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Many risk prediction models have been proposed for heart failure (HF), but few studies have used only information available to general practitioners (GPs) in primary care electronic health records (EHRs). We describe the predictors and performance of models built from GP-based EHRs in two cohorts of patients 10 years apart.Linked primary and secondary care data for incident HF cases in England were extracted from the Clinical Practice Research Datalink for 2001-02 and 2011-12. Time-to-event models for all-cause mortality were developed using a long list of potential baseline predictors. Discrimination and calibration were calculated. A total of 5966 patients in 156 general practices were diagnosed in 2001-02, and 12 827 patients in 331 practices were diagnosed in 2011-12. The 5-year survival rate was 40.0% in 2001-02 and 40.2% in 2011-12, though the latter population were older, frailer, and more comorbid; for 2001-02, the 10-year survival was 20.8% and 15-year survival 11.1%. Consistent predictors included age, male sex, systolic blood pressure, body mass index, GP domiciliary visits before diagnosis, and some comorbidities. Model performance for both time windows was modest (c = 0.70), but calibration was generally excellent in both time periods.Information routinely available to UK GPs at the time of diagnosis of HF gives only modest predictive accuracy of all-cause mortality, making it hard to decide on the type, place, and urgency of follow-up. More consistent recording of data relevant to HF (such as echocardiography and natriuretic peptide results) in GP EHRs is needed to support accurate prediction of healthcare needs in individuals with HF.

BackgroundThe adoption of remote consultations, catalysed by the COVID-19 pandemic, has transformed the delivery of primary care services. We evaluated the impact of remote consultations on the quality of primary care.MethodsSix databases were searched. Studies evaluating the impact of remote consultations, for any disease, were included. Title and abstract screening, and full-text screening were performed by two pairs of investigators. Risk of bias was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis of the results was performed.FindingsThirty studies (5,469,333 participants) were included in the review. Remote consultations generally had a positive or equivalent impact compared to face-to-face (F2F) consultations, particularly in reducing patient costs and improving time efficiency. The effectiveness of remote consultations was non-inferior to F2F care in six out of seven studies evaluating this aspect. Two studies found that remote consultations reduced wait times for appointments. Younger, female patients were more likely to use remote consultations and those of lower socioeconomic status were less likely to use video consultations than telephone appointments. The impacts on safety and patient-centeredness were largely inconclusive.InterpretationRemote consultations may be equally as effective as F2F care and have a potentially positive impact on the efficiency and timeliness of care. Those of lower socioeconomic status were more likely to use consultations delivered via telephone than videoconference. Developing a strong evidence-base capitalising on real-world data as well as clinical trials is crucial for the future development of remote consultations and tailoring them to patient needs and preferences.FundingNational Institute for Health and Care Research Applied Research Collaboration Northwest London.What is already known on this topicExisting literature reviews exploring remote consultations have primarily been confined to assessing their impact on effectiveness, efficiency, or specific clinical conditions whilst utilising a broad definition regarding what constitutes remote services. Evidence was largely heterogeneous, often focussing on interventions delivered in secondary care facilities or by specialists only. There is a paucity of systematic reviews pertaining to primary care.What this study addsThis systematic review investigates the impact of remote consultations on the quality of primary care. Our results show that remote consultations may be equally as effective as F2F care and have a potentially positive impact on efficiency, timeliness of care, and reduced rates of follow-up in secondary or tertiary care. Patients from lower socioeconomic backgrounds were more likely to use consultations delivered via telephone than video conference.How this study might affect research, practice or policyOur systematic review has demonstrated that remote consultations have the potential to be just as effective as F2F consultations by reducing waiting times, patient costs, and rates of follow-up in hospitals. However, there currently remains a lack of robust studies available exploring the effect of remote consultations on patient safety, equity, and patient-centredness, highlighting areas where future research efforts need to be devoted. Data collection methods more bespoke to the primary care context, better accounting for patient characteristics and needs, and inclusive of its intended end-users, are necessary to generate a stronger evidence base to inform future remote care policies.

ObjectivesEconomic evaluations of interventions for people with mental–physical multimorbidity, including a depressive disorder, are sparse. This study examines whether such interventions in adults are cost-effective.DesignA systematic review.Data sourcesMEDLINE, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Scopus, Web of Science and NHS EED databases were searched until 5 March 2022.Eligibility criteriaWe included studies involving people aged ≥18 with two or more chronic conditions (one being a depressive disorder). Economic evaluation studies that compared costs and outcomes of interventions were included, and those that assessed only costs or effects were excluded.Data extraction and synthesisTwo authors independently assessed risk of bias in included studies using recommended checklists. A narrative analysis of the characteristics and results by type of intervention and levels of healthcare provision was conducted.ResultsA total of 19 studies, all undertaken in high-income countries, met inclusion criteria. Four intervention types were reported: collaborative care, self-management, telephone-based and antidepressant treatment. Most (14 of 19) interventions were implemented at the organisational level and were potentially cost-effective, particularly, the collaborative care for people with depressive disorder and diabetes, comorbid major depression and cancer and depression and multiple long-term conditions. Cost-effectiveness ranged from £206 per quality-adjusted life year (QALY) for collaborative care programmes for older adults with diabetes and depression at primary care clinics (USA) to £79 723 per QALY for combining collaborative care with improved opportunistic screening for adults with depressive disorder and diabetes (England). Conclusions on cost-effectiveness were constrained by methodological aspects of the included studies: choice of perspectives, time horizon and costing methods.ConclusionsEconomic evaluations of interventions to manage multimorbidity with a depressive disorder are non-existent in low-income and middle-income countries. The design and reporting of future economic evaluations must improve to provide robust conclusions.PROSPERO registration numberCRD42022302036.

Mental health protocol Copyright information © Author(s) (or their employer(s)) 2023. Introduction: The mental health of children and young people in the UK has been declining and has continued to worsen throughout the pandemic, leading to an increase in mental health-related emergencies. In response, the Best for You programme was developed as a new service designed to integrate mental healthcare for children and young people between acute hospital and community services. The programme is comprised of four new services: a rapid assessment young people’s centre with dual-trained staff, a co-located day service offering family-based care,a digital hub, designed to integrate with the fourth element of the model, namely community support and mental health services. This evaluation protocol aims to assess the development, implementation and outcomes of the Best for You programme and develops a scalable model that could be implemented in other parts of the National Health Service (NHS). Methods and analysis: This mixed-methods realist evaluation aims to delineate the components of the system to assess their interdependent relationships within a wider context. Data collection will include interviews, participant observations, focus groups and the collection of local quantitative healthcare data. The research will be conducted across four phases. Phase 1—captures the development of the underlying programme theory. Phase 2—a process evaluation testing the programme theory. Phase 3— an outcome and economic evaluation. Phase 4—consolidation of learning from phases 1–3 to identify barriers, facilitators and wider contextual factors that have shaped implementation drawing on the Consolidated Framework for Implementation Research. Ethics and dissemination:: Ethical approval for the evaluation was received from the NHS local ethics committee. Embedded within the evaluation is a formative review to feedback and share learning with stakeholders to scale-up the programme. Findings from this study will be disseminated in peer-reviewed journals as well as presentations o be useful to service user organisations and networks. The National Institute for Health and Care Research Applied Research Collaboration Northwest London; CW+ Charity.

BACKGROUND In the context of a deepening global shortage of health workers, and particularly the COVID-19 pandemic, there is growing international interest in and use of online symptom checkers (OSCs). However, the evidence surrounding the safety and accuracy of OSCs remains inconclusive so far. The triage and diagnostic accuracy of these tools is an essential aspect that needs to be addressed before pushing any further implementation. OBJECTIVE This systematic review aimed to summarise the existing peer-reviewed literature evaluating the triage accuracy (directing users to appropriate services based on their presenting symptoms) and diagnostic accuracy of OSCs aimed at lay users for general health concerns. METHODS Searches were conducted in Medline, Embase, CINAHL, HMIC and Web of Science, as well as the citations of the studies selected for full-text screening. We included peer-reviewed studies published in English between 1 January 2010 and 17 February 2022 with a controlled and quantitative assessment of triage and/or diagnostic accuracy of OSCs directed at lay users. We excluded tools supporting health professionals, and disease- or speciality-specific OSCs. Screening and data extraction were carried out independently by two reviewers for each study. We performed a descriptive narrative synthesis. RESULTS 21,284 studies were screened and 14 were included. These used either clinical vignettes, medical records or direct input by patients. Six studies reported on both triage and diagnostic accuracy, seven focused on triage accuracy, and one on diagnostic accuracy. These outcomes were assessed based on the diagnostic and/or triage recommendation attached to the vignette in the case of vignette studies, and/or those provided by nurses or GPs, including through face-to-face and phone consultations. Both diagnostic and triage accuracy varied greatly between OSCs. Overall diagnostic accuracy was deemed to be low, and almost always lower than the comparator. Similarly, most studies showed suboptimal triage accuracy overall, with a few notable exceptions. The main variables affecting the levels of diagnostic and triage accuracy were the severity and urgency of the condition, the use of AI algorithms and demographic questions. However, the impact of each variable differed across tools and studies, making it difficult to draw any solid conclusions. Included studies had either a moderate or high risk of bias according to the revised tool for the Quality Assessment of Diagnostic Accuracy Studies 2. CONCLUSIONS While OSCs have significant potential to provide accessible and accurate health advice and triage recommendations to users, more research is needed to validate their triage and diagnostic accuracy prior to wide-scale adoption in community and healthcare settings. Future studies should aim to use a common methodology and/or agreed standard for evaluation to facilitate objective benchmarking and validation. CLINICALTRIAL

BackgroundTrials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. The authors co-developed an implementation intervention to improve use of three AMS strategies: enhanced communication strategies, delayed prescriptions, and point-of-care C-reactive protein tests (POC-CRPTs).AimTo investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing.Design and settingNine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an ‘antibiotic champion’.MethodRoutinely collected prescribing data were compared between the intervention and the control practices. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention.ResultsThere was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual champions’ preconceptions of strategies and the opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPTs; one practice chose all three. POC-CRPTs was used more when allocated to one person.ConclusionClinicians need detailed information on exactly how to adopt AMS strategies. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.

UNSTRUCTURED The use of patient-facing online symptom checkers (OSCs) has expanded in recent years, but their accuracy, safety, and impact on patient behaviours and healthcare systems remains unclear. The lack of a standardised process of clinical evaluation has resulted in significant variation in approaches to OSC validation and objective evaluation of outcomes. The aim of this paper is to characterise a set of congruent requirements for a standardised vignette-based clinical evaluation process of OSCs. Discrepancies in the findings of comparative studies to date suggest that different steps in OSC evaluation methodology can significantly influence outcomes. A standardised process with a clear specification for vignette-based clinical evaluation is urgently needed to guide developers and to facilitate the objective comparison of OSCs. We propose 15 recommendation requirements for an OSC evaluation standard. A third-party evaluation process and protocols for prospective real-world evidence studies should also be prioritised to quality assure OSC assessment.

Vaccine programmes for young people during the covid-19 pandemic have highlighted common legal and ethical dilemmas that can arise when consenting children aged under 18 for medical treatment or intervention.1 -3 These can be especially challenging when a parent or guardian’s views differ from those of the child. This article summarises the issues around consenting children under 18 for treatment using vaccination as an exemplar. Most of the article is based on guidance and law in the UK; however, the principles behind the laws described may be applicable in other settings. We recommend that health professionals outside the UK also check their local laws regarding consent for children’s treatments and vaccinations.

Background Trials have identified several antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England and evidence is lacking around how to support high-prescribing general practices to implement AMS. We co-developed a customizable implementation intervention to improve adoption and use of three AMS strategies; enhanced communication strategies with/without patient leaflets, delayed prescriptions, and point-of-care C-reactive protein testing (POC-CRPT). This study aimed to investigate the use of the implementation intervention in high-prescribing practices and its effect on antibiotic prescribing. Methods Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via the ‘Antibiotic Optimisation’ website with practices required to identify an in-practice ‘Antibiotic Champion’. In a mixed-methods evaluation, we compared routinely collected prescribing data between 9 intervention and 45 matched control practices using a difference in differences analysis. Intervention material use was assessed through website monitoring and practice requests for supplies. Surveys and interviews were conducted with professionals at baseline and follow-up timepoints to capture experiences of using the intervention. Results There was no evidence that the intervention affected antibiotic prescribing. Engagement with intervention materials differed substantially between practices and depended on the individual Antibiotic Champion's preconceptions regarding the AMS strategies and opportunity to do the implementation tasks. Champions in five practices initiated changes to encourage use of at least one of the three AMS strategies, mostly POC-CRPT and patient leaflets. One Champion used the website resources to drive discussions about implementation of all three strategies in their practice. Elsewhere, lack of website engagement meant clinicians did not recognize novelty in the communication and delayed prescription content. POC-CRPT was used most often when equipment was allocated to one person in a practice. Conclusions AMS strategies are complex interventions and require clinicians to have detailed knowledge on how to adopt them in practice if they are to reduce antibiotic prescribing. Successful adoption may be achieved by allocating one or two persons to use an AMS strategy rather than all clinicians. Although effective in trials, remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.

UNSTRUCTURED The use of online symptom checkers (OSCs) is increasing but their safety, efficacy and impact on healthcare systems remain unclear. The lack of a standardised validation process and the absence of third-party testing requirements have resulted in significant variation in OSC clinical performance. Discrepancy in the findings of comparative studies to date suggests that several steps in OSC evaluation methodology can significantly influence outcomes. A uniform validation process with a clear specification is urgently required to objectively assess the performance of OSCs and help improve patient safety. Careful consideration and clear guidance for each of these steps will be required to create an objective validation standard that is robust and fair. An objective validation process could support the widescale adoption of OSC in the community setting with the potential to reduce pressure on scarce NHS resources, especially for self-limiting conditions.

UNSTRUCTURED Triage errors are a major concern in health care due to resulting harmful delays in treatments or inappropriate allocation of resources. With the increasing popularity of digital symptom checkers in pre–primary care settings, and amid claims that artificial intelligence outperforms doctors, the accuracy of triage by digital symptom checkers is ever more scrutinized. This paper examines the context and challenges of triage in primary care, pre–primary care, and emergency care, as well as reviews existing evidence on the prevalence of triage errors in all three settings. Implications for development, research, and practice are highlighted, and recommendations are made on how digital symptom checkers should be best positioned.

Triage errors are a major concern in health care due to resulting harmful delays in treatments or inappropriate allocation of resources. With the increasing popularity of digital symptom checkers in pre–primary care settings, and amid claims that artificial intelligence outperforms doctors, the accuracy of triage by digital symptom checkers is ever more scrutinized. This paper examines the context and challenges of triage in primary care, pre–primary care, and emergency care, as well as reviews existing evidence on the prevalence of triage errors in all three settings. Implications for development, research, and practice are highlighted, and recommendations are made on how digital symptom checkers should be best positioned.

Introduction: Multidisciplinary team (MDT) meetings could facilitate coordination of care for individuals living with multimorbidity, yet there is limited evidence on their effectiveness. We hence explored the common characteristics of MDT meetings in primary care and assessed the effectiveness of interventions that include such meetings, designed to improve outcomes for adults living with multimorbidity. Methods: A systematic review of literature was conducted using MEDLINE and EMBASE. A narrative synthesis was performed, extracting study and MDT meeting characteristics, in addition to any outcomes reported. Results: Four randomised controlled trials that were conducted in the United States of America were identified as eligible, recruiting a total of 3,509 adults living with multimorbidity. Common MDT meeting themes include regular frequency of discussion, the absence of patient involvement and the participation of three or four multiprofessionals. Significant improvements were observed in response to interventions with an MDT component across most measures, yet this trend did not extend to physical health outcomes. Discussion: It is unclear if the results in this review are sufficient to support the widespread implementation of MDT meetings in primary care, for adults living with multimorbidity. Due to the paucity of studies collated, further research is required to inform widespread implementation.

ObjectivesTo estimate the long-term survival of two cohorts of people diagnosed with heart failure 10 years apart and to assess differences in patient characteristics, clinical guideline compliance and survival by diagnosis setting.MethodsData for patients aged 18 and over with a new diagnosis of heart failure in the Clinical Practice Research Datalink in 2001–2002 (5966 patients in 156 practices) and 2011–2012 (12 827 patients in 331 practices). Survival rates since diagnosis were described using Kaplan-Meier plots. Compliance with national guidelines was summarised.Results2011/2012 patients were older than those diagnosed a decade before, with lower blood pressure and cholesterol but more comorbidity and healthcare contacts. For those diagnosed in 2001/2002, the 5-year survival was 40.0% (40.2% in the 2011/2012 cohort), 10-year survival was 20.8%, and 15-year survival 11.1%. Improvement in survival between the two time periods was seen only in those diagnosed in primary care (5-year survival 46.0% vs 57.4%, compared with 33.9% and 32.6% for hospital-diagnosed patients).Beta-blocker use rose from 24.3% to 39.1%; renin–angiotensin system blockers rose from 31.8% to 54.3% (both pConclusionsThe 10 years saw some long-term survival gains but only modest improvement in national clinical guideline compliance, from a low baseline, despite the introduction of national initiatives.

ObjectiveTo summarise the literature on frequent attendances to hospital emergency departments (EDs) and describe sociodemographic and clinical characteristics of children who attend EDs frequently.SettingHospital EDs.ParticipantsChildren Primary outcome measuresOutcomes measures were defined separately in each study, and were predominantly the number of ED attendances per year.ResultsWe included 21 studies representing 6 513 627 children. Between 0.3% and 75% of all paediatric ED users were frequent users. Most studies defined four or more visits per year as a ‘frequent ED’ usage. Children who were frequent ED users were more likely to be less than 5 years old. In the USA, patients with public insurance were more likely to be frequent attenders. Frequent ED users more likely to be frequent users of primary care and have long-term conditions; the most common diagnoses were infections and gastroenteritis.ConclusionsThe review included a wide range of information across various health systems, however, children who were frequent ED users have some universal characteristics in common. Policies to reduce frequent attendance might usefully focus on preschool children and supporting primary care in responding to primary care oriented conditions.

The use of patient-facing online symptom checkers (OSCs) has expanded in recent years, but their accuracy, safety, and impact on patient behaviors and health care systems remain unclear. The lack of a standardized process of clinical evaluation has resulted in significant variation in approaches to OSC validation and evaluation. The aim of this paper is to characterize a set of congruent requirements for a standardized vignette-based clinical evaluation process of OSCs. Discrepancies in the findings of comparative studies to date suggest that different steps in OSC evaluation methodology can significantly influence outcomes. A standardized process with a clear specification for vignette-based clinical evaluation is urgently needed to guide developers and facilitate the objective comparison of OSCs. We propose 15 recommendation requirements for an OSC evaluation standard. A third-party evaluation process and protocols for prospective real-world evidence studies should also be prioritized to quality assure OSC assessment.

ObjectivesTo review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction and cost effectiveness.Data sourcesEmbase, Medline, PsycINFO and Health Management Information Consortium (HMIC) databases.Study designA systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.Data collection/extraction methodsWe included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions.Principal findingsThirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions.ConclusionsThis review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.

Background: frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. Objectives: to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of comorbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). Design: observational study. Setting: primary care in England. Subjects: all adult patients diagnosed with HF in primary care between 2010 and 2013. Methods: we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. Results: of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, comorbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. Conclusions: this study suggests that frailty has predictive power beyond its comorbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.

OBJECTIVE: Primary care physicians (PCPs) play a key role in responding to the COVID-19 epidemic. The objective of this study was to explore the influencing factors associated with self-reported psychological distress among a sample of PCPs in China in relation to COVID-19. METHODS: An online survey was distributed to a sample of PCPs in Chengdu city between February 10 and February 13, 2020. The survey consisted of three sections: demographic characteristics, COVID-19-related questions, and the General Health Questionnaire-12 (GHQ-12). After 5 months, a follow-up survey investigating the change of the GHQ-12 was conducted. RESULTS: A total of 712 PCPs completed the baseline survey (11.8% of those invited), 55.6% were female and 74.4% were aged between 30 and 49 years. High levels of psychological distress (GHQ-12 ≥3) were observed in 29.2% and were associated with low preparedness, high work impact, working with infected residents, personal life impact, and concerns, as well as older age and being married (p values < .05). Logistic regression analysis showed that psychological distress was associated with low preparedness (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.87-0.96), high work impact (OR = 1.11, 95% CI = 1.03-1.20), personal life impact (OR = 1.12, 95% CI = 1.07-1.17), and safety-related concerns (OR = 1.09, 95% CI = 1.02-1.16). At the 5-month assessment point, high psychological distress was less frequent (21.8%). CONCLUSIONS: COVID-19 has resulted in high levels of distress in approximately 30% of PCPs in China. Factors associated with high psychological distress levels include low preparedness and high levels of work impact, personal life impact, and concerns. These findings highlight the importance of enhancing psychological health throughout the course of infectious pandemics.

Growing demand for access to NHS primary care means services are under increasing pressure. Many GP providers are using digital technologies (video/email/other online consultations) to try to improve access and efficiency. Alongside this is rapid growth in health technologies, which collect, measure, or interpret health data, and provide health information or advice. Many technologies have positive potential; however, the speed with which they are becoming available, increasingly blurred boundaries between health and lifestyle technologies and traditional healthcare provision, and the confidence and skills GPs have in using digital health technologies, bring new complexities and concerns. Successful adoption of innovative technologies in primary care requires effective preparation of future and current primary care workforce, enabling appropriate use by healthcare professionals, patients, and communities. Although some training programmes do exist, these are not routinely integrated within primary care training. There is a distinct gap in both training and capacity building in this area, and the evidence base to inform development and content of training is limited. In this article we explore risks and challenges of digital technologies in primary care and relate these to training needs for GPs, trainees, and medical students. In this analysis we draw on literature as well as first-hand experience of practising GPs. In June 2019 we conducted two workshops on digital health with approximately 30 GP teachers who supervise medical students’ placements, which informed our understanding of four key areas of digital health risks and challenges in general practice. Based on risks and challenges identified, we present recommendations for training to support the implementation of digital primary care. ### Consultation skills Telephone consultations (TCs) were initially introduced to meet increased patient demand to speak to a doctor. As early as 1978 TCs were described as being as much a part of a doctor’s equipment as a stethoscope, and …

Background There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed. Objective This study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing. Methods Searches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases’ inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations). Results In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations. Conclusions There is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.

BACKGROUND There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed. OBJECTIVE This study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing. METHODS Searches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases’ inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations). RESULTS In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations. CONCLUSIONS There is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.

BackgroundIn 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%–23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016.AimTo investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design & settingLongitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.MethodLinear generalised estimating equations models were fitted, examining the effect of the 2015–2016 QP on the number of antibiotic items per specific therapeutic group age–sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015–2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction ppConclusionIn high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

Background Studies estimating excess length of stay (LOS) attributable to nosocomial infections have failed to address time-varying confounding, likely leading to overestimation of their impact. We present a methodology based on inverse probability–weighted survival curves to address this limitation. Methods A case study focusing on intensive care unit–acquired bacteremia using data from 2 general intensive care units (ICUs) from 2 London teaching hospitals were used to illustrate the methodology. The area under the curve of a conventional Kaplan-Meier curve applied to the observed data was compared with that of an inverse probability–weighted Kaplan-Meier curve applied after treating bacteremia as censoring events. Weights were based on the daily probability of acquiring bacteremia. The difference between the observed average LOS and the average LOS that would be observed if all bacteremia cases could be prevented was multiplied by the number of admitted patients to obtain the total excess LOS. Results The estimated total number of extra ICU days caused by 666 bacteremia cases was estimated at 2453 (95% confidence interval [CI], 1803–3103) days. The excess number of days was overestimated when ignoring time-varying confounding (2845 [95% CI, 2276–3415]) or when completely ignoring confounding (2838 [95% CI, 2101–3575]). Conclusions ICU-acquired bacteremia was associated with a substantial excess LOS. Wider adoption of inverse probability–weighted survival curves or alternative techniques that address time-varying confounding could lead to better informed decision making around nosocomial infections and other time-dependent exposures., This study illustrates how to estimate the excess length of stay due to nosocomial infections in the presence of time-varying confounding. The number of excess days was substantially overestimated when ignoring time-varying confounding, suggesting that future studies should adopt similar methodology.

BackgroundClinical commissioning involves ethically challenging decisions about health resource allocation. However, commissioners come from a range of professional backgrounds with varying levels of training and expertise in ethical decision-making. Hence, they may lack the relevant training and resources to feel fully prepared for this increasingly demanding role.AimThis study aims to provide insight into how prepared commissioners feel in making ethical decisions; what ethics learning needs they might have; and how these might be addressed.Design and settingThis qualitative interview study explored the experiences of commissioners working for clinical commissioning groups (CCGs) in England.MethodEighteen participants were interviewed between December 2017 and July 2018 using a purposive sampling approach to participant selection. Transcriptions were coded and analysed using the constant comparative method of thematic analysis.ResultsMost participants had not received ethics training in preparation for, or during, their commissioning role, and reported difficulties identifying and analysing ethical issues. Participants often felt uncomfortable about decisions they were involved in, attributing this to a number of factors: a sense of moral unease; concerns that CCGs’ decision-making processes were not sufficiently transparent; and that CCGs were not fully accountable to the population served.ConclusionCommissioners face complex decisions involving ethical issues, and associated moral unease is exacerbated by a lack of ethics training and lack of confidence in identifying and analysing these. This study shows a clear need for additional support and ethics training for commissioners to support them in this area of decision-making.

Background There were about 850 000 people diagnosed with chronic obstructive pulmonary disease (COPD) in England in 2018, and possibly twice as many remain undiagnosed. Starting with the patient's first record of COPD, this study aimed to identify changes in diagnosis, management, and outcomes in COPD over time. Methods In this descriptive study, we identified each patient's first record of COPD in primary or secondary care during April 1, 2005, and March 31, 2007 (cohort 1), and during April 1, 2015, and March 31, 2017 (cohort 2). We used the Clinical Practice Research Datalink (CPRD) GOLD database, which contains anonymised patient-level records from a sample of general practices in the UK that use Vision software. General practice records are linked to the Hospital Episode Statistics database, which captures all admissions to English hospitals. The record of COPD was identified with predefined Read and International Classification of Diseases 10 (known as ICD-10) codes. The research protocol was approved by the Independent Scientific Advisory Committee for the Medicines and Healthcare products Regulatory Agency database research (protocol number 19_116). Findings We included 37 268 patients with incident COPD (19 266 males and 18 002 female); 57·4% (n=21 392) were from cohort 2. For 24 649 patients (66·1%), the diagnosis was first recorded in secondary care: 40·9% (n=6489 of 15 876) in cohort 1 compared with 84·9% (n=18 160 of 21 392) in cohort 2. However, 14·5% (n=2295) in cohort 1 and 43·0% (n=9207) in cohort 2 transferred out from their general practice before their first COPD record; most of these patients had their first COPD diagnosis in secondary care. More than half of patients with their diagnosis in secondary care had COPD recorded not as a primary diagnosis (51·6% [n=3347] in cohort 1 vs 63·3% [n=11 495] in cohort 2), casting doubt on the diagnosis. For 11 242 patients from cohort 2 with COPD in secondary care, general practices stopped submitting data to CPRD before the COPD diagnosis; consequently, an initial diagnosis could have been made between the time that the practice stopped submitting data and the hospital admission. Interpretation The background and context of data entry or coding can have an impact on the interpretation of diagnostic data in administrative datasets. When diagnostic codes are used as a starting point for examination of trends in COPD diagnosis and management with CPRD, care is needed to overcome various potentially misleading data artifacts. Funding This study is funded by the National Institute for Health Research Health Services and Delivery Research stream. The views expressed in this Abstract are those of the authors.

Background Delayed (or “backup”) antibiotic prescription, where the patient is given a prescription but advised to delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care. However, this strategy is not widely used in the United Kingdom. This study aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help increase appropriate use of this prescribing option. Methods and findings We conducted an online choice experiment in 2 UK general population samples: adults and parents of children under 18 years. Respondents were presented with 12 scenarios in which they, or their child, might need antibiotics for a respiratory tract infection (RTI) and asked to choose either an immediate or a delayed prescription. Scenarios were described by 7 attributes. Data were collected between November 2018 and February 2019. Respondent preferences were modelled using mixed-effects logistic regression. The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The samples reflected the UK population in age, sex, ethnicity, and country of residence. The most important determinant of respondent choice was symptom severity, especially for cough-related symptoms. In the adult sample, the probability of choosing delayed prescription was 0.53 (95% confidence interval (CI) 0.50 to 0.56, p < 0.001) for a chesty cough and runny nose compared to 0.30 (0.28 to 0.33, p < 0.001) for a chesty cough with fever, 0.47 (0.44 to 0.50, p < 0.001) for sore throat with swollen glands, and 0.37 (0.34 to 0.39, p < 0.001) for sore throat, swollen glands, and fever. Respondents were less likely to choose delayed prescription with increasing duration of illness (odds ratio (OR) 0.94 (0.92 to 0.96, p < 0.001)). Probabilities of choosing delayed prescription were similar for parents considering treatment for a child (44% of choices versus 42% for adults, p = 0.04). However, parents differed from the adult sample in showing a more marked reduction in choice of the delayed prescription with increasing duration of illness (OR 0.83 (0.80 to 0.87) versus 0.94 (0.92 to 0.96) for adults, p for heterogeneity p < 0.001) and a smaller effect of disruption of usual activities (OR 0.96 (0.95 to 0.97) versus 0.93 (0.92 to 0.94) for adults, p for heterogeneity p < 0.001). Females were more likely to choose a delayed prescription than males for minor symptoms, particularly minor cough (probability 0.62 (0.58 to 0.66, p < 0.001) for females and 0.45 (0.41 to 0.48, p < 0.001) for males). Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently showed similar patterns of preferences. Study limitations include its hypothetical nature, which may not reflect real-life behaviour; the absence of a “no prescription” option; and the possibility that study respondents may not represent the views of population groups who are typically underrepresented in online surveys. Conclusions This study found that delayed prescription appears to be an acceptable approach to reducing antibiotic consumption. Certain groups appear to be more amenable to delayed prescription, suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses., Liz Morrell and co-workers investigate individual preferences for immediate or delayed antimicrobial prescriptions., Author summary Why was this study done? Antibiotic resistance is a growing threat to global public health, and reduction of unnecessary antibiotic consumption is essential. An effective strategy to reduce antibiotic prescribing in primary care is delayed prescribing, where the patient is given a prescription but told to “wait and see” and take the antibiotics if their condition gets worse or does not improve; however, despite supporting evidence from randomised trials, this approach is not widely used in UK primary care. As doctor’s prescribing decisions can be influenced by factors such as patient concerns, our study aimed to understand which factors affect patients’ acceptance of delayed prescription and the relative importance of these factors. What did the researchers do and find? We designed an online choice experiment that had 12 possible situations a patient might encounter if they went to see their doctor about a respiratory tract infection (RTI). For each, we asked whether they would prefer an immediate or a delayed antibiotic prescription. A total of 802 adult members of the public and a further 801 adults who were parents of at least 1 child under 18 completed the survey. The most important features affecting prescription preference were the symptoms and how long they (or their child) had been ill. Respondents were most likely to choose the delayed prescription for minor symptoms like a common cold (probability of 53%) or minor sore throat (47%) and less likely for a serious chest infection (30%); only 37% chose delayed prescription for a sore throat, swollen glands, and fever, although this is likely to be a viral illness. We identified groups of respondents—for example, females and people who are knowledgeable about antibiotics—who were the most amenable to delayed prescription. What do these findings mean? The general public have some understanding that immediate antibiotics are not needed for colds, but better education on their (lack of) a role in viral sore throats may be helpful. Primary care doctors wishing to use more delayed prescription, but concerned about patient acceptance, could increase use among the more amenable groups. Patients will need reassurance that delayed prescription is appropriate for the more serious symptoms such as fever and on the typical duration of these illnesses.