for the inclusion of a specific model within the analysis due to limitations connected with the range of the confidence intervals. This limit may vary depending on the distribution of frequencies of the specific models identified included in the RACat. Furthermore, the analyses will exclude revisions caused by infection, since the premature failure of these prostheses cannot be attributed to a poor outcome of the implant.For the grouping of the models of prosthesis and detection of results potentially better or worse than expected in comparison with the reference group, three aspects will be considered: the type of prosthesis, the fixation and, for total hip replacements, the bearing surface.As regards the type of prosthesis, we will use the same classification system previously used by both the RACat and by studies conducted within the context of other international joint replacement registries with extensive, well-established track records –8, classConcerning the type of fixation used for the prosthesis, the following methods will be considered: cemented . non-cemented (none of the components cemented for either hip or knee prostheses), hybrid  and reverse hybrid .To analyse total hip replacements, we will also consider the bearing surface between the different components of the prosthesis, such as metal on metal, metal on polyethylene, ceramic on ceramic and ceramic on polyethylene. Moreover, in total hip prostheses comprising different components, the analysis will also take into account the combinations noted in the stem and cup models.We will consider the following patient characteristics: gender, age and comorbidity at the time of the operation, evaluated based on the Charlson comorbidity index (CCI) adapted for the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) , 30. TheIn order to achieve the objectives, the following analyses will be performed sequentially:Firstly, the models and combinations used over the course of the period of study will be described. For each model or combination, the total frequency implanted will be calculated, along with the relative frequency according to prosthesis group and year. Furthermore, whenever the frequency of the specific prosthesis model or combination allows, the Kaplan-Meier method will be used to calculate the crude revision risk for any cause (except infection periprosthetic fracture and luxation), at 1, 3 and 5 years, with corresponding 95% confidence interval (95% CI).Subsequently, to identify prosthesis models whose results are better or worse than expected, two different but mutually complementary methodological approaches will be employed consecutively. As the main standard to be followed, we will use the methodology proposed by de Steiger et al.  within tn = 10) will be included. Furthermore, we will use funnel plots to graph the SRR (y-axis) against the expected number of replacements (x-axis). Confidence intervals of 95% (95% CI) and 99% (99% CI) will be constructed, deeming that a prosthesis above or below 95% CI or 99% CI has a result that could be better or worse than expected with regard to the mean for its group. This outlier status indicates that the number of replacements performed is significantly lower or higher than the number of replacements expected with regard to the mean figure for the group  [Secondly, as a complementary analysis to the above methodology, a methodological approach based on standardised replacement ratios (SRR) will be used in accordance with the methodology proposed by the NJR also adapted for the specific characteristics of the RACat . In this 99% CI) , 23, 25.Once both types of analysis have been conducted, and taking into account as the reference results those obtained on the basis of the first approach, the models obtained will be compared to determine if their results are potentially better or worse than expected. As such, the results obtained on the basis of the second methodology proposed will serve firstly as an element facilitating the visualisation of the results, and secondly as a confirmation element if the first approach reveals results that could potentially be better or worse than expected in comparison with the corresponding type.Lastly, models identified by the first and/or second approach will be evaluated by the advisor committee of the RACat, a panel of experts in orthopaedic surgery and traumatology working with the RACat. As result of this evaluation and once a consensus about the different models will be reached, we will proceed to identify those with results potentially better or worse than expected, according to both clinical and statistical criteria, having considered possible sources of bias from both perspectives.Once the process has been completed, and with the goal of routine implementation within the RACat, all aspects of the development of this study will be considered, in order to identify possible key points. This will entail a retrospective analysis of the difficulties and limitations encountered within each of the tasks performed so we can identify the most important aspects to take into account regarding implementation.As far as we know, aside from studies that group results together by prosthesis type and clinical trials of specific prosthesis models –15, 31, Presently, there is no clear standard on the most appropriate procedure to detect models whose results could be better or worse than expected. Despite this, after reviewing the strengths and limitations of the different options previously used for this purpose , 25, 32,As for the specific methods used previously, various approaches have been identified, based on different methodologies such as survival models, cumulative sum of results (CUSUM) or ratios of cases observed and expected, among others , 24, 26.Concerning the limitations of the present work, the main one is related to the results obtained from the funnel plots, as suggested by previous studies –25. ThesOn the other hand, given that only prosthesis models or combinations of prosthesis models whose frequency allows us to draw valid conclusions from the analyses performed will be included, the results obtained will be limited to the most commonly used prostheses, excluding highly infrequent models. Nonetheless, a descriptive analysis of the frequency of all models included in the RACat will be performed which will therefore enable the identification of those models that given their low frequency of usage were not included. Additionally, given that the routine implementation of this methodology within the RACat is addressed, if the models remain in use in subsequent years, they could ultimately achieve a cumulative frequency of usage that would allow them to fulfil the inclusion criteria, and thus allow us to perform the proposed analyses.With regard to the information available on joint replacement operations in the RACat, this is not complete, since the mandate to report all the prosthesis models used in public hospitals in Catalonia took effect in March 2017. However, as mentioned above, during the study period, 53 of 61 public hospitals were involved in submitting information, which accounted for more than 85% of public health procedures conducted in Catalonia [In conclusion, by observing the performance of the different prosthesis models compared to the general performance observed within their reference group, our study will contribute to the current needs to identify and ascertain knee and hip prosthesis models whose results could be better or worse than expected. This identification process has a potential impact on patients, surgeons, industry and healthcare managers. Finally, we expect that this monitoring methodology could be routinely implemented to assess the different prosthesis models and promote the use of those that have positive results both in Catalonia as in the National Health System of Spain.


Rural China has experienced an increasing health burden because of stroke. Stroke patients in rural communities have relatively poor awareness of and adherence to evidence-based secondary prevention and self-management of stroke. Mobile technology represents an innovative way to influence patient behaviors and improve their self-management.This study is part of the System-Integrated Technology-Enabled Model of Care  to improve the health of stroke patients in resource-poor settings in China. This study aimed to develop and pilot-test a mobile phone message–based package, as a component of the SINEMA intervention.The SINEMA trial was conducted in Nanhe County, Hebei Province, China. A total of 4 villages were selected for pretrial contextual research and pilot study. The 5 stages for developing the mobile phone messages were as follows: (1) conducting literature review on existing message banks and analyzing the characteristics of these banks; (2) interviewing stroke patients and caregivers to identify their needs; (3) drafting message contents and designing dispatching algorithms for a 3-month pilot testing; (4) collecting feedback from pilot participants through questionnaire survey and in-depth interviews on facilitators and barriers related to their acceptance and understanding of messages; and (5) finalizing the message-based intervention based on participants’ feedback for the SINEMA trial.On the basis of 5 existing message banks screened out of 120 papers and patients’ needs identified from 32 in-depth interviews among stroke patients and caregivers, we developed a message bank containing 224 messages for a pilot study among 54 community-dwelling stroke patients from 4 villages. Of 54 participants, 51 (response rate: 94.4%) completed the feedback survey after receiving daily messages for 3 months. Participants’ mean age was 68 years (SD 9.2), and about half had never been to school. We observed a higher proportion of participants who were in favor of voice messages  than text messages . Among participants who received voice messages (n=43) and text messages (n=40), 41 and 30, respectively, self-reported a full or partial understanding of the contents, and 39  and 32 , respectively, rated the messages as helpful. Analyses of the 32 interviews further revealed that voice messages containing simple and single-theme content, in plain language, with a repeated structure, a slow playback speed, and recorded in local dialect, were preferred by rural stroke patients. In addition, the dispatching algorithm and tools may also influence the acceptance of message-based interventions.By applying multiple methodologies and conducting a pilot study, we designed and fine-tuned a voice message–based intervention package for promoting secondary prevention among community-dwelling stroke patients in rural China. Design of the content and dispatching algorithm should engage both experts and end users and adequately consider the needs and preferences of recipients. Stroke is the leading cause of death and disability in China. According to recent estimates, stroke-related deaths reached around 1.1 million in China, accounting for 23% of total deaths in rural areas and 21% in urban areas  did not care about it. Only the village doctor told us some [information].Patient #8Village doctors, considered as the key source of information and the first contact of care, also had the minimal capacity to provide intensive health education to patients because of their existing high workload of serving more than 1000 residents in the village. Therefore, general knowledge related to stroke secondary prevention was required in the message bank.In the interview, many patients admitted that they were not able to adhere to all secondary prevention medications. The main reasons for nonadherence to medication use included their forgetfulness because of declining memory, impaired mental function, or busy working lives. We found that most of the patients we interviewed lived alone or with their spouse alone, without any other caregivers to remind them to take their medications:I often forgot to take medicine. He [the patient’s husband] usually put all the medicines on my table and reminded me to take them...If he also forgot, we would forget about it totally.Patient #11Considering the lack of reminders and the suboptimal adherence among most stroke patients, we decided that the message should act as a reminder for patients to promote their adherence to treatment.Through the interview, we also found that, even for people who were aware of the importance of stroke secondary prevention, they had little knowledge of how to perform physical activities or rehabilitation. For example, almost no patients knew the proper frequency and intensity of physical activities that they should achieve, nor the strategies to protect themselves from injury during exercise. In addition, walking was the most common way of exercise for most patients involved in the interview, and few patients knew how to train their upper limbs in their physical activities to promote their recovery of daily functions:He [the physician] just told me to walk more.Patient #2I do not have other forms of exercise. I just walk for a while every morning in the village...I usually sit or sleep at home for most of the remaining day.Patient #4Therefore, we believe that providing more tips and guidance on how to undertake the guideline-recommended physical activity and rehabilitation will match the needs of stroke patients.A total of 54 stroke patients from 4 villages in 2 townships in Nanhe County participated in the pilot study from February to May 2017. Among them, 51 participants (response rate: 94.4%) completed the feedback survey after the pilot study. Among participants who responded to the feedback survey, 40  and 43  stated that they had successfully received text messages or voice messages during the pilot study, respectively. After the pilot study, we interviewed 8 participants. Their feedback covered a variety of perspectives, including the content of the message, the form, and algorithms of message dispatching, and other barriers related to receiving and understanding the messages. This feedback guided our decision making in optimizing the message contents and sending the algorithm to fit the local context.In line with the quantitative results, we also found that not all participants were able to understand the messages fully. Barriers to acceptance included the broad scope and complex content of the information covered in the messages, the relevance of messages toward their health conditions, the complexity of the terms and languages, and their own capacity to read and memorize information.Many patients told us that they usually had poor memory and would easily forget things. They could usually understand the messages, but they would forget most of the contents after a short while if too much information was covered in a single message:I could understand the message when I listened to it, but I would forget most of them quickly after I put down my phone.Patient #6In addition to the preference for simple information within a message, participants also reported that some terms in the messages were not in plain language, which made the messages more difficult to understand.In terms of the impact of messages on helping them in managing the risk factors, some of the participants reported that not all the information was relevant to them. For example, messages related to smoking or drinking were only applicable to a small proportion of participants we interviewed:He [the patient] drank every day before the stroke occurrence, but he quit after it. He doesn’t dare to drink anymore.Spouse of Patient #2Almost all patients who participated in the interview showed greater interest in and spoke highly of the voice messages, whereas very few participants reported that they had read text messages. This was mainly because of participants’ illiteracy in reading text or their technical capability in checking text messages on the phone:My child bought a feature phone for me, and I know how to dial or pick up a call...I never read text messages. I am illiterate.Patient #2Participants also identified the potential factors that may facilitate their acceptance and understanding toward voice messages. Almost all participants involved in the interviews agreed that they preferred messages using the local dialect rather than standard Mandarin. Some of the participants also mentioned that a slower playback speed of the voice messages might improve their understanding of the message contents. In addition, participants recommended repeating the messages or extending the duration of messages so that they could better absorb the information when listening:Sometimes I was doing my housework when I picked up the phone. She [the voice message] spoke too fast, and the message ended before I could concentrate my mind to listen to it.Patient #4In terms of the frequency and timing of message dispatch, most participants said that they were willing to receive the messages daily. In addition, participants suggested that receiving the message in the morning would be more helpful, especially for reminding them of taking medicines:I often forget the medicines I should take in the morning because I usually have housework to do. But I usually can remember to take the medication at night before going to bed.Patient #1I would like to take the medicines, but I inevitably forget to do it sometimes... It would be, of course, good if someone can remind me every day.Patient #2From our interview, we also found some other factors that may influence the implementation of the message-based intervention. Patients reported that they would reject phone calls from unknown numbers because they were afraid that it could be a phone scam. The numbers used to send the voice messages were different every day at the beginning of the pilot study, so some of the participants were cautious about the messages received and refused to listen to the voice messages. Participants mentioned that it would be easier for them to get the voice messages if the same number was used.On the basis of the results from the pilot study, we made a series of decisions regarding the contents and dispatching algorithms of the messages to fit the local context and our target population better. Considering the prevalence of illiteracy and poor technical capacity in reading text messages, we decided to only use voice message delivery for the main study. To increase stroke patients’ understanding of the messages, we simplified the themes, structure, and language of each message. We highlighted the focus on medication adherence and physical activities that were appropriate for most stroke patients. Only a small proportion of the total messages were supplemented by general information related to stroke and management of other risk factors. In addition, we further refined each message by retaining only one key piece of information and used the same structure for each message . The application of the health belief model  and the We also improved the message recording and dispatch algorithm to better suit the preferences of the target population. We continued to record voice messages using the local dialect and selected a slower playback speed, with the message being repeated twice per message delivery. In addition, we decided not to dispatch any text messages but rather send out voice messages daily. We changed the message dispatch time from 7 pm to 7 am so that the messages can better remind patients of medication taking. Furthermore, we optimized our message dispatch system so that a single consistent sender phone number would be displayed on participants’ phones.A message bank containing 92 voice messages was developed to support the SINEMA main trial. These messages were repeated for 4 times to support the year-long intervention. The voice messages had been delivered to more than 600 stroke patients who participated in the SINEMA trial in rural China since July 2017. During the year-long intervention, a total of more than 100,000 messages were sent to participants and some caregivers in the intervention arm if they had a phone and were willing to receive the messages.In this study, we applied a multiple methodological study approach to develop mHealth messages to promote secondary prevention of stroke among community-dwelling stroke patients in rural China. We created the initial messages based on existing message banks from previous studies; involved patients in the initial study design in capturing their needs; evaluated patients’ acceptance through a 3-month pilot study, including quantitative surveys and in-depth interviews; and finally, refined and optimized the message contents and dispatching algorithm based on the feedback provided by participants.This study is one of the few studies that have developed message-based intervention among people with cardiovascular diseases  and the Message-based interventions have been increasingly applied to promote chronic disease management. However, less attention had been paid to content design than its effectiveness. A number of studies have tested the effectiveness of phone-based interventions implemented among various populations worldwide ,28,29, bOur study also revealed that the design of messages should adequately consider the local context and characteristics of the target audience. We found that message structure, language, complexity and relevance, and repetition are factors that influence patients’ acceptance and understanding. This finding is in line with some of the previous studies. For example, Muench and Baumel  analyzedOur study has some limitations. First, in this pilot study, the acceptance of messages was measured using a self-designed short survey, rather than actual statistics from the message dispatch system in the number of messages received and reviewed. Thus, self-report bias could be introduced, as participants may have overrated their acceptance and understanding of messages when interviewed by village doctors because of recall or social desirability bias. In addition, although the questionnaire was designed based on previous studies in China, we did not conduct reliability and validity testing for the questionnaire; thus, we were not able to rule out all potential measurement errors from the study. Second, the participants involved in our contextual research and pilot study were conveniently sampled with a relatively small sample size based on set inclusion criteria. For example, more than 60% of our participants were male, and such proportion is higher than the proportion in general stroke patients, although the nationwide epidemiological study found a higher age-specific prevalence of stroke among men than that among women for the age groups of above 40 years . AlthougOur study also has several strengths. First, we have applied multiple methodologies, including literature review, expert consultation, qualitative in-depth interviews, and a pilot study, including a quantitative survey and personal interviews. By doing so, we were able to ensure a deeper involvement of the target population in the study design and gain a more comprehensive understanding of their needs, acceptance, and preferences. Second, the messages were developed by researchers and verified by health care professionals and village doctors. Such collaboration ensured that the messages were designed based on the clinical evidence and behavior change theories with conscientious consideration of local context. By applying these strategies, the contents of messages could be made reliable, feasible, and understandable. Third, the results of the initial design and pilot study were incorporated into the refinement of both the final content and delivery algorithm, potentially ensuring better acceptance and effectiveness of the message-based intervention.In summary, our study demonstrates the potential of using voice message interventions to improve chronic disease prevention and management among people with low education level in resource-limited settings. The development process indicates the importance of contextualization, which includes involving the target audience early and considering their preference and characteristics in the design process. The findings on the preference of participants for voice messages and the potential factors related to the acceptance add new evidence to the literature. These findings have general implications beyond stroke care in rural China and will be informative to other researchers who plan to develop message-based interventions for other disease conditions or in other research settings.We recommend future studies to describe the message development procedures so that researchers could have better insight on the underlining mechanisms of the message design and the contextual environment that enabled the intervention implementation, which will facilitate the construction of the evidence based on the impact of the message-based interventions. In addition, more studies are needed to understand further the generalizability of the key aspects of message optimization that we found through our study among other populations. With such knowledge, we could better design the content and dispatching algorithms of the message-based interventions with higher adoption and maintenance.


In most European countries, the proportion of females and males pursuing a career in Technology and Engineering is quite different. The under-representation of women in these jobs may be attributable to a variety of factors, one of which could be the negative and stereotyped perception of these work sectors as unsuitable for women. The purpose of this study was to determine whether stereotyped perceptions impact the job representation of males and females in the Construction Industry, which is a particularly male-dominated work sector. Three construction organizations in the West Midlands (United Kingdom) were studied by means of ethnographic interviews and observations. Three (6.7%) of the 45 research participants (mean age 44.3) were women (focusing only in people working in Construction sites). There was a high differentiation of activities between the males and females. Biased perceptions and personality traits attribution played a fundamental role in such a differentiation. Despite some main limitations , this study focused on some important practical implications for current work policies: changing the mindsets of people (starting from school age), using new flexible strategies and creating the role of internal advocates. The findings provide definitive evidence of the need to increase the promotion of social communication and public campaigns on gender equalities in male-dominated work sectors, taking into account the cognitive processes behind gender differences. The findings also give new hints on re-thinking the contribution of Psychology, particularly Cognitive Psychology, in fields with allegedly wide gender gaps. The percentage of women pursuing a career in Technology and Engineering is still very low  at approThere are stereotyped perceptions against women in the CI, attributable to their suitability for such careers . The spaimplicit personality theory describes the specific patterns and biases a person adopts when developing impressions based on a limited amount of initial information about an unfamiliar person modeling, where the great majority of information about gender is transmitted by models of an individual’s direct environment, such as family, peers and other important people in their social and occupational life. Also, the media and internet persistently model gender-affiliated roles and behaviors.(II)enactive experience, which is the process of internalizing information about what is proper behavior for certain genders by the reactions it produces in others.(III)direct tuition, where people attempt to influence gender behaviors in others by using either approval and consent or disapproval and displeasure.This paper reports on stereotyped gender perceptions in the CI. It is based on a larger EU study on stress in the CI .The research was conducted using ethnography. Ethical approval was obtained from our employer (University) and informed consent and privacy statements were obtained from all the participants. An intensive effort was made to grasp the participants’ perspectives in the broad fieldwork which continued until saturation  was adjuFour approaches were utilized to collect data: observation, field notes, two-prong interviews (unstructured and semi-structured) and colloquial discussion. These different methods facilitated an in-depth acquisition of knowledge through the intersection or convergence principle , and triSeveral visits to work places and meetings were held with 45 people, and 55 observations were limited to people working on open sites Table . During The activities of males and females were found to be strongly differentiated, as shown in Table softer activities  to women and harder activities  to men.A typical description of a construction worker is: a man with physical skills, such as strength and endurance, and the ability to cope with different environmental difficulties  and manage power relationships . Males occupied all of the managerial positions observed. It was often reported that women had managerial positions at offices and not on sites. However, these office positions were often operating under higher positions occupied by men. This differentiation was often attributed to gender traits and personality: the idea that men are more goal-oriented, charismatic and directive, while women are more sensitive, cooperative and responsive. In line with the implicit personality theory , these dThe study also observed differentiation in the impact of work activities on the level of stress perceived at work. While stress and concerns in women were more related to their ability to communicate and negotiate , stress in men was much more related to time management, changes to plans and adhering to strict deadlines  and manual capabilities.Building was in the males of our family…. My grandfather was a bricklayer, my father was a bricklayer, so it was in the blood.” Following the social cognitive perspective, the gender-based relations in construction work were developed in both routine, day-to-day interactions and legitimized within the larger social and organizational context in which divisions of labor, power and culture were defined. Indeed, the study found a paradigm of gender differences built by modeling , enactive experience , and direct tuition .Consolidated experiences and tradition also informed role differentiation. As reported by a worker, “Our study found a marked diversity in the roles and activities of men and women, suggesting the presence stereotyping, in line with the implicit theory of personality . The datThere are relatively few Psychology studies on the construction sector. Hence, one novelty of this study is the appraisal of construction workers through the lens of psychology. Another novelty is the differentiation of the perceived level of stress and coping mechanisms: women had to cope more with their communication skills while men had to cope more with their organizational skills.Although this study does not indicate a definitive solution for overcoming gender inequalities, it highlights the importance of considering reasoning processes, associated bias and fallacious inferences when promoting policies of gender equality in the workplace. In some countries, such as the United Kingdom, women have been positively encouraged through, for instance, proactive recruitment campaigns and communication activities using positive images of tradeswomen and active enforcement of equal opportunity policies . HoweverJob rotation  may alsoIn Behavioral Science and Cognitive Psychology, “nudging” is “any factor that significantly alters the behavior of humans” , p. 175 Last but not least, it is important to promote more thoughtful policies on the work-family balance. The preponderance of men in the CI is explained by the lack of trained women, and sometimes the lack of supporting policies for women at work, which, for instance, makes it difficult for women to re-enter the labor market after a career break due to childbearing or other family reasons .This is an initial study and the current findings require further investigation. In fact, it must be acknowledged that the context explored might not be representative of the whole CI. In addition, it is important to compare our results with longitudinal studies in order to evaluate how career perspectives develop over time. In spite of these limitations, this study has some practical implications for future work policies that promote gender equality. In particular, the study is intended to highlight three points:•Changing mind-sets starting from school age: gender diversity and equality have to be promoted better at school and during early education.•Industries need to create more flexible strategies for women including working from home, job-sharing and consulting assignments.•Promoting gender equality by creating internal advocates. Having employees who champion this advocacy means they can oversee short-term actions and sustain long-term ones toward equality.This is one of the first studies to be conducted in the CI with a psychological perspective. The study identified stereotypical perceptions and behaviors in the construction sector. Stress affects many construction workers and the way men respond to it is different from the way women do. The results and suggestions from this study should be factored in work-family policy reflections. Male-dominated work sectors, such as the CI, have to think more creatively about the promotion of gender participation in their environments, and Psychology can give new insights and perspectives to rethink equality and gender-balanced contributions.SR carried out the ethnography. SR and EC performed the analysis and drafted the manuscript. PH participated in the design of the study and drafted the manuscript. All authors read and approved the final manuscript.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.


Although emergency medical services (EMS) and pre-hospital care have existed in the Kingdom of Saudi Arabia (KSA) since 1934, emergency medicine (EM) is a relatively new medical field in the country that was not formally recognized as a medical specialty until 2001. In 2005, the Saudi Board of Emergency Medicine formed to develop, implement, and evaluate a standardized curriculum for EM residents. Since then, EM and the pre-hospital system in the KSA has evolved and grown. This article provides an overview of emergency medicine in Saudi Arabia and the progress it has made in the pre-hospital system, healthcare delivery system, and emergency medicine training. Finally, we will discuss the challenges and opportunities faced as this specialty continues to develop. The Kingdom of Saudi Arabia (KSA) is the fifth largest country in Asia and the second in the Arab world in terms of area , 2 and hHealthcare in the KSA is delivered primarily through a publicly funded health system accounting for 80% of the healthcare provided in the country through more than 3000 primary care centers spread across the KSA. The Ministry of Health (MoH) is the main provider, operating around 60% of the hospitals and primary care centers. Other governmental agencies, including the Ministry of Defense (MoD), the Ministry of National Guard (MNG), the Royal Commission for Jubail and Yanbu, the Ministry of Education, and the Ministry of the Interior (MoI) provide the other 20% of publicly funded healthcare, mostly to predefined beneficiaries such as their employees and their dependents . The remThe government funds the public healthcare system via the parenting ministry  to the corresponding health system. In addition to its role in financing and delivering healthcare, the MoH, with a budget of nearly 6 billion SR ($1.6 billion USD), is responsible for the country’s public health, policy and planning, and regulation. In line with Saudi Vision 2030, a roadmap for social and economic development in the KSA, the MoH is working with other governmental agencies to change the way healthcare is delivered.Healthcare in Saudi Arabia predates the establishment of the modern state known as the KSA, with most of the early development occurring in Makkah because of the frequent medical needs experienced by the Hajj and Umrah pilgrims flocking to the holy city from around the world. A public health department, based in Makkah, was established in 1925. The first school of nursing was opened in 1926, followed by the School of Health and Emergences in 1927 , 5 to trWhile some developments occurred from 1934 to 2005, EMS education for first responders and emergency medical technicians (EMTs) during this period was limited to basic courses and workplace training . In 2005Pre-hospital emergency response is provided by a third-party service model fully operated by the SRCA, the 91st member of the International Federation of Red Cross and Red Societies . The SRCHowever, the current EMS service model in the KSA is no longer the responsibility of SRCA; rather, it is the responsibility of the healthcare sector (public or private). For example, the General Directorate of Emergency and Disaster and Ambulance Services is responsible for all IFTs within MoH medical centers. Non-MoH institutes provide EMS to their catchment areas, but that represents a very small segment of the population. The private sector has no pre-hospital emergency care involvement and provides minimal services to patients who require non-critical transportation services, appointments for bed-ridden patients, hemodialysis, and discharges. Moreover, there are no specific regulations or scope of practice that oversee the provision of pre-hospital care, but efforts are ongoing to establish these regulatory documents and practices.Prior to 1990, emergency medicine (EM) as a specialty was non-existent; instead, the departments of medicine, surgery, pediatrics, and obstetrics and gynecology treated their own emergencies in the emergency departments (EDs). In the 1990s, two major hospitals in Riyadh, King Faisal Specialist Hospital and the Ministry of National Guard Health Affairs Hospital, introduced American models of EDs. However, American contractors and expatriates operated these hospitals, and the entire emergency medical staff was composed of non-nationals. To increase the number of nationals in their EDs, these two hospitals established scholarships to send physicians to study EM as a specialty in Canadian and American universities. The returning graduates observed the need to start a national EM program, so they applied to the SCFHS to accept EM as a specialty based on a North American curriculum for residency training. At the time, the SCFHS determined the field was not ready to start its own EM Board, so they applied to well-established medical boards to accept EM as part of their specialty. The Surgical Scientific Board welcomed them with the help of the head of Emergency Department at King Khalid University Hospital. In 2000, EM was approved as a specialty under surgery, a coordination committee for EM was formed, and residency training of its first batch of four residents began. The training was provided in both the Health Affairs and in King Faisal Hospitals in Riyadh. In 2005, the SCFHS approved EM as an independent specialty and the Saudi Board of Emergency Medicine (SBEM) was formed. To this day, the SBEM is mandated to oversee and accredit EM residency programs, which now 22 different training centers across the kingdom.Medical specialty training in Saudi Arabia evolved in non-academic healthcare institutes providers, leading to significant discrepancies in training and certification until the SCFHS was established. The SCFHS has several bodies responsible for training and certification such as the SBEM, which approves the curriculum and training standards. Additionally, an EM exam committee independent of the SBEM administers board certification exams and reports to a central exam committee. Moreover, all the site program directors serve on regional supervisory committees to synchronize the training in all the sites and ensure they meet the national standards.SBEM residency training is a structured 4-year postgraduate training program in emergency medicine, supervised and regulated by the SCFHS. The residency-training program provides the trainees to acquire the following competencies and function effectively as per the CanMEDS roles framework competencies. The 4-year residency-training program is divided into two parts: junior residency (the first 2 years) and senior residency . During the senior residency years, residents are allocated to various subspecialties in EM in addition to seven rotations per year training in the ED. Residents are required to complete the allocated rotations satisfactorily for a given year and pass the end-of-year evaluation exams before moving from one academic year to the next.After successful completion of all program requirements and obtaining the Final In-Training Evaluation Report, candidates receive a training completion certificate issued by the regional supervising training committee. The candidate is then eligible to take the Saudi Board Certification Final Examination in EM. Successful candidates receive the SBEM certificate and are licensed as a senior registrar by the SCFHS and begin independently working as EM attending physicians or consultants , 11.Although the SBEM curriculum is based on the North American model, some aspects of training are particular to the KSA, such as the Hajj rotation during which residents provide medical care to the 1–2 million Muslim pilgrims of different ages, nationalities, and ethnic backgrounds. The workforce is recruited from all over the KSA, including EM residents who spend a mandatory 1-month rotation in Hajj during their senior year, called the Hajj Mission Rotation. Hajj presents a unique opportunity for EM residents to gain experience in multiple aspects of healthcare service while meeting the medical needs of the pilgrims. They learn how to deliver high-quality medical care with limited resources and considerable language barriers , 13.The first fellowship to be established was the pediatric EM fellowship, which is a 2-year program that accepts graduates of both EM and pediatric boards. It began in 2006 and has several approved training sites across the KSA, all of which have fully dedicated pediatric emergency departments. The goal of this fellowship is to prepare graduates for all the possible emergencies seen in children aged 0–14 years, which is the upper limit for pediatric patients in the KSA, building on the pediatric training the EM residents received during residency. Two new fellowships specially designed for EM graduates are provided by the ED of Ministry of National Guard Health Affairs Hospital: a 2-year combined EMS and Disaster Management fellowship and a 1-year Emergency Ultrasound fellowship. The first prepares graduates to become competent directors of EMS departments as well as disaster and mass casualty response teams. The second prepares graduates with the competencies required to become bedside ultrasound directors, trainers, and quality assurance specialists for EDs.The need for trained EM providers is huge but the number of SBEM graduates is still not enough to cover many regions in Saudi Arabia, especially rural and peripheral areas. A 2-year diploma in EM was started in 2017. It is a postgraduate training program with 13 blocks per academic year in which the trainee undergoes in clinical rotations similar to the first 2 years of the SBEM in addition to the Hajj rotation. After successful completion of 2 years of training and passing the final oral and written exams, the trainee will be recognized as a registrar by the SCFHS .The MoH, through its Emergency Departments Support Program (EDSP), has implemented an organized education outreach program, also called a boot camp course, for the education and training of general practitioners (GPs) working in peripheral EDs with the aim to improve and update the current practice of GPs regarding the most recent EM research.The SCFHS identifies EM (consultant) attending as a board-certified emergency physician who completed residency training in EM. Practicing EM attending physicians received their residency training locally, in the SBEM, or internationally in different countries such as the USA, Canada, Australia, South Africa, and France. Another subset of EM attending physicians is certified by the Arab Board of Emergency Medicine, which is regulated by the Arab Board of Health Specialization. Still, in the KSA, there is a massive need for certified EM physicians. To date, some hospitals and even cities still do not have a certified emergency physician working in the EDs and GPs or physicians who are internal medicine or general surgery training are acting as ED team leader.In the KSA, simulation-based learning has begun to be utilized by some academic hospitals with institutional capabilities and resources for simulation education. Bootcamps for emergency medicine residents are organized yearly to deliver a focused training for major EM procedures using simulation. A SCFHS project to integrate simulation-based learning in residency training, including EM residencies, is currently underway. A focus group conducted educational needs assessment to develop specialized simulation-based courses. Courses are designed and developed by EM physicians with medical education and simulation background. The program started in cities that have resources for running simulation courses, and have the opportunity to expand further. For instance, a mobile simulation truck is developed for future use to conduct simulation courses in the peripheral facilities without simulation resources, which holds promise for the improvement of EM training in underserved regions.The only society for EM physicians in the KSA is SASEM, which is affiliated with the SCHS. It was formed in 2008 and is run by a board of emergency physicians. It provides working groups for EMS, ultrasound, disaster management, toxicology, EM nursing, trauma, and critical care. It also runs the annual SASEM conference hosted in a variety of cities across the country, which is the main gathering of EM physicians in the KSA. Other notable symposiums include the Saudi Emergency Medicine Assembly (SEMA) and Best of EM, which are organized annually by groups interested in education. The training sites offer a large number of workshops specific to the practice of EM in the fields of bedside ultrasound, airway management, EM and surgical procedures, resuscitation, and emergency radiology. There is Saudi Association of EMS affiliated with SCFHS.The work environment in ED across the KSA is suboptimal in the majority of all non-academic and rural EDs. Among the reasons for this suboptimal quality is that the EDs are functioning in an outdated way in which patients are mainly treated by non-emergency trained physicians from other medical fields, such surgery, pediatrics, and general practice, who acquire their emergency skills through unsupervised experiences. Another reason is the fact that the ED is considered a temporary station for new medical staff before being assigned to their designated floors and, in some occasions, is a place where underperforming medical staff is assigned. Last but not least is the lack of awareness among the healthcare system’s leadership on the importance of a specialized ED, leading to under-budgeting and under-resourcing.Academic EDs and hospitals with North American ED models are becoming increasingly attractive, competitive work environments for new graduate medical students, emergency residents, and qualified emergency physicians because of their high-quality care, efficiency, safe triaging, organized patient flow, cutting-edge technology, and the presence of qualified senior staff. However, other than these prestigious institutions, most emergency healthcare in Saudi Arabia is provided by physicians with little to no post-graduate training or who have been trained in other medical specialties , 15. MorRelatively speaking, EM in the KSA is in better condition in relation to other countries in the Middle East and ranks highly in tertiary care centers . It was Strengthening of emergency care is an important step on the path to universal health coverage and is endorsed by WHO as “an essential part of integrated healthcare delivery” . MoreoveThe KSA is not an exception from the rest of the world facing serious public health concerns and has seen an increased chronic diseases burden. Current evidence has indicated that KSA has the 7th highest rate of diabetes mellitus (DM) in the world , 19 and Currently, the ED functions as the main gateway to medical care in the KSA. While the healthcare system is transitioning from acute care to preventative and primary care, that requires a great deal of health policy research and effortful implementation that can anticipate and proactively address issues based on the trends of other external institutions and from evidence from within the Saudi hospital system. Additionally, EDs in some regions are more strained than others. For instance, a recent study revealed that emergency services in the Abha district of southwestern KSA faced a lack of some essential equipment and drugs . The AbhA study by Aalam et al. found that although EM residency training programs in the KSA are all of reasonably high quality as measured by the Postgraduate Hospital Educational Environment Measure (PHEEM) instrument, compared to American EM residents, Saudi EM trainees reported feeling less competent in managing multiple traumas and perceived faculty supervision and faculty interest in education as less strong; they also reported seeing more patients per hour than US residents . These fTo address the problems in Saudi EDs, a number of solutions have been proposed and implemented with varying degrees of success. The common thread that connects all the proposed solutions shared the goal of reserving the ED for truly emergent health issues rather than the current trend of patients using the ED as the main gateway to hospital admission.One way to achieve this goal involves other providers filling the existing gap in care, particularly primary care physicians (PCPs), urgent care facilities, home healthcare, and rehabilitation services. Urgent care can provide quick access to medical care, including after-hours . Urgent cares can also release some of the burden placed on EDs and fill in during PCPs’ off hours, which can be quite useful to patients. Moreover, improved primary care and referral systems  can relieve some of the pressure placed on EDs. Understanding the barriers and enablers to accessing primary healthcare will likely help reduce inequalities in access to and utilization of primary healthcare, especially suburban and rural populations. Strengthening and monitoring of the follow-up system and the communication between PCPs and EDs is one way to overcome the barriers faced by PCPs. For example, among patients who reported being frequent users of EDs, approximately one third cited the “availability of modern diagnostic equipment” (37.3%) and “to avoid taking time off from work” (33.0%) as reasons for using EDs . FindingInitiation of preliminary discharge by designating patients for early discharge the next day.Establishing a discharge room/lounge for inpatients who have been discharged and are awaiting transportation, medications or education.Establishing a discharge coordinator position to coordinate procuring information that is required to discharge the patient.Implementing monetary incentives and nonmonetary incentives for physicians and nurses to promote efficient and early discharge of patients who are ready to go home .In addition to increasing access to healthcare, the KSA has many opportunities to improve the quality of healthcare provided. One way to improve healthcare quality is to enhance patient flow coordination and facilitation. This enhancement could be achieved through measures such as establishing the role of a “bed czar” or patient flow manager. This person would be responsible for ensuring timely transfer of ED patients to assigned inpatient beds. Assigning a dedicated nurse with admissions/discharge/transfer duties who is specifically responsible for facilitating discharges to accelerate available beds for admissions. Furthermore, the development of accelerated triage and registration processes based on patient’s acuity could reduce waiting times . Along tFlow is of the utmost importance to high quality are and is prioritized in most quality assurance (QA) objectives. Flow, or lack thereof, is also a factor in waiting time and triage procedures in EDs Waiting times can have a dire impact on high acuity patients. Long waiting time is associated with delays in time-sensitive treatments for serious conditions typically requiring admission . Many EDDiversion management and reduction is still another way the quality of healthcare can be improved. This improvement requires establishing new protocols and monitoring systems to allow early warning when the system is approaching its maximum capacity and its threshold for diversion. Additionally, this would necessitate developing a hospital-wide diversion response protocol to focus existing resources on facilitating all appropriate patient discharges in a timelier manner. Finally, the creation of a community-wide diversion plan in collaboration with local hospitals and the community’s emergency medical services unit could help establish a common protocol for hospitals going on and off diversion or bypass .In addition to enhancing access to healthcare through diversification of options and emphasis on primary care, improved provision of healthcare in the KSA can also be achieved through better EMS education, training and staffing. One problem with EMS is that the majority of EMS calls are for relatively minor complaints or non-medical complaints. For example, a recent study of EMS transport calls found that an alarming 25% of calls made during the study period were reported as non-transported calls. Of those, 70% stemmed from refusal by patient while 22.4% of were canceled by dispatch [Gender also plays an important role in the quality of EMS care. In a conservative nation like the KSA, the care provided to men and women can be disparate. For example, the ratio of males to females in EMS calls was 2:1; males accounted for 722 calls (51.9%) while females accounted for only 325 (23.4%). In a significant number of cases, the gender was not listed [The KSA has reached nearly 100 years of providing healthcare to its people. However, the healthcare system in the KSA only reached modern standards of quality in the early 2000s. For the past 10+ years, the healthcare system has rapidly improved, reaching the level of quality achieved by many healthcare systems in the West. In the coming years, an increasing emphasis on primary care is expected to begin to ameliorate the common problem of EDs being treated as the gateway to the hospital. Moreover, promising trends in the development of simulation-based education, improvements in residency programs and curricula, and diversification of healthcare providers indicate that the rapid progress experience over the course of the last decade is poised to continue for the next decade and beyond. Roadmaps like the National Transformation Plan 2020 and the Saudi Vision 2030 have also begun to pave the way for future developments. It is now the task of Saudi EM physicians and healthcare policymakers to conduct practical research and implement data-drive, evidence-based policies, and procedures to continue to guide efforts to move towards a more preventive and primary care healthcare model.