{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T20:55:04Z","timestamp":1786740904303,"version":"build-2736575974"},"reference-count":57,"publisher":"BMJ","issue":"12","license":[{"start":{"date-parts":[[2025,12,18]],"date-time":"2025-12-18T00:00:00Z","timestamp":1766016000000},"content-version":"unspecified","delay-in-days":17,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Innovation Fund of the German Federal Joint Committee","award":["01VSF16057"],"award-info":[{"award-number":["01VSF16057"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,11,25]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Geriatric patients are at increased risk of developing postoperative neurocognitive disorders, including delirium. Existing evidence-based perioperative interventions need to be implemented into routine care to improve postoperative outcomes. In this qualitative interview study, we wanted to collect stakeholder experiences to understand the implementation process of a multi-component intervention to prospectively facilitate future implementation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Descriptive qualitative evaluation research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Single-centre at a German major urban academic hospital.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>22 interviews were conducted with n = 7 geriatric patients after surgery who had received a comprehensive geriatric assessment and an individualised perioperative multi-component intervention, and n = 15 healthcare professionals, including nurses, physicians and medical assistants working in the perioperative care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>Semi-structured interviews were conducted, addressing the implementation procedure of the multicomponent intervention and the experience with it within the routine setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>The implementation outcomes were adoption, acceptance, appropriateness, feasibility and sustainability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Transcribed audio recordings were analysed with directed content analysis. Most intervention components could be adopted during the pilot trial. Implementation barriers were identified. Limited resources and logistic constraints threatened feasibility and sustainability. Acceptance of patients and healthcare providers regarding an intervention depended on its perceived appropriateness, which varied per intervention component, workspace and duration of the implementation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>We were able to replicate and extend previous findings on the implementation of improved perioperative care. To facilitate the implementation success and motivation to implement evidence-based measures, resource allocation needs to be adjusted and standard operational procedures, as well as the cross-sectional collaboration, must be simplified.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT03325413\">NCT03325413<\/jats:ext-link>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-104460","type":"journal-article","created":{"date-parts":[[2025,12,18]],"date-time":"2025-12-18T10:50:34Z","timestamp":1766055034000},"page":"e104460","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Evaluating the implementation process of a multicomponent perioperative intervention for prevention of postoperative functional decline in geriatric patients: a qualitative study"],"prefix":"10.1136","volume":"15","clinical-trial-number":[{"clinical-trial-number":"nct03325413","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6681-5152","authenticated-orcid":false,"given":"Lisa","family":"Lebherz","sequence":"first","affiliation":[{"name":"Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"},{"name":"Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9272-7386","authenticated-orcid":false,"given":"Cynthia","family":"Olotu","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Birgit","family":"Koch","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rainer","family":"Kiefmann","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"H\u00e4rter","sequence":"additional","affiliation":[{"name":"Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Levente","family":"Kriston","sequence":"additional","affiliation":[{"name":"Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,12,18]]},"reference":[{"key":"2026010703472337000_15.12.e104460.1","unstructured":"Statistisches Bundesamt (Destatis) . Pressemitteilung nr. 437: 7,1 millionen der 65-j\u00e4hrigen und \u00e4lteren personen in deutschland leben mit einer gesundheitlichen beeintr\u00e4chtigung. 2020. Available: https:\/\/www.destatis.de\/DE\/Presse\/Pressemitteilungen\/2020\/11\/PD20_437_231.html [Accessed 21 Nov 2024]."},{"key":"2026010703472337000_15.12.e104460.2","doi-asserted-by":"crossref","first-page":"3405","DOI":"10.2147\/JMDH.S431168","article-title":"Incidence and Factors Related to Prolonged Postoperative Cognitive Decline (POCD) in Elderly Patients Following Surgery and Anaesthesia: A Systematic Review","volume":"16","author":"Arefayne","year":"2023","journal-title":"J Multidiscip Healthc"},{"key":"2026010703472337000_15.12.e104460.3","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1007\/s40266-016-0413-y","article-title":"Practical Management of Anaesthesia in the Elderly","volume":"33","author":"Str\u00f8m","year":"2016","journal-title":"Drugs Aging"},{"key":"2026010703472337000_15.12.e104460.4","doi-asserted-by":"crossref","first-page":"2552","DOI":"10.1053\/j.jvca.2023.08.154","article-title":"Cognitive Deficits in Executive and Language Functions Predict Postoperative Delirium","volume":"37","author":"Olotu","year":"2023","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"2026010703472337000_15.12.e104460.5","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1016\/j.chest.2024.04.045","article-title":"Identifying Risk of Postoperative Cardiorespiratory Complications in OSA","volume":"166","author":"Azzopardi","year":"2024","journal-title":"Chest"},{"key":"2026010703472337000_15.12.e104460.6","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.15767"},{"key":"2026010703472337000_15.12.e104460.7","first-page":"3","article-title":"Potentially Inadequate Medications in the Elderly: PRISCUS 2.0","volume":"120","author":"Mann","year":"2023","journal-title":"Dtsch Arztebl Int"},{"key":"2026010703472337000_15.12.e104460.8","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1016\/j.ejso.2020.06.011","article-title":"From preoperative assessment to preoperative optimization of frail older patiens","volume":"47","author":"Carli","year":"2021","journal-title":"Eur J Surg Oncol"},{"key":"2026010703472337000_15.12.e104460.9","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aes139"},{"key":"2026010703472337000_15.12.e104460.10","unstructured":"Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (AWMF) . S3-leitlinie \u201evermeidung von perioperativer hypothermie\" \u2013 aktualisierung 2019. Available: https:\/\/www.awmf.org\/uploads\/tx_szleitlinien\/001018l_S3_Vermeidung_perioperativer_Hypothermie_2019-08.pdf [Accessed 23 Nov 2024]."},{"key":"2026010703472337000_15.12.e104460.11","doi-asserted-by":"publisher","DOI":"10.1016\/j.bja.2020.10.037"},{"key":"2026010703472337000_15.12.e104460.12","doi-asserted-by":"publisher","DOI":"10.1097\/EJA.0000000000001876"},{"key":"2026010703472337000_15.12.e104460.13","doi-asserted-by":"crossref","first-page":"e12","DOI":"10.1002\/bjs.10033","article-title":"Making the elderly fit for surgery","volume":"103","author":"Hulzebos","year":"2016","journal-title":"Br J Surg"},{"key":"2026010703472337000_15.12.e104460.14","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1016\/j.jgo.2020.04.011","article-title":"Implementation of a preoperative multidisciplinary team approach for frail colorectal cancer patients: Influence on patient selection, prehabilitation and outcome","volume":"11","author":"van der Vlies","year":"2020","journal-title":"J Geriatr Oncol"},{"key":"2026010703472337000_15.12.e104460.15","doi-asserted-by":"publisher","DOI":"10.1016\/j.anclin.2014.11.002"},{"key":"2026010703472337000_15.12.e104460.16","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2016.05.014"},{"key":"2026010703472337000_15.12.e104460.17","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1002\/clc.23302","article-title":"Perioperative care of the geriatric patient for noncardiac surgery","volume":"43","author":"Wolfe","year":"2020","journal-title":"Clin Cardiol"},{"key":"2026010703472337000_15.12.e104460.18","doi-asserted-by":"crossref","first-page":"1833","DOI":"10.1016\/j.jamda.2020.03.023","article-title":"Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis","volume":"21","author":"Thillainadesan","year":"2020","journal-title":"J Am Med Dir Assoc"},{"key":"2026010703472337000_15.12.e104460.19","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/s13741-020-0136-9","article-title":"Adherence to recommended practices for perioperative anesthesia care for older adults among US anesthesiologists: results from the ASA Committee on Geriatric Anesthesia-Perioperative Brain Health Initiative ASA member survey","volume":"9","author":"Deiner","year":"2020","journal-title":"Perioper Med"},{"key":"2026010703472337000_15.12.e104460.20","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-024-10665-1","article-title":"Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review","volume":"24","author":"Sontag","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"2026010703472337000_15.12.e104460.21","first-page":"3197","article-title":"Feasibility of a novel exercise prehabilitation programme in patients scheduled for elective colorectal surgery: a feasibility randomised controlled trial","volume":"28","author":"Northgraves","year":"2020","journal-title":"Support Care Cancer"},{"key":"2026010703472337000_15.12.e104460.22","doi-asserted-by":"crossref","first-page":"5930","DOI":"10.1080\/09638288.2021.1952319","article-title":"PREsurgery thoughts - thoughts on prehabilitation in oncologic gynecologic surgery, a qualitative template analysis in older adults and their healthcare professionals","volume":"44","author":"van der Zanden","year":"2022","journal-title":"Disabil Rehabil"},{"key":"2026010703472337000_15.12.e104460.23","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/j.jagp.2023.09.003","article-title":"A Perioperative Mental Health Intervention for Depressed and Anxious Older Surgical Patients: Results From a Feasibility Study","volume":"32","author":"Abraham","year":"2024","journal-title":"Am J Geriatr Psychiatry"},{"key":"2026010703472337000_15.12.e104460.24","doi-asserted-by":"crossref","unstructured":"Barnes K , Hladkowicz E , Dorrance K , et al . Barriers and facilitators to participation in exercise prehabilitation before cancer surgery for older adults with frailty: a qualitative study. BMC Geriatr 2023;23. doi:10.1186\/s12877-023-03990-3","DOI":"10.1186\/s12877-023-03990-3"},{"key":"2026010703472337000_15.12.e104460.25","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1016\/j.jgo.2019.05.001","article-title":"\u201cI am busy surviving\u201d - Views about physical exercise in older adults scheduled for colorectal cancer surgery","volume":"11","author":"Agasi-Idenburg","year":"2020","journal-title":"J Geriatr Oncol"},{"key":"2026010703472337000_15.12.e104460.26","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1016\/j.jclinane.2018.02.011","article-title":"Recommendations for Preoperative Management of Frailty from the Society for Perioperative Assessment and Quality Improvement (SPAQI)","volume":"47","author":"Alvarez-Nebreda","year":"2018","journal-title":"J Clin Anesth"},{"key":"2026010703472337000_15.12.e104460.27","doi-asserted-by":"publisher","DOI":"10.1007\/s10488-010-0319-7"},{"key":"2026010703472337000_15.12.e104460.28","doi-asserted-by":"crossref","unstructured":"Olotu C , Lebherz L , H\u00e4rter M , et al . Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study. BMJ Open 2019;9. doi:10.1136\/bmjopen-2019-031837","DOI":"10.1136\/bmjopen-2019-031837"},{"key":"2026010703472337000_15.12.e104460.29","doi-asserted-by":"crossref","unstructured":"Olotu C , Lebherz L , Mende A , et al . Feasibility and effectiveness of an evidence-based intervention bundle to improve peri-operative care of older adults: A quality improvement study. Eur J Anaesthesiol Intensive Care 2024;3. doi:10.1097\/EA9.0000000000000055","DOI":"10.1097\/EA9.0000000000000055"},{"key":"2026010703472337000_15.12.e104460.30","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzm042"},{"key":"2026010703472337000_15.12.e104460.31","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.g1687","article-title":"Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide","volume":"348","author":"Hoffmann","year":"2014","journal-title":"BMJ"},{"key":"2026010703472337000_15.12.e104460.32","doi-asserted-by":"publisher","DOI":"10.1093\/geront\/9.3_Part_1.179"},{"key":"2026010703472337000_15.12.e104460.33","doi-asserted-by":"publisher","DOI":"10.1080\/08870440903194015"},{"key":"2026010703472337000_15.12.e104460.34","doi-asserted-by":"publisher","DOI":"10.1007\/s10508-012-0016-6"},{"key":"2026010703472337000_15.12.e104460.35","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2288-13-117","article-title":"Using the framework method for the analysis of qualitative data in multi-disciplinary health research","volume":"13","author":"Gale","year":"2013","journal-title":"BMC Med Res Methodol"},{"key":"2026010703472337000_15.12.e104460.36","unstructured":"Dresing T , Pehl T , Schmieder C . Manual (on) transcription: Transcription conventions, software guides, and practical hints for qualitative researchers. 3rd edn.2015. Available: http:\/\/www.audiotranskription.de\/english\/transcription-practicalguide.htm [accessed 24 Nov 2024]."},{"key":"2026010703472337000_15.12.e104460.37","doi-asserted-by":"publisher","DOI":"10.1177\/1049732305276687"},{"key":"2026010703472337000_15.12.e104460.38","doi-asserted-by":"crossref","unstructured":"Wang T , Tan J-YB , Liu X-L , et al . Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. BMJ Open 2023;13. doi:10.1136\/bmjopen-2022-062158","DOI":"10.1136\/bmjopen-2022-062158"},{"key":"2026010703472337000_15.12.e104460.39","first-page":"64","article-title":"Forgone care and financial burden due to out-of-pocket payments within the German health care system","volume":"36","author":"Bremer","year":"2014","journal-title":"Health Econ Rev"},{"key":"2026010703472337000_15.12.e104460.40","doi-asserted-by":"crossref","unstructured":"Kumar A , Schoenstein M . Managing Hospital Volumes: Germany and Experiences from OECD Countries. OECD Health Working Papers 2013;64. Available: https:\/\/doi.org\/10.1787\/5k3xwtg2szzr-en","DOI":"10.1787\/5k3xwtg2szzr-en"},{"key":"2026010703472337000_15.12.e104460.41","doi-asserted-by":"crossref","unstructured":"Fuchs TI , Pfab C , Kiselev J , et al . Barriers and facilitators to the implementation of prehabilitation for elderly frail patients prior to elective surgery: a qualitative study with healthcare professionals. BMC Health Serv Res 2024;24. doi:10.1186\/s12913-024-10993-2","DOI":"10.1186\/s12913-024-10993-2"},{"key":"2026010703472337000_15.12.e104460.42","doi-asserted-by":"crossref","unstructured":"Thillainadesan J , Jansen J , Close J , et al . Geriatrician perspectives on perioperative care: a qualitative study. BMC Geriatr 2021;21. doi:10.1186\/s12877-021-02019-x","DOI":"10.1186\/s12877-021-02019-x"},{"key":"2026010703472337000_15.12.e104460.43","doi-asserted-by":"crossref","unstructured":"Lodge ME , Dhesi J , Shipway DJ , et al . The implementation of a perioperative medicine for older people undergoing surgery service: a qualitative case study. BMC Health Serv Res 2024;24. doi:10.1186\/s12913-024-10844-0","DOI":"10.1186\/s12913-024-10844-0"},{"key":"2026010703472337000_15.12.e104460.44","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13012-022-01245-0","article-title":"The updated Consolidated Framework for Implementation Research based on user feedback","volume":"17","author":"Damschroder","year":"2022","journal-title":"Implementation Sci"},{"key":"2026010703472337000_15.12.e104460.45","doi-asserted-by":"crossref","unstructured":"Waring J , Martin GP , Hartley P , et al . Implementing a perioperative care of older people undergoing surgery (POPS) service: findings from a multi-site qualitative implementation study. Age Ageing 2023;52. doi:10.1093\/ageing\/afad149","DOI":"10.1093\/ageing\/afad149"},{"key":"2026010703472337000_15.12.e104460.46","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1111\/ors.12435","article-title":"Breaking barriers: implementing evidence\u2010based practice","volume":"12","author":"Patel","year":"2019","journal-title":"Oral Surg"},{"key":"2026010703472337000_15.12.e104460.47","doi-asserted-by":"crossref","unstructured":"Wu M , Chen Z , Xu Y , et al . A qualitative study of geriatric specialist nurses\u2019 experiences to navigate delirium in the elderly. BMC Nurs 2024;23. doi:10.1186\/s12912-024-02100-x","DOI":"10.1186\/s12912-024-02100-x"},{"key":"2026010703472337000_15.12.e104460.48","doi-asserted-by":"crossref","first-page":"1375","DOI":"10.1007\/s12630-022-02298-x","article-title":"Identifying barriers and facilitators to routine preoperative frailty assessment: a qualitative interview study","volume":"69","author":"Hladkowicz","year":"2022","journal-title":"Can J Anesth\/J Can Anesth"},{"key":"2026010703472337000_15.12.e104460.49","doi-asserted-by":"crossref","DOI":"10.1186\/s13017-022-00471-7","article-title":"Perceptions and practices surrounding the perioperative management of frail emergency surgery patients: a WSES-endorsed cross-sectional qualitative survey","volume":"18","author":"Viswanath","year":"2023","journal-title":"World J Emerg Surg"},{"key":"2026010703472337000_15.12.e104460.50","doi-asserted-by":"crossref","unstructured":"Cowie J , Nicoll A , Dimova ED , et al . The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review. BMC Health Serv Res 2020;20. doi:10.1186\/s12913-020-05434-9","DOI":"10.1186\/s12913-020-05434-9"},{"key":"2026010703472337000_15.12.e104460.51","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-024-11388-z","article-title":"Bridging the gap: evaluation of preoperative patients\u2019 education by comparing expectations and real-perioperative surgical experiences: a mixed-methods descriptive cross-sectional study","volume":"24","author":"Ali","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"2026010703472337000_15.12.e104460.52","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.amjmed.2021.07.028","article-title":"Geriatric Preoperative Optimization: A Review","volume":"135","author":"Zietlow","year":"2022","journal-title":"Am J Med"},{"key":"2026010703472337000_15.12.e104460.53","doi-asserted-by":"crossref","unstructured":"Eamer G , Gibson JA , Gillis C , et al . Surgical frailty assessment: a missed opportunity. BMC Anesthesiol 2017;17. doi:10.1186\/s12871-017-0390-7","DOI":"10.1186\/s12871-017-0390-7"},{"key":"2026010703472337000_15.12.e104460.54","first-page":"326","article-title":"Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients","volume":"50","author":"Ron","year":"2024","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"2026010703472337000_15.12.e104460.55","doi-asserted-by":"publisher","DOI":"10.2147\/jmdh.S295549"},{"key":"2026010703472337000_15.12.e104460.56","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.1093\/ageing\/afab066","article-title":"Developing a virtual geriatric perioperative medicine clinic: a mixed methods healthcare improvement study","volume":"50","author":"Joughin","year":"2021","journal-title":"Age Ageing"},{"key":"2026010703472337000_15.12.e104460.57","doi-asserted-by":"crossref","unstructured":"Nathan N , Powell BJ , Shelton RC , et al . Do the Expert Recommendations for Implementing Change (ERIC) strategies adequately address sustainment? Front Health Serv 2022;2. doi:10.3389\/frhs.2022.905909","DOI":"10.3389\/frhs.2022.905909"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-104460","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T11:49:43Z","timestamp":1767786583000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-104460"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12]]},"references-count":57,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12,18]]},"published-print":{"date-parts":[[2025,12]]}},"alternative-id":["10.1136\/bmjopen-2025-104460"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-104460","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12]]}}}