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.

Examine patterns in declined referrals to secondary healthcare in New Zealand by sociodemographics, region, health specialty and over time, as an important marker of potential unmet healthcare need (UMN) for specialist care. The primary hypothesis was that UMN varies by sociodemographic groups, region and health specialty and has increased over time.

A repeated cross-sectional analysis using administrative data from the National Patient Flow (NPF) Collection (2018–2022).

Nationwide, encompassing all first specialist assessments (FSA) referrals to public hospital specialists in New Zealand.

Individuals referred by general practitioners for FSA.

The primary outcome was FSA referrals being declined at prioritisation.

Among 2 918 557 first referrals for FSA, the observed rate of declined at prioritisation was 13.1%. Among those referred, females had a significantly higher risk of being declined (relative risk (RR), 1.069; 95% CI, 1.062 to 1.075), while those in younger (0–9 years: RR, 0.853; 95% CI, 0.841 to 0.865 and 10–19 years: RR, 0.891; 95% CI, 0.879 to 0.904) and older (80+years: RR, 0.955; 95% CI, 0.944 to 0.967) age groups as well as Māori (RR, 0.817; 95% CI, 0.810 to 0.824) and Pacific peoples (RR, 0.706; 95% CI, 0.695 to 0.716) had a significantly lower risk. There was also significant variation in risk of being declined by region and health specialty. The overall risk of being declined increased by 4.1% annually (RR, 1.041; 95% CI, 1.039 to 1.044). Significant increases in risk of declined over time were also observed across all sociodemographic groups, with higher risks for non-Māori/non-Pacific individuals (RR, 1.045; 95% CI, 1.043 to 1.048) and those in less deprived areas (RR, 1.057; 95% CI, 1.052 to 1.063).

UMN in New Zealand has significantly increased, exacerbating health inequities and straining primary care. Policy interventions are urgently needed to address these disparities, particularly in high-risk specialties and populations. This method of quantifying an important marker of UMN may inform global health equity initiatives.

The evidence for the optimal duration of psychotherapy for borderline personality disorder (BPD) is scarce. Two previous trials have compared different durations of psychotherapy. The first compared 6 months versus 12 months of dialectical behaviour therapy for BPD (the FASTER trial). The second compared 5 months versus 14 months of mentalisation-based therapy for BPD (the MBT-RCT trial). The primary objective of the present study will be to provide an individual patient data pooled analysis of two randomised clinical trials by combining the two short-term groups and the two long-term groups from the FASTER and MBT-RCT trials, thereby providing greater statistical power than the individual trials. Accordingly, we will evaluate the overall evidence on the effects of short-term versus long-term psychotherapy for BPD and investigate whether certain subgroups might benefit from short-term versus long-term psychotherapy.

An individual patient data pooled analysis of the FASTER trial and the MBT-RCT trial will be conducted. The primary outcome will be a composite of the proportion of participants with a suicide, a suicide attempt or a psychiatric hospitalisation. The secondary outcome will be the proportion of participants with self-harm. Exploratory outcomes will be BPD symptoms, symptom distress, level of functioning and quality of life. We will primarily assess outcomes at 15 months after randomisation for the FASTER trial and at 16 months after randomisation for the MBT-RCT trial. Predefined subgroups based on the design variables in the original trials will be tested for interaction with the intervention as follows: trial, sex (male compared with female), age (below or at 30 years compared with above 30 years) and baseline level of functioning (Global Assessment of Functioning baseline score at 0–49 compared with 50–100).

The statistical analyses will be performed on anonymised trial data that have already been approved by the respective ethical committees that originally assessed the included trials. The final analysis will be published in a peer-reviewed scientific journal and the results will be presented at national seminars and international conferences.

CRD42024612840.

RaCeR 2 is a pragmatic multicentre, open-label, randomised controlled trial, with full economic evaluation. The primary aim is to assess whether individualised (early) patient-directed rehabilitation (EPDR) results in less shoulder pain and disability at 12 weeks postrandomisation following surgical repair of full-thickness tears of the rotator cuff of the shoulder compared with the current standard (delayed) rehabilitation. This paper provides the protocol for the RaCeR 2 health economic evaluation.

The health economic analysis of RaCeR 2 is made up of three phases: (1) development of an initial state-transition model structure, (2) within-trial cost consequence analysis and (3) long-term model-based cost-effectiveness analysis (CEA) from the National Health Service and Personal Social Service perspective in England. Descriptive statistics (eg, mean, standard deviation, 95% confidence intervals and minimum and maximum values) will be reported for within-trial resource use, costs and health-related quality of life (HRQoL). Health state-specific costs and HRQoL will be estimated using regression model approaches and used to inform a state-transition simulation model designed to quantify the long-term costs and quality-adjusted life years (QALYs) experienced by patients over the model’s time horizon. Where appropriate, final CEA model results will be reported as cost per QALY gained for individualised EPDR versus standard (delayed) rehabilitation. Model assumptions and overall parameter uncertainty will be tested using probabilistic sensitivity analysis and scenario analyses. All regression analyses will be adjusted for baseline participant demographic and symptomatic characteristics.

A favourable ethical review was granted by London-Stanmore Research Ethics Committee (23/LO/0195) on 13 April 2023. Findings will be disseminated in peer-reviewed journals, at scientific conferences, and via the study website.

ISRCTN11499185

Clinicians and patients have been found to attribute musculoskeletal (MSK) pain to normal age-related changes seen on imaging, which can negatively impact patient outcomes and increase healthcare costs. While some studies have tested interventions to improve how MSK imaging findings are communicated, their impact has been limited. Applying a behavioural science framework has the potential to identify the rationale and target of these interventions to inform future intervention design—an analysis that has not yet been conducted. This study aims to identify the Behaviour Change Techniques (BCTs), the behavioural targets and the theoretical basis of interventions seeking to affect the communication of MSK imaging.

Scoping review using the Capability, Opportunity, Motivation - Behaviour (COM-B) model.

Searches of MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 9 February 2024.

We included studies that have developed or evaluated interventions which target the communication of MSK imaging findings. Interventions targeting both patients and clinicians were included. Experimental and quasi-experimental study designs were included, and studies that focused on serious or specific known causes of MSK pain were excluded.

Two independent authors extracted study participant data and intervention details. A theory of behaviour called the COM-B model was used to map the BCTs and behavioural components targeted by studies.

We identified 11 studies from 2486 studies in our electronic search. 11 different BCTs were identified across 11 studies. The most common techniques were framing/reframing (nine studies), adding objects to the environment (eight studies), incompatible beliefs (seven studies) and avoidance/reducing exposure to cues for the behaviour (four studies). Only two studies (feasibility studies) used behavioural theory to guide their intervention design. While one study showed a large effect, most interventions had little to no impact on pain, disability, or fear over time.

This review highlighted a lack of studies targeting clinician knowledge and the provision of high-quality patient resources about the nature of MSK pain, even though the broader literature identifies both as enablers of effective health communication. Additionally, the absence of a theory-informed design likely resulted in attempts to reassure patients about normal age-related imaging findings without providing an alternate, more coherent explanation for symptoms. Future interventions should focus on enhancing clinician psychological capability (knowledge) as well as clinician and patient reflective motivation (beliefs) to enable more helpful explanations of MSK symptoms. The key challenge for future interventions will be achieving these aims in a way that is effective, consistent and practical.

Open Science Framework (https://doi.org/10.17605/OSF.IO/ECYS8).