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Urine collection devices to reduce contamination in urine samples for diagnosis of uncomplicated UTI: a single-blind randomised controlled trial in primary care

Background Urine collection devices (UCDs) are being marketed and used in clinical settings to reduce urine sample contamination, despite inadequate supporting evidence. Aim To determine whether UCDs, compared with standardised instructions for urine sample collection, reduce the proportion of contaminated samples. Design and setting Single-blind randomised controlled trial in general practices in England and Wales. Method Women aged ≥18 years presenting with symptoms attributable to urinary tract infection (UTI) were randomised (1:1:1) to use either a Peezy UCD or a Whiz Midstream UCD, or were given standardised verbal instructions (SVI) for midstream sample collection. The primary outcome was the proportion of urine samples reported as contaminated by microbiology laboratory analysis. Results A total of 1264 women (Peezy UCD: n = 424; Whiz Midstream UCD: n = 421; SVI: n = 419) were randomised between October 2016 and August 2018. Ninety women were excluded from the primary analysis as a result of ineligibility or lack of primary outcome data, leaving 1174 (Peezy UCD: n = 381; Whiz Midstream UCD: n = 390; SVI: n = 403) for intention-to-treat analysis. The proportion of contaminated samples was 26.5% with the Peezy UCD, 28.2% with the Whiz Midstream UCD, and 29.0% with SVI (relative risk: Peezy UCD versus SVI = 0.91, 95% CI = 0.76 to 1.09, P = 0.32; Whiz Midstream UCD versus SVI = 0.98, 95% CI = 0.97 to 1.20, P = 0.82). There were 100 (25.3%) device failures with the Peezy UCD and 35 (8.8%) with the Whiz Midstream UCD; the proportion of contaminated samples was similar after device failure samples were excluded. Conclusion Neither the Peezy UCD nor the Whiz Midstream UCD reduced urine sample contamination when used by women presenting to primary care with suspected UTI. Their use cannot be recommended for this purpose in this setting.

Clinicians’ and patients’ experiences of managing heart failure during the COVID-19 pandemic: a qualitative study

Background Severe acute respiratory coronavirus 2 (SARS-CoV-2), also known as coronavirus disease 2019 (COVID-19), resulted in unprecedented societal and healthcare provision change, which has been implemented at pace. Little is known about the indirect impacts of these changes and what the future effects may be. Aim To explore patients’ and clinicians’ experiences of managing heart failure (HF) during the COVID-19 pandemic. Design & setting Qualitative study in three regions of the UK: Cambridgeshire, Greater Manchester, and the West Midlands. Method Semi-structured interviews (n = 30) were conducted with older adults with established HF and healthcare providers from primary and secondary health services involved in their care. Interviews were analysed thematically. Results Compliance with the government guidance ‘Stay at home, protect the NHS, and save lives’ during the COVID-19 pandemic, and perceptions relating to risk from COVID-19 and underlying morbidity, drove ‘being careful’ behaviours and organisational changes. Enacting behavioural change and implementing organisational change resulted in opportunities and challenges for health and healthcare practice. Conclusion Perception of risk led to significant behavioural and organisational change during the pandemic. Some changes described by both patients and clinicians, such as enhanced relationships and self-monitoring, present as opportunities, and consideration should be given as to how to maintain or develop these. Equally, indirect impacts of COVID-19 and the associated lockdown, such as disengagement and withdrawal, and the fallout from reluctance to access health services, should be acknowledged and interventions to address these challenges are needed.

Perspectives of young people who access support for mental health in primary care: a systematic review of their experiences and needs

Background There is an increasing demand for mental health support in primary care, especially for young people. To improve mental health support for young people in general practice, the needs of young people must be considered. Aim To explore the experiences of young people (aged 12–25 years) on receiving mental health care in primary care and identify the needs of young people who present with mental health concerns. Design and setting A systematic review and narrative synthesis. Method This was a systematic review and narrative synthesis. Six databases were searched for literature relating to young people’s experiences of receiving mental health care in primary care. Additional handsearching and manual internet searching were conducted. Narrative synthesis was employed. Results Five papers and a further two reports from manual internet searching were found, resulting in the inclusion of 1823 young people from four different countries (UK, US, Ireland, and Canada) for synthesis. The synthesis generated four themes: the centrality of a trusting relationship; showing empathy and taking concerns seriously; being given time to talk; and barriers to accessing mental health support in primary care. Conclusion Young people need a trusting relationship to discuss sensitive issues. To enable high-quality and effective mental health consultations with young people and the development of trust, GPs require unhurried consultations and the ability to maintain continuity of care.

Comparative effectiveness of statins on non-high density lipoprotein cholesterol in people with diabetes and at risk of cardiovascular disease: systematic review and network meta-analysis

Objective To compare the efficacy of different statin treatments by intensity on levels of non-high density lipoprotein cholesterol (non-HDL-C) for the prevention of cardiovascular disease in people with diabetes. Design Systematic review and network meta-analysis. Data sources Medline, Cochrane Central Register of Controlled Trials, and Embase from inception to 1 December 2021. Review methods Randomised controlled trials comparing different types and intensities of statins, including placebo, in adults with type 1 or type 2 diabetes mellitus were included. The primary outcome was changes in levels of non-HDL-C, calculated from measures of total cholesterol and HDL-C. Secondary outcomes were changes in levels of low density lipoprotein cholesterol (LDL-C) and total cholesterol, three point major cardiovascular events (non-fatal stroke, non-fatal myocardial infarction, and death related to cardiovascular disease), and discontinuations because of adverse events. A bayesian network meta-analysis of statin intensity (low, moderate, or high) with random effects evaluated the treatment effect on non-HDL-C by mean differences and 95% credible intervals. Subgroup analysis of patients at greater risk of major cardiovascular events was compared with patients at low or moderate risk. The confidence in network meta-analysis (CINeMA) framework was applied to determine the certainty of evidence. Results In 42 randomised controlled trials involving 20 193 adults, 11 698 were included in the meta-analysis. Compared with placebo, the greatest reductions in levels of non-HDL-C were seen with rosuvastatin at high (−2.31 mmol/L, 95% credible interval −3.39 to −1.21) and moderate (−2.27, −3.00 to −1.49) intensities, and simvastatin (−2.26, −2.99 to −1.51) and atorvastatin (−2.20, −2.69 to −1.70) at high intensity. Atorvastatin and simvastatin at any intensity and pravastatin at low intensity were also effective in reducing levels of non-HDL-C. In 4670 patients at greater risk of a major cardiovascular events, atorvastatin at high intensity showed the largest reduction in levels of non-HDL-C (−1.98, −4.16 to 0.26, surface under the cumulative ranking curve 64%). Simvastatin (−1.93, −2.63 to −1.21) and rosuvastatin (−1.76, −2.37 to −1.15) at high intensity were the most effective treatment options for reducing LDL-C. Significant reductions in non-fatal myocardial infarction were found for atorvastatin at moderate intensity compared with placebo (relative risk=0.57, confidence interval 0.43 to 0.76, n=4 studies). No significant differences were found for discontinuations, non-fatal stroke, and cardiovascular deaths. Conclusions This network meta-analysis indicated that rosuvastatin, at moderate and high intensity doses, and simvastatin and atorvastatin, at high intensity doses, were most effective at moderately reducing levels of non-HDL-C in patients with diabetes. Given the potential improvement in accuracy in predicting cardiovascular disease when reduction in levels of non-HDL-C is used as the primary target, these findings provide guidance on which statin types and intensities are most effective by reducing non-HDL-C in patients with diabetes. Systematic review registration PROSPERO CRD42021258819.

Rise in prescribing for anxiety in UK primary care between 2003 and 2018: a population-based cohort study using Clinical Practice Research Datalink

Background Little is known about trends in prescribing of anxiolytics (antidepressants, benzodiazepines, beta-blockers, anticonvulsants, and antipsychotics) for treatment of anxiety. Several changes may have affected prescribing in recent years, including changes in clinical guidance. Aim To examine trends in prescribing for anxiety in UK primary care between 2003 and 2018. Design and setting A population-based cohort study using Clinical Practice Research Datalink (CPRD) data. Method Analysis of data from adults (n = 2 569 153) registered at CPRD practices between 2003 and 2018. Prevalence and incidence rates were calculated for prescriptions of any anxiolytic and also for each drug class. Treatment duration was also examined. Results Between 2003 and 2018, prevalence of any anxiolytic prescription increased from 24.9/1000 person-years-at-risk (PYAR) to 43.6/1000 PYAR, driven by increases in those starting treatment, rather than more long-term use. Between 2003 and 2006, incidence of any anxiolytic prescription decreased from 12.8/1000 PYAR to 10.0/1000 PYAR; after which incidence rose to 13.1/1000 PYAR in 2018. Similar trends were seen for antidepressant prescriptions. Incident beta-blocker prescribing increased over the 16 years, whereas incident benzodiazepine prescriptions decreased. Long-term prescribing of benzodiazepines declined, yet 44% of prescriptions in 2017 were longer than the recommended 4 weeks. Incident prescriptions in each drug class have risen substantially in young adults in recent years. Conclusion Recent increases in incident prescribing, especially in young adults, may reflect better detection of anxiety, increasing acceptability of medication, or an earlier unmet need. However, some prescribing is not based on robust evidence of effectiveness, may contradict guidelines, and there is limited evidence on the overall impact associated with taking antidepressants long term. As such, there may be unintended harm.

Negotiating ‘the problem’ in GP home visits to people with dementia

Self-growth, wellbeing and volunteering - Implications for social prescribing: A qualitative study

Volunteering - the giving of time and support, without expectation of payment, for the good of others, a community or organization – may bring about benefits to health and wellbeing. Formal volunteering may be considered as part of a social prescription to which link workers may refer patients. This paper explores the role that volunteering may play as part of social prescribing by considering the impact it can have on health and wellbeing and highlighting factors that link workers may need to consider when connecting patients to volunteering opportunities. We conducted interviews with 22 museum volunteers to explore how volunteering affected their physical and emotional wellbeing, and consider the potential consequences of these experiences for social prescribing. We analysed the interviews using thematic analysis to develop a descriptive model of how volunteering may influence health and wellbeing through encouraging self-growth. Our analysis highlights that volunteering can provide “enabling environments” and opportunities for “stretch” and can contribute to people's health and wellbeing by improving their “sense of self”, “connection to others”, and “sense of community”. Our findings have implications for the use of volunteering as part of social prescribing and for volunteering organizations accepting social prescribing referrals to volunteering. These include the need to recognise the diverse needs of people receiving social prescribing and the need to tailor volunteering offers to these needs, as well as the need for link workers to be aware of the environments and support available to individuals at the volunteering organizations they are being referred to.

Unintended consequences of online consultations: a qualitative study in UK primary care

Background Health services are increasingly using digital tools to deliver care, and online consultations are being widely adopted in primary care settings. The intended consequences of online consultations are to increase patient access to care and increase the efficiency of care. Aim To identify and understand the unintended consequences of online consultations in primary care. Design and setting Qualitative interview study in eight general practices using online consultation tools in South West and North West England between February 2019 and January 2020. Method Thematic analysis of semi-structured interviews with 19 patients and 18 general practice staff. Results Consequences of online consultations were identified that restricted patient access to care by making it difficult for some patients to communicate effectively with a GP and disadvantaging digitally-excluded patients. This stemmed from patient uncertainty about how their queries were dealt with, and whether practices used online consultations as their preferred method for patients to contact the practice. Consequences were identified that limited increases in practice efficiency by creating additional work, isolation, and dissatisfaction for some staff. Conclusion Unintended consequences often present operational challenges that are foreseeable and partly preventable. However, these challenges must be recognised and solutions resourced sufficiently. Not everyone may benefit and local decisions will need to be made about trade-offs. Process changes tailored to local circumstances are critical to making effective use of online consultation tools. Unintended consequences also present clinical challenges that result from asynchronous communication. Online consultation tools favour simple, well-formulated information exchange that leads to diffuse relationships and a more transactional style of medicine.

Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) from pre and asymptomatic infected individuals. A systematic review

Background The role of SARS-Cov-2 infected persons who develop symptoms post-testing (presymptomatics) or not at all (asymptomatics) in the pandemic spread is unknown. Objectives To determine infectiousness and probable contribution of asymptomatic (at the time of testing) to pandemic SARS-CoV-2 spread. Data sources LitCovid, medRxiv, Google Scholar, and WHO Covid-19 databases (to 31 March 2021) and references in included studies. Study eligibility criteria Studies with a proven or hypothesized transmission chain based either on serial PCR cycle threshold readings and/or viral culture and/or gene sequencing, with adequate follow-up. Participants People exposed to SARS-CoV-2 within 2-14 days to index asymptomatic (at time of observation) infected individuals. Assessment of risk of bias Reliability of symptom and signs was assessed within contemporary knowledge; transmission likelihood was assessed using adapted causality criteria. Methods Systematic review. We contacted all included studies’ corresponding authors requesting further details. Results We included 18 studies from a diverse setting with substantial methodological variation (this field lacks standardized methodology). At initial testing, prevalence of asymptomatic cases was 12.5-100%. Of these, 6-100% were later determined to be presymptomatic, this proportion varying according to setting, methods of case ascertainment, and population. Nursing/care home facilities reported high rates of presymptomatic: 50-100% (n=3 studies). Fourteen studies were classified as high risk of, and four studies as at moderate risk of symptom ascertainment bias. High risk studies may be less likely to distinguish between presymptomatic and asymptomatic cases. Six asymptomatic studies and four presymptomatic studies reported culturing infectious virus; data were too sparse to determine infectiousness duration. Three studies provided evidence of possible and three of probable/likely asymptomatic transmission; five studies provided possible and two probable/likely presymptomatic SARS-CoV-2 transmission. Conclusions High-quality studies provide probable evidence of SARS-CoV-2 transmission from presymptomatic and asymptomatic individuals, with highly variable estimated transmission rates.

Statin treatment and LDL-cholesterol treatment goal attainment among individuals with familial hypercholesterolaemia in primary care

Objectives Guidance recommends statin treatment in familial hypercholesterolaemia (FH) to achieve at least a 50% reduction in low-density lipoprotein cholesterol (LDL-C). We assessed statin prescribing rates and LDL-C treatment goal attainment among individuals with FH in primary care. Methods Using primary care electronic health records from the UK Clinical Practice Research Datalink, we identified adults with recorded diagnosis of FH, statin treatment and measures of LDL-C prior to (baseline) and 12 months after initiating statin treatment. The percentage change in LDL-C was determined, and then baseline and treatment characteristics were assessed by LDL-C treatment goal attainment. Results Of 3064 adults (mean age 50.8 years) with recorded diagnosis of FH and repeat LDL-C measures, 50% reduction in LDL-C from baseline was attained in 895 individuals (29.2%) in 12 months. Compared with those who did not attain this goal, these people were predominantly women; they were older at time of FH diagnosis (53.4 years vs 49.7 years) and first statin treatment (53.2 years vs 49.2 years) and had higher pretreatment total cholesterol (8.20 (SD 1.38) mmol/L vs 7.57 (SD 1.39) mmol/L) and pretreatment LDL-C (5.83 (SD 1.36) mmol/L vs 5.25 (SD 1.40) mmol/L). A higher proportion of individuals who attained the treatment goal was prescribed high-potency and medium-potency statins (24.3% and 71.7% vs 20.2% and 69.3%, respectively). Conclusions Less than a third of individuals on statin treatment for FH in the community achieve recommended reductions in LDL-C. Greater awareness and optimisation of treatment for FH using higher-potency statins are needed.

Are we asking the right questions? Working with the LGBTQ+ community to prioritise healthcare research themes

Conversations about research priorities with members of the public who identify as Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) and are not researchers are not common. We reviewed published research priorities covering LGBTQ+ topics and held an online workshop. The review identified 18 LGBTQ+ research published priority sets. Some focussed on specific populations such as women or men, younger or older people or people living within families. Five were on transgender and gender nonconforming populations. Priorities were achieved by different methods such as workshops and surveys. People involved in setting priorities mostly included researchers, health practitioners and advocacy organisations, two studies involved LGBTQ+ public in their process. Research priorities identified in the review were grouped into themes which were prioritised during the workshop. For the online workshop, participants were recruited using local (Cambridge, UK) LGBTQ+ networks and a national advert and offered payment for their time. Participants personal priorities and experiences contributed to agreeing a final list of seven research themes in priority order. Participants’ experiences of healthcare, mental health advocacy, care homes, caring responsibilities, schools and family units were helpful. From the workshop the three top research themes were: healthcare services delivery, prevention, and particular and multiple challenges of people identifying as lesbian, gay, bisexual, transgender or queer. Research themes interconnected in many ways as shown by the comments from workshop participants. This paper describes why these priorities were important from participants’ perspective and offers information about how to run an inclusive and respectful public involvement research exercise.

Rheumatic Conditions as Risk Factors for Self-Harm: A Retrospective Cohort Study

Objective To examine the risk of self-harm in rheumatic conditions. Methods We conducted a retrospective cohort study using data from the Clinical Practice Research Datalink. Patients with ankylosing spondylitis, fibromyalgia, osteoarthritis, or rheumatoid arthritis were identified from 1990 to 2016 and matched to patients without these conditions. Incident self-harm was defined by medical record codes following a rheumatic diagnosis. Incidence rates (per 10,000 person-years) were reported for each condition, both overall and year-on-year (2000–2016). Cox regression analysis determined risk (hazard ratio [HR] and 95% confidence interval [95% CI]) of self-harm for each rheumatic cohort compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by age and sex. Due to nonproportionality over time, osteoarthritis was also stratified by disease duration (<1 year, ≥1 to <5 years, ≥5 to <10 years, and ≥10 years). Results The incidence of self-harm was highest in patients with fibromyalgia (HR 25.12 [95% CI 22.45–28.11] per 10,000 person-years) and lowest for osteoarthritis (HR 6.48 [95% CI 6.20–6.76]). There was a crude association with each rheumatic condition and self-harm, except for ankylosing spondylitis. Although attenuated, these associations remained after adjustment for fibromyalgia (HR 2.06 [95% CI 1.60–2.65]), rheumatoid arthritis (HR 1.59 [95% CI 1.20–2.11]), and osteoarthritis (1 to <5 years HR 1.12 [95% CI 1.01–1.24]; ≥5 to <10 years HR 1.35 [95% CI 1.18–1.54]). Age and sex were weak effect modifiers for these associations. Conclusion Primary care patients with fibromyalgia, osteoarthritis, or rheumatoid arthritis (but not ankylosing spondylitis) are at increased risk of self-harm compared to people without these rheumatic conditions. Clinicians need to be aware of the potential for self-harm in patients with rheumatic conditions (particularly fibromyalgia), explore mood and risk with them, and offer appropriate support and management.

Use of menopausal hormone therapy and risk of dementia: nested case-control studies using QResearch and CPRD databases

Objective To assess the risks of developing dementia associated with different types and durations of menopausal hormone therapy. Design Two nested case-control studies. Setting UK general practices contributing to QResearch or the Clinical Practice Research Datalink (CPRD), using all links to hospital, mortality, and social deprivation data. Participants 118 501 women aged 55 and older with a primary diagnosis of dementia between 1998 and 2020, matched by age, general practice, and index date to 497 416 female controls. Main outcome measures Dementia diagnoses from general practice, mortality, and hospital records; odds ratios for menopausal hormone treatments adjusted for demographics, smoking status, alcohol consumption, comorbidities, family history, and other prescribed drugs. Results Overall, 16 291 (14%) women with a diagnosis of dementia and 68 726 (14%) controls had used menopausal hormone therapy more than three years before the index date. Overall, no increased risks of developing dementia associated with menopausal hormone therapy were observed. A decreased global risk of dementia was found among cases and controls younger than 80 years who had been taking oestrogen-only therapy for 10 years or more (adjusted odds ratio 0.85, 95% confidence interval 0.76 to 0.94). Increased risks of developing specifically Alzheimer’s disease were found among women who had used oestrogen-progestogen therapy for between five and nine years (1.11, 1.04 to 1.20) and for 10 years or more (1.19, 1.06 to 1.33). This was equivalent to, respectively, five and seven extra cases per 10 000 woman years. Detailed risk associations for the specific progestogens studied are also provided. Conclusion This study gives estimates for risks of developing dementia and Alzheimer’s disease in women exposed to different types of menopausal hormone therapy for different durations and has shown no increased risks of developing dementia overall. It has shown a slightly increased risk of developing Alzheimer’s disease among long term users of oestrogen-progestogen therapies.

‘'Ethno…graphy?!? I can't even say it”: Co-designing training for ethnographic research for people with learning disabilities and carers

Background There is a strong ethical case and an urgent need for more participatory research practices in disability research but a lack of resources to support this. It is important to involve people with learning disabilities and carers at all stages, including when designing training for co-research. Methods We co-developed training materials to support people with learning disabilities and carers to work as ethnographic co-researchers and for academic researchers to facilitate co-research. We focused on what people with learning disabilities and carers thought was important to learn. Findings Whilst not all types of research methods are easy to democratise, ethnographic observation is a research method that lends itself well to participatory co-research. Conclusions For people to be able to meaningfully participate, research processes need to become more accessible and transparent. Training that considers the needs and priorities of people with learning disabilities and carers and addresses the confidence gap is key for meaningful co-research.

Trends in the recording of anxiety in UK primary care: a multi-method approach

Purpose Anxiety disorders are common. Between 1998 and 2008, in the UK, GP recording of anxiety symptoms increased, but the recording of anxiety disorders decreased. We do not know whether such trends have continued. This study examined recent trends in the recording of anxiety and explored factors that may influence GPs’ coding of anxiety. Methods We used data from adults (n = 2,569,153) registered with UK general practices (n = 176) that contributed to the Clinical Practice Research Datalink between 2003 and 2018. Incidence rates and 95% confidence intervals were calculated for recorded anxiety symptoms and diagnoses and were stratified by age and gender. Joinpoint regression was used to estimate the years trends changed. In addition, in-depth interviews were conducted with 15 GPs to explore their views and management of anxiety. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Results The incidence of anxiety symptoms rose from 6.2/1000 person-years at risk (PYAR) in 2003 to 14.7/1000 PYAR in 2018. Between 2003 and 2008, the incidence of anxiety diagnoses fell from 13.2 to 10.1/1000 PYAR; markedly increasing between 2013 and 2018 to 15.3/1000 PYAR. GPs mentioned that they preferred using symptom codes to diagnostic codes to avoid assigning potentially stigmatising or unhelpful labels, and commented on a rise in anxiety in recent years, especially in young adults. Conclusion Recent increases in the recording of both anxiety diagnoses and symptoms may reflect increased presentation to primary care, especially in young adults. There is a clear need to understand the reasons for this, and this knowledge may be critical in the prevention and treatment of anxiety.

Brief Mindfulness-Based Interventions: Teacher and Course Attendee Perspectives on Content

Objectives While brief mindfulness-based interventions (MBIs) show promise, stakeholder involvement in their design is lacking and intervention content can vary substantially. The aim of this study is to explore stakeholder perspectives of brief MBIs, brief MBI content, and adapting existing MBIs. Methods In this convergent mixed methods design study, 22 mindfulness teachers and 20 mindfulness course attendees completed an online UK-based survey. Twenty-six participants were female, and mean age was 50.8 years. Data from closed questions were analysed using descriptive and inferential statistics, and data from open questions were analysed using reflexive thematic analysis. Results Findings suggest a brief MBI could comprise five 80-min sessions and include focused attention practice, informal mindfulness, inquiry, psychoeducation, and 20 min of daily home practice. Opinions of some elements differed among participants, such as the body scan, poetry, and the sitting with difficulty practice. Four themes were generated from participants’ comments about their attitudes to brief MBIs, which were generally positive but expressed concerns about insufficient content and poor delivery. Three themes were generated about adapting MBIs, suggesting tensions between adhering to a curriculum and meeting group needs. Five themes were generated from views about the content and characteristics of MBIs, highlighting the importance of accessibility, teacher training, and participant safety. Conclusions Brief MBIs may increase access to mindfulness training, yet there is a need for adequate governance and transparency regarding their strengths and limitations. Clarity and evidence of MBI mechanisms along with scientific literacy in teachers will support fidelity-consistent modifications.

Out-of-hours services and end-of-life hospital admissions: a complex intervention systematic review and narrative synthesis

Background Out-of-hours (OOH) hospital admissions for patients receiving end-of-life care are a common cause of concern for patients, families, clinicians, and policymakers. It is unclear what issues, or combinations of issues, lead OOH clinicians to initiate hospital care for these patients. Aim To investigate the circumstances, processes, and mechanisms of UK OOH services-initiated end-of-life care hospital admissions. Design and setting Systematic literature review and narrative synthesis. Method Eight electronic databases were searched from inception to December 2019 supplemented by hand-searching of the British Journal of General Practice. Key search terms included: ‘out-of-hours services’, ‘hospital admissions’, and ‘end-of-life care’. Two reviewers independently screened and selected articles, and undertook quality appraisal using Gough’s Weight of Evidence framework. Data was analysed using narrative synthesis and reported following PRISMA Complex Intervention guidance. Results Searches identified 20 727 unique citations, 25 of which met the inclusion criteria. Few studies had a primary focus on the review questions. Admissions were instigated primarily to address clinical needs, caregiver and/or patient distress, and discontinuity or unavailability of care provision, and they were arranged by a range of OOH providers. Reported frequencies of patients receiving end-of-life care being admitted to hospital varied greatly; most evidence related to cancer patients. Conclusion Although OOH end-of-life care can often be readily resolved by hospital admissions, it comes with multiple challenges that seem to be widespread and systemic. Further research is therefore necessary to understand the complexities of OOH services-initiated end-of-life care hospital admissions and how the challenges underpinning such admissions might best be addressed.

Factors affecting the documentation of spoken safety-netting advice in routine GP consultations: a cross-sectional study

Background Previous studies have reported how often safety-netting is documented in medical records, but it is not known how this compares with what is verbalised and what factors might influence the consistency of documentation. Aim To compare spoken and documented safety-netting advice and to explore factors associated with documentation. Design and setting A cross-sectional study, using an existing GP consultations archive. Method Observational coding involving classifying and quantifying medical record entries and comparison with spoken safety-netting advice in 295 video-/audio-recorded consultations. Associations were tested using logistic regression. Results Two-thirds of consultations (192/295) contained spoken safety-netting advice that applied to less than half of the problems assessed (242/516). Only one-third of consultations (94/295) had documented safety-netting advice, which covered 20.3% of problems (105/516). The practice of GPs varied widely, from those that did not document their safety-netting advice to those that nearly always did so (86.7%). GPs were more likely to document their safety-netting advice for new problems (P = 0.030), when only a single problem was discussed in a consultation (P = 0.040), and when they gave specific rather than generic safety-netting advice (P = 0.007). In consultations where multiple problems were assessed (n = 139), the frequency of spoken and documented safety-netting advice decreased the later a problem was assessed. Conclusion GPs frequently do not document the safety-netting advice they have given to patients, which may have medicolegal implications in the event of an untoward incident. GPs should consider how safely they can assess and document more than one problem in a single consultation and this risk should be shared with patients to help manage expectations.

Factors affecting primary care practitioners’ alcohol-related discussions with older adults: a qualitative study

Background Risk of harm from drinking is heightened in later life, owing to age-related sensitivities to alcohol. Primary care services have a key role in supporting older people (aged ≥50 years) to make healthier decisions about alcohol. Aim To examine primary care practitioners’ perceptions of factors that promote and challenge their work to support older people in alcohol risk-reduction. Design and setting Qualitative study consisting of semi-structured interviews and focus groups with primary care practitioners in Northern England. Method Thirty-five practitioners (GPs, practice/district nurses, pharmacists, dentists, social care practitioners, and domiciliary carers) participated in eight interviews and five focus groups. Data were analysed thematically, applying principles of constant comparison. Results Practitioners highlighted particular sensitivities to discussing alcohol among older people, and reservations about older people’s resistance to making changes in old age; given that drinking practices could be established, and promote socialisation and emotional wellbeing in later life. Age-related health issues increased older people’s contact with practitioners, but management of older people’s long-term conditions was prioritised over discussion of alcohol. Dedicated time to address alcohol in routine consultations with older people and training in alcohol intervention facilitated practitioners, particularly pharmacists and practice nurses. Conclusion There are clear opportunities to support older people in primary care to make healthier decisions about alcohol. Dedicated time to address alcohol, training in identification of alcohol-related risks (particularly those associated with old age), and tailored interventions for older people, feasible to implement in practice settings, would help primary care practitioners to address older people’s alcohol use.

A feasibility trial of a digital mindfulness-based intervention to improve asthma-related quality of life for primary care patients with asthma

Asthma outcomes remain suboptimal, despite effective pharmacotherapy. Psychological dysfunction (such as anxiety) is common, and associated with poorer outcomes. We evaluated a digital mindfulness programme as an intervention to improve asthma-related quality of life for primary care patients, in a prospectively registered randomized-controlled feasibility study. We offered ‘Headspace’, a widely-used digital mindfulness intervention, to adults with asthma through 16 UK GP practices. Participants were randomized on a 2:1 basis to the mindfulness intervention, or waitlist control. Participants completed questionnaires (including asthma symptom control, asthma-related quality of life, anxiety, depression) at baseline, 6-week and 3-month follow-up. 116 participants completed primary outcomes at 3-month follow-up: intervention 73 (79%), control 43 (84%). Compared to baseline, the intervention group but not the control group reported significantly improved asthma-related quality of life, with a between-group difference favoring the intervention group that was not significant (Mean difference = 0.15, 95%CI − 0.13 to 0.42). Intervention use varied (ranging from 0 to 192 times) but was generally high. Digital mindfulness interventions are feasible and acceptable adjunct treatments for mild and moderate asthma to target quality of life. Further research should adapt ‘generic’ mindfulness-based stress-reduction to maximize effectiveness for asthma, and validate our findings in a fully-powered randomized controlled trial.