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A cohort study of trends in the prevalence of pregestational diabetes in pregnancy recorded in UK general practice between 1995 and 2012
Objective: To describe the characteristics of pregnant women with and without pregestational diabetes and to estimate the prevalence of pregestational diabetes in pregnant women recorded in a UK primary care database. Methods: The data source for this study is The Health Improvement Network (THIN) primary care database. Pregnant women with and without diabetes aged 16 years and over were identified using diagnostic Read codes and prescriptions for antidiabetics from medical records. Data were examined on: age, body mass index (BMI), social deprivation, smoking, ethnicity and glycaemic control. The prevalence of pregestational diabetes was calculated by diabetes type and calendar year between 1995 and 2012. Results: Data from 400 434 pregnancies suggests that women with pregestational diabetes were: older (median 29, 32 vs 29 years for type 1, type 2 and without diabetes, respectively), had higher BMI (median 25.0, 30.4 vs 23.9 k/m2 for type 1, type 2 and without diabetes, respectively) and were registered with a general practice for longer than pregnant women without diabetes. The prevalence of type 1 diabetes in pregnancy increased from 1.56 to 4.09 per 1000 pregnancies between 1995 and 2015. For type 2 diabetes the increase was from 2.34 to 5.09 per 1000 pregnancies between 1995 and 2008 followed by a more rapid increase to 10.62 per 1000 pregnancies by 2012. Conclusions: Pregnant women with pregestational diabetes were older, had higher BMI and were registered for longer than women without diabetes. The prevalence of type 1 and type 2 diabetes increased in pregnancy. The prevalence of type 2 diabetes rose more rapidly with a marked increase after 2008.
‘One man’s medicine is another man’s poison’: a qualitative study of user perspectives on low intensity interventions for Obsessive-Compulsive Disorder (OCD)
Background Low intensity interventions based on cognitive-behavioral therapy (CBT) such as computerized therapy or guided self-help can offer effective and accessible care for mild to moderate mental health problems. However, critics argue that by reducing therapist input and the level of experience of the professionals delivering therapy, low intensity interventions deprive users of critical ‘active ingredients’. Thus, while demand management arguments support the use of low intensity interventions for OCD, their integration into existing mental health services remains incomplete. Studies of user views of low intensity interventions can offer valuable insights to define their role and optimize their implementation in practice. Methods Qualitative interviews (n = 36) in adults with OCD explored user perspectives on the initiation, continuation and acceptability of two low intensity CBT interventions: guided self-help (6 h of professional support) and computerized CBT (1 h of professional support), delivered within the context of a large pragmatic effectiveness trial (ISRCTN73535163). Results While uptake was relatively high, continued engagement with the low intensity interventions was complex, with the perceived limitations of self-help materials impacting on users’ willingness to continue therapy. The addition of professional support provided an acceptable compromise between the relative benefits of self-help and the need for professional input. However, individual differences were evident in the extent to which this compromise was considered necessary and acceptable. The need for some professional contact to manage expectations and personalize therapy materials was amplified in users with OCD, given the unique features of the disorder. However, individual differences were again evident regarding the perceived value of face-to-face support. Conclusions Overall the findings demonstrate the need for flexibility in the provision of low intensity interventions for OCD, responsive to user preferences, as these preferences impact directly on engagement with therapy and perceptions of effectiveness.
Brief pain re-assessment provided more accurate prognosis than baseline information for low-back or shoulder pain
Research investigating prognosis in musculoskeletal pain conditions has only been moderately successful in predicting which patients are unlikely to recover. Clinical decision making could potentially be improved by combining information taken at baseline and re-consultation. Methods: Data from four prospective clinical cohorts of adults presenting to UK and Dutch primary care with low-back or shoulder pain was analysed, assessing long-term disability at 6 or 12 months and including baseline and 4–6 week assessments of pain. Baseline versus short-term assessments of pain, and previously validated multivariable prediction models versus repeat assessment, were compared to assess predictive performance of long-term disability outcome. A hypothetical clinical scenario was explored which made efficient use of both baseline and repeated assessment to identify patients likely to have a poor prognosis and decide on further treatment. Results: Short-term repeat assessment of pain was better than short-term change or baseline score at predicting long-term disability improvement across all cohorts. Short-term repeat assessment of pain was only slightly more predictive of long-term recovery (c-statistics 0.78, 95% CI 0.74 to 0.83 and 0.75, 95% CI 0.69 to 0.82) than a multivariable baseline prognostic model in the two cohorts presenting such a model (c-statistics 0.71, 95% CI 0.67 to 0.76 and 0.72, 95% CI 0.66 to 0.78). Combining optimal prediction at baseline using a multivariable prognostic model with short-term repeat assessment of pain in those with uncertain prognosis in a hypothetical clinical scenario resulted in reduction in the number of patients with an uncertain probability of recovery, thereby reducing the instances where patients may be inappropriately referred or reassured. Conclusions: Incorporating short-term repeat assessment of pain into prognostic models could potentially optimise the clinical usefulness of prognostic information.
Prescribing of medication to prevent glucocorticoid harms in patients with Polymyalgia Rheumatica: a cross-sectional study and two emulated target trials in the Clinical Practice Research Datalink Aurum
Abstract Objectives Polymyalgia rheumatica (PMR) is a common indication for long-term glucocorticoid (GC) treatment. Bone- and gastro-protective medications are recommended for those at high-risk of adverse events from GCs but no trials have evaluated their effectiveness in PMR. We describe bone-/gastro-protective medicine prescribing in people with PMR and evaluate its impact on adverse GC outcomes using a target trial approach. Methods A sample of >40,000 individuals aged ≥50 years, with a coded PMR diagnosis from January 2010-March 2022, prescribed GCs within 21 days of first PMR diagnosis code, was constructed in CPRD Aurum. Prescriptions were defined as prevalent (pre-PMR diagnosis), incident (at diagnosis), or late (post-diagnosis, still GC-treated), reported stratified by age/gender/deprivation. A target-trial approach assessed the effect of: a) bisphosphonates on fragility fractures and b) proton-pump inhibitors/H2-receptor antagonists (PPIs/H2RAs) on gastrointestinal (GI) ulceration/bleeding. Treatment effect, adjusted for confounders, was modelled using targeted maximum likelihood estimation. Results 67.2% were co-prescribed bisphosphonates and 78.6% PPIs/H2RAs. Males and those in more deprived areas were less likely to receive bisphosphonates. 1.40% (95%CI 1.10%,1.70%) of those prescribed vs 2.32% (2.12%,2.52%) of those not prescribed bisphosphonates for 12 months experienced a fracture (risk difference 0.92% points [0.56%,1.27%], NNT 109). Prescribing gastro-protective medications was not associated with serious GI events. Conclusion Rates of prescribing to mitigate GC harms are higher than previously reported. Bisphosphonates are associated with approximately one less fragility fracture per year for every 100 people treated. Gastro-prophylaxis is not associated with reduced risk of GI ulceration/bleeding, suggesting potential to reduce prescribing for this indication.
Health visitor and community health nurse perspectives of supporting parents caring for unsettled babies: a qualitative interview study
Abstract Objectives: The aims of this study were to explore how health visitors (HVs) and community health nurses (CHNs) assess unsettled baby behaviours, how their perceptions of these behaviours influence decisions about support offered, and how able they feel to deliver support to families of unsettled babies. Design: Qualitative semi-structured interviews were conducted, recorded and transcribed. Data were analysed using Reflexive Thematic Analysis. Setting: Potential participants were invited nationally via social media and via Health Visiting Service managers from an NHS Trust. Interviews took place remotely. Participants: 17 HVs and 3 CHNs were purposively selected to include a wide range of perspectives. Results: Three themes were developed, (1) HVs' perceptions of parents' sense-making which explains how HVs/CHNs understand parents' beliefs around unsettled babies; (2) care pathway which highlights the importance HVs place on creating emotional space for the baby, the parent and the health visitor within the pathway (containment); and (3) service delivery decline, which outlines the impact of funding cuts to the services on the HVs' ability to provide support for families. Lastly, a new concept - the Tipping Point model - was created to holistically conceptualise the experiences of HVs providing support for unsettled babies in the UK. Conclusions: Policy makers need to organise services to value and support the role of the health visiting team in 'containment'. HVs identified a training need around assessing and advising about unsettled babies to place them in a stronger position to support families. Further research is needed into different models of support for families of unsettled babies from the wider primary care team and/or from digital services.
Exploring the barriers and facilitators to discussing social media in primary care for young adults with mental health concerns: a qualitative study
Background Social media is a pervasive part of young peoples’ lives and may influence their mental health. Primary care is often the first point of care when seeking help for mental health problems. However, little is known about how young adults with mental health problems experience and perceive primary care support for managing social media. Aim To explore young adults’ views on help-seeking for social media use in primary care in relation to mental health problems. Design & setting Qualitative interview study with 28 young adults aged 18–25 with self-reported mental health problems across England. Method Semi-structured interviews were analysed thematically to identify barriers and facilitators to help-seeking. Themes were organised using the Theory of Planned Behaviour - attitudes, social norms and perceived behavioural control. Results Barriers for help-seeking included attitudes that social media was a secondary issue and low expectations of meaningful support; perceived negative attitudes and limited understanding of social media by primary care clinicians, communities and families; and constrained ability to seek help due to limited consultation time and uncertainty around how to seek help. Facilitators included clinicians offering practical strategies, raising the topic non-judgmentally, receiving training to better understand young people’s digital lives, longer appointment times, and clearer information about support in primary care for social media-related concerns. Conclusion Young adults with mental health concerns face multiple barriers to discussing social media in primary care, shaped by attitudes and structural challenges. Addressing these through clinician training, communication, and service adaptations may enhance engagement and support.
Teamwork and relational infrastructure: a qualitative study of modern UK general practice
Abstract Background Clinical and support staff in modern general practice must work across in-person and digital modalities to deliver high-quality, safe care in a context of high workload, constant change and intermittent crisis. Navigating this environment is cognitively and emotionally demanding and requires complex teamwork. Staff morale is often low, and staff turnover high. Aims 1. To understand how the context of modern UK general practice affects staff wellbeing and teamwork. 2. To develop our understanding of how to improve these aspects of work culture. Design and Setting Multi-site case study of 10 GP practices across England, Wales, and Scotland. Method Mixed qualitative methods, incorporating ethnographic observations, interviews, and focus groups, to develop case studies. First, we conducted an in-depth longitudinal study of two practices focused on developing theory, which we cross-compared with eight others. Our analysis was informed by theories from organisational research, including psychological safety, relational coordination and attentional infrastructure. Results Staff wellbeing and effective teamwork depended on positive team relations. Practices in which such relations were valued and nurtured (i.e. those with a strong relational infrastructure) appeared to have stronger team identities, better coordination of work tasks, and higher overall staff wellbeing than those in which team relations were not actively nurtured. Staff relations were built and sustained through various individual actions and organisational routines. Conclusion This study has identified elements of 'relational infrastructure' with the potential to improve team relations, communication, and coordination, which may also enhance practices' resilience to withstand change and crises.
Understanding the retention and support needs of UK first contact practitioner physiotherapists in primary care; a realist review
Background First Contact Practitioner Physiotherapists (FCPPs) have been widely implemented in UK general practice through the Additional Roles Reimbursement Scheme to improve access to musculoskeletal (MSK) care and reduce GP workload. While evidence suggests clinical and economic benefits, concerns are emerging regarding practitioner burnout and turnover. Understanding how contextual factors contribute to these outcomes is essential for sustainable workforce planning. Aim To explore how the UK based FCPP role interacts with workplace contexts to influence practitioner wellbeing, burnout, and turnover intentions, and to identify implications for support and service design. Methods A realist review of UK-based literature examining the implementation and experiences of FCPPs and comparable primary care roles was conducted in line with RAMESES standards. Initial programme theories were developed through stakeholder consultation and iteratively refined using published evidence. Data were synthesised into context–mechanism–outcome configurations (CMOCs), organised across four domains: role characteristics, personal characteristics, caseload complexity, and working environment. Results Thirty-three CMOCs were synthesised. Role ambiguity and poorly defined boundaries contributed to inappropriate referrals and role overload, intensifying an already complex caseload. These pressures were exacerbated by limited supervision and organisational support, leading to emotional strain, professional isolation, and increased burnout risk. Although practitioner experience and resilience could mitigate some effects, reliance on individual coping without adequate structural support undermined sustainability and contributed to turnover intentions. Conclusion Burnout and turnover intentions among FCPPs arise primarily from systemic and organisational factors rather than individual shortcomings. Addressing role clarity, supervision, interprofessional integration, and workload alignment is essential to support practitioner wellbeing and ensure the long-term sustainability of FCPP roles.
Social and Ethical Aspects of Remote and Hybrid Care in the Special Allocation Scheme in general practice (SEARCH): A mixed methods feasibility study protocol
Home Browse Social and Ethical Aspects of Remote and Hybrid Care in the Special... ALL Metrics 154 Views 11 Downloads Get PDF Get XML Cite Export Track Share ▬ Study Protocol Social and Ethical Aspects of Remote and Hybrid Care in the Special Allocation Scheme in general practice (SEARCH): A mixed methods feasibility study protocol [version 1; peer review: 3 approved with reservations] Natassia Brenman https://orcid.org/0000-0002-6567-21291, Jackie van Dael1, Francesca Dakin https://orcid.org/0000-0002-4105-46171, Kelly Howells2, Jessica Drinkwater https://orcid.org/0000-0003-1034-07812, Anne-Laure Donskoy3, Clive Rowe4, Nicky Pyper5, Sara Shaw https://orcid.org/0000-0002-7014-47931 Author details Abstract Background Despite the growing body of research on remote primary care and access for (digitally) excluded groups, very little is known about care for patients who have been deliberately excluded from mainstream services. The ‘Special Allocation Scheme’ (SAS) in England provides GP services to patients who have been excluded from their GP practice after being reported for violent behaviour. Patients registered on SAS are likely to be offered remote services, in part because patients are often placed in an ‘out-of-area’ SAS practice. Our aim is to find out more about the needs of patients on the SAS, whether and when it is appropriate to offer remote options, and who these options might benefit or disadvantage. We also aim to develop safe, ethical, and meaningful ways to involve patients with experience on the scheme in research and service development. Methods Workstream 1 includes a national scoping survey of SAS provision across England. Workstream 2 comprises of three ethnographic case studies of SAS services, including observation and interviews with patients, NHS staff and national/regional decision makers. Workstream 3 involves two codesign workshops with patients, researchers, clinicians, support staff and third sector care providers to co-produce a set of reflections and best practices to inform future research and service redesign in this context. An iterative and participatory-informed PPIE approach is adopted throughout, involving patients and other stakeholders from early conceptualisation to study design, analysis and codesign of outputs. Conclusions Whilst remote solutions can improve access to primary care for some, they are not suitable for every patient population and can widen health inequalities. This is a novel study in a critically under-researched area of service delivery with clear practical and ethical implications for practice. Findings will develop understanding and transferable learning for SAS delivery and inform the design of a future study.
Methods to establish a Pregnancy Register in the QResearch Database
Abstract Background: Electronic health records are increasingly used to conduct pregnancy-related research as pregnant women are under-represented in research. Creating a register of pregnancies by combining data from primary and secondary care will further facilitate research in pregnancy. This work describes the construction of an algorithm to create a unified pregnancy cohort in the QResearch database during the emergency phase of the COVID-19 pandemic. Methods: National primary care records in the QResearch® database were linked to patient-level data from Hospital Episode Statistics (HES) datasets. Females aged 15-50 years with a pregnancy outcome recorded between 30 December 2020 and 30 September 2022 were included. Pregnancy (delivery/loss) episodes were identified and cohort demographics reported using a three-stage algorithm. Pregnancy start dates were derived using a combination of HES and primary care data, or individually estimated where no corresponding date could be identified. Results: 266,758 women with 279,027 pregnancies are captured in the register. 232,673 pregnancies (83.4%) are deliveries (99.5% livebirths and 0.5% stillbirths) and 46,354 (16.6%) pregnancies are pregnancy losses. Pregnancy losses are highest amongst those of Caribbean (23.1%; n = 781) ethnicity and lowest in those of Pakistani ethnicity (13.9%, n = 1,579). 82.4% of pregnancies are derived from HES maternity records, 10.6% from primary care records, 3.4% from HES Admissions, and 3.6% from HES Procedures. Conclusion: The construction of a pregnancy register in QResearch® offers a valuable resource for future research. Its methodology can be adapted to construct new cohorts over any period, providing a comprehensive resource on pregnancy outcomes and events.
What do patients and clinicians think about continuity in general practice in England? a qualitative study
Abstract Background: Relational continuity - an ongoing therapeutic relationship between a patient and a clinician - has long been a hallmark of general practice. However, its prevalence in England has declined over the past decade amid increasing demand, workforce shortages, and structural changes in primary care delivery. Aim: To explore patient and clinician views on continuity in general practice, and understand the factors influencing these perspectives. Design and setting: A qualitative study using interviews and focus groups conducted in England between July 2024 and February 2025. Method: Semi-structured interviews were conducted with 17 primary care staff, and six focus groups were held with 40 patients. Staff were recruited through team contacts and snowballing. Patients were recruited through adverts in general practices. Inductive thematic analysis was informed by theoretical models of continuity, Reeve and Byng's United Model of Generalism, and the biopsychosocial model of care. Data were coded using NVivo software. Results: Four themes were identified: many patients lack experience of continuity and struggle to understand its value; patients and clinicians often prioritise other elements of care, such as quick access, over continuity; views on the value of continuity are shaped by beliefs about the role of general practice; and there is scepticism about the feasibility of restoring continuity within current system constraints. Conclusion: We may be reaching a tipping point, whereby a critical mass of patients views general practice solely as a method of accessing biomedical services from whichever staff member is available. If we want to improve continuity, we need to act before changes in attitudes and care delivery make change an impossibility.
Violence and abuse towards staff by patients and the public in general practice since COVID-19
Abstract Background General practice (family medicine) experiences more violence and abuse by patients and the public than other healthcare settings. There is limited research on such experiences amongst non-clinical staff, and no direct comparisons between staff groups in general practice. Aims To explore: The extent of violence and abuse from patients or the public towards general practice staff between 2020 and 2023; Staff correlates and environmental correlates for violence and abuse; Potential impacts of violence and abuse regarding staff feeling of safety and support at work. Design and Setting An online survey of general practice staff was conducted across England between 11/7/23 and 30/11/23. Methods Questions covered demographics, physical violence and threats, verbal abuse, harassment, and inappropriate sexual behaviours experienced or witnessed between 2020 and 2023. It asked whether participants felt safe and supported at work. Results Participants (N=1,152, 44% clinical, 56% non-clinical) were aged 21-75 years (mean=47.3 years, SD=11.1). Overall, 93.7% reported violence and abuse, with 92.3% reporting verbal abuse, 47.7% reporting physical violence or threats, 60.5% reporting feeling harassed, and 23.7% reporting inappropriate sexual behaviours. Additionally, 21% of staff felt unsafe but only 57.1% felt supported at work. Non-clinical, younger or less experienced staff and those in urban and deprived areas experience more violence and abuse. Those experiencing it more frequently felt less safe and supported. Conclusions Violence and abuse from patients and the public towards general practice staff may be prevalent and increased since the COVID-19 pandemic. Those at greater risk require more organisational support.
Experiences and knowledge of nurses, occupational therapists, pharmacists and physiotherapists about certifying fit notes: a UK-wide survey
Abstract Objective To identify facilitators and barriers to fit note certification among nurses, occupational therapists, pharmacists and physiotherapists (NOPPs), and identify ongoing training needs. Design An online survey informed by the Theoretical Domains Framework (TDF) was used to gather data from NOPPs to identify implementation barriers and personal, social and environmental influences on fit note certification. Data were analysed using descriptive statistics. Mean TDF domain scores were calculated (mean scores ≤3.5 indicated barriers, ≥5 indicated facilitators). Free-text data were thematically analysed using the TDF. Setting United Kingdom. Participants The survey was completed by 198 respondents: physiotherapists (n=66, 33%), occupational therapists (n=49, 25%), nurses (n=44, 22%), pharmacists (n=39, 20%). Results Only 47 (24%) of survey respondents had certified fit notes; 66 (37%) had completed training, most pharmacists had done neither. TDF analysis indicated three barriers: 1) ‘skills’ (being able to certify, review and practice completing fit notes) (mean=3.32, SD=0.75, 95% CI 1.84, 4.80); 2) ‘goals’ (the level of priority given to fit note completion) (mean=3.22, SD=0.51, 95% CI 2.21, 4.22); 3) ‘memory, attention and decision processes’ (disagreeing with the statement: ‘certifying fit notes is something I do automatically’) (mean=2.73, SD=0). Free-text comments suggested that low ‘skills’ rates may be due to lack of opportunity to do training. The low priority afforded to completing fit notes, which was not done automatically as part of their role, may reflect the lack of organisational policies/guidelines or priorities. The only facilitator identified was ‘belief about consequences’ (mean=5.74, SD=0.12, 95% CI: 5.50, 5.98). Participants believed that certifying fit notes was useful and worthwhile. Conclusions Legislation allowing NOPPs to undertake fit note certification does not appear to have been successfully implemented. Further resources are required to provide NOPPs with the necessary skills/confidence (e.g., via training) to certify fit notes, supporting more patients to return to and remain in work.
Identification and Management of Binge-Eating Disorder and Bulimia Nervosa in Primary Care Settings: A Qualitative Systematic Review of Healthcare Professionals' and Patients' Perceptions
ABSTRACT Objective To understand how the identification and management of binge-eating disorder (BED) and bulimia nervosa (BN) in primary care settings are perceived by both patients and healthcare professionals, and how rates of identification and referral for support may be improved. Methods A systematic review of qualitative studies was conducted. Eight databases were searched in August 2025. Studies were excluded if they focused on secondary or tertiary care, patients under the age of 16, or anorexia nervosa. Data on sample, type of eating disorder, year of publication, and country were extracted, and thematic synthesis was used to synthesize the data. The quality of studies was assessed using the Critical Appraisal Skills Programme checklist for qualitative research. Results Twenty-five studies were included. Four articles were of high quality; the rest (N = 21) were medium with a moderate risk of bias. Most of the studies were from the United Kingdom (N = 9), with 14 focusing on healthcare professionals' and 13 on patients' perspectives. The main factors influencing the identification and management of BED/BN were identified to be knowledge and understanding of the conditions, healthcare professional–patient interactions, attitudes and emotions toward BED/BN and the healthcare system, and the existence and accessibility of treatment and referral pathways. Discussion The interaction of these factors is discussed in relation to the literature, and gaps in research and clinical practice are identified, such as a limited separation of eating disorder categories, which could help inform the development of strategies to improve the identification and management of BED and BN. Summary Many healthcare professionals in primary care do not feel confident identifying or managing binge-eating disorder and bulimia nervosa, partly due to limited knowledge, unclear guidance, and poor access to specialist services. Patients often feel dismissed or misunderstood when seeking help for these eating disorders, which can prevent them from getting the care they need and discourage them from continuing to seek support. Improving how these conditions are recognized and treated in primary care will require better training for healthcare professionals, clearer referral pathways, and more inclusive, accessible support services for patients.
Generalism as a cross-disciplinary practice in medicine: Mixed-studies systematic review
Abstract Objective: To clarify who generalist physicians are and what characterizes their practice. Data sources: MEDLINE, PsycInfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science. Study selection: Empirical studies (quantitative, qualitative, mixed methods) that described the attributes of generalist physicians across various disciplines in the clinical literature. Synthesis: A total of 262 studies from 25 countries met inclusion criteria. Forty-seven percent of studies lacked essential participant information. The remaining studies primarily framed generalism in terms of an absence of specialist training, reflecting a "deficit model" of care. We identified 4 archetypes of generalist practice: broad-based knowledge, generalism as adaptive expertise, generalism as integrative expertise, and generalism as interpretive expertise. Conclusion: Generalism lacks a consistent meaning across clinical disciplines in medicine. Four archetypes of practice are proposed to promote cross-disciplinary dialogue and guide the design of future health care systems and professional roles.
Characterising generalism in clinical practice: a systematic mixed studies review protocol
Background Generalist physician care is associated with improved patient outcomes. Despite initiatives to promote generalism in educational settings, recruitment to generalist disciplines remains less than required to serve societal needs. Increasingly this impacts not just general practice but also generalist specialties such as internal medicine, surgery, and paediatrics. One potential factor for this deficit is a lack of explicit attention to generalism as a praxis, including clarifying key aspects of generalist expertise. Aim To examine empirical clinical literature on generalism, and characterise how generalism is described and delivered by physicians in primary and secondary care. Design & setting A systematic mixed studies review (SMSR) including quantitative, qualitative, mixed-methods studies, and systematic reviews of physician generalist practice. Method MEDLINE, Psycinfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science will be searched for English language studies from 1999 to present, using a structured search. Given study heterogeneity, quality appraisal will not be performed. Two reviewers will perform study selection for each study. Data extraction will focus on how generalism is defined and characterised, including the clinical care provided by generalists and patient experiences of generalist care. Quantitative and qualitative data will be summarised in tabular and narrative form. Convergent synthesis design will then be used to synthesise quantitative and qualitative data. Conclusion Findings will characterise generalism and generalist practice from a grassroots clinical perspective. By identifying similarities and differences across generalist disciplines, this work will inform more focused educational initiatives on generalism at undergraduate and postgraduate level, including collaborations between generalist disciplines.
Frequency of low-density-lipoprotein-cholesterol measurement and risk of major adverse cardiovascular outcomes: a 5-million-person nationwide cohort study
Cardiovascular disease (CVD) is a leading cause of mortality globally and in the UK, with significant efforts focused on early risk identification and prevention. Elevated low-density lipoprotein cholesterol (LDL-C) is a key modifiable risk factor for cardiovascular disease (CVD), yet the impact of LDL-C monitoring frequency on major adverse cardiovascular events (MACE) remains unclear. This study evaluated the relationship between LDL-C measurement frequency and the risk of MACE in a large, nationwide cohort. A retrospective cohort study using anonymised electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum, linked to hospitalisation, social deprivation, and mortality data. The cohort included individuals registered for at least one year with at least one recorded low-density LDL-C measurement between 1 January 2000 and 31 December 2022. The primary outcome was MACE, defined as a composite of non-fatal coronary heart disease, non-fatal stroke, or cardiovascular death. Multivariable Cox proportional hazards models and Kaplan-Meier survival plot were used to estimate the incidence and hazard ratios (HRs) by LDL-C monitoring frequency. The study cohort comprised 5,133,574 individuals, with 2,733,144 (53.2%) being women. The median follow-up duration was 3.31 years (IQR: 7.39-12.11). Among the 5,133,574 individuals, the incidence of MACE declined with more frequent LDL-C monitoring, from 1937.0 (95% CI: 1928.2-1945.8) events per 100,000 person-years (one measurement) to 1615.4 (95% CI: 1605.8-1625.0), 1484.6 (95% CI: 1473.7-1495.6), and 1204.9 (95% CI: 1200.1-1209.6) for those with two, three, and four or more measurements, respectively. Compared to individuals with one LDL-C measurement, the adjusted HRs for MACE were 0.703 (95% CI: 0.698-0.709), for two measurements, 0.570 (95% CI: 0.565-0.575) for three, and 0.312 (95% CI: 0.310-0.314) for four or more. The Kaplan-Meier curve demonstrated improved event-free survival with increased LDL-C monitoring (log-rank p<0.0001). More frequent LDL-C monitoring was associated with a lower risk of MACE. These findings highlight the potential benefits of regular LDL-C monitoring as a potentially impactful strategy for CVD prevention and long-term risk management.
Experiences of Social Relationships for Adults Living With Multiple Long-Term Conditions: A Qualitative Interview Study
Abstract Background: Social relationships are important for self-management and outcomes of multiple long-term conditions (MLTC). Previous research indicates MLTC negatively impacts social relationships and people living with MLTC do not feel adequately supported to manage their health. However, there is limited understanding of the processes and contextual factors that influence social relationships in the context of MLTC. This study explored experiences of social relationships for adults living with MLTC to improve understanding of their social relationship needs. Methods: Semi-structured telephone interviews were conducted with 22 people living with MLTC in Southern England. Participants were recruited through charity networks and GP practices. Eligibility criteria were: individuals aged ≥ 45 years living with MLTC within the community. Participants were purposively sampled to include diverse characteristics in terms of age, gender, and residential area deprivation. Transcribed interview data were analysed using reflexive thematic analysis. Results: Four themes were developed. 'There is no single route to meaningful social connection' reflected how participants achieved, valued, and maintained meaning in relationships in diverse ways. 'Change in sense of self' captured the mental load, nostalgia, low mood and depressive symptoms experienced because of MLTC, which was reported to negatively impact their relationships with others. 'A need to be seen and understood' described how participants valued social relationships that enabled them to talk about their conditions with others who have shared experiences. Participants experienced a sense of abandonment when they felt unable to share their needs and experiences with family and close friends. Some participants experienced distress around the need to self-manage their health, which was reinforced by limited health and care services. 'Altered interaction' reflected how MLTC required participants to find new ways to maintain social connection. Conclusion: Meaningful connection may be achieved through diverse social relationships, including acquaintances and support groups. Further efforts to connect people to these forms of relationships could improve self-management of MLTC, though strategies may vary for adults with different characteristics and health needs. Interventions that target mental burden, nostalgia, low mood and depressive symptoms experienced because of MLTC could support appropriate and meaningful social connection. Further research is needed to test these relationships. Patient and public contribution: Three public contributors shaped the design of this study by sharing their experiences and views of key issues people who lack adequate social support may experience and how this might impact management of their health. They noted the importance of speaking to a range of people to understand social relationship needs of people living with MLTC, as experiences will vary. Two public contributors reviewed and helped refine the interview topic guide and commented on the importance of tone when conducting interviews, to encourage participants to share their experiences. One public contributor supported analysis of the transcripts through coding, discussion, and manuscript review. They highlighted the abandonment expressed by participants and how participants appeared to want to be seen as independent despite wanting and needing more support.
The association of loneliness and social isolation with multimorbidity over 14 years in older adults in England: A population-based cohort study
Abstract Background Previous longitudinal studies have linked multimorbidity to loneliness (feeling alienated) and social isolation (having reduced social contact). However, the nature of these associations over time is unclear. Objective To examine bidirectional associations of multimorbidity with loneliness and social isolation over a 14-year follow-up in a nationally representative cohort of adults aged ≥ 50 years. Methods This retrospective cohort study used seven waves of data (collected between 2004/2005 and 2018/2019) from adults in the English Longitudinal Study of Ageing. Multimorbidity was defined as the presence of ≥2 long-term conditions. Loneliness was measured using the 3-item University of California Los Angeles (UCLA) scale. Social isolation was derived based on cohabitation status, frequency of contact with children, relatives, and friends, and social organisation membership. We used Cox proportional hazards models adjusted for social isolation or loneliness, demographic and health behaviour variables. Results The cohort consisted of 6031 adults with baseline and follow-up data on loneliness, social isolation, multimorbidity, and other covariates. Loneliness was associated with increased risk of incident multimorbidity [aHR (95 % CI): 1.38 (1.15–1.65)], whereas social isolation was not [aHR (95 % CI): 0.97 (0.81–1.16)]. Multimorbidity was associated with increased risk of incident loneliness [aHR (95 % CI): 1.55 (1.30–1.84)], but not significantly associated with subsequent risk of incident social isolation [aHR (95 % CI): 1.09 (0.92–1.28)]. Conclusions An independent bidirectional association exists between loneliness and multimorbidity. Interventions targeting loneliness may prevent or delay multimorbidity and also improve wellbeing for people with multimorbidity.
A mixed methods exploration of the experiences of physical activity providers in supporting children and adolescents with type 1 diabetes in the UK
Abstract Children and adolescents with type 1 diabetes mellitus (T1D) are less active than recommended and than their peers without T1D. Several barriers to physical activity have been reported, including lack of confidence in the support received from those who facilitate physical activity such as sports coaches and PE teachers (physical activity providers). This study aims to explore the experiences and needs of physical activity providers in supporting children and adolescents with T1D to engage in structured physical activity. A mixed-methods study, including an online survey and semi-structured interviews, was conducted to provide a broad understanding of the current context along with more in-depth exploration of strategies implemented. Thirty-four participants completed the survey and nine participated in semi-structured interviews. Survey data were summarised descriptively. Qualitative data were analysed using a reflective thematic approach. Fewer than one-third of respondents had received T1D-related training, and only 12% were aware of relevant policies at their institution. Despite moderate confidence among half of the respondents in supporting children and adolescents with T1D, nearly all expressed a need for specific training. Two overarching themes emerged from the interviews: the existing context within which providers operate and effective strategies to support T1D-related physical activity. Conclusion: Findings suggest improvements can be made to (1) training for physical activity providers to allow them to better support children and adolescents with T1D to participate in physical activity and (2) policies to help ensure a supportive and safe environment for children and adolescents with T1D.
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