This study explored how Structured Medication Reviews (SMRs) are being undertaken and the challenges to their successful implementation and sustainability.

A cross-sectional mixed methods online survey.

Primary care in England.

120 clinical pharmacists with experience in conducting SMRs in primary care.

Survey responses were received from clinical pharmacists working in 15 different regions. The majority were independent prescribers (62%, n=74), and most were employed by Primary Care Networks (65%, n=78), delivering SMRs for one or more general practices. 61% (n=73) had completed, or were currently enrolled in, the approved training pathway. Patient selection was largely driven by the primary care contract specification: care home residents, patients with polypharmacy, patients on medicines commonly associated with medication errors, patients with severe frailty and/or patients using potentially addictive pain management medication. Only 26% (n=36) of respondents reported providing patients with information in advance. The majority of SMRs were undertaken remotely by telephone and were 21–30 min in length. Much variation was reported in approaches to conducting SMRs, with SMRs in care homes being deemed the most challenging due to additional complexities involved. Challenges included not having sufficient time to prepare adequately, address complex polypharmacy and complete follow-up work generated by SMRs, issues relating to organisational support, competing national priorities and lack of ‘buy-in’ from some patients and General Practitioners.

These results offer insights into the role being played by the clinical pharmacy workforce in a new country-wide initiative to improve the quality and safety of care for patients taking multiple medicines. Better patient preparation and trust, alongside continuing professional development, more support and oversight for clinical pharmacists conducting SMRs, could lead to more efficient medication reviews. However, a formal evaluation of the potential of SMRs to optimise safe medicines use for patients in England is now warranted.

To explore how pre-existing conditions affect the diagnostic process for potential cancer in primary care patients.

Qualitative interview study using thematic analysis underpinned by a critical realist approach.

Primary care practices recruited through four Clinical Research Networks and UK health charities across England.

Interviews were conducted with 75 patients with one or more pre-existing conditions (anxiety/depression, diabetes, obesity, chronic obstructive pulmonary disease, Parkinson’s disease or multiple long-term conditions (four or more)) and 28 primary care professionals (general practitioners and nurses).

The study identified legitimacy as a central theme influencing patient trajectories in the health system while trying to receive a diagnosis for symptoms with which they presented to primary care. Patients engaged in self-triage to determine whether symptoms were ‘legitimate’ enough to seek care. Subsequent triaging steps (by receptionists, nurses and online systems) acted as gatekeepers, with decisions influenced by effectiveness of describing the symptom and subjective impressions. During consultations, clinicians relied on a mix of symptom narrative clarity, medical history and objective ‘metrics’ (eg, blood results, family history) to determine legitimacy for further investigations. Pre-existing conditions could either lower the threshold for referrals or obscure potential cancer symptoms. The stigma associated with mental health diagnoses often undermined perceived legitimacy and contributed to delays.

Legitimacy is continuously negotiated throughout the diagnostic pathway. It is shaped by social, moral and biomedical judgements. To promote early cancer diagnosis for patients with pre-existing conditions, clinicians must make legitimacy assessments explicit, reduce stigma especially around mental health and standardise triage processes.

The objective of this study was to understand primary care clinician perspectives on a novel linked health data system to facilitate diabetes prevention for individuals with a history of gestational diabetes mellitus (GDM). We used the conceptual example of linking the National Gestational Diabetes Register with primary care electronic health records to understand clinicians’ views on potential implementation.

A qualitative study of semistructured interviews with primary care clinicians.

Australian primary care.

Primary care clinicians (n=14). Inclusion criteria were: general practitioners (GPs), practice nurses and/or diabetes educators working in primary care in Australia, and seeing individuals with a history of GDM; aged 18 years and over; and willing to voluntarily contribute to the project. There were no exclusion criteria.

Clinicians’ views on acceptability, feasibility and utility were characterised by realistic optimism for a linked data system to improve GP workflow and patient outcomes. Clinicians noted existing pressures on primary care and patient concerns regarding confidentiality and privacy, and that these factors should be considered in the development process. Clinicians envisaged three functions for their clinical management systems: (1) automatically updating a patient’s past history; (2) generating actionable alerts and (3) generating recall lists.

Primary care clinicians were unanimously supportive of a linked health data system to facilitate diabetes prevention. Consistent with previous studies, we identified the key clinician-related enabler as the integration into existing GP workflows to facilitate pro-active clinical care. Point-of-care tools and preventative care consultations could increase the uptake of screening and provide opportunities for patient education post partum.

In combination with effective prevention programmes, and health policy and system supports, linked health data systems could be part of the equation for type 2 diabetes prevention for individuals with a history of GDM. Larger acceptability, feasibility, co-design and implementation studies are recommended.

To understand general practitioners’ (GPs’) experience of existing care pathways for people with moderate-severe Alzheimer’s Disease (AD) and explore their attitudes towards potential modifications to these pathways.

Secondary thematic analysis of qualitative interviews, originally conducted with GPs to explore prescribing of memantine in general practice. The theoretical domains framework was used to structure the data.

The study participants were recruited via an online survey completed by GPs across England.

Semi-structured, qualitative interviews were conducted with thirteen male and ten female GPs from a range of general practices in England.

Insights into GPs’ views and experiences regarding existing and possible care pathways for individuals with moderate to severe AD.

Gaps in GPs’ current levels of knowledge and skill in respect of caring for patients with moderate-to-severe AD affect their confidence and ability to identify opportunities for additional treatments. While GPs emphasise their role as providers of holistic care, features of the current healthcare context, including a lack of additional funding, inhibit their willingness to assume additional responsibilities as part of a revised pathway.

A considerable knowledge, skills and confidence gap must be addressed to support the implementation of new care pathways that include revised responsibilities for GPs. GPs need appropriate support and resources to manage their patients’ changing needs and to provide the best possible pharmacological management as the disease develops.

To provide bottom-up guidance on improving post-COVID care using patients’ experiences with received care and their perceived health

Qualitative study design using focus group interviews

30 patients with post-COVID condition recruited through purposive sampling based on patient complexity and diversity

Three dimensions for potential improvements of post-COVID care were identified: (1) building, supporting and maintaining patient resilience, (2) redesigning healthcare pathways to meet patient needs and (3) embedding post-COVID care in health systems and organisations. A conceptual framework that could guide improvements in post-COVID care was developed.

This study revealed several opportunities for improving and implementing post-COVID care following a person-centred approach in multidisciplinary integrated care pathways with an integrative vision of health.

The Episodic Disability Questionnaire (EDQ) was developed to measure the presence, severity and episodic nature of disability experienced among persons with chronic conditions. Our aim was to assess the sensibility, utility and implementation considerations of the EDQ among older adults with complex health needs.

Cross-sectional measurement study involving quantitative and qualitative methods of data collection.

We recruited community-dwelling older adults (65 years of age or older) living with complex health needs receiving care from a primary healthcare team in Toronto, Canada.

We administered the EDQ, sensibility questionnaire (assessing face and content validity, and ease of usage, with each item scored from 0 to 7 with greater scores indicating greater sensibility) and demographic questionnaire, followed by a semi-structured interview in the home or clinical setting. Using an interview guide, we asked participants about their perspectives on utility, format and implementation of the EDQ in clinical practice. We considered the EDQ sensible if the median score on the sensibility questionnaire was ≥5/7 for ≥80% of items and if none of the items had a median score of ≤3/7. We conducted a team-based directed content analysis of the interview transcripts.

The median age of the 11 participants in this study was 83 years of age. All participants reported living with two or more chronic health conditions, with osteoarthritis (n=5) and diabetes (n=4) most frequently reported. The EDQ met the criterion for sensibility as measured by the sensibility questionnaire. Interview data from participants (n=10) indicated that the EDQ represents the health-related challenges among this sample of older adults with complex health needs, captures the episodic nature of disability and was easy to use. Utility of the EDQ included providing clinicians with a holistic understanding of health challenges older adults face, aiding in intervention planning and measuring changes in disability over time. Six of the participants also expressed uncertainty as to how the EDQ specifically could be used by clinicians in their care. Considerations for implementation included mode of administration (paper or electronic) and the importance of communicating EDQ scores with older adults based on individual preferences.

The EDQ possesses sensibility and utility for use among this sample of older adults living with complex health needs in home or clinical care settings.

In the UK, approximately 5.4 million adults live with asthma, of whom one in five have an uncontrolled form. Uncontrolled asthma reduces quality of life and increases healthcare use. Engaging with peers through online health communities (OHCs) can empower patients to self-manage their long-term condition. While OHCs have been in existence for several years and growing numbers of patients access them, the role of primary care in signposting patients to them has been minimal and ad hoc. We have co-developed with patients and healthcare professionals (HCPs) an intervention for adult patients with asthma, consisting of an appointment with a primary care HCP to introduce online peer support and sign patients up to an established asthma OHC, followed by OHC engagement. Feasibility work found the intervention acceptable to patients and HCPs. This protocol outlines our plan to test the intervention’s effectiveness and cost-effectiveness.

An individual randomised controlled trial will be carried out. Eligible participants will be recruited via an online survey sent to adult patients on the asthma register in 50–70 general practices in several UK locations. Participants will be invited to attend a one-off, face-to-face appointment with a primary care HCP, during which they will be individually randomised to the intervention or usual care. An asthma control test (primary outcome) and other measures of clinical effectiveness will be collected at baseline and every 3 months over a 12-month follow-up period. Descriptive and inferential statistics will be used to compare outcome measures between study arms. Cost-effectiveness assessment of the intervention compared with current standard of asthma management in primary care will be reported. A sample of patients and HCPs will be interviewed at study exit and the data analysed thematically.

The study was approved by a National Health Service Research Ethics Committee (reference: 25/NE/0006). Written consent will be obtained from all participants. Findings will be disseminated through various means, including sharing with general practices, conference presentations and peer-reviewed publications.

NCT06849245.

To investigate the prognostic value of the Subgroups for Targeted Treatment (STarT) Screening Tool adapted for concussion (STarT-C) on persistent symptoms and disability at 6–9 months following mild traumatic brain injury (mTBI).

Secondary analysis of two prospective studies: an observational cohort study in New Zealand and usual care control arm of a clinical trial in Canada (ClinicalTrials.gov Registry (NCT04704037)).

Participants in the New Zealand cohort were recruited from concussion clinics (five sites) and those in the Canadian cohort were recruited from emergency departments/urgent care centres (eight sites).

New Zealand participants (n=93, median age 37 years, 60% women) were assessed at median=6 weeks post-injury (T1) and 6 months later (T2). Canadian participants (n=223, median age 38 years, 56% women) were assessed at median=2 weeks (T1) and 6 months later (T2).

Symptoms at T2 were assessed using the validated Rivermead Postconcussion Symptoms Questionnaire (RPQ) and disability using the WHO Disability Assessment Schedule 2.0 12-item Interview.

In linear regression analyses, the STarT-C predicted symptom burden (R²=18–36%) and disability (R²=15–18%) at T2 in both cohorts. While the additional prognostic value over and above baseline variables was substantial (delta R² 8–40%), the additional prognostic value over the RPQ at T1 was variable and generally lower (delta R²=1–9%).

The STarT-C—a brief screening tool—predicted persistent symptoms and disability in adults following mTBI. The incremental prognostic value of the STarT-C over the RPQ may be variable, but regardless, the tool may be useful for identifying those at risk of prolonged recovery who may benefit from early psychological intervention.

Relational continuity of care (RCC) refers to the sustained therapeutic relationship between a patient and a clinician, which fosters trust, enhances communication and facilitates the accumulation of knowledge about the patient. RCC is associated with enhanced patient outcomes, reduced hospital admissions, lower mortality rates, decreased healthcare costs and improved patient experience. Despite these benefits, reorganisations within the NHS and workforce challenges have led to an increased reliance on multidisciplinary and part-time working, resulting in fragmented care and a decline in RCC. Our study aims to explore who needs RCC, under what circumstances, to what extent and why, with the goal of informing optimal implementation strategies.

We will conduct a realist review to develop an evidence-based programme theory explaining the mechanisms underlying RCC, the populations that benefit most, the contextual factors influencing RCC and effective care models. Following Pawson’s five iterative stages, we will: (1) Locate existing theories, (2) Search for relevant evidence, (3) Select appropriate articles, (4) Extract and organise data and (5) Synthesise findings to draw conclusions. A stakeholder advisory group, comprising policymakers, healthcare professionals, public contributors and patients, will be engaged throughout the process. We will adhere to Realist And Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) for realist reviews to ensure methodological rigor.

Our findings will inform practical, evidence-based recommendations for optimising RCC within general practice. Outputs will include peer-reviewed publications, conference presentations, plain English summaries, social media infographics, a short video and end-of-study events. Collaborations with stakeholders and public involvement will ensure both accessibility and impact. Ethical approval is not required for this review.

Multimorbidity contributes significantly to poor population health outcomes while straining healthcare systems. Although some multimorbid patients experience an accelerated health decline (a decline in well-being or functional status that cannot be attributed to the natural ageing-related health deterioration), others can remain stable for years. Identifying risk factors for accelerated health decline in persons with multimorbidity could help prevent complications and reduce unnecessary interventions. Our review, therefore, aims to map the evidence on the clinical, biographical and healthcare-related factors associated with an accelerated health decline in multimorbid individuals.

We will use the evidence-mapping review methodology. We will perform a systematic comprehensive literature search in Medline via Pubmed, Cochrane Library, EMBASE, Web of Science and Google Scholar using two broad concepts: ‘multimorbidity’ and ‘longitudinal studies’. We will search with MeSH terms (eg, ‘Multimorbidity’ (Majr), ‘Longitudinal Studies’ (Majr)) and free text words (eg, multimorbidity, multiple chronic condition*, longitudinal), from inception to date of the final search. All original quantitative studies involving participants in primary care and related healthcare settings will be included. Abstract/titles and full-text screening and data extraction will be performed independently by two or more researchers to minimise selection and reporting bias, with conflicts resolved by consensus. The data will be analysed qualitatively, and topics will be extracted to create evidence clusters. Risk factors will be classified in groups and cross-referenced against the outcomes from respective studies into combinations of exposure-outcome clusters. The resulting evidence clusters will be described narratively and presented as bubble plots. The search, initiated in January 2023, will be updated following this protocol review to reflect the most current evidence; exact dates will be reported in the results manuscript.

Due to the nature of the proposed evidence map, ethics approval will not be required. Results from our research will be disseminated through publications in peer-reviewed journals and presentations at local, national and international conferences.

https://osf.io/q72xa/

This study validates the previously tested Screening for Poverty And Related social determinants to improve Knowledge of and access to resources (‘SPARK Tool’) against comparison questions from well-established national surveys (Post Survey Questionnaire (PSQ)) to inform the development of a standardised tool to collect patients’ demographic and social needs data in healthcare.

Cross-sectional study.

Pan-Canadian study of participants from four Canadian provinces (SK, MB, ON and NL).

192 participants were interviewed concurrently, completing both the SPARK tool and PSQ survey.

Survey topics included demographics: language, immigration, race, disability, sex, gender identity, sexual orientation; and social needs: education, income, medication access, transportation, housing, social support and employment status. Concurrent validity was performed to assess agreement and correlation between SPARK and comparison questions at an individual level as well as within domain clusters. We report on Cohen’s kappa measure of inter-rater reliability, Pearson correlation coefficient and Cramer’s V to assess overall capture of needs in the SPARK and PSQ as well as within each domain. Agreement between the surveys was described using correct (true positive and true negative) and incorrect (false positive and false negative) classification.

There was a moderate correlation between SPARK and PSQ (0.44, p60), SPARK correctly classified 90.5% (n=176/191).

SPARK provides a brief 15 min screening tool for primary care clinics to capture social and access needs. SPARK was able to correctly classify most participants within each domain. Related ongoing research is needed to further validate SPARK in a large representative sample and explore primary care implementation strategies to support integration.

Respiratory tract infection tests are increasingly available in primary care and are expected to expand in the future. However, there is limited understanding of clinicians’ views on their benefits and how to effectively integrate them into daily clinical practice.

The aim of this study was to explore healthcare professionals’ views on using respiratory tract infection tests to safely reduce unnecessary antibiotic prescriptions for respiratory tract infections in primary care based on their experience in routine practice.

A qualitative study design was employed. Two focus group discussions were conducted.

These focus group discussions were conducted in February 2025, involving 18 Spanish primary care professionals, both experts and non-experts in rational antibiotic use and antimicrobial resistance. Data were audio-recorded or video-recorded, transcribed and analysed thematically.

Participants agreed that respiratory tract infection tests help optimise antibiotic prescriptions, reduce uncertainty, ensure the appropriate consumption of resources and guide treatment based on aetiology. While most professionals view microbiological tests and C-reactive protein testing as complementary, non-experts preferred microbiological tests. Professionals considered that patients value knowing the aetiology over the prognosis, supporting shared decision-making and addressing patients’ demands more effectively. Concerns remain about using these tests as stand-alone tools and the medicalisation of self-limiting conditions. Other barriers mentioned included the high cost and time-consuming nature, the need for better professional training and the challenge of managing the increased workload associated with their use.

This study highlights how clinicians perceive respiratory tract infection tests to aid prescribing decisions amid uncertainty. Both positive and negative views were reported. Participants agreed that these tests optimise antibiotic prescriptions and guide treatment, but there are still important barriers to their implementation.

A dashboard was developed with and for Irish general practitioners (GPs) to improve their understanding of practice data. The aim of this study was to design and develop interactive CARA dashboards to enable Irish GPs to visualise patient data and compare their data with other practices.

An interpretivist qualitative approach was taken to create a deeper understanding of how GPs view and engage with data. It included four stages: (a) problem formulation, (b) building, intervention and evaluation, (c) reflection and learning and (d) formalisation of learning. The process included interviews to explore what type of information GPs need, as well as iterative testing of the CARA dashboard prototype.

General practice.

GPs, design experts and domain experts (antibiotic prescribing and stewardship).

Key challenges identified from the interviews (context, sense-making, audits, relevance, action, engagement and ease of use) formed the basis for developing the CARA dashboard prototype. The first exemplar dashboard focused on antibiotic prescribing to develop and showcase the proposed platform, including automated audit reports, filters (within-practice) and between-practice comparisons, as well as a visual overview of practice demographics. The design thinking approach helped to capture and build an understanding of the GPs’ perspectives and identify unmet needs. This approach benefits the quality improvement methodology commonly adopted across healthcare, which aims to understand the process, not the users.

The development of a useful dashboard is based on two key elements: users’ requirements and their continued involvement in the development of content and overall design decisions. The next step will be an incremental inclusion of GPs using the dashboard and an exploratory study on dashboard engagement. Additional dashboards, such as for chronic disease, will be developed.

Intrathoracic cancers, such as lung cancer, mesothelioma and thymoma, represent diagnostic challenges in primary care. We aimed to summarise evidence on the performance of imaging techniques that could aid the detection of intrathoracic cancers in low prevalence settings.

Systematic review and quality appraisal using Quality Assessment of Diagnostic Accuracy Studies-2 and Grading of Recommendations Assessment, Development and Evaluation.

MEDLINE, Embase and Web of Science were searched with a predesigned search strategy for articles from January 2000 to January 2024.

We included studies relevant for primary care, where participants were suspected of having intrathoracic cancer and reported on at least one diagnostic performance measure. We excluded studies where the cancer diagnosis was already established. Data extraction and synthesis screening were conducted independently by two reviewers. Data extraction and quality appraisal were conducted by one reviewer and checked by a second reviewer.

Out of 30 539 records identified by the database searches, 13 studies were included. There was heterogeneity in the types of cancers, populations included and reported diagnosis pathways for suspected cancers. Imaging modalities investigated included chest X-ray (three studies), computer tomography (CT, six studies), magnetic resonance imaging (two studies), positron emission tomography CT (two studies), ultrasound (two studies) and scintigraphy (one study). Chest X-ray sensitivity reported for lung cancer ranged from 33.3% to 75.9%, with specificity ranging from 83.2% to 95.5%. For CT, reported sensitivity varied from 58% for pleural malignancy to 100% for lung cancer. One study investigating an artificial intelligence tool to detect lung cancer found poor detection performance in a real-world patient cohort.

We found a limited number of studies reporting on the diagnostic performance of usual imaging techniques when used in unselected primary care settings for the diagnosis of intrathoracic cancer in symptomatic patients. There is a need for more studies evaluating such techniques in the general population presenting in primary care, where the prevalence is relatively low. A better understanding of the performance could lead to better detection strategies for intrathoracic cancers in primary care. Intrathoracic cancers, such as lung cancer, mesothelioma and thymoma, represent diagnostic challenges in primary care. We aimed to summarise evidence on the performance of imaging techniques that could aid the detection of intrathoracic cancers in low prevalence settings.

Primary care electronic health records provide a rich source of information for inequalities research. However, the reliability and validity of the research derived from these records depend on the completeness and resolution of the codelists (ie, collections of medical terms/codes) used to identify populations of interest. The aim of this project was to develop comprehensive codelists for identifying people from ethnic minority groups, people with learning disabilities (LDs), people with severe mental illness (SMI) and people who are transgender.

We followed a three-stage process to define and extract relevant codelists. First, groups of interest were defined a priori. Next, relevant clinical codes, relating to the groups, were identified by searching Clinical Practice Research Datalink (CPRD) publications, codelist repositories and the CPRD Code Browser. Relevant codelists were extracted and merged according to group, and duplicates were removed. Finally, the remaining codes were reviewed by two general practitioners (GPs).

The curated codelists were compared using a representative sample in the UK. The frequencies of individuals identified using the curated codelists were assessed and compared with widely used alternative codelists.

Comprehensiveness was assessed in a representative CPRD population of 10 966 759 people.

After removal of duplicates and GP review, codelists were finalised with 325 unique codes for ethnicity, 558 for LD, 499 for SMI and 38 for transgender. Compared with comparator codelists, an additional 48 017 (76.6%), 52 953 (68.9%) and 508 (36.9%) people with LD, SMI or transgender code were identified. The proportions identified for ethnicity, meanwhile, were consistent with expectations for the UK (eg, 6.50% Asian, 2.66% black and 1.44% mixed).

The curated codelists are more sensitive than those widely used in practice and research. Discrepancies between national estimates and primary care records suggest potential record/retention issues. Resolving these requires further investigation and could lead to improved data quality for research.

‘Hotspotters’ are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. As reliable data on effective interventions for this population are scarce, the goal of this study is to assess the cost-effectiveness of proactive, personalised, integrated care for this group.

The Hotspotters Project is planned as a stepped wedge cluster randomised controlled trial in 20 primary care practices in the Netherlands. All practices and participants will begin with standard care during the control period (2–8 months), followed by an intervention (12 months) consisting of a positive health intake with goal setting, multidisciplinary meetings, a personalised care plan and proactive care management. The study will conclude with a follow-up (2–8 months), resulting in a total study duration of 22 months. We plan to include 200 patients with (a) problems on two or more life domains and (b) at least two acute care encounters in the previous year. Possible Hotspotters are identified using an Adjusted Clinical Groups-based algorithm or via a local primary healthcare team.

Questionnaires and routine care data will be used to gather data on cost-effectiveness, which will then be assessed using multilevel analysis, with levels for the individual, cluster and duration of control period. Secondary outcomes will include psychological outcomes on self-regulation (proactive coping, patient activation, self-efficacy and intention), experience of care (satisfaction, perceived autonomy support and qualitative data from focus groups) and quality of life, qualitative analysis of the Positive Health approach, implementation outcomes and process evaluation including integration of care.

The Ethics Committee of Leiden University Medical Centre granted approval (METC-LDD, P21.123). Results will be shared through peer-reviewed publication and (inter)national conference presentations.

NCT05878054.

Studies show conflicting evidence regarding individuals’ healthcare costs following bariatric surgeries. This study aimed to evaluate the healthcare costs of individuals with obesity before and after bariatric surgery and compare them to a matched control group.

Retrospective cohort study.

Primary care nationwide.

This retrospective cohort study included all adults insured by Maccabi Healthcare Services who underwent bariatric surgery between 2015 and 2019 and a control group matched by body mass index, age, gender and socioeconomic status (case n=10 178).

We collected each patient’s annual costs for six consecutive years (3 years before and after the index date). We used generalised linear mixed models to assess the interaction between time (presurgery vs postsurgery) and group (bariatric vs control) on healthcare costs during the second and third years before and after surgery, adjusting for covariates not matched between groups, including smoking status, ethnicity and comorbidities. The analyses were made in three age groups: young adults (18–39), adults (40–64) and older adults (65 or more).

From 2015–2019, 10 178 bariatric surgeries were performed (51.9% sleeve gastrectomy, 36.7% bypass surgeries and 11.4% combined surgeries). Total healthcare costs increased after the index date in both the bariatric and control groups, with a greater absolute increase in the bariatric group; however, the between-group differences in cost changes were not statistically significant (p=0.987 for younger adults, p=0.311 for adults and p=0.771 for older adults).

While healthcare costs increased in both groups following the index date, the lack of a significant difference between the bariatric and control groups suggests that bariatric surgery may not lead to short-term cost savings. Ongoing long-term follow-up is essential to fully understand its economic impact.

To evaluate the effectiveness of nutrition care delivered by general practitioners (GPs) compared with usual or no care on dietary and health outcomes in adults with diet-related chronic conditions or risk states and to examine which intervention components are associated with effectiveness.

A systematic review of randomised controlled trials (RCTs).

CINAHL, Embase, MEDLINE and ProQuest Nursing and Allied Health databases were searched in October 2021 and updated in February 2024 for articles related to GPs, nutrition care and diet-related health outcomes.

Published RCTs were included according to the following criteria: adults with or at risk of diet-related chronic conditions; nutrition care delivered by GPs in the primary care setting; usual or no care as comparators; and dietary and/or health outcomes with a minimum 3-month follow-up. No restriction was placed on the date of publication.

Duplicates were reconciled in EndNote. Two reviewers independently screened the titles, abstracts and full texts in Covidence. Two independent reviewers completed the critical appraisal and data extraction. Disagreements were resolved through discussion or with a third reviewer. The Motivation Actions and Prompts (MAP) framework was used to analyse the behaviour change components of study interventions. Results were reported using narrative synthesis and certainty in findings was summarised using GRADEpro GDT software.

Seven RCTs met the inclusion criteria (5744 patients). The trials were conducted in Australia, Italy and the USA from 1991 to 2013, with follow-up periods from 3 to 12 months. A consistent effect in favour of the intervention was found for diet scores (2 RCTs, 3038 participants). Other outcomes had mixed effects: (1) fat intake (2 RCTs, 2299 participants) – one study with an effect in favour of the intervention and one with mixed effects; (2) blood pressure (3 RCTs, 3063 participants) – one study with mixed effects and two with no effect; (3) body mass index (6 RCTs, 5538 participants) – two studies with an effect in favour of the intervention, two with no effect and two reporting no between group differences; (4) body weight (2 RCTs, 511 participants) – one study with an effect in favour of the intervention and one with no effect and (5) cholesterol (4 RCTs, 2505 participants) – one study with an effect in favour of the intervention and three with mixed effects and/or limited reporting. All studies had a motivation and action route to behaviour change and two had a prompted component, according to the MAP framework. The interventions spanned nine behaviour change groupings and 16 behaviour change techniques. There was a very low certainty of findings in all cases and the studies were of low to moderate methodological quality.

There is mixed evidence of the effectiveness of GP-delivered nutrition care among adults with diet-related chronic conditions or risk states. Additionally, most interventions did not include prompting and had a limited range of behaviour change techniques. The effectiveness of nutrition care delivered by GPs is an understudied area that warrants greater experimental investigation and requires more robust methods and reporting.

CRD42021289011.

Multimorbidity is prevalent and associated with complex treatment requirements. In order to assist general practitioners (GPs) addressing these requirements, the web application gp-multitool.de has been designed, which facilitates implementation of the German clinical practice guideline for multimorbidity. We will conduct a cluster-randomised clinical trial evaluating an intervention based on this tool. This protocol summarises methods and discusses ethics and dissemination of this study.

Participating patients are recruited by cooperating GP practices. Inclusion criteria are an age of 65 years or older, enrolment in any disease management programme and multimorbidity operationalised by two additional chronic conditions. To avoid postrandomisation selection bias, practices are randomised as clusters after baseline assessment of all participating patients from the respective practice. In our intervention, patients receive access to different assessments including patient preferences by email, fill out the electronic assessment forms on any device with access to the internet, receive a medication review and discuss the assessment results with their GPs. GPs in the control group do not have access to the digital tool and provide care as usual. The primary outcome is staying at least once for at least one night in hospital during the 12-month observation period. Secondary outcomes are contacts with GPs and outpatient specialists, self-reported health, health-related quality of life, patient satisfaction and GP-reported and patient-reported quality of care. A sample size of 660 patients from 66 GP practices is needed. Data are analysed by mixed effects regression models.

Ethics approval was obtained by the ethics committee of the Medical Association of Hamburg (2022–1 00 786-BO-ff). Study results will be presented on scientific conferences and published in journal articles. In addition, healthcare professionals, patient representatives and the interested public will be informed about study results at a symposium.

The study was registered in clinicaltrials.gov (NCT06831994).

Frequency of general practitioners’ (GPs’) antibiotic prescribing for acute, self-limiting respiratory tract infections (aRTIs) is high. The practice environment and culture influence the clinical behaviour, including prescribing behaviour, of GP specialist vocational trainees (registrars). We aimed to assess inter-practice variability in registrars’ antibiotic prescribing.

This was a cross-sectional analysis from the Registrar Clinical Encounters in Training (ReCEnT) cohort study, from 2010 to 2020.

ReCEnT documents registrars’ clinical experiences and behaviours. Before 2016, 5 of 17 Australian training regions participated in ReCEnT. From 2016, three of nine regions (~40% of Australian registrars) participated.

3210 registrars (response rate 91.8%) from 1286 training practices contributed to the analysis.

The outcomes were prescription of an antibiotic for new diagnoses of (1) all aRTIs and (2) acute bronchitis diagnoses specifically. Prescribing percentages were calculated at the training practice level. Intraclass correlation coefficients (ICCs) were used to measure the ratio of interpractice variation to total variance. Median ORs (MORs) were also estimated to quantify interpractice variability.

Practice-level antibiotic prescribing percentages ranged from 0% to 100% for both aRTIs and acute bronchitis diagnoses in the primary analysis. ICCs for aRTI prescribing were 0.08 (unadjusted) and 0.02 (adjusted). For acute bronchitis, ICCs were 0.10 (unadjusted) and 0.05 (adjusted). MORs were 1.66 (unadjusted) and 1.32 (adjusted) for aRTIs. MORs for acute bronchitis were 1.80 (unadjusted) and 1.53 (adjusted). This indicates a marked variation in the odds of a patient receiving antibiotics for an aRTI if randomly attending different practices.

There was considerable interpractice variation in registrars’ antibiotic prescribing frequencies. Further research is required to examine the factors accounting for this variation and to develop practice-level interventions to reduce antibiotic prescribing in high-prescribing practices.