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ObjectiveHeart failure (HF) is a malignant condition requiring urgent treatment. Guidelines recommend natriuretic peptide (NP) testing in primary care to prioritise referral for specialist diagnostic assessment. We aimed to assess association of baseline NP with hospitalisation and mortality in people with newly diagnosed HF.MethodsPopulation-based cohort study of 40 007 patients in the Clinical Practice Research Datalink in England with a new HF diagnosis (48% men, mean age 78.5 years). We used linked primary and secondary care data between 1 January 2004 and 31 December 2018 to report one-year hospitalisation and 1-year, 5-year and 10-year mortality by NP level.Results22 085 (55%) participants were hospitalised in the year following diagnosis. Adjusted odds of HF-related hospitalisation in those with a high NP (NT-proBNP >2000 pg/mL) were twofold greater (OR 2.26 95% CI 1.98 to 2.59) than a moderate NP (NT-proBNP 400–2000 pg/mL). All-cause mortality rates in the high NP group were 27%, 62% and 82% at 1, 5 and 10 years, compared with 19%, 50% and 77%, respectively, in the moderate NP group and, in a competing risks model, risk of HF-related death was 50% higher at each timepoint. Median time between NP test and HF diagnosis was 101 days (IQR 19–581).ConclusionsHigh baseline NP is associated with increased HF-related hospitalisation and poor survival. While healthcare systems remain under pressure from the impact of COVID-19, research to test novel strategies to prevent hospitalisation and improve outcomes—such as a mandatory two-week HF diagnosis pathway—is urgently needed.

Numerous drivers push specialist diagnostic approaches down to primary care (‘diagnostic downshift’), intuitively welcomed by clinicians and patients. However, primary care’s different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the ‘false-positive paradox’. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population ‘disease’ burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended ‘market failure’ effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents ‘value’, neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.

What you need to know Hip pain in young adults is not normal and can be severe and disabling, affecting work, parenting, and leisure activities.1 2 The causes of hip pain in young adults (aged 16–50) tend to receive less attention than those in children (including Perthes’ disease, slipped capital femoral epiphysis, and septic arthritis) and in older patients (usually osteoarthritis). Imaging studies might not reveal an underlying problem, even where the patient’s symptoms are a consequence of clinically significant pathology. Research has improved understanding of the causes of hip pain in young adults, including femoroacetabular impingement syndrome (FAI) and dysplasia of the hip, and has identified new treatments, although evidence is still limited.3 4 Importantly, both FAI and hip dysplasia are treatable causes of hip pain in young adults.4–6 This Practice Pointer aims to help the non-specialist evaluate young adults presenting with hip pain, and provides an update on common young adult hip pathologies. Hip problems in young adults can be considered as problems within the joint itself (intra-articular) or …

ObjectiveWe report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric ED.MethodsAn electronic sepsis screening tool was implemented in the paediatric EDs of two large UK secondary care hospitals between June 2018 and January 2019. Patients eligible for screening were children < 16 years of ages excluding those with minor injuries or who were brought directly to resuscitation. Subsequently, a retrospective evaluation was performed to determine the performance of the tool alone and in combination with clinical assessment after triage, to identify septic patients, using sensitivity, specificity, positive, negative predictive values (PPV and NPV) and likelihood ratios.Results19 912 children were triaged during the study period, of whom 90 (0.45%) were classified as having sepsis. 99% of all eligible patients were screened. The eST alerted for 2651 (13.3%) patients. After immediate physician assessment, 151 were treated for sepsis in the ED, of whom 70 had a final diagnosis of sepsis. Eight patients who were not thought to be septic returned with sepsis within 24 hours. The eST showed a sensitivity of 86.7% (95% CI 77.5% to 92.6%), specificity 87.0% (95% CI 86.5% to 87.5%), PPV 2.94% (95% CI 2.35% to 3.68%), NPV 99.9% (95% CI 99.8% to 99.9%) which improved with combined clinical assessment to a sensitivity of 90.0% (95% CI 81.4% to 95.0%), specificity 99.4 (95% CI 99.3% to 99.5%), PPV 42.0 (95% CI 35.0% to 49.3%) and NPV 99.9% (95% CI 99.9% to 99.9%).ConclusionUtilisation of a novel triage-based eST allowed sepsis screening in over 99% of eligible patients. The screening tool showed good accuracy to recognise sepsis at triage in the ED, which was augmented further by combining it with clinician assessment. The screening tool requires further refinement through multicentre evaluation to avoid missing sepsis cases.

ObjectiveTo assess whether a faecal immunochemical test (FIT) could be used to select patients with suspected colorectal cancer (CRC) symptoms for urgent investigation.DesignMulticentre, double-blinded diagnostic accuracy study in 50 National Health Service (NHS) hospitals across England between October 2017 and December 2019. Patients referred to secondary care with suspected CRC symptoms meeting NHS England criteria for urgent 2 weeks wait referral and triaged to investigation with colonoscopy were invited to perform a quantitative FIT. The sensitivity of FIT for CRC, and effect of relevant variables on its diagnostic accuracy was assessed.Results9822 patients were included in the final analysis. The prevalence of CRC at colonoscopy was 3.3%. The FIT positivity decreased from 37.2% to 19.0% and 7.6%, respectively, at cut-offs of 2, 10 and 150 µg haemoglobin/g faeces (µg/g). The positive predictive values of FIT for CRC at these cut-offs were 8.7% (95% CI, 7.8% to 9.7%), 16.1% (95% CI 14.4% to 17.8%) and 31.1% (95% CI 27.8% to 34.6%), respectively, and the negative predictive values were 99.8% (95% CI 99.7% to 99.9%), 99.6% (95% CI 99.5% to 99.7%) and 98.9% (95% CI 98.7% to 99.1%), respectively. The sensitivity of FIT for CRC decreased at the same cut-offs from 97.0% (95% CI 94.5% to 98.5%) to 90.9% (95% CI 87.2% to 93.8%) and 70.8% (95% CI 65.6% to 75.7%), respectively, while the specificity increased from 64.9% (95% CI 63.9% to 65.8%) to 83.5% (95% CI 82.8% to 84.3%) and 94.6% (95% CI 94.1% to 95.0%), respectively. The area under the receiver operating characteristic curve was 0.93 (95% CI 0.92 to 0.95).ConclusionFIT sensitivity is maximised to 97.0% at the lowest cut-off (2 µg/g); a negative FIT result at this cut-off can effectively rule out CRC and a positive FIT result is better than symptoms to select patients for urgent investigations.Trial registration numberISRCTN49676259.

Funder: Wellcome Trust, OBJECTIVES: Chronic rhinosinusitis (CRS) symptoms are experienced by an estimated 11% of UK adults, and symptoms have major impacts on quality of life. Data from UK and elsewhere suggest high economic burden of CRS, but detailed cost information and economic analyses regarding surgical pathway are lacking. This paper estimates healthcare costs for patients receiving surgery for CRS in England. DESIGN: Observational retrospective study examining cost of healthcare of patients receiving CRS surgery. SETTING: Linked electronic health records from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics databases in England. PARTICIPANTS: A phenotyping algorithm using medical ontology terms identified 'definite' CRS cases who received CRS surgery. Patients were registered with a general practice in England. Data covered the period 1997-2016. A cohort of 13 462 patients had received surgery for CRS, with 9056 (67%) having confirmed nasal polyps. OUTCOME MEASURES: Information was extracted on numbers and types of primary care prescriptions and consultations, and inpatient and outpatient hospital investigations and procedures. Resource use was costed using published sources. RESULTS: Total National Health Service costs in CRS surgery patients were £2173 over 1 year including surgery. Total costs per person-quarter were £1983 in the quarter containing surgery, mostly comprising surgical inpatient care costs (£1902), and around £60 per person-quarter in the 2 years before and after surgery, of which half were outpatient costs. Outpatient and primary care costs were low compared with the peak in inpatient costs at surgery. The highest outpatient expenditure was on CT scans, peaking in the quarter preceding surgery. CONCLUSIONS: We present the first study of costs to the English healthcare system for patients receiving surgery for CRS. The total aggregate costs provide a further impetus for trials to evaluate the relative benefit of surgical intervention.

ObjectiveTo describe the population, heart failure (HF) diagnosis rate, and 1-year hospitalisation and mortality of patients with suspected HF and elevated N-terminal pro B-type natriuretic peptide (NTproBNP) investigated according to UK National Institute for Health and Care Excellence (NICE) guidelines.MethodsNICE recommends patients with suspected HF, based on clinical presentation and elevated NTproBNP, are referred for specialist assessment and echocardiography. Patients should be seen within 2 weeks when NTproBNP is >2000 pg/mL (2-week pathway: 2WP) or within 6 weeks when NTproBNP is 400–2000 pg/mL (6-week pathway: 6WP). This is a retrospective, multicentre, observational study of consecutive patients with suspected HF referred from primary care between 2014 and 2016 to dedicated secondary care HF clinics based on the NICE 2WP and 6WP. Data were obtained from hospital records and episode statistics. Mortality and hospitalisation rates were calculated 1 year from NTproBNP measurement.Results1271 patients (median age 80; IQR 73–85) were assessed, 680 (53%) of whom were female. 667 (53%) were referred on the 2WP and 604 (47%) on the 6WP. 698 (55%) were diagnosed with HF (369 HF with reduced ejection fraction) and 566 (45%) as not HF (NHF). 1-year mortality was 10% (n=129) and hospitalisation was 33% (n=413). Patients on the 2WP had higher mortality and hospitalisation rates than those on the 6WP, 14% vs 6% (pConclusionsOutcomes using the NICE approach of short waiting time targets for specialist assessment of patients with suspected HF and raised NTproBNP are not known. The model identifies an elderly population a high proportion of whom have HF. Irrespective of diagnosis, patients have high rates of adverse outcomes. These contemporary real-world data provide a platform for discussions with patients and shaping HF services.

BackgroundOver the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing AKI CDSSs within routine hospital care.MethodsAn ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption.ResultsThe two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation and the wider system of care. A common tension was associated with attempts to maximise benefit while minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice.ConclusionsOur analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (eg, digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work.

ObjectivesTo explore patients’ experiences of getting a diagnosis of eye disease, the psychological impact of this and how this could be improved.DesignAn exploratory qualitative interview study using a narrative approach and inductive methods.SettingThis study was conducted with patients who had attended ophthalmic appointments in primary and secondary care and in opticians located in the South of England.Participants18 people diagnosed with eye disease in England.ResultsFour themes were identified: the convoluted process of being diagnosed, the impact of clinicians’ words, the search for information and reflections on what could be improved. The prolonged wait for a definitive diagnosis was a source of frustration and anxiety for many patients. Professionals’ words and tone when delivering a diagnosis sometimes affected a patient’s view of their diagnosis and their later ability to come to terms with it. Patients were desperate for information, but many felt they were not provided with sufficient information at the time of diagnosis and did not know whether to trust information found online. Participants felt the provision of a hospital liaison service and/or counselling could mitigate the impact on patients and families.ConclusionsInteractions with clinicians can have a lasting impact on how a diagnosis is experienced and how well the patient is able to come to terms with their visual impairment. Receiving little or no information left patients feeling lost and unsupported. This led them to search for information from less reliable sources. Clinicians should consider how they communicate a diagnosis to patients, how and when they offer information about diagnosis and prognosis and where possible signpost patients to additional support systems and counselling services as early as possible.

We read with interest the recent article by Newsome et al which provides guidelines for general practitioners on the management of abnormal liver blood tests based on the clinical recognition pattern of elevated liver enzymes and recommendations on non-invasive laboratory based liver fibrosis scores such as Fibrosis-4 (FIB-4) to exclude advanced fibrosis.1 Patients with low FIB-4 values should be managed in primary care, those with intermediate test results receive further diagnostics by an enhanced liver fibrosis test or ultrasound based elastography methods while those with high FIB-4 score are directly referred to secondary care. Newsome’s recommendations are especially relevant for non-alcoholic fatty liver disease (NAFLD), the most common aetiology of elevated liver enzymes in the primary care setting in the Western world.2 In NAFLD, the key predictor for liver related outcome and mortality is liver fibrosis.3 4 In Germany by the year 2030, 17 million NAFLD patients will present without fibrosis, but …

The number of patients with deep brain stimulation (DBS) devices implanted is increasing. Although practices vary between centres, patients are typically given training and information from their DBS nurse or clinician, as well as a comprehensive device manual and contact details for their device manufacturer. However, for the lifetime of a patient with a DBS system, most of their secondary care often occurs in a centre without a co-located DBS service. The local neurologist is often asked pragmatic questions regarding the do’s and don’ts for patients with DBS systems. While a DBS centre or device manufacturer can provide advice, we thought that it will be helpful to outline the overall management of DBS for movement disorders and the approach to commonly raised questions. We describe briefly the clinical application of DBS and discuss common scenarios where there are possible compatibility issues around the device.

IntroductionIncreasing numbers of children and young people (CYP) are receiving prescriptions for antidepressants. This is the protocol of a study aiming to describe the trends and variation in antidepressant prescriptions in CYP in England, and to examine the indications for the prescriptions recorded and whether there was contact with secondary care specialists on or around the time of the first antidepressant prescription.Methods and analysisAll eligible CYP aged between 5 and 17 years in 1998–2017 from the QResearch primary care database will be included. Incidence and prevalence rates of any antidepressant prescription in each year will be calculated. We will examine four different antidepressant classes: selective serotonin reuptake inhibitors, tricyclic and related antidepressants, serotonin and norepinephrine reuptake inhibitors and other antidepressants, as well as for individual drugs. Linked primary and secondary care data (hospital episode statistics) in the year before and up to 6 months after the first antidepressant prescription will be examined for CYP whose first antidepressant prescription was in 2006–2017. Whether there were records of indications and being seen by psychiatric or paediatric specialists will be identified. Trends over time and differences by region, deprivation and ethnicity will be examined using Poisson regression.DiscussionThis large, population-based study will give an up-to-date picture of antidepressant prescribing in CYP and identify any variation. Understanding what indications are recorded when CYP are being prescribed antidepressants, and whether this was done in partnership with secondary care specialists, will provide evidence of whether appropriate guidelines are being followed.

ObjectiveThe aim of this research was to ascertain the effectiveness of current electronic prescribing (EP) systems to prevent a standardised set of paediatric prescribing errors likely to cause harm if they reach the patient.DesignSemistructured survey.SettingUK hospitals using EP in the paediatric setting.Outcome measuresNumber and type of erroneous orders able to be prescribed, and the level of clinical decision support (CDS) provided during the prescribing process.Results90.7% of the erroneous orders were able to be prescribed across the seven different EP systems tested. Levels of CDS varied between systems and between sites using the same system.ConclusionsEP systems vary in their ability to prevent harmful prescribing errors in the hospital paediatric setting. Differences also occur between sites using the same system, highlighting the importance of how a system is set up and optimised.

ObjectiveTo investigate the impact of EyeSi surgical simulators on posterior capsule rupture (PCR) rates of cataract surgery performed by first and second year trainee surgeons.DesignA Royal College of Ophthalmologists’ National Ophthalmology Database audit study of first and second year surgeons’ PCR rates over seven consecutive National Health Service (NHS) years. Participating centres were contacted to ascertain the date when their surgeons had access to an EyeSi machine and whether this was on-site or off-site. Operations were classified as before, after or no access to EyeSi.SettingThe study took place in 29 NHS Ophthalmology Units in a secondary care setting.ResultsTwo-hundred and sixty five first and second year trainee surgeons performed 17 831 cataract operations. 6919 (38.8%) operations were performed before access to an EyeSi, 8648 (48.5%) after access to an EyeSi and 2264 (12.7%) operations by surgeons with no access to an EyeSi. Overall, there was a 38% reduction in the first and second year surgeon’s unadjusted PCR rates from 4.2% in 2009 to 2.6% in 2015 for surgeons with access to an EyeSi, and a 3% reduction from 2.9% to 2.8% for surgeons without access to an EyeSi. The overall first and second year unadjusted PCR rates for before, after and no access to EyeSi were 3.5%, 2.6% and 3.8%, respectively. The decrease in the with-access to an EyeSi group PCR rate was similar for surgeons with access to an EyeSi ‘on site’ or ‘off site’.ConclusionsFirst and second year trainee surgeons’ unadjusted PCR rates have decreased since 2009 which has significant benefits for patients undergoing cataract surgery. This 38% reduction in complication rates aligns with the introduction of EyeSi simulator training.

BackgroundThirteen residential care homes and 10 nursing homes specialising in older people in Rushcliffe, England, participated in an improvement programme. The enhanced support provided included regular visits from named general practitioners and additional training for care home staff. We assessed and compared the effect on hospital use for residents in residential and nursing homes, respectively.MethodsUsing linked care home and administrative hospital data, we examined people aged 65 years or over who moved to a participating care home between 2014 and 2016 (n=568). We selected matched control residents who had similar characteristics to the residents receiving enhanced support and moved to similar care homes not participating in the enhanced support (n=568). Differences in hospital use were assessed for residents of each type of care home using multivariable regression.ResultsResidents of participating residential care homes showed lower rates of potentially avoidable emergency admissions (rate ratio 0.50, 95% CI 0.30 to 0.82), emergency admissions (rate ratio 0.60, 95% CI 0.42 to 0.86) and Accident & Emergency attendances (0.57, 95% CI 0.40 to 0.81) than matched controls. Hospital bed days, outpatient attendances and the proportion of deaths that occurred out of hospital were not statistically different. For nursing home residents, there were no significant differences for any outcome.ConclusionsThe enhanced support was associated with lower emergency hospital use for older people living in residential care homes but not for people living in nursing homes. This might be because there was more potential to reduce emergency care for people in residential care homes. In nursing homes, improvement programmes may need to be more tailored to residents’ needs or the context of providing care in that setting.

ObjectivesThe Conversation, Understand, Replace, Experts and evidence-based treatment (CURE) project implemented an evidence-based intervention that offers a combination of pharmacotherapy and behavioural support to tobacco-dependent inpatients. Understanding key characteristics of CURE’s implementation strategy, and identifying areas for improvement, is important to support the roll-out of nationwide tobacco dependence services. This study aimed to (1) specify key characteristics of CURE’s exiting implementation strategy and (2) develop theoretical-informed and stakeholder-informed recommendations to optimise wider roll-out.Design and methodsData were collected via document review and secondary analysis of interviews with 10 healthcare professionals of a UK hospital. Intervention content was specified through behaviour change techniques (BCTs) and intervention functions within the Behaviour Change Wheel. A logic model was developed to specify CURE’s implementation strategy and its mechanisms of impact. We explored the extent to which BCTs and intervention functions addressed the key theoretical domains influencing implementation using prespecified matrices. The development of recommendations was conducted over a two-round Delphi exercise.ResultsWe identified six key theoretical domains of influences: ‘environmental context and resources’, ‘goals’, ‘social professional role and identity’, ‘social influences’, ‘reinforcement’ and ‘skills’. The behavioural analysis identified 26 BCTs, 4 intervention functions and 4 policy categories present within the implementation strategy. The implementation strategy included half the relevant intervention functions and BCTs to target theoretical domains influencing CURE implementation, with many BCTs focusing on shaping knowledge. Recommendations to optimise content were developed following stakeholder engagement.ConclusionsCURE offers a strong foundation from which a tobacco dependence treatment model can be developed in England. The exiting strategy could be strengthened via the inclusion of more theoretically congruent BCTs, particularly relating to ‘environmental context and resources’. The recommendations provide routes to optimisation that are both theoretically grounded and stakeholder informed. Future research should assess the feasibility/acceptability of these recommendations in the wider secondary-care context.

BackgroundAustralia has unrestricted access to direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment. In order to increase access to treatment, primary care providers are able to prescribe DAA after fibrosis assessment and specialist consultation. Transient elastography (TE) is recommended prior to commencement of HCV treatment; however, TE is rarely available outside secondary care centres in Australia and therefore a requirement for TE could represent a barrier to access to HCV treatment in primary care.ObjectivesIn order to bridge this access gap, we developed a community-based TE service across the Sunshine Coast and Wide Bay areas of Queensland.DesignRetrospective analysis of a prospectively recorded HCV treatment database.InterventionsA nurse-led service equipped with two mobile Fibroscan units assesses patients in eight locations across regional Queensland. Patients are referred into the service via primary care and undergo nurse-led TE at a location convenient to the patient. Patients are discussed at a weekly multidisciplinary team meeting and a treatment recommendation made to the referring GP. Treatment is initiated and monitored in primary care. Patients with cirrhosis are offered follow-up in secondary care.Results327 patients have undergone assessment and commenced treatment in primary care. Median age 48 years (IQR 38–56), 66% male. 57% genotype 1, 40% genotype 3; 82% treatment naïve; 10% had cirrhosis (liver stiffness >12.5 kPa). The majority were treated with sofosbuvir-based regimens. 26% treated with 8-week regimens. All patients had treatment prescribed and monitored in primary care. Telephone follow-up to confirm sustained virological response (SVR) was performed by clinic nurses. 147 patients remain on treatment. 180 patients have completed treatment. SVR data were not available for 19 patients (lost to follow-up). Intention-to-treat SVR rate was 85.5%. In patients with complete data SVR rate was 95.6%.ConclusionCommunity-based TE assessment facilitates access to HCV treatment in primary care with excellent SVR rates.

The COVID-19 pandemic created challenges which exposed inefficiencies, inequities, lack of resiliency and outdated models for the delivery of cardiovascular care around the globe. At the same time, the response to this crisis has allowed rapid transformation of our systems of care, including widespread use of digital interfaces, streamlining of care pathways and improved integration of patient-centric clinical services. In the hope of ensuring that this positive transformation is carried forward the British Cardiovascular Society (BCS) has outlined these changes and identified additional areas that require improvement as summarised in a short article in this issue of Heart 1 with the full report available on the BCS website.2 As they conclude: ‘cardiology, like other specialties, needs to assimilate and act on the lessons learnt during the pandemic. This will require a restructuring of the way that we all work and deliver clinical services.’ The insights summarised in the BCS report and the changes implemented by the NHS in the UK can provide a useful frame of reference that other healthcare systems around the world might consider in their long-term approach to improving care of patients with cardiovascular disease (figure 1). Figure 1 Potential interactions between primary and secondary care. AECG, ambulatory ECG; CP, chest pain; CTCA, CT coronary angiography; EHR, electronic health records; EOL, end of life; EP, electrophysiology; GP, general …

ObjectivesThe primary objective of this paper was to independently evaluate the currently available web-based software options for virtual consultations in a secondary care setting.DesignComparative study.SettingUK.ParticipantsWeb-based software options for virtual consultations in a secondary care setting.Main outcome measuresEight predetermined measures of functionality were assessed including time to setup, availability of a diary system, ability to book appointments in advance, ability to send patient reminders, ability to add a second caller, text messaging functionality, need for the patient to download an app and web browser compatibility.ResultsNine platforms met the inclusion criteria for web-based standalone video consultation solutions. Four offered immediate access via an nhs.net email address. Six platforms used an appointment diary system, with five allowing clinicians to see which patients were ready and waiting for consultation at any particular time. Four of the platforms had the facility to book appointments in advance and send appointment details via text message or email. Five of the platforms had the ability to add a second caller. One platform required the patient to download a mobile phone app. All platforms were compatible with Google Chrome, Safari, Firefox and Microsoft Edge (Chromium or Blink versions).ConclusionsThe uptake of virtual online consultations has been accelerated by the COVID-19 pandemic and the National Health Service (NHS) has become a forced ‘early-adopter’. Many of the solutions do well to address the demand; however, more work is required for it to be embedded into routine service and fulfil the aims of the NHS Long Term Plan: allow patients more choice and flexibility in their care. It is vital that once normality resumes, research focuses on the outcomes of virtual online consultations, with focus on factors such as patient satisfaction, length of appointment, time to diagnosis and initiation of management.

ObjectiveIron deficiency anaemia (IDA) occurs in 2%–5% of men and postmenopausal women in the developed world and, if left untreated, can significantly impair quality of life or decompensate chronic illnesses. Approximately 10% of men and postmenopausal women with IDA have underlying gastrointestinal malignancy. This study identifies trends in the management of IDA in secondary care in England.Design/methodThe Hospital Episode Statistics database was used to analyse IDA-related hospital and outpatient admissions (elective and non-elective) in National Health Service England between April 2012 and March 2018. Outcome measures included rates of readmission, length of stay (LOS) and cost per admission.ResultsBetween 2012/2013 and 2017/2018, there was a 72% increase in hospital admissions for patients with a primary diagnosis of IDA and a 68% increase in hospital spells, with the number of cases being managed non-electively increasing by 58%. Non-electively managed patients had a longer LOS (3.10 vs 0.04 days, respectively) and increased rate of readmissions within 30 days (24.1% vs 6.6%) versus patients managed electively. Average day-case cost was £449 versus £1676 for non-elective admission. Across the 195 clinical commissioning groups (CCGs) in England, non-elective spells per 100 000 population demonstrated extensive and widening variability, ranging from 18 to 118 in 2017/2018 compared with 11–55 in 2012/2013.ConclusionThe current analysis highlights several opportunities to improve patient outcomes and reduce costs. There is an opportunity to improve day-case services by looking at the difference between CCGs and the variability in care and to reduce the number of non-elective admissions.

ObjectiveTo quantify the association between patient self-management capability measured using the Patient Activation Measure (PAM) and healthcare utilisation across a whole health economy.Results12 270 PAM questionnaires were returned from 9348 patients. In the adjusted analyses, compared with the least activated group, highly activated patients (level 4) had the lowest rate of contact with a general practitioner (rate ratio: 0.82, 95% CI 0.79 to 0.86), emergency department attendances (rate ratio: 0.68, 95% CI 0.60 to 0.78), emergency hospital admissions (rate ratio: 0.62, 95% CI 0.51 to 0.75) and outpatient attendances (rate ratio: 0.81, 95% CI 0.74 to 0.88). These patients also had the lowest relative rate (compared with the least activated) of ‘did not attends’ at the general practitioner (rate ratio: 0.77, 95% CI 0.68 to 0.87), ‘did not attends’ at hospital outpatient appointments (rate ratio: 0.72, 95% CI 0.61 to 0.86) and self-referred attendance at emergency departments for conditions classified as minor severity (rate ratio: 0.67, 95% CI 0.55 to 0.82), a significantly shorter average length of stay for overnight elective admissions (rate ratio 0.59, 95% CI 0.37 to 0.94),and a lower likelihood of 30- day emergency readmission (rate ratio: 0.68 , 95% CI 0.39 to 1.17), though this did not reach significance.ConclusionsSelf-management capability is associated with lower healthcare utilisation and less wasteful use across primary and secondary care.

Children with unilateral cerebral palsy (UCP) have complex health, education and social care needs. Delayed gross motor milestones are the most common presenting feature, and much of the early management focuses on gross motor skills and lower limb management. In later childhood, adolescence and adulthood, upper limb function has significant impact on activity, participation and independence. There is clear pathophysiological rationale and emerging clinical evidence that earlier intervention to improve upper limb function is beneficial. Whereas most children with UCP are managed in secondary care, it is recommended that the assessment and delivery of specialist intervention for the upper limb occurs at a regional centre.

Since the outbreak of covid-19, overseas electives have been placed indefinitely on hold for UK medical students. With ever changing guidelines on social contact, health systems under intense pressure, and shifting rules on travel, universities are no longer able to sanction students travelling outside of the UK to complete their elective placements. This pause should provide us with an opportunity to consider whether the seemingly obvious advantages of overseas electives for future doctors can be justified, when in truth they hold both potential for harm and an underlying sentiment that is somewhat troubling. Many UK medical students, as well as medical educators, will undoubtedly be disappointed by what is, to all intents and purposes, another sad casualty of this pandemic. But it’s not just about students looking for that next high yield, “in real life” learning experience. In the General Medical Council’s own Outcomes for Graduates , they state that as part of their education, future doctors should “describe and illustrate from their own professional experience the range of settings in which patients receive care, including in the community, in patients’ homes, and in primary and secondary care provider settings.”1 Although it …

Oliver is right that primary and secondary care should work together better.1 The joy of palliative medicine is that I work across both sectors; my experience means I have greater sympathy with my primary care colleagues than do many of those in secondary care. With apologies to …

Learning objectives Chest pain is a frequent symptom at presentation in both primary and secondary care. There are several international guidelines available for patients with stable chest pain including the NICE (National Institute for Health and Care Excellence) guidelines ‘Chest pain of recent onset’ which were updated in 2016,1 2 the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS ‘Guidelines for the diagnosis and management of patients with stable ischemic heart disease’ for which there was a focused update in 2014,3 4 and the 2013 ESC (European Society of Cardiology) ‘Guidelines for the management of stable coronary artery disease’.5 In this article, we will highlight the 2016 NICE guidelines for the diagnosis of stable chest pain including assessment of clinical findings, risk stratification models, and invasive and non-invasive investigations. It is important to appreciate that the 2016 guidelines were an update of the 2010 guidelines, not a full revision, and only certain aspects were reassessed; this review focuses on these sections. We will also highlight similarities and difference between the other international guidelines. ### Patient population Cardiovascular disease remains an important cause of morbidity and mortality globally and was the second most common cause of death in the UK in 2014.6 Although mortality from coronary artery disease (CAD) is decreasing, the prevalence of CAD has remained relatively constant between 3% and 4%.7 Chest pain is a frequent symptom …

England’s health secretary must “confront the reality” facing NHS primary care, including the unsustainable workload, poor practice premises, the huge care backlog, and the transfer of work from secondary care, the BMA has said. The call came after Sajid Javid met the BMA General Practitioners Committee chair, Richard Vautrey, on 23 September to discuss the growing incidence of abuse of GPs and the increased support that primary …

WHO is aiming for the eradication of the hepatitis C virus (HCV) as a global health threat by 2030. However, concerns have been raised about how the COVID-19 pandemic may affect eradication efforts.1 One long-standing barrier to achieving the WHO goals is the high prevalence of HCV in marginalised populations.2 Homelessness is a significant risk factor for HCV infection in the UK, with chronic prevalence in this group estimated at 29%.3 Homeless people diagnosed with HCV infection are also less likely to complete treatment. The reasons for this are complex, but involve mistrust of medical services, inflexibility of secondary care pathways and geographic mobility.4 During the COVID-19 pandemic, homeless people across Somerset were housed in temporary accommodation through the national ‘Everyone in’ initiative. This provided a unique opportunity for eradication efforts by reducing the geographic mobility of this population, and provided a setting in which HCV patients could be managed. In this letter, we describe a targeted multidisciplinary programme to identify and …

BackgroundThe United Kingdom COVID-19 pandemic response included large scale changes to emergency healthcare delivery across primary care, secondary care and ambulance services without fully understanding potential unintended effects. Our aim was to ascertain themes within the emergency response that could be modified to mitigate against future excess deaths.MethodsA structured judgement review of the entire care pathway (primary care, secondary care, 111 and 999 calls) for deaths registered in Salford during weeks 12-19 of 2020, creating a single integrated record of all Healthcare interactions and outcomes between 1stMarch 2020 and death for all patients. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale, and themes associated with potential harm.Results522 deaths (197 hospital, 190 care homes): 51% female, 81% Caucasian, 35% dementia, age 79±9 years, 44% COVID-19 cause of death.18% of deaths contained avoidability themes. In people aged ≥75 years who lived at home this was 53%, in care home residents 29%, in learning disability patients 44%. For COVID-19 and non-COVID-19 deaths the figures were 49% and 23%. 15 deaths were judged more than 50:50 avoidable. For higher avoidability (score 2 or 3), 44% had >2 themes.Common themes were delays in patients presenting to care providers (10%, n=53), delays in testing (27%, 139), avoidable exposure to COVID-19 (29%, 149), delays in provider response (6%, 32), and sub-optimal care (34%, 177).Pre-hospital healthcare contact frequently was primary care 81%, 999 56%, NHS 111 11%. The most common outcome of 111 calls was advice to contact GP (34%). 46 patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9).ConclusionsThe initial emergency response to COVID-19 was associated with late presentation, sub-optimal assessments, and delays in receiving care. The effects had multifaceted impacts and will require complex remedy.

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure ‘oxygen access’. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (

Primary and secondary care are using more telemedicine and virtual professional collaboration to clear backlogs, reports Jacqui Wise. Using networks to deliver care, and better use of surgical beds, will be needed to restore routine services after the pandemic

Iron deficiency anaemia (IDA) presents the treating clinician with two issues: first, the need to establish a cause, and second, the need to correct the anaemia to improve symptoms and prevent complications. With a wide spectrum of severity, a host of potential causes ranging from benign to life-threatening, and multiple options for correction, one can expect significant variation in the management of IDA among clinicians. It is within this context that Brookes et al take a macroscopic view of the trends in incidence and management of IDA in England between 2012 and 2018.1 A number of pertinent observations have been made. Overall, secondary care encounters for IDA increased, presumably due to increased recognition; there was a 68% increase in total hospital encounters for a primary diagnosis of IDA, encompassing a 58% increase in non-elective and 74% increase in day-case hospital encounters. The relative increase in day-case in comparison to non-elective management is important, given the significantly greater costs associated with the latter; while total annual day-case management costs in 2017/2018 (£46 million) were similar to total non-elective costs (£42.4 million), four times as many patients were managed as day-cases (n=1 03 806) compared with non-electively (n=25 275). However, there was noticeably wide variation among different health networks across England in rates of non-elective management, signifying a need for a unified approach. Given the large cost discrepancy, an important question to answer is how best to manage patients in order to facilitate day-case management and prevent non-elective admissions. This should begin with ensuring early recognition of IDA. The association between deprivation and non-elective admissions suggests that lower socioeconomic status patients may be more likely to present at a later, more severe stage requiring admission. The reasons for this association deserve …

If the province were scaled to England’s population, nearly eight million people would have been waiting over a year for hospital treatment, writes Lisa Smyth—and many for much longer

General practitioners should consider seeing all children under five with respiratory symptoms in person and referring them to secondary care if necessary, NHS England has advised. The guidance, given in NHS England’s latest bulletin to primary care staff, comes amid concerns that respiratory viruses which have been suppressed by measures such as social distancing and mask wearing during the past year will rise as covid-19 restrictions are …

What you need to know Dupuytren’s disease is a common condition of the hand affecting the palmar fascia. Initially, it manifests as pitting or thickening of skin over the palm. Later on, it can develop into nodules or cords that act as the powerhouse of the disease. These can then progress to contractures manifesting as flexion deformities of fingers (fig 1). The contracture can span across metacarpophalangeal and interphalangeal joints, most commonly affecting the ring and little fingers.1 Rates of prevalence vary greatly depending on the population group and study design.2 It is estimated that the condition affects between 3% and 5% of the UK population,3 but the exact numbers vary significantly between age groups and geographical locations. Fig 1 Dupuytren's contracture affecting the metacarpophalangeal joint (right hand) and interphalangeal joint (left hand) Science Photo Library In the UK and in other settings, eligibility criteria for the management of Dupuytren’s disease may vary,4 both in the community and in secondary care. This clinical update provides a summary of the latest evidence on operative and non-operative treatments including an overview of current guidelines. The exact cause of Dupuytren’s disease is unknown, although microvascular angiopathy has been suggested as a possible underlying mechanism.5 There is a strong genetic association, with one study finding 80% heritability.6 It is more common in northern Europeans, with highest rates of prevalence in Icelandic and Scandinavian populations.7 The age of first presentation is usually between 50 and 70 years old, …

ObjectiveTo investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not.DesignPopulation-based longitudinal open cohort study.SettingEnglish primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases.PopulationWomen exposed to PPH during the study period matched for age and date of delivery, and unexposed.MethodsWe conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models.Outcome measuresRisk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack.ResultsDuring a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57).ConclusionOver a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD.

With covid-19 causing growing waiting lists and ongoing staff shortages, greater use of robotics in secondary care and beyond might offer a way of dealing with the pressures facing the NHS in a post-pandemic world. Jo Best reports

PurposeTo obtain consensus opinion for the development of a standards framework for the development and implementation of virtual clinics for glaucoma monitoring in the UK using a modified Delphi methodology.MethodsA modified Delphi technique was used that involved sampling members of the UK Glaucoma and Eire Society (UKEGS). The first round scored the strength of agreement to a series of standards statements using a 9-point Likert scale. The revised standards were subjected to a second round of scoring and free-text comment. The final standards were discussed and agreed by an expert panel consisting of seven glaucoma subspecialists from across the UK. A version of the standards was submitted to external stakeholders for a 3-month consultation.ResultsThere was a 44% response rate of UKEGS members to rounds 1 and 2, consisting largely of consultant ophthalmologists with a specialist interest in glaucoma. The final version of the standards document was validated by stakeholder consultation and contains four sections pertaining to the patient groups, testing methods, staffing requirements and governance structure of NHS secondary care glaucoma virtual clinic models.ConclusionsUse of a modified Delphi approach has provided consensus agreement for the standards required for the development of virtual clinics to monitor glaucoma in the UK. It is anticipated that this document will be useful as a guide for those implementing this model of service delivery.

Haematuria can be a troublesome symptom with various different methods of presentation and aetiologies. Microscopic haematuria is a common coincidental finding often found when the patient has presented for another reason. We will discuss the subject of haematuria but will focus the majority of this article on the discussion of microscopic haematuria, including a definition, the important features to cover in the history and examination, aetiologies to suspect in children and infants, and a suggested approach to assessing these patients in secondary care.

The baby with atypical or ambiguous genitalia is usually born in secondary care. For most clinicians, this is an unfamiliar and challenging scenario with the potential for life-long ramifications arising from a consultation led by an unprepared clinician. Language needs to be used carefully with particular clarity when liaising with parents, local health professionals and the specialist multidisciplinary team. Confidence in the recognition and assessment of atypical or ambiguous genitalia in a newborn will guide the local clinician when deciding on the initial investigations required and is a foundation for subsequent management. The local team have key roles in the initial support for parents as well as managing expectations at a time of great uncertainty. There are numerous different diagnoses that can result in atypical or ambiguous genitalia. The clinical findings should guide the initial investigations, and there are many pitfalls when it comes to interpreting the results. The aim of this article is to provide an initial approach to the management of a baby born with atypical or ambiguous genitalia.

The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care.Objectives(1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care.MethodMEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined as any organised cooperation between the GP and specialist secondary services in the care of the patient including shared consultations, case conferences that involved at least both the GP and the specialist clinician and/or other secondary services, and/or any formal shared care arrangements between the GP and specialist services. The specialist secondary service is either a specialist palliative service or a service providing specialist care to a palliative population. A narrative framework was used to describe the findings.Results17 studies were included. There is some evidence that integrated palliative care can reduce hospitalisations and maintain functional status. There are substantial barriers to providing integrated care. Principles and facilitators of the provision of integrated palliative care are discussed.ConclusionsThis is an emerging field and further research is required assessing the effectiveness of different models of integrated palliative care.

This article provides a review of the treatment of decompression illness (DCI) in the military setting. For those personnel who deliver military healthcare at all levels, there is an overview of the clinical picture, diagnosis and treatment aims when dealing with patients with DCI. The treatment aims are discussed using a situational approach from the perspectives of primary care, pre-hospital care through secondary care and onward to treatment by the diving medicine specialist. With ongoing medical support to worldwide diving operations, this narrative review provides an update in current DCI management for those involved in caring for military divers.

Gastro-oesophageal reflux disease (GORD) is a common presentation to primary care and has large direct and indirect effects on the UK economy. The purpose of this review is to highlight the management strategies for GORD among military personnel in primary and secondary care. Particular emphasis is placed on the outcomes from each form of treatment and the possible impact on deployability, in keeping with current UK military medical policy and guidance.

Commentary on: Zeng C, Dubreuil M, LaRochelle MR, et al. Association of tramadol with all-cause mortality among patients with osteoarthritis. JAMA 2019;321:969–82Commentary by: Dr Catrin Page and Dr Teck Khong Clinical Pharmacology, St George's, University of London, UKSeries Editor: Dr Teck Khong, DTB Associate Editor Clinical Pharmacology, St George's, University of London, London, UK

AimsTo assess current procedures of processing positive blood cultures against national standards with an aim to evaluate its clinical impact and to determine the utility of currently available rapid identification and susceptibility tests in processing of blood cultures.MethodsBlood cultures from three secondary care hospitals, processed at a centralised laboratory, were prospectively audited. Data regarding processing times, communication with prescribers, changes to patient management and mortality within 30 days of a significant blood culture were collected in a preplanned pro forma for a 4-week period.ResultsOf 2206 blood cultures, 211 positive blood cultures flagged positive. Sixty-nine (3.1%) of all cultures were considered to be contaminated. Fifty per cent of blood cultures that flagged positive had a Gram stain reported within 2 hours. Two (0.99%) patients with a significant bacteraemia had escalation of antimicrobial treatment at the point of reporting the Gram stain that was subsequently deemed necessary once sensitivity results were known. Most common intervention was de-escalation of therapy for Gram-positive organisms at the point of availability of pathogen identification (25.6% in Gram positive vs 10% in Gram negative; p=0.012). For Gram-negative organisms, the most common intervention was de-escalation of therapy at the point of availability of sensitivity results (43% in Gram negatives vs 17.9% in Gram positive; p=0.0097). Overall mortality within 30 days of a positive blood culture was 10.9% (23/211). Antibiotic resistance may have contributed to mortality in four of these patients (three Gram negative and one Gram positive).ConclusionGram stain result had the least impact on antibiotic treatment interventions (escalation or de-escalation). Tests that improve identification time for Gram-positive pathogens and sensitivity time for Gram-negative pathogens had the greatest impact in making significant changes to antimicrobial treatment.

Salisbury makes a good point about the differing views of what an opinion from a secondary care expert entails.1 Often it means different things to the patient, consultant, and referring GP. As a hospital consultant, I am aware that while I am an expert on a portfolio of medical conditions I am definitely not an expert on the …

Effective communication between members of the multidisciplinary team is imperative for patient safety. Within the Medicine for the Elderly wards at Royal Victoria Hospital (RVH) in Dundee, we identified an inefficient process of information-sharing between the orthopaedics outpatient department (OPD) at the main teaching hospital and our hospital’s rehabilitation teams, and sought to improve this by introducing several changes to the work system. Our aim was for all patients who attended the OPD clinic to have a plan communicated to the RVH team within 24 hours.Before our intervention, clinic letters containing important instructions for ongoing rehabilitation were dictated by the OPD team, transcribed and uploaded to an electronic system before the RVH team could access them. We analysed clinic attendances over a 4-week period and found that it took 15 days on average for letters to be shared with the RVH teams. We worked with both teams to develop a clinical communication tool and new processes, aiming to expedite the sharing of key information. Patients attended the OPD with this form, the clinician completed it at the time of their appointment and the form returned with the patient to RVH on the same day.We completed multiple Plan–Do–Study–Act cycles; before our project was curtailed by the COVID-19 pandemic. During our study period, seven patients attended the OPD with a form, with all seven returning to RVH with a completed treatment plan documented by the OPD clinician. This allowed rehabilitation teams to have access to clinic instructions generated by orthopaedic surgeons almost immediately after a patient attended the clinic, essentially eliminating the delay in information-sharing.The introduction of a simple communication tool and processes to ensure reliable transfer of information can expedite information-sharing between secondary care teams and can potentially reduce delays in rehabilitation.

ObjectivesThe study aim was to explore experiences of patients with pleural mesothelioma of follow-up care in three National Health Service (NHS) Trusts to develop recommendations for practice.DesignThe study design was qualitative and comprised three interlinked phases: a documentary analysis, interviews and consultation meetings. Altheide and Johnson’s Analytic Realism theoretical framework guided the thematic data analysis process.SettingThe study was conducted in three NHS Trusts in South England. Two were secondary care settings and the third was a tertiary centre.ParticipantsThe secondary care trusts saw 15–20 patients with new mesothelioma per year and the tertiary centre 30–40. The tertiary centre had a designated mesothelioma team. Twenty-one patients met the inclusion criteria: >18 years, mesothelioma diagnosis and in follow-up care. Non-English speaking participants, those unable to provide written informed consent or those whom the clinical team felt would find participation too distressing were excluded. All participants were white, 71% were 70–79 years old and 71% were men. Three consultation meetings were conducted with key stakeholders including mesothelioma nurse specialists, patients with mesothelioma, carers and local clinical commissioning group members.Main outcome measuresSpecific outcomes were to gain a detailed understanding of mesothelioma follow-up care pathways and processes and to develop coproduced recommendations for practice.ResultsMesothelioma pathways were not always distinct from lung cancer care pathways. All trusts provided follow-up information and resources but there was varied information on how to access local support groups, research or clinical trial participation. Five themes were developed relating to people; processes; places; purpose and perception of care. Coproduced recommendations for improving mesothelioma follow-up pathways were developed following the consultation meetings.ConclusionsThis study has developed recommendations which identify the need for patients with pleural mesothelioma to access consistent, specialist, streamlined mesothelioma care, centred around specialist mesothelioma nurses and respiratory consultants, with input from the wider multidisciplinary team.

ObjectivesTo evaluate the short-term (12 weeks) safety and utilisation of rivaroxaban prescribed to new-user adult patients for the treatment of deep vein thrombosis and pulmonary embolism and for the prevention of recurrent deep vein thrombosis and pulmonary embolism in a secondary care setting in England and Wales.DesignAn observational cohort study using the technique of Specialist Cohort Event Monitoring.SettingThe Rivaroxaban Observational Safety Evaluation study was conducted across 87 participating National Health Service secondary care trusts in England and Wales.Participants1532 patients treated with rivaroxaban for the prevention and treatment of deep vein thrombosis/pulmonary embolism from September 2013 to January 2016.InterventionsNon-interventional postauthorisation safety study of rivaroxaban.Primary and secondary outcome measures(1) Risk of major bleeding in gastrointestinal, intracranial, and urogenital sites and (2) risk of all major and clinically relevant non-major bleeds.ResultsOf a total of 4846 patients enrolled in the study from September 2013 to January 2016, 1532 were treated with rivaroxaban for the prevention and treatment of deep vein thrombosis/pulmonary embolism. The median age of the deep vein thrombosis/pulmonary embolism cohort was 63 years, and 54.6% were men. The risk of major bleeding within the gastrointestinal, urogenital and intracranial primary sites was 0.7% (n=11), 0.3% (n=5) and 0.1% (n=1), respectively. The risk of major bleeding in all sites was 1.5% (n=23) at a rate of 8.3 events per 100 patient-years.ConclusionsIn terms of the primary outcome risk of major bleeding in gastrointestinal, intracranial and urogenital sites, the risk estimates in the population using rivaroxaban for deep vein thrombosis/pulmonary embolism were low (Trial registration numbersClinicalTrials.gov Registry (NCT01871194); ENCePP Registry (EUPAS3979).

On 7 December 2015, the British Society of Gastroenterology and the Royal College of Physicians held a joint conference: GI cancer in the UK: can we do better? The meeting was timely as, although outcomes for patients with most gastrointestinal cancers in the UK have steadily improved in the past 10 years, survival figures remain substantially worse than in many other comparable nations. After defining the scale of the problem, the issues around early diagnosis were discussed. Screening as prevention has huge potential where there are defined premalignant conditions. Uptake into the Bowel Cancer Screening Programme (BCSP) is variable but in some areas remains low. It is hoped that with the National Screening Committee recommendation to replace the guaiac faecal occult blood test (gFOBT) with the faecal immunochemical test (FIT), the planned age extension and the continued roll-out of bowel scope screening by the National Health Service (NHS) will extend the value of the programme further. The view from primary care suggested that many factors affect the decision to make a referral for suspected cancer. Lack of direct access to testing was highlighted as a concern, as was the compounding issue of the many patients who delay seeking care. The Independent Cancer Force is the latest of several bodies calling for general practitioners (GPs) to be able to refer ‘direct to test’. However, a particular concern from secondary care relates to further stretching of diagnostic resources already under pressure—and how that can be addressed in times of austerity. Waiting times for endoscopy have begun to rise, yet capacity to expand is limited. Training, recruitment and retention of clinical staff were all highlighted as key issues limiting the availability of these procedures. Various practical ways to improve detection with endoscopy were proposed, as were possible ways to support and retain staff. While …

When I sat down to consider the topic for this issue, it was January 2020 and the number of people affected by the strange pneumonia-like illness being reported in Wuhan could still be written with two figures, rather than the current eight. I wanted to choose a topic that would be relevant to those with an interest in primary or secondary care, something with thought provoking ethical and legal issues, something that would be important across different life stages. I also wanted the topic to be enticing enough for people to want to pick up the issue and read—and so the sex issue of BMJ Student was launched. Our themed articles cover sexual and reproductive health from several points of view, …