Care Excellence Research Articles

Implementing national care guidelines in local authorities in England and Wales: a theory-of-change

BackgroundThe delivery of high-quality services in chronically underfunded social or long-term care systems is a major challenge internationally. National guidelines, developed by the National Institute for Health and Care Excellence, set out how local authorities in England and Wales should fund and provide care based on best available evidence. Theoretical and participatory approaches can usefully inform the design and evaluation of implementation strategies for guidelines. The aim of the study is to develop a Theory-of-Change for how the implementation of these guidelines is expected to lead to impacts from a local authority perspective.MethodsAs part of a comparative case study (The ‘Valuing Care Guidelines’ study; February 2022 to April 2024) with three local authority sites in England and Wales, we involved altogether 17 participants in two Theory-of-Change online workshops per site, each of 2 hours. Additional data gathered from the same participants as part of the overall study were used to conceptualise and enrich information from the workshops.ResultsParticipants described the Theory-of-Change map as follows: A wide range of activities (categorised in stages of ‘pre-implementation’, ‘implementation’, ‘sustainment and scaling’) and skills were required to implement guidelines, and achieve long-term organisational sustainability and service delivery outcomes, leading to final impacts for service users and carers. Participants described a co-creation implementation model, led by ‘Implementation Support Practitioners’, who utilised relational skills to achieve motivation, trust, and confidence at different organisational levels, addressing contextual barriers such as inadequate staffing, lack of resources and of organisational support systems. Consistent use of guidelines by frontline staff could only be achieved if the value of guideline implementation was promoted widely, and if consideration was given to the roles of stakeholders, such as the inspection body, local health care providers, users and carers.ConclusionsOur study is the first to investigate the implementation of national social care guidelines by local authorities in England and Wales. It generates insights that can guide implementation practice as well as inform the evaluation of future implementation strategies.

Summary of Best Evidence for Perioperative Management Practices in Hair Transplantation Patients : Facial Skeleton.

To integrate and summarize the best evidence on perioperative management practices for hair transplantation patients, providing an evidence-based reference for clinical. An exhaustive literature search was conducted to identify the best evidence for managing patients undergoing hair transplantation during the perioperative period. The databases searched included Up To Date, BMJ Best Practice, UK National Institute for Health and Care Excellence, National Guideline Clearing House, Scottish Intercollegiate Guidelines Network, Guidelines International Network, Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, PubMed, Web of Science, European Dermatology Forum, China National Knowledge Infrastructure, Wanfang Data, Medlive Guideline Network, and Sinomed. The search spanned publications from February 2013 to February 2024, focusing on clinical decisions, evidence summaries, guidelines, and expert consensus. We finally identified 22 articles with high-quality results (consisting of 9 clinical decisions, 6 guidelines, 7 expert consensuses), providing 41 pieces of evidence across seven categories: assessment of transplantation conditions, transplant planning and preoperative preparation, anesthetic preparations, surgical methods and operation skills, postoperative wound management, medication-related guidance, optimization of nursing and treatment strategies. Special emphasis has been placed on the sections covering anesthesia preparation, surgical methods, and operational techniques, with detailed explanations provided. The summarized best evidence on perioperative management practices for hair transplantation patients can serve as evidence-based guidelines for clinical. It is recommended that clinical staff adopt evidence-based recommendations to improve and optimize patient outcomes and promote postoperative recovery. As these evidences came from different countries, factors such as the clinical environment should be evaluated before application. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Including carer health-related quality of life in NICE health technology assessments in the United Kingdom.

The impact of health technologies may extend beyond the patient and affect the health of people in their network, like their informal carers. The National Institute for Health and Care Excellence (NICE) methods guide explicitly allows the inclusion of health-related quality of life (HRQoL) effects on carers in economic evaluations when these effects are substantial, but the proportion of NICE appraisals that includes carer HRQoL remains small. This paper discusses when inclusion of carer HRQoL is justified, how inclusion can be substantiated, and how carer HRQoL can be measured and included in health economic models. Inclusion of HRQoL in economic evaluations can best be substantiated by data collected in (carers for) patients eligible for receiving the intervention. To facilitate combining patient and carer utilities on the benefit side of economic evaluations, using EQ-5D to measure impacts on carers seems the most successful strategy in the UK context. Alternatives to primary data collection of EQ-5D include vignette studies, using existing values, and mapping algorithms. Carer HRQoL was most often incorporated in economic models in NICE appraisals by employing (dis)utilities as a function of the patient's health state or disease severity. For consistency and comparability, economic evaluations including carer HRQoL should present analyses with and without carer HRQoL.

Optimizing Electronic Health Records for Enhanced Clinical Decision Support and Improved Patient Care through Advanced Data Integration and Machine Learning Algorithms

Electronic Health Records (EHRs) have changed the way healthcare is provided by recording patient information, making it easier to handle data, and letting healthcare workers talk to each other without any problems. But EHRs haven't completely come to their full guarantee however when it comes to making strides quiet care and making proficient choices superior. This theoretical talks almost a other way to make strides EHR frameworks by utilizing progressed information integration and machine learning methods. The objective is to create clinical choice back way better and, within the conclusion, make understanding comes about way better. The recommended approach makes the foremost of the colossal sum of information in electronic wellbeing records (EHRs) by combining distinctive sorts of information, such as organized clinical information, unorganized composed notes, restorative images, genetic information, and real-time real signs. Diverse information sources are brought together utilizing progressed information integration strategies to form a full understanding profile that appears the patient's wellbeing state and therapeutic foundation as a entirety. This bound together data environment is the premise for building progressed machine learning models that can draw valuable conclusions, figure how patients will do, and recommend the most excellent care for each individual. Machine learning methods are exceptionally vital for getting valuable data from EHR information. These calculations can discover mystery associations and complex designs by utilizing strategies like profound learning, normal dialect preparing, and expectation modeling. They can also accurately predict clinical events. These models are always learning and getting better, so they can change to new patient data and clinical situations.

Retrospective evaluation of prescribing pattern and utilization of antiepileptic drugs in pediatric, neurosurgery, and psychiatry wards: A comparative study to the standard treatment guidelines.

Antiepileptic drugs (AED) are progressively utilized for off-label conditions other than epilepsy, like bipolar disorder and migraine. The objective of this study was to evaluate current prescribing patterns and utilization of AED in pediatric, neurosurgery, and psychiatry wards and to compare them to the standard treatment guidelines. A descriptive, cross-sectional study was conducted in Ayyub Teaching Hospital, Abbottabad from December 1st, 2018 to April 2019. Data on demographic and clinical characteristics, utilization patterns of AED, adherence to standard treatment guidelines, and frequency of potential drug-drug interactions were analyzed using descriptive statistics. Among 410 patients, 54.3% (n = 223) were male, 45.6%(n = 187) were female, and 63.7% (n = 261) were from the 1 to 18 years' age group. The majority 47.3% (n = 194) were from the pediatric ward followed by neurosurgery 28.7%(n = 118). Among the studied patients, 96.1% of them had comorbid conditions other than epilepsy alone. With regards to types of seizures unclassified seizures were the most common seizure type (59.8%; n = 245) followed by generalized tonic clonic seizures 23.4% (n = 96). In this study, the most frequently utilized AED was sodium valproate 59.0% (n = 242) followed by antiepileptic first-generation medicines were commonly used (76.3%). Although a total of 77.6% of the patients showed nonadherence to National Institute for Health and Care Excellence guidelines and 87.6% of them showed drug interactions. Findings from this study showed prescription patterns and utilization of AED in patients with epilepsy and non-epilepsy disorders which may help healthcare providers in making accurate clinical decisions.

Entrustable Professional Activities in Medical Education: SELECT Leadership, Values-Based Patient-Centered Care, Health Systems, and Scholarly Excellence

Entrustable Professional Activities (EPAs) represent a concept in medical education that has gained significant traction over the last few years, particularly in the context of competency-based medical education. An EPA refers to a specific task or responsibility that can be entrusted to a trainee once they have demonstrated the necessary competence. EPAs provide concrete tasks that a trainee should be able to complete at various stages of training in order to clarify expectations and responsibilities they should master. The University of South Florida Morsani College of Medicine (USFMCOM), Scholarly Excellence, Leadership Experiences, Collaborative Training (SELECT) MD program pairs a unique four-year longitudinal leadership program including the domains of leadership, values-based patient-centered care, health systems, and scholarly excellence with an innovative medical degree program. Students in the SELECT program spend the first two years on the campus in Tampa, Florida, and the clinical years on the regional campus in Allentown, Pennsylvania. These additional threads of curriculum call for a unique set of EPAs. A working group of faculty, students, and administrators within the college from both the main and regional campus developed EPAs for each of the above listed areas of focus within the curriculum. In this paper, the authors describe how Entrustable Professional Activities were developed at MCOM to assess the SELECT curriculum in the areas of leadership, values-based patient-centered care, health systems, and scholarly excellence.

Addressing disparities in the long-term mortality risk in individuals with non-ST segment myocardial infarction (NSTEMI) by diabetes mellitus status: a nationwide cohort study.

The aim of this study was to investigate how diabetes mellitus affects longer term outcomes in individuals presenting to hospital with non-ST segment elevation myocardial infarction (NSTEMI). We analysed data from 456,376 adults hospitalised between January 2005 and March 2019 with NSTEMI from the UK Myocardial Ischaemia National Audit Project (MINAP) registry, linked with Office for National Statistics death reporting. We compared outcomes and quality of care by diabetes status. Individuals with diabetes were older (median age 74 vs 73 years), were more often of Asian ethnicity (13% vs 4%) and underwent revascularisation (percutaneous coronary intervention or coronary artery bypass graft surgery) (38% vs 40%) less frequently than those without diabetes. The mortality risk for those with diabetes compared with those without was significantly higher at 30 days (HR 1.19, 95% CI 1.15, 1.23), 1 year (HR 1.28, 95% CI 1.26, 1.31), 5 years (HR 1.36, 95% CI 1.34, 1.38) and 10 years (HR 1.39, 95% CI 1.36, 1.42). In individuals with diabetes, higher quality inpatient care, assessed by opportunity-based quality indicator (OBQI) score category ('poor', 'fair', 'good' or 'excellent'), was associated with lower mortality rates compared with poor care (good: HR 0.74, 95% CI 0.73, 0.76; excellent: HR 0.69, 95% CI 0.68, 0.71). In addition, compared with poor care, excellent care in the diabetes group was associated with the lowest mortality rates in the diet-treated and insulin-treated subgroups (diet-treated: HR 0.64, 95% CI 0.61, 0.68; insulin-treated: HR 0.69, CI 0.66, 0.72). Individuals with diabetes experience disparities during inpatient care following NSTEMI. They have a higher risk of long-term mortality than those without diabetes, and higher quality inpatient care may lead to better long-term survival.

What Evidence Exists to Support Palliative Allied Health Practice in Aged Care: A Scoping Review.

Background: As our population ages, the demand for aged care services and palliative care is expected to increase. Allied health professionals have a diverse set of skills to offer in the management of older adults. This scoping review aimed to identify what evidence exists to support the best practice of allied health clinicians in palliative and aged care. Methods: Searches were conducted using broad keywords and MeSH headings with relevance to palliative, ageing and allied health care in the databases Ovid MEDLINE (R), CINAHL, EMCARE, INFORMIT, REHABDATA, PEDRO and SCOPUS, as well as the grey literature. Results: Only 15 studies met the inclusion criteria. A prominent finding was that regular exercise interventions delivered improved mobility, balance, sleep and quality of life outcomes when measured (n = 5). Broader allied health input and outcomes, such as nutrition, were not well described, other than to suggest an interprofessional approach contributed to health benefits where these were observed. Conclusions: The lack of research creates uncertainty about what excellent care looks like and how it can be measured, making it harder for allied health professionals to advocate for funded time in providing care at the end of life and leading to poorer outcomes for older adults.

Wristwatches in bare-below-the-elbows out-of-hospital policies: time for a review

Background: Bare-below-the-elbows (BBE) policies are common in infection prevention and control strategies but the evidence relating to wristwatch prohibition is slim and varied in quality. No dispensation is considered for those working outside hospital, which poses unique infection prevention and control challenges. Blanket approaches may be putting patients at further risk of healthcare-acquired infections (HCAIs). Aims: This review aimed to collate evidence and bring clarity to the ongoing debate surrounding mandated BBE policy, specifically relating to wristwatches worn within the prehospital setting. Methods: Three searches were undertaken, and results refined against an inclusion criterion to ensure relevance. Findings: Wristwatches can be considered a vector for HCAI; however, most data on this are confounded by other known risk factors. No studies were conducted outside a hospital environment. Alternative time sources used by clinicians such as touchscreen phones are a significant pathogen vector. Conclusion: Four policy evidence-based recommendations are made in relation to this topic. The National Institute for Health and Care Excellence (NICE) should review this topic as the evidence base underpinning its guidance is inadequate.

OTHR-04 PATIENT SATISIFACTION WITH NURSING CARE AMONG PEDIATRIC CANCER PATIENTS ATTENDING UGANDA CANCER INSTITUTE MULAGO KAMPALA UGANDA

Abstract PURPOSE To assess the level of patients’ satisfaction with nursing care among pediatric cancer patients attending Uganda Cancer Institute in order to improve the quality of oncology services provided by the nurses to the pediatric patients at UCI. INTRODUCTION Patient satisfaction is significant and usually used as an indicator for measuring the degree of excellence in health care. Patient satisfaction is the patient’s perception of care received compared with the care expected. A survey carried out by the Ministry of Health (MoH) in 2020 showed that more than half of the patients who visit Ugandan hospitals have to wait for more than an hour before they can see a health worker only to be told there’s no medicine or equipment to assist in their diagnosis. A number of studies have been conducted, however, there was little information on patients’ satisfaction with nursing care among pediatric cancer patients attending Uganda Cancer Institute and this left grey area for the researcher to conduct the study in this health facility. METHODS The study was done among sample size of fifty-six (56) respondents who were the caregivers of children between 0-17 years getting treatment at UCI. A cross sectional study design was used for this research, quantitative method of data collection using a questionnaire. RESULTS The study findings showed the respondents largely were satisfied with nursing care but problems of accessing clean water for drinking (52%), failure to give diagnostic talk (68%), no comfortable rooms for privacy (52%), nurse patient ratio at (63%) and nurses’ failure to give follow up calls (84%) were among the dissatisfactions. CONCLUSION The researcher concluded majority of respondents were satisfied with nursing care at UCI pediatrics nursing care. However, they expressed dissatisfactions in some crucial areas that need immediate attention of the hospital management.

Evaluation of efficacy of oral calcium phosphate as an adjunct to standard-of-care regular phototherapy in cases of neonatal jaundice: a hospital-based double-blind, randomised, placebo-controlled trial

ObjectiveNeonatal jaundice is the most common cause of neonatal morbidity and rehospitalisation in the first week of life, affecting approximately 60% of term and 80% of preterm neonates, with 10%...

Seizures and Epilepsy: An Overview for UK Medical Students.

Epilepsy is a common neurological disorderimpacting millions globally, marked by recurrent, unprovoked seizures. This review article, tailored for UK medical students, provides a broad clinical overview of epilepsy, focusing on its pathophysiology, classification, and management strategies. The article clarifies the distinction between epilepsy and seizures and delves into key areas, including risk factors, clinical features, and differential diagnosis. The discussion extends to diagnostic methods, underscoring the importance of conducting a thorough evaluation in diagnosing and managing epilepsy effectively. Data were drawn from the UK National Institute for Health and Care Excellence (NICE) guidelines, World Health Organization (WHO) reports, and key peer-reviewed studies. Particular attention was given to UK-specific data on epilepsy incidence, treatment gaps, and clinical outcomes. A review of relevant literature was conducted, covering epidemiology, pathophysiology, diagnostic protocols, and management strategies based on UK practices. Finally, the article addresses the acute management of seizures and the pharmacological and non-pharmacological management of epilepsy based on the NICE guidelines. The goal is to offer medical students a concise yet comprehensive understanding of epilepsy, preparing them for practical, evidence-based decision-making in clinical practice.

A Review and Comparative Case Study Analysis of Real-World Evidence in European Regulatory and Health Technology Assessment Decision Making for Oncology Medicines

ObjectivesReal-world evidence (RWE) is valuable in supporting regulatory and health technology assessment (HTA) decisions; however, the actual contribution to approvals remains elusive. This study aimed to review RWE approaches and use in oncology medicine approvals in Europe and understand cohesion and discrepancy in the acceptance of the RWE by the European Medicines Agency (EMA) and European HTA bodies. MethodsThis scoping review involved a search of the EMA database, National Institute for Health and Care Excellence (NICE), Gemeinsamer Bundesausschuss (G-BA), and Haute Autorité de Santé (HAS) websites to identify final reports and appraisals for oncology medicines with references to RWE. The selection was guided by research terms associated with RWE study designs, data sources, and outcomes. Qualitative analysis was used to systemize the data. Case studies assessed by more than one agency were selected for comparative assessment of RWE approach, use, and acceptability. ResultsRWE was mainly leveraged as an external control for indirect treatment comparisons or contextualization to support clinical trial results by the EMA, NICE, G-BA, and HAS. However, this approach was mostly rejected due to methodology biases. Comparative assessment of RWE acceptability for the same oncology medicines across agencies suggests discrepancies between EMA and European HTA bodies and among NICE, G-BA, and HAS. ConclusionsThere is diverging acceptance of RWE in EMA and European HTA bodies with no clear consensus on the most effective way to leverage RWE in approvals. With the introduction of the joint European Union Joint Clinical Assessment in 2025, it is crucial for European HTA bodies and EMA to develop synergetic standards for the use of RWE to ensure equitable and timely access to medicines.

Hip Fracture Management in a Major Trauma Centre: The Impact of 'Smart Phrase' Integration Into Electronic Clerking on Culture and Adherence to Guidelines.

The National Institute for Health and Care Excellence (NICE) introduced guidelines in 2011 for the management of hip fractures in patients over the age of 65. NICE CG124 recommended different procedures depending on the demographics of the patient and fracture pattern. In terms of compliance in 2019, Addenbrooke's Hospital (ADH) was found to be in line with the national average, although room for improvement was noted. The aim of this study was to identify and address areas of substantial non-compliance at ADH. A total of 1636 patients who sustained a hip fracture between 2017 and 2020 and who subsequently underwent surgery at ADH were retrospectively analysed. We collected data from the National Hip Fracture Database (NHFD), digital medical records, and digital imaging systems. We then amended the clerking proforma by adding a 'smart phrase' and re-analysed another 543 patients who attended ADH following hip fracture between 2021 and 2022, using the same data collection methods. From 2017-2020, total adherence to CG124, Section 1.6, was 76.04%. Our results demonstrated that 56.43% of all hip fracture patients indicated for total hip arthroplasty (THA) did not have documented consideration for the procedure. In 2021-22, following the addition of our 'smart phrase,' we made to the clerking proforma, total adherence improved to 87.43%, with only 42.11% of THA-indicated patients lacking documented consideration of the procedure, down from 65.41% in 2020. The use of our smart phrase decreased during the follow-up without a corresponding drop in compliance. In January 2023, NICE CG124 underwent changes, rendering our ADH changes outdated. However, we have demonstrated that we can increase NICE guideline compliance by standardising and encouraging formal documentation of the decision-making process. As electronic patient record (EPR) systems become more widespread, we have shown how 'smart phrases' can be used to generate change and increase compliance, even over a short period of time.

The management of idiopathic toe walking.

The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care. An established Delphi approach with predetermined steps and degree of agreement based on a standardized protocol was used to determine consensus. The steering group members and Delphi survey participants included members from the British Society of Children's Orthopaedic Surgery (BSCOS) and the Association of Paediatric Chartered Physiotherapists (APCP). The statements included definition, assessment, treatment indications, nonoperative and operative interventions, and outcomes. Descriptive statistics were used for analysis of the Delphi survey results. The AGREE checklist was followed for reporting the results. A total of 227 participants (54% APCP and 46% BSCOS members) completed the first round, and 222 participants (98%) completed the second round. Out of 54 proposed statements included in the first round Delphi, 17 reached 'consensus in', no statements reached 'consensus out', and 37 reached 'no consensus'. These 37 statements were then discussed, reworded, amalgamated, or deleted before the second round Delphi of 29 statements. A total of 12 statements reached 'consensus in', four 'consensus out', and 13 'no consensus'. In the final consensus meeting, 13 statements were voted upon. Five were accepted, resulting in a total of 31 approved statements. In the aspects of practice where sufficient evidence is not available, a consensus statement can provide a strong body of opinion that acts as a benchmark for excellence in clinical care. This statement can assist clinicians managing children with ITW to ensure consistent and reliable practice, and reduce geographical variability in practice and outcomes. It will enable those treating ITW to share the published consensus document with both carers and patient groups.

Comparative outcomes of selective laser trabeculoplasty delivered by optometrists compared with ophthalmologists: a UK-based multicentre observational study

BackgroundSelective laser trabeculoplasty (SLT), a National Institute for Care and Health Excellence recommended first-line treatment for open-angle glaucoma and ocular hypertension, is increasingly delivered by optometrists. This retrospective multicentre observational...

Hospitalists And The Learning Environment

The role of today’s teaching attending hospitalist has evolved significantly compared to past faculty attendings. Hospitalists’ attending rounds have consistently demonstrated higher quality and value than those of traditional faculty attendings. Academic hospitalists are tasked with balancing the delivery of excellent patient care, maintaining operational efficiency, and providing optimal medical education within academic settings.

Artificial Intelligence (AI) In Dental Clinical Practice

Artificial intelligence (AI) characterized as the ability of a machine to mimic human intelligence, has been a breakthrough in technological advancements during the last few decades and has made a huge impact on our everyday life. In current scenario, it has become necessary for the dental professionals too to get oriented with clinical as well as technological advancement to provide easy, rapid, relatively cost-effective and excellent patient care. In dentistry, artificial intelligence has been playing a significant role in improving diagnosis, treatment planning and quality of patient care. But dental practice involves more than just disease diagnosis and includes evaluating correlation between clinical and radiographic findings and administering customized definitive treatment to the patients. Hence, AI cannot replace dentists but can definitely help reducing his efforts and assisting him in decision making. This review provides information about the existence of this new technology, its current applications and its influence on dental practice

Influence of a community practice innovation on a statewide cancer drug repository network.

115 Background: Cancer drug repositories (CDRs) have the potential to minimize cancer medication waste while improving medication access to patients in need. Despite multiple states having legislation allowing for CDR programs, implementation remains suboptimal. The first CDRs to launch in Michigan were a fortuitous result of the support provided in embedding clinical pharmacists into community oncology practices via the Pharmacists Optimizing Oncology Care Excellence in Michigan, POEM, program. We describe these grassroot efforts as well as barriers to sustainability, ultimately resulting in formation of a statewide CDR Network, YesRx. Methods: This qualitative analysis of barriers and facilitators was conducted from interviews with Michigan’s first CDRs. Virtual group meetings were conducted monthly for 6-months from January 2023 – June 2023. Meetings were led by the coordinating center team of POEM. Workgroup attendees included POEM pharmacists who established the first 3 CDR programs in the State, a medical oncologist and longstanding advocate of CDRs, and a patient representative. Brainstorming sessions included open ended questions on experiences to date, benefits of CDR programs, barriers to growth, limitations in current CDR models, and beneficial areas for support. Interview findings were categorized as barriers or facilitators of site-specific implementation and recommendations for CDR model optimization. Results: All 3 CDRs reported positive outcomes from initiating the CDRs related to patient benefit and physician satisfaction. Items reported as challenges/barriers in the sustainability of individual site-managed CDRs: space (inventory growth exceeded designated storage capacity), complexity of inventory tracking, resources (staff and financial), inability to search state-wide for available inventory, inability to easily transfer medications between CDR sites (due to cost, documentation, and staff), inability to ship medications directly to a patient’s home, inability to serve cancer patients across the State who may be in need of medication or interested in donating. The top recommendations for CDR model optimization formed by this workgroup were a centralized, shared database of CDR inventory across the State, support for CDR medication transfers, and additional resource and storage capabilities. YesRx, a nonprofit service organization, was founded in July 2023 in collaboration with the first 3 CDRs to address the experienced barriers resulting in exponential state-wide access. Conclusions: Grassroot efforts of community-based clinical oncology pharmacists resulted in the first CDR programs in Michigan and their experiences guided the launch of a statewide network of CDRs created to expand cancer medication access for vulnerable and underserved people and communities.

What happens between first symptoms and first acute exacerbation of COPD - observational study of routine data and patient survey.

Chronic obstructive pulmonary disease affects nearly 400 million worldwide - over a million in the United Kingdom - and is the third leading cause of death. However, there is limited understanding of what prompts a diagnosis, how long this takes from symptom onset and the different approaches to clinical management by primary care professionals. Map out the clinical management and National Health Service contacts from symptom presentation to chronic obstructive pulmonary disease diagnosis and first acute exacerbation of chronic obstructive pulmonary disease in three time periods; construct risk prediction for first acute exacerbation of chronic obstructive pulmonary disease. Retrospective cohort study and cross-sectional survey. Primary care. Patients with incident chronic obstructive pulmonary disease aged > 35 years in England. None. First acute exacerbation of chronic obstructive pulmonary disease. Clinical Practice Research Datalink Aurum; new online survey. Forty thousand five hundred and seventy-seven patients were diagnosed between April 2006 and March 2007 (cohort 1), 48,249 between April 2016 and March 2017 (cohort 2) and 4752 between March and August 2020 (cohort 3). The mean (standard deviation) age was 68.3 years (12.0); 47.3% were female. Around three-quarters were diagnosed in primary care, with a slight fall in cohort 3. Compliance with National Institute for Health and Care Excellence diagnostic guidelines was slightly higher in cohorts 2 and 3 for all patients; 35.8% (10.0% in the year before diagnosis) had all four elements met for all cohorts combined. Multilevel modelling showed considerable between-practice variation in spirometry. The survey on the charity website had 156 responses by chronic obstructive pulmonary disease patients. Many respondents had not heard of the condition, hoped the symptoms would go away and identified various healthcare-related barriers to earlier diagnosis. Clinical Practice Research Datalink analysis showed notable changes in post-diagnosis prescribing from cohort 1 to 2, such as increases in long-acting muscarinic antagonist (21.7-46.3%). Triple therapy rose from 2.9% in cohort 2 to 11.1% in cohort 3. Documented pulmonary rehabilitation rose from just 0.8% in cohort 1 to 13.7% in cohort 2 and 20.9% in cohort 3. For all patients combined, the median time to first acute exacerbation of chronic obstructive pulmonary disease in patients who had one was 1.4 years in cohorts 1 and 2. Acute exacerbation of chronic obstructive pulmonary disease prediction models identified some consistent predictors, such as age, deprivation, severity, comorbidities, post-diagnosis spirometry and annual review. Models without post-diagnosis general practitioner actions had a c-statistic of around 0.70; the highest c-statistic was 0.81, for cohort 2 with post-diagnosis general practitioner actions and 6-month follow-up. All models had good calibration. The three most important predictors in terms of their population attributable risks were being a current smoker and offered smoking cessation advice (32.8%), disease severity (30.6%) and deprivation (15.4%). The highest population attributable risks for variables with adjusted hazard ratios < 1 were chronic obstructive pulmonary disease review (-27.3%) and flu vaccination (-26.6%). Symptom recording and chronic obstructive pulmonary disease diagnosis vary between practice; predicted forced expiratory volume in 1 second had many missing values. There has been some improvement over time in chronic obstructive pulmonary disease diagnosis and management, with large changes in prescribing, though patient and system barriers to further improvement exist. Data available to general practitioners cannot generate risk prediction models with sufficient accuracy. It will be important to expand the COVID-era cohort with longer follow-up and augment general practitioner data for better prediction. This study is registered as Researchregistry.com: researchregistry4762. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/72) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 43. See the NIHR Funding and Awards website for further award information.