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Zhong L, Lopez D, Pei S, Gao J. Healthcare system resilience and adaptability to pandemic disruptions in the United States. Nat Med 2024; 30:2311-2319. [PMID: 38956198 DOI: 10.1038/s41591-024-03103-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/31/2024] [Indexed: 07/04/2024]
Abstract
Understanding healthcare system resilience has become paramount, particularly in the wake of the COVID-19 pandemic, which imposed unprecedented burdens on healthcare services and severely impacted public health. Resilience is defined as the system's ability to absorb, recover from and adapt to disruptions; however, despite extensive studies on this subject, we still lack empirical evidence and mathematical tools to quantify its adaptability (the ability of the system to adjust to and learn from disruptions). By analyzing millions of patients' electronic medical records across US states, we find that the COVID-19 pandemic caused two successive waves of disruptions within the healthcare systems, enabling natural experiment analysis of the adaptive capacity of each system to adapt to past disruptions. We generalized the quantification framework and found that the US healthcare systems exhibit substantial adaptability (ρ = 0.58) but only a moderate level of resilience (r = 0.70). When considering system responses across racial groups, Black and Hispanic groups were more severely impacted by pandemic disruptions than white and Asian groups. Physician abundance was the key characteristic for determining healthcare system resilience. Our results offer vital guidance in designing resilient and sustainable healthcare systems to prepare for future waves of disruptions akin to COVID-19 pandemics.
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Affiliation(s)
- Lu Zhong
- Department of Computer Science, Rensselaer Polytechnic Institute, Troy, NY, USA
- Network Science and Technology Center, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Dimitri Lopez
- Department of Computer Science, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Sen Pei
- Department of Environmental Health Sciences, Columbia University, New York City, NY, USA
| | - Jianxi Gao
- Department of Computer Science, Rensselaer Polytechnic Institute, Troy, NY, USA.
- Network Science and Technology Center, Rensselaer Polytechnic Institute, Troy, NY, USA.
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2
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Bicher M, Zuba M, Rainer L, Bachner F, Rippinger C, Ostermann H, Popper N, Thurner S, Klimek P. Supporting COVID-19 policy-making with a predictive epidemiological multi-model warning system. COMMUNICATIONS MEDICINE 2022; 2:157. [PMID: 36476987 PMCID: PMC9729177 DOI: 10.1038/s43856-022-00219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In response to the SARS-CoV-2 pandemic, the Austrian governmental crisis unit commissioned a forecast consortium with regularly projections of case numbers and demand for hospital beds. The goal was to assess how likely Austrian ICUs would become overburdened with COVID-19 patients in the upcoming weeks. METHODS We consolidated the output of three epidemiological models (ranging from agent-based micro simulation to parsimonious compartmental models) and published weekly short-term forecasts for the number of confirmed cases as well as estimates and upper bounds for the required hospital beds. RESULTS We report on three key contributions by which our forecasting and reporting system has helped shaping Austria's policy to navigate the crisis, namely (i) when and where case numbers and bed occupancy are expected to peak during multiple waves, (ii) whether to ease or strengthen non-pharmaceutical intervention in response to changing incidences, and (iii) how to provide hospital managers guidance to plan health-care capacities. CONCLUSIONS Complex mathematical epidemiological models play an important role in guiding governmental responses during pandemic crises, in particular when they are used as a monitoring system to detect epidemiological change points.
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Affiliation(s)
- Martin Bicher
- grid.5329.d0000 0001 2348 4034Institute of Information Systems Engineering, TU Wien, Favoritenstraße 8-11, A-1040 Vienna, Austria ,dwh simulation services, dwh GmbH, Neustiftgasse 57-59, A-1070 Vienna, Austria
| | - Martin Zuba
- Austrian National Public Health Institute, Stubenring 6, A-1010 Vienna, Austria
| | - Lukas Rainer
- Austrian National Public Health Institute, Stubenring 6, A-1010 Vienna, Austria
| | - Florian Bachner
- Austrian National Public Health Institute, Stubenring 6, A-1010 Vienna, Austria
| | - Claire Rippinger
- dwh simulation services, dwh GmbH, Neustiftgasse 57-59, A-1070 Vienna, Austria
| | - Herwig Ostermann
- Austrian National Public Health Institute, Stubenring 6, A-1010 Vienna, Austria ,grid.41719.3a0000 0000 9734 7019Private University for Health Sciences, Medical Informatics and Technology GmbH, UMIT, Eduard-Wallnöfer-Zentrum 1, A-6060 Hall in Tirol, Austria
| | - Nikolas Popper
- grid.5329.d0000 0001 2348 4034Institute of Information Systems Engineering, TU Wien, Favoritenstraße 8-11, A-1040 Vienna, Austria ,dwh simulation services, dwh GmbH, Neustiftgasse 57-59, A-1070 Vienna, Austria ,Association for Decision Support Policy and Planning, DEXHELPP, Neustiftgasse 57-59, A-1070 Vienna, Austria
| | - Stefan Thurner
- grid.22937.3d0000 0000 9259 8492Section for Science of Complex Systems, Medical University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria ,grid.484678.1Complexity Science Hub Vienna, Josefstädterstraße 39, A-1080 Vienna, Austria ,grid.209665.e0000 0001 1941 1940Santa Fe Institute, 1399 Hyde Park road, Santa Fe, NM 87501 USA
| | - Peter Klimek
- grid.22937.3d0000 0000 9259 8492Section for Science of Complex Systems, Medical University of Vienna, Spitalgasse 23, A-1090 Vienna, Austria ,grid.484678.1Complexity Science Hub Vienna, Josefstädterstraße 39, A-1080 Vienna, Austria
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3
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Stress-testing the resilience of the Austrian healthcare system using agent-based simulation. Nat Commun 2022; 13:4259. [PMID: 35871248 PMCID: PMC9308034 DOI: 10.1038/s41467-022-31766-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractPatients do not access physicians at random but rather via naturally emerging networks of patient flows between them. As mass quarantines, absences due to sickness, or other shocks thin out these networks, the system might be pushed to a tipping point where it loses its ability to deliver care. Here, we propose a data-driven framework to quantify regional resilience to such shocks via an agent-based model. For each region and medical specialty we construct patient-sharing networks and stress-test these by removing physicians. This allows us to measure regional resilience indicators describing how many physicians can be removed before patients will not be treated anymore. Our model could therefore enable health authorities to rapidly identify bottlenecks in access to care. Here, we show that regions and medical specialties differ substantially in their resilience and that these systemic differences can be related to indicators for individual physicians by quantifying their risk and benefit to the system.
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4
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Luo A, Yu Z, Liu F, Xie W. The Chain Mediating Effect of the Public's Online Health Information-Seeking Behavior on Doctor-Patient Interaction. Front Public Health 2022; 10:874495. [PMID: 35719674 PMCID: PMC9201044 DOI: 10.3389/fpubh.2022.874495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This paper aims to explore the influence mechanisms of online health information-seeking behavior (OHISB) on doctor-patient interactions from a psychological perspective, using theory as a guide, which can effectively guide the mode of doctor-patient interaction after search behavior in China. Methods We conducted a convenient web-based survey among members of the public who engage in searching behavior in China using a pretested structured questionnaire. Structural equation modeling was performed for path analysis and mediating effect testing. Results The findings of the study show that (1) 4 control variables (education level, occupation, income, and diagnosed disease) had significant differences in online health information-seeking behavior; 7 control variables (age, gender, living area, education level, occupation, income, medical insurance) were significantly different in doctor-patient interaction behaviors. (2) perceived disease severity (95% CI: 0.003, 0.04, P < 0.001), perceived action benefits (95% CI: 0.059, 0.138, P < 0.001), and e-health literacy (95% CI: 0.061, 0.155, P < 0.001) were positive predictors between OHISB and doctor-patient interactions. (2) E-health literacy and perceived disease severity (95% CI: 0.001, 0.013, P < 0.05), and e-health literacy and perceived action benefits (95% CI: 0.082, 0.166, P < 0.001) play chain mediating roles between OHISB and doctor-patient interactions. Conclusions E-health literacy, perceived disease severity, and perceived action benefits act as chain mediators between OHISB and doctor-patient interactions.
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Affiliation(s)
- Aijing Luo
- The Third Xiangya Hospital of Central South University, Changsha, China.,The Second Xiangya Hospital of Central South University, Changsha, China.,Key Laboratory of Medical Information Research, College of Hunan Province, Central South University, Changsha, China.,School of Life Sciences, Central South University, Changsha, China
| | - Zhen Yu
- The Third Xiangya Hospital of Central South University, Changsha, China.,Key Laboratory of Medical Information Research, College of Hunan Province, Central South University, Changsha, China.,School of Life Sciences, Central South University, Changsha, China
| | - Fei Liu
- The Third Xiangya Hospital of Central South University, Changsha, China.,Key Laboratory of Medical Information Research, College of Hunan Province, Central South University, Changsha, China.,School of Life Sciences, Central South University, Changsha, China
| | - Wenzhao Xie
- The Third Xiangya Hospital of Central South University, Changsha, China.,Key Laboratory of Medical Information Research, College of Hunan Province, Central South University, Changsha, China.,School of Life Sciences, Central South University, Changsha, China
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Zurynski Y, Herkes-Deane J, Holt J, McPherson E, Lamprell G, Dammery G, Meulenbroeks I, Halim N, Braithwaite J. How can the healthcare system deliver sustainable performance? A scoping review. BMJ Open 2022; 12:e059207. [PMID: 35613812 PMCID: PMC9125771 DOI: 10.1136/bmjopen-2021-059207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic. OBJECTIVES We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured. DESIGN Scoping review of peer-reviewed articles and editorials published from database inception to February 2021. DATA SOURCES PubMed and Ovid Medline, and snowballing techniques. ELIGIBILITY CRITERIA We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS. DATA EXTRACTION AND SYNTHESIS After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts. RESULTS Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible. CONCLUSIONS To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems.
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Affiliation(s)
- Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, North Ryde, New South Wales, Australia
| | - Jessica Herkes-Deane
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Joanna Holt
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, North Ryde, New South Wales, Australia
| | - Elise McPherson
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Gina Lamprell
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Genevieve Dammery
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, North Ryde, New South Wales, Australia
| | - Isabelle Meulenbroeks
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, North Ryde, New South Wales, Australia
| | - Nicole Halim
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, North Ryde, New South Wales, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- NHMRC Partnership Centre for Health System Sustainability, Macquarie University, North Ryde, New South Wales, Australia
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Ismail SA, Bell S, Chalabi Z, Fouad FM, Mechler R, Tomoaia-Cotisel A, Blanchet K, Borghi J. Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view. Wellcome Open Res 2022; 7:151. [PMID: 38826487 PMCID: PMC11140310 DOI: 10.12688/wellcomeopenres.17834.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 06/04/2024] Open
Abstract
Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives - all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.
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Affiliation(s)
- Sharif A. Ismail
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Sadie Bell
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Zaid Chalabi
- Institute for Environmental Design and Engineering, University College London, London, WC1E 6BT, UK
| | - Fouad M. Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Reinhard Mechler
- Advanced Systems Analysis Program, International Institute for Applied Systems Analysis, Laxenburg, A-2361, Austria
| | - Andrada Tomoaia-Cotisel
- RAND Corporation, Santa Monica, 90401-3208, USA
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, University of Geneva, Geneva, 1211, Switzerland
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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7
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Arthur WB. Foundations of complexity economics. NATURE REVIEWS. PHYSICS 2021; 3:136-145. [PMID: 33728407 PMCID: PMC7844781 DOI: 10.1038/s42254-020-00273-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 05/05/2023]
Abstract
Conventional, neoclassical economics assumes perfectly rational agents (firms, consumers, investors) who face well-defined problems and arrive at optimal behaviour consistent with - in equilibrium with - the overall outcome caused by this behaviour. This rational, equilibrium system produces an elegant economics, but is restrictive and often unrealistic. Complexity economics relaxes these assumptions. It assumes that agents differ, that they have imperfect information about other agents and must, therefore, try to make sense of the situation they face. Agents explore, react and constantly change their actions and strategies in response to the outcome they mutually create. The resulting outcome may not be in equilibrium and may display patterns and emergent phenomena not visible to equilibrium analysis. The economy becomes something not given and existing but constantly forming from a developing set of actions, strategies and beliefs - something not mechanistic, static, timeless and perfect but organic, always creating itself, alive and full of messy vitality.
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Affiliation(s)
- W. Brian Arthur
- Santa Fe Institute, Santa Fe, NM USA
- Intelligent Systems Lab, PARC, Palo Alto, CA USA
- Stellenbosch Institute for Advanced Study, Stellenbosch, South Africa
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8
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Qi X, Mei G, Cuomo S, Xiao L. A network-based method with privacy-preserving for identifying influential providers in large healthcare service systems. FUTURE GENERATIONS COMPUTER SYSTEMS : FGCS 2020; 109:293-305. [PMID: 32296253 PMCID: PMC7157485 DOI: 10.1016/j.future.2020.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 05/31/2023]
Abstract
In data science, networks provide a useful abstraction of the structure of many complex systems, ranging from social systems and computer networks to biological networks and physical systems. Healthcare service systems are one of the main social systems that can also be understood using network-based approaches, for example, to identify and evaluate influential providers. In this paper, we propose a network-based method with privacy-preserving for identifying influential providers in large healthcare service systems. First, the provider-interacting network is constructed by employing publicly available information on locations and types of healthcare services of providers. Second, the ranking of nodes in the generated provider-interacting network is conducted in parallel on the basis of four nodal influence metrics. Third, the impact of the top-ranked influential nodes in the provider-interacting network is evaluated using three indicators. Compared with other research work based on patient-sharing networks, in this paper, the provider-interacting network of healthcare service providers can be roughly created according to the locations and the publicly available types of healthcare services, without the need for personally private electronic medical claims, thus protecting the privacy of patients. The proposed method is demonstrated by employing Physician and Other Supplier Data CY 2017, and can be applied to other similar datasets to help make decisions for the optimization of healthcare resources in the response to public health emergencies.
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Affiliation(s)
- Xiaoyu Qi
- School of Engineering and Technology, China University of Geosciences (Beijing), China
| | - Gang Mei
- School of Engineering and Technology, China University of Geosciences (Beijing), China
| | - Salvatore Cuomo
- Department of Mathematics and Applications, University of Naples Federico II, Italy
| | - Lei Xiao
- School of Engineering and Technology, China University of Geosciences (Beijing), China
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9
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Jovanović A, Klimek P, Renn O, Schneider R, Øien K, Brown J, DiGennaro M, Liu Y, Pfau V, Jelić M, Rosen T, Caillard B, Chakravarty S, Chhantyal P. Assessing resilience of healthcare infrastructure exposed to COVID-19: emerging risks, resilience indicators, interdependencies and international standards. ACTA ACUST UNITED AC 2020; 40:252-286. [PMID: 32837821 PMCID: PMC7271643 DOI: 10.1007/s10669-020-09779-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the moment of preparation of this paper, the world is still globally in grip of the Corona (COVID-19) crisis, and the need to understand the broader overall framework of the crisis increases. As in similar cases in the past, also with this one, the main interest is on the “first response”. Fully appreciating the efforts of those risking their lives facing pandemics, this paper tries to identify the main elements of the larger, possibly global, framework, supported by international standards, needed to deal with new (emerging) risks resulting from threats like Corona and assess the resilience of systems affected. The paper proposes that future solutions should include a number of new elements, related to both risk and resilience. That should include broadening the scope of attention, currently focused onto preparation and response phases, to the phases of “understanding risks”, including emerging risks, and transformation and adaptation. The paper suggests to use resilience indicators in this process. The proposed approach has been applied in different cases involving critical infrastructures in Europe (energy supply, water supply, transportation, etc., exposed to various threats), including the health system in Austria. The detailed, indicator-based, resilience analysis included mapping resilience, resilience stress-testing, visualization, etc., showing, already before the COVID-19, the resilience (stress-testing) limits of the infrastructures. A simpler (57 indicator based) analysis has, then been done for 11 countries (including Austria). The paper links these results with the options available in the area of policies, standards, guidelines and tools (such as the RiskRadar), with focus on interdependencies and global standards—especially the new ISO 31,050, linking emerging risks and resilience.
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Affiliation(s)
- A Jovanović
- EU-VRi European Risk & Resilience Institute, 70178 Stuttgart, Germany.,R-Tech Steinbeis Advanced Risk Technologies, Fangelsbachstr. 14, 70178 Stuttgart, Germany
| | - P Klimek
- Medical University Vienna, Vienna, Austria
| | - O Renn
- Institute for Advanced Sustainability Studies (IASS), Potsdam, Germany
| | | | - K Øien
- SINTEF, Trondheim, Norway
| | - J Brown
- ISO, Thales, Melbourne, Australia
| | - M DiGennaro
- Johanniter Unfallhilfe e.V., Frankfurt, Germany
| | - Y Liu
- Beijing Municipal Institute of Labor Protection (BMILP), Beijing, China
| | - V Pfau
- EU-VRi European Risk & Resilience Institute, 70178 Stuttgart, Germany
| | - M Jelić
- R-Tech Steinbeis Advanced Risk Technologies, Fangelsbachstr. 14, 70178 Stuttgart, Germany
| | - T Rosen
- R-Tech Steinbeis Advanced Risk Technologies, Fangelsbachstr. 14, 70178 Stuttgart, Germany
| | - B Caillard
- EU-VRi European Risk & Resilience Institute, 70178 Stuttgart, Germany
| | - S Chakravarty
- R-Tech Steinbeis Advanced Risk Technologies, Fangelsbachstr. 14, 70178 Stuttgart, Germany
| | - P Chhantyal
- R-Tech Steinbeis Advanced Risk Technologies, Fangelsbachstr. 14, 70178 Stuttgart, Germany
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