INTRODUCTION:Open disclosure is an open discussion with a patient and/or family member about an incident(s) that resulted in harm to that patient while they were receiving healthcare. It is widely considered an ethical and moral imperative and is what patients and families want when harm occurs. However, there is a dearth of research on patient and family experiences of open disclosure and limited measures available to measure the quality of current processes. This research aimed to address this gap by using an evidence-informed approach to working with experts by experience to co-design a mechanism to measure patient experience of open disclosure. METHODS:We adopted a co-design approach, which involves partnering with stakeholders in the healthcare system to address a shared goal and working collaboratively to develop consensus about how best to address an identified challenge. A co-design team was established which included experts by experience (those with direct patient/family experience of open disclosure; n = 5), patient advocates (n = 2), patient and service user engagement lead in the health system (n = 2), quality and patient safety managers/advisors (n = 3), members of the National Open Disclosure Team (n = 3) and academics/researchers (n = 3). A one-day in-person workshop was held using the World Café approach whereby a series of small group discussions on sub-topics helped develop consensus on how to measure experience. RESULTS:Participants agreed that a brief survey, focusing on key aspects of the open disclosure process would be the optimal way for patients and relevant others to provide feedback that could support learning and quality improvement. Participants acknowledged the use of open text comment boxes within the survey would be useful to allow respondents to elaborate on their experience further, if desired. Furthermore, the survey should provide the option for the respondent to indicate if they would like to speak to someone about their experience of open disclosure in more detail. The co-design team agreed that everyone who has experience of open disclosure, regardless of level of harm, should be eligible and invited to take part in providing feedback on their experiences. A draft survey was developed by the group and is presented in full. CONCLUSIONS:This paper documents the co-design approach adopted on this sensitive topic and shares recommendations that emerged from the co-design process of how experiences of open disclosure should be measured for the purposes of improvement. While the survey was deemed optimal by co-design group members, it is acknowledged that this could be challenging for some to complete. This draft survey however offers a valuable starting point to understanding if the process is working as intended for patients and families who experience harm.
BACKGROUND:The work or practice environments of health professionals play a central role in their retention in the healthcare system and their ability to provide quality patient care. The aim of the study was to examine and compare the satisfaction of early-career health professionals in the WiSDOM (Wits longitudinal Study to Determine the Operation of the labour Market among its health professional graduates) study with their clinical practice environments (CPEs) in South Africa, and the factors influencing their satisfaction. METHODS:WiSDOM, a prospective longitudinal cohort study, consists of eight health professions: clinical associates, dentists, doctors, nurses, occupational therapists, oral hygienists, pharmacists, and physiotherapists. Every year we collect information on the cohort's involvement in direct patient care, their perceived workload, availability of medicines and equipment for patients in their care, and their satisfaction with the clinical practice environment (CPE).We used Stata®19 for analysis. We used panel linear regression to investigate factors associated with the cohort's satisfaction with their clinical practice environments from 2018 to 2024, and logistic regression to evaluate the association between CPE and intention to leave in 2024. RESULTS:In 2024, the mean age of the cohort was 30.9 (± 2.0), the majority were female (74.4%) and working in urban areas (92.7%). In 2024, 59.7% of the overall cohort reported a heavy workload compared to 69.2% in 2018. Over the follow-up period, reported problems with the availability of medicines or equipment were worse in the public sector and in rural areas, compared to the private sector and urban areas respectively.The cohort's satisfaction score with the CPE was 6.7 out of 10 in 2018 and 6.9 in 2024. The predictors of CPE were year of follow-up, health profession, employment sector, and geographic location. Nurses (β=-1.2; 95% CI -1.7, -0.7; p < 0.001), and pharmacists (β=-0.7; 95% CI -1.1, -0.4; p < 0.001) scored their CPE significantly lower compared to the other professional groups. Health professionals in the public sector (β=-1.1; 95% CI -1.3, -0.9; p < 0.001) and in rural areas (β=-0.6; 95% CI -0.9, -0.3; p < 0.001) were less satisfied with their CPE compared to those in the private sector and urban areas respectively. Dissatisfaction with the CPE was significantly associated with intention to leave the workplace and the profession. CONCLUSION:The study findings underscore the need for positive clinical practice environments for early-career health professionals in South Africa both as a health workforce and patient safety imperative.
BACKGROUND:Although the acute care for the elderly (ACE) model has been studied in relation to activities of daily living (ADL), depressive symptoms, and quality of life, the pathways linking frailty with post-discharge quality of life remain insufficiently understood. This study examined whether ADL and depressive symptoms sequentially mediated the association between frailty and quality of life among elderly patients receiving acute care. METHODS:This retrospective cohort study with longitudinal follow-up included 11,231 elderly acute care patients from three large medical centers in Taiwan between January 1, 2020, and June 30, 2023. Frailty, ADL, depressive symptoms, and quality of life were assessed at admission and one year after discharge using the Clinical Frailty Scale, ADL scale, Geriatric Depression Scale, and EQ-5D-3L. Serial mediation and moderated mediation analyses were conducted using the PROCESS macro in SPSS version 23.0. RESULTS:One-year ADL and depressive symptoms sequentially mediated the association between admission frailty and one-year quality of life (indirect effect = 0.131, 95% CI 0.038∼0.231). Frailty scores significantly decreased and ADL scores improved from admission to one year after discharge (p < 0.05). Moderated mediation analyses showed that BMI, Charlson Comorbidity Index, alcohol use, nasogastric tube placement, and nutritional status modified specific mediation pathways (p < 0.001). CONCLUSION:Frailty among elderly patients receiving acute care was associated with post-discharge quality of life through pathways involving ADL and depressive symptoms. It supports comprehensive assessment and early post-discharge interventions targeting functional and psychological well-being, while recognizing that causal relationships cannot be established from observational data.
BACKGROUND:Organizational culture, defined as the shared values, assumptions, and norms that influence behavior within organizations, is widely recognized as a key determinant of patient safety in healthcare systems. Within acute care settings, medication safety represents a critical component of patient safety and depends on the ability of healthcare professionals to recognize risks, communicate openly, and intervene before errors result in patient harm. However, medication use is inherently interdisciplinary and requires effective coordination between multiple professional groups. Understanding how organizational culture influences medication safety practices across healthcare professions is therefore essential to inform governance, policy, and improvement strategies. This study aimed to achieve expert consensus on the organizational cultural factors influencing medication safety practices, barriers to medication error reporting, and strategies to strengthen medication safety in acute healthcare settings. METHODS:A modified electronic Delphi method was used to synthesize expert perspectives. A multidisciplinary panel of 41 healthcare professionals practicing in Malta's acute care system was invited to participate, including nurses, midwives, medical doctors, and pharmacists. In Round 1, participants completed an exploratory qualitative questionnaire consisting of three open-ended questions addressing cultural influences on medication safety, barriers to error reporting, and potential improvement strategies. Responses were analyzed using inductive content analysis, generating thematic categories that informed the development of 20 structured statements grouped into four domains: organizational safety culture and psychological safety; workforce and operational pressures; reporting culture and barriers; and strategies to strengthen medication safety. In Round 2, participants rated the importance of each statement using a five-point Likert scale. Consensus was predefined as ≥70% agreement. RESULTS:A total of 28 out of 41 healthcare professionals participated in Round 1 (68.3% response rate), including nurses (n = 15), midwives (n = 5), medical doctors (n = 5), and pharmacists (n = 3). Round 1 identified seven categories grouped into four domains, with blame culture emerging as a key barrier to medication error reporting. In Round 2 (n = 25/41; 61.0% response rate), consensus (≥70%) was reached for all but one statement. The strongest consensus centered on psychological safety, open communication, and adequate staffing. CONCLUSION:Findings indicate that medication safety is shaped primarily by organizational culture and systemic conditions rather than technical safeguards alone. Establishing a psychologically safe, non-punitive environment supported by engaged leadership and appropriate workforce conditions is fundamental for encouraging transparent reporting, organizational learning, and safer medication practices. These insights can inform policy development, organizational governance, and future research aimed at strengthening medication safety cultures in healthcare systems.
BACKGROUND:High-quality intrapartum care is essential for preventing avoidable maternal and neonatal morbidity and mortality. Although facility birth has expanded in Ethiopia, less is known about the observed content of care delivered during labour, birth and the immediate postpartum period in Dire Dawa Administration. METHODS:This secondary cross-sectional analysis used direct-observation and provider-survey data from a parent facility-based maternity-care study conducted in nine public health facilities in Dire Dawa Administration, Ethiopia. The facilities comprised two hospitals, five urban health centres and two rural health centres. Eligible women undergoing spontaneous vaginal birth were observed continuously from admission through childbirth and up to six hours postpartum or discharge. A total of 811 observations and data from 84 intrapartum-care providers were analysed. The observed quality of intrapartum care was measured with a structured 28-item checklist adapted from MCHiP/SMGL tools and WHO recommendations. Multilevel linear regression was used because observations were hierarchically clustered within providers and facilities. RESULTS:The mean observed intrapartum-care quality index was 48% (SD 29). Quality varied by stage of care: initial assessment 45%, first stage of labour 56%, second stage 26%, third stage 65%, immediate neonatal care 35% and early maternal postpartum care 42%. In adjusted analysis, health centres scored higher than hospitals (β = 5.50; 95% CI: 4.30 to 6.70), while rural facilities scored lower than urban facilities (β = -3.47; 95% CI: -5.49 to -1.44). Provider in-service training was positively associated with quality (β = 0.84; 95% CI: 0.34 to 1.34), whereas emergency or complication care was negatively associated with quality (β = -2.89; 95% CI: -4.42 to -1.36). CONCLUSION:Observed intrapartum care in public facilities in Dire Dawa Administration showed substantial quality gaps, particularly during the second stage of labour and immediate newborn and early postpartum care. The findings highlight uneven adherence to recommended clinical actions across facility type, facility location and care context.
BACKGROUND:Falls are among the most common adverse events in hospitalized patients, with about 30% leading to injury. We developed a machine learning model to predict which in-hospital fall events would lead to patient injury, thereby supporting post-fall risk stratification. METHODS:We retrospectively analyzed data from 410 patients who had experienced falls at a tertiary general hospital in China. Among them, 134 patients (32.7%) had fall-related injuries. The dataset was divided into training and test sets at a 7:3 ratio by outcome-stratified random sampling. Least absolute shrinkage and selection operator regression was used for feature selection to identify relevant predictors. Four machine learning models-logistic regression, random forest, extreme gradient boosting, and support vector machine-were developed and assessed. Model performance was evaluated in the test set using the area under the receiver operating characteristic curve, Brier score, and calibration curves. According to model performance, the optimal model was selected, and multivariable logistic regression analysis was then performed to determine independent risk factors. RESULTS:In the test cohort, the logistic regression model showed the strongest predictive ability (AUC = 0.863, 95% CI: 0.785-0.941; Brier score = 0.142). Five independent risk factors were detected, including impaired consciousness (OR = 3.35, 95% CI: 1.58-7.10), reduced muscle strength (OR = 3.93, 95% CI: 1.87-8.26), use of high-risk medications (OR = 10.07, 95% CI: 5.05-20.07), ward-related environmental hazards (OR = 3.30, 95% CI: 1.63-6.69), and hypocalcemia (OR = 2.10, 95% CI: 1.05-4.19). Based on this model, a nomogram was developed, and decision curve analysis indicated a positive net clinical benefit within the threshold probability range of 0.10-0.80. CONCLUSION:A prediction model based on five routinely collected clinical variables was developed to estimate fall-related injury risk after an in-hospital fall. The logistic regression model showed a favorable balance among predictive performance, calibration, interpretability, and clinical feasibility. This model may help support post-fall injury risk stratification, triage for further assessment, and monitoring decisions in hospitalized patients who have already experienced a fall.
BACKGROUND:Medication reconciliation is a key patient-safety process during transitions of care, but its routine documentation and associated medication-list findings are not well described in Saudi tertiary hospital practice. This study aimed to characterize medication reconciliation documentation, documented medication discrepancies, and documented medication-list modifications at King Saud University Medical City (KSUMC). METHODS:A retrospective observational study was conducted using routinely collected electronic health record data for hospitalized patients at KSUMC between June 2023 and June 2024. Eligible records contained the medication-related fields required for analysis, including home medications at admission, medications documented during hospitalization, medication reconciliation documentation status, documented discrepancy status, discharge medication information, and documented medication modification status. Patient-level outcomes used the study population denominator (N = 471), whereas medication-level modifications used the reviewed medication-record denominator (N = 2641). Descriptive statistics were calculated using R software (version 4.4.3). RESULTS:A total of 471 patients were included. Mean age was 46.1 years (SD 18.3), and 58.6% (276/471) were male. Medication reconciliation was documented in 20.8% (98/471) of records. The mean number of home medications at admission was 4.5 (SD 3.4), and the mean number of medications documented during hospitalization was 5.3 (SD 3.8). At least one documented medication discrepancy was identified in 3.8% (18/471) of patients. Documented medication modifications were recorded for 6.5% (172/2641) of reviewed medication records. CONCLUSION:Medication reconciliation was documented in only one-fifth of reviewed electronic records, indicating an important documentation gap in routine practice. The distinction between patient-level discrepancies and medication-level modifications should be maintained in future audits. More standardized electronic documentation, including a mandatory reconciliation checklist at admission and discharge, may improve the visibility and auditability of medication reconciliation at KSUMC.
BACKGROUND:Postnatal care (PNC) is essential for reducing maternal and neonatal morbidity and mortality, especially in countries like India, where healthcare inequities persist. This study investigates the use and determinants of quality postnatal care (QPNC) in India, using Andersen's Behavioral Model of Health Services Utilization. QPNC in this study refers to the receipt of recommended skilled, timely, and appropriate PNC components. METHODS:The study used data from the National Family Health Survey (NFHS)-5, comprising 163893 mother-newborn pairs. QPNC was operationalized using three dimensions: skilled care by qualified providers, timely first postnatal check-up within 24 hours, and receipt of essential postnatal interventions (e.g., cord examination, breastfeeding counselling, and other essential interventions). Multivariable logistic regression was applied to identify determinants of QPNC uptake, and secondary analyses examined determinants of each individual QPNC dimension. RESULTS:Only 49.8% of mother-newborn dyads received complete QPNC. Although 77.8% of mothers and 82.1% of newborns received timely postnatal check-ups, substantial gaps remained in essential care components such as cord examination (73.5%) and counselling on newborn danger signs (73.3%). Marked geographic disparities were observed, with Tamil Nadu (82.7%) and Andhra Pradesh (71.9%) reporting high QPNC utilization, whereas Nagaland (<9%), Bihar, Uttar Pradesh, and several northeastern states performed poorly. At the district level, 46 districts reported QPNC below 20%, mainly in Bihar and Nagaland. QPNC utilization was comparatively higher in private facilities and higher-tier public institutions. Maternal education (AOR = 1.08), wealth status (AOR = 1.20), health insurance (AOR = 1.24), media exposure (AOR = 1.25), ≥4 antenatal care visits (AOR = 1.79), and institutional delivery (AOR = 17.71) increased the likelihood of receiving QPNC. Larger household size (AOR = 0.93), healthcare access barriers (AOR = 0.92), and caesarean delivery were associated with lower QPNC utilization, while vaginal delivery was associated with higher odds of QPNC compared with caesarean delivery (AOR = 1.18). CONCLUSION:Substantial socioeconomic, institutional, and geographic disparities persist in QPNC utilization across India. Improving continuity and completeness of PNC requires strengthening maternal education, financial protection, healthcare infrastructure, and counselling support, particularly in underserved regions. Targeted district-level and facility-level interventions are essential to improve maternal and newborn health outcomes.
BACKGROUND:Whether delayed completion of discharge summary compromises patient safety following hospitalisation for community-acquired pneumonia remains unknown. The objectives of this study were to quantify the timeliness of discharge summary completion and to investigate the relationship between delayed completion of discharge summary and 30-day post-discharge outcomes. METHODS:As part of a cohort study conducted in France, we analysed a sample of 1004 patients (median age, 78 years) discharged alive after a hospitalisation for pneumonia. The primary outcome was defined as a composite adverse event outcome of death or unplanned readmission within 30 days of discharge. We performed inverse probability of treatment weighting analysis based on propensity score to estimate odds ratios (ORs) of 30-day post-discharge adverse events for patients for whom a discharge summary was not completed by the day of discharge. RESULTS:A summary was completed on the day of discharge for 305 patients (30%, 95% confidence interval [CI], 28 to 33). These patients were older, had more severe pneumonia on admission, and were more likely to exhibit impaired functional independence, receive ≥5 concomitant medications, necessitate advanced care and be clinically unstable at discharge. After inverse probability weighting, the 30-day estimates of post-discharge adverse events were 12% and 14% (OR, 1.12; 95% CI, 0.72 to 1.75), with unplanned readmission rates of 9.6% and 10% (OR, 1.09; 95% CI, 0.65 to 1.84) and all-cause mortality rates of 6.9% and 4.3% (OR, 0.61; 95% CI, 0.31 to 1.21) for patients with and without a summary completed on the day of discharge, respectively. CONCLUSIONS:Although this study found no association between delayed completion of discharge summaries and post-discharge adverse events, the availability of a discharge summary in the early follow-up period may enhance other aspects of the quality of care among survivors of hospitalisation for pneumonia.
BACKGROUND:A significant contributor to preventable medication-related harm is opioids. Within Australian hospitals, opioids have contributed to deaths, hospital admissions, and in-hospital related harm. Given these harms, there is a need to ensure opioids are used safely and that systems that support safe opioid use are in place and are effective. These should be monitored and when required, actions should be taken where a need for performance improvement is identified, or system change is warranted. Hence, the aim of this study was to develop a consensus-based suite of opioid-related safety and quality indicators (SQIs) that are evidence-informed, important and feasible for routine monitoring across an entire health service. METHODS:A structured search of the academic and grey literature was undertaken to identify relevant SQIs. A 22-member hospital-based multidisciplinary clinical reference group (CRG) participated in a modified Delphi multi-round electronic survey. Participants rated the importance and feasibility of each SQI on a 9-point Likert scale. Between survey rounds, participants were provided with an individualized report and a virtual meeting was held to enable group discussion on views relating to non-consensus indicators. Consensus was defined as a median score rated as high (i.e. >6.5) and a lower interquartile range not <5. RESULTS:In total, 121 articles were identified from the academic literature, seven within the grey literature and two procedures. After abstract and full-text review, nine articles/documents containing relevant SQIs were identified. There were 30 SQIs extracted and after rationalization, 23 SQIs were presented to participants. Survey round 1 participants proposed 11 additional indicators, resulting in a total of 34 indicators being considered by the CRG. There were 22 clinicians who expressed an interest in participating in the survey rounds and CRG meeting. Response rate for round 1 was 91% (n = 20), CRG meeting was 50% (n = 11) and survey round 2 was 77% (n = 17). In total, 17 indicators reached consensus for importance and feasibility. CONCLUSION:Consensus has been reached on 17 opioid-related SQIs which have been deemed important and feasible by a multidisciplinary CRG. Implementing these into practice will assist with monitoring and reporting of the effectiveness of opioid medication safety systems and identify improvement opportunities, ultimately enhancing patient safety.
BACKGROUND:The mortality rate of surgical patients in Africa is twice the global average. Pan-African studies have identified that this excess mortality is driven by deaths arising from postoperative complications. Preventable deaths can be reduced with enhanced monitoring in the postoperative period. This study reports on the first of a two-phase Quality Improvement (QI) programme, '5 Rs to Rescue', designed to reduce failure to rescue for surgical patients in Africa. METHODS:Using a QI approach, we co-produced a failure to rescue intervention with stakeholders across four African countries (Ethiopia, South Africa, Tanzania, and Uganda). These initial interventions were as follows: (i) Risk assessment using a validated tool, (ii) Recognition of patient deterioration using an early warning system (EWS), (iii) Response to patient deterioration (using locally defined protocols, (iv) Reassessment using an EWS, and (v) Reflection on care provided. These were tested and refined in clinical practice at nine hospitals through QI approaches. We interviewed frontline staff, project leaders, and QI advisors at the end of Phase 1 to learn from their experience to refine the intervention prior to Phase 2. Deductive thematic analysis was used, sensitized by constructs from the Consolidated Framework for Implementation Research (CFIR). RESULTS:We interviewed 11 frontline staff, seven national project leads and five QI advisors. From the CFIR-based coding, two cross-cutting, higher-order themes were developed to describe the participant's experience. Theme 1 centred around the substantial relational work involved in leading the 5Rs project. Surgeons reported the recurrent communication required to engage, train, and motivate all the necessary stakeholders. Surgical and nursing hierarchies were poorly linked in many settings, initially hampering these relational efforts. Theme 2 centred on the complexity of the 5Rs tools being introduced into complex, and already overstretched systems. A long period was required for nurses and doctors to become familiarized with the proposed '5Rs' tools. Although their value was broadly accepted, not all tools were a good fit for all the project settings. Potential solutions to overcome barriers identified in Phase 2 included a longer QI programme, more emphasis on involving nurse leaders and selection of a less complicated 'EWS' for detecting patient deterioration. CONCLUSION:Developing a multifaceted intervention that fits within complex, resource-limited contexts is a major challenge for efforts to improve patient care. This Phase 1 evaluation has provided actionable learning, targeting specific barriers, to be incorporated into an improved failure to rescue QI programme being developed in Phase 2.
BACKGROUND:National clinical registries are widely used to benchmark quality indicators and improve care. Advancing registry-based auditing toward learning health care systems (LHCS) requires structural integration of continuous evaluation and improvement cycles. One way to operationalize the check phase of the Plan-Do-Check-Act cycle is through best practice meetings (BPMs), in which health care professionals transparently discuss inter-hospital variation in clinical outcomes and formulate targeted improvement actions. Since 2018, the Dutch Institute for Clinical Auditing (DICA) has organized BPMs across multiple registries. This study provides the first descriptive overview of the structure, participant experiences, and facilitators and barriers to the organization and conduct of BPMs. METHODS:A descriptive mixed-methods study was conducted. Data on session characteristics (e.g. number, topics, format) and follow-up actions were obtained through a survey among coordinators of DICA registries. Participant satisfaction scores from evaluations of BPMs held between 2018 and 2025 were retrospectively extracted, where available. Semi-structured interviews were held with four registry coordinators and one project manager. Interviews were thematically analysed to identify facilitators and barriers to the organization and conduct of BPMs. RESULTS:In total, 55 BPMs were held across 14 registries. Most were national and multidisciplinary. Frequently discussed topics included length of stay, treatment waiting times, Textbook Outcome, and mortality. Best practices and/or quality improvement actions were formulated for 22 of 55 BPMs (40%). The mean participant satisfaction score was 4.0 on a 5.0-point Likert scale. Five themes were identified through thematic analysis of interviews: preparation, setting and format, learning climate, implementation, and cyclical learning. Facilitators included sharing data in advance, skilled moderation, an open and safe atmosphere, and recurring themes; barriers included an online setting that hampered interaction, concerns regarding data quality, and discussion of too many topics during a single meeting. CONCLUSION:BPMs appear to be a feasible and well-accepted instrument to support data-driven quality improvement across hospitals. Implementation of BPMs could support LHCS by operationalizing the learning cycle from benchmarking to shared learning, action planning, and follow-up. Future research should evaluate whether BPMs lead to implementation of improvement actions and measurable changes in clinical outcomes.
BACKGROUND:Gestational diabetes mellitus (GDM) is a major obstetric complication associated with adverse maternal and neonatal outcomes. Although the oral glucose tolerance test (OGTT) remains the diagnostic gold standard, its implementation is often constrained by logistical, financial, and infrastructural limitations, particularly in low- and middle-income countries. Point-of-care (POC) glucometers offer a rapid and accessible alternative; however, their diagnostic accuracy in pregnant populations remains uncertain. METHODS:This systematic review followed the Joanna Briggs Institute (JBI) methodology for diagnostic test accuracy reviews. Electronic databases including PubMed, EMBASE, and the Cochrane Library, as well as gray literature sources, were searched for studies published from 2013 to March 2025. Eligible studies included pregnant women screened for GDM using POC glucometers compared with OGTT as the reference standard. Data on diagnostic performance and methodological quality were extracted and assessed using JBI and QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tools. Due to substantial heterogeneity, findings were synthesized narratively. RESULTS:Six studies comprising 2856 pregnant women were included. Reported sensitivity ranged from 27.0% to 100%, while specificity ranged from 31.5% to 98.8%. Diagnostic performance varied widely depending on device type, enzymatic method, calibration of diagnostic thresholds, and pre-analytical handling. Studies employing validated enzymatic methods and calibrated capillary thresholds demonstrated higher accuracy, whereas unadjusted cut-offs and inconsistent procedures were associated with poor performance. CONCLUSION:Point-of-care glucometers may serve as alternative tools for GDM diagnosis in resource-constrained settings; however, their reliability is highly dependent on procedural rigor and threshold validation. Further standardized, high-quality studies are required before routine clinical adoption can be recommended.
