BACKGROUND AND OBJECTIVES:Health-care faces increasing complexity in addressing multimorbidity, integrating social and medical care, and implementing innovative technologies. While complex interventions are increasingly used to address these challenges, their success heavily relies on proper implementation and evaluation. Process evaluations are crucial for understanding how interventions work in reality, yet they remain rather rare in health-care research. Despite growing attention to evaluation frameworks, inconsistent reporting and lack of transparency in process evaluation methodologies make it difficult for researchers to design and replicate these evaluations effectively. METHODS:The Checklist for RepOrting Process evaluations (CROP) was developed through a systematic two-phase approach. First, we created an initial rehabilitation-focused version based on literature analysis of process evaluations in rehabilitation, the Medical Research Council framework, and reporting guidelines for qualitative, implementation, and process evaluation evidence synthesis. Second, the checklist was refined through a five-round international online Delphi survey with experts in process evaluation and implementation research. Experts evaluated 31 initial items for relevance, clarity, and importance using four-point Likert scales. Content and face validity were assessed using validity indices. Expert feedback prompted expansion from rehabilitation-specific to health care-wide applicability from round 2 onward. RESULTS:The five-part Delphi study involved between eight and 11 experts participating in each round. Starting with 31 items, only nine initially achieved consensus on both clarity and relevance. From round 2 onward, importance was added as a third evaluation criterion. Through iterative refinement, scale content validity improved from 0.73-0.90 for clarity and remained high for relevance (0.93-0.96). Items achieving consensus on importance consistently paralleled relevance patterns. Face validity exceeded 0.80 from round 3 onward. The final CROP comprises 29 items achieving expert consensus (90%-100%) across all three dimensions and health care-wide appropriateness. Expert consensus confirmed the checklist's expansion from rehabilitation programs to broader health-care applications. CONCLUSION:The CROP achieved robust content validity and expert consensus, evolving from a rehabilitation-specific tool to provide the first standardized reporting instrument for process evaluations across health-care settings. This addresses a significant methodological gap and has potential to improve quality and transparency of process evaluation research, supporting researchers, practitioners, journal editors, and peer reviewers in health-care programs.

OBJECTIVE:Chronic pain patients experience more work disability leading to unemployment and major individual, societal and economic burden. Implanted neurostimulation has proven good results in terms of pain relief for chronic pain patients. As new stimulation techniques, paradigms and targets are being researched, a comprehensive synthesis of the effects of implanted neurostimulation on occupational outcomes remains undetermined. METHODS:MEDLINE (via PubMed), Embase, Scopus & Web of Science were systematically searched. Risk-of-bias was assessed using the modified Downs & Black checklist. Random-effects meta-analyses, including a Bayesian approach, were conducted to provide estimates of work status and return to work rates. The study protocol was prospectively registered on PROSPERO (CRD42024501152). RESULTS:67 studies were identified for inclusion in the review; 56 were included in the meta-analysis. The paired odds to work following neurostimulator implantation increased significantly (OR 5.17; 95%CI 2.89-9.23; I2=49.0%; n = 56; P < 0.0001) and were confirmed in the conservative random-effects (OR 3.39; 95%CI 2.00-5.75; n = 56; P < 0.0001) and Bayesian model with uniform prior (OR 5.68; 95%CI 3.08-11.79; n = 56). The pooled estimate for the proportion of patients returning to work across neurostimulation modalities was 26.05% (95%CI 20.73%-32.18%; I2=68.9%; n = 55). CONCLUSIONS:Implanted electrical neurostimulation is associated with increased paired odds to work and enabled chronic pain patients to return to work. The best effects were achieved following peripheral nerve stimulation and in patients suffering head-related pain.

BACKGROUND:Intrathecal drug delivery (IDD) offers a therapeutic option for patients suffering from refractory pain or severe spasticity. By allowing targeted and continuous infusion directly into the intrathecal space, IDD bypasses the blood-brain barrier and enhances therapeutic effectiveness of the drug. Following the implantation of an IDD pump, the most commonly performed postoperative maintenance procedure is the pump refill (at regular intervals). This process can be burdensome for patients, affects their comfort, and carries significant risks. The current aim of this study is to evaluate whether intrathecal pump refills performed at home provide a difference in patient comfort compared to refills conducted in the hospital. METHODS:The IMPROVE study is a monocentric, randomized controlled crossover trial, including 82 patients. For this study, each patient will undergo four intrathecal pump refill procedures (two at home and two in the outpatient clinic) allocated in a randomized order. The primary objective of this study is to determine whether at-home refills provide a difference in patient comfort compared to hospital-based refills. Secondary objectives include assessing differences in quality of life, pain, stress, anxiety, self-efficacy, caregiver burden, patient preferences, safety, and overall cost-effectiveness between the two settings. Patients will be followed over the course of four intrathecal pump refills, which is estimated to span approximately one year. DISCUSSION:Within the IMPROVE project, pump refills will be performed through hospital at home. If at-home intrathecal pump refills prove more comfortable for patients and cost-effective for society, this would strengthen the patient-centred care model and support adopting this approach as the new standard treatment for IDD patients. A graphical abstract is provided in the supplementary materials (S1 Fig). TRIAL REGISTRATION:Details on the study site can be found at ISRCTN with identifier: ISRCTN18031921; [href:https://doi.org/10.1186/ISRCTN18031921]https://doi.org/10.1186/ISRCTN18031921. The trial was registered in the ISRCTN registry on 18 November 2025.

Background:Chronic stroke and spinal cord injury (SCI) lead to persistent motor impairments that reduce independence and quality of life. Although rehabilitation is essential to address these challenges, the amount of therapy provided during the chronic phase remains limited, while the long-term costs of care are substantial. Objective:The INTeRAcT (Intensive Rehabilitation Programme Integrating Advanced Technology) trial investigates a high-dose, intensive-targeted, and personalized rehabilitation program through an integrated clinical, health economic, and process evaluation. Methods:This single-blind randomized controlled trial will include 100 adults in the chronic phase after stroke or SCI. Participants will be randomized to either the INTeRAcT intervention group (n=50) or a control group receiving usual care (n=50). The intervention group will receive 90 hours of personalized motor rehabilitation over 3 weeks, including upper and lower limb therapy, with and without technology, cardiovascular fitness training, and self-management education. Both groups then resume usual care and are followed for 9 months. Clinical assessments are performed at baseline (T0), after 3 weeks (T1, postintervention), and after 9-months follow-up (T2) by a blinded assessor. The primary outcome is independence in daily life, assessed using the Functional Independence Measure for stroke and the Spinal Cord Independence Measure for SCI. Secondary outcomes include the EQ-5D-5L, Canadian Occupational Performance Measure, Goal Attainment Scaling, Fatigue Severity Scale, and stroke-specific measures such as the Action Research Arm Test, Fugl-Meyer Assessment, 6-Minute and 10-Meter Walk-Test, and the Stroke Self-Efficacy Questionnaire. Group differences in clinical change will be analyzed using multivariate linear models. Health economic data will be collected using diaries and questionnaires, capturing direct and indirect costs. Cost-effectiveness will be assessed through a trial-based cost-utility analysis over 9 months and a Markov model over a lifetime horizon. The process evaluation follows the UK Medical Research Council framework, using mixed methods with quantitative and qualitative data from diaries, interviews, and observations, analyzed descriptively and thematically. Results:The funding of the project started in February 2023. Protocol version 5 (accepted March 15, 2024). Participant recruitment occurred between June 2023 and September 2024, with a total of 102 participants enrolled. Data collection ended in July 2025. Data analysis is ongoing. Conclusions:This protocol outlines a randomized controlled trial integrating clinical, health economic, and process evaluations to assess a high-dose, individualized rehabilitation program. The findings will provide evidence on effectiveness, cost-effectiveness, and implementation feasibility in chronic stroke and SCI, supporting the optimization of long-term neurorehabilitation care.

BACKGROUND:CME, or Continuing Professional Development, is essential for maintaining clinical competence and delivering evidence-based care. Rapid advances in neuromodulation, spanning medicine, engineering, and neuroscience create an ongoing need for specialized training. Founded in 1995, the European Continuing Medical Training (ECMT) organization offers an independent, ethically grounded model of education in this field. This study describes the strategic development, implementation, and outcomes of ECMT's programs over three decades. MATERIALS AND METHODS:We conducted a retrospective descriptive analysis of ECMT internal data, program records, participant evaluations, and accreditation documents from 1995 to 2025. Quantitative metrics (course counts, participant numbers, and Net Promoter Scores [NPS]) assessed activity volume and satisfaction. Qualitative content analysis of strategic plans, stakeholder feedback, and policy changes identified key trends and adaptation strategies. RESULTS:Since 1995, ECMT has delivered 637 courses to approximately 10,000 physicians globally, covering spinal cord stimulation, deep brain stimulation, intrathecal drug delivery, sacral nerve modulation, and other neuromodulation therapies. Participation stayed stable over time, including during the COVID-19 shift from in-person to hybrid and virtual formats. The overall median NPS was 81.5 (interquartile range 71.75-93), indicating consistently high satisfaction. After 2018 regulatory changes, ECMT moved from European-level to national accreditation while preserving independent certification. The Accelerated Fellows' Program, launched in 2019, strengthened blended learning and mentorship for neurosurgeons and anesthesiologists. CONCLUSIONS:Across three decades, ECMT has become a leading platform for independent, high-quality education in neuromodulation and neuroscience. Its sustained output and high satisfaction illustrate how mission-driven, nonprofit CME providers can adapt to technologic change, regulatory shifts, and global disruptions while maintaining educational quality and impact. Continued innovation in blended learning and strategic collaborations will support ECMT's ongoing contribution to lifelong medical learning and clinical excellence.

Abstract Background and aims Neurological conditions are a leading cause of long-term disability and rehabilitation needs. High-dose rehabilitation may improve persistent motor symptoms following stroke or spinal cord injury (SCI). We investigated the clinical and cost-effectiveness of the INTeRAcT treatment in adults in the chronic phase after stroke or SCI. Methods Participants were randomised to either the INTeRAcT treatment or usual care. INTeRAcT consisted of three weeks, 90-hour personalised, goal-directed motor rehabilitation, integrating rehabilitation technology, cardiovascular fitness and self-management. The primary outcome was the Functional-Spinal Cord Independence Measure (FIM-SCIM), and a secondary outcome was the goal attainment scale (GAS), both assessed at baseline (T0), after three weeks (T1) and nine months (T2). Analyses followed the intention-to-treat principle using multivariate linear models, with Cohen’s d effect sizes reported. Cost-effectiveness was assessed via trial-based cost-utility analysis over nine months from a healthcare perspective, applying a €50,000/QALY willingness-to-pay threshold. Results 101 participants (59 stroke – 42 SCI) were included. INTeRAcT (n=50) resulted in significant improvements compared to usual care (n=51) in FIM-SCIM from T0–T2 (mean difference (95% CI) = 4.1 (2.4–5.8), d=1.08), in GAS from T0–T1 (17.2 (13.9-20.5); d=3.1) and from T0–T2 (17.2 (13.0-21.5); d=2.1). No difference was observed for FIM-SCIM from T0–T1. The incremental cost-effectiveness ratio was €73,553/QALY. Conclusions INTeRAcT improved long-term independence in daily activities and the achievement of rehabilitation goals in the chronic phase after stroke and SCI, but was not cost-effective within nine months. The findings demonstrate clinical effectiveness; longer follow-up is needed to assess lifetime cost-effectiveness. Conflict of interest

Exposure to per- and poly-fluoroalkyl substances is associated with adverse health outcomes and may generate substantial healthcare and societal costs. This concept study presents an interdisciplinary framework that links epidemiological evidence, health economic modeling, and legal analysis to estimate the health-related costs of PFAS pollution and explore compensation under the polluter pays principle. The framework combines systematic evidence synthesis, pooled effect estimates, and population attributable fractions to quantify the disease burden attributable to PFAS exposure. These estimates are integrated into cost-of-illness analyses to assess preventive and curative healthcare costs, productivity losses, and wider societal impacts. Legal analysis, including hypothetical cases and existing compensation fund mechanisms, is used to examine how quantified health-related costs can inform liability and compensation approaches. By connecting scientific evidence, economic valuation, and legal reasoning, the framework supports evidence-informed policymaking and adaptable compensation mechanisms as knowledge on PFAS-related health effects develops.

Air pollution is the world’s greatest environmental health risk. Pollutants that pose large health concerns are particulate matter (PM2.5 and PM10), ozone (O3), carbon monoxide (CO), nitrogen dioxide (NO2), and sulphur dioxide (SO2). These compounds (especially PM2.5 and PM10) contribute to the onset of diseases, such as respiratory diseases (e.g., asthma, chronic obstructive pulmonary disease (COPD), or lung cancer) and cardiovascular diseases. Abatement interventions are implemented to reduce air pollution and thereby the risk of these diseases. This systematic review examined the published scientific evidence on the cost-effectiveness of strategies aimed at reducing or controlling air pollution and assessed the reporting quality of included studies. It employed rigorous data extraction and quality scoring procedures to ensure the reliability and validity of our findings. Overall, there is substantial evidence supporting the cost-effectiveness of interventions aimed at reducing air pollution. Seventy-four studies and four policy reports were included in this review. Predominantly, cost–benefit analyses have been reported (n = 40), reflecting the multisectoral impacts and associated costs of air pollution. Only four cost–utility analyses were found, indicating the need for more research within this domain. Additionally, eight articles reported one or more non-economic results. Thirty-nine studies focused on particulate matter (PM), and eleven focused on nitrogen oxides (NOx). The quality assessment yielded moderate results. The heterogeneity of studies and moderate quality of reporting make it difficult to compare results and draw definitive conclusions.

Introduction A considerable number of patients present with an upper limb impairment after stroke, which has a significant impact on daily life activities and quality of life. Currently, based on a Cochrane review, there is no high-quality evidence for any of the upper limb interventions used in routine practice. Therefore, the Jessa Hospital developed an additional arm-hand boost programme (AHA-BOOST), a novel, stratified intervention that integrates neurophysiological knowledge with an early start to optimise poststroke upper limb recovery.Methods and analysis This multicentre randomised controlled trial with parallel design compares AHA-BOOST with a dose-matched programme for the lower limbs. Both interventions are in addition to usual care and consist of a combination of group sessions (1 hour per day, 5 times per week) and individualised therapy (two 30 min sessions per week) provided over 4 weeks. In total, 80 subacute stroke patients will be recruited from five rehabilitation centres in Belgium and randomised to one of both interventions. Patients will be followed up until 12 months post stroke to support a cost-utility analysis and assess long-term clinical effects of the programme. Various outcomes are collected at different time points: preintervention, immediately post intervention, 3 months post intervention, 6 months post stroke and 12 months post stroke. The Action Research Arm Test is the clinical primary outcome. The secondary outcomes are: Fugl-Meyer assessment—upper extremity, Stroke Upper Limb Capacity Scale, Barthel Index, modified Rankin Scale, Stroke Impact Scale and EuroQoL 5D-5L (EQ-5D-5L). The clinical analysis includes a multivariate analysis of variance (MANOVA) analysis for comparing clinical changes between both groups and a subgroup analysis to explore the effects in different types of stroke survivors. Additionally, a process evaluation, guided by the Medical Research Council Framework, will assess key aspects of the implementation, including delivery (structures and resources), dose, reach, fidelity, adaptations, quality, mechanisms of change and the context. Both quantitative and qualitative data will be collected using the following tools during the intervention: therapy diaries for each session; video recordings of AHA-BOOST group sessions and after the intervention using: interviews with patients, therapists and management. The qualitative data will be assessed using content and thematic analysis and the quantitative data with descriptive statistics. Ultimately, in addition to the EQ-5D-5L, direct and indirect healthcare costs are collected for the health economic evaluation. A cost-utility analysis will be performed with a time horizon of 12 months post stroke comparing both therapies, and a Markov model will assess the cost-effectiveness of AHA-BOOST on a lifetime horizon. To test the robustness of the results, sensitivity and scenario analysis will be performed.Ethics and dissemination Ethical approval has been obtained by different ethical committees (UZ/KU Leuven (central committee), UZ Gent, Gasthuiszusters Antwerpen and Maria Middelares). The study will be performed in accordance with the protocol, current International Council for Harmonisation (ICH) and Good Clinical Practice (ICH-GCP) guidelines, and applicable regulatory requirements. The current approved protocol is version 5, dated 7 May 2025. Protocol amendments will be submitted to all involved ethical committees. The study results will be disseminated through peer-reviewed publications, conference presentations and stakeholder reports.Trial registration number NCT06517251.

Background Spillover effects of pain medication tapering (PMT) programs in patients with chronic pain (CP) are underexplored. This systematic review presents current research on the study of spillover effects of PMT in patients with CP and provides suggestions for examination of spillover effects in health economic research of PMT. Understanding spillover effects enable wide-ranging assessment of interventions, including its broader impacts. Methods Literature was searched up to September 2023 in Web of Science, PubMed, Scopus, Embase, PsychINFO, APA PsychNet, Cochrane library, Econlit, and grey literature sources including Google Scholar, CADTH, Mednar and the WHO website. QualSyst was used for Risk of bias assessment. The study protocol was registered prospectively in PROSPERO (CRD42023461763). Results were classified into five domains and incorporated into the expanded impact inventory framework. No funding was obtained. Results Of 2099 records initially identified, six qualitative studies of varying quality were included. In the healthcare domain, additional demands on healthcare delivery, patients switching between healthcare providers and psychosocial impacts for healthcare providers were key findings. Scientific spillovers entailed evidence-based recommendations, enhanced PMT awareness and knowledge dissemination. Sociological effects encompassed bias affecting underrepresented groups and community-level benefits. No spillovers were found in other categories. Future research should extend beyond patient-centered outcomes to comprehensively assess PMT’s societal impact and reveal indirect benefits currently underrepresented in the literature. Conclusions Spillover effects of PMT in patients with CP were identified. Considering spillovers can allow policymakers to optimize healthcare policies and resource allocation in healthcare. Inclusion of only six studies is a limitation of this study.

BackgroundPatient-level simulation (PLS) models overcome some major limitations of conventional cohort models and have broad applicability in healthcare, yet limited knowledge exists about their potential in cancer care.ObjectivesThis systematic review aims to: (1) describe the application areas of PLS models in cancer care, (2) identify commonly used model structures, (3) evaluate the quality of reporting based on established guidelines, and (4) critically discuss the potential and limitations of PLS models in this context.MethodsA systematic literature search was completed in Web of Science, PubMed, EMBASE and EconLit. Reasons underlying the use of PLS models were identified with a conventional inductive content analysis and reporting quality was assessed with an 18-item checklist based on the ISPOR-SMDM guidelines.ResultsThe number of publications increased over time and most studies used state-transition microsimulation (49.25%) or discrete event simulation (48.51%). Two main application areas could be discerned, namely disease progression modelling (DPM) (78.36%) and health and care systems operation (HCSO) (21.64%). In the DPM domain, the use of PLS models was mainly motivated by the need to represent patient heterogeneity and history. In the HCSO domain, PLS models were used to better understand and improve cancer care delivery. Average reporting quality was 65.2% and did not improve over time.ConclusionPLS models can be used to simulate the progression of cancer and to model cancer care delivery. In the DPM domain more direct comparisons with cohort models are required to establish the relative advantages of PLS models and in the HCSO domain the impact on clinical practice needs to be systematically assessed. Furthermore, adherence to the ISPOR-SMDM guidelines should be improved.

OBJECTIVE:Patients who have previously attempted suicide are at a substantially increased risk of a repeated attempt. We have conducted a cost-utility analysis of the Attempted Suicide Short Intervention Programme (ASSIP) and compared it with treatment as usual in a Flemish population. METHODS:A closed-cohort Markov-model was used to simulate suicide over a time-horizon of 20 years in a cohort of prior suicide attempt patients. This model is used to estimate Incremental Cost Effectiveness Ratios (ICERs) from societal and healthcare perspectives. A separate 'tipping-point' scenario was included, where the treatment effectiveness regresses over time. RESULTS:ASSIP is shown to be a dominant strategy from the societal perspective and cost-effective from a healthcare perspective: the ICER after 10 years is € 1,133 and after 20 years € 304. In the tipping-point scenario, an regression of up to 82,7% after the intervention remains cost-effective, assuming an ICER threshold of € 44000 per QALY. CONCLUSION:Our study found that ASSIP is cost-effective in the Flemish region, saving both healthcare costs and societal expenses over time. Implementing ASSIP could provide significant economic and health benefits within 10 years, making it a valuable investment for improving mental health care.

Objective: Patients with therapy-refractory chronic spinal pain after spinal surgery experience increased disability, resulting in substantial loss of employment and consequently lower quality of life. Despite findings that rehabilitation improves socio-economic outcomes in other chronic pain conditions, evidence for patients with chronic spinal pain after spinal surgery is limited. A systematic review was conducted to provide an overview of rehabilitation interventions and their effectiveness to improve work participation for patients with chronic spinal pain after spinal surgery. Methods: MEDLINE (via PubMed), Scopus, Embase, and Web of Science, were systematically searched. Risk of bias was assessed using the modified Downs and Black checklist and GRADE was used to assess certainty of evidence. The review protocol was prospectively registered on PROSPERO (CRD42022346091). Results: The search yielded 1,289 publications. Full-text screening of 48 articles resulted in the inclusion of 6 publications. The included interventions comprised multiple treatment components, consisting of back school, self-care, functional restoration, multidisciplinary rehabilitation, physiotherapy, and digital care programmes to improve work participation. Conclusion: Rehabilitation to improve return to work for patients with chronic spinal pain after spinal surgery was supported only by low-certainty evidence. Rehabilitation therapies that are personalized and that integrate the patient’s work seem most suitable.

BACKGROUND:Return to work (RTW) after cardiovascular diseases (CVDs) is crucial to mitigating the societal and economic burden of productivity losses. This review of reviews explores common and disease-specific predictors of RTW within the framework of the International Classification of Functioning, Disability, and Health (ICF). METHODS:A systematic review of systematic reviews was conducted to identify both common and disease-specific predictors of RTW for individuals with cardiovascular diseases (CVDs), including acute coronary syndrome (ACS), chronic coronary artery disease (CCAD), heart failure (HF), and stroke. Predictors were analysed across contextual domains (personal and environmental factors) and functional domains (body structure, body function, activities, and participation). The methodological quality of the included reviews was evaluated using the AMSTAR-2 tool. RESULTS:A total of 28 reviews were included. Key common predictors included functional capacity, psychological well-being, work characteristics and social support, while disease-specific predictors involved the severity of disease and treatment characteristics. Modifiable factors, such as workplace accommodation and psychological challenges, were identified as critical targets for intervention. CONCLUSIONS:Early identification of at-risk individuals and the integration of personalized rehabilitation strategies are critical for improving RTW outcomes and health-related quality of life. This review enhances the understanding of RTW predictors, contributing to optimized rehabilitation processes and reduced economic burden associated with CVDs. Future research should investigate the clinical applicability of these findings and explore the broader application of these common RTW predictors across other chronic conditions, to inform vocational reintegration strategies. (Word count: 238).

Environmental noise, a significant public health concern, is associated with adverse health effects, including cardiovascular diseases, cognitive impairments, and psychological distress. Noise reduction strategies are essential for mitigating these effects. Despite evidence of their health benefits, limited information exists on the cost-effectiveness of such strategies to guide resource allocation. This study systematically reviewed economic evaluation studies of interventions aimed at reducing environmental noise to assess their cost-effectiveness and inform policymaking. A systematic review following PRISMA 2020 guidelines was conducted across MEDLINE, EMBASE, and Web of Science. Eligible studies were full economic evaluations addressing environmental noise reduction strategies, assessing both costs and health effects. Screening and data extraction were performed independently by two reviewers. Quality appraisal employed the CHEERS 2022 checklist. Narrative synthesis was used to analyze findings due to heterogeneity in study designs, methodologies, and outcomes. Costs were standardized to 2024 euros. From 2906 identified records, five studies met the inclusion criteria, primarily focused on traffic-related noise. Three studies conducted cost-utility analyses, and two employed cost–benefit analyses. Reported interventions included sound insulation, take-off trajectory adjustments, and noise barriers. Economic evaluations varied significantly in methodologies, cost categories, and health outcomes. The health economic studies yielded mixed results, ranging from findings that demonstrated cost-effectiveness to those where the costs exceeded the benefits. There are currently too few health economic evaluations to draw robust conclusions about the cost-effectiveness of environmental noise mitigation strategies. Future research should adopt standardized approaches and robust sensitivity analyses to enhance evidence quality, enabling informed policy and resource allocation decisions.

BACKGROUND:Care pathways are increasingly used in healthcare systems globally to guide patient care and improve outcomes. These pathways offer a structured approach to managing patient care processes, potentially reducing costs and enhancing efficiency. However, the dynamic and complex nature of healthcare presents challenges in analyzing and improving these pathways, particularly due to the unique and varied patient journeys. This study focuses on the use of administrative data to map care pathways for pediatric Traumatic Brain Injury (TBI) patients, a population significantly impacted by high mortality and disability rates. OBJECTIVE:The objective of this research is to map and analyze care pathways using a novel methodology inspired by Hidden Markov chains. The study aims to overcome challenges in analyzing the dynamic and complex nature of the healthcare processes, particularly in a heterogeneous patient population. By using administrative data, the goal is to provide valuable insights into care pathways of these patients. METHODS:The study utilizes a study case dataset comprising of 4074 children admitted to Belgian hospitals for TBI in 2016, with administrative data encompassing healthcare services up to one-year post-TBI. The proposed methodology involves representing care pathways as Hidden Markov chains, where the transition between states is determined by the current medical treatment. Hierarchical clustering based on similarity of care paths, volume, and median timepoint is applied to identify subpopulations. RESULTS:Hierarchical clustering reveals distinct clusters, each characterized by unique care pathways. The clusters show variations in the length of care pathways, proportion of mild to severe cases, and vary with unique treatment events. Visualization of these pathways provides a comprehensive understanding of the treatment patterns within each cluster. CONCLUSION:The study introduces a novel methodology for mapping care pathways. Uncovering these different care pathways enhances the understanding of the variation in care and might lead to improving the quality of care received by patients.