Precarious employment, such as housecleaning, is one important structural contributor to health inequities. We used an employment quality (EQ) framework to characterize the impact of employment conditions on mental and self-reported ill-health among Latinx housecleaners in the New York City metropolitan area. Using a community-based participatory research approach, we collected cross-sectional survey data from 402 housecleaners between August 2019 and February 2020 to characterize housecleaners’ EQ and its association with depression, perceived stress, and self-reported health. We also measured work-related irritant eye, skin, and respiratory symptoms, which have been shown in previous research to be associated with housecleaners’ exposure to chemical components of cleaning products. Our housecleaner cohort was largely female and immigrant and most had worked at least five years. Survey items capturing the EQ dimensions of unbalanced interpersonal relations, low material resources, and violations of workers’ rights were associated with increased odds of depression, perceived stress, and self-reported ill-health. Work-related irritant eye, skin, and respiratory symptoms were also independently associated with mental and self-reported ill-health and some of the effects of EQ on health were potentially partially mediated through their association with work-related irritant symptoms. Findings can inform directions for community-based educational and policy initiatives to improve housecleaners’ employment quality. The changing nature of the economy, compounded by the economic impacts of the COVID-19 pandemic, has increased the number of workers in work arrangements that are less likely to offer long term employment stability and guaranteed wages and benefits ,3. The rThe development and validation of EQ measurement tools is an ongoing process , though Health studies applying an EQ framework have demonstrated the greatest health risk for those employed in jobs with the poorest EQ and for whom the term “precarious employment” is commonly used . AdditioApplying a holistic framework for examining associations between work and health that considers the role of workplace hazards and EQ together also provides opportunities to identify more comprehensive solutions to reduce the role of work in ill-health and improve health equity . EQ measSafe and Just Cleaners is a mixed methods community-based participatory research (CBPR) study exploring the role of chemical exposures from household cleaning products on the health and well-being of Spanish speaking Latinx housecleaners in the New York City (NYC) metropolitan area . HouseclWe report on our analysis of data from a cross-sectional survey collected by the Safe and Just Cleaners study between August 2019 and February 2020 that characterized dimensions of housecleaners’ EQ and the association of those EQ measures with ill-health. We hypothesized that housecleaners’ low EQ was a cause of housecleaners’ ill-health and lower well-being. We also hypothesized that one potential pathway for how EQ affects health is by leading to higher levels of work-related irritant symptoms as workers trade off safer work practices to work quickly and avoid conflicts with their clients, especially given the inherent insecurity of their jobs and earnings. Our study posed the following specific research questions: (1) using an EQ framework, what are the employment conditions of Latinx housecleaners in the NYC area; (2) is poorer EQ a potential cause of poorer mental and self-reported health among housecleaners . We also included items assessing their access to benefits such as sick leave and health insurance. Finally, we included a series of questions related to experiences of seven types of discrimination at work based on: gender, age, race, ethnicity, being an immigrant, the language they speak, and their sexual orientation . For theTo characterize the fifth dimension, interpersonal power relations with the employer, we focused exclusively on the cleaner-client relationship since our focus group data pointed to that as the primary power dynamic housecleaners experienced. In developing these survey items, we drew on the well-developed job content construct used to characterize the psychosocial work environment and job-related stress , since iTo assess workers experiences of work-related irritant health effects, we created survey items related to symptoms of work-related respiratory, skin, and eye irritation, consistent with previous studies showing increases in these types of symptoms among housecleaners ,24,25. FTo evaluate mental health, we used the Center for Epidemiologic Studies Depression 10-item Scale (CES-D-10)  and CoheWe included survey items related to demographic characteristics and other individual factors that might influence health including educational attainment, time in the United States, English language comfort, and family composition including whether they were their family’s primary wage earner. We initially developed or identified survey items in English and then bilingual team members translated them into Spanish, except when using previously validated translations of existing measures. When selecting items in English, the study team considered the items’ cultural or linguistic translatability for a NYC-based Spanish speaking population. In addition, we performed cognitive and pilot testing to assure that survey items were interpreted as intended and made edits directly to the Spanish version, when indicated, prior to fielding the survey . Our fundamental approach to outreach was to work through community-based organizations known and trusted by our target Latinx communities and to capture the experiences of housecleaners working in urban apartments and suburban homes. We recruited participants in four of five boroughs in NYC and two suburban neighborhoods in Westchester County, New York with a focus on neighborhoods with the highest Latinx density based on American Community Survey data . We usedThe survey was administered by fluent Spanish speakers either at the offices of a community partner or in publicly available quiet spaces, such as the public library, and responses were directly entered into a tablet or computer. Study data were collected and managed using the REDCap electronic data capture tool hosted at the Icahn School of Medicine at Mount Sinai . Visual We collected screening eligibility information from 925 potential participants and 327 were eliminated—of those eliminated, 301 (92%) had not worked within the previous 2 months and 26 (8%) had worked in housecleaning for less than 6 months. The remaining 598 participants were invited to participate in the study and 419 (70%) completed the survey. Of the 419 participants, 17 left the survey session after completing less than half of the survey and are not included in this analysis, leaving 402 housecleaners included in our analysis. Information on the participation rate by recruitment approach may help others recruiting similar hard to reach worker populations. We found that street outreach had the lowest participation rate (62%) and recruitment through our community partner’s classes and social programs had the highest participation rate (75%). The analytic strategy proceeded in stages. Initially, survey items focusing on individual characteristics and the different aspects of EQ were assessed descriptively (research question 1). Next, we used principal components analysis (PCA) to determine whether the questionnaire items designed to capture the same EQ dimension could be grouped into a single variable. The criteria for determining if individual EQ items could be grouped included having an eigenvalue greater than one and component item loadings greater than 0.40. Since the EQ items themselves were measured using ordinal scaling, the inter-item measure that formed the basis of the PCA analysis was the polychoric inter-item correlation. A similar PCA process was used to assess whether the survey items related to work-related irritant symptoms  could be combined into a single variable. For items meeting the PCA criteria to be combined, we generated a single variable by summing the scores for the individual items.Once the combined EQ and irritant symptom variables were developed, we examined statistical associations between the EQ variables and the irritant symptom variable using multiple linear regression. In this modeling, we included individual characteristics such as age, education level, and English proficiency as well as the EQ variables. This analysis was performed as the first step of a mediation analysis to test whether some of the effects of EQ on mental and self-reported health were mediated through the impact of low EQ on housecleaners’ work practices generating higher hazardous exposures and irritant symptoms,  as the dependent variables, while adjusting the model for any significant individual level covariates (pathway A in Once we selected the best logistic regression model (model 1), we developed a second model by adding the irritant symptom variable to model 1. Model 2 was used for two objectives: (A) to determine if the irritant symptom variable impacted the mental and self-reported health outcomes; and (B) to determine if the inclusion of the irritant symptom variable in the equation for each of the three outcomes mediated the effects of any of the EQ variables on health outcomes  female. The sample’s average age was 44; standard deviation (SD) 10.3; all were foreign-born but had lived in the United States on average 15 years (SD 9.0); 122 (30%) have only completed a primary school education; and only 14% reported feeling comfortable with spoken English. Many (44%) were the primary wage earner for their family. Demographically, our sample was very similar to the estimated 343,527 housecleaners in the United States in 2019, based on an analysis of microdata from the US Census Current Population Survey, and was especially like the 61.5% of cleaners nationally who are Hispanic or Latino [Descriptive findings of the EQ-related survey items are summarized in Lack of access to health insurance was very common (49%). Only 15% reported having access to paid sick leave and 48% reported not being able to take sick leave, whether paid or unpaid, because of fear of employer retaliation. While the average wage rate was $15 per hour, instances of unfair pay occurred commonly with 44% reporting pay below the minimum wage and 20% reporting not being paid the amount the client promised (wage theft) in the last year. A third of housecleaners (34%) reported some experiences of discrimination at work and the most common forms of reported discrimination experienced at work were due to being an immigrant, their ethnicity, or the language they speak.Housecleaners also reported unbalanced interpersonal power relations with clients, including clients having control over how housecleaners’ work was done  and, to a lesser extent, they experienced time pressures . Housecleaners also reported unsupportive client behavior  and 18% reported verbal abuse from clients. Many housecleaners (57%) reported experiencing communication barriers, at least sometimes, with clients due to language spoken .Our survey found the following work-related conditions: 16% reported respiratory symptoms that improved when away from work, which included either an asthma diagnosis by a health care provider (5%) or night-time shortness of breath (13%); 27% reported skin rash that improved when away from work; and 84% reported some level of eye irritation at work  .Using cut points for the CES-D-10  and Cohen’s PSS , we found that 24% of housecleaners could be classified as depressed, while 44% experienced moderate or severe stress. We found that 29% of respondents reported fair or poor versus good/very good/excellent self-reported health .Using PCA, the survey questions designed to capture the same dimension of EQ were assessed to determine whether they could be combined into a single variable. This process allowed us to reduce the number of items in three of the EQ dimensions: interpersonal power relations; material resources and workers’ rights .We also used PCA to assess whether the irritant symptom questions  could be combined into a single irritant symptom variable, with the presence of skin or respiratory symptoms each adding 1 point and the eye symptoms adding up to 3 points . The descriptive statistics and the component loadings for both the irritant symptom and EQ items that were combined, as well as the name for the combined variable, are shown in As a preliminary step in our mediation analysis, we examined the associations between EQ variables and the work-related irritant symptoms score using multiple linear regression analysis. We found that variables from the dimensions of unbalanced power relations with clients (time pressures and unsupportive or abusive clients), low material resources , and inadequate workers’ rights  were all associated with more irritant symptoms .In model 1, we found that measures capturing the EQ dimensions of unbalanced interpersonal relations with clients, low material resources, and violations of workers’ rights were associated with all three health outcomes. In addition, we found a dose response relationship between more years of work as a cleaner and poorer self-reported health. Working for an agency compared to being self-employed was associated with lower levels of depression, though this finding was based on a small sample of agency workers and requires further evaluation.The individual demographic variables important in the models include associations between discomfort with spoken English and poorer self-reported health, which mirrors our finding of the association of language barriers in client communication  and higher perceived stress. The other individual variable, cleaners who reported being the primary family wage earner, had increased odds for being depressed which was consistent with the higher odds for depression for those with higher job-related financial insecurity .In model 2, reporting more work-related irritant symptoms was associated with both mental and self-reported health outcomes with odds ranging between 1.37 and 1.54 independent of the EQ variables. In this second model we also assessed the potential for partial mediation of the effects of low EQ on health through the effect of poor EQ on housecleaners’ work-related irritant symptoms , especially for such a hard-to-reach population, those who chose to participate could be a select population. Additionally, our survey items characterizing housecleaners EQ were all self-reported and we had no way to test their validity. Nonetheless, the demographic and employment characteristics of our study population are very similar to data from other national samples of housecleaners ,19,20. AFinally, our measure of irritant work-related symptoms likely results from housecleaners’ exposures to chemical components of cleaning products, as has been shown in previous research ,24,25, tIn this study, we explored how dimensions of employment quality together with workplace exposures can contribute to Latinx housecleaners mental and self-reported overall health. Our data characterizing the precarious working conditions for Latinx housecleaners in NYC is supported by similar findings by others. We add to this literature by demonstrating the role of poor employment quality in mental and self-reported ill-health, illustrating the pathways through which precarious work contributes to ill-health and health inequities. Our use of the EQ framework in our survey design contributed to the planning and implementation of our project’s public health educational and policy-oriented activities, a key component of our CBPR approach. Similar applications of an EQ framework could provide important insights for intervention pathways to improve health for other workers in precarious employment. Additional and more comprehensive policy approaches that address employment quality in addition to reducing workplace exposures are needed to promote greater health equity.


Cardiovascular disease (CVD) is the most common cause of morbidity and mortality worldwide, and early accurate diagnosis is the key point for improving and optimizing the prognosis of CVD. Recent progress in artificial intelligence (AI), especially machine learning (ML) technology, makes it possible to predict CVD. In this review, we first briefly introduced the overview development of artificial intelligence. Then we summarized some ML applications in cardiovascular diseases, including ML−based models to directly predict CVD based on risk factors or medical imaging findings and the ML−based hemodynamics with vascular geometries, equations, and methods for indirect assessment of CVD. We also discussed case studies where ML could be used as the surrogate for computational fluid dynamics in data−driven models and physics−driven models. ML models could be a surrogate for computational fluid dynamics, accelerate the process of disease prediction, and reduce manual intervention. Lastly, we briefly summarized the research difficulties and prospected the future development of AI technology in cardiovascular diseases. Cardiovascular disease (CVD) is an important cause that threatens human health and represents a heavy economic burden on society and families ,2. EtiolArtificial intelligence (AI) is an exciting new field in cardiovascular disease, revolutionizing medical practice . AI can In this review, we systematically summarized the recent research progress of artificial intelligence applications for cardiovascular diseases, including the prediction of morbidity or mortality of the cardiovascular disease and the prediction of cardiovascular biomechanics modeling. We focused on machine learning−based models to predict CVD and ML−based vascular hemodynamic geometries, equations, and methods. Finally, we briefly summarized several common difficulties of AI technology and prospected the future development of AI technology in cardiovascular disease.Artificial intelligence can be referred to as the science of realizing human intelligence on machines (Computers). In the past 70 years, artificial intelligence has been widely applied to many subjects and achieved fruitful results . MachineSince the 2010′s, ML algorithms have continuously improved, becoming more sophisticated and containing hierarchies, which gave rise to the popular Deep Learning (DL). Deep learning, a sub−field of machine learning, has been extensively studied and imitates the working model of the human brain and uses a multi−layer neural network to train data and develop an automatic prediction model  20,21,2,221,22. Machine learning and deep learning algorithms have been used to accelerate the diagnosis and prediction of cardiovascular diseases ,29,30,31We mainly discuss two types of ML−based approaches to predict cardiovascular diseases. The first approach is to build a machine learning model that directly outputs the incidence, mortality, or prognosis of CVDs by inputting clinical follow−up data and risk factors of subjects without CVDs, or clinical data and medical imaging of patients with CVDs. However, it requires massive patient data for training, and conventional prediction models are inadequate for assessing disease progression in complex lesions owing to the patient−specific anatomical, physiological, and functional difficulties. Another approach is to predict the complex patient−specific pathological process of CVDs by learning cardiovascular biomechanics based on numerical simulation. Computational models based on physical principles of cardiovascular systems, combined with medical imaging and patient characteristics, enable the derivation of hemodynamic information  inaccessible by medical images alone. Machine learning could be applied to the basic model and governing equations of the cardiovascular system and new numerical methods to accelerate the simulation process and realize personalized flow simulation. Both approaches are of great significance in evaluating the occurrence of cardiovascular diseases .Cardiovascular disease has long incubation periods and complicated pathogenic factors, which leads to the failure of timely identification and treatment . A risk To improve the accuracy and speed of disease diagnosis of the above prediction models, AI−based approaches were applied to CVDs, which would help doctors to identify patients with different risk layers in advance and further reduce the incidence of mortality and adverse events. Several studies compared the ML−based model with the traditional risk prediction model . For exaArtificial intelligence is also utilized in prognosticating cardiovascular outcomes based on imaging data combined with clinically available risk predictors, effectively reducing complications and sudden death events. Motwani et al.  used a rArtificial intelligence also has many applications for other cardiovascular diseases besides CADs. Based on echocardiographic data, ML algorithms were used to establish the discrimination models between hypertrophic cardiomyopathy from physiological hypertrophy seen in athletes  and betwCardiovascular biomechanics could also be applied to predict the occurrence of cardiovascular diseases ,51 as thComputational modeling and simulation methods were frequently applied to solve flow problems in blood vessels. Numerical analysis methods of cardiovascular biomechanics mainly rely on a grid−based approach, including finite difference analysis (FDA) , finite Machine learning could break down computing tasks and make all kinds of machine assistance possible in cardiovascular biomechanics modeling. In particular, the ML approach could be applied to the extraction of geometric features, the study of governing equations, and the surrogate for CFD ,85,86. IThe traditional method of computational fluid dynamics needs to extract structures and features of blood vessels manually ,78,79, wML models have been used to automatically segment medical images for creating 3D computer models in recent years. Especially in patient−specific biomechanical modeling, each cardiovascular disease leads to multi−feature 3D morphologies, such as atherosclerosis , aneurysThe governing equation of the flow in blood vessels is generally regarded as Navier−Stokes (N−S) equation, which is a highly nonlinear partial differential equation (PDE) system , and theThe sparse regression technology was used to learn the coefficients and derivative forms of each order in the Taylor series. This method implemented interpretable machine learning techniques but requires the construction of function libraries to ensure that the function involved is included ,132. RaiA more recent ML paradigm, a physics−informed neural network, has been proposed to identify scalar parameters in partial differential equations ,136,137.The artificial intelligence−based solution method for computational fluid dynamics is driven by data or physical models. The data−driven model is based on existing model equations, which constantly update or optimize the original empirical coefficients . The phyThe neural networks based on data firstly obtain high fidelity data according to the existing flow field simulation or experimental methods and then construct the neural network mapping relationship to replace the original partial differential equation after learning the data based on machine learning technology, which could obtain the numerical solution to the flow field quickly and efficiently ,103. MorThe successful development of ML models has been verified in massive applications. Recent work in machine learning combined with finite element calculations has also shown promise for collagen tissues .The deep learning approach has gradually emerged in cardiovascular biomechanics modeling with the rapid development of artificial intelligence. For example, DL models were developed to directly evaluate the stress distribution of thoracic aortic aneurysms bypassing the finite element calculation process . Liang eAs a general−purpose function approximation , the AI−The data−driven neural network requires quantities of high−fidelity data, but it is difficult to apply it when the sample data is small or cannot be obtained . In the Both data−driven models and physical−driven models have promoted the development of computational fluid dynamics and explored a new way for cardiovascular disease prediction. However, the success has only been demonstrated on several canonical issues ,126,127,The increasing maturity of artificial intelligence and the continuous expansion of its application in the medical field brought revolutionary changes to medical practice. ML−based models could predict the morbidity or mortality of CVDs more accurately and faster than the traditional prediction model, which could alter the prediction method of CVDs. ML models could also provide new theories, methods, and research paradigms for biomechanics modelling. However, there are still several challenges that need ironing out. (1) Database: The early prediction of CVDs is inseparable from massive datasets and data quality. The high−precision mechanical calculation needs huge computing resources, and it is difficult to obtain data on some rare diseases . In addiGiven the above, artificial intelligence has made remarkable achievements in the past decades, but the data quality, as well as the validity, stability, generalization, and explainability of the model need to be further improved. AI will be a development direction and trend of medical treatment in the future, and it will alleviate the pressure of medical treatment in some aspects, improve the speed and quality of medical services, and promote the continuous development and progress of human medicine.We summarized the recent advances of the machine learning−based model to directly predict CVDs based on risk factors or medical imaging findings, as well as the machine learning−based hemodynamics with vascular geometries, equations, and methods for indirect assessment of cardiovascular diseases. Machine learning models could be a surrogate for computational fluid dynamics, accelerate the process of disease prediction and reduce manual intervention.


Older adults were uniquely affected during the COVID-19 pandemic, given that they were most at risk of serious complications and death if infected. Numerous preventative measures were abruptly mandated, including stay at home orders and social distancing that led to social isolation. Given this context, the aim of this qualitative study is to explore the lived experiences, perceived challenges, and mechanisms for resilience of older adults during the first wave of the pandemic. Our sample (n=50), derived from a larger international study with data from 15 countries, includes individuals 60 or older in Puerto Rico and mainland United States. Following thematic analysis of responses from an online survey, three themes were identified: resilience through reflection and adaptation, resilience through critique of systemic problems and injustices, and resilience through reaffirmation of values. Findings support various recommendations for improving support to older adults in future crises.


The exact nature of sex and gender differences in knee osteoarthritis (OA) among patient candidates for total knee arthroplasty (TKA) remains unclear and requires better elucidation to guide clinical practice. The purpose of this investigation was to survey physician practices and perceptions about the influence of sex and gender on knee OA presentation, care, and outcomes after TKA.The survey questions were elaborated by a multidisciplinary scientific board composed of 1 pain specialist, 4 orthopedic specialists, 2 physiatrists, and 1 expert in gender medicine. The survey included 5 demographic questions and 20 topic questions. Eligible physician respondents were those who treat patients during all phases of care . All survey responses were anonymized and handled via remote dispersed geographic participation.Fifty-six physicians  accepted the invitation to complete the survey. In general, healthcare professionals expressed that women presented worse symptomology, higher pain intensity, and lower pain tolerance and necessitated a different pharmacological approach compared to men. Pain and orthopedic specialists were more likely to indicate sex and gender differences in knee OA than physiatrists. Physicians expressed that the absence of sex and gender-specific instruments and indications is an important limitation on available studies.Healthcare professionals perceive multiple sex and gender-related differences in patients with knee OA, especially in the pre- and perioperative phases of TKA. Sex and gender bias sensitivity training for physicians can potentially improve the objectivity of care for knee OA among TKA candidates. Osteoarthritis (OA) is the leading cause of functional disability and reduced quality of life among adults in developed countries. OA of the knee accounts for more than 80% of the total disease burden  with an The prevalence of knee OA continues to grow alongside increases in its risk factors such as age and obesity .Nonetheless, the exact nature of sex and gender differences in knee OA and especially in-patient candidates for TKA remains unclear and requires better elucidation before it can influence clinical practice for the purpose of improving patient care.sex refers to biological differences between men and women that involves physical and physiological characteristics, including chromosomes, gene expression, hormone levels, and reproductive/sexual anatomy, that may play a role in the pathogenesis of disease and response to treatment. Gender refers to socially constructed characteristics such as norms, roles, and relations influenced by society and culture at the time. People develop their gender roles in response to the environment in which they grow up and live, in response to the upbringing they receive at home and at school, depending on family and peer group interactions and expectations and according to trends and fashions in the media. In addition, political affiliation, social status, and economic availability can modify gender roles, that in some societies are more rigid than those in others Gender contribute to differences in vulnerabilities and susceptibilities to illness, can influence experiences of crises and emergency situations, health behaviors and how illness is experienced; gender influences also access to healthcare, uptake of health services, and globally health outcomes [Sex and gender interact in complex ways to affect health outcomes –7; sex routcomes .Female sex is a well-established risk factor for knee OA in older adults –13. MoreAmong available treatments, total knee arthroplasty (TKA) is a safe and cost-effective option that alleviates both pain and functional limitation related to end-stage knee OA –20. EmerHere, we performed a survey of healthcare professionals in Italy who attend candidates for TKA during all phases of care  in order to inform physician perceptions about the influence of sex and gender on knee OA presentation and management.This study was a survey of physicians who treat patient candidates for TKA during all phases of care  in Italy. Survey questions were designed to focus on the influence of sex and gender on knee OA presentation, care, and outcomes of TKA. Questions were elaborated by a multidisciplinary scientific board composed of 1 pain specialist, 4 orthopedic specialists, 2 physiatrists, and 1 expert in gender medicine. The survey was active for a period of 8 weeks  and communicated to a panel of physicians via e-mail using a password-protected web link. All survey responses were anonymized and handled via remote dispersed geographic participation.The survey included 5 demographic questions and 21 survey questions about common practices and perceptions related to the influence of sex or gender on symptomology and pain severity, pharmacological therapy, postoperative outcomes, rehabilitation strategy, and patient satisfaction  accepted the invitation to participate and six respondents provided incomplete survey responses. Professional categories included anesthesiologists and pain specialists (9 respondents), physiatrists (17 respondents), orthopedic specialists (23 respondents), and the scientific board (7 respondents). Most respondents were male (71%), aged between 41–60 years (53%), worked in university settings (57%) and were geographically located in the south of Italy (46%). Twenty-seven percent of respondents saw up to 10 patients with knee OA or knee replacement per month, 37% saw between 11 and 20 patients, and 36% saw more than 20 patients per month.Sixty-seven percent of healthcare professionals disagreed with the assertion that male patients exhibit a more severe symptomatology than women upon first presentation (Q1), whereas 29% agreed with this assertion, and 4% were in total agreement. In contrast, 74% of respondents agreed or totally agreed that, among candidates with equivalent clinical and functional characteristics, women presented with poorer subjective impressions of functional limitation than men (Q2).When characterizing preoperative pain severity among candidates for knee replacement (Q3), the overall impression was that pain is less tolerated by female patients (60%), whereas 38% expressed that pain is more intense in female patients, and an equivalent proportion expressed that pain intensity is absolutely independent of sex Fig. . Forty pEighty percent of respondents agreed that socioeconomic and cultural characteristics influence the perception of pain (Q4).Eighty-six percent of respondents affirmed that the presence of comorbidities influenced their therapeutic and/or rehabilitative choices in patients with knee OA, independent of sex (Q5). Only 40% agreed that there are sex or gender differences in responses to available pain treatments in candidates for TKA (Q6). In the sub-analysis by physician specialty, 74% of physiatrists disagreed with this statement. When respondents were asked to qualify their “yes” responses to this question, most specified that they were referring to non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and generally lower efficacy of analgesics among women compared to men. Conversely, Ninety% of respondents disagreed that the prescription of pharmacological treatment is guided by gender-specific indications (Q7).With regard to the pharmacological agents prescribed by respondents to treat pain related to knee arthritis, NSAIDs and Coxib were most commonly used by 73% of respondents, followed by paracetamol (60%) and opioid-paracetamol combinations . Only pain specialists reflected higher agreement with the presence of a sex or gender difference, whereas physiatrists disagreed.Eighty-five percent of respondents agreed that early and correct management of pain and inflammation in the perioperative phase can positively influence the final outcome of TKA independent of sex (Q12), while 13% expressed that this was especially true among female patients. In contrast, 61% agreed that, among patients with similar clinical, functional, radiographic, and psycho-emotive characteristics, gender can significantly influence clinical outcomes of knee replacement (Q13). When responses were divided by physician specialty, a gender difference was most heavily supported by pain specialists (88%) and to some degree orthopedics (65%). Forty-seven percent of respondents agreed that chronic knee pain in the preoperative period (> 18 months) predicts pain around the prosthesis independent of sex; 35% disagreed with the statement and 18% agreed especially in female patients (Q14). Finally, 57% agreed that the psycho-emotional state of TKA candidates can significantly influence postoperative outcomes independent of sex (Q15). Thirty-seven percent asserted that this was especially true in female patients. When responses were divided by physician specialty, pain therapists, and orthopedic specialists were most likely to support a sex difference . Yet, 76% disagreed that postsurgical treatment and rehabilitation should be guided by gender-specific indications (Q17). Respondents who agreed with this statement specified compliance as an important gender-specific difference, as well as level of pain and muscle condition or bone health prior to surgery. In a question administered only to physiatrists, 73% disagreed that gender-specific “analgesic” physiotherapy techniques are useful for postoperative rehabilitation (Q18).Fifty percent of respondents agreed that dissatisfaction after total knee replacement occurs independent of sex, whereas the other half qualified that dissatisfaction is more frequent in female patients (Q19). When divided by physician specialty, pain therapists, and orthopedic specialists were more likely to indicate a female predilection whereas physiatrists overwhelmingly asserted that treatment dissatisfaction is independent of sex (87%).Finally, 74% of respondents agreed that current literature regarding TKA is potentially biased by the use of scales that are not validated for gender-specific indications (Q20).The present survey of healthcare professionals indicated that physicians who treat candidates for TKA, especially pain specialists and orthopedic specialists, perceive significant sex and gender differences in disease presentation, symptom management, and treatment responses. Although these perspectives are partly supported by available literature, the survey responses emphasized a need to focus more clearly on what sex and gender differences truly mean for the clinical management of knee OA. The absence of measures and treatments that take into consideration gender-specific indications could represent a missed opportunity for improved patient care.The interaction of pain and gender/sex is an emerging and extremely complex research topic –30. In gAnother important opinion expressed by physicians and especially pain specialists in our survey was that women may require a different  pharmacological approach and/or experience less efficacy of pharmacological pain treatment or poorer outcomes of TKA compared to men. Sex differences in analgesic responses have been reported wherein female sex and gender tend to be associated with lesser analgesia , 44. WomAnother intriguing idea emerging from the survey was the importance of assessing pain and prescribing treatment using gender and sex-specific indications. In response to Q26, a majority of respondents agreed that the absence of measures validated for gender-specific indications is a shortcoming of available studies on knee OA. At present, there are no specific validated tools available to facilitate an approach tailored by sex/gender in knee OA or chronic pain in general. The development of such tools may aid future investigations of the influence of sex and gender on pain as well as the detection of sex differences in a clinically meaningful manner that can inform physician decision-making.Having defined inherent sex and gender differences contributing to divergent disease presentation in OA, it is equally important to examine biases among healthcare professionals and sex differences in these perceptions. First, it is noteworthy that a majority of respondents to our survey were male. Inherent sex or gender bias among male physicians has been systematically investigated: in interview studies, male physicians perceived men seeking medical help as brave and stoic, whereas women were described as sensitive, complaining, or hysterical . To thisThe present study had a few limitations. First, the nature of this study as a survey best informs physician perceptions and not necessarily the actual nature of sex differences in knee OA, although many trends observed in our study are supported by available literature. Second, as aforementioned, a majority of respondents were male, consistent with the demographic characteristics of the included physician specialties  in Italy. Future investigations may consider balancing the sex of survey participants to better inform perceived sex and gender differences in healthcare settings. Third, this survey was restricted to physicians in Italy and may reflect some cultural bias. A recent decree (law 3/2018 article 3) calls for the integration of gender medicine into the practices of the Italian National Health Service, but a lack of education and training among physicians nationwide represents an important obstacle to its successful implementation. Finally, it should be noted that, while sex and gender differences in knee OA have important bearing on its clinical management, they represent only one dimension of a multifactorial influence on outcome comprised of socioeconomic status, comorbidities, and other variables. Studies should consider whether disparities are due to sex or gender differences in disease incidence, disease expression or severity, or additional factors by examining a variety of inequity types. Further research is needed to better inform the influences of these factors individually and together on the management and outcomes of knee OA.In conclusion, the results of our survey demonstrate that healthcare professionals perceive multiple sex and gender-related differences in patients with knee OA, especially in the pre and perioperative phases of TKA. The exact nature and significance of these differences between men and women should be better investigated with regard to differences in disease severity; clinical factors at initial presentation; physical, biochemical, and psycho-emotive characteristics; and socioeconomic as well as cultural factors. At the same time, it is necessary to evaluate bias in physician perceptions about sex and gender. In Italy and world


Early detection of dementia is critical for intervention and care planning but remains difficult. Computerized cognitive testing provides an accessible and promising solution to address these current challenges.The aim of this study was to evaluate a computerized cognitive testing battery (BrainCheck) for its diagnostic accuracy and ability to distinguish the severity of cognitive impairment.A total of 99 participants diagnosed with dementia, mild cognitive impairment (MCI), or normal cognition (NC) completed the BrainCheck battery. Statistical analyses compared participant performances on BrainCheck based on their diagnostic group.BrainCheck battery performance showed significant differences between the NC, MCI, and dementia groups, achieving 88% or higher sensitivity and specificity  for separating dementia from NC, and 77% or higher sensitivity and specificity in separating the MCI group from the NC and dementia groups. Three-group classification found true positive rates of 80% or higher for the NC and dementia groups and true positive rates of 64% or higher for the MCI group.BrainCheck was able to distinguish between diagnoses of dementia, MCI, and NC, providing a potentially reliable tool for early detection of cognitive impairment. In proportion with the growth of the aging population, the incidence of dementia is on the rise and is projected to affect nearly 14 million people in the United States and upwards of 152 million people globally in the coming decades . CurrentConsidered an early symptomatic stage of dementia, mild cognitive impairment (MCI) signifies a level of cognitive impairment between normal cognition (NC) and dementia . While nNeuropsychological tests (NPTs) represent a more extensive and comprehensive class of cognitive evaluation . They alComputerized cognitive assessment tools have been developed to address the issues of accessibility and efficiency -34. TheyThis study evaluated BrainCheck, a computerized cognitive test battery available on mobile devices, such as smartphones, tablets, and computers, making it portable and allowing it to be administered remotely. In addition to offering automated scoring and instant interpretation, BrainCheck requires short administration and testing times, comparable to traditional screening instruments, but provides detailed insight into multiple aspects of cognitive functioning that only comprehensive NPTs can. BrainCheck has previously been validated for its diagnostic accuracy in detecting concussion  and demeThis study was approved by the University of Washington (UW) Institutional Review Board (IRB) for human subject participation (review number STUDY00000790).Participants were recruited from a research registry maintained by the Alzheimer’s Disease Research Center associated with the UW Medicine Memory and Brain Wellness Center clinic . This reUsing the provided primary cognitive diagnosis within the registry, participants were divided into one of three groups: (1) NC, indicated by subjective cognitive complaint or no diagnosis of cognitive impairment, some of which were self-reported; (2) MCI, representing both amnestic and nonamnestic subtypes; or (3) dementia, which included dementia due to AD, frontotemporal dementia, vascular dementia, Lewy body dementia, mixed dementia, or atypical AD.A total of 5 participants were not recruited from the registry but via snowball sampling from other participants. The recruitment of these participants was simply due to convenience, typically a family member or friend that was also available at the time of testing. Out of these 5 participants, 4 of them were placed into the NC group after their self-reports denied symptoms or a history of cognitive impairment; these 4 were not patients of the memory clinic. The remaining participant was a patient from the memory clinic, just not a part of the registry, and was placed in the AD group based on their most recent diagnosis retrieved from their medical records. Testing for these 5 participants was administered on-site.Data for on-site administration was collected from October 2019 to February 2020. A session was held either in the participant’s home or in a well-lit, quiet, and distraction-free public setting. Consent forms were reviewed and signed by the participant or their legally authorized representative and an examiner, with both parties obtaining a copy. The study was designed for participants to complete one session with a moderator using a provided iPad  connected to Wi-Fi to complete the BrainCheck battery. Prior to testing, participants were briefed on BrainCheck, and moderator guidance was limited to questions and assistance requested by the participant during the practice portions. Participants received a gift card (US $20) for participation at the conclusion of the study session.Due to the COVID-19 pandemic and interest in preliminary data on remote cognitive testing, study procedures were modified to accommodate stay-at-home orders in Washington state. Data collection resumed from April to May 2020, with modified procedures using remote administration. These participants provided written and verbal consent and were administered the BrainCheck battery remotely over a video call with the moderator. Participants used their personal iPads or touchscreen computer browsers to complete the BrainCheck battery. The same method for on-site administration, as described above, was used for remote administration.A short description for each of the five assessments comprising the BrainCheck battery (V4.0.0) is listed in Table S1 in Statistical analyses were performed using Python  and R  programming languages. All tests were 2-sided, and significance was accepted at the 5% level (α=.05). Comparison of means of groups was made by an analysis of variance test for normally distributed data. The chi-square test was used to analyze differences in categorical variables.P values were corrected using the Tukey method for multiple comparisons. To assess the accuracy of the BrainCheck Overall Score in the binary classification of participants in the different diagnostic groups , receiver operating characteristic (ROC) curves with area under the curve (AUC) calculations were generated to determine diagnostic sensitivity and specificity. In these binary classifications, sensitivity  and specificity  are measured, with the more severe group as cases and the less severe group as controls. For example, the MCI group represents cases in the MCI versus NC classification, but it represents controls in the dementia versus MCI classification. In assessing BrainCheck for three-group classification, we used volume under the three-class ROC surface method from Luo and Xiong [To evaluate BrainCheck performance among participants in different diagnostic groups while adjusting for age, sex, and administration type, linear regression was used in which the outcome variables were duration to complete BrainCheck battery, individual BrainCheck assessment scores, and BrainCheck Overall Scores. nd Xiong  to definA total of 241 individuals were contacted to participate, and 99 participants completed the study. Demographic details of the participants are provided in We found that most participants in the NC group were able to complete the assessments, whereas the dementia group had a higher time-out rate, with the MCI group falling in between the two . The timBrainCheck assessments were compared across the three groups using a linear regression model with age, sex, and administration type as regressors . IndividP<.001). Pairwise comparisons with Tukey adjustments for multiple comparisons show that the NC group scored significantly higher than the MCI group (P=.002) and the dementia group (P<.001), and the MCI group scored significantly higher than the dementia group . Using an existing normative population database, partly compiled from controls in previous studies ,39, the  P<.001; .Using ROC analysis, BrainCheck Overall Scores achieved a sensitivity of 88% and a specificity of 94% for classifying between dementia and NC participants (AUC=0.95), a sensitivity of 86% and a specificity of 83% for classifying between MCI and NC participants (AUC=0.84), and a sensitivity of 83% and a specificity of 77% for classifying between dementia and MCI participants  [Although not all individual assessments in the BrainCheck battery differentiated between NC, MCI, and dementia, we observed a general trend for each assessment showing that dementia participants had the lowest scores, whereas the NC participants had the highest scores. Individual assessments that did show significant differences in the scores between NC and MCI groups and between dementia and MCI groups included Immediate Recognition and Digit Symbol Substitution. Notably, Digit Symbol Substitution showed significant differences in performance between all three diagnostic groups, whereas a previous study found that Digit Symbol Substitution did not show significant differences between cognitively healthy and cognitively impaired groups  , likely In comparison to comprehensive NPTs, which can typically last a few hours and sometimes require multiple visits , BrainChA limitation of this study was that participants were not diagnosed by a physician at the time point of BrainCheck testing. Thus, participants were placed into the diagnostic groups based on their most recent clinical diagnosis available in their electronic health record, or for the few NC participants without medical evaluations, based on their report of no cognitive symptoms or diagnosis of cognitive impairment. The period from the most recent clinical diagnosis to the date of BrainCheck testing varied among the diagnostic groups; the dementia group had the fewest days from their latest clinical evaluation , followed by the MCI group  and the NC group . These large time intervals in a degenerative population leave room for cognition to worsen over time, potentially blurring the lines in the severity of cognitive impairment, where participants may have progressed to MCI from NC and to dementia from MCI during that period. This would make distinguishing NC from cognitive impairment more difficult, yet diagnostic accuracy among the groups remains high. Furthermore, the median number of days since the last clinical evaluation for NC participants was as high as 645 days. This could suggest that the NC participants did not feel an inclination to seek out further cognitive evaluation during the extended time period, and may not have experienced noticeable cognitive decline. Future validity studies should ensure that a physician evaluation and diagnosis occur closer to the time of BrainCheck testing to address these limitations.Another limitation was that although not all individual assessment scores could differentiate the three groups, the pattern of differences across these scores may contain useful diagnostic information. The use of the BrainCheck Overall Score as an average of all individual assessment scores appears to work effectively, but does not take into account the other relationships seen across individual scores. Furthermore, some individual scores may be more informative for detecting cases, whereas others may be informative for gauging severeness. Future studies recruiting a larger sample size in each group will allow for an investigation into whether machine learning methods can extrapolate these relationships and improve the diagnostic accuracy of BrainCheck.When administration type was considered in linear regression model analyses, scores only showed significant differences among the three diagnostic groups instead of administration types. While remote administration was not designed into the original study, stay-at-home orders due to COVID-19 required modifications, and efforts were made to provide preliminary data for remote use. With preliminary outcomes indicating feasibility for remote administration, a more robust study and increased sample size will be needed to fully validate BrainCheck’s cognitive assessment via its remote feature.The use of computerized cognitive tests provides the opportunity to increase test accessibility for an aging population with an increased risk of cognitive impairment. The findings in this study demonstrate that BrainCheck could distinguish between three levels of cognitive impairment: NC, MCI, and dementia. BrainCheck is automated and quick to administer, both in person and remotely, which could help increase accessibility to testing and early detection of cognitive decline in an ever-aging population. This study paves the way for a comprehensive longitudinal study, exploring BrainCheck in early detection of dementia and monitoring of cognitive symptoms over time, including further comparison to gold-standard neuropsychological assessments.


Older people are the highest users of health services but are less likely to use a patient portal than younger people.This scoping review aimed to identify and synthesize the literature on contextual factors that impact the implementation of patient portals in acute care hospitals and among older people.A scoping review was conducted according to the PRISMA-ScR  guidelines. The following databases were searched from 2010 to June 2020: MEDLINE and Embase via the Ovid platform, CINAHL and PsycINFO via the EBSCO platform, and the Cochrane Library. Eligible reviews were published in English; focused on the implementation of tethered patient portals; included patients, health care professionals, managers, and budget holders; and aimed at identifying the contextual factors  that impact the implementation of patient portals. Review titles and abstracts and full-text publications were screened in duplicate. The study characteristics were charted by one author and checked for accuracy by a second author. The NASSS  framework was used to synthesize the findings.In total, 10 systematic reviews published between 2015 and 2020 were included in the study. Of these, 3 (30%) reviews addressed patient portals in acute care hospitals, and 2 (20%) reviews addressed the implementation of patient portals among older people in multiple settings . To maximize the inclusion of the literature on patient portal implementation, we also included 5 reviews of systematic reviews that examined patient portals in multiple care settings . Contextual factors influencing patient portal implementation tended to cluster in specific NASSS domains, namely the condition, technology, and value proposition. Certain aspects within these domains received more coverage than others, such as sociocultural factors and comorbidities, the usability and functionality aspects of the technology, and the demand-side value. There are gaps in the literature pertinent to the consideration of the provision of patient portals for older people in acute care hospitals, including the lack of consideration of the diversity of older adults and their needs, the question of interoperability between systems (likely to be important where care involves multiple services), the involvement of lay caregivers, and looking beyond short-term implementation to ways in which portal use can be sustained.We identified important contextual factors that impact patient portal implementation and key gaps in the literature. Future research should focus on evaluating strategies that address disparities in use and promote engagement with patient portals among older people in acute care settings. Patient portals  consist of an internet-based application that accesses the electronic health record of a health care organization and provides timely access to medical records, laboratory results, appointment bookings, repeat prescriptions, and secure messaging with health care professionals, among other content and functionality . PatientThe greatest benefit to patients and the health service can be achieved by optimizing portal use among older people . Older pThere are numerous reviews of patient portal features, functionality, adoption, and implementation, with the vast majority focusing on family practice settings. A review examining portal use in multiple health care settings was published by Antonio et al . This umThe aim of this scoping review was to identify and synthesize the literature on contextual factors that impact the implementation of patient portals in acute care hospitals and among older people.Our primary interest was to improve the engagement with patient portals among older people in acute care hospitals. However, we needed a broad scope of the literature to capture learning from studies in multiple settings  and patient groups , given the potential generalizability of the findings across settings.This scoping review followed the methodological framework described by Arksey and O’Malley  and the To build on the existing literature, we used a theoretical framework to provide a semantic structure to the synthesis of our findings. The NASSS  framework  providedA search strategy was developed in collaboration with an academic librarian. As a preliminary examination of the literature indicated that only a few reviews focused solely on acute care hospitals or older adults and because the specific health care setting was not always immediately clear, we decided not to include filters for population or health care setting in order not to exclude potentially relevant publications.The full search strategy is shown in To generate sufficient breadth of coverage for the scoping review, inclusion criteria were defined to capture maximum learning with respect to the implementation of tethered patient portals among older people and in acute care hospitals. Specifically, 3 categories of reviews were eligible for consideration:Systematic reviews of patient portals in acute care hospitalsSystematic reviews of reviews (with both primary studies and reviews) of patient portals in multiple settings, including acute care hospitalsSystematic reviews of patient portals for older adults in multiple settings, including acute care hospitalsIntroduction section); reviews focused on patient portals for older adults ; reviews focused on patient portals for patients, health care professionals, managers, and budget holders in acute care hospitals; reviews of reviews of patient portals in settings that include acute care hospitals; reviews focused on contextual factors  that impact the implementation of patient portals; systematic reviews; scoping reviews; narrative reviews; qualitative meta-syntheses; meta-ethnographies; and reviews of reviews.The inclusion criteria were as follows: reviews published since 2010 in English; reviews focused on the implementation of tethered patient portals Exp Patient Portals/Health Records, PersonalPatient ADJ2 Portal*.mpElectronic ADJ2 Portal.mp adj2 (record* or info*)).mpPatient accessible record*.mpPHR.mpePHR.mpor/1-8 (MEDLINE) or/3-8 (EMBASE)Meta analysis/Meta-analysis.ti,ab,pt.Meta-ethno*.ti,ab,pt.Review.ti,ab.pt.or/10-13and/9,14Limits – English Language, 2010-current, humansSearch terms for CINAHL and PsycINFO (via EBSCO)MH “Patient Portals”MH “Medical Records, Personal”Patient n2 Portal*Electronic n2 PortalPersonal n2  n2 (record* or info*)Patient accessible record*PHRePHRor/1-8 (CINAHL) or/3-8 (PsycInfo)MH Meta analysisMeta-analysisMeta-ethno*Review.ti,ab.pt.or/10-13and/9,14Limits – English Language, 2010-currentSearch terms for Cochrane LibraryExp Patient PortalsHealth Records, PersonalHealth Records, ElectronicSearch results were imported into EndNote reference management software , and duplicates were removed automatically and double checked manually. Two reviewers (JH and ZK) independently screened titles and abstracts. Any discrepancies in the articles identified for full-text screening were discussed, and consensus was reached. Full-text articles of potentially eligible reviews were assessed independently by 2 reviewers (JH and ZK) against the prespecified inclusion and exclusion criteria. Discrepancies were resolved through discussion. The reasons for exclusion were recorded and included in the PRISMA diagram .NASSS Framework section), together with the authors’ recommendations for future research. The form was piloted on 4 studies. A single reviewer (JH) read each study and extracted the study characteristics and data on contextual factors from the results and discussion sections. The discussion sections were included in the charting process, as they often provide additional material to enhance the interpretation of review findings. The data extraction for each of the 4 articles was cross-checked by another team member  to verify whether data charting was performed in accordance with the 7 NASSS framework domains. Data charting was then completed by a single reviewer (JH) and independently verified by another member of the team (ZK).In accordance with the Arksey and O’Malley framework for scoping reviews , a data A narrative approach was used to summarize the results of the scoping review. In line with the usual practice for scoping reviews , no atteA total of 2065 references were identified . After tThe reviews were published between 2015 and 2020. Of the 10 included reviews, 4 (40%) originated from the United States , 2 (20%)Of the included reviews, 7 (70%) did not specify a particular framework for the analysis of the results -24,27,28To establish the breadth of coverage of this scoping review, an indication of the extent of overlap of studies in the included reviews was determined. The included reviews contained 206 studies , excluding the 109 references of Otte-Trojel et al , which, The results and discussion sections of the included studies were successfully mapped to the NASSS framework domains and subdomains. The findings for each domain are presented and a summary is provided in The included reviews documented patient portals that are open to individuals with a variety of health conditions, including acute and chronic diseases and high-risk conditions. Reviews focusing on patient portals in acute care hospitals included adult patients with acute medical conditions , inpatieThere was limited consideration of how clinical characteristics played a role in patient portal use. An examination of inpatient portals  highlighA total of 3 (30%) reviews suggested that patients with greater disease severity  or with The NASSS framework considers how complexity occurs when a condition or an illness is associated with sociocultural factors  and comorbidities . The impact of these factors on patient portal adoption received more extensive coverage in the included reviews, along with concerns about the potential for the exacerbation of health inequalities owing to disparities in engagement, as outlined subsequently.The included reviews suggested that portal adoption is associated with having a higher socioeconomic status, being female, being of White ethnicity, being younger, and being a younger senior citizen ,26,27.Low health literacy and numeracy in patient groups ,22,27 asCertain comorbidities, such as vision and hearing loss, decreased dexterity and mobility, and declining cognitive function, were identified as barriers to portal use ,22. ThesThe included reviews did not outline the technology in detail but identified several material and technical features that promote patient portal adoption and user satisfaction, including a well-designed interface ,28, easeConversely, poor usability features, such as poor interface design ,26,27, tThe reviews suggested that participatory and iterative design ,27 and iSeveral reviews highlighted potential difficulties in defining the functionality of a patient portal system, including the differing information needs of patients and health professionals , differiThe information privacy and security aspects of patient portals were reported to be an area of concern. This could be patients’ concerns regarding their personal health information ,21,23-27Accessibility of the technology for patients , includiIn terms of the data held in the patient portal, 1 (10%) review suggested that the data set needed to be comprehensive, reliable, complete, understandable, and valid , with anSeveral reviews raised the issue of health professionals’ concerns about patients’ access to health information via portals, particularly sensitive information, with questions about how patients can deal with the information without professionals’ help with interpretation and support ,24,26,27The reviews suggested that training and support can help portal use ,26 and tAlthough the included reviews did not address how the patient portal technology was procured, the lack of interoperability for achieving appropriate data exchange between systems was identified as a barrier to adoption ,26. PortThe reviews did not address the issue of the business case for patient portals from the developer’s perspective but did examine it from the health care system’s point of view, primarily with respect to the difficulties in establishing such a case ,24.Uncertainty around cost savings and financial sustainability, as well as reimbursement models for electronic services , contribA recommendation for ensuring a sustainable business case was to have a trial period before committing to the purchase of a portal . This alThe reviews suggested that patient portals do satisfy patients’ need for information  -22,27,28Professionals valued patient portals as a mechanism for enhancing patient care  through As indicated under domain 2 (the technology), where patients perceive portals as useful, they are prepared to overcome the technical barriers to portal use . HoweverThe reviews highlighted that the adoption of patient portals can raise questions regarding health professionals’ scope of practice and professional identity. There are implications in terms of health professionals’ confidence and ability to interact with the technology ,26,27; tMoreover, 1 (10%) review suggested that when health professionals advocated collaborative working with patients and had confidence in using patient portals, this acted as a facilitator of implementation . ConversProfessionals’ support and encouragement of patients’ use of portals were identified as mechanisms to facilitate the adoption of portals among patients -27. BothThe included reviews did not directly address expectations of the involvement of the wider care network or lay caregivers in the adoption of patient portals, although it is acknowledged that older patients may lack help or support to access a portal . This suThe included reviews highlighted the importance of organizational leadership support in promoting portal adoption ,28 throuOne (10%) review pointed to the potential for variability in portal implementation  in situations where providers have the discretion to interpret government legislation . This isA constrained financial context will impact the implementation of portal technology ,27. One The included reviews highlighted the range of preparatory work that organizations need to do to support portal implementation. Organizational policies such as universal access ; securitless disadvantaged  [The challenges of making decisions on adoption and funding were highlighted by the included reviews. Organizations need to decide on the balance between costs, implementation time, and the flexibility of the portal architecture , includiestions) . Howeverestions) .Concerns among health professionals regarding the potential impact of patient portals on workload and workflow were identified in the reviews ,24,26,27Some solutions addressing workflow concerns were presented, including integrating data release to patients with workflow patterns to facilitate health professional follow-up with patients when the results are made available  and provThese issues are linked to the involvement of health professionals at the technology design stage (domain 2), where concerns about the potential impact on workflows can be raised, and to the points raised earlier about the development of policies around integration by organizational leadership and proactive communication around the integration of portals into workflows.The included reviews suggest the development of national and international information exchange  and other standards  as a facilitator of portal implementation ,28.One (10%) review identified health professionals’ liability concerns as a factor that will promote patient access to records  . For couBarriers to portal implementation identified in the reviews included nonstandardized rules for developing and managing health information infrastructures  and regulations for data protection and management  that do not cover portal developers or hosting organizations, creating uncertainty about appropriate data governance . In addiOne (10%) review pointed to inadequate or contradictory reimbursement structures for electronic services as a wider contextual barrier to the implementation of patient portals , inhibitIn the included reviews, there was little consideration of the long-term adaptability and sustainability of the patient portals. The focus of attention was on development and short-term implementation issues.Two long-term considerations were mentioned in the literature. The first was a general concern that the medical record maintains its integrity as a working document that facilitates the transfer of knowledge among many health professionals . The secThere was no coverage of organizational resilience to critical or unforeseen events and ability to adapt to them.There are links among the different domains. For example, the severity of an individual’s illness can affect their ability to interact with portal technology, raising questions about expectations of the involvement of lay caregivers (domain 4: the adopter system), organizational policies on proxy access (domain 5: the organization), privacy and security features (domain 2: the technology), and information governance (domain 6: the wider context). Similarly, organizational leadership and support (domain 5: the organization) for the development and implementation of portals can ensure inclusive and iterative portal design (domain 1: the technology), addressing not only usability and functionality issues but also the perceived value  of the technology, as well as concerns about the impact of portals on health professional roles and identities (domain 4: the adopter system) and workload and workflow (domain 5: the organization).There are gaps in the literature pertinent to the consideration of the provision of patient portals among older people in acute care hospitals, including the lack of consideration of the diversity of older adults and their needs, the question of interoperability between systems (likely to be important where care involves multiple services), the involvement of lay caregivers and looking beyond short-term implementation to ways in which portal use can be sustained.This scoping review provides an overview of the contextual factors that impact the implementation of patient portals through an exploration of the emerging literature on patient portal use and engagement in acute care hospitals and among older people. Patients with chronic disease or greater disease severity were found to engage more with portals; however, comorbidities associated with the aging process were identified as barriers to portal use (domain 1: the condition). Perceived benefits from the supply side supported the adoption of portals, such as the potential for lower hospital costs, as did benefits from the demand side, such as engagement in care or self-management . Training for patients and staff should address technology literacy, the use of portal features, capacity-related concerns , and perceived value among health care professionals (domain 2: the technology). Older patients may lack help or support to access a portal; however, expectations of the involvement of lay caregivers in the adoption of patient portals were not reported (domain 4: the adopter system). Organizational leadership facilitates portal adoption, such as working with developers on portal design, developing policies for user training, and integrating portals into clinical workflows (domain 5: the organization). The development of national and international information exchange  and other standards  was as a facilitator of portal implementation within the wider context (domain 6: the wider context). The reviews did not report on the long-term adaptability or sustainability of patient portals or organizational resilience. There were concerns that most portals are implemented within a single organization and that implementation across organizational contexts or in fragmented care delivery contexts would be challenging. This is important for the care of older people (domain 7: embedding and sustaining).The diversity of older adults and their patient portal needs are not well understood. Older patients are more likely to experience chronic disease or greater severity of disease, and patients with chronic illness and greater severity of disease were found to engage more with portals owing to the perceived benefits of self-management, empowerment, and enhanced patient care. However, comorbidities related to age, such as vision and hearing loss, decreased dexterity and mobility, and declining cognitive function impede portal use. Variability in portal use and engagement among older people will, in part, be linked to the reasons for variability in internet use. Low income is the largest impediment to internet use among older people, followed by being aged >75 years, living alone, mobility, and memory or concentration problems . This scAn important gap in the literature identified by this review was the lack of consideration of the involvement of the wider care network or lay caregivers in the adoption of patient portals. Many impediments to internet use among older people are linked to the increased likelihood of receiving care, for example, older age, mobility, and memory or concentration problems . Older pNone of the included studies addressed the procurement process for patient portals. In the United Kingdom, there are a handful of providers that offer patient portals to acute care hospitals, such as Epic and Cerner. Patient portals differ in the extent to which they provide an off-the-shelf product or a tailored product with features that can be switched on or off depending on organizational readiness and capacity to facilitate them, such as patient-clinician communication. This review found that decentralized architectures were more compatible with local needs and implemented more quickly but were associated with higher costs . FurtherThis scoping review used a comprehensive set of search terms to identify literature from electronic databases and followed robust procedures for citation and full-text screening in duplicate. Study overlap is a recognized limitation of reviews of reviews, where the primary studies may be reported in >1 systematic review and hence findings are overemphasized. This review included 156 primary studies and 50 reviews. We found that 19 (9.2%) of these 206 studies appeared in >1 review, indicating that study overlap was minimal, although we did not track overlap in the reference lists of all the included reviews. The NASSS framework provides a semantic structure by which to explore multilevel contextual factors impacting the implementation of digital health interventions. NASSS has largely been used to predict and evaluate implementation programs, but more recently, the framework has been used to synthesize review findings ,36.The number of reviews that focused exclusively on acute care hospitals  and older people  was low, which led to a broader scope of the extensive literature, primarily conducted in family practice and other patient groups, to capture learning and potential generalizability of the findings across settings and patients. In broadening the scope of the review, there were similarities with the umbrella review conducted by Antonio et al , who usePapers were selected in accordance with our definition of a patient portal, and we were guided by the authors’ description of a patient portal. There is substantial literature on the contextual factors impacting patient portal use, with approximately 200 studies identified by the included reviews. However, there are few studies that evaluated interventions to address disparities in the use of patient portals . As highThis review provides implications for portal adoption and implementation that can inform current practice. This review found that cost, interoperability, trialability, and adaptability were all facilitators of portal adoption. Among hospitals in England deciding which portal product to adopt, GDE trusts play an important role in sharing detailed journeys through a digital technology via GDE blueprints, which are intended to promote scale-up, spread, and sustainability. To maximize the impact of GDE blueprints, they must be reported in an honest and transparent manner, with details on the challenges as well as the benefits of portals’ adoption, engagement, and sustained use. Descriptions of portal implementation must clearly delineate implementation strategies, such as detailed information on training for staff and patients  and communication strategies for the technical, interpersonal, and workflow aspects of patient portals. NHS Digital has created a Personal Health Records adoption toolkit, which offers generic support to organizations looking to implement a patient portal . FurtherThis scoping review found that contextual factors influencing patient portal implementation tended to cluster in specific domains: (1) the condition, (2) the technology, and (3) the value proposition. Certain aspects within these domains received more coverage than others, such as sociocultural factors and comorbidities, the usability and functionality aspects of the technology, and the demand-side value. There are gaps in the literature pertinent to the consideration of the provision of patient portals for older people in acute care hospitals, including the lack of consideration of the diversity of older adults and their needs, the question of interoperability between systems (likely to be important where care involves multiple services), the involvement of lay caregivers, and looking beyond short-term implementation to ways in which portal use can be sustained. There is substantial literature on the contextual factors impacting patient portal use. Future research should focus on evaluating strategies that address disparities in use and promote engagement with patient portals among older people in acute care settings.


There is an urgent need for countries worldwide to promote the green transformation of their economies and reduce environmental pollution. Based on China’s Green Credit Guidelines policy in 2012 and the data of Chinese listed companies from 2007 to 2021, we conducted an empirical test using the difference-in-differences method. The results showed that green finance policies inhibit technological innovation in heavily polluting enterprises, and the stronger the enterprise’s operating capacity, the weaker this inhibiting effect. The study also shows that bank loan, loan term, corporate management motivation, and business confidence have intermediation effects. Therefore, countries should improve green financial policies and promote technological innovation in heavily polluting enterprises in order to reduce environmental pollution and promote green growth. There have been increasing concerns on the issue of environmental pollution . To solv2 emissions and promoting economic and industrial structural transformation using data from G7 countries. Danish and Ulucak [Technological innovation plays a key role in solving environmental problems and promoting green growth. The importance of technological innovation in facilitating production transformation and increasing the total factor productivity of firms has been repeatedly highlighted by scholars . Long-teGreen finance contributes to environmental protection and economic growth. On the one hand, financial development can mobilise savings, promote capital accumulation, and improve capital allocation, and thus contribute to economic growth . On the The relationship between green finance and technological innovation has an impact on whether green finance policies and technological innovation can be fully effective and is important for solving the environmental pollution problem and promoting green growth. China has implemented green finance policies and is committed to promoting green growth . The ChiTherefore, we regarded the release of the Guidelines as the implementation of green financial policy and, using the data of Chinese listed companies from 2007 to 2021, explored the relationship between green finance and technological innovation. The innovations of this study are as follows: First, this study identified the heterogeneous effects of green finance policies on technological innovation. Second, this study indicated the crucial role of policy signal in the influence of green finance on technological innovation. Third, this study determined the influencing factors of banks and enterprises.The remainder of the paper is organised as follows: Relevant literature mainly includes the environmental and technological innovation effects of green finance. Regarding environmental effects, green finance promotes a greener industrial structure and guides enterprises to change their traditional production methods in favour of clean production , and thuFinancial markets can promote technological innovation by efficiently allocating financial resources and sharing the risk of R&D . ConversSome scholars believe that environmental regulation inevitably increases firms’ running costs, and therefore crowds out their investments in technological innovation and diminishes their advantages . In contFrom the above literature, it can be seen there is a paucity of literature that directly studies the interactions between green finance and technological innovation. The existing studies on this topic suffer from the following limitations: First, the studies are on green innovation rather than technological innovation. Technological innovation includes not only green innovation but also other technological innovation such as innovation to improve productivity. Secondly, the research findings are controversial. Thirdly, there is a lack of in-depth and comprehensive analysis of the mechanism of action between green finance and technological innovation. Therefore, there is a need for further research on this topic.In this study, the compliance cost effects, innovation compensation effects, and policy signalling effects of green financial policies were analysed.As a market-led environmental regulation policy, the Guidelines require banks to use firms’ environmental performance as an important basis for credit allocation, thus prompting firms to increase their environmental expenditures to obtain loans. Given the limited resources, the increase in environmental protection costs may crowd-out funds for other production activities, including R&D. Therefore, the Guidelines may have a ‘cost compliance effect’, creating a disincentive for technological innovation. In contrast, the Guidelines increase the environmental costs of obtaining credit, thereby increasing cost pressures on firms. Under this pressure, firms may seek technological innovations to improve productivity and thus compensate for the increased environmental costs. Thus, the Guidelines may have an ‘innovation compensation effect’ and promote technological innovation.As R&D activities are characterised by long investment cycles, high capital requirements, and uncertain outcomes , sustainIn general, the ‘compliance cost effect’ of green finance policies can inhibit technological innovation, while the ‘innovation compensation effect’ promotes it. The ‘policy signalling effect’ inhibits the ‘innovation compensation effect’. Therefore, green finance policies generally discourage technological innovation.Accordingly, we proposed Hypothesis 1:Hypothesis 1 (H1).Green financial policies in general behave as a disincentive to technological innovation.The Guidelines require banking financial institutions to develop specific credit policies for restricted industries, such as heavily polluting industries, and to deny credit for non-compliance with environmental performance. This reduces the lending banks do to heavily polluting industries. There is a problem of excessive credit in China’s heavily polluting industries , and a rAccordingly, we proposed Hypothesis 2:Hypothesis 2 (H2).Green financial policies promote technological innovation by reducing bank loans and weakening constraints on technological innovation of companies.In the case of short loan terms, changes in business conditions and market demand are small and loans can be recovered; therefore, the loan risk is manageable. However, for longer loan terms, the business conditions, market demand, and policy direction may change significantly, and the loan risk is more variable. The policy signals released by the Guidelines have made banks aware of the potential for further tightening of policy restrictions on heavily polluting industries in the future, which could increase the financial risk of enterprises and the associated credit risk for banks. Therefore, under the influence of the Guidelines, banks have tended to shorten the maturity of credit to hedge potential policy risks. As the maturity structure of debt needs to match the asset structure  and techAccordingly, we proposed Hypothesis 3:Hypothesis 3 (H3).Green financial policies discourage technological innovation by shortening the term of loans.The implementation of the Guidelines has prompted banks to strengthen their supervision of companies and reduce the incentive of their management. First, banks have strengthened their oversight of corporate environmental practices. The Guidelines require banking institutions to dynamically assess and classify the environmental risks of their clients, with the relevant results serving as an important basis for their ratings and credit access. Second, banks have strengthened their supervision of business operations. Banks are an important player in corporate governance  and can Accordingly, we proposed Hypothesis 4:Hypothesis 4 (H4).Green financial policies reduce the scope for corporate autonomy and reduce the incentive of corporate management, and thereby discourage technological innovation.Business confidence is a composite judgement made by firms based on their understanding of the current situation and economic information . GovernmAccordingly, we proposed Hypothesis 5:Hypothesis 5 (H5).Green financial policies discourage technological innovation by weakening business confidence.Operational capability indicates the efficiency of an enterprise’s use of resources to achieve its management objectives. First, companies with strong operational capabilities can allocate their assets in a rational manner, and thus can reduce the crowding out of R&D investment by environmental costs and focus more resources on R&D. Second, in the face of a deteriorating market environment, companies with strong operational capabilities are more confident of surviving the strong market competition in the future and therefore have a greater willingness to engage in technological innovation.Accordingly, we proposed Hypothesis 6:Hypothesis 6 (H6).The stronger the operational capacity of the enterprise, the weaker the inhibitory performance of green financial policies on technological innovation.In this study, an empirical test was conducted using data from Chinese listed companies for the period 2007–2021. The Wind and CSMAR databases provided data to support this study. The following companies were excluded: financial companies, companies with unusual transactions, insolvent companies, and data deficient companies. The continuous variables were tail shrunk to avoid non-normal data effects. Finally, we obtained 19,469 annual observations.The model is as follows:Commonly used indicators for measuring technological innovation are innovation inputs and outputs, with the former generally using R&D input indicators and the latter generally using patent application indicators. This study focused on whether an enterprise’s innovation activities are more active. Thus, R&D input indicators can indicate a company’s technological innovation accurately, and in a timely manner. Specifically, the dependent variable of the empirical model is R&D expenditure as a percentage of total assets.When the company is in one of the heavily polluting industries, the We introduced the following control variables: enterprise size (denoted by Size), taking total assets to natural logarithm; net margin on total assets (denoted by Roa), which is the net profits divided by the total assets; gearing ratio (denoted by Lev), which is liabilities divided by assets; asset structure (denoted by Coa), which is the current assets divided by the total assets; company growth (denoted by Grow), which is year-on-year growth in operating income; return on net assets (denoted by Roe), which is the net profits divided by average shareholders’ equity.The difference in magnitude between the variables is reasonable according to This study conducted empirical tests using the difference-in-differences method, and this method assumes that the dependent variables in both the control group and the treatment group have the same change before the policy implementation. Parallel trend tests were conducted using the visual observation method and the event study method, respectively.First, the dummy variable As shown in We replaced the initial dependent variable with R&D expenditure as a percentage of operating revenue to test robustness. As seen in As shown in We constructed models (2) and (3) to test the mediating roles of bank lending, credit term structure, management motivation, and business confidence.Bank loans: short-term borrowing plus long-term borrowing as a percentage of total assets;Credit maturity structure: expressed as long-term borrowing divided by short-term borrowing, with a larger ratio indicating a more long-term credit maturity structure;Management motivation: measured using management expenses divided by gross operating revenue, with a higher ratio indicating more active management activity, i.e., more motivated management;Business Confidence: measured using intangible assets, cash paid for fixed assets, and other long-term assets as a percentage of total assets, with larger ratios indicating that business decisions tend to be more long-term, reflecting the greater confidence of business decision-makers in the future.The following indicators were selected for the intermediary variables:The regression coefficients of the DID on bank loans without and with the inclusion of control variables were negative , indicatThe DID coefficient was not significant for the bank loan regression. To ensure the rigour of the study, the Bootstrap test was conducted. As shown in As column (1) in We constructed model (4) for testing the moderating effects.As shown in In this study, multiple effects of green financial policies were analysed from three perspectives: compliance cost effect, innovation compensation effect, and policy signalling effect. The mediating and moderating effects of green financial policies on technological innovation were also analysed. Furthermore, an empirical test was conducted using the difference-in-differences method. The following conclusions were drawn. First, green finance inhibited technological innovation owing to the pessimistic attitude of heavily polluting firms towards the returns expected from technological innovation. Second, green financial policies weakened the constraints of banks on technological innovation by lowering bank loans, and thus promoted technological innovation. Third, green financial policies resulted in shorter credit terms, lower management incentives, and weaker business confidence, and thus discouraged technological innovation. Fourth, the stronger the operating capacity of enterprises, the weaker the policy’s inhibiting effect on technological innovation.Accordingly, the following recommendations are made for improving green financial policies and using technological innovation to achieve green growth. First, avoid the wholesale rejection of heavily polluting industries and emphasise green transformation and upgrading. It is not reasonable to shut down heavily polluting industries across the board; therefore, guiding enterprise transformation is a necessary step to combat environmental pollution while considering economic development. The emphasis on transformation and upgrading can give confidence to the industry while curbing the blind expansion and sloppy development of heavily polluting industries. This can guide market players to be proactive rather than passive and motivate enterprises to address the contradiction between maximising profits and environmental constraints through technological innovation. Second, banks should be guided to adjust their credit maturity structure for enterprises in heavily polluting industries. Owing to their own interests, banks lack the incentive to extend the credit maturity of enterprises in heavily polluting industries. Therefore, the green financial policy should strengthen the guidance and constraint for banks to increase the proportion of long-term loans to provide stable financial security for R&D and innovation. Finally, banks should be guided to reduce their intervention in the normal operation of enterprises while strengthening their environmental review. Banks’ loan reviews and interventions can impact the normal business activities of enterprises. Green financial policies should guide and restrain the behaviour of banks to avoid excessive intervention in business activities ,32,33,34In the study, we analysed the significance of technological innovation and green finance with regards to promoting green growth and reducing environmental pollution, as well as their relationships. However, this study also had some limitations. First, this study was based on the Green Credit Guidelines from China, and different countries have different green financial policies; therefore, the applications of the findings of this study to other countries require further analysis. Second, owing to word limit, this study did not specifically analyse the heterogeneous role of technological innovation in different industries. Further research can be done in the future in the above two respects.