British Journal of General Practice

Background: Social prescribing has expanded rapidly in England and internationally. However, the collection of consistent data to monitor and evaluate its reach and impact remains to be challenging. Methods: This study used routine data from the Clinical Practice Research Datalink (CPRD) Aurum in England. UpSet plots were used to describe intersections among different social prescribing codes, and between social prescribing and other non-clinical interventions. After identifying potential problematic intersections, we fitted multilevel regression models to examine variation between general practices and to understand factors associated with potentially problematic coding. Findings: Between 2019 and 2025, approximately 3.8 million consultations involving social prescribing codes were recorded in CPRD Aurum. Social prescribing codes were most often recorded individually (38.1%), but intersections existed both among different social prescribing codes, and between social prescribing and related non-clinical support. Many intersections reflect plausible stages and scenarios within the social prescribing pathway. However, some coding patterns appeared ambiguous or potentially inconsistent, particularly those related to social prescribing being offered and referrals being made. Results from the multilevel regression models suggested that 28.4-34.6% of variation in these codes was attributable to differences between practices, and problematic coding varied by region and year of recording. Interpretation: Our findings highlight opportunities to improve the quality and consistency of social prescribing coding in primary care, thereby strengthening service monitoring and evaluation both in England and internationally. They also provide important insights for researchers using CPRD data to investigate social prescribing.

Background: Early cancer detection is aided by timely GP referrals. However, GP practices face pressures, particularly in deprived areas, which may be associated with diagnostic inequalities. Aim: To examine whether within-practice changes in access, workforce, and population income deprivation were associated with diagnostic care indicators. Design and setting: Retrospective longitudinal study of 6,194 practices between 2015-2019 and 2022-2023. Method: Panel fixed-effects regression examined USC referral rates, USC PPV, USC sensitivity, and emergency presentation rates. Predictors were patient-reported access, GP workforce, and practice population income deprivation. Results: Per one SD increase within practices, (i) USC referral rates were lower with better appointment-making experience (-1.4%) and older average GP age (-3.5%), and higher with female GP share (+1.3%); GP FTE showed a small positive association (+0.7% to +0.8%). (ii) USC PPV increased with older average GP age (+2.2%). (iii) USC sensitivity was lower with older average GP age (-1.1%); emergency presentations showed limited association with access or workforce factors. Practices had higher emergency presentation rates when serving the most deprived rather than least deprived populations (+13.7%). There was little evidence that deprivation modified access and workforce associations. Average GP age was an exception: USC referral associations weakened from Q2 to Q5, USC PPV peaked at Q3, and USC sensitivity was significant only in the most deprived quintile. Conclusion: Practice-level access and workforce factors were associated mainly with USC referral activity. Persistent deprivation gaps in emergency presentation suggest monitoring USC referrals alongside PPV, sensitivity, and emergency presentations.

BACKGROUND Safe and effective antidepressant deprescribing strategies are needed in general practice where most antidepressant prescribing occurs. METHODS We conducted a pragmatic, cluster-randomised controlled trial in general practice to test invitation to general practitioner (GP) review combined with resources to inform shared decision-making and guide hyperbolic tapering for stopping antidepressants compared to usual care. Adults taking antidepressants for longer than 12 months were recruited from 26 Australian GP practices between March 2023 and November 2024, irrespective of their intention to stop or depression or anxiety symptom scores. The primary outcome was cessation at 12 months. Secondary outcomes included cessation at 6 months, and >75% dose reduction and depression, anxiety and withdrawal symptom scores at 6 and 12 months. RESULTS Overall, 483 patients were randomised. Mean age was 50 years; 73% were women; mean duration of antidepressant use was 14.1 years. Cessation at 12 months was observed in 32 of 215 (14.9%) intervention and 16 of 187 (8.6%) usual care patients (odds ratio (OR) = 1.95 [95%CI, 1.00 to 3.81]; p=0.050). Cessation at 6 months was observed in 11.7% intervention vs 4.8% usual care (OR = 2.68; 95%CI, 1.18 to 6.05), and >75% dose reduction at 12 months in 19.6% intervention vs 9.9% usual care (OR = 2.28; 95%CI, 1.20 to 4.31). Symptom scores were similar between groups. No adverse events were attributable to the intervention. CONCLUSIONS In general practice, invitation to GP antidepressant review combined with information and guidance on hyperbolic tapering can support cessation or dose reduction without causing adverse effects or relapse. Absolute cessation rates were modest but still meaningful given the high prevalence of long term antidepressant use. TRIAL REGISTRATION ANZCT registry identifier, ACTRN12622001379707p.

Background Effective communication during consultations is facilitated by clinical empathy and realistic optimism, and can enhance patient satisfaction with care, alleviate symptoms, and improve quality of life. However, primary care systems are under significant strain and changing rapidly, which may affect practitioners' ability to communicate empathically and convey realistic optimism, with implications for the patient-practitioner relationship and patient outcomes. Understanding patients' perspectives of healthcare communication in the current clinical context is therefore important. We aimed to explore patients' experiences and perceptions of communication in UK primary care consultations, focussing on the communication of clinical empathy and realistic optimism. Methods A qualitative interview study was conducted as part of a multi-centre cluster-randomised trial of EMPathicO, a brief e-learning package for Primary Care Practitioners (PCPs) on communicating clinical empathy and realistic optimism. Participants were not aware whether their general practice had access to EMPathicO or not. Interviews were conducted within 7-14 days of participants' consultations, explored their views and experiences of clinical empathy and realistic optimism, and were transcribed verbatim. Interviews were analysed using Ritchie and Spencer's Framework Method. Results We conducted semi-structured audio-recorded qualitative telephone interviews with 71 participants from 29 primary care practices taking part in the EMPathicO trial. Following comprehensive mapping of data to the framework derived following initial analysis, four themes were agreed. Overall, most participants described positive empathic consultations with their PCPs, however, participants' experiences were shaped by wider systemic and contextual factors. They described a stretched and inefficient primary care system impacting empathy and optimism; the impact of PCP 'preparedness' as a marker for empathy; how consultation modality (i.e. in-person or telephone) shaped perceptions of empathy, and how PCPs sharing next steps in participants' treatment and management could foster realistic optimism. Conclusions While clinical empathy and realistic optimism may be experienced by patients during consultations with practitioners, the wider contextual challenges of accessing and navigating primary care systems can threaten overall perceptions of feeling cared for. Future primary care policy and workforce training must consider these system pressures to preserve effective communication in consultations and positive patient-practitioner encounters.

Introduction Primary care productivity and performance are hard to measure because patient health is not measured systematically and consistently. In England, productivity is measured using output (appointment volume) and two value-based metrics: waiting times and patient satisfaction. Higher productivity should improve all these metrics: more appointments should shorten waits, and shorter waits should raise patient satisfaction. However, little evidence tests how output and value-based metrics are associated. Methods We conducted a retrospective observational study of NHS primary care in England, 2018 to 2024, using Appointments in General Practice and the GP Patient Survey. Across Integrated Care Boards (ICBs), we examined the relationship between changes in appointment volume, waiting times, and patient dissatisfaction over two periods, 2018-2022 and 2022-2023, stratified by staff group and appointment mode. Results Completed appointments rose between 2018 and 2024, with care shifting towards non-GP staff and virtual delivery. Across ICBs in 2018-2022, per million additional appointments, waiting time changed by -0.04 days (95% CI: -0.10, 0.03) and dissatisfaction by 0.02 percentage points (95% CI: -0.36, 0.40). Per additional day of waiting, dissatisfaction changed by -1.40 percentage points (95% CI: -3.21, 0.42). In 2022-2023, the corresponding estimates were -0.31 days (95% CI: -0.57, -0.04), -0.75 percentage points (95% CI: -3.05, 1.56), and 2.85 percentage points (95% CI: 1.20, 4.51). Conclusion Increased appointment volume was not associated with shorter waiting times or lower patient dissatisfaction, and shorter waiting times were not associated with lower patient dissatisfaction. Either quality metrics do not respond to output, the key factor providers control, or they do not capture the dimensions of quality that matter. Performance frameworks that assess primary care productivity through these metrics should be reviewed.

Background: Maternal postpartum checks with a general practitioner (GP) are recognised as an essential service in England and vital for recovery after pregnancy and reducing risk of long-term morbidity. Despite this, its reported fewer than of women have a record of the examination in the recommended 6-8 weeks, with observed disparities in uptake nationally. The impact of the COVID-19 pandemic disrupted delivery of these checks nationally, but there is limited data on the impact of the pandemic and its recovery for regional populations representing diversity and areas of dense poverty and ethnic minority populations. This study utilised region level data to assess the impact of COVID-19 on postnatal care. Methods: Anonymised electronic health records with clinical coded birth events for females, aged 16-49 years, were analysed for patients registered with a GP using the Greater Manchester Care Record (GMCR) between January 2018 and August 2023. Unique delivery episodes were defined and monthly rates calculated separately for women with a postnatal-related code within 4-, 6-, 8-, or 12-weeks or 1 year follow-up. Rates were also generated by key maternal demographics to assess any differences in postpartum care. Interrupted time series, modelling the onset of the pandemic estimated the IRR of 0.49 (95% CI 0.40-0.58). To assess the impact of maternal characteristics on the odds of non-attendance at examination, a logistic regression adjusting for various maternal characteristics was fitted. Results: There were 114,874 unique delivery episodes, relating to 85,076 women in the 12-week follow up cohort; 72,595 episodes to 55,784 women in 8-weeks and 28,846 episodes to 24,018 women in 6-weeks. The rate of postpartum checks was greater the longer the follow-up period. For checks within 8 weeks the first lockdown reduced from ~325 per 1000 delivery episodes in 2019 to 225 per 1000 by April 2020 (30.8%), which remained low, before returning to pre-pandemic rates by rates by October 2022. Rates remained lower overall for Black, or Asian women compared to White. Conclusion: The COVID-19 pandemic reduced postnatal follow-up in primary care across Greater Manchester, with rates frequently falling outside the recommended 6-8 week window. Significant disparities exist in the provision and uptake of these services. Improved integration of data across care sites, combined with enhanced risk management, could increase equity in access and support the timely delivery of care for those at greatest risk of postnatal complications and longer-term health issues.

Background People diagnosed with severe mental illnesses (SMI) including bipolar disorder, schizophrenia and psychosis are disproportionately exposed to adverse social determinants of health, contributing to premature morbidity and mortality. Social prescribing aims to address social risk factors for poor health by linking patients in primary care to community activities. However, whether people with SMI access social prescribing through primary care remains unexplored. Aims To describe prevalence of, and sociodemographic characteristics associated with, social prescribing consultations in patients with SMI in primary care. Methods Using the UK Clinical Practice Research Datalink, we identified patients aged 18+ with a diagnosis of SMI between 2004-2019. We calculated the percentage of patients with SMI who received a social prescribing consultation between 2019-2023 and used logistic regression to examine associations between sociodemographic, health-related factors and social prescribing consultations and refusals. We used fixed effects analysis to determine whether a new diagnosis of SMI made between 2019-2023 was associated with an increased odds of receiving a social prescribing consultation. Results Among 112,334 patients with SMI, 0.8% received a social prescribing consultation in 2019 increasing to 9.5% in 2023. Between 2020-2023, older age (OR=1.18-2.34), being female (OR=1.16-1.31) and living in more deprived areas (OR=1.14-1.49) were associated with higher odds of receiving a social prescribing consultation amongst patients with SMI. Across all years, patients with SMI and depression (OR=1.32-1.92), diabetes (OR=1.19-1.35) or obesity (OR=1.17-1.54) also had increased odds. In 140,514 patients with time-varying SMI status, a new diagnosis of SMI was associated with higher odds of receiving a social prescribing consultation (OR=1.39, 95% CI 1.26-1.53). Conclusion Since 2019, social prescribing consultations among patients with SMI in primary care have increased and are reaching those in areas of higher deprivation and with greater health needs. Strategies to remove barriers to consultations among younger adults and males are still needed

Objectives To evaluate the early implementation of tirzepatide for the management of obesity in primary care in England, including variations in Integrated Care Board (ICB) service delivery models, access criteria, and initial prescribing activity following national policy introduction (June 2025). This paper reports the initial phase of a wider mixed methods national evaluation of tirzepatide delivery models for initial priority cohorts defined in NHS England interim commissioning guidance. Design National study combining 1) mapping of ICB implementation plans using a questionnaire, publicly available data and documents, and stakeholder discussions, and 2) analysis of English Prescribing Dataset (EPD) to investigate tirzepatide prescribing trendsusing interrupted time-series methods to compare monthly prescriptions before and after June 2025 (implementation start) against a synthetic control series based on semaglutide prescribing. Setting ICBs across England. Participants 23/42 ICBs (55%) responded, of which 13 also took part in stakeholder meetings. For 17 ICBs (40%), we additionally extracted information from publicly available documents. Main outcome measures Descriptions of service delivery models, access criteria, and ICB characteristics; stakeholder-reported implementation challenges; and prescribing trends over time. Results We were able to categorise models of care for 40/42 ICBs. A general practice-led delivery model was most commonly planned (18/40; 45%), followed by community/local-based delivery (8; 20%), custom models (8; 20%), and specialist weight management service (SWMS) community outreach (6; 15%). Four ICBs (10%) planned to use more than one model of care. Most ICBs reported following national priority cohort eligibility criteria 31/39 (79%), while eight (21%) applied additional prioritisation criteria due to funding constraints. Stakeholder discussions highlighted variation in the interpretation of model definitions, variation in operationalisation, and challenges related to affordability, insufficient workforce capacity, and tight timelines, with some ICBs not yet prescribing at the time of stakeholder meetings (November 2025). Analyses of EPD showed a steady increase in tirzepatide prescribing over time, with no evidence that the June 2025 policy implementation date produced any additional increase beyond background diabetes-related trends. Conclusions Early implementation of tirzepatide prescribing in primary care has been characterised by heterogeneous service models, local adaptations of access criteria, and slow implementation of obesity-related prescribing. Findings highlight the challenges of implementing new pharmacological treatments including patient management within routine care and the need for clear guidance, realistic timelines, and system capacity. Ongoing evaluation is needed to understand how service models evolve and implications for access, equity, and outcomes.

Purpose Prescribing to lactating women is constrained by limited evidence. Published compatibility classifications provide clinical guidance and a discrete research comparator. How often prescribing diverges from that guidance, and what characteristics are associated with divergence, is unknown at national scale. Methods Retrospective analysis of prescriptions filled during lactation, identified in the 2012-2014 MarketScan Commercial Claims Database. Prescriptions were classified as concordant (Hale's lactation risk category L1-L3) or discordant (L4-L5). Multivariable logistic regression identified factors associated with concordance. Results Of 96,484 new prescriptions, 95,710 (99.2%) were concordant and 774 (0.8%) were discordant. Discordant prescriptions were filled later after delivery (median 59 vs 33 days) and had a day supply three times longer (30 vs 10 days). In multivariable analysis (N=28,732), concordant prescriptions were associated with maternal age under 35 (adjusted odds ratio (aOR)=1.34, 95% confidence interval (CI): 1.02-1.75) and chronic-condition medications (aOR=10.94, 95% CI: 6.47-18.50), and were less likely within 14 days of delivery (aOR=0.53, 95% CI: 0.38-0.73) and with each additional day of supply (aOR=0.96, 95% CI: 0.96-0.96). Compared with family practice, concordance did not differ for obstetric, internal medicine, or emergency medicine prescriptions, but prescriptions from other provider types had lower odds of concordance (aOR=0.57, 95% CI: 0.41-0.79). Conclusions Prescribing during lactation was overwhelmingly concordant with published compatibility guidance; the rare divergence was patterned by prescription and prescriber characteristics. Because the categories are an expert classification rather than consensus guidance, divergence should not be read as inappropriate prescribing.

Objective: To determine outcomes by referral route (any Advice and Guidance [A&G] versus elective referrals only) for patients with inflammatory bowel disease (IBD), Parkinson's disease, and systemic lupus erythematosus (SLE). Design: Population-based retrospective cohort study. Setting: Linked Clinical Practice Research Datalink (CPRD) Aurum primary care records, 2015-2022. Participants: Patients with incident diagnosis of IBD, Parkinson's disease, or SLE. Main Outcome Measures: Time from the earliest recorded A&G or elective referral to diagnosis, first recorded definitive treatment and first attended outpatient appointment. Secondary outcomes included counts of primary care consultations, prescriptions, referrals, and outpatient appointments. Propensity score weighted flexible parametric survival analyses accounted for differences between exposure groups. Results: Among 71,145 eligible patients, A&G was recorded for 1,137 (3.0%) with IBD, 971 (3.4%) with Parkinson's, and 243 (4.9%) patients with SLE. Compared with elective referral only, A&G was associated with slower time to diagnosis for IBD (adjusted median difference 15.9 weeks; hazard ratio 0.58, 95% confidence interval 0.52 to 0.66), Parkinson's disease (11.4 weeks; 0.57, 0.51 to 0.64), and SLE (6.3 weeks; 0.82, 0.73 to 0.91). However, A&G was not associated with a longer time to treatment or first attended outpatient appointment. An increase in primary care consultations following A&G was observed in patients later diagnosed with IBD and SLE. Conclusion: A&G was associated with a longer diagnostic interval than elective referral only. These findings do not establish that A&G caused diagnostic delay. A&G might be used at an earlier stage of more complex diagnostic pathways.

Background Anxiety, depression and menstrual problems are conditions that significantly impact an individual's health and wellbeing yet, barriers to healthcare can prevent access to appropriate medical care. Trust in doctors is a notable factor as previous studies have shown that it affects engagement with healthcare services and has declined in recent years. Methods Using the Avon Longitudinal Study of Parents and Children, we investigated associations between trust in doctors and healthcare access at two timepoints, for anxiety, depression (mothers and partners) and menstrual problems (mothers only). Results Mothers reporting greater trust in doctors were more likely to access care for anxiety (n=1849, adjusted odds ratio (AOR) 1.11, 95% confidence interval (95% CI) 1.08-1.14), depression (n=2411, AOR 1.10, 95% CI 1.07-1.12), and menstrual problems (n=1723, AOR 1.04 95% CI 1.01-1.06). If mothers and partners endorsed 'the doctor is always helpful', they were more likely to access care for depression (mothers: n=2005, AOR 1.30, 95% CI 1.16-1.46; partners: n=580, AOR 1.46, 95% CI 1.05-2.03) and for anxiety (mothers: n=1892, AOR 1.35, 95% CI 1.19 to 1.54; partners: n=734, AOR 1.40, 95% CI 1.02-1.91). Implications This study supports association between trust in doctors and healthcare access for anxiety, depression and menstrual problems, particularly amongst mothers. This contributes to previous literature that suggests that trust remains an important factor in understanding treatment gaps, and that researchers and clinicians must work to improve public trust in healthcare systems.

Introduction: Primary care electronic health records (EHRs) are an important resource for health research, but death recording in primary care EHRs may be incomplete or differ from Office for National Statistics (ONS) death registrations. We used OpenSAFELY-TPP to assess the completeness and concordance of death recording and provide recommendations for using date-of-death information. Methods: Using linked primary care EHRs and ONS death registrations, we assessed whether ONS-registered deaths from 2020-2025 had a primary care date of death and, where present, calculated the difference between dates. Where a primary care date was absent, we assessed death-related SNOMED CT codes. Analyses were conducted overall and by year, population subgroup, and general practice. We also examined GP registration end dates and primary-care-recorded deaths without a corresponding ONS record, including monthly patterns near the data extraction date. Results: Among 1,409,275 ONS-registered deaths, 88% had the same date recorded in primary care and 8% had no corresponding primary care date. Among 1,324,995 deaths recorded in primary care, <2% had no corresponding ONS record. Deaths recorded in only one source were more frequent among people aged <45 years and those from Mixed, Asian or Asian British, Black or Black British, and Chinese or Other ethnic groups. ONS-only dates were also more frequent in London and the West Midlands. Primary-care-only deaths increased close to date of data extraction, reaching 7% in February 2026. Same-day GP deregistration increased from 9% in 2020 to 85% in 2025. Conclusions: Death recording in primary care EHRs showed high completeness and concordance with ONS registrations, but discrepancies remained for recent deaths and some population groups. Data recency and population-specific completeness should therefore be considered when using linked mortality data for research.

Background: GPs are often the first clinicians to assess acute chest pain in gatekeeper healthcare systems, but usually with limited diagnostic support. They must distinguish conditions that can be managed safely in primary care from those requiring immediate hospital evaluation, particularly acute coronary syndrome (ACS), while avoiding unnecessary over-referral to already pressured emergency departments. We evaluated HEART-GP, a novel GP-led strategy combining structured clinical assessment, fingerstick point-of-care high-sensitivity troponin I testing, and ECG when available. Methods: We performed a prospective, multicentre, paired diagnostic accuracy study in four Dutch out-of-hours primary care centres implementing the HEART-GP strategy. Patients with acute non-traumatic chest pain and possible ACS according to the treating GP were enrolled from March 2023 to August 2025. Before troponin results were available, GPs recorded intended management, allowing paired comparison with unaided clinical judgement. The HEART-GP strategy recommended urgent referral for high clinical suspicion, troponin of >=4 ng/L, or ischaemic ECG. The primary outcome was adjudicated 6-week major adverse cardiovascular events (MACE). The study was registered as ISRCTN11954040. Findings: Of 1104 patients who underwent HEART-GP, 917 were included. MACE occurred in 62 (6.8%) and myocardial infarction in 52 (5.7%). HEART-GP classified 478 (52.1%) as low risk. For MACE, sensitivity was 95.2% (95% CI 86.5-99.0) and negative predictive value was 99.4% (98.1-99.8); three MACE occurred in the low-risk group, with no cardiac deaths. For myocardial infarction, sensitivity was 98.1% (89.7-100) and negative predictive value was 99.8% (98.6-100). Compared with unaided GP judgement, HEART-GP improved sensitivity for MACE (95.2% vs 67.7%; p<0.001) and myocardial infarction (98.1% vs 67.3%; p<0.001), and reduced urgent referrals (439 [47.9%] vs 483 [52.7%]; p=0.042). Interpretation: HEART-GP showed high rule-out safety and may support GP diagnostic certainty and efficient referrals in patients with possible ACS. Implementation requires training, governance, safety-netting, and local pathways.

Mobile clinical-support applications can facilitate access to evidence-based information at the point of care, but evidence on their usability and perceived usefulness among newly graduated physicians working in health facilities with limited capacity is scarce. We assessed physicians experiences with BMJ Best Practice using a convergent mixed-methods study. All 81 eligible physicians assigned to rural facilities were invited; 32 enrolled and received application access and training. After three months, participants completed an online survey, and 23 reported using the application. Ten physicians reporting the highest consultation frequency were purposively selected for semi-structured interviews. Survey findings showed a predominantly favorable perception of usability: for most items, 70%-90% of participants agreed or strongly agreed with the statements assessed. Among users, 14 of 23 (60.9%) used the mobile application and 9 (39.1%) used the web version. Interviews indicated that participants valued rapid searches, organized and evidence-based information, and support for diagnostic reasoning, referral decisions, learning, and clinical confidence. Barriers included limited connectivity, difficulties searching in Spanish, automatic updates, challenges locating or using some calculators, and treatment information that was sometimes insufficiently specific. Most importantly, participants could not always implement recommendations because suggested medicines, diagnostic tests, or other resources were unavailable in their facilities. Mobile clinical-support applications may complement decision-making and learning among early-career physicians in rural primary care. However, their practical value depends not only on usability and evidence quality, but also on adaptation to users language, workflow, connectivity, and local service capacity.

Background: The 10 Year Health Plan for England indicates governmental intention to shift care from hospital to community. Disease Modifying Treatments (DMTs) and biomarker tests for dementia will likely be introduced, with potentially significant impacts on community care, particularly general practice. Aim: To explore dementia diagnosis, post diagnostic support and expectations around future care in primary care settings. Design and Setting: Codesigned survey with general practitioners (GPs), policy researchers, carers and people with lived experience. One GP per practice invited from five English Integrated Care Boards (ICBs). Methods: Inductive content analysis for qualitative responses and non-weighted means calculated for quantitative answers. Findings contextualised using national data. Results: Between September and December 2025, 80/1094 (7.3%) eligible practices participated (80 GPs). Most, (79/80, 98.8%) used cognitive assessments and 100% (80/80) blood tests to support dementia diagnosis, with 27/70 (39.7%) able to order brain scans directly. GPs primarily conducted annual physical, mental or care plan reviews for people with known dementia. Respondents considered it unlikely (47/80, 58.8%) they would formally diagnose dementia or assess (50/80, 62.3%) for DMT eligibility in the next five years. GPs considered it somewhat/most likely (54/80, 67.5%) they could offer blood biomarker tests and continue established DMT prescribing or monitoring (61/80, 76.3%). Resource, capacity and training needs were perceived barriers. Conclusion: GPs are the first point of contact for accessing a dementia diagnosis in England. Accommodating novel diagnostic tools and treatments requires a reimagining of the relationship between primary, secondary and social care to address GP reported constraints.

Background: This study focused on adults with complex care needs due to problems on multiple life domains and consequent high acute care use. The Hotspotters Project was undertaken to assess the effects of proactive integrated care on health outcomes and healthcare costs in this group. We evaluated the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of the Hotspotters Project in order to identify factors that influenced implementation and outcomes. Method: This mixed method study followed the RE-AIM-framework, using validated questionnaires, routine care data and semi-structured interviews. Qualitative data from patients and care providers offered insight in the quantitative outcomes. Quantitative data were analyzed descriptively (SPSS), and interview transcripts were analyzed using inductive thematic content analysis (Atlas.ti). Results: As acute care use was lower than expected, few patients were eligible (153/1403) and subsequent low enrollment (n=30) limited conclusions regarding effectiveness. Nevertheless, the intervention improved collaboration with social work, and the structured intake was valued for the overview of patients complex needs. Many practices adopted the intervention into regular care, despite the complex inclusion process. Care providers proposed revising the target population and recruitment to better reflect the Dutch context. Conclusion: Although cost-effectiveness could not be assessed, this study nonetheless provides insights that can help future interventions and trials to better match patients needs, adapt to local context and reduce patients study burden. Adapting the definition of patients with complex needs to a local context can strengthen the rationale for implementation and enhance patient motivation.

Objective Although numerous clinical prediction models (CPMs) have been developed to identify pregnancies at risk of serious adverse outcomes, most lack robust external validation, which restricts their reliability in clinical practice. This study aims to systematically review and externally validate existing clinical prediction models for Gestational Diabetes Mellitus (GDM), Pre-eclampsia (PE), Stillbirth, and Small-for-Gestational-Age (SGA) focusing on models for use in pre-conception or early pregnancy. The models were evaluated using a large, representative primary care cohort to assess their performance within a UK population. Method and Analysis A two-stage systematic review identified CPMs for GDM, PE, Stillbirth, and SGA. Eligible models used routinely collected maternal characteristics, fully reported the model equation, and included predictors commonly measured during the preconception or early pregnancy period. Validation was performed using the UK Clinical Practice Research Datalink (CPRD Aurum), including over 1.58 million pregnancies for women aged 14 - 49 between 2000 to 2020. Model performance was assessed through discrimination (C-statistic), calibration-in-the-large (CITL), calibration slope and calibration plot, with pooled estimates across 20 imputations. Results Of 30 studies included, 48 models were identified, comprising 47 binary outcome models and one continuous outcome model, and 23 models used UK cohorts. Models were developed in cohorts comprising 101 to 113,415 participants (median N=5,013). Whilst 29 models have been externally validated, only three have been validated in cohorts including UK population satisfying the requisite sample size. Across all outcomes, most models demonstrated limited generalisability in the UK population. The C-statistic for GDM ranged from 0.29 to 0.77, for PE from 0.42 to 0.71, whilst models for stillbirth and SGA showed weaker discrimination from 0.54 to 0.56 and 0.58 to 0.62, respectively. Models across all outcomes exhibited substantial miscalibration, with calibration-in-the-large ranging from -5.66 to 1.35, and calibration slope from -0.65 to 17.61. Conclusion Existing CPMs for pre-conception and early prediction of adverse pregnancy outcomes showed poor discrimination and frequent miscalibration in a large UK cohort. Whilst some models for SGA had excellent performance, most existing models for GDM, PE, and stillbirth demonstrated suboptimal generalisability, likely a result of differences in population characteristics and outcome prevalence. Therefore, most CPMs evaluated are not suitable for direct implementation in UK clinical practice and require further calibration, updating, even re-development using large, representative data before achieving clinical utility.

Background: In primary care, rising demand and shrinking capacity produce chaotic variability during clinic days, yet this daily "schedule volatility" and its drivers are rarely measured. Objective: To measure primary care physicians' (PCPs') assessments of daily schedule volatility and its contributing factors, and to identify potential electronic health record (EHR)-derived measures to proxy these constructs. Design: Observational pilot study pairing contemporaneous end-of-day text-message (SMS) surveys with matched EHR data. Setting: Five primary care clinics in the University of Maryland Medical System, August to December 2025. Participants: Eight PCPs with at least 50% clinical effort. Measurements: Daily schedule volatility (5-point Likert rating) and contributing factors, collected by SMS after clinic close; four EHR-derived outcome measures (same-day visit closure, cumulated time to chart closure, and the presence and volume of EHR work after 7pm) and 16 contributing-factor measures spanning tardiness, no-shows and cancellations, asynchronous ("InBasket") volume, and schedule structure. PCP-rated volatility was dichotomized (top two "difficult-to-manage" categories vs. others) and compared using bivariate tests. Results: Of 150 surveys, 105 were completed (70% response rate; median response 27 minutes). Difficult-to-manage days were uncommon (14% of days), although patient tardiness, no-shows, long-running visits, and InBasket burden were each reported on >40% of days. Difficult days involved more evening EHR work (55% vs. 19%; p=0.033), higher asynchronous volume (median 13 vs. 4 patient-message encounters; p=0.022), and higher visit volume (median 17 vs. 7; p=0.001). No-shows and same-day cancellations were not associated with volatility. Limitations: Single-system pilot; bivariate, cross-sectional, and hypothesis-generating. Conclusion: PCPs' experience of chaotic clinic days is measurable and appears driven more by asynchronous burden and visit volume than by patient no-shows or tardiness; evening EHR work is a promising scalable proxy. Primary Funding Source: American Medical Association.

Abstract Background: Randomized trials show substantial weight loss with semaglutide and tirzepatide under structured care, but little is known about whether patients in routine practice continue therapy, reach a maintenance dose, and have their weight measured. Objectives: To describe the first year after initiation of semaglutide or tirzepatide for obesity, including care patterns, maintenance-dose attainment, weight documentation, and total body weight loss (TBWL). Methods: This retrospective cohort study used Epic Cosmos, an electronic health record network of >350 US health systems, to identify adults with obesity and without diabetes who initiated injectable semaglutide or tirzepatide in 2024. Outcomes over 12 months included prescribing persistence, discontinuation, switching, add-on therapy, and reinitiation; attainment of Food and Drug Administration (FDA)-labeled maintenance doses; availability of follow-up weight; and TBWL across progressively restricted populations. Results: Among 743,153 adults (60.1% semaglutide; mean age, 48.5 years; 72.5% female), 12-month prescribing persistence was 29.9% for semaglutide and 35.9% for tirzepatide. FDA-labeled maintenance-dose attainment was 28.3% and 55.0%, respectively, and only 8.8% and 16.4% remained prescribing persistent at a maintenance dose with a recorded weight at 12 months. About half of initiators lacked a 12-month weight. Among all initiators, [&ge;]5% TBWL was documented in 25.6% (semaglutide) and 30.4% (tirzepatide), rising to 51.9% and 61.9% among those with recorded weight, 66.1% and 79.5% among those also prescribing persistent, and 82.9% and 87.3% among those further at a maintenance dose. Conclusions: In routine practice, most patients initiating semaglutide or tirzepatide did not remain on therapy, reach a maintenance dose, and have weight documented through the first year. Documented weight loss was greatest among those completing each step of care, suggesting continuation, dose escalation, and monitoring as targets for improvement.

Aims To develop a 'core' dataset of diabetes related variables to support reproducible research using UK routinely collected health data. Methods A workshop was conducted bringing together diabetes healthcare professionals, researchers, and patient and public representatives to discuss and prioritise variables for inclusion in the Diabetes Core Dataset. Core variables were those considered to be highest priority for diabetes research and available at high quality in NHS data routinely used for research (primary care [GP] and Hospital Episode Statistics [HES] data). Candidate variables for inclusion in the Diabetes Core Dataset were from a review of existing core datasets and expert opinion. Participants scored variables anonymously based on priority for diabetes research. Results 25 variables from existing diabetes core datasets and 87 other candidate variables were considered for inclusion in the Diabetes Core Dataset. All 25 of those from existing diabetes core datasets and 5 of the 87 candidate variables met the core requirements for inclusion. In addition, 7 variables were identified as high priority but not included in the core dataset as they are not currently available in GP/HES data; these were labelled as 'future high priority' variables for diabetes research. Conclusions A new diabetes core dataset for UK EHR research has been developed using a consensus-based process. The core dataset is openly available and can be flexibly applied in UK EHR (https://healthdatagateway.org/en/tool/426), including in new NHS Research Secure Data Environment platforms, to enhance reproducible research to improve the clinical care of people with diabetes and associated conditions.