Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 17 appraisals
Journal of medical Internet research
Barriers and Facilitators to Implementing Digital Health Technologies for Remote Management of NCDs in Rural Areas: Mixed Methods Systematic Review
BACKGROUND: Digital health technologies (DHTs) have the potential to improve care delivery and outcomes for patients with noncommunicable diseases. Yet their implementation in rural settings remains uneven, and the factors influencing uptake are not well understood. OBJECTIVE: This mixed methods systematic review aimed to identify barriers and facilitators influencing the implementation and use of DHTs for remote management of noncommunicable diseases in rural areas. METHODS: We searched Medline, Embase, and CINAHL from inception to February 12, 2026, using terms related to digital health, noncommunicable diseases, and rural settings. Following the Joanna Briggs Institute methodology for mixed-method systematic review, we synthesized quantitative and qualitative studies. Barriers and facilitators were categorized using the Consolidated Framework for Implementation Research, and study quality was appraised using the Mixed Methods Appraisal Tool. RESULTS: From the initial 1491 records, 14 studies met the inclusion criteria, with most conducted in high-income countries (n=11). Key barriers included technical challenges (software instability and hardware issues), poor internet connectivity, financial constraints, and workforce constraints, such as staff shortages and heavy workloads. Key facilitators included user-friendly technology design, strong leadership, effective teamwork, and ongoing communication. Evidence was predominantly qualitative, with only limited quantitative data available. CONCLUSIONS: DHTs show promise for improving access and continuity of care for cardiovascular disease, hypertension, and diabetes in rural settings; however, their impact is constrained by structural inequities, including limited broadband access, workforce shortages, and financial fragility. These findings highlight important implications for research, policy, and practice, including the need for rigorous mixed methods evaluations sensitive to rural contexts, long-term equity-oriented financing mechanisms, and strengthened organizational readiness to support effective DHT uptake.
2 Aug 2026
Read appraisal →BMJ open ophthalmology
Screening for diabetic retinopathy with artificial intelligence in a primary care setting: a comparative cost analysis
OBJECTIVE: Cost analysis of autonomous artificial intelligence (AI)-based screening of diabetic retinopathy (DR) for adults with diabetes at a primary care clinic. METHODS AND ANALYSIS: This study provides a comparative cost analysis of actual results using AI-based DR screening with counterfactual results based on all patients going through the physician-based referral system. A cost analysis is conducted using cost data from published sources, provincial billing codes, statistical sources, and patient characteristics from a clinical study to compare autonomous AI-based screening for DR versus physician-based screening. Costs considered include direct costs of operating the AI system, physician fees, and indirect costs to patient time. Along with total cost comparisons, a cost per DR case detected is estimated and a sensitivity analysis based on variations in AI costs is provided. RESULTS: Over the study period, 202 participants were screened for DR using autonomous AI. The majority (93.6%, n=189) of AI-based DR screening exams were completed successfully. The AI-based scenario results in total direct costs of $C7919.04 and indirect costs of $C5728.80, resulting in total costs of $C13 647.84 per 100 patients. The traditional physician-based approach results in total direct costs of $C8240 and indirect costs of $C19 998.09, resulting in total costs of $C28 238.09 for 100 patients. When costs are converted to costs per unit outcome, the total cost per diagnosed DR case is $C620.36 for the AI-based approach and $C1283.55 for the physician-based approach; the AI-based cost per diagnosed case was 52% lower. CONCLUSION: Given the lower cost per diagnosed case of the AI-based approach, there are advantages to the implementation of AI-based screening for DR.
1 Aug 2026
Read appraisal →Preventing chronic disease
Reducing Rates of Cesarean Delivery in Rural US Communities: A Systematic Review of Interventions and Approaches to Care
INTRODUCTION: Cesarean deliveries are the most common major surgery in the US, with rates rising disproportionately in rural communities. While sometimes medically necessary, unnecessary cesarean births increase risks for maternal death, long-term complications, and intergenerational health effects that contribute to the burden of chronic disease. This systematic review examined studies describing interventions and approaches to care that reported outcomes related to reducing cesarean delivery rates in rural US communities. METHODS: We searched 4 databases in September 2025. Studies were eligible if they were conducted in rural US settings and reported cesarean-related outcomes associated with an intervention or care approach. We categorized interventions as patient level, provider level, or health system level. Two reviewers independently screened articles for inclusion, extracted data, and assessed study quality using the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. RESULTS: Nine studies met inclusion criteria. Of the 2 patient-level interventions, psychosocial education was associated with lower cesarean delivery rates (21% in intervention vs 40% in control), whereas a mobile health application showed only a marginal difference (27.1% among application users vs 27.7% among nonusers). None were categorized at the provider level. Seven interventions tested system-level models, primarily comparing hospitals with different staffing patterns; family medicine-led hospitals had lower rates of low-risk nulliparous, term, singleton, vertex cesarean delivery than hospitals staffed by both family medicine physicians and obstetricians (23% vs 28%), certified nurse-midwife-managed births had lower cesarean delivery rates than family medicine physician-managed births (8% vs 14%), and collaborative maternity care models integrating midwives, nurses, and obstetricians were associated with cesarean delivery rates declining from 26.2% to 11.2%. CONCLUSION: System-level approaches, particularly those that restructure maternity care teams, emphasize family medicine physician-led models, and integrate midwifery and culturally grounded childbirth practices, are more consistently associated with lower cesarean delivery rates in rural US settings than patient-level interventions alone. Future efforts to reduce unnecessary cesarean deliveries should prioritize strategies tailored to the variability of rural care capacity.
31 July 2026
Read appraisal →PloS one
The economic burden of Type 2 Diabetes by social determinants of health: A systematic review.
BACKGROUND: The unequal distribution of resources in society generates social gradients that translate into health inequalities and differential use of health care resources and their costs. Non-medical factors such as employment, income, ethnicity and education impact the prevalence and treatment outcomes of patients with type 2 diabetes mellitus (T2DM); however, there is a scarcity of articles assessing the relationship between health inequalities and the economic costs of treatment. Therefore, we conducted a systematic review of published studies examining the cost differences of treating T2DM across social determinants of health (SDH). METHODS: We systematically searched MEDLINE, Embase, PsycINFO, EconLit, and NHS EED for original peer-reviewed articles that provided cost differences of treating T2DM by SDH: education, income, employment, residency and ethnicity. We grouped the studies by each SDH and calculated the percentage differences where possible between the lowest and highest ends of the gradient (education, income and employment). Residency was categorised as rural vs. urban and ethnicity as white or general population vs other ethnic minorities. RESULTS: We included 19 articles retrieved internationally from varying healthcare systems. Results were contextualised given the healthcare financing model. In countries with high out-of-pocket expenses, Black and Hispanic ethnic backgrounds and rural residence were associated with lower direct health care and costs likely to be determined by ability to pay rather than clinical need. Indirect costs such as lost productivity due to absenteeism were also lower in unemployed, and lower income groups. CONCLUSIONS: There are evident health disparities in the direct and indirect economic consequences of T2DM. The effect of decreased healthcare use and costs on treatment outcomes needs to be further explored to inform policies to ensure healthcare delivery is based on clinical need rather than socio-economic factors.
28 July 2026
Read appraisal →Journal of radiation research
Prioritizing radiotherapy infrastructure in depopulating societies: a 2050 blueprint from Akita, Japan.
In super-aged and depopulating societies, repeated travel requirements for radiotherapy (RT) can amplify geographic inequities in access to advanced techniques. The aim of this study was to determine optimal placement of intensity-modulated radiotherapy (IMRT)-capable facilities in Akita Prefecture-a leading-edge case of Japan's demographic transition-using p-median optimization under population projections through 2050. Using 1-km mesh population data for 2020 and official projections for 2030, 2040 and 2050, we calculated one-way automobile travel times from each mesh centroid to RT facilities with the Open Source Routing Machine based on OpenStreetMap road data. A 60-min travel-time threshold defined access coverage. IMRT-capable facilities were identified from official insurance-designation lists. Optimal placement was determined using a population-weighted p-median model, with the number of facilities prespecified as one per 200 000 population. In 2020, 10 external-beam RT facilities provided near-universal 60-min coverage (99.99%; mean 12.8 min), whereas the single IMRT-capable facility covered only 70.3% (uncovered 285 273; mean 42.5 min). Optimized placement with five IMRT-capable facilities increased coverage to 99.99% (uncovered 89) and reduced mean travel time to 14.2 min. Under population projections, optimized placement maintained >99% coverage through 2050 with three facilities, and three core locations were consistently selected across all time horizons. These temporally stable core locations can serve as priority targets for long-term IMRT infrastructure investment in aging and depopulating regions.
27 July 2026
Read appraisal →Journal of medical Internet research
Digital Health Technologies Are Bridging the Maternal Mortality Gap
Disparities in maternal outcomes along socioeconomic, racial, ethnic, and geographic lines are well established. In this News and Perspectives article, JMIR Correspondent Anika Nayak reports on the growth and potential of digital health interventions in bridging the rural-urban maternal mortality gap.
26 July 2026
Read appraisal →Journal of robotic surgery
Safety and feasibility of robotic telesurgery in urological procedures: a systematic review and meta-analysis of clinical data
Robotic telesurgery has emerged as a potential solution to expand access to specialized surgical care; however, clinical evidence remains fragmented across procedures and robotic platforms. We conducted this meta-analysis to assess the feasibility and safety of robotic telesurgery across urological procedures. An electronic search was conducted on PubMed, Scopus, Web of Science (WoS) and the Cochrane Library from inception through April 2026 according to PRISMA guidelines. Clinical studies reporting robotic telesurgery in urology were included regardless of study design. The primary outcome of interest was procedural success, defined as completion without conversion to a local surgeon or an alternative surgical approach. Secondary outcomes included complication rates and round-trip latency (RTL). Nineteen studies involving 164 patients were included. The pooled procedural success rate was 0.92 (95% CI: 0.86-0.96). No conversions to open or laparoscopic surgery were reported across the included studies. The pooled complication rate was 0.12 (95% CI: 0.07-0.20), with events occurring in a limited number of studies. RTL data were available from 14 studies, with a pooled mean latency of 123.30 milliseconds (ms) (95% CI: 81.76-164.83) demonstrating substantial heterogeneity (I² = 99.99%). Robotic telesurgery in urology demonstrates excellent technical feasibility and a favorable short-term safety profile in carefully selected cases. However, variability in network performance and procedure-specific requirements remain important considerations. Further prospective studies with standardized reporting and long-term outcome assessment are needed before widespread clinical adoption can be recommended.
21 July 2026
Read appraisal →Journal of robotic surgery
The future of surgery in space exploration
Long-duration human space missions expose astronauts to microgravity, creating unprecedented surgical risks in environments where evacuation is impossible and communication delays limit real-time intervention. Understanding the feasibility and requirements of robot-assisted surgery in space is essential to ensure crew survival and mission continuity. A literature review was conducted using PubMed, Scopus, and aerospace medicine databases. Studies on surgical risks in spaceflight, robotic and tele-operated surgical systems, and translational applications were identified and thematically synthesized. Microgravity-induced physiological changes complicate surgical management. Anticipated emergencies include intra-abdominal pathologies, trauma, and craniofacial injuries. Miniaturized robotic systems with tele-mentored and semi-autonomous capabilities demonstrated feasibility in simulated and orbital environments, addressing constraints related to latency, sterility, and limited crew expertise. Translational applications include improved surgical access in remote, military, and low-resource settings on Earth. However, challenges remain in system reliability, training, ethics, and resource constraints. Robotic-assisted surgery represents a mission-critical capability for deep-space exploration and transformation for terrestrial surgical care. Integrated technological, training, and ethical frameworks are required to ensure safe tele-operated surgical interventions in extreme environments, improving global equity in surgical care.
21 July 2026
Read appraisal →JMIR cancer
AI-Enhanced Predictive Analytics to Optimize Tele-Oncology Implementation in Rural Settings: Scoping Review
BACKGROUND: Tele-oncology addresses geographic barriers to cancer care, but implementation challenges persist in rural settings. AI-enhanced predictive analytics offer opportunities for optimizing deployment through personalized, data-driven strategies; however, evidence in rural tele-oncology contexts remains limited, and critical equity considerations remain underexamined. OBJECTIVE: This scoping review aimed to map evidence on AI-enhanced predictive analytics in tele-oncology implementation, with particular attention to rural and underserved populations, to identify research gaps and inform implementation science priorities. METHODS: We searched 5 databases (PubMed, Embase, CINAHL, Web of Science, and IEEE Xplore) using 4 concept domains (tele-oncology, rural implementation barriers, AI or predictive analytics, implementation science) from January 2015 through November 2025. Two independent reviewers screened 330 unique records (title or abstract; Cohen κ=0.78), with the principal investigator resolving conflicts. Of 138 full-text reviews (κ=0.82), 4 studies met inclusion criteria. Data extraction captured study characteristics, AI applications, implementation factors, and outcomes. We used narrative thematic analysis to map findings into three themes: (1) the current tele-oncology implementation landscape in rural and underserved settings, (2) potential AI applications addressing implementation challenges, and (3) implementation considerations for AI systems themselves. RESULTS: Four included studies (1 pilot feasibility study, 1 proof-of-concept validation study, 1 cross-sectional predictive study, and 1 platform development study; published 2019-2025) demonstrated limited evidence at the intersection of AI, tele-oncology, and rural health equity. Patient characteristics predicted telehealth modality preferences with 86.2% accuracy, revealing that male patients exhibited 66% increased odds of video selection versus female patients (P=.004), and urban residents showed 101% increased odds compared to rural counterparts (P<.001). Liu et al demonstrated that disadvantaged populations engaged with AI-generated health literacy content 2.52-fold more frequently than nondisadvantaged counterparts. However, all 4 studies documented substantial implementation barriers (patient, provider, organizational, and system levels) persisting despite technological sophistication. Organizational threshold effects, where remote monitoring interventions succeeded with adequate provider capacity but failed under resource constraints-suggest that algorithmic innovations cannot overcome structural limitations in rural facilities. No studies explicitly examined algorithmic bias, cross-population validation, or potential harms in rural contexts. Geographic concentration in high-resource countries (United States n=2, Greece n=1, and Singapore n=1) and limited oncology-specific focus underscore structural gaps in knowledge generation for underserved populations. CONCLUSIONS: Current evidence remains insufficient to support definitive practice recommendations. The observed evidence gap may reflect broader structural inequities in knowledge generation: populations with the greatest implementation challenges appear to remain substantially underrepresented in AI and digital health literature. Future research should prioritize comparative effectiveness studies in authentic rural contexts with implementation science outcomes, equity-centered cross-population validation, specification of translation mechanisms linking AI predictions to implementation strategies, health economic analyses, and mechanistic research on sociotechnical integration factors, ensuring technological innovation reduces rather than perpetuates disparities in cancer care.
19 July 2026
Read appraisal →Transactions of the Royal Society of Tropical Medicine and Hygiene
Predicting challenges and opportunities in improving snakebite envenoming management in Ghana
BACKGROUND: Snakebite envenoming (SBE) is a neglected tropical disease and a major public health crisis in Africa. We integrated a maximum difference experimental design and machine learning (ML) models to predict challenges and opportunities for improving SBE management in Ghana. METHODS: This cross-sectional study included 137 healthcare workers, identified through multistage sampling, from August to December 2024 in two districts of the Eastern Region, Ghana. We employed five-fold cross-validation and analysed the dataset using 12 ML models. RESULTS: The most significant obstacle to managing SBE was 'delayed health-seeking behaviour by patients', followed by 'high cost of treatment' and 'inadequacy/shortage of antivenom'. On the opportunity side, 'increasing public awareness and knowledge about snakebite prevention and initial management before reaching a healthcare facility' was deemed crucial. Other opportunities such as 'conducting research into alternative management for snakebite to complement or replace antivenoms' and 'increasing awareness and knowledge about snakebite management among healthcare workers' were also recognized as trade-offs. CONCLUSIONS: This study significantly contributes to the existing research on artificial intelligence/ML, as previous studies have not quantified the challenges and opportunities in managing SBE. Policymakers and healthcare providers can use these findings to implement strategies such as promoting better health-seeking behaviours, subsidizing treatment costs, ensuring access to effective antivenom and raising public awareness about snakebite prevention and initial care.
9 July 2026
Read appraisal →The Tohoku journal of experimental medicine
At-Home Deaths and Regional Factors in Japan
In Japan, at-home deaths are not always popular, yet many people hope to spend their end-of-life at home, which makes this a socio-medical issue. Regional factors are associated with at-home deaths, but their relative importance has not been known. The present study investigated the relationship between at-home deaths and regional factors and ranked their importance at the municipal level in Japan. We used national open data on at-home deaths, population, medical resources, causes of death, economic factors and geographic factors as well as built the prediction model for at-home deaths using Extreme Gradient Boosting (XGBoost) regression. The Shapley Additive Explanations (SHAP) value was applied to rank the importance of regional factors and explain the XGBoost model. As a result, the median prevalence of at-home deaths across municipalities was 12.7%. A higher prevalence of at-home deaths was observed in large metropolitan areas such as Tokyo, Osaka, and Nagoya. SHAP values revealed that latitude was the most important factor in rank, followed by the number of clinics providing end-of-life care, longitude, population density, and population change rate. In conclusion, geographic and population-related factors were ranked highly among regional factors associated with at-home deaths. These findings may be informative for community planning to realize at-home deaths nationwide.
7 July 2026
Read appraisal →Telemedicine journal and e-health : the official journal of the American Telemedicine Association
Implementation and Evaluation of Virtual Care in Canadian Health Care Systems: A Scoping Review
OBJECTIVE: This scoping review examined available evidence in implementation and evaluation of virtual care in Canada. Virtual care saw recent uptake due to the COVID-19 pandemic; however, to ensure quality of care, rigorous implementation and evaluation frameworks are needed. METHODS: Peer-reviewed and gray literature were searched to determine extent, range, and nature of evidence surrounding implementation and evaluation of virtual care based on the guidelines of the Joanna Briggs Institute. Although virtual care can encompass synchronous and asynchronous modalities, this review focused on synchronous virtual care, defined as real-time interactions between patients and providers via videoconferencing or telephone. Search included MEDLINE, EMBASE, Psych Info, and CINAHL databases and national and provincial health system, professional organization, and regulatory websites. Inclusion criteria included videoconferencing or telephone and English and French Canadian sources. Citations were screened by two researchers at title, abstract, and full-text levels. RESULTS: Two hundred and eight (208) manuscripts were included for analysis. High numbers of studies on patient satisfaction, process outcomes, and barriers were identified, with underrepresentation of health and systems outcomes and impact evaluations. There were very few studies examining hybrid care, planetary health, and use of virtual care with equity-deserving groups. DISCUSSION: This scoping review identified areas of importance for future research, including the use of virtual care in rural and remote regions, inpatient, long-term, and emergency settings, hybrid care, economic and planetary health impacts, and artificial intelligence. As well, enhancing standardization of implementation and evaluation guidelines will optimize quality of care and best practice.
3 July 2026
Read appraisal →IEEE transactions on bio-medical engineering
EMI Cancellation for Shielding-Free Ultra-Low-Field MRI
OBJECTIVE: Ultra-Low-Field Magnetic Resonance Imaging (ULF MRI) offers low cost and portability but suffers from electromagnetic interference (EMI) in unshielded environments. This study developed a deep learning-based active EMI suppression method to overcome these limitations. METHODS: Using a 68mT ULF MRI system, human body coupling was identified as a primary EMI pathway. We proposed EMIC-Net, a U-Net architecture incorporating Transformer and hybrid attention mechanisms, to learn the data-driven nonlinear mapping from sensing coil signals to radio-frequency (RF) receiver coil interference. Acquired data underwent phase and gain compensation prior to model training. The model's efficacy was validated through in vivo human brain imaging, comparing its performance with EDITER and standard CNN methods, and by assessing the impact of varying EMI coil numbers and training data volumes. RESULTS: EMIC-Net effectively suppressed complex dynamic EMI. It restored image SNR from 2.35 dB to 17.63 dB, with significant PSNR and SSIM improvements. Image quality neared shielded acquisitions and surpassed comparative methods. Three EMI coils provided optimal balance, and the model showed data efficiency, requiring a small dataset for effective training. CONCLUSION: The EMIC-Net method accurately predicts and efficiently removes EMI in unshielded ULF MRI, offering superior performance and practicality. SIGNIFICANCE: This research promotes portable, low-cost ULF MRI for primary healthcare and bedside diagnosis. It also offers insights for mitigating complex EMI issues in other RF sensing domains.
2 July 2026
Read appraisal →Journal of robotic surgery
Telesurgery and remote surgery research: a bibliometric analysis of scientific growth, collaboration, and thematic evolution
Telesurgery and remote surgery have gained relevance in surgical innovation due to advances in robotics, telepresence, artificial intelligence, and high-speed communication networks. Despite this progress, the global evolution, collaborative structure, and thematic development of this field remain insufficiently characterized. A bibliometric study was conducted using records retrieved from Web of Science. Publications on telesurgery and remote surgery published up to 2025 were included. Bibliographic data were processed and analyzed using the bibliometrix package in R. Bibliometric indicators, citation metrics, country productivity, journal output, author contributions, collaboration networks, and keyword-based thematic patterns were assessed. A total of 476 publications on telesurgery were included, distributed across 290 journals. Scientific production showed sustained growth, with an annual growth rate of 20.59%, a mean document age of 6.06 years, and peak output in 2024. The average citation count was 28.54 citations per document. The United States and China were the leading contributors, with 151 and 120 publications, respectively, and also acted as the main hubs in the international collaboration network. The most cited studies focused on telerobotic systems for minimally invasive surgery, telerobotic neurovascular interventions, and ultra-reliable low-latency communications. Keyword analysis showed a progressive shift from early clinical feasibility and surgical applications toward connectivity, latency, robotic systems, extended reality, blockchain, and artificial intelligence. These trends indicate the transition of telesurgery from a clinically exploratory field to a technology-driven research domain. Telesurgery and remote surgery constitute a rapidly expanding and technologically driven research field. Future progress will require stronger international collaboration, real-world clinical validation, standardized outcome assessment, and strategies to reduce technological inequities across regions.
23 June 2026
Read appraisal →BMC research notes
Survey to evaluate clinical benefits and acceptance in international tele-intensive care unit collaboration
OBJECTIVES: Tele-intensive care unit (TICU) networks have evolved quickly in recent years and have proved their value in providing care for the critically ill. Objective measures to assess performance and quantify success e.g. clinical and economic outcome parameters are desirable but not easily accessible in international collaboration with very diverse clinical settings and legal prerequisites. Therefore, we initiated a study to evaluate the performance in our tele-intensive care unit network. METHODS: We conducted an online survey addressing clinical staff at ten spoke sites in four countries connected to one TICU hub to assess subjective clinical benefit, acceptance and potential for improvement. RESULTS: The majority of the 30 participants felt well supported clinically and personally, with a high acceptance and trust as well as a positive working relationship in tele-medical collaboration. Ethical principles and data protection were discovered to be persistently of utmost significance in tele-intensive care unit networks. CONCLUSION: International telemedicine in critical care is perceived positively without major differences between diverse health care systems when crossing borders, showing potential for improvement to guide future clinical and research approaches. Clinical trial registiry: The study was registered on August 11th, 2023 with the German Clinical Trials Register (DRKS-IDDRKS00032246; https://www.drks.de/search/de/trial/DRKS00032246/details ).
24 May 2026
Read appraisal →Oral and maxillofacial surgery
Early versus delayed management of maxillofacial fractures: a systematic review and meta-analysis with context-based subgroup analysis
PURPOSE: Maxillofacial fractures are common injuries caused by traffic accidents, interpersonal violence, and falls. In resource-limited or remote settings, definitive management is often delayed due to limited diagnostic facilities, lack of surgical expertise, and referral constraints, raising concerns about increased complication rates. The current literature reports conflicting results. Some studies suggest that delayed management does not significantly affect outcomes, whereas others show higher complication rates and functional impairment. Therefore, this review aims to identify the associations between delayed management and complications. METHODS: This review followed PRISMA guidelines and was registered in PROSPERO. Observational studies published between 2005 and 2025 were systematically retrieved from PubMed, Europe PMC, ScienceDirect, and OpenAlex. Thirteen studies met the inclusion criteria, with nine included in the meta-analysis. RESULTS: Pooled analysis demonstrated no statistically significant difference in overall complication rates between delayed and early management (RR 1.07; 95% CI 0.72-1.60; p = 0.72), with no evidence of substantial publication bias. CONCLUSION: Although no significant difference in the occurrence of complications was found between delayed and early management of maxillofacial fractures, there was a tendency for complications such as infection, malunion, or nonunion to occur more frequently in the delayed management group.
19 May 2026
Read appraisal →Journal of global health
Impact of travel time to health facilities on perinatal outcomes: a systematic review with narrative synthesis and meta-analysis
BACKGROUND: Evidence-based global guidance on safe travel time for small or sick newborns who require transfer to health facilities after birth is lacking. A two-hour threshold is frequently cited in low- and middle-income countries (LMICs), while 30 minutes is commonly used in high-income countries (HICs). Although these thresholds are widely referenced, their empirical basis and consistency across levels of newborn care and journey types have not been systematically examined. This study synthesises the evidence linking travel time and perinatal outcomes. METHODS: We conducted a systematic review with narrative synthesis and meta-analysis to assess the impact of travel time or distance (home-to-facility or interfacility) on stillbirth, perinatal mortality, and neonatal mortality. We searched Embase, MEDLINE, and Cochrane Central Register of Controlled Trials for published studies from 2014 to 2023. Given substantial methodological heterogeneity, we used narrative synthesis as the primary analytical approach and conducted random-effects meta-analyses where studies were sufficiently comparable (≥2 with similar definitions and outcome windows), pooling effect estimates for travel time thresholds of 30 minutes, 1 hour, or 2 hours and travel distances of 5, 10, and 15 km. We assessed bias using the Newcastle-Ottawa Scale for cohort and case-control studies. RESULTS: Of 8317 screened records, 166 were eligible for full-text review, with 37 studies meeting the inclusion criteria- All but two had low or moderate risk of bias. Most studies (n = 26) came from LMICs and documented higher perinatal survival with shorter journeys. Studies from HICs demonstrated lower out-of-hospital birth, lower morbidity, and lower mortality with shorter journeys though associations were weaker. Across the narrative synthesis, shorter travel times were consistently associated with better outcomes. Exploratory pooling suggested a greater than 3-fold higher odds of survival for interfacility journeys under 30 minutes (odds ratio (OR) = 3.25; 95% confidence interval (CI) = 1.90-5.57) and over 2-fold higher odds of survival for journeys from any location to hospitals at all thresholds (OR = 2.06; 95% CI = 1.60-2.65 for 2 hours; OR = 2.20; 95% CI = 1.46-3.33 for 1 hour; OR = 1.92; 95% CI = 1.10-3.34 for 30 minutes), though prediction intervals were wide, reflecting methodological and contextual diversity. CONCLUSIONS: We found that shorter journeys were associated with better perinatal outcomes, with the highest survival rates observed for journeys under 30 minutes to the hospital. Due to substantial contextual and methodological heterogeneity, pooled estimates should be interpreted as illustrative, rather than definitive. A travel time norm of 30 minutes or one hour is preferable to the two-hour threshold currently used in LMICs. To safeguard perinatal survival rates, any travel-time standard should be balanced with corresponding quality of care standards. REGISTRATION: PROSPERO: CRD42023460423.
16 May 2026
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