This paper aims to describe the development of an inventory of chronic ambulatory care sensitive conditions (ACSCs) relevant to the Malaysian context and identify potentially preventable hospitalisations in the Malaysian Ministry of Health (MOH) facilities based on the developed list.

Consultative panel discussion, multi-panel modified Delphi and secondary health data analysis.

Setting: Malaysian MOH healthcare facilities.

42 experts from the family medicine and internal medicine specialties (modified Delphi), and 2022 inpatient data from MOH hospitals (secondary health data analysis).

A list of chronic ACSCs tailored to the Malaysian context and the proportion of potentially preventable hospitalisation in MOH hospitals.

10 conditions were identified as chronic ACSCs for Malaysia, namely angina, asthma, chronic kidney disease, convulsions and epilepsy, chronic obstructive pulmonary disease, diabetes mellitus, heart failure, hypertension, iron deficiency anaemia and ischaemic heart disease. In 2022, these conditions accounted for 8.6% of potentially preventable hospitalisations among the total hospitalisations in MOH hospitals.

This study provides a base list of chronic ACSCs tailored to the Malaysian context, which enables monitoring of potentially preventable hospitalisations due to chronic conditions. The findings underscore a proportion of hospital admissions that could potentially be avoided through interventions that enhance outpatient care. The conditions identified as ambulatory care sensitive provide specific targets for policy action and resource allocation to optimise outpatient health services and thus reduce the burden of hospitalisations in the country.

Malaysian National Medical Research Register, NMRR ID-23–02149-TBZ (https://nmrr.gov.my/research-directory/45c901d6-f121-4e79-9f38-dd7d283ec9a6).

To compare primary care for depression among patients detected in the first 21 months of the SARS-CoV-2 pandemic to patients detected pre-pandemic, and examine whether depression care was associated with patient characteristics.

Retrospective pre–post study using de-identified data from electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).

Primary care clinics enrolled in CPCSSN from 1 January 2018 to 31 December 2021.

Patients with a valid CPCSSN case definition of depression detected between 01 January 2018 and 31 December 2021 were included in the cohort and categorised by detection date (pre-pandemic or during Canadian pandemic waves).

Primary care encounters, psychotropic prescriptions and selective serotonin reuptake inhibitor (SSRI) prescriptions were observed at 3 and 12 months post-detection. Multivariable regression evaluated associations between patients’ depression detection timing and depression care, adjusting for age, sex, rurality, neighbourhood deprivation quintile, province, number of observable comorbidities and pre-detection psychotropic use.

91 453 patients with depression were identified, of whom 53% were detected pre-pandemic. Patients detected during the pandemic were younger and less comorbid than those detected pre-pandemic. Proportions of patients with any encounter, psychotropic prescriptions and SSRI prescriptions were higher for patients detected during every pandemic wave compared with patients detected pre-pandemic. The adjusted incidence rate ratios (aIRRs) of number of encounters (aIRR=1.15; 95% CI 1.13 to 1.17), psychotropics (aIRR=1.11, 95% CI 1.09 to 1.13) and SSRIs prescribed (aIRR=1.12; 95% CI 1.10 to 1.15) within 3 months of detection were higher among patients detected during the first pandemic wave compared with those detected pre-pandemic. Socio-demographic characteristics had weaker associations with outcomes compared with timing of detection. Results were similar within 12 months of detection.

Overall, primary care for depression was maintained during the pandemic despite challenging circumstances. Increases in paediatric encounter rates and increased prescribing in younger adults warrant further investigation to understand the factors driving these patterns.

ClinicalTrials.gov NCT05813652.

Most patients with health conditions necessitating time off work consult in primary care. Offering vocational advice (VA) early within this setting may help them to return to work and reduce sickness absence. Previous research shows the benefits of VA interventions for musculoskeletal pain in primary care, but an intervention for a much broader primary care patient population has yet to be tested. The Work And Vocational advicE feasibility study tested patient identification and recruitment methods, explored participants’ experiences of being invited to the study and their experiences of receiving VA.

A mixed method, single arm feasibility study comprising both quantitative and qualitative analysis of recruitment and participation in the study.

Primary care.

The study included participant follow-up by fortnightly Short Message Service text and 6-week questionnaire. Stop/go criteria focus on recruitment and intervention engagement. The semistructured interviews explored participants’ experiences of recruitment and receipt and engagement with the intervention.

19 participants were recruited (4.3% response rate). Identification of participants via retrospective fit-note searches was reasonably successful (13/19 (68%) identified), recruitment stop/go criteria were met with ≥50% of those eligible and expressing an interest recruited. The stop/go criterion for intervention engagement was met with 16/19 (86%) participants having at least one contact with a vocational support worker. Five participants were interviewed; they reported positive experiences of recruitment and felt the VA intervention was acceptable.

This study demonstrates that delivering VA in primary care is feasible and acceptable. To ensure a future trial is feasible, recruitment strategies and data collection methods require additional refinement.

NCT04543097.

This pilot study aimed to estimate the prevalence of frailty, prefrailty and multimorbidity among adults aged 40–69 in Montenegro and to assess the feasibility of measuring these conditions in primary care to inform the design of a future large-scale study. We also aimed to examine differences in frailty scores and chronic disease burden across age subgroups, describe the profiles of prefrail/frail versus robust individuals and contextualise the findings within a broader public health framework.

Cross-sectional pilot study.

Primary healthcare centre, Podgorica, Montenegro.

A total of 165 adults aged 40–69 were recruited during routine follow-up visits for chronic conditions or preventive check-ups with their primary care physicians. Patients with acute conditions or injuries were excluded.

Primary outcomes were the prevalence of frailty and prefrailty (based on an adapted Fried frailty phenotype) and multimorbidity (defined as ≥2 coexisting chronic conditions). Secondary outcomes included comparisons of frailty scores and the number of chronic conditions across age subgroups (40–54, 55–64, 65–69), as well as sociodemographic and clinical differences between prefrail/frail and robust participants. Historic national mortality and healthcare utilisation trends since 2012 were also analysed.

Frailty and prefrailty prevalence was 6.1% (95% CI 2.9% to 10.8%) and 46.7% (95% CI 38.8% to 54.5%), respectively, while multimorbidity affected 23% of participants (95% CI 16.8% to 30.2%). The number of chronic diseases and frailty score increased significantly across age groups (p

This pilot study demonstrates that assessing frailty, prefrailty and multimorbidity in primary care settings in Montenegro is feasible and provides essential insights for designing a future large-scale study. Our preliminary evidence revealed a considerable proportion of prefrail individuals and a smaller proportion of frail individuals, as well as a notable burden of multimorbidity among adults aged 40–69 in Montenegro, particularly among those aged ≥55. This group could benefit from more timely preventive interventions at the primary care level, early detection of prefrailty, frailty and multimorbidity, which would ultimately enhance the resilience of the national healthcare system.

The work of receptionists in general practice is evolving rapidly and becoming more complex due to a number of changes within primary and community care services, such as increased digitalisation. In under-served areas, these changes have been further complicated by under-resourcing and workforce challenges around staff recruitment and retention. The National Health Service (NHS) 10-year health plan is set to accelerate further significant changes. There is limited understanding about how and why these changes and workforce challenges are impacting and will impact the future work of receptionists in general practice in under-served areas.

This realist review will build on an existing programme theory related to general practitioner workforce sustainability. The review will examine what works, for whom, how and under what circumstances for receptionist work in general practice, in under-served areas. For example, how influences such as the expectations of patients (in under-served communities), poor staffing or limited career progression. Key stakeholders, including public contributors and individuals from general practice settings, will inform the realist review.

The review will be conducted using existing secondary and grey literature sources. The search strategy comprises five electronic databases: Medline, Embase, PsycINFO, CINAHL and Web of Science Core Collection (SCIE, SSCI, AHCI) with a date limit of 2015 applied to the search. The review will follow Pawson’s five steps: (1) shaping the scope of the review; (2) searching for evidence; (3) document selection and appraisal; (4) data extraction and (5) data synthesis. The findings will be reported in accordance with the Realist and Meta-narrative Evidence Synthesis Evolving Standards.

Ethical approval is not needed for secondary analysis. The findings of this review will contribute to ongoing work as part of our ‘Workforce Voices’ programme of research. They will be disseminated to policymakers, commissioners, providers of health and social care and primary care and community healthcare teams through peer-reviewed publications, members of the public, conference presentations, social media and recommendations.

Opioid analgesic medications play a critical role in pain management but are associated with significant risks, including addiction. General practitioners in primary care account for a substantial proportion of opioid prescriptions, and prescribing practices may not always fully align with clinical guidelines. Given the limited evidence supporting long-term opioid use for chronic non-cancer pain, there is a pressing need for interventions that promote safer, guideline-concordant prescribing. The Smarta Val (Smart Choices) trial will evaluate whether a new multicomponent intervention, comprising an educational seminar, written materials and feedback on prescribing over 12 months, can improve opioid prescribing practices in primary care.

This cluster randomised pragmatic trial will assess changes in opioid prescribing across primary healthcare centres (PHCCs) in Stockholm, Sweden. Consenting PHCCs will be randomised 1:1 to either the intervention group, receiving the multicomponent intervention, or the active control group, receiving a leaflet on prescribing recommendations. A sample size of 24 PHCCs per group is required to detect differences in opioid prescribing between groups. A third group of non-randomised observational reference PHCCs will be included to provide contextual information on prescribing practices during the study period. Data sources include regional healthcare databases, baseline and 12-month follow-up questionnaires, and an intervention delivery form. The primary outcome is the change in prescription of opioids at 12 months. Secondary outcomes are the change in prescription of opioids at 24 months and the change in the specific opioid substances prescribed at 12 months.

The study has been approved by the Swedish Ethical Review Authority (Dnr 2021-06739-01). Participation in the study requires informed consent from PHCC managers in the intervention and active control groups. Results will be disseminated through international peer-reviewed journals and conference presentations.

NCT05577026.

Global migration has steadily risen, with 16% of the UK population born abroad. Migrants (defined here as foreign-born individuals) face unique health risks, including potential higher rates and delays in diagnosis of infectious and non-communicable diseases, compounded by significant barriers to healthcare. UK Public Health guidelines recommend screening at-risk migrants, but primary care often faces significant challenges in achieving this, exacerbating health disparities. The Health Catch-UP! tool was developed as a novel digital, multidisease screening and catch-up vaccination solution to support primary care to identify at-risk adult migrants and offer individualised care. The tool has been shown to be acceptable and feasible and to increase migrant health screening in previous studies, but to facilitate use in routine care requires the development of an implementation package. This protocol describes the development and optimisation of an implementation package for Health Catch-UP! following the person-based approach (PBA), a participatory intervention development methodology, and evaluates our use of this methodological approach for migrant participants.

Through engagement with both migrants and primary healthcare professionals (approximately 80–100 participants) via participatory workshops, focus groups and think-aloud interviews, the study aims to cocreate a comprehensive Health Catch-UP! implementation package. This package will encompass healthcare professional support materials, patient resources and potential Health Catch-UP! care pathways (delivery models), developed through iterative refinement based on user feedback and behavioural theory. The study will involve three linked phases (1) planning: formation of an academic–community coalition and cocreation of guiding principles, logic model and intervention planning table, (2) intervention development: focus groups and participatory workshops to coproduce prototype implementation materials and (3) intervention optimisation: think-aloud interviews to iteratively refine the final implementation package. An embedded mixed-methods evaluation of how we used the PBA will allow shared learning from the use of this methodology within the migrant health context.

Ethics approval granted by the St George’s University Research Ethics Committee (REC reference: 2024.0191). A community celebration event will be held to recognise contributions and to demonstrate impact.

To explore whether routine electronic healthcare records can be used to identify triggers for initiating advance care planning (ACP) and the optimal time window to initiate ACP. We aimed to assess the prevalence of triggers for initiating ACP as defined for use in routine data, whether their presence is associated with death, and what their position is relative to a previously identified ‘optimal time window for ACP’.

Nested case-control study within a large dynamic population cohort dataset.

Primary care population-based, anonymised data extracted from GP centres in the South Holland province, The Netherlands.

We selected records of individuals aged ≥65 registered with their general practice from 1 Jan 2014 to 1 Jan 2017. Cases were individuals who died between 1 Jan 2017 and 1 Jan 2020. Controls were individuals who remained alive. Cases were matched by age to controls in a 1:4 ratio.

Outcomes include prevalence of triggers for ACP in the records of deceased and living individuals; association of the triggers’ presence with death; timing of the identified triggers in deceased individuals relative to the ‘optimal time window for ACP’.

We included 17098 records, 4139 from deceased individuals (mean age 81) and 12959 from living individuals (mean age 79). Triggers most strongly associated with death were consultations concerning malignancy (OR 8.35, 95% CI 7.42 to 9.41), hospital admissions (OR 7.32, 95% CI 6.75 to 7.94), emergency department referrals (OR 7.11, 95% CI 6.52 to 7.75), registered home visits (OR 5.97, 95% CI 5.51 to 6.47), consultations concerning heart failure (OR 5.25, 95% CI 4.59 to 5.99), dementia (OR 4.75, 95% CI 3.99 to 6.56), opioid prescriptions (OR 4.58 (4.25–4.93), consultations concerning general decline/feeling old (OR 4.15, 95% CI 3.72 to 4.64) and skin ulcers/pressure sores (OR 4.04, 95% CI 3.55 to 4.61). Those closest to the median of the optimal time window for ACP were consultations regarding dyspnoea, general decline/feeling old, heart failure, skin ulcers/pressure sores and fever, opioid prescriptions, emergency department referrals, registered home visits and hospital admissions.

Clinical triggers for initiating ACP in general practice can be recognised within the routine electronic health records and they align well with the ‘window of opportunity’ to initiate ACP.

On 1 January 2023, Ontario expanded pharmacists’ scope of practice, allowing them to prescribe medications for 13 minor ailments, including antibiotics for uncomplicated urinary tract infections (UTIs) and Lyme disease (LD) prophylaxis. This study evaluates pharmacist billing claims and pharmacist and physician antibiotic-prescribing rates before and after policy implementation.

An interrupted time series analysis measuring changes in prescribing trends post-implementation.

This retrospective study analysed visit claims and antibiotic prescribing for UTIs and LD prophylaxis before policy implementation (2022) and after (2023–2024) in Ontario.

Data from Ontarians

Prescribing rates were standardised per 1000 inhabitants, stratified by provider type, patient age and sex, and antibiotic type.

In 2023 and 2024, pharmacists submitted over 1.47 million minor ailment claims, with UTIs making up 34.2% and LD prophylaxis making up 2.6% of total claims. UTI claims were primarily for women aged 25–64, and LD prophylaxis peaked in spring and fall. Pharmacist prescribing of eligible urinary drugs in females increased by 33.3 per 1000 person-years (95% CI 30.8 to 36.6) while physician prescribing decreased by 23.3 (95% CI –32.2 to –15.3), leading to a modest net increase of 10.1 (95% CI 0.0 to 18.7). Pharmacist prescribing of doxycycline was offset by decreased physician prescribing, resulting in no change (0.0, 95% CI –1.0 to 0.9). Pharmacist prescribing for other antibiotics was low over the study timeframe, while physician prescribing increased, which was driven by increased prescribing of penicillins and macrolides.

There was a clear increase in pharmacist prescribing for eligible drugs in the eligible population post-policy implementation. Pharmacists in Ontario appear to be prescribing within policy limits for uncomplicated UTIs and LD prophylaxis.

The Cohort of Health-Related Outcomes in Chronic Illness Care in General Practice was established using data collected as part of a cluster-randomised trial. This aims to support the trial’s follow-up and enable further examination of the interplay between chronic disease, multimorbidity (MM), polypharmacy (PP) and quality of life (QoL) in a Danish general practice setting.

The cohort comprises 35 977 adult patients from 250 general practices participating in a cluster-randomised trial and had a response rate of 22.4%. Participants were either registered as chronic care patients or had attended an annual chronic disease consultation. They completed a comprehensive questionnaire on self-reported chronic conditions, medication use, QoL, treatment burden and patient-centred care. Additionally, 431 general practitioners (GPs) from the participating practices completed a questionnaire about managing patients with complex MM.

Among participants, 51.9% were female, the mean age was 65.6 (SD 12.9) years, 93.1% had education beyond basic schooling, and half were retired. Conditions from more than one organ system-based disease group were reported by 82.2%, and 94.6% used one or more prescription medications. The main challenges reported by the participating GPs in managing patients with complex MM were keeping time and obtaining an overview of the patient’s health status.

Cohort data will be linked with Danish registries to improve the detection and treatment of chronic conditions and PP in general practice.

The cluster randomised trial (MM600) is registered with ClinicalTrials.gov ID: NCT05676541.

To determine the use, frequency and factors linked to the use of any electronic point of care resources (ePOC resources) used by early-career general practitioners (GPs in training, otherwise known as GP residents or registrars) during consultations; and the frequency, and factors linked to the use of evidence-based clinical summaries.

Cross-sectional analysis of data collected as part of the Registrar Clinical Encounters in Training (ReCEnT) project from 2018 to 2022. Every 6 months, GP trainees record 60 consecutive consultations, including information about their use of resources.

Australian training general practices.

3024 GP trainees in community-based vocational training.

The primary outcome was the use of ePOC resources, and the secondary outcome was the use of evidence-based ePOC summaries.

A total of 3024 GP trainees accessed electronic resources during patient encounters for 67 651/628 855 (10.8%) of diagnoses/problems. Use of ePOC resources increased 4% per year over the study period. Therapeutic Guidelines was accessed most often (27 435/79 536, 34.7% of all ePOC use) followed by Australian Medicines Handbook (7507, 9.4%) and HealthPathways (6965, 8.7%). Various factors were associated with increased use of ePOC resources, including increasing patient age, diagnosis/problem type, increasing years of experience prior to GP training and stage of training. GP trainees rarely accessed dedicated evidence-based clinical summaries.

Australian GP trainees use a range of resources to answer their clinical questions, mostly from Therapeutic Guidelines and prescribing compendiums, but also system specific resources that are free to access.

The global prevalence of osteoarthritis (OA) is expected to rise as the population ages, leading to increased physical impairments that often reduce physical activity. Knee OA, in particular, is a leading cause of chronic pain and disability in people over 40. OA progression varies among individuals, with factors such as higher age and body mass index contributing to a more rapid progression. However, research suggests that engaging in physical activity such as hiking and running may help alleviate pain and slow OA progression. However, current literature on the relationship between physical activity and knee OA is largely retrospective, lacks comparative analyses across different physical activity types and rarely considers the intensity of physical activity. To address these gaps, the LoaD study was designed as a prospective cohort study aimed at examining how different physical activity types (ie, hiking, running, cycling and tennis) and their intensities relate to knee OA progression over 24 months in physically active individuals with early signs of the condition.

This prospective cohort study will include 300 participants (75 per physical activity group), who will be followed for 24 months. Eligible participants are aged 45–65, meet the National Institute for Health and Care Excellence (NICE) criteria for clinical knee OA and engage in a minimum weekly activity level for either running (60 min), cycling (120 min), playing tennis (60 min) or hiking (1 hike of 10 km). Baseline and follow-up assessments will include MRI, physical examination (eg, biometrics, lower extremity strength) and blood sampling for molecular biomarker assessment (eg, genetics, inflammatory biomarkers). Participants will receive monthly online questionnaires (eg, demographics, lifestyle, general health, history of knee injuries) and their physical activities will be tracked continuously by global positioning system data from wearable devices. The study’s primary outcomes focus on knee OA progression and symptom changes. These will be assessed through (1) structural progression of knee OA, measured using the MRI Osteoarthritis Knee Score (MOAKS) and (2) clinical symptom progression evaluated by (a) the Knee Injury and Osteoarthritis Outcome Score sport and recreation function subscale and (b) Visual Analogue Scale for pain during an activity nominated by the participant to be the most aggravating for knee pain in the past month (VASNA, 0–10). Differences between groups on the primary outcomes will be analysed using mixed-effects models to determine the impact of activity type and intensity on knee OA progression.

The study is approved by the Erasmus MC Medical Research and Ethics Committee (MREC) (MEC-2022-0420). The results of this study will be made publicly available through peer-reviewed international open-access scientific journals and national and international conferences. Participants will be informed about the results as soon as they are published.

Artificial intelligence (AI)-based clinical decision support systems (CDSSs) are currently being developed to aid prescribing in primary care. There is a lack of research on how these systems will be perceived and used by healthcare professionals and subsequently on how to optimise the implementation process of AI-based CDSSs (AICDSSs).

To explore healthcare professionals’ perspectives on the use of an AICDSS for prescribing in co-existing multiple long-term conditions (MLTC), and the relevance to shared decision making (SDM).

Qualitative study using template analysis of semistructured interviews, based on a case vignette and a mock-up of an AICDSS.

Healthcare professionals prescribing for patients working in the English National Health Service (NHS) primary care in the West Midlands region.

A purposive sample of general practitioners/resident doctors (10), nurse prescribers (3) and prescribing pharmacists (2) working in the English NHS primary care.

The proposed tool generated interest among the participants. Findings included the perception of the tool as user friendly and as a valuable complement to existing clinical guidelines, particularly in a patient population with multiple long-term conditions and polypharmacy, where existing guidelines may be inadequate. Concerns were raised about integration into existing clinical documentation systems, medicolegal aspects, how to interpret findings that were inconsistent with clinical guidelines, and the impact on patient-prescriber relationships. Views differed on whether the tool would aid SDM.

AICDSSs such as the OPTIMAL tool hold potential for optimising pharmaceutical treatment in patients with MLTC. However, specific issues related to the tool need to be addressed and careful implementation into the existing clinical practice is necessary to realise the potential benefits.

Delayed antibiotic prescribing (DAP) has demonstrated efficacy in reducing inappropriate antibiotic use for uncomplicated respiratory tract infections (uRTIs) in primary care across high-income countries. However, evidence regarding its effectiveness in low-income and middle-income countries remains limited. This cluster-randomised controlled trial (cRCT) aims to evaluate the effectiveness of DAP for optimising antibiotic use in primary healthcare institutions (PHIs) in China.

We designed a pragmatic, multicentre, open-label, three-arm cRCT in adult patients with uRTIs. The study will involve 12 PHIs in Korla City of China. Participating institutions will be randomised at a 1:1:1 ratio to three parallel arms: (1) DAP-intervention arm, (2) Immediate antibiotic prescribing comparator arm and (3) Usual care (observational arm). The primary outcome is symptom duration. Secondary outcomes include symptom severity, antibiotic use, adverse events, patient satisfaction and patient belief regarding antibiotic efficacy.

Ethics committee approval of this study was obtained from Peking University Institution Review Board (IRB00001052-24169). The findings will be disseminated through peer-reviewed publications and presentations at scientific conferences.

ChiCTR2500097330.

People without access to recognised and understood speech and/or written communication methods can experience exceptional disadvantage in health settings. This can result in poor health outcomes, lengthier hospital admissions and adverse events, including preventable deaths. Despite numerous attempts to integrate augmentative and alternative communication into health settings, the first-person ‘voice’ of the patient is often not accessible or prioritised, deferring instead to others, such as parents or carers, or the ‘best guess’ by healthcare professionals. The Talking Scrubs project aims to form a bridge to augmentative and alternative communication by locating key communication icons on scrubs (and scrubs/vest) to be used with patients (in and of themselves) and/or to prompt the use of patient individualised communication methods. The paper describes the methodological process for Stage 4 of the project. Prior stages involved investigating the concept, developing and validating instrument measures and co-designing and feasibility pilot testing the scrubs/vests. Stage 4 (this protocol) aligns with the diagnostic process, to test the feasibility and effectiveness of the scrubs intervention at two large, metropolitan medical centres with 5–10 general practitioners, approximately 30 patients and up to 10 flow-on diagnostic screening clinicians such as nurses and phlebotomists. Stage 4 is the first time the instrument measures will be applied and re-tested post-validation.

Using mixed methods, Stage 4 will apply the communication self-efficacy instruments co-designed in Stage 2 and validated in Stage 3 to measure effectiveness of the scrubs intervention by comparing pre-intervention and post-intervention changes in both clinician and patient population groups. Qualitative interviews, agency recorded data and participant journal recordings (optional) will be used to identify feasibility. SPSS V.29 (IBM, Chicago, Illinois, USA) will be applied to analyse participant communication self-efficacy measures and NVIVO V.10 (Lumiverso, Denver, Colorado, USA) to the retrieved qualitative data.

Stages 3 and 4 have ethics approval from the University of South Australia Ethics Committee identification number 206 930 and are registered as a clinical trial with Australia and New Zealand Clinical Research Trials (ANZCRT) with registration number 12625000490471p. Stage 1 (national survey) and Stage 2 (stakeholder focus groups) received ethics approval from Flinders University. Findings will be disseminated through national and international health translation platforms, publications, media and on the Talking Scrubs website.

ANZCRT with the registration number ACTRN12625000490471p.

In 2023, 21% of deaths occurred in residential aged care facilities (RACFs), a setting expected to play an increasing role in palliative and end-of-life care (PEoLC). General practitioners (GPs) oversee and deliver PEoLC in residential and nursing homes, yet little is known about their practice. We conducted a systematic review of the published evidence concerning how GPs provide this care: what they do and the quality, challenges and facilitators of that care.

Systematic review and narrative synthesis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Medline, Embase, CINAHL, PsycINFO, Web of Science, Scopus and NHS Evidence and grey literature via Google Scholar were searched through 9 October 2024.

We included studies presenting new empirical data from qualitative, quantitative or mixed methods, were published in the English language and conducted in the UK, the European Union, Australia, New Zealand and Canada. We excluded studies with no new empirical data, discussion papers, conference abstracts, opinion pieces, study participants under 18 years old and in care settings other than RACF.

One independent reviewer used standardised methods to search and screen study titles for inclusion. This reviewer assessed all abstracts of the included papers, and a second independent reviewer screened 60% of the abstracts to validate inclusion. Risk of bias was assessed using Gough’s Weight of Evidence assessment. Thematic analysis was used to describe the contents of the included papers; a narrative synthesis approach was taken to report the findings at a more conceptual level.

The search identified 5936 titles: 35 papers were eligible and included in the synthesis. This is a nascent evidence base, lacking robust research designs and characterised by small sample sizes; the results describe the factors observed to be important in the delivery of care. Care provision is extremely variable; no models of optimal care have been put forward or tested. Challenges to care provision occur at every level of the care system. At macro level, service-level agreements and policies vary: at meso level, team-working, communication technology solutions and equipment availability vary: at micro level, GPs’ interests in providing PEoLC vary as does their training. No study addresses residents’ and relatives’ experiences and expectations of GPs' involvement in PEoLC in RACFs.

The limited evidence base highlights that GP care at end of life for RACF residents varies greatly, with enablers and challenges at all levels in the existing care systems. Little research has examined GP PEoLC for RACF residents in its own right; insight is derived from studies that report on this issue as an adjunct to the main focus. With national policies focused on moving more PEoLC into community settings, these knowledge deficits require urgent attention.

To evaluate adherence to National Health Service (NHS) patient registration ID guidelines among General Practitioners’ (GP) practices.

A mystery shopper study, including website reviews and phone calls.

Rural and urban parts of the United Kingdom’s West Midlands.

85 randomly selected GP practices.

In January–April 2024, GP’s websites were reviewed before phone calls in which our ‘mystery shopper’ was asked to register without photo ID and proof of address.

Of 85 GP practices, 60 (71%) breached NHS guidance either online or over the phone, with only 25 (29%) consistently following NHS guidance. Phone calls to rural (vs urban) GP practices were more likely to yield refusal of registration without photo ID and proof of address, despite rural (vs urban) GP practices making similar statements online. During some phone calls, practices sought to negotiate a compromise by requesting less robust ‘documentation’, such as an addressed parcel.

GP practices commonly refuse registration to people without photo ID or proof of address, thus creating ‘sludge’ and undermining access to healthcare especially for poor, vulnerable patients, including immigrants. Changing GP practices’ websites would not address this problem if erroneous information is still provided over the phone. GPs and practice managers should ensure that all staff follow NHS guidance to allow registration without these documents.

Ambulatory care sensitive conditions (ACSCs) are conditions for which the provision of timely and skilled primary care can reduce risks of hospitalisation when preventing, treating or controlling a disease. For this reason, hospitalisations for ACSC have been commonly employed by health systems as an indicator of effectiveness for the primary level of care. This study aims to evaluate whether the provision of primary care services by physicians with residency training in family medicine is associated with rates of general hospitalisations for ACSCs in the Brazilian Unified Health System network in the city of Belo Horizonte, Brazil.

Longitudinal ecological study using a Generalised Linear Model for Gamma-distributed variables.

Primary healthcare centres in Belo Horizonte, Brazil, from January 2017 to December 2021, aggregated at the primary healthcare centres level.

Data aggregated at the primary healthcare centre level, encompassing socioeconomic, professional and health-related variables.

Incidence rates of hospitalisations for ACSCs, adjusted for age and sex.

After adjusting for age, sex and socioeconomic variables using the Health Vulnerability Index, a higher concentration of family physicians was significantly associated with a lower incidence of hospitalisations for ACSCs. If all physicians in the primary care network were family physicians, compared with a scenario in which none were, an estimated 11.89% reduction in hospitalisations would be expected (95% CI 7.3% to 16.3%, p

The findings suggest that specialisation in family medicine positively impacts health outcomes by reducing hospitalisations for ACSCs. These results can inform the development of evidence-based public policies to enhance primary care effectiveness.

Chronic insomnia is a prevalent but under-recognised sleep disorder in the UK, affecting 6.8%–14.9% of adults. It is associated with significant health and economic burdens, yet remains under-diagnosed and poorly managed in primary care. This study aimed to address key gaps in the understanding, diagnosis and management of chronic insomnia and to develop consensus-based recommendations to optimise care pathways across the National Health Service.

A modified Delphi consensus study.

UK primary care, involving general practitioners, pharmacists and sleep specialists.

A multidisciplinary steering group of seven UK healthcare professionals (HCPs) with expertise in chronic insomnia developed 39 statements. These were tested in a two-round Delphi survey distributed to a panel of 201 HCPs. Consensus was defined as ≥75% agreement on a 4-point Likert scale.

Consensus was reached for 37 of the 39 statements. Key findings included the recognition of chronic insomnia as a distinct chronic condition, the recommendation to include routine sleep-related screening in primary care and the need for increased HCP training in cognitive behavioural therapy for insomnia and pharmacological treatment. Respondents highlighted the necessity for greater awareness and public engagement regarding insomnia and its treatment options. In spite of mitigating biases, responses may have been subject to acquiescence bias.

The study identifies systemic barriers to effective insomnia care and calls for chronic insomnia to be prioritised in UK primary care. The resulting consensus recommendations aim to reduce the burden of untreated insomnia, improve patient outcomes, enhance healthcare delivery and increase economic productivity.

To conduct a synthesis of existing empirical and grey literature to identify the contexts and mechanisms that enable the adoption, offer, uptake and return of faecal immunochemical testing (FIT) in the primary care pathway in England, UK, for patients with signs or symptoms of suspected colorectal cancer (CRC). From this, develop a theory about how specific programme activities lead to certain outcomes.

A realist synthesis.

Medline (OVID), EMBASE (OVID), CINAHL (EBSCO), Scopus (Elsevier) and grey literature sources until end of July 2023.

The purpose of the work was to determine how different factors interact within a health system to optimise the approach to implementing and using symptomatic FIT (sFIT) in clinical practice for patient benefit. The criteria used to bound the scope of the synthesis included date (published between 2017 and July 2023), exposure of interest (sFIT in the primary care pathway for patients with signs or symptoms of suspected CRC), geographic location of study (countries that make up the UK), language (English) and participants (adults). Any study design and type of publication was considered.

Given the recognised lack of literature on the implementation of sFIT, it was crucial to include insights from grey literature. To do this, key national groups and organisations—involved or related to this subject—were methodically identified and appropriate papers and reports identified.

A thematic approach was used to identify relevant data in included records and allow realist insights to be obtained. Inductive and deductive coding enabled detection of key data. Arguments were generated and developed into context–mechanism–outcome configurations (CMOCs). Iteratively, an initial list of 38 CMOCs was refined to 14 themes and 19 CMOCs. These were then structured to create a multifaceted, multilevel realist synthesis programme theory.

Systematic searching led to the full appraisal of 99 records to determine suitability of each to confirm, refute or help develop theory. Studies were assessed for rigour and relevance to inform selection. The process resulted in 45 records being chosen for inclusion, of which 28 were from database searches and 17 from grey literature sources.

The key contexts and mechanisms that help optimise adoption, offer, uptake and return of sFIT have been elucidated (although partially). These can be broadly summarised into the 10 ‘Cs’: creating a compelling Case and Conditions for change, reaching Consensus through Collaborative working, fostering a Culture that values Clinical judgement, building Confidence by developing Capabilities and, finally, ensuring Clarity and Coherence of both practical processes and safety netting procedures.

Fundamentally, optimising the adoption, offer, uptake and return of sFIT in primary care for patients with signs or symptoms of suspected CRC is predicated on developing the acceptability of this initiative to every stakeholder at every level within a health system.