British Journal of General Practice

Background In 2024, one-third of GP appointments in England were conducted by telephone. What happens during these consultations is largely unknown. Aim To test the feasibility of collecting recorded GP telephone consultations with linked data and consent for future research use. Design and setting Retrospective observational study in seven practices in South West England. Method Adults who had a telephone consultation at practices that routinely record calls were invited to consent to retrieval of call audio, a 4-month electronic health record (EHR) extract and a post-consultation patient questionnaire. Practice-level consent rates were analysed using regression models. Results Of 28 clinicians recruited, 19 GPs had consultations with patients whose recordings were retrievable, usable, and consented for future research. Of 2,053 invitations, 123 patients consented (6.0%). Consent was lower in more deprived practices (IMD 1-2 vs 9-10: OR=0.22, 95CI=0.09-0.54). Of 101 recordings retrieved, 96 were usable and 91 had consent for future research. 86/91 were linked to EHRs and 89/91 to post-consultation patient questionnaires. Mean consultation duration was 7 minutes 13 seconds; audible typing was heard in 69% (63/91). 161 problems were discussed (mean 1.77 per consultation). Most patients were happy their consultation was by telephone (96/117, 82%), although the majority reported usually preferring face-to-face appointments (68/115, 59%). Conclusion It is feasible to assemble a reusable archive of GP telephone consultations with linked data. However, recruitment was low using retrospective remote consent. Future work should test alternative recruitment approaches, particularly to improve patient engagement at practices serving deprived populations.

Objective: The shortage of general practitioners (GPs) in Australia has intensified interest in team-based care for hypertension, involving pharmacists and nurses. This study explored primary care provider experiences, barriers, and facilitators related to implementing team-based care in Australia. Design: Qualitative study using semi-structured interviews with primary care providers. Methods: We conducted 51 interviews with GPs (n=24), nurses (n=12), and pharmacists (n=15), purposively selected from diverse primary care settings. Analysis combined deductive coding, informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research, with inductive thematic analysis to identify emergent themes. Results: Interviews demonstrated a predominantly GP-centred care model, with nurse and pharmacist involvement largely confined to supporting roles, including blood pressure measurement, prescription refills, patient follow-up and counselling. Their contributions were constrained by barriers at both practice (e.g., limited GP support, fragmented communication across providers) and health system levels (e.g., limited financial incentives and restricted reimbursement pathways). Despite their critical role in care planning, nurses described being hamstrung by workload and limited direct funding for hypertension-related services. Pharmacists reported unreimbursed blood pressure checks and restricted funding for medication reviews that constrained the sustainability of their hypertension services. Role ambiguity and the absence of standardised protocols on task sharing further limited collaboration, with nurses and pharmacists describing concerns about overstepping professional boundaries. Attitudes towards team-based care ranged from active disregard (outright rejection) to conditional acceptance and occasional active uptake (strong endorsement). Conclusion: Despite clear willingness among nurses and pharmacists to alleviate GP burden, team-based care is rarely implemented in routine practice. Addressing system-level barriers (funding models that incentivise team-based care and standardised treatment protocols that clarify shared workflows), alongside provider-level barriers (stronger awareness and training that normalises task sharing), is critical to support genuine team-based hypertension care in Australia.

Multimorbidity, the co-existence of two or more long-term conditions, is up to three times more prevalent among people with cancer than in the general population and is associated with poorer survival, particularly for cancers with a more favourable prognosis such as colorectal cancer. In Scotland, multimorbidity is the norm among older adults, emerges earlier in socioeconomically deprived populations, and may contribute to comparatively low cancer survival rates. Despite this, the influence of multimorbidity on the colorectal cancer pathway remains poorly understood. We conducted a Scottish data-linkage study of adults diagnosed with colorectal cancer between 2010 and 2014, linking the Scottish Cancer Registry to national prescribing, hospital admissions, death registration, and bowel screening datasets. Prescribing data were used to derive overall and system-specific comorbidity measures as a proxy for multimorbidity and active disease burden. Associations with stage at diagnosis, treatment, survival, and screening uptake were examined using logistic regression and Cox proportional hazards models adjusted for demographic and clinical covariates. Among 19,043 patients, 87% had at least one prescribing-based comorbidity, most commonly cardiovascular, nervous system, and gastrointestinal conditions. Overall comorbidity burden was not associated with stage at diagnosis, although laxative-related prescribing was associated with later-stage disease. Increasing comorbidity burden reduced the likelihood of receiving any treatment and surgery, while associations varied across system-specific comorbidities. Higher comorbidity burden was also associated with increased all-cause and colorectal cancer-specific mortality, particularly among patients with respiratory, nervous system, and haematological/nutritional conditions. Screening uptake was not associated with overall comorbidity burden but did differ by system-specific comorbidity. Prescribing-based multimorbidity was highly prevalent and strongly associated with treatment patterns and mortality among patients with colorectal cancer. System-specific multimorbidity measures provided greater discrimination than overall morbidity counts, highlighting the importance of considering distinct multimorbidity profiles when assessing cancer pathways and designing targeted interventions for optimising treatment and survival. Keywords (primary health care, general practice, multimorbidity, comorbidity, colorectal cancer, early diagnosis, cancer treatment, survival)

Background: High blood pressure (BP) is an often treatable cause of cardiovascular disease. We developed an intervention, featuring a cardiovascular expert team and a toolbox, to support healthcare professionals (HCPs) in hypertension management and enhance patient self-management. Aim: This study evaluates the adoption and feasibility of this intervention. Design and Setting: A mixed-methods study in general practices in the Netherlands. Methods: HCPs could consult a cardiovascular expert team and use a self-management toolbox for their patients as preferred. We interviewed HCPs guided by the Consolidated Framework of Implementation Research (CFIR), and HCPs completed the Determinants of Implementation Behaviour Questionnaire (DIBQ). Using CFIR-ERIC matching tool, we matched implementation strategies to identified barriers. Adults with elevated BP, who were prescribed at least two blood pressure lowering medications were eligible to participate. Patient and disease characteristics were extracted from the electronical medical record. Results: Of 591 eligible patients at thirteen general practices, 176 participated. The cardiovascular expert team was well-received, with 33 unique consultations, although nurse practitioners (NPs) might need the expertise of the expert team more frequently than general practitioners (GP) (adoption). The toolbox was perceived as challenging to use (feasibility). We subsequently identified three key strategies to improve implementation. Mean systolic and diastolic BP were 158/87 mmHg at baseline and 148/85 mmHg after 12 months, although this change cannot be conclusively linked to the intervention. Conclusions: Structured implementation strategies may be helpful in hypertension management. The cardiovascular expert team was considered valuable, but might be better targeted to NPs rather than GPs.

Objectives We aimed to describe the characteristics of children and young people referred to social prescribing across the UK and understand what social prescribing looks like for these young people. Additionally, we aimed to explore whether access to and experiences of social prescribing vary with age and have changed from 2017 to 2025. Overall, we aimed to identify whether social prescribing reduces or exacerbates health inequalities among children and young people, and whether this has changed over time. Design Analysis of social prescribing electronic health records Setting Social prescribing hubs and services across the UK that use Access Elemental (a cloud-based social prescribing platform) Participants 52,585 individuals referred to social prescribing in 2017-2025 aged 4-25 years (mean=20.04, SD=4.71), of whom 57% were female, 39% male, <2% were in other gender groups, and 3% did not disclose their gender Primary and secondary outcome measures We summarised the characteristics of young people and described the care pathway received. We then used regression models to test whether these factors differed by age and over time. Results Most individuals were aged 18 and over, 91% lived in urban areas and 58% lived in the top three most deprived deciles of the UK. Most were referred by GPs or other allied health workers (79%) and mental health was the leading reason for referral (44%). The typical pathway included 4.64 social prescribing contacts (SD=7.70) totalling 66 minutes (SD=108), with 34% receiving an onward referral to community support. The average age of those referred to social prescribing increased over time. Conclusions Our findings indicate that social prescribing currently has limited reach for those under 18 and this disparity may be increasing. It was promising that children and young people referred to social prescribing were more likely to live in deprived areas. However, given current findings, more work is needed to increase the reach of social prescribing for children and young people across the UK.

To characterise the potential learning effects from a GenAI-based clinical decision support tool (CDST), we examined clinician behaviour within a cluster-randomised trial. The tool, AI Consult, parsed clinician notes written (in real-time) to document patient encounters and would raise green, yellow, or red flags to indicate no, potential, or critical risks of harm (respectively) in decisions the clinician made. Over several months, clinicians with access to the AI Consult tool produced fewer red (Intervention: 14% reduction, p = 0.032 vs. Control: 6% increase, p = 0.383) and yellow flags (Intervention: 6.8% reduction, p = 0.005 vs. Control: 3% increase, p = 0.231), whereas those without access to the tool showed no such effect. If this type of learning effect is a consistent emergent property across CDSTs, there might be an opportunity to reimagine their purpose: from addressing gaps in care quality to instead being a health system-strengthening investment.

Introduction: Hypertension is the world's leading cause of death, and depression its leading cause of disability. Control rates for these noncommunicable diseases (NCDs) are low in low and middle-income countries (LMICs). Many LMICs have programs to screen and treat underserved communities for infectious diseases, but evidence to adapt them to treat NCDs is limited. We developed and tested a non-communicable disease program through Ghana's Community-Based Health Planning and Services (CHPS) primary care initiative. Methods: We trained 8 CHPS nurses to diagnose and treat hypertension and depression through door-to-door screening and pharmacotherapy. Physician assistants provided telehealth supervision. We combined this treatment with volunteer counseling to boost medication adherence, improve mood, and change health behaviors. We called the 90-day intervention the CHPS Opportunity for Mentally and Behaviorally Integrated NCD Engagement (COMBINE). Results: We recruited 60 adults from 580 screened: 37 with hypertension (mean blood pressure (BP) of 149/91 mm Hg) and 23 with depression (mean physician health questionnaire (PHQ-9) score of 13.3). After 90 days, 57/60 (95%) completed the intervention: 32/37 (86%) achieved blood pressure control (mean BP 122/75 mm Hg), and 19 of 20 (95%) achieved depression control (mean PHQ-9 score 2.0). After 12 months, 51/60 were retained: 33/37 with hypertension (89%) and 18/23 with depression (78%), with a mean BP of 121/75 and PHQ-9 score of 1.4 respectively. All 51 (100%) achieved disease control at 12 months. 5 persons left by migration and 4 by escalation to higher-level care. Conclusions: The COMBINE model achieved high levels of diagnosis, care retention, and disease control, with minimal adverse events, in a remote setting with limited usual NCD care. This model suggests a novel means to improve the care cascade for these and other noncommunicable diseases through existing non-physician care models in LMICs, warranting further controlled testing at scale.

Purpose In deprescribing studies, a prescription-free gap is typically used to determine if patients discontinued their treatment. An appropriate gap depends on the typical time between prescriptions during continued use. This work aims to characterise the interval between prescriptions of chronic drugs using different methods for a cohort of older people in primary care in Ireland. Methods The empirical prescription interval was analysed for 38,154 patients for the twenty most common drug classes and the association between covariates and the interval was analysed using a multi-level model. Estimates were also compared to those obtained from the parametric waiting time distribution (pWTD) approach. Results Available covariates had consistent relationships with prescription intervals across drug classes. For example, each additional prescription issue was associated with an increase in the interval by 5.0 (NSAIDs) to 19.7 days ("Other antidepressants"). Full public health cover was associated with a -29.0 day (inhaled adrenergics) to -11.0 day (opioids) change relative to partial cover, while other/private cover had a -17.9 day (benzodiazepines and associated drugs) to -7.1 day (SSRI and SNRIs) change relative to partial cover. The pWTD also produced consistent estimates of the population interval for most drugs. Conclusions The interval varied substantially within drug classes, due to a mixture of patient, practice and unmodelled factors. Variation between practices was effectively explained, with residual variation between patients and within patients. The pWTD approach is useful for describing complex distributions of intervals, and may be more appropriate for inferring a gap than summarising truncated data.

Background: Dihydropyridine calcium channel blockers (DHP-CCB) are widely prescribed antihypertensives whose adverse effects may trigger unnecessary prescribing of additional medications, termed prescribing cascades (PC). We aimed to identify potential DHP-CCB-induced PCs using high-throughput sequence symmetry analysis (HTSSA). Methods: Using Medicare claims data (2011-2020), we identified new users aged [&ge;]66 years with continuous enrollment [&ge;]360 days before and [&ge;]180 days after DHP-CCB initiation. We screened for initiation of 446 "marker" drug classes within {+/-}90 days of DHP-CCB initiation. Sequence ratios compared marker drug initiation after versus before DHP-CCB initiation. Adjusted sequence ratios (aSR), accounting for prescribing trends over time, were calculated with 95% CIs >1 considered statistically significant. Clinical experts classified statistically significant signals as potential PCs through consensus. Results: Among 388,862 DHP-CCB initiators (mean age 76.6 {+/-} 7.5 years; 62.5% women, 92.3% with hypertension), 82 of 446 marker drug classes had significantly elevated aSRs, of which 24 were classified as potential PCs. Strongest signals ranked by highest aSR included other systemic hemostatics (aSR 2.99; 95% CI, 1.10-8.16), other nasal preparations (aSR 1.99; 95% CI, 1.47-2.70), and drugs used in erectile dysfunction (aSR 1.85; 95% CI, 1.27-2.70). Other clinically relevant signals, ranked by number needed to harm (lowest to highest), included sulfonamides (NNTH 104; 95% CI, 98-111), electrolyte solutions (NNTH 216; 95% CI, 196-241), and osmotically acting laxatives (NNTH 710; 95% CI, 540-1056). Conclusion: Potential PCs identified in this Medicare cohort reflected known and underrecognized adverse effects of DHP-CCBs. Further studies are needed to evaluate the clinical consequences of these PCs.

Background: Kenya replaced the National Health Insurance Fund with the Social Health Authority in October 2024, making the 2022 Kenya Demographic and Health Survey the last nationally representative pre-transition baseline. Evidence on insurance coverage and treatment gaps among adults already diagnosed with hypertension or diabetes remains limited, including how these patterns differ by sex. We aimed to estimate the level, distribution, and correlates of insurance coverage and treatment gaps among diagnosed adults at the close of the NHIF era. Methods: We conducted a cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey. Insurance status, prior diagnosis, and current medication use were reported by respondents. Analyses were sex-stratified and survey-weighted, with adjusted prevalence ratios estimated to assess associations between insurance coverage and treatment gaps. Wealth-related inequality was examined using concentration indices. Results: The analytic sample included 1,932 diagnosed adults (1,384 women and 548 men). Any insurance coverage was 47.7%, largely driven by National Health Insurance Fund enrolment (43.4%). Overall, 63.8% of diagnosed adults reported not receiving treatment, including 67.1% of women and 59.8% of men, with treatment gaps exceeding 60% across all wealth quintiles. Insurance coverage was strongly pro-rich, whereas treatment gaps were distributed across the wealth gradient. After adjustment, insurance was not strongly associated with lower treatment-gap prevalence among women or men, with no evidence of effect modification by sex. Among women, lack of money for treatment was reported as a major barrier far more frequently among the uninsured than the insured. Conclusions: Before the Social Health Authority transition, Kenya faced both incomplete insurance coverage and substantial treatment gaps among adults diagnosed with hypertension or diabetes. These findings provide a critical pre-transition benchmark and suggest that expanding insurance enrolment alone may be insufficient to close treatment gaps without improvements in benefit depth, medicine availability, and frontline readiness for chronic care delivery.

Background Physically Disabled women are less likely to access cervical screening than non-disabled women, yet little research has been conducted to understand the problems that Disabled women face or potential solutions. Methods A cross-sectional online survey was conducted with 1493 UK-based participants who identified as having a physical disability, impairment, condition, or difference that makes cervical screening difficult or impossible. Participants were presented with statements about cervical screening problems and potential solutions and asked to indicate agreement using a 5-point scale. They also provided open-ended comments. Data were analysed using descriptive statistics, multinomial logistic regression and thematic analysis. Results More than half of participants reported delaying/missing (46.8%) or never attending (8.8%) screening, with most of those (71.0% and 81.4% respectively) indicating that the main reason was disability-related factors. The highest levels of agreement for problems were for concerns about pain, embarrassment, and fear of what the test might find and for potential solutions were for having a doctor or nurse who is willing to try different solutions, discusses specific needs, and understands physical disability. Never-attendance (OR = 0.022, 95% CI 0.014, 0.035) and delaying or missing appointments, (OR = 0.057, 95% CI 0.043, 0.076) negatively predicted future screening attendance. Six themes were identified from open-ended comments, supporting and extending the quantitative findings. Conclusion Disabled women face the same problems related to cervical screening as non-disabled women and additionally face disability-specific problems. Cervical sample taker training should incorporate ways to support physically Disabled women to have equitable access to screening.

Objectives: Diabetes affects over 500 million people globally and glycemia is inadequately managed. Metformin is the most frequently prescribed initial treatment for type 2 diabetes globally, yet glycemic response trajectories to metformin in routine real-world care and predictors of treatment response have not been well described. We aimed to identify glycemic response trajectories in adults prescribed metformin monotherapy as initial type 2 diabetes treatment and predictors of poor glycemic response to metformin. Design: Observational cohort study using latent class mixed models to identify hemoglobin A1c (HbA1c) trajectory classes, followed by random forests machine learning to predict trajectory class membership. Setting: US Veterans Affairs Healthcare System Participants: Adults treated with metformin alone for >30 days after diabetes diagnosis with a minimum of two HbA1c measurements from 90 days prior to two years after the first metformin prescription (N=140,413). Exposures: Demographic, laboratory, vital sign, and comorbidity data were included as predictors of metformin response trajectory Main Outcomes and Measures: We included all HbA1c measurements (487,604 total) for two years after metformin initiation to define metformin glycemic response trajectories. Results: We identified three HbA1c trajectories: stably low (89.7% of sample, mean HbA1c decrease from 7.2% to 6.6%), brisk response (7.1% of sample, mean HbA1c decrease from 11.4% to 7.0%), and non-response (3.1% of sample, mean HbA1c increase from 8.9% to 10.8%). Of those in the stably low and brisk response classes at 2 years, 91% maintained HbA1c at approximately 7% on metformin alone for 5 years after drug initiation. Prediction models could accurately predict brisk response (91% accuracy) but not metformin non-response (59% accuracy). Conclusions: Most individuals treated initially with metformin monotherapy have a beneficial and durable glycemic response. Predicting individuals who will not respond to metformin may be challenging but is evident within six months with recommended glycemic surveillance. The findings support current guidelines for HbA1c surveillance when initiating diabetes treatment.

BACKGROUND: The UK National Institute for Health and Care Excellence recommends routine enquiry about domestic violence and abuse (DVA) in maternity care. We aimed to explore patterns and predictors of DVA enquiry during routine first antenatal care ( booking) appointments with midwives in South East London. METHODS: We conducted an observational cohort study using cross-sectional data collected through the St Thomas Hospital midwifery service between 1st January 2019 and 31st March 2023. Pseudonymised data were extracted from maternity records, comprising demographics, mental and physical health information, social factors, and DVA enquiry. We used linear mixed modelling to test associations between predictors and DVA enquiry. RESULTS: The dataset comprised 7,932 booking appointments with 7,007 women (median age: 32 years; ethnicity: 52% White, 27% Black, 7% Asian, and 15% other). Enquiry was made about current experiences of DVA in 79.4% of appointments. Black-identifying women (OR=1.28, 95% CI [1.11,1.46]) and those born in Sub-Saharan Africa (OR=1.37 [1.14,1.64]) were more likely to be asked than white-identifying and UK-born women. Single women were more likely to be asked than married or cohabiting women (OR=1.22 [1.08,1.38]). Those living in more deprived neighbourhoods were more likely to be asked (OR=1.07 [1.01,1.14]). Multivariable modelling found that being born in Sub-Saharan Africa or Southern Europe, and living alone but with additional support were all associated with increased DVA enquiry, while being born in North America or requiring an interpreter were associated with decreased enquiry CONCLUSIONS: Despite recommendations for routine DVA enquiry during all booking appointments, a substantial proportion of pregnant individuals were not asked between 2019 to 2023. Predictors of DVA enquiry reflected practical barriers (e.g. language), and known or perceived predictors of DVA risk (e.g. deprivation). Our findings suggest that midwives consciously or unconsciously prioritise DVA enquiry for women they believe are at greatest risk, against national guidelines.

Introduction: Blackpool, England's most deprived local authority, has the highest drug-related death rate in the country. People in police custody with problem substance use are a key Core20PLUS5 inclusion-health group, yet referral from the police into structured drug and alcohol treatment is fragmented and relies heavily on self-report. We evaluated the current police-to-treatment route in Blackpool and designed an evidence-informed unified pathway. Materials and Methods: A mixed-methods service evaluation and pathway-design project was conducted during a six-month General Practice / Public Health rotation. Routinely collected referral data from Horizon (the local specialist drug and alcohol service) covering the 47-month period from December 2019 to October 2023 were analysed. Findings were triangulated with national policy, the Project ADDER and Liaison and Diversion evaluations, and the international evidence on police-led pre-arrest diversion. Results: Of 5,900 total referrals into Horizon over 47 months, only 269 (4.56%) originated from the police. Police referrals accounted for fewer than 5% of monthly referrals in 30 of 47 months, for 5 to 9.9% in 16 months, and for >/= 10% in only one month (10.8%, December 2022). Blackpool recorded 76 drug-misuse deaths in 2019-21 (19.4 per 100,000, approximately four times the England rate). A six-step unified pathway is proposed: Initiate Referral (opt-out, from ADDER Police and Liaison and Diversion); Initial Assessment; Tailored Treatment Plan; Continuous Support; Collaboration and Monitoring; and Evaluation and Adjustment. Conclusions: Police contact is markedly under-used as a gateway to treatment despite Blackpool having the highest drug-related mortality in England. An opt-out, multi-agency pathway anchored in Core20PLUS5 has the potential to narrow the treatment gap, reduce re-offending, and address the structural health inequalities that drive premature mortality.

Background The use of oral retinoids and valproate during pregnancy can cause birth defects. In 2018, the EMA revised Pregnancy Prevention Programs (PPPs) for these medications. Pharmacy technicians in Denmark dispense prescription medications and must counsel customers. Aims This study aimed to examine knowledge of the teratogenicity of oral retinoids and valproate and use of the relevant PPPs among pharmacy technicians in Denmark. Methods A cross-sectional survey was conducted in spring 2025 using questionnaires developed for and tested in an international project. Data was collected via relevant Facebook groups and email invitations. Descriptive statistics were used for analyses. Results For oral retinoids, 80 respondents were analyzed; 95% were women, 86% were pharmacy technicians, the mean age was 37.2 years. Most dispensed oral retinoids several times per month. Two respondents did not know retinoids were teratogenic. The most used PPP measure was the outer packaging warning (54%). Informing women about teratogenic effects was the most common practice. For valproate, 41 respondents were analyzed. Their characteristics were similar to those of respondents in the oral retinoid survey. Most dispensed valproate once per month. One-third did not know valproate was teratogenic. The outer packaging warning was used by 19%. The most common practice was referring to the prescribing physician if pregnancy was suspected. Conclusion Danish pharmacy technicians knowledge about teratogenic drugs and the PPP was poorer than that of pharmacists, especially regarding valproate, and requires attention in educational programs. The feasibility of PPP measures for both oral retinoids and valproate should be optimized.

Objective To determine if it is possible to assess individual patient risk of the development of colorectal cancer (CRC) in people in high-risk groups due to their family history. Design/Method Retrospective observational study of prospectively collected data from consecutive patients referred for a colonoscopy. 2,478 consecutive patients were referred to a single colorectal surgical practice in Sydney, Australia between 1977 and 2018 for a colonoscopy because of a family history of CRC. Of these, 1,963 have been followed for more than 10 years and are the subject of this paper. Histopathological findings categorised as normal (N), non-advanced adenoma (NAA) or advanced neoplasia (AN) with AN proven to be the precursor to CRC. Intervention Colonoscopic screening on the basis of contemporary practice to 2006 and subsequently according to Australian National Health and Medical Research Council guidelines. Results Participants with normal or low-risk findings in the first decade remain at lower risk of CRC for 30 years from the commencement of screening. Conclusion It is possible to stratify individual patients in a high relative risk cohort into those with high or low personal risk of CRC based on colonoscopic findings in the first 10 years of surveillance. Those with no AN in the first ten years have a lower 30-year risk of developing AN than the general community. This offers the possibility of structuring surveillance programs around individual risk rather than group risk, lessening the need for multiple surveillance colonoscopies in the majority of such patients and improving the cost effectiveness of CRC screening at the population level.

Effective hypertension management depends on sustained engagement with primary care, and there is a need to understand the magnitude and determinants of follow-up loss in real-world primary care. We analyzed electronic health record (EHR) data from 26,541 patients with hypertension across primary care practices participating in the EvidenceNOW quality-improvement initiative. We characterized retention in care, longitudinal blood pressure (BP) control, and predictors of loss to follow-up using descriptive statistics, cumulative retention curves, and multivariable Cox proportional-hazards regression. At baseline, mean systolic and diastolic BP were 140.0 {+/-} 20.6 and 84.7 {+/-} 13.0 mmHg, respectively; only 10.7% (95% CI 10.4-11.1) of patients had controlled BP and 18.1% never returned for any follow-up visit. Among the 21,729 patients who had [&ge;]1 follow-up encounter, retention declined steeply over time--from 59.9% at 6 months to 16.3% at 36 months. Patients identifying as Black/African American (adjusted hazard ratio [aHR] 1.44; 95% CI 1.33-1.56), Hispanic/Latino (aHR 1.43; 1.35-1.52), or Other race/ethnicity (aHR 1.50; 1.41-1.59) had significantly higher hazards of being lost to follow-up than White patients, whereas older age, female sex, comorbid diabetes, heart failure, chronic kidney disease, stroke, and baseline BP control were each independently protective. Among patients retained for at least 12 months, BP control rose to 63.7% and remained near 64-66% through 36 months. These findings reveal a substantial and inequitable longitudinal care-engagement gap that is likely a principal driver of suboptimal hypertension control in the United States and identify actionable demographic and clinical targets for primary-care retention interventions.

OBJECTIVES To quantify socioeconomic inequalities in antibiotic prescribing for common infections in primary care, and assess whether these inequalities arise from differences in consultation frequency, prescribing behaviour, or variation in vaccination uptake, smoking, and body mass index. DESIGN Population based cohort study. SETTING Primary care data from Clinical Practice Research Datalink, England. PARTICIPANTS 17,195,399 children and adults estimated to have been registered with a general practice in 2019. MAIN OUTCOME MEASURES Antibiotic prescribing rates (prescriptions per person-year), consultation rates (consultations per person-year), and probability of receiving an antibiotic prescription following consultation. RESULTS Higher deprivation was associated with higher antibiotic prescribing rates for most respiratory tract indications. In children, prescribing rates were 44.8% (95% confidence interval [CI] 41.9% to 47.7%) higher for upper respiratory tract infections and 47.6% (95% CI 44.2% to 51.3%) higher for lower respiratory tract infections in the most versus least deprived twentile. In adults, prescribing rates for lower respiratory tract infections were 22.7% (95% CI 21.4% to 24.1%) higher in the most deprived twentile. Prescribing rates for other indications showed weak, U-shaped, or negative associations with deprivation. Prescribing inequalities were primarily driven by inequalities in consultation rates rather than probability of receiving antibiotics once consulted. Lower influenza vaccination uptake partly accounted for higher consultation rates for respiratory infections among more deprived children, while smoking prevalence contributed to inequalities among adults. CONCLUSIONS Socioeconomic inequalities in antibiotic prescribing vary by indication type and are largely explained by consultation frequency. Reducing inequalities may require interventions that decrease the need to consult, e.g. improving influenza vaccination coverage in children and reducing smoking among adults, rather than focussing solely on prescribing behaviour.

ObjectiveRecurrent urinary tract infections (rUTIs) significantly decrease quality of life and antibiotics are becoming increasingly less effective due to antimicrobial resistance. Alternative effective treatment strategies are urgently needed for rUTIs. Prior studies have indicated that women can experience resolved or improved rUTI following electrofulguration (EF). To further investigate these findings, we report on the design and methodology behind a randomized trial examining two treatment arms: standard prolonged antibiotic treatment with nitrofurantoin (NF) alone or in combination with EF. Patients and MethodsThe aim of this randomized trial is to determine, at two institutions, the efficacy of two interventions for rUTI associated with early stages of chronic cystitis (stages 1 and 2): conventional 6 months low-dose (100mg) NF daily antibiotic suppression alone (NF) or conventional NF with EF (EF + NF). The study is also designed to analyze changes in the urinary microbiomes in the two different treatment arms and to determine the durability of clinical outcomes in both treatment arms at 2 years after the end of each intervention. The primary outcomes will be obtained from 6 to 18 months, as well as 18 - 30 months following completion of the original 6-month intervention. Failure is defined based on UTI symptoms documented by a validated questionnaire with a documented urine culture confirming a bacterial strain at each UTI episode following the end of the 6-month intervention. ConclusionsThis randomized trial is designed to examine the efficacy and durability of treating women with rUTIs using the standard of care of NF alone, or an EF procedure with NF.

Background Since July 2022, Australian National Cervical Screening Guidelines have recommended anyone eligible for cervical screening be offered the choice between having their sample collected by a clinician with a speculum, or self-collection using a vaginal swab. Method We recruited screen-eligible people to an online survey between December 2023 and April 2024, via a paid social media (Meta) campaign, and stakeholder and community networks. Using binary logistic regression, we assessed demographic and screening history factors associated with having previously heard of self-collection. In participants screened since July-2022, we assessed factors associated with being offered a choice between self-collection and clinician-collection; choosing self-collection (among those offered choice); and using self-collection (among all recently screened participants). Results Of the 9,928 participants, 70.2% had heard of self-collection. Among those screened since July 2022, 36.1% were offered a choice in screening method. Awareness was associated with increasing age (p-trend <0.001), with participants aged >65 years most likely to have heard of self-collection (adjusted odds ratio (aOR): 1.69, 95% confidence interval (95%CI): 1.31-2.18). Compared to participants who self-reported regularly attending cervical screening, both not-regular and never screeners (based on self-reported screening history, frequency, age and sexual history) were less likely to have heard of self-collection (aOR:0.80 [95%CI:0.72-0.89] and aOR:0.73 [95%CI:0.56-0.96], respectively; p<0.001). Participants who attended a specialised womens/sexual health clinic were more likely to have heard of self-collection (aOR:1.32 (95%CI:1.06-1.64), p;<0.001), and to report being offered choice (aOR:1.62 (95%CI 1.22-2.14), p<0.001) at their last cervical screen. Half of the participants who were offered a choice opted for self-collection (N=803/1,617; 49.7%). Not-regular screeners were twice as likely (aOR:2.31 (95%CI:1.74-3.07), p<0.001) to choose self-collection as regular-screeners. Conclusion Given almost 50% of women nationally are now choosing self-collection, these findings imply national uptake might be close to plateauing overall. In high income settings where a choice in screening methods is introduced with the aim of improving screening equity, resources, adequate training, and health promotion tools should be provided prior to program launch to support healthcare providers in offering choice and facilitate improved participation in screening programs. Raising community awareness of screening options is important and needs to reach under-screened groups.