BJGP Open

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 [≥]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.

BackgroundHealth literacy (HL) influences communication quality, treatment adherence, and equity in care. However, how general practitioners (GPs) recognize and respond to patients HL in everyday clinical reasoning remains insufficiently understood. ObjectiveTo investigate how Danish GPs incorporate patients health literacy into decisions about prescribing pain medication for chronic musculoskeletal pain, using insights from surveys, interviews, and a literature review. MethodsA mixed-methods design combined survey data from 39 Danish GPs, seven qualitative interviews, and a synthesis of 14 studies on HL in general practice. The literature was used to contextualize and contrast the empirical findings. Quantitative data were analyzed descriptively, while qualitative data underwent thematic analysis. All three datasets were integrated through mixed-methods comparison to assess convergence, divergence, and complementarity. ResultsAcross the integrated survey, interview, and literature findings, HL emerged as a largely implicit but consistent element of GP decision-making. In the Danish survey and interview data, some GPs explicitly reported considering HL in prescribing decisions, yet interviews showed that HL more often influenced clinical reasoning indirectly through intuition and conversation. GPs adapted communication, explanations, and treatment planning to their perceptions of patient understanding, but these adjustments were rarely guided by structured tools or frameworks. Conversation appeared as the main approach for assessing comprehension, echoing patterns observed in the literature. Many Danish GPs perceived most patients as competent and self-managing, a perception the literature cautions may mask hidden comprehension challenges. Finally, both local interviews and existing studies highlighted digital HL as an emerging theme, with GPs commonly managing patients online health information through conversational reframing rather than formal strategies. ConclusionsHL is tacitly integrated into GP reasoning but remains under-recognized as a professional skill. Making HL an explicit component of communication training, reflective practice, and prescribing guidelines could improve patient understanding, shared decision-making, and treatment equity.

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.

BackgroundOxycodone is widely prescribed for managing acute pain in emergency departments (ED), but the appropriateness of this prescription is not fully established. Although concerns about opioid misuse and dependence drive efforts to reduce inappropriate prescribing, there is increasing recognition of the importance of adequate pain management. Therefore, it is essential to develop appropriate prescribing criteria that balance the risks and benefits of opioids, ensuring their benefits are maximised while minimising potential harm. ObjectiveFollowing the recommended format for a research protocol paper, this protocol describes the process and methods used to develop evidence-based criteria for oxycodone prescribing in the ED, informed by scientific evidence and expert clinical judgment, using the RAND/UCLA Appropriateness Method. MethodThe process will be carried out in sequential stages. First, scope and key terms will be defined, and then a targeted literature review will be conducted to synthesise available evidence. Subsequently, based on this synthesis and the investigator teams clinical insights, clinical scenarios will be developed in collaboration with field experts. A multidisciplinary panel comprising specialists in emergency medicine, emergency nurses, and pharmacists will evaluate these scenarios in two rounds. Each scenario will be rated on a 1-9 scale, where 1 indicates that harm outweighs benefit and 9 indicates that benefit outweighs harm. The median rating score will fall between 1 and 9, where 1-3 without disagreement is inappropriate, 4-6 without disagreement is uncertain, and 7-9 without disagreement is appropriate. Disagreement is defined as at least three experts scoring in both extremes. Final scenario ratings will be presented according to their assessed appropriateness and used to inform appropriateness criteria for prescribing oxycodone in the adult ED. ConclussionThe RAND/UCLA Appropriateness Method offers a systematic and evidence-informed framework for developing prescribing criteria to support the appropriate use of oxycodone in adult ED.

ObjectivesCurrent methods of health expenditure reporting make spending on palliative care services difficult to quantify. This paper (1) examines trends in the components of government (public) spending on health-related long-term care reported in the UK Health Accounts for the period of 2013 to 2022 to establish the wider context of palliative care expenditure, and (2) relates these trends to existing knowledge of expenditure on specialist palliative care services in the UK. MethodsWe conducted a descriptive secondary analysis of annually reported government expenditure on health-related long-term care between 2013 and 2022 from the UK Health Accounts dataset. We contrasted this with UK governmental and non-governmental spending on specialist palliative care services using annual expenditure figures reported by Hospice UK. ResultsReal-terms UK government spending on health-related long-term care grew by {pound}6.4 billion (22.9%) between 2013 and 2022, from {pound}27.9 to {pound}34.3 billion. Real-terms spending on specialist palliative care grew by {pound}110 million (10.7%) over the same period, from {pound}1,027 to {pound}1,137 million. In 2022, spending on inpatient care comprised the majority of government health-related long-term care expenditure ({pound}22.6 billion; 65.9%). Home-based care comprised one-third ({pound}11.8 billion; 33.4%). Outpatient care accounted for 0.7% ({pound}260.2 million). Equivalent data was not available for analysis of specialist palliative care expenditure. ConclusionsLow granularity of UK national health expenditure accounts limits national and international comparisons of spending on palliative care. However, it is clear that UK expenditure on specialist palliative care services has not kept pace with growth in expenditure on health-related long-term care. What is already known on this topicO_LIGlobal demand for palliative care is increasing as rates of serious life-limiting illness, dementia, cancer and multiple long-term conditions rise internationally. C_LIO_LIIncreasing complexity of illness and population ageing are two factors implicated in both rising healthcare expenditure and growing demand for palliative care internationally. C_LIO_LIThe UK has previously been ranked as providing the highest quality of palliative care amongst international competitors - however, concerns about the longevity of funding sources for specialist palliative care services has led to calls for further investment. C_LI What this study addsO_LIReal terms UK government spending on health-related long-term care - which includes, but is not limited to, palliative care services - increased by 22.9% between 2013 and 2022. C_LIO_LIOver the same period, UK spending on specialist palliative care services as reported by Hospice UK grew by only 10.7%. C_LIO_LIOur results take into account health-related social care spending, which forms a key part of care for people living with illness, including those receiving palliative care services. C_LI How this study might affect research, practice or policyO_LIThe future of funding for specialist palliative care in the UK is uncertain, and current funding frameworks are complex. This paper adds to ongoing policy discussions surrounding this issue, highlighting the discrepancy between growth in public sector spending on health-related long-term care and overall spending on specialist palliative care services (from governmental and non-governmental sources). C_LI

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.

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.

BackgroundAnticipatory injectable medications for symptom control are a key end-of-life care intervention. However, ensuring their safe and timely use in the community is a global challenge. The needs and priorities of stakeholders involved in processes for prescribing and administering these medications remain underexplored. We must understand these perspectives to design inclusive and adaptive systems. AimTo identify the needs and priorities of key stakeholders involved in community-based systems for using anticipatory injectable medications. DesignWe adopted a qualitative exploratory design, using an online survey between September and October 2024. Participants provided anonymised demographic information and completed up to four prompts capturing their stakeholder role, needs and priorities. Data were analysed using a combined inductive-deductive framework to produce synthesised shortlists of priorities and needs. Setting/participantsUK-based professional and public participants were recruited through social media, professional networks, charities, and public engagement events. ResultsIn total, 439 participants contributed 729 responses across various stakeholder groups. Findings revealed substantial diversity in stakeholder needs and priorities, both within and between groups. However, most stakeholder groups prioritised timely care, minimising of suffering, and wanted nationally consistent guidance for using injectable medications. Broader societal influences also shaped responses. ConclusionsOur findings highlight wide diversity in priorities and needs between stakeholders for using anticipatory injectable medications in the community. We propose that inclusive system design should include comprehensive assessment of key stakeholders needs and priorities, with the aim of providing better care. Our study demonstrates that stakeholder needs assessment offers a valuable framework to achieve this. What is already known about the topic?O_LIAnticipatory injectable medications are a widely used intervention in several countries to support timely end-of-life symptom control at home. C_LIO_LIThere are ongoing challenges with delays, inconsistent access, and variations in prescribing and governance across regions, indicating that system design influences both timeliness and safety. C_LIO_LIExisting research has primarily focused on the needs of individual professional groups, and no prior work has mapped the differing needs of all stakeholders involved in these systems. C_LI What this paper adds?O_LIOur study demonstrates that stakeholder groups have diverse needs but most share some core priorities -timely care, national consistency in practice guidance, and minimising suffering. C_LIO_LIWider societal factors and concerns shape stakeholder expectations of end-of-life medication systems. C_LIO_LIOur approach to stakeholder needs assessment reveals system requirements that consensus-based or single-perspective approaches often overlook. C_LI Implications for practice, theory, or policyO_LISystem improvements should be tailored to the specific needs of key stakeholder groups rather than assuming uniform priorities. C_LIO_LIStrong cross-stakeholder support exists for national, practical guidance on anticipatory prescribing, equipment, training, and governance. C_LIO_LIStakeholder needs assessment offers a useful method for designing safer, more responsive end-of-life medication systems. C_LI

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

BackgroundType 2 diabetes (T2DM) and cognitive impairment are common long-term chronic conditions affecting older people in hospital. Cognitive impairment can complicate glucose monitoring and lead to diabetes-related emergencies in T2DM. Traditionally, point of care test (POCT) measurements of capillary blood glucose are conducted in-hospital for T2DM while continuous glucose monitoring (CGM) is not widely used. AimTo understand the feasibility, acceptability and tolerability of using CGM in older in-patients with T2DM and cognitive impairment. MethodsThirty-two older people (mean age = 78.7 {+/-}6.7 years) with comorbid T2DM and cognitive impairment (AMT [≤]8/10 and Mini-ACE [≤]22/30) were recruited within a tertiary care hospital in the UK. All participants were naive to CGM and were asked to wear blinded Dexcom G7 sensors for up to 10 days. Participants were asked about feasibility, acceptability and tolerability questions at the point of sensor removal. ResultsTwenty-nine participants (96%) reported no pain during CGM fitting. All participants (100%) agreed that they did not notice wearing the sensor, and it did not affect their day-to-day hospital activities. All participants (100%) found it very easy or easy to have the sensor fitted and wearing it for 10 days, with 27 participants (90%) finding CGM convenient. Seventeen participants (57%) reported favourable perceptions of the subcutaneous sensor sensation. ConclusionCGM use in older in-patients with T2DM and cognitive impairment is highly feasible and acceptable for patients. Future studies and trials are now needed to evaluate the clinical use of CGM for glucose monitoring in hospitalised or community-dwelling older individuals with T2DM and cognitive impairment.

QuestionDo advanced practice physiotherapists succeed in conducting shared decision-making (SDM)? DesignA prospective cross-sectional observational study of patients with musculoskeletal pain and their perceptions of SDM measured using the CollaboRATE instrument. Written feedback was collected after consultation to gain understanding of patients experiences of their consultations. ParticipantsChronic pain patients (n = 5123) diagnosed with either upper limb (n = 1230, 24%), lower limb ((n = 3044, 59.4%), or foot/ankle pain (n = 849, 16.6%) consulting an advanced practice physiotherapist across two hospitals in the UK between January 2023 and December 2024. ResultsMean total CollaboRATE scores across all items were 11.9 ({+/-}0.53). Overall, 4906 (95.8%) of participants gave the maximum CollaboRATE score of 12. No significant differences were observed between sites (p < .001). A regression model including site and pain category was statistically significant but explained minimal variance (R{superscript 2} = 0.004), suggesting other factors contribute more substantially to SDM perceptions. From 949 patient responses, our qualitative analysis revealed a generally positive SDM experience with advanced practice physiotherapists. Feedback clustered around five key themes: 1) feeling valued and involved, 2) communication, expertise, and clarity, 3) compassionate and professional care, 4) efficient organisation, and 5) negative experiences. ConclusionAdvanced practice physiotherapists were largely successful in facilitating SDM, with patients reporting positive experiences across both clinical sites. While quantitative findings showed minimal influence of site or pain category, qualitative insights highlighted the importance of clinician communication, empathy, and involvement of patients in care planning as key drivers of SDM perceptions.

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.

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.

ObjectiveTo explore how younger and older adults in the UK experience, manage, and seek treatment for long COVID-related cognitive impairments, and to identify their treatment preferences and expectations. DesignQualitative study using Charmazs (2014) constructivist grounded theory methodology. SettingOnline, semi-structured interviews conducted with UK adults reporting long COVID-related cognitive symptoms, recruited via patient support groups and research panels. ParticipantsTwenty-one adults with long COVID cognitive impairments: 10 younger participants aged 25-38 years and 11 older participants aged 60-72 years. Main outcome measuresPatients lived experiences, coping strategies, healthcare interactions, and treatment preferences and expectations for non-pharmacological and pharmacological interventions, analysed through iterative coding, constant comparison, and theory generation. ResultsIn the absence of effective treatments, both age groups relied heavily on self-management strategies (e.g., memory aids, structured routines, pacing). Interactions with healthcare were characterised by validation from some clinicians but widespread frustration at the lack of treatment options. Younger adults were more proactive in seeking experimental therapies and clinical trials, while older adults emphasised pragmatic adaptation, independence, and cautious optimism. Across groups, participants preferred non-pharmacological interventions (e.g., cognitive rehabilitation) but also expressed hope for biomedical treatments. The central process identified was "striving for agency" in the face of ongoing cognitive difficulties. ConclusionsThis study highlights the urgent unmet need for evidence-based interventions to address long COVID-related cognitive impairment. Health services should provide practical cognitive rehabilitation and support, and clinicians should acknowledge and validate patients cognitive struggles rather than dismissing them as normal ageing or purely psychogenic in origin. Research into therapeutics (e.g. cognitive training programs, pharmacotherapies) is urgently desired by the participants in this study. Effective solutions will need to be holistic and individualised - addressing not only memory and concentration deficits but also the psychological and social challenges associated with long COVID cognitive impairment in different age groups. WHAT IS ALREADY KNOWN ON THIS TOPICO_LIA large proportion of people with long COVID experience persistent cognitive difficulties, often described as "brain fog," with substantial impact on daily functioning and employment. C_LIO_LIMost studies have focused on symptom prevalence, biological mechanisms, or broad psychosocial consequences. C_LIO_LILittle is known about patients treatment preferences and expectations, and almost no research has explored generational differences between younger and older adults. C_LI WHAT THIS STUDY ADDSO_LITo our knowledge, this is the first qualitative study in the UK to compare younger and older adults perspectives on managing long COVID-related cognitive impairment. C_LIO_LIBoth groups described "striving for agency" through self-management, validation-seeking in healthcare, and balancing preferences for pharmacological and non-pharmacological treatments. C_LIO_LIYounger adults were more proactive in seeking experimental therapies and trial participation, while older adults emphasised pragmatic adaptation and maintaining independence. C_LI HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICYO_LIHealthcare services should expand access to cognitive rehabilitation and psychosocial support, while clinicians should validate patients experiences rather than attributing them to ageing or stress. C_LIO_LIFuture research must test both pharmacological and non-pharmacological interventions, with study designs informed by patient priorities and generational needs. C_LIO_LIPolicymakers and service providers should tailor care pathways to life stage: supporting younger adults with workplace accommodations and research opportunities, while providing older adults with reassurance, independence-focused care, and monitoring for possible accelerated cognitive ageing. C_LI

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.

Background.Only one in five people with hypertension have their blood pressure (BP) controlled (<140/90 mmHg). Patient education improves BP control, yet there is limited guidance to adapt to individuals evolving needs across the hypertension management journey. This study aimed to identify key behavioural barriers and enablers to patient education throughout the hypertension management journey, which were synthesised into patient personas to support translation and practical application. Methods.Qualitative interviews with adults ([&ge;]18) who self-monitor BP, and primary care providers involved in hypertension care. Interviews explored the experience of accessing and delivering patient education for BP measurement and management. Using framework analysis, patient personas were developed in three steps: 1) thematic analysis of patient interviews to identify key barriers and enablers to hypertension patient education and mapping the identified barriers and enablers to key time-points in the hypertension journey (diagnosis, treatment initiation, long-term management), 2) clustering behavioural factors via the capability, opportunity, motivation-behaviour model, which were then synthesised as preliminary patient personas and refined using practitioner interviews and, 3) validation by consumer consultation feedback sessions. Results.Patients (n=27) and practitioners (n=12; n=4 general practitioners, n=4 nurses, and n=4 pharmacists) were aged 18-60 years (52% of patients and 100% of practitioners fell within this age range). Several behavioural barriers to patient education for hypertension management included patient overwhelm, inconsistent guidance provided by health professionals, and perceived patient disengagement, while a strong desire to self-manage was a consistent enabler. Six clusters of behavioural barriers and enablers were synthesised as patient personas, capturing the factors that shape education needs and experiences across the hypertension management journey. Conclusions.The patient personas highlight opportunities for tailored patient education strategies through the development of patient personas. Practice implications.The patient personas provide a practical tool for designing person-centred interventions in primary care.

Background/ObjectiveBarriers in access to care have prompted development of innovative care delivery models for patients with obstructive sleep apnea (OSA). One such innovation is management of uncomplicated OSA by primary care providers (PCPs), which reserves specialist capacity for more complex patients. We developed a clinical guideline and subsequently, an online clinical pathway to support PCPs in OSA management. We aimed to evaluate the impact of these initiatives on PCP behaviour by assessing changes in the complexity of newly referred patients. MethodsWe compared data for new OSA referrals to the Foothills Medical Centre Sleep Centre in Calgary, Canada, received during three distinct referral periods: prior to the clinical guideline (November 2016 - March 2017; Period 1), after implementation of the clinical guideline (April 2017 - November 2018; Period 2), and after publication of the online primary care pathway (December 2018 - November 2019; Period 3). The primary outcome was OSA severity as defined by the oxygen desaturation index (ODI) on home sleep apnea testing performed at the time of referral. Secondary outcomes included severity of daytime sleepiness and proportion of patients with severe OSA or severe daytime sleepiness at the time of referral. Multivariable linear and logistic regression models were constructed to quantify the associations between study outcomes and Period after adjustment for baseline covariates. ResultsAmong the 2489 patients with sleep study data available, patients referred in Period 3 had more severe OSA (ODI, mean nocturnal oxygen saturation, proportion with severe OSA) compared to patients referred in earlier Periods. Severity of sleepiness did not increase across Periods. In multivariable analysis adjusting for demographics and comorbidities, ODI was significantly associated with Period (regression coefficient 1.70 (0.39, 3), p = 0.011) but severe OSA was not (odds ratio 1.17 (0.99, 1.39), p = 0.069). ConclusionsOSA severity increased following implementation of educational resources to support primary care OSA management. These findings suggest that with appropriate supports, PCPs may be more comfortable managing less severe OSA patients independently and only refer more severe cases for specialist consultation.

BackgroundChronic kidney disease (CKD) affects approximately 10% of adults in England. <1% progress to end stage-kidney disease (ESKD), significantly impacting health-related quality of life with high healthcare costs. CKD is associated with cardiovascular disease risk. New therapies to improve outcomes highlight the need for effective risk stratification. AimTo explore primary care teams views and experiences of CKD risk stratification. Design and SettingQualitative interview and focus group study with GP practices in South England, South London and Yorkshire. Method26 semi-structured interviews with GPs, pharmacists and practice nurses, and 4 focus groups (31 participants) with practice teams including clinical, administration and management staff, February 2024 to January 2025 across 20 practices, informed by normalisation process theory (NPT), using thematic analysis. ResultsWe identified 4 key themes: 1) Awareness of diagnostic criteria and risk stratification tools, 2) Value of coding CKD and discussion of risk, 3) Barriers to CKD risk stratification, 4) Improving CKD risk stratification. Despite universal awareness of diagnostic criteria, there was low awareness of risk stratification tools. Coding was perceived as valuable for health professionals but not for patients. Concerns included increasing patient anxiety and over-medicalisation. Time pressures and lack of incentivisation were perceived as key barriers. Improved healthcare professional education, guidelines, pathways and technology/automation were highlighted as areas of potential improvement. ConclusionPrimary care awareness of CKD is high, but workload, time pressures, and concerns regarding patient anxiety and over-medicalisation contribute to incomplete risk stratification. Refining risk stratification procedures and effective patient communication could improve care.

BackgroundTotal knee arthroplasty (TKA), partial knee arthroplasty (pKA), and arthroscopic meniscectomy are among the most commonly performed procedures for knee osteoarthritis and degenerative meniscal tears in the United States, yet concerns persist regarding overuse, variable clinical benefit, and high costs. Orthobiologic treatments, including platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have emerged as less invasive alternatives, but downstream health care resource use (HCRU) and costs associated with these treatments relative to surgery are not well established. MethodsWe conducted a retrospective, observational cohort study using linked commercial insurance claims data and a national orthobiologic treatment registry to compare downstream HCRU and costs following orthobiologic versus surgical treatment of knee conditions. Two comparisons were evaluated separately: (1) PRP versus arthroscopic meniscectomy among patients with degenerative meniscal pathology and minimal osteoarthritis, and (2) BMAC with or without PRP versus TKA or pKA among patients with knee osteoarthritis. Eligible procedures occurred between 2016 and 2023. Propensity score matching was used to balance demographic and clinical confounders. Co-primary outcomes were total health care costs at 12 and 24 months post-procedure, with exploratory analyses at 36 and 48 months. Costs were estimated using multiple approaches, including Medicare-based estimates, commercial payer estimates, and aggregate allowed amounts. HCRU outcomes included outpatient visits, physical therapy, imaging, opioid use, repeat injections, and subsequent surgery. ResultsAfter matching, analyses included 167 PRP-treated patients matched to 1,670 meniscectomy patients and 165 BMAC/PRP-treated patients matched to 1,650 TKA/pKA patients, with good balance across pre-specified confounders. Progression to subsequent surgery after orthobiologic treatment was rare at 12 and 24 months in both cohorts. Compared with TKA/pKA, BMAC/PRP was associated with lower overall health care use for several services, including outpatient visits, physical therapy, knee radiographs, and opioid prescriptions, although magnetic resonance imaging was more frequent following orthobiologic treatment. Total costs at 12 and 24 months were consistently higher for TKA/pKA than for BMAC/PRP across all costing methods. In the PRP versus meniscectomy comparison, differences in health care use were modest, and costs were similar or lower for PRP depending on the costing approach. Exploratory analyses through 48 months showed similar patterns, with persistently low rates of subsequent surgery after orthobiologic treatment and generally higher cumulative costs following surgical intervention. ConclusionsIn this real-world, propensity-matched analysis of commercially insured patients, orthobiologic treatments with PRP or BMAC were associated with similar or lower downstream health care costs compared with commonly performed surgical alternatives for selected patients with degenerative meniscal tears or knee osteoarthritis. Progression to surgery following orthobiologic treatment was uncommon through two years and remained low in longer-term exploratory analyses. These findings support the consideration of orthobiologic therapies as potentially lower-cost alternatives to surgery for appropriately selected patients and may inform shared decision-making and payer policy.

Acute pain in hospitalised patients is common and is associated with adverse outcomes, yet African data are scarce. We conducted an international prospective point-prevalence study of adult inpatients across Africa to determine pain prevalence and severity, and explored associations with critical illness and survival status. On a single day, investigators assessed patients worst pain in the preceding 24 hours using a 0-10 visual-numerical scale and recorded vital signs. Critical illness was defined as [&ge;]1 vital sign out of range, according to predefined definitions. Survival was assessed at day 7. Data are presented as median [IQR], n (%), and odds ratios with 95% confidence intervals. Between September and December 2023, 19438 patients from 180 hospitals in 22 African nations were included (age 40 [29; 59] years; 56% female). 67.9% of patients reported pain, with 2795 patients reporting severe pain (pain of [&ge;]7/10). Pain severity did not differ significantly by sex overall, but females [&le;]40 years old, with hypertension or cancer, admitted for trauma or infection, or in surgical wards had higher mean pain ranks than males. Severe pain odds decreased by 11% per standard deviation increase in age. Patients with severe pain had greater odds of critical illness and death within seven days. These findings provide the first large-scale evidence of acute pain burden in African hospitals. Pain is highly prevalent, with one in seven patients reporting severe pain. Future research of effective and feasible strategies to manage acute pain and reduce pain-related adverse clinical outcomes is needed in Africa.