Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality.

A search strategy designed following a Problem, Intervention, Comparator, Outcome model was used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources.

A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease ‘inappropriate referrals’ by up to 50%; templates increase documentation and awareness of risk factors; mixed interventions combining different intervention types provide tangible improvements in content and appropriateness.

Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve.

To explore health professionals’ experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting.

Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improving the quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals’ experiences when referring patients. Reports suggest that a health care professional’s attitude towards a treatment affects the willingness of patients to accept advice.

Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory.

Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.

To explore general practitioners’ (GPs) management of osteoarthritis (OA).

OA represents a large burden on primary care. Little is known about GPs’ current management of OA, especially influences on their prescribing quality care and the barriers they face while doing so.

A total of 1006 GPs were randomly selected and invited to participate in an online survey on assessment and treatment of OA, on factors influencing their management, burden on their practice, and on the need for improving care.

There were 232 respondents (23%). National Institute for Health and Clinical Excellence (NICE) guidance (65%) and professional experience (64%) were the biggest influences on OA management. When assessing patients, pain and mobility were most frequently assessed, with quality of life, independent living, sleep and depression addressed by over half of them. In all, 52% did not use educational materials; only a third of users rated their current educational material as good or very good. Treatments employed were largely in line with NICE recommendations. Prescription review was reported by a high proportion (74%). Achieving adequate pain control and lack of time were the most frequently cited challenges, whereas more time with patients, collaboration with specialist colleagues and improved communication tools were the most common needs identified to improve OA management. In summary, national guidelines are an important influence for GP treatment of OA. This survey has highlighted issues about the adequacy of information available for OA, about GPs’ need for more time with OA patients and their interaction with specialist colleagues.

This randomised control trial (RCT) study examined the effectiveness of a mentalisation-based perinatal group intervention, Nurture and Play (NaP), in improving mother–infant interaction quality and maternal reflective functioning and in decreasing depressive symptoms.

Few preventive prenatal interventions have been developed for primary health care settings for mothers with depressive symptoms. Furthermore, previous prenatal intervention studies have only concentrated on reducing depressive symptoms and have not directly addressed enhancing optimal parenting qualities.

The participants were 45 pregnant women with depressive symptoms. Women in the randomly assigned intervention group (n = 24) participated in the manualised, short-term NaP intervention group from pregnancy until the baby’s age of seven months, whereas control group women received treatment as usual (TAU). Maternal emotional availability (EA), reflective functioning (RF) and depressive symptoms were measured before the intervention and at the infants’ 12 months of age, and changes were evaluated using repeated measure analyses of variances (ANOVAs).

The results showed that the intervention group displayed higher maternal sensitivity and RF and more reduction in depressive symptoms than the control group when babies were 12 months old. These findings provide preliminary support for the effectiveness of the NaP intervention.

To evaluate the validity of the Stanford Brief Activity Survey (SBAS) and Exercise Vital Sign (EVS) questionnaire against accelerometer-determined time in moderate-to-vigorous physical activity (MVPA) among African-American (AA) women.

Limited research has evaluated the validity of brief physical activity (PA) questionnaires among AA women. Since the validity of PA questionnaires may differ among members of varying racial/ethnic groups, research is needed to explore the validity of self-report PA measures among AA women.

A total of 30 AA women [M age=35.5±5.3; M body mass index (BMI)=31.1±7.8] wore ActiGraph GT3X+ accelerometers (ActiGraph, LLC, Pensacola FL, USA) for seven days and completed both the SBAS and EVS at two different assessment periods (T1 and T2). Criterion validity was calculated using Spearman’s rank order correlations between each questionnaire score and accelerometer-measured MVPA. Sensitivity, specificity, and positive and negative predictive values were calculated using accelerometer-measured MVPA as the criterion to determine the ability of each questionnaire to predict whether or not a participant was meeting the 2008 US PA Guidelines.

Spearman correlation coefficients between questionnaire scores and minutes of accelerometer-measured MVPA were low (EVS, r=0.27 at T1 and r=0.26 at T2; SBAS, r=0.10 at T1 and r=0.28 at T2) and not statistically significant (P’s>0.05). The EVS had sensitivity, specificity, and negative and positive predictive values of 27, 89, 59, and 68% at T1 and 33, 74, 38, and 70% at T2, respectively. The SBAS had sensitivity, specificity, and negative and positive predictive values were 18, 79, 33, and 62% at T1 and 67, 58, 43, and 79% at T2. While both questionnaires may be useful in identifying AA women who do not meet the 2008 PA Guidelines, using the questionnaires to identify AA women meeting the PA Guidelines should be done with caution.

This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study.

Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences.

Survey data were collected during 2011–2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling.

Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care.

The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor–patient relationship as well as a broad range of services offered by PC physicians.

This paper aims to provide a detailed analysis of the diagnostic process of lung cancer from a primary-care perspective.

Diagnosing lung cancer at a stage where curative treatment is possible remains a challenge. Beginning to understand the complexity and difficulty in the diagnostic journey should enable the development of interventions in order to facilitate timelier diagnosis.

A national study of significant events was conducted whereby general practitioners (GPs) in Wales were asked to report data relating to the diagnostic process of recent lung cancer diagnoses using a standard template. Both qualitative and quantitative data were analysed.

Case reports were received from 96 general practices on 118 patients. A total of 96 patients (81.4%) presented with respiratory symptoms. A total of 79 patients (66.9%) had a GP-initiated X-ray before diagnosis. A total of 23 patients (19.5%) had a chest X-ray that did not initially show suspicion of lung cancer. A total of 25 patients (21.2%) were diagnosed after a GP-initiated acute admission. Analysis of free-text qualitative data showed that, for many patients, their GP behaved in an exemplary manner. However, for some patients, the GP could have made more of the opportunities presented for timelier diagnosis. There were a number of atypical and complex presentations, where the opportunities for more timely diagnosis were more limited. A variety of causes of diagnostic delays in secondary care were reported. These findings will inform health policy, and will inform the design of interventions to try to facilitate more timely diagnosis for symptomatic patients. We encourage greater compliance with diagnostic guidelines and greater vigilance for patients presenting with atypical symptoms, as well as for patients whose initial chest X-rays are normal.

To establish what factors are important for patients to engage in a new intervention for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and make recommendations to general practitioners (GPs) on preparing a patient for referral to such a service.

NICE guidelines recommend a prominent role for primary care in the management of patients with CFS/ME, with prompt diagnosis and appropriate referral for evidence-based treatments.

A qualitative study nested within a multi-centre randomised controlled trial of two new nurse therapist delivered interventions. Semi-structured interviews carried out with 19 patients who had received pragmatic rehabilitation (PR) in the trial. Interviews were transcribed verbatim and an iterative approach used to develop themes from the data set.

Factors that influence whether or not a patient engages with PR for CFS/ME are ensuring that the patient feels accepted and believed, that they accept the diagnosis, and that the model implicated by the treatment offered to the patient matches the model of illness held by the patient. If patients hold a clearly incompatible model of their illness, it is unlikely that they will engage with, and successfully complete, therapy. It is vital that the GP elicits and explores such illness beliefs either before making a referral to maximise patient engagement in therapy, or that an initial session with the therapist explores attitudes to the treatment model offered and then works with the patient’s model.

This study aimed to explore attitudes, beliefs and experiences regarding polypharmacy and discontinuing medications, or deprescribing, among community living older adults aged ≥65 years, using ≥5 medications. It also aimed to investigate if health literacy capabilities influenced attitudes and beliefs towards deprescribing.

Polypharmacy use is common among Australian older adults. However, little is known about their attitudes towards polypharmacy use or towards stopping medications. Previous studies indicate that health literacy levels tend to be lower in older adults, resulting in poor knowledge about medications.

A self-administered survey was conducted using two previously validated tools; the Patients’ Attitude Towards Deprescribing (PATD) tool to measure attitudes towards polypharmacy use and deprescribing and the All Aspects of Health Literacy Scale (AAHLS) to measure functional, communicative and critical health literacy. Descriptive statistical analysis was conducted.

The 137 responses showed that 80% thought all their medications were necessary and were comfortable with the number taken. Wanting to reduce the number of medications taken was associated with concerns about the amount taken (P<0.001), experiencing side effects (P<0.001), or believing that one or more medications were no longer needed (P<0.000). Those who were using ten or more medications were more likely to want to reduce the number taken (P=0.019). Most (88%) respondents would be willing to stop medication/s in the context of receiving this advice from their doctor. Willingness to consider stopping correlated with higher scores on the critical health literacy subscale (P<0.021) and overall AAHLS score (P<0.009). Those with higher scores on the overall AAHLS measure were more likely to report that they understood why their medications were prescribed (P<0.000) and were more likely to participate in decision-making (P=0.027). Opportunities to proactively consider deprescribing may be missed, as one third of the respondents could not recall a recent review of their medications.

A comparative analysis of concepts and practices of GP-nurse collaborations in primary health centres in Slovenia and Spain.

Cross-professional collaboration is considered a key element for providing high-quality comprehensive care by combining the expertise of various professions. In many countries, nurses are also being given new and more extensive responsibilities. Implemented concepts of collaborative care need to be analysed within the context of care concepts, organisational structures, and effective collaboration.

Background review of primary care concepts (literature analysis, expert interviews), and evaluation of collaboration in ‘best practice’ health centres in certain regions of Slovenia and Spain. Qualitative content analysis of expert interviews, presentations, observations, and group discussions with professionals and health centre managers.

In Slovenian health centres, the collaboration between GPs and nurses has been strongly shaped by their organisation in separate care units and predominantly case-oriented functions. Conventional power structures between professions hinder effective collaboration. The introduction of a new cross-professional primary care concept has integrated advanced practice nurses into general practice. Conventional hierarchies still exist, but a shared vision of preventive care is gradually strengthening attitudes towards team-oriented care. Formal regulations or incentives for teamwork have yet to be implemented. In Spain, health centres were established along with a team-based care concept that encompasses close physician–nurse collaboration and an autonomous role for nurses in the care process. Nurses collaborate with GPs on more equal terms with conflicts centring on professional disagreements. Team development structures and financial incentives for team achievements have been implemented, encouraging teams to generate their own strategies to improve teamwork.

Clearly defined structures, shared visions of care and team development are important for implementing and maintaining a good collaboration. Central prerequisites are advanced nursing education and greater acceptance of advanced nursing practice.

To explore childrens’ and parents’ views and experiences of attending a hospital-based childhood obesity clinic, in order to inform the development of services in primary care.

The prevalence of childhood obesity in the UK is rising. Previous literature identifies the need for long-term, regular follow-up during weight management programmes, and acknowledges the difficulties families face when making lifestyle changes. Primary care has been identified as a possible clinical setting that can meet these needs. However, there is a paucity of evidence to guide the development of such services.

A qualitative interview study was undertaken in a hospital-based childhood obesity clinic in Bristol, England. Short in-depth interviews were held with 21 parents and 11 children attending this clinic. Interviewees were purposefully sampled to ensure interviews were held covering participants of varying age, gender and success in reducing their BMI. The interviews were audiotaped, fully transcribed and analysed thematically.

Families valued the multidisciplinary team approach used in the clinic in terms of the education and support it offered. They enjoyed regular follow-up, reporting that this provided ongoing support and motivation. Families whose children succeeded in BMI reduction appeared more resourceful and tended to embrace ideas for making lifestyle changes. Unsuccessful families, however, found it harder to alter their lifestyle and often met barriers to change. The authors conclude that community obesity clinics will need to provide a multidisciplinary service offering regular support and individualized exercise and dietary advice whilst attempting to address barriers to change.

The aims of this study were twofold: (a) to explore whether specific components of shared decision making were present in consultations involving nurse prescribers (NPs), pharmacist prescribers (PPs) and general practitioners (GPs) and (b) to relate these to self-reported patient outcomes including satisfaction, adherence and patient perceptions of practitioner empathy.

There are a range of ways for defining and measuring the process of concordance, or shared decision making as it relates to decisions about medicines. As a result, demonstrating a convincing link between shared decision making and patient benefit is challenging. In the United Kingdom, nurses and pharmacists can now take on a prescribing role, engaging in shared decision making. Given the different professional backgrounds of GPs, NPs and PPs, this study sought to explore the process of shared decision making across these three prescriber groups.

Analysis of audio-recordings of consultations in primary care in South England between patients and GPs, NPs and PPs. Analysis of patient questionnaires completed post consultation.

A total of 532 consultations were audio-recorded with 20 GPs, 19 NPs and 12 PPs. Prescribing decisions occurred in 421 (79%). Patients were given treatment options in 21% (102/482) of decisions, the prescriber elicited the patient’s treatment preference in 18% (88/482) and the patient expressed a treatment preference in 24% (118/482) of decisions. PPs were more likely to ask for the patient’s preference about their treatment regimen (χ2=6.6, P=0.036, Cramer’s V=0.12) than either NPs or GPs. Of the 275 patient questionnaires, 192(70%) could be matched with a prescribing decision. NP patients had higher satisfaction levels than patients of GPs or PPs. More time describing treatment options was associated with increased satisfaction, adherence and greater perceived practitioner empathy. While defining, measuring and enabling the process of shared decision making remains challenging, it may have patient benefit.

The objective of this study was to assess determinants of poor sleep quality which is an under-diagnosed and under-treated problem in elderly patients with diabetes mellitus, hyperlipidemia and hypertension.

Poor sleep quality is linked to decreased quality of life, increased morbidity and mortality. Poor sleep quality is common in the elderly population with associated cardiometabolic risk factors such as diabetes, hyperlipidemia and hypertension.

This is a cross-sectional study undertaken in the primary healthcare setting (Singhealth Polyclinics-Outram) in Singapore. Singaporeans aged 65 years and above who had at least one of the three cardiometabolic risk factors (diabetes, hypertension and hyperlipidemia) were identified. Responders’ sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire and were divided into those with good quality sleep and those with poor quality sleep, based on the PSQI score. Information on demographics, co-morbidities and lifestyle practices were collected. Descriptive and multivariate analyses of determinants of poor sleep were determined.

There were 199 responders (response rate 88.1%). Nocturia (adjusted prevalence rate ratio 1.54, 95% confidence interval 1.06–2.26) was found to be associated with an increased risk of poor sleep quality in elderly patients with diabetes mellitus, hypertension and hyperlipidaemia. Nocturia, a prevalent problem in the Asian elderly population, has been found to be associated with poor sleep quality in our study. Hence, it is imperative to identify and treat patients with nocturia to improve sleep quality among them.

Obesity is a major risk factor for osteoarthritis (OA) whilst there is some evidence that diabetes also increases risk. Metformin is a common oral treatment for those with diabetes.

The aim is to investigate whether metformin reduces the risk of OA.

This was a cohort study set within the Consultations in Primary Care Archive, with 3217 patients with type 2 diabetes. Patients at 13 general practices with recorded type 2 diabetes in the baseline period (2002–2003) and no prior record of OA were identified. Exposure was a prescription for metformin. Outcome was an OA record during follow up. Cox proportional hazard models with Gamma frailty term were fitted: adjusted for age, gender, deprivation, and comorbidity.

There was no association between prescribed metformin treatment at baseline and OA (adjusted HR: 1.02, 95% CI: 0.91, 1.15). A similar non- significant association was found when allowing exposure status of prescription of metformin to vary over time.

In this paper, we assess the degree to which the observed consistency in maternal health-care utilization can be accounted for by social and economic demand determinants at individual and household level on the one hand and community access to health services in terms of health, road and education facilities on the other.

Data from the three rounds of national family health survey of India (NFHS-1, -2 and -3) conducted in 1992–93, 1998–99 and 2005–06 are used in this analysis. The results of the analysis are presented in two sections. First, statewise profiles of maternal health-care utilization from NFHS-1, -2 and -3 are presented to compare the trends. Second, the influence of demand and access factors estimated from multi-level logistic regression models are presented for selected states of India.

Results reveal that inequalities in maternal health-care utilization by socio-economic status have narrowed because of the impact of complementing factors of greater community access, and social and economical advancement in the south Indian states, where overall maternal health-care coverage is at the top end of the scale. In contrast, in the demographically lagging northern states of India, which are at the bottom end of the health coverage scale, both access and socio-economic demand determinants indicate greater inequalities in maternal health-care utilization.

Lack of access to health care, slow progress in socio-economic conditions and cultural constraints are major determinants of poor maternal health-care coverage among Indian states.

The four primary care (PC) core functions (the ‘4Cs’, ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health. However, their broad definitions have led to variations in their assessment, in the innovations implemented to improve these functions and ultimately in their performance.

To update and operationalise the 4Cs’ definitions by using a literature review and analysis of enhancement strategies, and to identify innovations that may lead to their enhancement.

Narrative, descriptive analysis of the 4Cs definitions, coming from PC international reports and organisations, to identify measurable features for each of these functions. Additionally, we performed an electronic search and analysis of enhancement strategies to improve these four Cs, to explore how the 4Cs inter-relate.

Specific operational elements for first contact include modality of contact, and conditions for which PC should be approached; for comprehensiveness, scope of services and spectrum of population needs; for coordination, links between PC and higher levels of care and social/community-based services, and workforce managing transitions and for continuity, type, level and context of continuity. Several innovations like enrolment, digital health technologies and new or enhanced PC provider’s roles, simultaneously influenced two or more of the 4Cs.

Providing clear, well-defined operational elements for these 4Cs to measure their achievement and improve the way they function, and identifying the complex network of interactions among them, should contribute to the field in a way that supports efforts at practice innovation to optimise the processes and outcomes in PC.

The aim of this study was to prioritize hospital admissions for ambulatory care sensitive conditions (ACSCs) and interventions for future research and implementation.

Initiatives aimed at reducing hospital admission need to be targeted at those patients who could avoid admission to hospital, either by prevention, earlier detection and treatment, or by the provision of alternative types of care. Admissions for ACSCs should ideally be prevented by care provided outside hospital.

The study used a modified Delphi method to elicit the views of an expert panel. The Delphi process comprised two rounds and used a Web-based questionnaire. Participants were purposively sampled and comprised primary and community care clinicians, emergency clinicians and commissioning managers. Quantitative data were analysed to produce descriptive statistics. Qualitative data were analysed using content analysis.

A total of 36 participants responded to both rounds of the Delphi survey. The condition given top priority was dementia, not currently a widely recognized ACSC or a national priority. The proportion of admissions that could be avoided by provision of care outside hospital was the most important factor in deciding which conditions to prioritize. Access to rapid response nursing and social care at home, intermediate care beds and mental health crisis teams were identified as key interventions to reduce admissions. Analysis of qualitative data showed several themes underlying clinical decisions to admit potentially avoidable admissions.

In conclusion, the conditions selected by the panel for prioritization showed some concordance with the National Health Services’ priorities in this area; but the condition given top priority by the panel – dementia – is not currently a national priority. The panel showed a high degree of consensus around interventions that might lower the rate of avoidable admissions. The highest rated interventions involve the direct delivery of rapid access care in the community.

To describe treatment and referral patterns and National Health Service resource use in patients with chronic pain associated with low back pain or osteoarthritis, from a Primary Care perspective.

Osteoarthritis and low back pain are the two commonest debilitating causes of chronic pain, with high health and social costs, and particularly important in primary care. Understanding current practice and resource use in their management will inform health service and educational requirements and the design and optimisation of future care.

Multi-centre, retrospective, descriptive study of adults (⩾18 years) with chronic pain arising from low back pain or osteoarthritis, identified through primary care records. Five general practices in Scotland, England (two), Northern Ireland and Wales. All patients with a diagnosis of low back pain or osteoarthritis made on or before 01/09/2006 who had received three or more prescriptions for pain medication were identified and a sub-sample randomly selected then consented to an in-depth review of their medical records (n=264). Data on management of chronic pain were collected retrospectively from patients’ records for three years from diagnosis (‘newly diagnosed’ patients) or for the most recent three years (‘established’ patients).

Patients received a wide variety of pain medications with no overall common prescribing pattern. GP visits represented the majority of the resource use and ‘newly diagnosed’ patients were significantly more likely to visit their GP for pain management than ‘established’ patients. Although ‘newly diagnosed’ patients had more referrals outside the GP practice, the number of visits to secondary care for pain management was similar for both groups.

This retrospective study confirmed the complexity of managing these causes of chronic pain and the associated high resource use. It provides an in-depth picture of prescribing and referral patterns and of resource use.