Impact of geographical cohorting, multidisciplinary rounding and incremental case management support on hospital length of stay and readmission rates: a propensity weighted analysis

Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients.

Syndromic retinitis pigmentosa caused by biallelic SCAPER frameshift variant

PURPOSE

Mutations in the SCAPER gene have previously been reported to be a rare cause of syndromic and non-syndromic autosomal recessive retinitis pigmentosa (RP). We report a case of syndromic RP caused by a frameshift heterozygous mutation in SCAPER. Our case has a relatively mild ocular phenotype with the presence of cone involvement noted on full field electroretinogram (ffERG) without impacting central or color vision.

MATERIALS AND METHODS

A 17-year-old male presented with progressive nyctalopia in both eyes. He underwent ophthalmic examination and multimodal imaging. A complete retinal degeneration panel consisting of 322 genes was used to screen for molecular causes of retinal dystrophy in this patient along with family segregation analysis.

RESULTS

Fundus examination of the proband revealed mild RP phenotype with waxy pallor of optic discs, attenuated retinal arterioles, and single bone spicule like pigmentary change in the mid-periphery bilaterally. Multimodal imaging and ffERG demonstrated a picture of RP with cone dysfunction without impacting central or color vision bilaterally. Examined family members were found to be normal. The proband was found to be heterozygous for two novel frameshift pathogenic variants in SCAPER c.3781del, p. (Val1261Serfs*26), c.868_869del, p. (Glu290Serfs*7) both leading to predicted premature termination. The family members tested were found to be heterozygous for SCAPER c.868_869del, p. (Glu290Serfs*7) pathogenic variant confirming their carrier status.

CONCLUSION

We report a case of a syndromic RP of previously unreported ocular phenotype associated with SCAPER pathogenic variant, which will add to the phenotypic spectrum of retinopathy and systemic features associated with pathogenic variants in SCAPER.

Protocol for a pragmatic cluster randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of Electronic RIsk-assessment for CAncer for patients in general practice (ERICA)

INTRODUCTION

The UK has worse cancer outcomes than most comparable countries, with a large contribution attributed to diagnostic delay. Electronic risk assessment tools (eRATs) have been developed to identify primary care patients with a ≥2% risk of cancer using features recorded in the electronic record.

METHODS AND ANALYSIS

This is a pragmatic cluster randomised controlled trial in English primary care. Individual general practices will be randomised in a 1:1 ratio to intervention (provision of eRATs for six common cancer sites) or to usual care. The primary outcome is cancer stage at diagnosis, dichotomised to stage 1 or 2 (early) or stage 3 or 4 (advanced) for these six cancers, assessed from National Cancer Registry data. Secondary outcomes include stage at diagnosis for a further six cancers without eRATs, use of urgent referral cancer pathways, total practice cancer diagnoses, routes to cancer diagnosis and 30-day and 1-year cancer survival. Economic and process evaluations will be performed along with service delivery modelling. The primary analysis explores the proportion of patients with early-stage cancer at diagnosis. The sample size calculation used an OR of 0.8 for a cancer being diagnosed at an advanced stage in the intervention arm compared with the control arm, equating to an absolute reduction of 4.8% as an incidence-weighted figure across the six cancers. This requires 530 practices overall, with the intervention active from April 2022 for 2 years.

ETHICS AND DISSEMINATION

The trial has approval from London City and East Research Ethics Committee, reference number 19/LO/0615; protocol version 5.0, 9 May 2022. It is sponsored by the University of Exeter. Dissemination will be by journal publication, conferences, use of appropriate social media and direct sharing with cancer policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN22560297.

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

BACKGROUND

Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow.

METHODS

A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed.

RESULTS

The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue".

CONCLUSIONS

The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

How well do Cognitive Behavioural Therapy and Behavioural Activation for depression repair anhedonia? A secondary analysis of the COBRA randomized controlled trial

A secondary analysis of the COBRA randomized controlled trial was conducted to examine how well Cognitive Behavioural Therapy (CBT) and Behavioural Activation (BA) repair anhedonia. Patients with current major depressive disorder (N = 440) were randomized to receive BA or CBT, and anhedonia and depression outcomes were measured after acute treatment (six months) and at two further follow up intervals (12 and 18 months). Anhedonia was assessed using the Snaith Hamilton Pleasure Scale (SHAPS; a measure of consummatory pleasure). Both CBT and BA led to significant improvements in anhedonia during acute treatment, with no significant difference between treatments. Participants remained above healthy population averages of anhedonia at six months, and there was no further significant improvement in anhedonia at 12-month or 18-month follow up. Greater baseline anhedonia severity predicted reduced repair of depression symptoms and fewer depression-free days across the follow-up period in both the BA and CBT arms. The extent of anhedonia repair was less marked than the extent of depression repair across both treatment arms. These findings demonstrate that CBT and BA are similarly and only partially effective in treating anhedonia. Therefore, both therapies should be further refined or novel treatments should be developed in order better to treat anhedonia.

Lattice distortions and the metal-insulator transition in pure and Ti-substituted Ca3Ru2O7

We report pair distribution function studies on the relationship between the metal-insulator transition (MIT) and lattice distortions in pure and Ti-substituted bilayer Ca₃Ru₂O₇. Structural refinements performed as a function of temperature, magnetic field and length scale reveal the presence of lattice distortions not only within but also orthogonal to the bilayers. Because of the distortions, the local and average crystal structure differ across a broad temperature region extending from room temperature to temperatures below the MIT. The coexistence of distinct lattice distortions is likely to be behind the marked structural flexibility of Ca₃Ru₂O₇under external stimuli. This observation highlights the ubiquity of lattice distortions in an archetypal Mott system and calls for similar studies on other families of strongly correlated materials.

Redistribution of ill-defined deaths: the Scottish Burden of Disease approach

Burden of disease (BoD) studies are an established method of quantifying health loss across - and within - a population. They aim to combine the impact of living with, and dying from, various health conditions to allow for comparability of conditions in an equitable manner. A key component of this is the calculation of the loss of years of life arising from premature death (Years of Life Lost (YLL)). Most high-income nations have robust death registration systems which ensure that deaths are routinely recorded, the causes are medically certified and the age at death is accurate. However, even in these situations the recording of ill-defined death (IDD) causes remains widespread and to some extent unavoidable, in that it is not always appropriate to undertake extensive investigation to establish an exact cause of death or the cause of death recorded does not map directly to disease groupings used routinely in BoD studies. The Scottish Burden of Disease (SBoD) uses cause of death data from the National Records of Scotland. These patient-level records include one underlying cause of death and up to 10 supplementary causes of death, all coded using ICD classifications. Around 12% of these deaths do not map directly to a BoD cause group and could therefore be considered ill-defined. The SBoD study have developed a 9-step hierarchical methodology for the redistribution of ill-defined deaths, utilising uses a mix of fixed and proportional redistribution and focusses on exploiting the data recorded on the death certificate at both an individual and population level. In this presentation we will describe the methodology used to redistribute ill-defined deaths in the Scottish study - the development, the application and the strengths and weaknesses of our approach. We will also discuss the example of COVID-19 and how competition between the underlying cause of death is likely to impact how we need to approach IDDs in the future.

Inequalities in the disease burden in Scotland: an area level analysis

In the context of increasing demand for evidence-based policy, attempts to address or mitigate the effects of disadvantage have been usefully informed by comprehensive indices of multiple deprivation. These indices combine indicators on a range of dimensions of deprivation to classify neighborhoods or localities. Through combining information on fatal and non-fatal health loss, burden of disease studies allow planners and policy-makers to have a better understanding of the contribution of different diseases and injuries to the total burden of disease. These estimates can be augmented through studies, stratified by investigating inequalities in the burden of disease due to area-based deprivation. Doing so, helps contribute to discussions about where prevention and service activity should be focused to address health inequalities. The Scottish Burden of Disease study uses the Scottish Index of Multiple Deprivation (SIMD) as means to report on of the extent of inequality in the burden of disease in Scotland between people living in the areas of greatest, and of least, multiple deprivation. The SIMD quantifies deprivation based on data zones, a geographical unit comparable to a postcode. Using pooled and weighted data from seven domains (employment, income, crime, housing, health, education and geographic access), each data zone is given a composite rank out of 6,505 data zones. The composite rank was then converted to a decile, with 1 assigned to the 10% most deprived data zones and 10 to the 10% least deprived. In this presentation we will show the key steps involved in undertaking an area-based analysis of health inequalities in the burden of disease in Scotland using results from the Scottish Burden of Disease 2019 study, and from our monitoring of COVID-19 disability-adjusted life years.

Monitoring the burden of disease in Scotland and the contribution of risk factors

Background

The Scottish Burden of Disease (SBoD) Study monitors the contribution of over 100 diseases and injuries to the population health in Scotland, in the context of disability-adjusted life years (DALYs). Providing robust estimates of burden is the first step in identifying areas of prevention which could have the biggest impact on health; including identification of modifiable risk factors and changes in the underlying risk factor prevalence. Our aim was to estimate DALYs for 2019, to describe the current burden in Scotland and as a baseline for future burden scenarios.

Methods

The SBoD 2016 study estimated the burden using routine data and patient-level record linkage. For this update, years lived with disability were estimated using 2016 age-sex-deprivation specific rates, assuming no change in disease prevalence from 2016, but taking account of changes to the population structure. Years of life lost were calculated from 2019 observed deaths and the application of the Global Burden of Disease (GBD) aspirational life table. Population attributable fractions (PAFs) were sourced from the GBD 2019 and risk factor prevalence from the Scottish Health Survey.

Results

In 2019 the leading causes of burden were ischaemic heart disease (IHD), Alzheimer's/other dementias, lung cancer, drug-use disorders and cerebrovascular disease, representing over a quarter (27%) of the total DALYs in Scotland. Application of PAFs shows that a proportion of the burden for each of these causes can be attributed to modifiable risk factors.

Conclusions

IHD continues to be the leading cause of health burden in Scotland in 2019. However recent years show an increase in burden of social causes and diseases affecting the ageing population. Application of PAFs demonstrate the importance of continuing to monitor both the burden of disease in Scotland and the prevalence of risk factors, to provide robust evidence for planning of local and national services.

Key messages

• The Scottish Burden of Disease continues to monitor the population health landscape of Scotland.

• Ischaemic heart disease continues to be the leading cause of burden in Scotland.

DIPG-05. How do potassium channels contribute to the growth and invasion of highly-aggressive brain cancers?

Glioblastoma (GBM) is a lethal form of high-grade glioma with a dismal median survival time of just 15 months. Characterised by its’ highly diffuse and intrinsic growth pattern, GBM invades the healthy brain at an alarming rate. While diffuse midline glioma (DMG) is a much rarer disease, it is even more lethal, with a 5-year survival rate of just 2%. Though GBM is largely diagnosed in adults, DMG primarily affects young children aged 5-9 years and accounts for 10% of all childhood CNS cancers. Thus, while rare, DMG is highly aggressive and currently has no effective treatments to extend survival times beyond the median of 9 months. There is a pressing need for the development of novel and improved targeted therapies for each of these devastating diseases. Ion channels have long been implicated in the progression of numerous cancer types, due to their integral roles in proliferation, cell cycle transition, apoptosis, migration, and cellular plasticity. Voltage-gated potassium channels (VGKCs), in particular, have strong links to the key processes of proliferation, migration and invasion in GBM tumours. Given that the majority of GBM-related deaths are attributed to secondary tumours and metastasis, targeting proteins that are integral to these processes could result in reduced recurrence. Preliminary evidence suggests a potential role for the VGKC subtypes Kv5.1, Kv7.2, and the Kv4 subfamily in GBM and DMG, due to observed upregulation of these genes in both patient-derived cell lines and tumour samples. These particular VGKC subtypes are highly novel with regards to these cancers, while their significant upregulation suggests they may be associated with tumour progression. Thus, we aim to further explore the relationship between ion channel function and tumourigenesis in GBM and DMG, with a specific focus on VGKC subtypes and their potential therapeutic value.

Quantifying the burden of disease in Scotland in 2018: a Scottish Burden of Disease study

Background

The Scottish Burden of Disease (SBoD) Study monitors the contribution of over 100 diseases and injuries to the population health in Scotland. Providing robust estimates of the burden is important as recent evidence has highlighted stalling life expectancy and worsening trends in self-assessed general health and understanding the burden of disease is the first step in identifying areas of prevention which could have the biggest impact on health. Our aim was to estimate disability-adjusted life years (DALYs) for 2018, for all causes of disease and injury.

Methods

The SBoD 2016 study estimated the burden for 132 causes of injury and disease using routine data and patient-level record linkage. For this update, years lived with disability were estimated using 2016 age-sex-deprivation specific rates, assuming no change in disease prevalence from 2016, but taking account of changes to the population structure. Years of life lost were calculated from 2018 observed deaths and the application of the Global Burden of Disease aspirational life table.

Results

In 2018 the leading causes of burden were ischaemic heart disease, Alzheimer's/other dementias, lung cancer, drug-use disorders and cerebrovascular disease, representing over a quarter (27%) of the total DALYs in Scotland. Of the 10 leading causes of disease burden, four are wholly attributable to ill-health, demonstrating the added-value of considering DALYs in conjunction with traditional measures of mortality and morbidity.

Conclusions

Ischaemic heart disease continues to be the leading cause of burden of disease in Scotland, however recent years show an increase in burden of social causes and diseases primarily affecting the ageing population. These changes in leading causes demonstrate the importance of continuing to monitor the burden of disease in Scotland, to provide robust evidence for planning of local and national services.

Key messages

The study demonstrates the added-value of considering the burden of disease, in conjunction with traditional measures of morbidity and mortality. Ischaemic heart disease continues to be the leading cause of burden of disease in Scotland.

Scottish Burden of Disease (SBOD) study: a population health surveillance system for meaningful action

In 2012, planning began to launch the Scottish Burden of Disease (SBOD) study. The aim was to create a population health surveillance system to assess the impact of over 100 causes of disease and injury, and risks, measured by disability-adjusted life years (DALYs). The study has become a mainstay over the last five years as a tool to aid strategic and proportionate decision-making. In 2017, its scope expanded to highlight the extent of inequalities in DALYs by socioeconomic status. Additionally, it now provides comprehensive estimates for 14 regional Health Boards, which are responsible for protecting and improving the health of their local populations. It also provides estimates for 32 local government regions, which provide services related to the broader determinants of health, such as: education, social care and housing. To help turn findings from the SBOD study into action, push, pull and integrated efforts are used. Push efforts involve working together with publishing and communications leads to share key findings. These are commonly in the form of plain English and academic reports, summary briefings, social media messages and infographics. Key messages are also shared through television, radio and newsprint. Pull efforts have recently been improved to house estimates within interactive R Shiny dashboards, which contain user-friendly charts and easy to download data. Integrated approaches involve working with relevant national and local stakeholders, to help shape national and local priority setting. Findings from the study are being used by national and local government and health institutions. Third sector organisations are also key users of SBOD findings, particularly for health conditions that generate high-levels of ill-health, rather than mortality. In 2021, the study will publish an update, and increase capacity on integrated efforts to further embed the SBOD in national and local strategic planning.

Socioeconomic inequalities in COVID-19 DALYs in Scotland, 2020

Aim

Our aim was to estimate the overall, and inequalities in the, population health impact of COVID-19 in Scotland, measured by disability-adjusted life years (DALYs) in 2020.

Methods

National deaths and daily case data were input into the consensus model outlined by the European Burden of Disease Network, to estimate DALYs. Total Years of Life Lost (YLL) were estimated, and for each deprivation quintile of the Scottish population. Years Lived with Disability (2% of all DALYs) were proportionately distributed to deprivation quintiles, based on YLL estimates. Socioeconomic inequalities were measured by the Relative Index of Inequality (RII), Slope Index of Inequality (SII), and attributable DALYs were estimated by using the least deprived quintile as a reference. Results were presented as a range, using a sensitivity based on YLL estimates using: cause-specific; and COVID-19 related deaths.

Results

COVID-19 DALYs ranged from 96,500 to 108,200 in 2020, representing the second leading cause of disease/injury in Scotland, in 2020. Marked socioeconomic inequalities were observed across several measures. The difference between the most and least deprived areas, measured by SII, was 2,048 to 2,289 DALYs per 100,000. The RII was 1.16, meaning that the rate in the most deprived areas was around 58% higher than the mean rate of the population. DALYs attributable to differences in socioeconomic status accounted for 40% of total COVID-19 DALYs.

Conclusions

The direct population health impact of COVID-19 in 2020 was substantial. Despite unprecedented mitigation efforts, in Scotland, a single case in early 2020 developed to having an impact second only to ischaemic heart disease. This impact was not shared equally, and socioeconomically deprived areas were hit hardest, a result confirmed across all measures of inequality. DALY estimation on both the ongoing direct, and indirect, pandemic harms will evidence the extent of impact on overall, and inequalities in, population health.

Key messages

The population impact of COVID-19 has been highly damaging. When measured by DALYs, the population health impact of COVID-19 in Scotland, during 2020, was second only to ischaemic heart disease. The population health impact of COVID-19 has not been shared equally, a result confirmed across all measures of socioeconomic inequality.

Post-injection endophthalmitis rates with reduced povidone-iodine prophylaxis in patients with self-reported iodine sensitivity

BACKGROUND

Our objectives were (1) to report the post-injection endophthalmitis rate over 18 months, and (2) to determine any difference in the incidence of endophthalmitis in patients treated with reduced or no 5% povidone-iodine (PI) due to self-reported PI sensitivity.

METHODS

We performed a retrospective cohort study of all patients who received intravitreal injections (IVIs) from January 1st, 2018 to June 26th, 2019. Information on patients' age, gender visual acuities, the number of injections, drug administered, self-reported iodine sensitivity and injection protocols were obtained from electronic and paper records. For endophthalmitis cases, vitreous culture results and treatment were also noted. Patients were divided into three cohorts based on the injection protocol used for statistical analysis.

RESULTS

During the study period 22,046 IVIs were administered to 3332 eyes of 2709 patients. Intolerance to PI was reported by 2.4% of patients. The incidence of endophthalmitis was 0.02% (4/21,185) with the standard 5% PI protocol, 0.78% (6/769) with a reduced PI protocol involving fewer drops of 5% PI and chlorohexidine 0.05% for periorbital skin cleansing, and 1.09% (1/92) without any PI use. Receiving the standard PI protocol was associated with significantly lower rates of endophthalmitis compared to both the reduced PI and no PI protocols (p < 0.0001).

CONCLUSIONS

Patients who opt for less or no PI use are likely at significantly increased risk of developing post-IVI endophthalmitis. It is imperative to educate, counsel and consent these patients accordingly while exploring alternative antiseptic solutions.

Human Labor Pain Is Influenced by the Voltage-Gated Potassium Channel KV6.4 Subunit

By studying healthy women who do not request analgesia during their first delivery, we investigate genetic effects on labor pain. Such women have normal sensory and psychometric test results, except for significantly higher cuff pressure pain. We find an excess of heterozygotes carrying the rare allele of SNP rs140124801 in KCNG4. The rare variant K_V6.4-Met419 has a dominant-negative effect and cannot modulate the voltage dependence of K_V2.1 inactivation because it fails to traffic to the plasma membrane. In vivo, Kcng4 (K_V6.4) expression occurs in 40% of retrograde-labeled mouse uterine sensory neurons, all of which express K_V2.1, and over 90% express the nociceptor genes Trpv1 and Scn10a. In neurons overexpressing K_V6.4-Met419, the voltage dependence of inactivation for K_V2.1 is more depolarized compared with neurons overexpressing K_V6.4. Finally, K_V6.4-Met419-overexpressing neurons have a higher action potential threshold. We conclude that K_V6.4 can influence human labor pain by modulating the excitability of uterine nociceptors.

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KCNG4 variant highly prevalent in women requiring no analgesia in childbirth

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KCNG4 variant encodes K_V6.4Met-419; K_V6.4 is a silent subunit modifying K_V activity

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K_V6.4Met-419 is retained in the cytoplasm and acts in a dominant-negative manner

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K_V6.4Met-419 overexpression results in hypoexcitable sensory neurons

Mutations in phospholipase C eta-1 (PLCH1) are associated with holoprosencephaly

BACKGROUND

Holoprosencephaly is a spectrum of developmental disorder of the embryonic forebrain in which there is failed or incomplete separation of the prosencephalon into two cerebral hemispheres. To date, dominant mutations in sonic hedgehog (SHH) pathway genes are the predominant Mendelian causes, and have marked interfamilial and intrafamilial phenotypical variabilities.

METHODS

We describe two families in which offspring had holoprosencephaly spectrum and homozygous predicted-deleterious variants in phospholipase C eta-1 (PLCH1). Immunocytochemistry was used to examine the expression pattern of PLCH1 in human embryos. We used SHH as a marker of developmental stage and of early embryonic anatomy.

RESULTS

In the first family, two siblings had congenital hydrocephalus, significant developmental delay and a monoventricle or fused thalami with a homozygous PLCH1 c.2065C>T, p.(Arg689*) variant. In the second family, two siblings had alobar holoprosencephaly and cyclopia with a homozygous PLCH1 c.4235delA, p.(Cys1079ValfsTer16) variant. All parents were healthy carriers, with no holoprosencephaly spectrum features. We found that the subcellular localisation of PLCH1 is cytoplasmic, but the p.(Cys1079ValfsTer16) variant was predominantly nuclear. Human embryo immunohistochemistry showed PLCH1 to be expressed in the notorcord, developing spinal cord (in a ventral to dorsal gradient), dorsal root ganglia, cerebellum and dermatomyosome, all tissues producing or responding to SHH. Furthermore, the embryonic subcellular localisation of PLCH1 was exclusively cytoplasmic, supporting protein mislocalisation contributing to the pathogenicity of the p.(Cys1079ValfsTer16) variant.

CONCLUSION

Our data support the contention that PLCH1 has a role in prenatal mammalian neurodevelopment, and deleterious variants cause a clinically variable holoprosencephaly spectrum phenotype.

Profiling of donor-specific immune effector signatures in response to rituximab in a human whole blood loop assay using blood from CLL patients

Rituximab is widely used in the treatment of haematological malignancies, including chronic lymphocytic leukaemia (CLL), the most common leukaemia in adults. However, some patients, especially those with high tumour burden, develop cytokine release syndrome (CRS). It is likely that more patients will develop therapy-linked CRS in the future due to the implementation of other immunotherapies, such as CAR T-cell, for many malignancies. Current methods for CRS risk assessment are limited, hence there is a need to develop new methods. To better recapitulate an in vivo setting, we implemented a unique human whole blood "loop" system to study patient-specific immune responses to rituximab in blood derived from CLL patients. Upon rituximab infusion, both complement-dependent cytotoxicity (CDC) and antibody-dependent cellular cytotoxicity (ADCC) profiles were evident in CLL patient blood, coincident with CLL cell depletion. Whereas B cell depletion is induced in healthy persons in the blood loop, only patients display B cell depletion coupled with CRS. With the exception of one donor who lacked NK cells, all other five patients displayed variable B cell depletion along with CRS profile. Additionally, inhibition of CDC or ADCC via either inhibitors or antibody Fc modification resulted in skewing of the immune killing mechanism consistent with published literature. Herein we have shown that the human whole blood loop model can be applied using blood from a specific indication to build a disease-specific CRS and immune activation profiling ex vivo system. Other therapeutic antibodies used for other indications may benefit from antibody characterization in a similar setting.

Forecasting the extent of future public health challenges using the Scottish Burden of Disease study

Background

Over the next 25 years in Scotland there is expected to be negative natural change in population growth in a rapidly ageing population. Recent evidence has highlighted the slowing of life expectancy gains and worsening trends in self-assessed general health. We have adapted the Scottish Burden of Disease study to forecast how demographic and health trends will shape future public health challenges. This is important in order to inform policy, service and workforce planning to meet anticipated needs.

Methods

For a baseline period of 2014-16 Disability-Adjusted Life Years (DALYs) were estimated for 132 causes of burden using routine data sources and patient-level record linkage techniques. Disability weights and disease models used to calculate Years Lived with Disability (YLD) were largely based on those from the Global Burden of Disease study, with life tables used to facilitate calculations of Years of Life Lost (YLL). The leading 20 causes were identified and trends in the occurrence of morbidity and mortality are currently being estimated up until 2019, and forecast to 2040, using age-period-cohort modelling. Crude and age-standardised rates will be used to monitor changes due to demography and exposure to the wider social determinants of health.

Results

In 2014-16, the leading causes of burden were ischaemic heart disease, neck and low back pain, depression, lung cancer and cerebrovascular disease. The leading 20 causes represented 68% of all-cause DALYs with ill-health and disability causing almost half of the burden.

Conclusions

Insights of the future trajectory of population health equip us with strong evidence to influence the need for a strong policy response on prevention. Estimates of the future occurrence of morbidities can be embedded in planning to ensure that services and the care workforce are proportionately designed to meet the increasing needs of a vulnerable ageing population.

Key messages

The most recent assessment highlighted that non-fatal and fatal health states approximately contribute equally to the overall disease burden in Scotland. Evidencing how future demographic and population health trends interact allows us to ensure that policy responses, care services and the care workforce can be designed based on anticipated needs.

The power of administrative data in national studies: experiences from the Scottish Burden of Disease study

In 2013, the Scottish Burden of Disease Study (SBoD) study set out with an ambitious aim of comprehensively estimating the burden of 132 causes of ill-health and mortality. The study utilised the rich and widespread data which is recorded as a by-product of individual encounters across the universally available and free at point-of-contact healthcare services in Scotland, and other long-standing survey initiatives. It was carried out as an independent national burden of disease study, but used Global Burden of Disease methodology for disability weights. In 2017, our first report outlined the contribution of causes of disease and injury of DALYs. This was followed up in a 2018, with a further report highlighting the effect of socioeconomic inequalities in DALYs.

In this presentation we will show the key steps involved in undertaking the SBoD study drawing on available data sources in Scotland. From the Scottish experience we will highlight important issues in knowledge translation for national burden of diseases studies to consider when specific choices are made on the methodological inputs into calculations for both YLL and YLD, specifically: (i) the differential impact between different life tables; (ii) the impact of differences in severity distributions; and (iii) the impact of using different standard populations when directly standardising rates.

Comparing international postgraduate training and healthcare context with the UK to streamline overseas GP recruitment: four case studies

BACKGROUND

There are ambitious overseas recruitment targets to alleviate current GP shortages in the UK. GP training in European Economic Area (EEA) countries is recognised by the General Medical Council (GMC) as equivalent UK training; non-EEA GPs must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained GPs. The CEGPR may be a barrier to recruiting GPs from non-EEA countries. It is important to facilitate the most streamlined route into UK general practice while maintaining registration standards and patient safety.

AIM

To apply a previously published mapping methodology to four non-EEA countries: South Africa, US, Canada, and New Zealand.

DESIGN & SETTING

Desk-based research was undertaken. This was supplemented with stakeholder interviews.

METHOD

The method consisted of: (1) a rapid review of 13 non-EEA countries using a structured mapping framework, and publicly available website content and country-based informant interviews; (2) mapping of five 'domains' of comparison between four overseas countries and the UK (healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation). Mapping of the domains involved desk-based research. A red, amber, or green (RAG) rating was applied to indicate the degree of alignment with the UK.

RESULTS

All four countries were rated 'green'. Areas of differences that should be considered by regulatory authorities when designing streamlined CEGPR processes for these countries include: healthcare context (South Africa and US), CPD and revalidation (US, Canada, and South Africa), and assessments (New Zealand).

CONCLUSION

Mapping these four non-EEA countries to the UK provides evidence of utility of the systematic method for comparing GP training between countries, and may support the UK's ambitions to recruit more GPs to alleviate UK GP workforce pressures.

Understanding why primary care doctors leave direct patient care: a systematic review of qualitative research

BACKGROUND

UK general practitioners (GPs) are leaving direct patient care in significant numbers. We undertook a systematic review of qualitative research to identify factors affecting GPs' leaving behaviour in the workforce as part of a wider mixed methods study (ReGROUP).

OBJECTIVE

To identify factors that affect GPs' decisions to leave direct patient care.

METHODS

Qualitative interview-based studies were identified and their quality was assessed. A thematic analysis was performed and an explanatory model was constructed providing an overview of factors affecting UK GPs. Non-UK studies were considered separately.

RESULTS

Six UK interview-based studies and one Australian interview-based study were identified. Three central dynamics that are key to understanding UK GP leaving behaviour were identified: factors associated with low job satisfaction, high job satisfaction and those linked to the doctor-patient relationship. The importance of contextual influence on job satisfaction emerged. GPs with high job satisfaction described feeling supported by good practice relationships, while GPs with poor job satisfaction described feeling overworked and unsupported with negatively impacted doctor-patient relationships.

CONCLUSIONS

Many GPs report that job satisfaction directly relates to the quality of the doctor-patient relationship. Combined with changing relationships with patients and interfaces with secondary care, and the gradual sense of loss of autonomy within the workplace, many GPs report a reduction in job satisfaction. Once job satisfaction has become negatively impacted, the combined pressure of increased patient demand and workload, together with other stress factors, has left many feeling unsupported and vulnerable to burn-out and ill health, and ultimately to the decision to leave general practice.

Workforce predictive risk modelling: development of a model to identify general practices at risk of a supply-demand imbalance

OBJECTIVE

This study aimed to develop a risk prediction model identifying general practices at risk of workforce supply-demand imbalance.

DESIGN

This is a secondary analysis of routine data on general practice workforce, patient experience and registered populations (2012 to 2016), combined with a census of general practitioners' (GPs') career intentions (2016).

SETTING/PARTICIPANTS

A hybrid approach was used to develop a model to predict workforce supply-demand imbalance based on practice factors using historical data (2012-2016) on all general practices in England (with over 1000 registered patients n=6398). The model was applied to current data (2016) to explore future risk for practices in South West England (n=368).

PRIMARY OUTCOME MEASURE

The primary outcome was a practice being in a state of workforce supply-demand imbalance operationally defined as being in the lowest third nationally of access scores according to the General Practice Patient Survey and the highest third nationally according to list size per full-time equivalent GP (weighted to the demographic distribution of registered patients and adjusted for deprivation).

RESULTS

Based on historical data, the predictive model had fair to good discriminatory ability to predict which practices faced supply-demand imbalance (area under receiver operating characteristic curve=0.755). Predictions using current data suggested that, on average, practices at highest risk of future supply-demand imbalance are currently characterised by having larger patient lists, employing more nurses, serving more deprived and younger populations, and having considerably worse patient experience ratings when compared with other practices. Incorporating findings from a survey of GP's career intentions made little difference to predictions of future supply-demand risk status when compared with expected future workforce projections based only on routinely available data on GPs' gender and age.

CONCLUSIONS

It is possible to make reasonable predictions of an individual general practice's future risk of undersupply of GP workforce with respect to its patient population. However, the predictions are inherently limited by the data available.

Laparoscopic cholecystectomy in the Acute Care Surgery model: risk factors for complications

Background

The Acute Care Surgery (ACS) model developed during the last decade fuses critical care, trauma, and emergency general surgery. ACS teams commonly perform laparoscopic cholecystectomy (LC) for acute biliary disease. This study reviewed LCs performed by an ACS service focusing on risk factors for complications in the emergent setting.

Methods

All patients who underwent LC on an ACS service during a 26-month period were identified. Demographic, perioperative, and complication data were collected and analyzed with Fisher’s exact test, χ² test, and Mann-Whitney U Test.

Results

During the study period, 547 patients (70.2% female, mean age 46.1±18.1, mean body mass index 32.4±7.8 kg/m²) had LC performed for various acute indications. Mean surgery time was 77.9±50.2 minutes, and 5.7% of cases were performed “after hours.” Rate of conversion to open procedure was 6%. Complications seen included minor bile leaks (3.8%), infection (3.8%), retained gallstones (1.1%), organ injury (1.1%), major duct injury (0.9%), and postoperative bleeding (0.9%). Statistical analysis demonstrated significant relationships between conversion, length of surgery, age, gender, and intraoperative cholangiogram with various complications. No significant relationships were detected between complications and BMI, pregnancy, attending experience, and time of operation.

Discussion

Although several statistically significant relationships were identified between several risk factors and complications, these findings have limited clinical significance. Factors including attending years in practice and time of the operation were not associated with increased complications. ACS services are capable of performing a high volume of LCs for emergent indications with low complication and conversion rates.

­

Level of evidence:IV

Identifying policies and strategies for general practitioner retention in direct patient care in the United Kingdom: a RAND/UCLA appropriateness method panel study

Background

The United Kingdom (UK) is experiencing a general practitioner (GP) workforce retention crisis. Research has focused on investigating why GPs intend to quit, but less is known about the acceptability and effectiveness of policies and strategies to improve GP retention. Using evidence from research and key stakeholder organisations, we generated a set of potential policies and strategies aimed at maximising GP retention and tested their appropriateness for implementation by systematically consulting with GPs.

Methods

28 GP Partners and GPs working in national stakeholder organisations from South West England and London were purposively sampled, and asked to take part in a RAND/UCLA Appropriateness Method panel. Panellists were asked to read an evidence briefing summary, and then complete an online survey on two occasions. During each round, participants rated the appropriateness of policies and strategies aimed at improving GP retention using a nine point scale (1 ‘extremely inappropriate’ to 9 ‘extremely appropriate’). Fifty-four potential policies and strategies (equating to 100 statements) were tested, focusing on factors influencing job satisfaction (e.g. well-being, workload, incentives and remuneration, flexible working, human resources systems). Ratings were analysed for panel consensus and categorised based on appropriateness (‘appropriate’, ‘uncertain’, ‘inappropriate’).

Results

12/28 GPs approached agreed to take part, 9/28 completed two rounds of the online survey between February and June 2018. Panellists identified 24/54 policy and strategy areas (41/100 statements) as ‘appropriate’. Examples included providing GP practices ‘at risk’ of experiencing GP shortages with a toolkit for managing recruitment and retention, and interventions to facilitate peer support to enhance health and wellbeing, or support portfolio careers. Strategies to limit GP workload, and manage patient demand were also endorsed.

Conclusions

The panel of experienced GPs identified a number of practical ways to improve GP retention through interventions that might enhance job satisfaction and work-life balance. Future research should evaluate the impact of implementing these recommendations.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-1020-x) contains supplementary material, which is available to authorized users.

Validating the Reliable Change Index with Tensor-Based Morphometry: the ADNI-MEM and the ADNI-EF

Objective

The Reliable Change Index (RCI) is a commonly used method for interpreting change in neuropsychological test scores over time. However, the RCI is a psychometric phenomenon that, to date, has not been validated by neuroanatomical evidence.

Method

Longitudinal neuroimaging and neuropsychological data from baseline and one-year follow-up visits were retrieved from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database. The RCI was used to identify participants showing reliable decline on ADNI-MEM and ADNI-EF factor scores, which provide composite measures of memory and executive functioning, respectively. For each cognitive test score, two groups (reliable change vs. no reliable change) were matched on potential confounding variables using a genetic algorithm. Longitudinal neuroanatomical data were analyzed using tensor-based morphometry.

Results

Whole brain analysis revealed that reliable change on ADNI-MEM was associated with extended atrophy of the temporal lobe, the parahippocampal gyrus, the entorhinal cortex, and the posterior cingulate gyrus (Left Figure). Similar extended atrophy patterns were found for reliable change on ADNI-EF, except that the atrophy was more extensive and of higher magnitude (Right Figure). Regional analysis further confirmed that in such brain regions, the reliable change group manifested higher grey matter loss than the no change group.

Conclusion

The current study not only validated clinical usage of the RCI with neuroanatomical evidence but also practically suggested patterns of likely brain atrophy when reliable cognitive decline is detected.

Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

Background

UK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.

Objectives

(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.

Design

This was a comprehensive, mixed-methods study.

Setting

This study took place in primary care in England.

Participants

General practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.

Main outcome measures

Systematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.

Results

Past research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.

Limitations

The survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.

Conclusions

This research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.

Study registration

This study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Cost and Outcome of BehaviouRal Activation (COBRA): a randomised controlled trial of behavioural activation versus cognitive-behavioural therapy for depression

BACKGROUND

Depression is a common, debilitating and costly disorder. The best-evidenced psychological therapy - cognitive-behavioural therapy (CBT) - is complex and costly. A simpler therapy, behavioural activation (BA), may be an effective alternative.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of BA compared with CBT for depressed adults at 12 and 18 months' follow-up, and to investigate the processes of treatments.

DESIGN

Randomised controlled, non-inferiority trial stratified by depression severity, antidepressant use and recruitment site, with embedded process evaluation; and randomisation by remote computer-generated allocation.

SETTING

Three community mental health services in England.

PARTICIPANTS

Adults aged ≥ 18 years with major depressive disorder (MDD) recruited from primary care and psychological therapy services.

INTERVENTIONS

BA delivered by NHS junior mental health workers (MHWs); CBT by NHS psychological therapists.

OUTCOMES

Primary: depression severity (as measured via the Patient Health Questionnaire-9; PHQ-9) at 12 months. Secondary: MDD status; number of depression-free days; anxiety (as measured via the Generalised Anxiety Disorder-7); health-related quality of life (as measured via the Short Form questionnaire-36 items) at 6, 12 and 18 months; and PHQ-9 at 6 and 18 months, all collected by assessors blinded to treatment allocation. Non-inferiority margin was 1.9 PHQ-9 points. We undertook intention-to-treat (ITT) and per protocol (PP) analyses. We explored cost-effectiveness by collecting direct treatment and other health- and social-care costs and calculating quality-adjusted life-years (QALYs) using the EuroQol-5 Dimensions, three-level version, at 18 months.

RESULTS

We recruited 440 participants (BA, n = 221; CBT, n = 219); 175 (79%) BA and 189 (86%) CBT participants provided ITT data and 135 (61%) BA and 151 (69%) CBT participants provided PP data. At 12 months we found that BA was non-inferior to CBT {ITT: CBT 8.4 PHQ-9 points [standard deviation (SD) 7.5 PHQ-9 points], BA 8.4 PHQ-9 points (SD 7.0 PHQ-9 points), mean difference 0.1 PHQ-9 points, 95% confidence interval (CI) -1.3 to 1.5 PHQ-9 points, p = 0.89; PP: CBT 7.9 PHQ-9 points (SD 7.3 PHQ-9 points), BA 7.8 PHQ-9 points (SD 6.5 PHQ-9 points), mean difference 0.0 PHQ-9 points, 95% CI -1.5 to 1.6 PHQ-9 points, p = 0.99}. We found no differences in secondary outcomes. We found a significant difference in mean intervention costs (BA, £975; CBT, £1235; p < 0.001), but no differences in non-intervention (hospital, community health, social care and medication costs) or total (non-intervention plus intervention) costs. Costs were lower and QALY outcomes better in the BA group, generating an incremental cost-effectiveness ratio of -£6865. The probability of BA being cost-effective compared with CBT was almost 80% at the National Institute for Health and Care Excellence's preferred willingness-to-pay threshold of £20,000-30,000 per QALY. There were no trial-related adverse events.

LIMITATIONS

In this pragmatic trial many depressed participants in both groups were also taking antidepressant medication, although most had been doing so for a considerable time before entering the trial. Around one-third of participants chose not to complete a PP dose of treatment, a finding common in both psychotherapy trials and routine practice.

CONCLUSIONS

We found that BA is as effective as CBT, more cost-effective and can be delivered by MHWs with no professional training in psychological therapies.

FUTURE WORK

Settings and countries with a paucity of professionally qualified psychological therapists, might choose to investigate the delivery of effective psychological therapy for depression without the need to develop an extensive and costly professional infrastructure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN27473954.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 46. See the NIHR Journals Library website for further project information.

Feasibility, acceptability and effectiveness of an online alternative to face-to-face consultation in general practice: a mixed-methods study of webGP in six Devon practices

OBJECTIVES

To evaluate the feasibility, acceptability and effectiveness of webGP as piloted by six general practices.

METHODS

Mixed-methods evaluation, including data extraction from practice databases, general practitioner (GP) completion of case reports, patient questionnaires and staff interviews.

SETTING

General practices in NHS Northern, Eastern and Western Devon Clinical Commissioning Group's area approximately 6 months after implementing webGP (February-July 2016).

PARTICIPANTS

Six practices provided consultations data; 20 GPs completed case reports (regarding 61 e-consults); 81 patients completed questionnaires; 5 GPs and 5 administrators were interviewed.

OUTCOME MEASURES

Attitudes and experiences of practice staff and patients regarding webGP.

RESULTS

WebGP uptake during the evaluation was small, showing no discernible impact on practice workload. The completeness of cross-sectional data on consultation workload varied between practices.GPs judged 41/61 (72%) of webGP requests to require a face-to-face or telephone consultation. Introducing webGP appeared to be associated with shifts in responsibility and workload between practice staff and between practices and patients.81/231 patients completed a postal survey (35.1% response rate). E-Consulters were somewhat younger and more likely to be employed than face-to-face respondents. WebGP appeared broadly acceptable to patients regarding timeliness and quality/experience of care provided. Similar problems were presented by all respondents. Both groups appeared equally familiar with other practice online services; e-consulters were somewhat more likely to have used them.From semistructured staff interviews, it appeared that, while largely acceptable within practice, introducing e-consults had potential for adverse interactions with pre-existing practice systems.

CONCLUSIONS

There is potential to assess the impact of new systems on consultation patterns by extracting routine data from practice databases. Staff and patients noticed subtle changes to responsibilities associated with online options. Greater uptake requires good communication between practice and patients, and organisation of systems to avoid conflicts and misuse. Further research is required to evaluate the full potential of webGP in managing practice workload.

Ranibizumab Plus Panretinal Photocoagulation versus Panretinal Photocoagulation Alone for High-Risk Proliferative Diabetic Retinopathy (PROTEUS Study)

PURPOSE

Comparison of the efficacy of ranibizumab (RBZ) 0.5 mg intravitreal injections plus panretinal photocoagulation (PRP) versus PRP alone in the regression of the neovascularization (NV) area in subjects with high-risk proliferative diabetic retinopathy (HR-PDR) over a 12-month period.

DESIGN

Prospective, randomized, multicenter, open-label, phase II/III study.

PARTICIPANTS

Eighty-seven participants (aged ≥18 years) with type 1/2 diabetes and HR-PDR (mean age, 55.2 years; 37% were female).

METHODS

Participants were randomized (1:1) to receive RBZ+PRP (n = 41) or PRP monotherapy (n = 46). The RBZ+PRP group received 3 monthly RBZ injections along with standard PRP. The PRP monotherapy group received standard PRP between day 1 and month 2; thereafter, re-treatments in both groups were at the investigators' discretion.

MAIN OUTCOME MEASURES

The primary outcome was regression of NV total, on the disc (NVD) plus elsewhere (NVE), defined as any decrease in the area of NV from the baseline to month 12. Secondary outcomes included best-corrected visual acuity (BCVA) changes from baseline to month 12, time to complete NV regression, recurrence of NV, macular retinal thickness changes from baseline to month 12, need for treatment for diabetic macular edema, need for vitrectomy because of occurrence of vitreous hemorrhage, tractional retinal detachment or other complications of DR, and adverse events (AEs) related to treatments.

RESULTS

Seventy-seven participants (88.5%) completed the study. Overall baseline demographics were similar for both groups, except for age. At month 12, 92.7% of participants in the RBZ+PRP group presented NV total reduction versus 70.5% of the PRP monotherapy participants (P = 0.009). The number of participants with NVD and NVE reductions was higher with RBZ+PRP (93.3% and 91.4%, respectively) versus PRP (68.8% and 73.7%, respectively), significant only for NVE (P = 0.048). Complete NV total regression was observed in 43.9% in the RBZ+PRP group versus 25.0% in the PRP monotherapy group (P = 0.066). At month 12, the mean BCVA was 75.2 letters (20/32) in the RBZ+PRP group versus 69.2 letters (20/40) in the PRP monotherapy group (P = 0.104). In the RBZ+PRP group, the mean number of PRP treatments over month 12 was 3.5±1.3, whereas in the PRP monotherapy group, it was 4.6±1.5 (P = 0.001). No deaths or unexpected AEs were reported.

CONCLUSIONS

Treatment with RBZ+PRP was more effective than PRP monotherapy for NV regression in HR-PDR participants over 12 months.

Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England

OBJECTIVE

To identify factors influencing general practitioners' (GPs') decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role.

DESIGN

Qualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care.

SETTING

South West England, UK.

PARTICIPANTS

41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles.

RESULTS

Reasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs' thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today's National Health Service for this group of GPs.

CONCLUSION

Future policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs' perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs' concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care.

Fetal Dysmorphology-Still an Essential Art. Analysis of the Limitations of Microarray in a Fetal Population and a Look Toward the Genome Sequencing Era

Cytogenomic microarray allows assessment of the genome at higher resolutions than traditional karyotyping. The objective of this study is to evaluate the utility of microarray in a routine fetal autopsy setting before the advent of routine fetal exome/genome sequencing and the issues these technologies may generate. A systematic review of fetal postmortems at 12-24 weeks gestation between January 2011 and December 2014 was undertaken. Cases where there was no consent for audit, research, or genetic testing were excluded as were cases referred to the Procurator Fiscal, stillbirths, and neonatal deaths. Copy number variations were detected in 16 cases. In addition, there was 1 case of uniparental disomy; not all of these were related to the phenotype. There were a number of cases with phenotypic abnormalities and normal array results. Five of these underwent directed mutation analysis-3 were positive. Genetic laboratory investigations such as microarray and Quantitative Fluorescent-Polymerase Chain Reaction may increase the diagnostic yield in the assessment of fetal dysmorphology. However, this study shows that genetic results not only require careful review given the potential uncertain significance but also require phenotypic assessment of the fetus by a competent fetal dysmorphologist to determine the likely causative effect of any detected anomaly. This best practice will also extend to next generation sequencing and interpretation of variants of unknown significance. Fetal medicine teams should ideally include specialists well versed in assessment of fetal anomaly to provide families with the best possible information about the cause of their pregnancy loss and their options for future pregnancies.

7-Hexagon Multifocal Electroretinography for an Objective Functional Assessment of the Macula in 14 Seconds

PURPOSE

We present the multifocal electroretinogram (mfERG) with a 7-hexagon array as an objective test of macular function that can be recorded in 14 s. We provide normal values and investigate its reproducibility and validity.

METHODS

Healthy participants underwent mfERG testing according to International Society for Clinical Electrophysiology of Vision (ISCEV) standards using the Espion Profile/D310 multifocal ERG system (Diagnosys, LLC, Lowell, MA, USA). One standard recording of a 61-hexagon array and 2 repeated recordings of a custom 7-hexagon array were obtained.

RESULTS

A total of 13 subjects (mean age 46.9 years) were included. The median response densities were 12.5 nV/deg2 in the center and 5.2 nV/deg2 in the periphery. Intereye correlations were strong in both the center (ρCenter = 0.821; p < 0.0001) and the periphery (ρPeriphery = 0.862; p < 0.0001). Intraeye correlations were even stronger: ρCenter = 0.904 with p < 0.0001 and ρPeriphery = 0.955 with p < 0.0001. Bland-Altman plots demonstrated an acceptable retest mean difference in both the center and periphery, and narrow limits of agreement. We found strong correlations of the center (ρCenter = 0.826; p < 0.0001) and periphery (ρPeriphery = 0.848; p < 0.0001), with recordings obtained by the 61-hexagon method.

CONCLUSIONS

The 7-hexagon mfERG provides reproducible results in agreement with results obtained according to the ISCEV standard.

Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): a qualitative process evaluation

OBJECTIVE

To explore participant views on acceptability, mechanisms of change and impact of behavioural activation (BA) delivered by junior mental health workers (MHWs) versus cognitive behavioural therapy (CBT) delivered by professional psychotherapists.

DESIGN

Semistructured qualitative interviews analysed using a framework approach.

PARTICIPANTS

36 participants with major depressive disorder purposively sampled from a randomised controlled trial of BA versus CBT (the COBRA trial).

SETTING

Primary care psychological therapies services in Devon, Durham and Leeds, UK.

RESULTS

Elements of therapy considered to be beneficial included its length and regularity, the opportunity to learn and not dwelling on the past. Homework was an important, although challenging aspect of treatment. Therapists were perceived as experts who played an important role in treatment. For some participants the most important element of therapy was having someone to talk to, but for others the specific factors associated with BA and CBT were crucial, with behavioural change considered important for participants in both treatments, and cognitive change unsurprisingly discussed more by those receiving CBT. Both therapies were considered to have a positive impact on symptoms of depression and other areas of life including feelings about themselves, self-care, work and relationships. Barriers to therapy included work, family life and emotional challenges. A subset (n=2) of BA participants commented that therapy felt too simple, and MHWs could be perceived as inexperienced. Many participants saw therapy as a learning experience, providing them with tools to take away, with work on relapse prevention essential.

CONCLUSIONS

Despite barriers for some participants, BA and CBT were perceived to have many benefits, to have brought about cognitive and behavioural change and to produce improvements in many domains of participants' lives. To optimise the delivery of BA, inexperienced junior MHWs should be supported through good quality training and ongoing supervision.

TRIAL REGISTRATION NUMBER

ISRCTN27473954, 09/12/2011.

Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners

OBJECTIVE

Given recent concerns regarding general practitioner (GP) workforce capacity, we aimed to describe GPs' career intentions, especially those which might impact on GP workforce availability over the next 5 years.

DESIGN

Census survey, conducted between April and June 2016 using postal and online responses , of all GPs on the National Health Service performers list and eligible to practise in primary care. Two reminders were used as necessary.

SETTING

South West England (population 3.5  million), a region with low overall socioeconomic deprivation.

PARTICIPANTS

Eligible GPs were 2248 out of 3370 (67 % response rate).

MAIN OUTCOME MEASURES

Reported likelihood of permanently leaving or reducing hours spent in direct patient care or of taking a career break within the next 5 years and present morale weighted for non-response.

RESULTS

Responders included 217 7 GPs engaged in patient care. Of these, 863 (37% weighted, 95%  CI 35 % to 39 %) reported a high likelihood of quitting direct patient care within the next 5 years. Overall, 1535 (70% weighted, 95%  CI 68 % to 72 %) respondents reported a career intention that would negatively impact GP workforce capacity over the next 5 years, through permanently leaving or reducing hours spent in direct patient care, or through taking a career break. GP age was an important predictor of career intentions; sharp increases in the proportion of GPs intending to quit patient care were evident from 52 years. Only 305 (14% weighted, 95%  CI 13 % to 16 %) reported high morale, while 1195 ( 54 % weighted, 95%  CI 52 % to 56 %) reported low morale. Low morale was particularly common among GP partners. Current morale strongly predicted GPs' career intentions; those with very low morale were particularly likely to report intentions to quit patient care or to take a career break.

CONCLUSIONS

A substantial majority of GPs in South West England report low morale. Many are considering career intentions which, if implemented, would adversely impact GP workforce capacity within a short time period.

STUDY REGISTRATION

NIHR HS&DR - 14/196/02, UKCRN ID 20700.

Abstract PR01: T cell responses to peptide-epitopes of choice can be boosted by immune complexes of circulating anti-tetanus toxoid antibodies

The ability of dendritic cells (DCs) to boost an antigen-specific immune response is utilized in several cancer immunotherapy strategies including therapeutic vaccination using long peptides. Water-based peptide vaccines are rapidly degraded and oil-based delivery strategies trap immune cells to unwanted sites or have inappropriate adjuvant properties. To enhance the uptake of synthetic long peptides (SLP) and activation of DCs we make use of circulating antibodies to mount cellular responses against tumor antigens of interest by conjugating a B cell epitope to a T cell epitope. The conjugation of the two improves the uptake of peptide/antibody complexes and concomitant activation of the same DC in contrast to SLPs which are not conjugated. Our identified B cell epitope of choice is derived from tetanus toxin (and named MTTE = minimal tetanus toxin epitope) and can be targeted by tetanus-specific antibodies that are present in most vaccinated individuals. SLPs harbor viral or tumor-derived epitopes specific for the disease of interest. We have applied a modified chandler loop model preserving intact cascade systems, to characterize how the vaccine is targeted to human immune cells. The B cell-T cell conjugate ([MTTE]3-SLP) is taken up by human monocytes and blood DCs in an antibody-dependent manner. Rather than FcγRs, the internalization of the antigen appears to be mediated through the classical pathway of the complement system as it is partly reduced by blocking C1q but not when blocking C3. A [MTTE]3-CMV conjugate, containing a T cell epitope from the pp65 protein of cytomegalovirus (CMV), strongly reactivates memory T cells when analyzed in blood from donors with CMV-specific T cells. The CMV-specific T cells rapidly produce IFNγ in response to the conjugate illustrating that the uptake of the conjugate leads to activation of antigen-specific T cells. Uptake as well as T cell activation occurs at low concentrations of the SLP conjugate, superior to a conjugate lacking the tetanus-sequence as well as to SLPs with or without added adjuvant (LPS). Additionally, when the B and T cell epitopes are separate entities but mixed, CMV-specific T cells are not activated, illustrating the requirement of conjugating the two. Our data show that we have a unique delivery system for peptide based vaccines that can aid induction of human T cell responses, and may potentiate immune responses in cancer patients.

Citation Format: E. Fletcher, W. van Maren, R. Cordfunke, J. Dinkelaar, R. Castelli, Jdc Codee, G. van der Marel, CJM Melief, JW Drijfhout, F. Ossendorp, Sm Mangsbo. T cell responses to peptide-epitopes of choice can be boosted by immune complexes of circulating anti-tetanus toxoid antibodies [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr PR01.

Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial

BACKGROUND

Depression is a common, debilitating, and costly disorder. Many patients request psychological therapy, but the best-evidenced therapy-cognitive behavioural therapy (CBT)-is complex and costly. A simpler therapy-behavioural activation (BA)-might be as effective and cheaper than is CBT. We aimed to establish the clinical efficacy and cost-effectiveness of BA compared with CBT for adults with depression.

METHODS

In this randomised, controlled, non-inferiority trial, we recruited adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder from primary care and psychological therapy services in Devon, Durham, and Leeds (UK). We excluded people who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal or had attempted suicide in the previous 2 months, or were cognitively impaired, or who had bipolar disorder or psychosis or psychotic symptoms. We randomly assigned participants (1:1) remotely using computer-generated allocation (minimisation used; stratified by depression severity [Patient Health Questionnaire 9 (PHQ-9) score of <19 vs ≥19], antidepressant use, and recruitment site) to BA from junior mental health workers or CBT from psychological therapists. Randomisation done at the Peninsula Clinical Trials Unit was concealed from investigators. Treatment was given open label, but outcome assessors were masked. The primary outcome was depression symptoms according to the PHQ-9 at 12 months. We analysed all those who were randomly allocated and had complete data (modified intention to treat [mITT]) and also all those who were randomly allocated, had complete data, and received at least eight treatment sessions (per protocol [PP]). We analysed safety in the mITT population. The non-inferiority margin was 1·9 PHQ-9 points. This trial is registered with the ISCRTN registry, number ISRCTN27473954.

FINDINGS

Between Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to BA and 219 (50%) to CBT. 175 (79%) participants were assessable for the primary outcome in the mITT population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group. BA was non-inferior to CBT (mITT: CBT 8·4 PHQ-9 points [SD 7·5], BA 8·4 PHQ-9 points [7·0], mean difference 0·1 PHQ-9 points [95% CI -1·3 to 1·5], p=0·89; PP: CBT 7·9 PHQ-9 points [7·3]; BA 7·8 [6·5], mean difference 0·0 PHQ-9 points [-1·5 to 1·6], p=0·99). Two (1%) non-trial-related deaths (one [1%] multidrug toxicity in the BA group and one [1%] cancer in the CBT group) and 15 depression-related, but not treatment-related, serious adverse events (three in the BA group and 12 in the CBT group) occurred in three [2%] participants in the BA group (two [1%] patients who overdosed and one [1%] who self-harmed) and eight (4%) participants in the CBT group (seven [4%] who overdosed and one [1%] who self-harmed).

INTERPRETATION

We found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals.

FUNDING

National Institute for Health Research.

Immediate Catheter Directed Thrombolysis for Thromboembolic Stroke During Carotid Endarterectomy

Background

Carotid artery endarterectomy (CEA) is a common procedure undertaken by vascular surgeons with over 5,000 procedures performed annually worldwide. Published rates of perioperative stroke range from 1.3% to 6.3%.

Case report

A case is presented in which on-table intra-cranial angiography and catheter directed thrombolysis were used for a thromboembolic occlusion of the distal internal carotid artery (ICA) and proximal middle cerebral artery (MCA). An 83-year-old lady developed a dense right hemiparesis while undergoing a CEA under local anaesthetic (LA). Immediate re-exploration of the endarterectomy did not reveal technical error. Intraoperative duplex scanning of the internal carotid artery revealed no detectable diastolic flow. On-table angiogram showed complete occlusion of the distal ICA and proximal MCA. Catheter directed administration of TPA was undertaken. The entire ICA and MCA were completely clear on a completion angiogram. The patient made a full neurological recovery.

Discussion and conclusion

Prompt diagnosis and treatment with intraoperative catheter directed thrombolysis can resolve thromboembolic occlusion of the ICA/MCA. It is argued that performing CEA under LA is useful for immediate recognition of perioperative stroke. Furthermore, the advantage is highlighted of vascular surgeons having both the resources and skillset to perform on-table angiography and thrombolysis.

•

Post-CEA stroke can be effectively treated with catheter directed thrombolysis.

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It is important to diagnose and treat distal or intracranial thromboembolism.

•

Rapid stroke recognition during CEA can be aided by performance under local anaesthetic.

•

Vascular surgeons should be able to perform intraoperative angiography and thrombolysis.

The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial)

BACKGROUND

Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice.

OBJECTIVES

In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice.

DESIGN

Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation.

SETTING

General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk).

PARTICIPANTS

Patients requesting same-day consultations.

INTERVENTIONS

Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation.

MAIN OUTCOME MEASURES

Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care.

RESULTS

Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it.

CONCLUSIONS

Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20687662.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

Assessment of estimated retinal atrophy progression in Stargardt macular dystrophy using spectral-domain optical coherence tomography

Aims

To estimate disease progression based on analysis of macular volume measured by spectral-domain optical coherence tomography (SD-OCT) in patients affected by Stargardt macular dystrophy (STGD1) and to evaluate the influence of software errors on these measurements.

Methods

58 eyes of 29 STGD1 patients were included. Numbers and types of algorithm errors were recorded and manually corrected. In a subgroup of 36 eyes of 18 patients with at least two examinations over time, total macular volume (TMV) and volumes of all nine Early Treatment of Diabetic Retinopathy Study (ETDRS) subfields were obtained. Random effects models were used to estimate the rate of change per year for the population, and empirical Bayes slopes were used to estimate yearly decline in TMV for individual eyes.

Results

6958 single B-scans from 190 macular cube scans were analysed. 2360 (33.9%) showed algorithm errors. Mean observation period for follow-up data was 15 months (range 3–40). The median (IQR) change in TMV using the empirical Bayes estimates for the individual eyes was −0.103 (−0.145, −0.059) mm³ per year. The mean (±SD) TMV was 6.321±1.000 mm³ at baseline, and rate of decline was −0.118 mm³ per year (p=0.003). Yearly mean volume change was −0.004 mm³ in the central subfield (mean baseline=0.128 mm³), −0.032 mm³ in the inner (mean baseline=1.484 mm³) and −0.079 mm³ in the outer ETDRS subfields (mean baseline=5.206 mm³).

Conclusions

SD-OCT measurements allow monitoring the decline in retinal volume in STGD1; however, they require significant manual correction of software errors.

Is the relationship between sedentary behaviour and cardiometabolic health in adolescents independent of dietary intake? A systematic review

Screen time, but not overall sedentary behaviour, is consistently related to cardiometabolic health in adolescents. Because of the associations screen time has with dietary intake, diet may be an important factor in the screen time and health relationship; however, evidence has not previously been synthesized. Thus, the aim of this systematic review was to explore whether the associations between various sedentary behaviours and cardiometabolic risk markers are independent of dietary intake in adolescents. Online databases and personal libraries were searched for peer-reviewed original research articles published in English before March 2014. Included studies assessed associations between sedentary behaviour and cardiometabolic markers in 12- to 18-year-olds and adjusted for dietary intake. Twenty-five studies met the inclusion criteria. From the 21 studies examining sedentary behaviour and adiposity, the majority found significant positive associations between television viewing, screen time and self-reported overall sedentary behaviour with markers of adiposity, independent of dietary intake. No significant associations between screen time with blood pressure and cholesterol were reported. Sedentary behaviour appears to be associated with adiposity in adolescents, irrespective of dietary intake. However, the variability of dietary variables between studies suggests further work is needed to understand the role of dietary intake when examining these associations in youth.

Exploring demographic and lifestyle associations with patient experience following telephone triage by a primary care doctor or nurse: secondary analyses from a cluster randomised controlled trial

BACKGROUND

The ESTEEM trial was a cluster randomised controlled trial that compared two telephone triage management systems (general practitioner (GP) or a nurse supported by computer decision support software) with usual care, in response to a request for same-day consultation in general practice.

AIM

To investigate associations between trial patients' demographic, health, and lifestyle characteristics, and their reported experiences of care.

SETTING

Recruitment of 20 990 patients occurred between May 2011 and December 2012 in 42 GP practices in England (13 GP triage, 15 nurse triage, 14 usual care).

METHOD

Patients reported their experiences via a postal questionnaire issued 4 weeks after their initial request for a same-day consultation. Overall satisfaction, ease of accessing medical help/advice, and convenience of care were analysed using linear hierarchical modelling.

RESULTS

Questionnaires were returned by 12 132 patients (58%). Older patients reported increased overall satisfaction compared with patients aged 25-59 years, but patients aged 16-24 years reported lower satisfaction. Compared with white patients, patients from ethnic minorities reported lower satisfaction in all three arms, although to a lesser degree in the GP triage arm. Patients from ethnic minorities reported higher satisfaction in the GP triage than in usual care, whereas white patients reported higher satisfaction with usual care. Patients unable to take time away from work or who could only do so with difficulty reported lower satisfaction across all three trial arms.

CONCLUSIONS

Patient characteristics, such as age, ethnicity and ability to attend their practice during work hours, were associated with their experiences of care following a same-day consultation request in general practice. Telephone triage did not increase satisfaction among patients who were unable to attend their practice during working hours.

TRIAL REGISTRATION NUMBER

ISCRTN20687662.

Implementing telephone triage in general practice: a process evaluation of a cluster randomised controlled trial

BACKGROUND

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. However, limited evidence exists of the challenges GP practices face in implementing telephone triage. We conducted a qualitative process evaluation alongside a UK-based cluster randomised trial (ESTEEM) which compared the impact of GP-led and nurse-led telephone triage with usual care on primary care workload, cost, patient experience, and safety for patients requesting a same-day GP consultation. The aim of the process study was to provide insights into the observed effects of the ESTEEM trial from the perspectives of staff and patients, and to specify the circumstances under which triage is likely to be successfully implemented. Here we report perspectives of staff.

METHODS

The intervention comprised implementation of either GP-led or nurse-led telephone triage for a period of 2-3 months. A qualitative evaluation was conducted using staff interviews recruited from eight general practices (4 GP triage, 4 Nurse triage) in the UK, implementing triage as part of the ESTEEM trial. Qualitative interviews were undertaken with 44 staff members in GP triage and nurse triage practices (16 GPs, 8 nurses, 7 practice managers, 13 administrative staff).

RESULTS

Staff reported diverse experiences and perceptions regarding the implementation of telephone triage, its effects on workload, and on the benefits of triage. Such diversity were explained by the different ways triage was organised, the staffing models used to support triage, how the introduction of triage was communicated across practice staff, and by how staff roles were reconfigured as a result of implementing triage.

CONCLUSION

The findings from the process evaluation offer insight into the range of ways GP practices participating in ESTEEM implemented telephone triage, and the circumstances under which telephone triage can be successfully implemented beyond the context of a clinical trial. Staff experiences and perceptions of telephone triage are shaped by the way practices communicate with staff, prepare for and sustain the changes required to implement triage effectively, as well as by existing practice culture, and staff and patient behaviour arising in response to the changes made.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20687662. Registered 28 May 2009.

A computer-assisted 3D model for analyzing the aggregation of tumorigenic cells reveals specialized behaviors and unique cell types that facilitate aggregate coalescence

We have developed a 4D computer-assisted reconstruction and motion analysis system, J3D-DIAS 4.1, and applied it to the reconstruction and motion analysis of tumorigenic cells in a 3D matrix. The system is unique in that it is fast, high-resolution, acquires optical sections using DIC microscopy (hence there is no associated photoxicity), and is capable of long-term 4D reconstruction. Specifically, a z-series at 5 μm increments can be acquired in less than a minute on tissue samples embedded in a 1.5 mm thick 3D Matrigel matrix. Reconstruction can be repeated at intervals as short as every minute and continued for 30 days or longer. Images are converted to mathematical representations from which quantitative parameters can be derived. Application of this system to cancer cells from established lines and fresh tumor tissue has revealed unique behaviors and cell types not present in non-tumorigenic lines. We report here that cells from tumorigenic lines and tumors undergo rapid coalescence in 3D, mediated by specific cell types that we have named “facilitators” and “probes.” A third cell type, the “dervish”, is capable of rapid movement through the gel and does not adhere to it. These cell types have never before been described. Our data suggest that tumorigenesis in vitro is a developmental process involving coalescence facilitated by specialized cells that culminates in large hollow spheres with complex architecture. The unique effects of select monoclonal antibodies on these processes demonstrate the usefulness of the model for analyzing the mechanisms of anti-cancer drugs.

Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis

BACKGROUND

Telephone triage is increasingly used to manage workload in primary care; however, supporting evidence for this approach is scarce. We aimed to assess the effectiveness and cost consequences of general practitioner-(GP)-led and nurse-led telephone triage compared with usual care for patients seeking same-day consultations in primary care.

METHODS

We did a pragmatic, cluster-randomised controlled trial and economic evaluation between March 1, 2011, and March 31, 2013, at 42 practices in four centres in the UK. Practices were randomly assigned (1:1:1), via a computer-generated randomisation sequence minimised for geographical location, practice deprivation, and practice list size, to either GP-led triage, nurse-led computer-supported triage, or usual care. We included patients who telephoned the practice seeking a same-day face-to-face consultation with a GP. Allocations were concealed from practices until after they had agreed to participate and a stochastic element was included within the minimisation algorithm to maintain concealment. Patients, clinicians, and researchers were not masked to allocation, but practice assignment was concealed from the trial statistician. The primary outcome was primary care workload (patient contacts, including those attending accident and emergency departments) in the 28 days after the first same-day request. Analyses were by intention to treat and per protocol. This trial was registered with the ISRCTN register, number ISRCTN20687662.

FINDINGS

We randomly assigned 42 practices to GP triage (n=13), nurse triage (n=15), or usual care (n=14), and 20,990 patients (n=6695 vs 7012 vs 7283) were randomly assigned, of whom 16,211 (77%) patients provided primary outcome data (n=5171 vs 5468 vs 5572). GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days compared with usual care (2·65 [SD 1·74] vs 1·91 [1·43]; rate ratio [RR] 1·33, 95% CI 1·30-1·36), and nurse triage with a 48% increase (2·81 [SD 1·68]; RR 1·48, 95% CI 1·44-1·52). Eight patients died within 7 days of the index request: five in the GP-triage group, two in the nurse-triage group, and one in the usual-care group; however, these deaths were not associated with the trial group or procedures. Although triage interventions were associated with increased contacts, estimated costs over 28 days were similar between all three groups (roughly £75 per patient).

INTERPRETATION

Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient's request for a same-day GP consultation, with similar costs to those of usual care. Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered.

FUNDING

Health Technology Assessment Programme UK National Institute for Health Research.

Question design in nurse-led and GP-led telephone triage for same-day appointment requests: a comparative investigation

OBJECTIVE

To compare doctors' and nurses' communication with patients in primary care telephone triage consultations.

DESIGN

Qualitative comparative study of content and form of questions in 51 telephone triage encounters between practitioners (general practitioners (GPs)=29; nurses=22) and patients requesting a same-day appointment in primary care. Audio-recordings of nurse-led calls were synchronised with video recordings of nurse's use of computer decision support software (CDSS) during triage.

SETTING

2 GP practices in Devon and Warwickshire, UK.

PARTICIPANTS

4 GPs and 29 patients; and 4 nurses and 22 patients requesting a same-day face-to-face appointment with a GP.

MAIN OUTCOME MEASURE

Form and content of practitioner-initiated questions and patient responses during clinical assessment.

RESULTS

A total of 484 question-response sequences were coded (160 GP; 324 N). Despite average call lengths being similar (GP=4 min, 37 s, (SD=1 min, 26 s); N=4 min, 39 s, (SD=2 min, 22 s)), GPs and nurses differed in the average number (GP=5.51, (SD=4.66); N=14.72, (SD=6.42)), content and form of questions asked. A higher frequency of questioning in nurse-led triage was found to be due to nurses' use of CDSS to guide telephone triage. 89% of nurse questions were oriented to asking patients about their reported symptoms or to wider-information gathering, compared to 54% of GP questions. 43% of GP questions involved eliciting patient concerns or expectations, and obtaining details of medical history, compared to 11% of nurse questions. Nurses using CDSS frequently delivered questions designed as declarative statements requesting confirmation and which typically preferred a 'no problem' response. In contrast, GPs asked a higher proportion of interrogative questions designed to request information.

CONCLUSIONS

Nurses and GPs emphasise different aspects of the clinical assessment process during telephone triage. These different styles of triage have implications for the type of information available following nurse-led or doctor-led triage, and for how patients experience triage.