BJGP Open

BackgroundCommunication issues across the primary-secondary care interface are considered one of the most important challenges in improving patient safety in primary care in the UK. Teleconferencing offers a potential means of improving communication during referrals but is largely unevaluated. AimTo explore teleconferencing as an alternative to written Advice and Guidance (A&G) referrals for neurology cases, by assessing its impact on GP-specialist communication and relationships, and exploring implications for patient care. Design and SettingA qualitative case study of a primary care network (PCN) and a secondary care centre in East Anglia. Methods18 clinicians and 10 other stakeholders were interviewed. Observations of teleconferences and a focus group with five PCN staff provided additional data. Data collection and analysis were guided by the Consolidated Framework for Implementation Research and Reflexive Thematic Analysis. ResultsAdvantages of teleconferencing identified by participants included greater clinician satisfaction, mutual educational value, streamlined patient journeys and continuity of care. Teleconferences were also seen to build GP-specialist relationships and reduce unnecessary outpatient referrals. Perceived issues included time constraints, clinical governance and funding sustainability; teleconferences were not seen as appropriate for all referrals. Overall, participants welcomed the teleconference approach but stressed the need to robustly assess its cost-effectiveness and replicability in other settings. ConclusionTeleconferencing is a potentially promising alternative to written A&G referrals and was perceived by participants to help build GP-specialist relationships. However, further studies are needed to assess clinical effectiveness and costs, and to guide future development and implementation. How this fits inO_ST_ABSWhat is known?C_ST_ABSReferral interventions involving direct GP-specialist dialogue can enhance referral quality, reduce outpatient referrals and improve GP-specialist relationships, with some demonstrating improved clinical outcomes. However, they often face sustainability challenges, and their cost-effectiveness and mechanisms of impact require further assessment. What does this study add?This qualitative study identifies key mechanisms through which virtual GP-specialist dialogue may lead to downstream benefits: enabling shared decision-making and delivering consultant-level care closer to home; empowering GPs to manage complex cases; and reducing overall workload across primary and secondary care systems. The programme theory developed can be used to guide future intervention design, implementation and evaluation.

BackgroundDementia affects over 57 million people worldwide. UK and international policy position personalised, conversation-based care planning as central to post-diagnostic support. However, delivery in primary care is inconsistent, and many practitioners lack dementia-specific communication training. Existing evidence focuses on single roles or settings, leaving a gap in understanding how communication operates across the primary care workforce. AimsTo identify what helps and hinders effective communication for integrated dementia care planning and determine the support and training needs of the wider primary care workforce. MethodsO_LISemi-structured interviews - 11 people with dementia, 13 family carers, and 19 primary care practitioners from diverse roles, exploring experiences of care planning conversations C_LIO_LIReflexive thematic analysis C_LI ResultsThree themes were developed, progressing from micro-level communication practices (Theme 1: Beyond the tick-box), through triadic dynamics (Theme 2: Balancing voices in the conversation), to organisational influences (Theme 3: From silos to meaningful shared care planning). Time and Conversation as intervention cut across all themes, shaping trust and disclosure. Participants reported reliance on tick box approaches, inconsistent preparation, and uncertainty about care plan purpose and ownership. Non-clinical roles were commonly viewed as well placed to support meaningful conversations, but were often described as constrained by unclear remit and weak integration. ConclusionsA persistent gap remains between policy ambitions and everyday practice. Time-pressured, checklist-driven encounters and fragmented systems undermine shared decision-making. The expanded primary care workforce offers untapped potential to address these gaps, but this requires clearer roles, formal integration, and targeted investment in communicative skills.

BackgroundEarlier identification and registration of people in the last year of life improves care quality and outcomes in general practice. However, there is little evidence on patients who subsequently no longer require end-of-life registration, nor on the safety or outcomes of de-registration following clinical review. AimTo determine the prevalence, safety, and prognostic validity of GP-led removal from the end-of-life register (EOL_R) using a systematic digital review process. Design and SettingObservational cohort study in eight practices in Wolverhampton, UK, using a whole-population integrated primary and secondary care dataset. MethodAll adults on the EOL_R were systematically reviewed using a digital end-of-life pathway (PRADA) incorporating robotic process analysis of recognised end-of-life care markers. GPs recorded a binary decision to retain or remove patients from the register. Mortality outcomes were compared with those retained on the EOL_R, a tightly propensity-matched cohort not on the register, and the residual general population over 15 months. ResultsOf 422 registered patients, 33 (7.8%) were removed following GP assessment. One-year survival in the removed group was statistically indistinguishable from the propensity-matched control cohort, and survival was significantly higher versus those retained on the EOL_R (60.4%, p<0.001). Removal demonstrated a negative predictive value for mortality of 90.9%. ConclusionGP-led removal from the end-of-life register can be undertaken safely and identifies a distinct group with substantially better prognosis. Digital systems that support systematic review, documentation, and follow-up should be incorporated into routine practice and reflected in national guidance and the Quality and Outcomes Framework. Statement boxesO_ST_ABSWhat is knownC_ST_ABSEarlier identification and registration of people in the last year of life improves care coordination and outcomes. However, little is known about patients who subsequently no longer require end-of-life registration, or whether removal following clinical review is associated with adverse outcomes. What this study addsIn a whole-population primary care cohort, General Practitioners removed 33 patients (7.8% of those registered) from the end-of-life register following structured clinical review. One-year survival in this group was equivalent to a tightly matched cohort not on the register, and survival was substantially higher than among patients retained on the register. A simple robotic based review process can prompt systematic reassessment, capture GP clinical judgement, and enable prospective monitoring following removal. ImplicationsEnd-of-life registration should be treated as a dynamic process requiring ongoing clinical review. Digital systems can support safe removal from registers by documenting decisions and embedding follow-up for patients whose prognosis remains uncertain. Evidence-based guidance and governance processes for a review process are needed to ensure people are not retained on registers unnecessarily. How this fits inEnd-of-life registers are intended to support proactive care for people in their last year of life, yet there is little evidence about patients who later stabilise and may no longer require registration. In eight UK practices, a systematic GP review supported by a digital end-of-life pathway identified a small but clinically important group suitable for removal, without adverse mortality outcomes. Beyond improving register accuracy, structured review creates opportunities for meaningful dialogue with patients, shared reassessment of care goals, and appropriate de-escalation of end-of-life labelling. Embedding routine, structured review with documented decisions and follow-up may also reduce unnecessary clinical workload and strengthen governance in primary care. Novelty StatementSystematic GP review of end-of-life registers, as stipulated in GMC guidance, is rarely evaluated. We propose a digitally driven, systematic and dynamic clinical-governance-led approach to register review.

Social prescribing has assumed increasing dominance in policy and practice internationally, including in the UK, where it has an increasing role in addressing social needs such as isolation, and social determinants of ill health. Although General Practitioners are perceived as key referral sources, social workers in one locality were found to play a significant role in referral. This suggests that the social work role in this context has been under recognised and under explored. This study sought to explore social workers' perceptions and experiences of social prescribing through an online survey conducted from January to June 2022. All UK social workers were eligible to participate, regardless of whether they had made referrals. A total of 105 responses were collected from all UK nations. Data was analysed using inductive thematic analysis. Four key themes were generated: contended and contested boundaries; complementary spaces; delineated spaces of simplicity and complexity; social work under threat. Participants recognised that social prescribing could provide valuable client support and could be a useful resource for social workers. However, they also expressed concerns about overlapping professional boundaries and the potential for social prescribing to encroach on social work, perceiving it as most appropriate for the delivery of support to those with 'low level' needs.

BackgroundThe COVID-19 pandemic significantly accelerated the adoption of telemedicine, but it also exposed gaps in effective remote clinical assessment, particularly for medically vulnerable patients in rural areas. The ORCHARD intervention aimed to address this by providing patients with a Medical Self-Assessment Box to enable self-reporting of vital signs during remote consultations. MethodsA single-centre randomised mixed-methods feasibility trial recruited medically vulnerable patients from a rural general practice in Northeast Scotland. Participants in intervention group received a home medical equipment box for use during telemedicine consultations over six months. Patients and GPs were interviewed and transcripts were analysed using Framework Analysis. ResultsTwelve (15%) of 82 eligible invited patients enrolled. Six each were allocated to intervention and control group. 50%(n=3)patients in intervention group used equipment in 45%(5 of 11)teleconsultations and rated it helpful in all 5 uses (100%). The intervention group had 18% fewer primary care contacts than controls. All remote consultations were by telephone. Framework Analysis of patient interviews identified facilitators such as ease of use, improved triage access, reassurance, and barriers related to GP non-engagement and written instructions. GP interviews identified clinical value in patient-generated readings, alongside concerns regarding workload and patient over-monitoring. ConclusionsHalf of intervention participants used the medical-equipment box during remote consultations, all finding it useful, though frequency of use varied among particpants.A randomised controlled trial to evaluate the effectiveness of the Medical Self-Assessment Box for optimising remote consulting in medically vulnerable rural patients is feasible.Prior to a definitive trial refinements are recommended to patient labelling, GP engagement, and training materials.

BackgroundGP practices in Scotland are changing with the emergence of megapractices. We aimed to update analyses of GP practice sizes in Scotland, and to begin the development of a typology of GP practices. MethodsFour methods were employed: 1. Analyses of routinely published data on GP practice sizes and listed GPs to identify and quantify megapractices; 2. Qualitative interviews; 3. Creation of commercial profiles; 4. Derivation of a GP practice typology. ResultsMost Scottish practices have less than 9,000 patients, but five megapractices with over 30,000 patients were identified. One had grown by over 18,000 patients in two years to almost 120,000 patients, with the next largest at almost 73,000 patients. Megapractices did not engage with interviews, but commercial profiling revealed an array of complex legal and financial arrangements for several of them. We suggest that the key parameters for describing practices should focus on: ownership, legal status and motives; the extent of service provision by doctors or Allied Health Professionals (AHPs); and practice list size. We tentatively propose four common practice types in Scotland: traditional practices, megapractices, social enterprise practices, and direct NHS provision, recognising substantial diversity amongst megapractices. ImplicationsPolicymakers should carefully consider the risks of the current drift in approach to GP provisioning. Evaluation of the impacts of new service models on healthcare access, health outcomes and inequalities is urgently needed.

BackgroundMany people experience long waiting times for hip and knee replacement surgery, negatively impacting physical conditioning and quality of life, and therefore need evidence-informed strategies to support them while they are waiting. ObjectiveTo develop consensus-based recommendations for supporting people waiting for hip or knee replacement in Scotland. DesignThree-round online modified Delphi study involving 17 people with experience of waiting for hip or knee replacement and 30 professionals involved in supporting them. MethodsTwo rounds of online survey and one online workshop. Participants rated agreement with 113 (round 1), 40 (round 2) and 20 (round 3) statements on a 5-point Likert scale, with consensus based on [&ge;]70% agreement. Items were modified and added in subsequent rounds based on content analysis of participant comments. The final recommendations represent items that reached consensus in both participant groups after 3 rounds. Results47 participants took part in round 1 (17 patients, 30 professionals), 41 in round 2 (13 patients, 28 professionals) and 23 in round 3 (8 patients, 15 professionals). Eighty-two of 113 statements reached consensus in round one, 20 of 40 in round two and 6 of 20 in round 3. The final recommendations comprise 108 statements relating to: preoperative education; patient optimisation; other interventions to support people waiting; and, strategies to support people waiting a long time for surgery. ConclusionsThese findings are an important step towards developing best practice guidance for supporting people waiting for hip and knee replacement in Scotland.

An understated disruption to health services brought about by the Covid-19 pandemic was the increase in deaths occurring outside a hospital. Since quality of end-of-life care is typically monitored through place of death and hospital activity, a new approach focused on care in community settings is needed. In this study, we aimed to test whether patient-centric measures of quality at the end of life can be derived from primary care electronic records. With the approval of NHS England, analysis was undertaken in OpenSAFELY-TPP using electronic health care records of over 970,000 patients who died between March 2019 and August 2023, covering periods before, during and after the pandemic. We developed two new measures of end-of-life care quality--specialist palliative care team contacts and advance care planning, and tracked the proportion of patients with these records, categorized by place and cause of death, along with an existing measure indicating palliative care needs. The proportion of people with a GP record of specialist palliative care was 4-5% on average, higher for those who died of cancer or died in a hospice. Advance care planning records increased from 19% to 27% (barring a decrease following the onset of the Covid-19 pandemic) driven in large part by increases for patients who died in care homes. Advance care planning and recording of palliative care needs were plausible measures to track changes in care, unlike the specialist palliative care measure where recorded use was sparse. Improved coding in primary care records would improve reliability of measures. Key messagesO_LIQuality of end-of-life care is traditionally measured by how patients use health services (for example emergency department attendances) C_LIO_LIWe used routine GP health records to track aspects of end-of-life care quality which matter to patients and discuss the impact of the covid-19 pandemic on these quality measures C_LIO_LIA new measure of advance care planning and the existing palliative care needs measure could be used to track end of life care delivered in the community C_LIO_LIThe measure of specialist palliative care was sparsely coded and unlikely to be useful unless coding and data linkage between GP and other systems improves C_LI

Objectives: For suspected hip fractures, prehospital protocols directing patients to an orthopaedic centre rather than the nearest emergency department (ED) could reduce time-to-surgery but may impact EMS travel burden. This study evaluates the impact of transfer protocols by quantifying transport to hospitals from long term care (LTC) facilities across Ontario. Methods: A retrospective cross-sectional analysis of all Ontario LTC facilities and hospitals was performed. Two protocols were modeled: standard transfer to the nearest ED with subsequent transfer if required, and selective transfer based on Collingwood Hip Fracture Rule prehospital screening1 directly to the nearest orthopaedic services (orthoED). Median one-way travel distances were calculated from Google Maps. Results: In Ontario, 15.4% of LTC residents require hospital destination decisions because their nearest ED lacks orthopaedic services; for these facilities, median distances were 2.7km to the ED and 36.0km to the orthoED. Among the 52 LTC facilities where selective transfer was distance-optimal, it substantially reduced travel for patients with hip fracture (31.1km vs 49.6km; P<.01) while only modestly increasing travel for patients without hip fracture. Where standard transfer was distance-optimal, little travel difference was noted for patients with hip fracture, however false positive screened patients traveled significantly further to an orthoED. Greatest negative consequences of selective transfer lie in the 1.3% of residents living farthest (>100km) from an orthoED. Conclusions: EMS direct transportation to hospitals with orthopaedics may improve hip fracture care but can increase EMS burden due to patients identified falsely as having a hip fracture, particularly in remote communities.

Context: In the UK, and in other countries, people living with a terminal illness are eligible for financial support to help with the costs of serious illness and to support their dignity and independence. This study investigates the take-up of benefits in the last year of life and identifies sociodemographic, clinical, and geographical factors associated with underclaiming. Methods: Retrospective cohort study using linked mortality, Census and benefits data for all people who died aged 16+ from chronic illnesses in England and Wales between 1 May 2018 and 30 April 2021. Outcome was receipt of non-means tested disability benefits in the last 12 months of life. We describe geographical variation in take up, and association with sociodemographic, clinical and geographical exposures using Poisson models. Findings: Our population included 1,049,493 eligible decedents, with an overall take-up rate of 65.9%. After adjusting for sociodemographic factors, variation in take-up by cause of death was wide: liver disease 44% (95% CI 43, 45%), heart failure 52% (51, 52%), cancer 62% (61, 62%), dementia 75% (74, 75%), and neurodegenerative diseases 90% (88, 91%). Across Local Authorities, the age-and-sex-standardised take-up varied from 53% to 78%; rates were generally higher in more deprived areas, but not uniformly. Conclusions: In England and Wales, 1 in 3 people who die from expected causes (120,000 each year) do not receive the benefits for which they are eligible. Our analysis uses novel data linkages and highlights clinical and sociodemographic groups and geographical areas that could be targeted with proactive take-up initiatives.

BackgroundHip fracture remains a leading cause of morbidity and mortality among older adults in the United States. The aim of this systematic and meta-analytical review is to synthesize available evidence on predictors of one-year mortality following hip fracture among older adults, guided by a socio-ecological framework. MethodsWe searched PubMed, Embase, Web of Science, CINAHL, and Scopus for U.S.-based studies published between 2010 and 2025 reporting one-year mortality after hip fracture. Studies were included if they evaluated predictors of mortality across pre-injury, perioperative, or post-discharge phases. Data were extracted on study design, population characteristics, mortality outcomes, and risk factors. Predictors examined in [&ge;]3 studies were pooled using random-effects meta-analysis, and narrative synthesis was conducted for predictors with limited data. Methodological quality was assessed using the Joanna Briggs Institute checklist. ResultsTwenty-eight studies (n = 835,226) met inclusion criteria. Pooled one-year mortality was 21.8%, ranging from 7.1% to 54.4%. Advancing age and male sex were consistent non-modifiable risk factors. Comorbidity burden, including congestive heart failure, chronic kidney disease, myocardial infarction, and dementia, and measures of frailty and functional impairment were among the strongest predictors, often doubling mortality odds. Perioperative factors such as higher injury severity and delayed surgery, and post-discharge factors including hospital readmission, missed follow-up visits, and postoperative complications, were also associated with increased mortality. ConclusionOne-year hip fracture-related mortality remains high and stems from multifactorial causes. A multi-level, systems-oriented approach may be necessary to meaningfully reduce long-term mortality in this growing and vulnerable population.

IntroductionRemote grip strength assessment offers potential for scalable at-home health monitoring, yet most validated methods require in-person supervision. The Squegg Smart Dynamometer is a Bluetooth-enabled device designed for both supervised and remote app-guided, self-administered testing. Validating self-administered grip strength assessment is essential for clinical and research use. This study evaluated whether self-administered grip strength measurements with the Squegg device are comparable to supervised testing, and examined the influence of participant and procedural factors. MethodsIn this prospective, within-subject comparative study, 96 healthy adults completed grip strength tests with the Squegg device under two modalities: self-administered (app-guided) and supervised (by trained personnel). Covariates included sex, hand dominance, age, education, prior grip testing experience, and test order. Analyses included Shapiro-Wilk tests, ANOVA, and Bland-Altman analysis. ResultsGrip strength residuals met normality assumptions. Guidance modality (self-administered vs. supervised) had no significant effect (F1,270 = 1.41, p = 0.24). The mean difference between modalities was 0.68 lbs relative to an average grip strength of 83.4 lbs (95% CI: -1.77 to 0.41). Sex explained 45% of between-subject variation. Within subjects, variation was associated with hand dominance (6%), test order (4%), and guidance modality (0.4%). No significant effects were observed for age, education, or prior device experience. Bland-Altman analysis showed consistent agreement across the grip strength range. ConclusionsSelf-administered grip strength assessments with the Squegg Smart Dynamometer are comparable to supervised testing, supporting its potential for remote patient monitoring. Future work should confirm findings in broader populations, home settings, and longitudinal contexts.

Background Lumbar fusion and decompression procedures are widely used for degenerative spine conditions but are associated with substantial health care costs and variable outcomes. Orthobiologic treatments, including platelet rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have emerged as less invasive options for select patients who meet surgical criteria. However, concerns remain that orthobiologic care may delay rather than avert surgery, potentially increasing downstream utilization and costs. Comparative evidence on real world utilization and costs is limited. Methods We conducted a retrospective, observational study using linked commercial insurance claims and a national orthobiologic treatment registry. Adults with lumbar degenerative disc disease (DDD) who met criteria for lumbar fusion or laminectomy, foraminotomy, discectomy, and facetectomy (LFDF) procedures, and who received PRP injection (with or without BMAC) or surgery between 2016 and 2023 were included. Two comparisons were evaluated: PRP versus lumbar fusion and PRP versus lumbar decompression procedures. Propensity score matching was used to balance cohorts on demographic characteristics, comorbidities, spine related diagnoses, prior health care use, and severity proxies. Outcomes included spine-related health care resource use and aggregate costs at 12 and 24 months, with exploratory analyses at 36 and 48 months. Costs were estimated using multiple approaches, including Medicare based estimates and commercial payer methods. Results After matching, 133 patients receiving PRP were compared with 2,560 patients undergoing fusion, and 198 patients receiving PRP were compared with 3,960 patients undergoing LFDF. Rates of subsequent spine surgery following PRP were low and below cell suppression thresholds through 24 months, with similar findings in exploratory longer-term analyses. Compared with surgical cohorts, patients receiving PRP had lower rates of postoperative imaging, home health services, and outpatient visits, with no consistent differences in opioid use, magnetic resonance imaging, or physical therapy. At 12 and 24 months, mean aggregate costs were significantly higher for fusion and LFDF cohorts across most costing methods. Cost differences were largest for fusion comparisons and were driven primarily by index procedure costs and higher reoperation and imaging rates in surgical cohorts. Findings were generally consistent across sensitivity and exploratory analyses. Conclusions Among select patients with degenerative spine conditions who meet surgical criteria, PRP was associated with lower health care utilization and substantially lower costs compared with lumbar fusion or LFDF, without evidence of increased progression to surgery. These findings support consideration of orthobiologic options for appropriately selected patients when surgery is not the only viable treatment option. Limitations include selection bias, absence of patient reported outcomes, and claims-based severity measures.

BackgroundPrimary care practitioners are well-positioned to support people of reproductive age in preparing for pregnancy and parenthood. Such "preconception care" is ideally delivered opportunistically during routine consultations, although limited time presents a barrier. AimTo achieve consensus on priority topics for opportunistic preconception care in general practice. Design and settingA three-step consensus study involving UK-based primary care practitioners and people of reproductive age. MethodThe consensus process involved: 1) identifying potential topics through literature and guideline reviews, workshops with people of reproductive age (n=15), and interviews with primary care practitioners who work in general practice (n=14); 2) prioritising topics using a Delphi survey (n=85 participants completing round one, n=63 completing all three rounds); and 3) agreeing on priority topics during an online consensus workshop (n=21 participants). Participants were recruited through a Public Advisory Group, charities, and professional organisations. ResultsReviews and workshops/interviews with people of reproductive age and practitioners identified 37 potential topics. The Delphi survey and consensus workshop identified 16 priority topics. These were combined into four overarching topic areas for discussion during relevant consultations: O_LIPatient knowledge of preconception health and pregnancy C_LIO_LIIdeas, concerns and expectations (e.g. pregnancy intention, prior pregnancy experiences) C_LIO_LIHealth conditions (e.g. medication use, mental/physical health, immunisation) C_LIO_LIHealth behaviours (e.g. folic acid supplement use, smoking, alcohol consumption). C_LI ConclusionThe agreed priority topic areas offer a structured foundation for delivering patient-centred, opportunistic preconception care in primary care. The findings support future co-development of practical tools and resources to enable routine implementation. How this fits inPreconception care improves pregnancy outcomes, but in UK general practice it is inconsistently delivered, partly due to limited time and guidance that offers little prioritisation for opportunistic consultations. This study identifies four overarching topic areas for preconception care, based on consensus among people of reproductive age and primary care practitioners. The resulting priority list offers clinicians a practical, flexible way to initiate patient-centred preconception care discussions within routine consultations.

Purpose: Neurogenic dysphagia is prevalent in neurological inpatients and associated with adverse outcomes, yet its independent economic impact after adjustment for frailty and functional status remains poorly quantified. We aimed to estimate the independent effect of dysphagia on hospital length of stay (LOS) and costs, to test whether this effect differs between geriatric and non-geriatric patients, and to quantify the probability and magnitude of cost savings from improvements in swallowing function. Methods: We analysed 10,375 neurological inpatient cases (2021-2024) at a German university hospital. Dysphagia was defined by fiberoptic endoscopic evaluation of swallowing (FEES) or ICD-10 R13 coding (n = 1,382; 13.3%). Bayesian Gamma-log regression with informative priors from historical data and published literature was used to model LOS and total case costs (German DRG), adjusted for age, sex, Hospital Frailty Risk Score (HFRS, R13-adjusted), self-care index ("Selbstpflege-Index", SPI), stroke status, and emergency admission. A geriatric cohort was defined as age >=70 and adjusted HFRS >=5 (n = 2,053; 19.8%). Posterior predictive simulation estimated cost savings for hypothetical improvements of 1-3 points on the Functional Oral Intake Scale (FOIS). Results: After comprehensive adjustment, dysphagia was independently associated with 46.5% longer LOS (posterior ratio 1.465; 95% credible interval [CrI] 1.397-1.537) and 28.2% higher total case costs (ratio 1.282; CrI 1.213-1.354). The dysphagia x geriatric interaction was small but credible and ran in opposite directions: slightly attenuated for LOS (interaction ratio 0.908, CrI 0.837-0.986) but slightly amplified for costs (1.096, CrI 1.012-1.185), consistent with complexity-driven DRG grouping in geriatric patients. The absolute economic burden remained larger in the geriatric cohort due to higher baseline costs. In the geriatric cohort, a one-point FOIS improvement yielded a 74.3% posterior probability of LOS-based savings (mean EUR 555/case); at three points, this rose to 84.2% (mean EUR 1,115/case). The direct cost model confirmed high benefit probabilities from the payer's perspective (82.6% at dFOIS = 3). Conclusions: Neurogenic dysphagia is an independent and substantial driver of hospital LOS and costs in neurological inpatients, even after adjustment for frailty and functional status. The proportional effect on costs is slightly larger in geriatric patients, while the LOS effect is slightly smaller, consistent with the mechanics of the G-DRG system. Bayesian simulation indicates that improvements in swallowing function carry a high probability of generating cost savings, supporting the characterisation of dysphagia as a modifiable economic target with particular relevance to geriatric neurology.

IntroductionAge-group specific disparities for dentalcare use persist in the United States. The COVID-19 led to delays in non-urgent dentalcare. We provide national estimates on dentalcare use and influencing factors for the U.S. population before and during the COVID-19. MethodsWe used nationally representative Medical Expenditure Panel Survey for over pre-COVID-19 years (2018-2019) and COVID-19 years (2020-2021) We estimated yearly survey-weighted trends in mean non-zero dental visits by age followed Poisson regression, controlling for a comprehensive set of confounders across five domains of influence. Dentalcare visits were defined as visits to any dentalcare provider. ResultsOverall analytic sample included non-institutionalized community living persons (unweighted n=6518, weighted N[~]320 million) grouped as ages 0-17, 18-44, 45-64, 65-74 and 75+ present in all four years The prevalence ratio (PR) for dental visits was slightly higher for ages 75+ in comparison to ages 65-74 across years 2018-2021 and increased from 1.73 (95% CI: 1.4, 2.1) to 1.84 (95% CI: 1.5, 2.3) to 2.13 (95% CI: 1.7, 2.7) from 2018 to 2020 but rebounding to near pre-pandemic level in 2021 to 1.66 (95% CI, 1.3, 2.0). Consistent factors during COVID-19 pandemic years 2020-2021 that increased dental visits included dental insurance, high income, and having a usual source of care (p<0.01). ConclusionsDentalcare use rebounded for older adults in 2021 but remained below pre-pandemic levels. Practical ImplicationsIncreasing dentalcare visits across ages remains a key policy priority. Continued monitoring of dentalcare use trends beyond COVID-19 among older adults is critical to improve their oral health.

Background: With an aging population and increasing comorbidities, supporting people to remain at home for as long as possible is essential. A major challenge in home care is ensuring coordinated, interprofessional collaboration among all actors involved: patients and their close ones, health and social care professionals, and the broader health and social network. To address this challenge, a new organizational model promoting reinforced interprofessional collaboration, the "Reseau Interprofessionnel Ambulatoire de Proximite" (Local Interprofessional Outpatient Network; RIAP) has recently been developed in the canton of Geneva. The aim of this paper is to present the protocol for a research project evaluating both the effectiveness and implementation of this model. Methods: This is a type-2 hybrid effectiveness implementation study guided by the RE-AIM framework, aiming to evaluate the RIAP organizational model and its implementation, context, and outcomes. This multi-method study will examine the RIAP model under real-world conditions. Routinely collected data on patient outcomes and institutional processes will be used to compare the RIAP model with usual care. Questionnaires will assess patients' perceptions of continuity of care, professionals' perceptions of interprofessional collaboration, and stakeholders' views on the acceptability of the model. Open-ended questions will be included to explore experiences and insights in greater depth, complemented by qualitative data on barriers and facilitators to implementation. Financial indicators will also be analyzed to contextualize the model within the institutional setting. Results: The EFFI-RIAP project began in October 2025 and has a planned duration of 22 months. The project will primarily rely on the reuse of institutional routine data, complemented by questionnaires and interviews scheduled for September 2026. At the time of submission, study preparation and institutional data processing are ongoing. Discussion: This research will provide insights into the clinical, organizational, and implementation-related effects of the RIAP model compared with usual care. The natural deployment of new RIAP teams will enable investigation of the organizational model under real-world conditions. The combined evaluation of the effectiveness and implementation of RIAP will assess the model's added value, inform refinement, and identify potential barriers and facilitators relevant to implementation in other teams.

Purpose: To understand how the Philips PAP device recall affected patient experiences, clinical practice, and health system responses. Methods: From November 2022 to August 2023, we interviewed individuals with OSA, physicians, respiratory therapists and health system leaders. We also received emailed responses from Health Canada. Interviews explored participants' experiences with the recall announcement and communication, their own responses and perceptions of actions taken by others, the overall impact of the recall and suggestions for improving future recall processes. Interviews were analyzed using an inductive thematic approach. Results: We interviewed 47 participants (16 individuals with OSA, 10 physicians, 17 public or private respiratory therapists, five health system leaders). Themes were organized into four domains: recall communication, execution, participant experiences, and the policy and regulatory context. Participants were confused due to inadequate information from Philips throughout the process. The burden of notifying patients and tracing devices mostly fell to healthcare providers and vendors, while replacement efforts were disorganized and frustrating. Individuals with OSA experienced emotional distress over therapy decisions and difficulties navigating the recall. Healthcare providers described moral distress from being unable to support patients adequately, and vendors faced additional logistical and financial strain. While regulatory authorities reported that Philips followed standard procedures, participants expressed a loss of trust in both the manufacturer and oversight systems. Conclusions: Interviews revealed that poor communication and execution of the Philips recall caused confusion, frustration and significant emotional and financial burden. Collaborative, context-specific strategies are required to improve future recalls.

BackgroundOptimal rehabilitation dosing after ischaemic stroke remains contested. Linear assumptions underlying conventional regression models may mask clinically important threshold effects, whereby functional gains accelerate or plateau beyond specific intensity thresholds. This study applied panel threshold regression to Australian hospital administrative data to identify endogenous breakpoints in the dose-response relationship between rehabilitation intensity and functional recovery. MethodsWe used a retrospective longitudinal cohort derived from the Australian Stroke Clinical Registry (AuSCR) and the National Hospital Cost Data Collection (NHCDC) for fiscal years 2018-2019 to 2022-2023. The analytical sample comprised 18,742 hospitalised ischaemic stroke patients across 48 public hospitals in five Australian states. The primary exposure was daily rehabilitation intensity (minutes of physiotherapy, occupational therapy, and speech pathology per inpatient day). The primary outcome was change in the modified Rankin Scale (mRS) score from admission to discharge. We employed Hansens (1999) panel threshold regression framework to test for single, double, and triple threshold effects, using bootstrap p-values (n=500) to establish statistical significance. Fixed-effects estimation controlled for unobserved hospital heterogeneity. Secondary outcomes included acute length of stay and discharge destination. Cost-related parameters were benchmarked against published Australian cost-effectiveness data. ResultsThe panel threshold model identified two statistically significant breakpoints in the intensity-recovery relationship (p<0.001 for both). Below the first threshold (27.4 minutes/day; 95% CI: 24.8-29.6), each additional minute of daily rehabilitation was associated with a 0.008-point reduction in mRS score (beta = -0.008, 95% CI: -0.011 to -0.005, p<0.001). Between the two thresholds (27.4 to 54.7 minutes/day; 95% CI: 51.2-58.9), the marginal benefit approximately doubled (beta = -0.018, 95% CI: -0.022 to -0.013, p<0.001). Above the upper threshold (>54.7 minutes/day), the marginal effect diminished substantially (beta = -0.004, 95% CI: -0.009 to 0.002, p=0.186), suggesting a ceiling effect. These dose-response patterns were consistent across age subgroups, stroke severity strata, and hospital volume tertiles. ConclusionsRehabilitation intensity thresholds exist in stroke inpatient recovery and are non-linear. Patients receiving between 27 and 55 minutes of daily multidisciplinary therapy derive disproportionate functional benefit per unit of resource investment. Scheduling rehabilitation below the lower threshold represents a clinically and economically suboptimal allocation of inpatient resources. These findings have direct implications for workforce planning, clinical pathway design, and value-based commissioning in Australian public hospitals.

BackgroundRecurrent sore throat affects a small minority of adults but can cause substantial morbidity. Evidence to guide tonsillectomy eligibility in adults is limited, and current criteria are extrapolated from paediatric populations. We aimed to describe the epidemiology, management, and prognosis of adult sore throat in UK primary care. MethodsUsing CPRD Aurum (2010-2020 adults with a first coded episode of sore throat or tonsillitis were identified and matched to controls. Episode frequency, antibiotic use, ENT referral, and tonsillectomy were analysed. Predictors of recurrent episodes ([&ge;]3 in 365 days), referral, and tonsillectomy were assessed using time-to-event, multinomial logistic, and multilevel mixed-effects regression models. FindingsOf 4.45 million adults, 1.70 million (38.3%) had [&ge;]1 episode; most (61.5%) had only one, but 4.1% experienced [&ge;]3 within 1 year. Recurrent episodes were more common in younger females and those from more deprived areas. Only 21,869 patients (0.5% of the exposed cohort) underwent tonsillectomy, and just 25.7% of these met Paradise criteria at any time; conversely, only 13.9% of those meeting criteria underwent surgery. Patients who had a tonsillectomy tended to be younger, female, and from less deprived areas. Pre-tonsillectomy episode rates were unexpectedly low, but the data indicated that individuals with high baseline burden continue to experience elevated episode rates over several years. ConclusionsRecurrent sore throat is uncommon, but those affected face substantial disease burden. Current tonsillectomy patterns are poorly aligned with disease burden and show inequities by deprivation. Earlier identification of adults likely to develop recurrent episodes, and more timely surgical intervention, may improve patient outcomes and the cost-effectiveness of tonsillectomy.