General Practitioner Referrals Research Articles

Assessment of breast cancer optimal care timeframes in a regional and rural real-world setting: A regional cancer centre experience in Australia.

e12614 Background: The Breast Cancer Optimal Care Pathway (Cancer Australia) is a national patient-centred guideline that seeks to standardise the management pathway for breast cancer patients and spans from early diagnosis through to survivorship. The guideline provides suggested optimal management-based timeframes including the time from general practitioner (GP) referral to specialist review (<2 weeks), time from specialist review to completion of investigations and multidisciplinary discussion (MDT) (<2 weeks), time to initiation of neoadjuvant therapy from MDT (<4 weeks) and time to surgery following completion of neoadjuvant therapy (<6 weeks). Methods: Retrospective data was obtained for patients undergoing neoadjuvant systemic therapy for newly diagnosed breast cancer between 2021 and 2023 at a regional tertiary cancer centre in Australia (Townsville University Hospital). Data included baseline patient demographics, tumour characteristics, staging, key optimal care pathway timepoints, treatment regimen and outcomes. Median and interquartile range were calculated for key timepoints. Results: Overall, 53 patients (100% female) were identified for inclusion. 10% of patients identified as Indigenous (n=5), 36% lived rurally (n=19) and 13% were treated using a tele-chemotherapy model (n=7). Receptor status was triple-negative in 20 patients (38%), hormone-positive in 17 patients (32%) and HER2-positive in 16 patients (30%). 15% of patients had stage I disease (n=8), 58% had stage II disease (n=31), 21% had stage III disease (n=11), while 6% of patients had oligometastatic stage IV disease at diagnosis (n=3). 24 patients (50%) were seen by a specialist within 2 weeks of GP referral (median: 15 days; IQR 9-19). 46 patients (87%) had a definitive management plan formulated at MDT within 2 weeks of specialist review (median: 5 days; IQR 4-9), with delays most commonly due to pending investigations (n=5; 9%). 48 patients (91%) proceeded with neoadjuvant therapy within 4 weeks of MDT (median: 14 days; IQR 11-22), with delays most commonly due to concurrent infections including COVID. 90% of patients (n=46) were ultimately commenced on neoadjuvant treatment within the 8-week optimal care timeframe from initial GP referral (median: 34 days; IQR 27-47). In comparison to patients living locally, patients residing in rural areas were less likely to achieve this target (79% v 97%, p=0.05). 83% of patients (n=43) underwent surgery within 6-weeks of completion of neoadjuvant treatment (median: 30 days; IQR 27-34). Conclusions: The neoadjuvant breast cancer optimal care timeframes were feasible to achieve in a regional and rural setting. However, further targeted research is needed to improve adherence to optimal care standards for patients from rural areas, such as the timeframe from initial referral to completion of investigations and MDT.

AB077. SOH24AB_072. Is it reasonable to recommend best medical therapy for peripheral arterial disease based on general practitioner (GP) referral alone?—A correlation of vascular clinic outcomes to GP referrals for peripheral arterial disease

AB077. SOH24AB_072. Is it reasonable to recommend best medical therapy for peripheral arterial disease based on general practitioner (GP) referral alone?—A correlation of vascular clinic outcomes to GP referrals for peripheral arterial disease

From symptom onset to ED departure: understanding the acute care chain for patients with undifferentiated complaints: a prospective observational study.

For most acute conditions, the phase prior to emergency department (ED) arrival is largely unexplored. However, this prehospital phase has proven an important part of the acute care chain (ACC) for specific time-sensitive conditions, such as stroke and myocardial infarction. For patients with undifferentiated complaints, exploration of the prehospital phase of the ACC may also offer a window of opportunity for improvement of care. This study aims to explore the ACC of ED patients with undifferentiated complaints, with specific emphasis on time in ACC and patient experience. This Dutch prospective observational study, included all adult (≥ 18 years) ED patients with undifferentiated complaints over a 4-week period. We investigated the patients' journey through the ACC, focusing on time in ACC and patient experience. Additionally, a multivariable linear regression analysis was employed to identify factors independently associated with time in ACC. Among the 286 ED patients with undifferentiated complaints, the median symptom duration prior to ED visit was 6 days (IQR 2-10), during which 58.6% of patients had contact with a healthcare provider before referral. General Practitioners (GPs) referred 80.4% of the patients, with the predominant patient journey (51.7%) involving GP referral followed by self-transportation to the ED. The median time in ACC was 5.5 (IQR 4.0-8.4) hours of which 40% was spent before the ED visit. GP referral and referral to pulmonology were associated with a longer time in ACC, while referral during evenings was associated with a shorter time in ACC. Patients scored both quality and duration of the provided care an 8/10. Dutch ED patients with undifferentiated complaints consulted a healthcare provider in over half of the cases before their ED visit. The median time in ACC is 5.5h of which 40% is spent in the prehospital phase. Those referred by a GP and to pulmonology had a longer, and those in the evening a shorter time in ACC. The acute care journey starts hours before patients arrive at the ED and 6 days of complaints precede this journey. This timeframe could serve as a window of opportunity to optimise care.

Factors and Reasons Associated With Appointment Non-attendance in Hospitals: A Narrative Review.

Non-attendance at hospital appointments is an extremely prevalent issue impacting healthcare systems on a daily basis. This phenomenon adversely affects patient health and healthcare providers, leading to delays in diagnosis and treatment, inefficient resource utilization, and increased healthcare expenses. The detrimental impact of non-attendance is not limited to patients who miss appointments, the knock-on effects of extended waiting times and reduced appointment availability are felt throughout healthcare systems. The purpose of this narrative review is to explore the factors underlying appointment non-attendance in hospital settings, to improve healthcare delivery and patient adherence. An extensive review of the existing global literature was conducted. Quantitative studies that explored the relationship between appointment non-attendance and patient characteristics, such as age, gender, marital status, education level, distance from the hospital, and source of referral, were included. Younger patients, males, individuals with lower levels of education, and those living farther from hospitals were more likely to miss appointments. Marital status was significant, with married patients showing better attendance, as was referral source, with general practitioner referrals associated with higher non-attendance. Qualitative studies identifying both patient-centered and hospital-specific reasons, such as forgetfulness, appointment time, protracted waiting times, patient-physician relationship, and patients' knowledge and perception of their health condition, were also included in the review. Lack of appointment reminders, difficulties in managing appointments, and inadequate patient-physician communication were significant hospital-specific reasons given for non-attendance. Patients' lack of awareness regarding the importance of attending appointments and limited understanding of their health conditions were also identified as patient-centered contributors. Non-attendance at hospital appointments is a multifaceted issue influenced by a range of socioeconomic, personal, and systemic factors. Addressing these factors requires a holistic approach that includes patient education, improved communication, and tailored healthcare delivery strategies, especially for vulnerable populations in rural areas. Enhanced reminder systems and streamlined appointment management could serve as pivotal interventions to reduce non-attendance rates, ultimately improving healthcare outcomes and resource utilization.

Audit of general practitioner referrals for erectile dysfunction within north central london

Audit of general practitioner referrals for erectile dysfunction within north central london

A retrospective audit of general practitioner's referrals to Guys and St Thomas' specialist menopause clinic between 2021 and 2022.

Purpose: We performed a retrospective audit of General Practitioners' (GPs) referrals to the specialist Menopause Clinic at Guys and St Thomas's (GSTT) between 2021 and 2022. We aim to establish the indication for the referrals and whether they were compliant with the National Institute for Health and Care Excellence Guidance NICE.Background: GSTT is a teaching hospital in central London that educates gynaecologists in training as well as (GP) for specialist certification in Menopause. The menopause clinic receives approximately 580 GP referrals per month from South East London practices. The current waiting time for an initial appointment is up to 1year. This delay reflects an increase in demand for menopause care and a deficit in service provision in many areas of the UK.NICE has recommended that GPs refer complicated cases to menopause specialists, with 11 specific criteria.Study Sample and Data Collection: We randomly selected 50 patients referred to the GSTT clinic by a GP between 2021 and 2022. Patient data were collected, including patient demographics, date of referral, indication for referral, date of consultation, waiting time, past medical history, investigations, and treatment instigated during the appointment.Results: The majority of referrals to the GSTT menopause Specialist clinic met the NICE guidelines (76%). One-sixth of the referrals could have been prevented or managed through alternative routes. Finally, although this is a small study, some patient unmet needs (PUNS) and GPs' educational needs have been identified.

Characteristics and Outcomes of Patients Referred to a General Practitioner by Victorian Paramedics

Objective Many patients who are attended by paramedics do not require conveyance to an emergency department (ED). Our study focuses on comparing the characteristics and outcomes of patients who were advised to follow up with a general practitioner (GP) by an attending paramedic with those of patients who were discharged at scene or transported to hospital. Methods This was a retrospective data linkage cohort study of ambulance, ED, hospital admission, and death records for all adults attended by paramedics in Victoria, Australia between the 1st of January 2015 and 30th of June 2019. Patients were excluded if they presented in cardiac arrest, resided in a residential aged care facility, or were receiving palliative care services. Outcomes of interest included reattendance by ambulance, ED presentation; and, a high acuity outcome which we defined as a patient who (1) presented to ED and received an Australasian Triage Scale of category 1 (Resuscitation) or 2 (Emergency) AND was admitted to a ward OR (2) was admitted to an Intensive Care Unit, Coronary Care Unit or Catheter laboratory (regardless of triage category) OR (3) died. Outcomes of interest were considered within 48-h of initial EMS attendance. Results A total of 1,777,950 cases were included in the study of which 3.1% were referred to a GP, 9.0% were discharged at scene without a follow-up recommendation, and 87.9% were transported to hospital. Patients referred to a GP were more likely than those discharged at scene to subsequently present to an ED within 48 h of their attendance (5.3% vs 3.8%). However, GP referral was not associated with any change to high acuity outcome (0.3% vs 0.2%) or ambulance reattendance (6.0% vs 6.0%) compared to discharge at scene. The only factors that were associated with ambulance reattendance, ED presentation, and a high acuity outcome were male gender and elevated temperature. Conclusions Despite increasing low and medium-acuity casework in this EMS system, paramedic referral to a GP is not common practice. Referring a patient to a GP did not reduce the likelihood of patients experiencing a high acuity outcome or recalling an ambulance within 48 h, suggesting opportunity exists to refine paramedic to GP referral practices.

Psychiatric disorders and the cancer diagnostic process in general practice: a combined questionnaire and register study exploring the patients’ experiences in Denmark

Objective Patients with psychiatric disorders are at risk of experiencing suboptimal cancer diagnostics and treatment. This study investigates how this patient group perceives the cancer diagnostic process in general practice. Design Cross-sectional study using questionnaire and register data. Setting General practice in Denmark. Subjects Patients diagnosed with cancer in late 2016 completed a questionnaire about their experiences with their general practitioner (GP) in the cancer diagnostic process (n = 3411). Information on pre-existing psychiatric disorders was obtained from register data on psychiatric hospital contacts and primary care treated psychiatric disorders through psychotropic medications. Logistic regression was used to analyse the association between psychiatric disorders and the patients’ experiences. Main outcome measures Patients’ experiences, including cancer worry, feeling being taken seriously, and the perceived time between booking an appointment and the first GP consultation. Box 1. Included survey items on the patients’ experiences Results A total of 13% of patients had an indication of a psychiatric disorder. This group more often perceived the time interval as too short between the first booking of a consultation and the first GP consultation. Patients with primary care treated psychiatric disorders were more likely to worry about cancer at the first presentation and to share this concern with their GP compared with patients without psychiatric disorders. We observed no statistically significant association between patients with psychiatric disorders and perceiving the waiting time to referral from general practice, being taken seriously, trust in the GP’s abilities, and the patients’ knowledge of the process following the GP referral. Conclusion The patients’ experiences with the cancer diagnostic process in general practice did not vary largely between patients with and without psychiatric disorders. Worrying about cancer may be a particular concern for patients with primary care treated psychiatric disorders.

'Through a kaleidoscope': A Foucauldian discourse analysis of Belgian policy regarding patients with a migration background and depression in general practices.

A higher prevalence of depression is found among patients with a migration background within the Belgian population. Nevertheless, this group is underrepresented in ambulant and residential mental health care services. Since general practitioners (GPs) have a crucial gatekeeping role, this led some researchers to investigate the possibility of a provider bias influencing GPs' assessment and referral of depressed patients with a migration background. However, GPs' accounts may be influenced by wider professional discourses present at the policy level, which are inevitably linked to institutions regulating the conduct of GPs. Therefore, this study applied a Foucauldian discourse analysis (a) to identify broader professional discourses in Belgian policy documents regarding patients with a migration background and depression in general practices, (b) to examine how patients with a migration background are discursively positioned and (c) to investigate which different balances of power in the relationship between GPs and patients with a migration background are demonstrated in the identified discourses. We identified three recurring discourses: (a) the othering discourse, (b) the health literacy discourse, and (c) the person-centred discourse. Our analysis demonstrated that the former two discourses illustrate the perpetuation of a biomedical discourse. While the last discourse is aligned with a counter-discourse associated with the person-centred care model in health care. Consequently, our analysis demonstrated the construction of a contradictory discursive framework throughout the various policy documents on which GPs might rely when speaking about patients with a migration background suffering from depression.

Balancing care and responsibility: The role of the general practitioner in specialist referrals.

Referrals are a critical component of the Australian healthcare system, with referrals from general practitioners (GPs) to non-GP specialists making up the majority of medical referrals. Given the key role referrals have in primary healthcare, it is important that GPs understand their legal and professional responsibilities when providing a referral and ensure they refer appropriately and effectively to provide the best healthoutcomes for patients. This article explores GP referrals to other health professionals and aims to describe a doctor's medicolegal obligations and responsibilities when making a referral. The responsibility of GPs in the referral process reflects their central coordinating role as providers of primary care, and the reliance patients place upon them to adviseand recommend treatment and investigations. Understanding the medicolegal obligations and responsibilities when writing a referral can help GPs find the right balance between respecting patient autonomy and the professional obligation to take reasonable steps to ensure referrals and investigations are acted upon appropriately. The key to an effective referral process is clear communication between practitioners and patients, to help align the expectations of all involved so they can agree and implement a shared treatment plan in the interests of the patient.

How does community pharmacy support patients living with asthma?

Abstract Introduction Asthma is a chronic respiratory condition that is currently an increasing issue worldwide. Particularly in the United Kingdom, 185 people are admitted to hospital because of an attack and 3 people die daily despite the National Healthcare Service (NHS) spending £1 billion on asthma care.1 Community pharmacies are taking on a more clinical role in the NHS but the extent of their role in primary care, specifically regarding helping patients living with asthma is unknown. Aim This study aimed to identify how community pharmacists reduced the general practitioners (GPs) workload by helping patients living with asthma. Methods The study used a 30-question survey to collect data from community pharmacists in North-East London boroughs (n=206 pharmacies). The survey consisted of both closed and open-ended questions, exploring the asthma interventions pharmacists conducted and the impact this had on patients, as well as the medication or devices that patients were struggling with the most and how confident pharmacists felt about all aspects of asthma. The paper-based survey was handed to each responsible pharmacist for completion. Data was input into SPSS for analysis. The study received ethical approval from Kingston University. Results Participants found the New Medicines Service to be the most helpful service (4.4/5) for patients living with asthma, followed by influenza vaccine (4/5), Community Pharmacy Consultation Service (CPCS) (3.8/5) and inhaler technique checks (3.8/5). The percentage of referrals to the GP that resulted from these services were 0-20% of patients in an average week. The most frequently referred medication was salbutamol (56.5%) due to its overuse or exacerbation of symptoms with Clenil® (15.2%) the second most referred medicine due to side-effects such as a sore throat. The most frequent inhaler device dispensed was the metered dose inhalers (94%), however the most troublesome inhalers were dry powder inhalers (50.8%) due to patient’s poor inhalation capacity, dexterity, inability to load the capsules and poor knowledge. Overall, pharmacists were confident in their ability to help asthma patients, however, younger pharmacists were less likely to check inhaler technique at every dispensing (p=0.016), more likely to check it only upon patient request (p=0.042) and were more likely to refer patients to the GP after consultations. Contrastingly, nearly all participants (93.2%) found their training for asthma and its services to be sufficient, with 62.5% using centre for pharmacy postgraduate education as their training provider. Discussion/Conclusion The results suggest that most of the time pharmacists were well trained, addressed patients concerns adequately and were able to support with adherence and usage of inhalers.2 It was clear that pharmacists do play an active role in the lives of asthma patients through the services they conduct. Their training allows pharmacists to be confident when carrying out these services so that majority of patient’s concerns are addressed within the pharmacy and only a few require GP referral. It may be beneficial to carry out technique checks more frequently, conduct asthma reviews within the pharmacy and provide additional resources to newly qualified pharmacists to aid their confidence in helping asthma patients.

The impact on the elapsed time to care and outcomes of a clinician-to-clinician electronic consultation program in patients diagnosed or suspected atrial fibrillation in primary care

Abstract Background An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Clinician-to-clinician electronic consultations (e-consultations) program as the first step in the ambulatory care organization for the general practitioner (GPs) referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care compared with a face-to-face consultation for all the referrals. Objective To evaluate the effect on outcomes of a reduced elapsed time to care after a clinician-to-clinician e-consultations program implementation (2013–2019) in comparison with previous in-person consultation (2010–2012) in the outpatient health care management in a Cardiology Department. Methodology We included 10,488 patients referred by general care practitioners for cardiology consultation with confirmed or suspected AF from 1 January 2010, to 31 December 2019. Until 2012, all patients were attended with an in-person consultation (2010–2012). In 2013, we instituted an e-consult program (2013–2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any clinical comment and change in therapy advice from cardiologist was directly implemented in this EPD. Results During the e-consultation period (2013–2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010– 2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6 ±8.9 vs. 22.5 ±8.1 days,p < .001) (Figure 1, A), and an increase of OAC use (61% [95% IC: 19.6%–102.4%], p < .001) (Figure 1, B). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30–.75]) and all-cause mortality (.42 [95% CI: .29– .62]). The OAC reduces the stroke mortality (.15 [95% CI: .06–.39]) and CV mortality (.43 [95% CI: .29–.62]) and all-cause mortality (.23 [95% CI: .17–.31]) (Figure 2). Conclusion A shared EPD-based clinician-to-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke, cardiovascular and all-cause mortality.

A universal electronic consultation programme at the cardiology department after general practitioner referrals improves healthcare outcomes in patients with health failure

Abstract Background Electronic consultation (e-Consult) is an emerging health care innovation developed to address excess wait times for specialist care by enabling primary care physicians (PCPs) to obtain a specialist consultant’s expert opinion in a timely manner 1. A recent wait time report in England showed that in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist. This result failed to meet their standard of 92% of patients waiting no more than 18 weeks for their consult 2. e-Consult services were shown to be effective in terms of providing faster access to specialist’s advice, with short response times (from 1 to 6 days) of the participating specialists and resulting in substantial avoidance of face-to-face referral visits 3. The recent ESC HF guideline made a "may be considered" recommendation for the use of home-based telemonitoring, according on a meta-analysis published in 2017 4,5. Nevertheless, never has been evaluated the impact on access to care and clinical outcomes of a clinician-to-clinician e-consult program as a first step for all the PCPs referrals to cardiologist in heart failure patients. Purpose We aimed to assess in patients with heart failure (HF) the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation (from 2013 to 2021) and to compare it with a one-time in-person consultation model (from 2010 to 2012) for all the primary care physicians’ referrals to a cardiology department. Methods We selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021: 4,851 were attended in e-consultation and 2,008 in one-time in-person consultations. Using an interrupted time series regression model, we analysed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated the elapsed time to cardiology care, cardiovascular (CV) and HF hospital admissions, and HF, CV and all-cause mortality. Results The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times to cardiology care (8.6 [8.7] vs 55.4 [79.9] days, p<0.001). and a reduction in the need for visits to the emergency department 1-year after e-consultation compared with the previous period (HR [IC95%]: 0.07 [0.05-0.08]). After e-consultation implantation, hospital admissions were reduced (RRi [IC95%]: 0,867 [0,875-0,838] for HF, 0,838 [0,825-0,856] for CV and 0,639 [0,635-0,651] all-cause), figure 1; and lower mortality (RRi [IC95%]: 0,981 [0,977-0,983] due to HF, 0,977 [0,970-0,980] for CV and 0,985 [0,984-0,985] for all-cause), figure 2. These results were maintained during the COVID-19 pandemic. Conclusion In HF patients, an outpatient care program that includes an e-consultation significantly reduced waiting times to cardiology care and was safe, with a lower rate of hospital admissions and mortality in the first year.Figure 1Figure 2

A multicentre review of the direct-access mammography programme in Ireland for women with breast pain

To assess the current use of the direct access mammography pathway for breast pain and the rate of breast cancer detection in this patient cohort. A retrospective review of general practitioner (GP)-referred mammograms performed during a 12-month period from January to December 2022 across four tertiary referral centres. With the use of medical records and GP referrals, patient demographics, presenting symptoms, family history, and clinical outcomes were recorded. The present study comprised 2,046 patients of which 21.6% did not report breast pain at the time of referral. Thirty-five per cent had a positive family history with 40% of these patients having no breast pain. Twelve per cent were recalled with 30% of these patients requiring biopsy. An overall cancer detection rate (CDR) of 7 per 1000 was determined for women with mastalgia. A CDR of 0 per 1,000 was determined for women <50 years with mastalgia alone and no additional risk factors for malignancy. Fisher's exact test showed no statistically significant association between breast pain and breast cancer. There was no statistically significant relationship found between breast pain and breast cancer. This review suggests a low cancer detection rate in women <50 years. In women <50 years with mastalgia without additional symptoms or family history, breast imaging is not required.

23 Rapid access stroke prevention clinic, are we adhering to international recommendations?

Abstract Background Transient Ischaemic attack (TIA), accounted for over 2000 hospital admissions in Ireland in 2020. 25% of all TIA presentations develop stroke. The European Stroke Organisation (ESO) and National Stroke Strategy have recommended the development of rapid access stroke prevention (RASP) clinics, to reduce morbidity associated with devastating stroke event and reduce unnecessary hospital admissions. This project reviews the functionality of a RASP clinic in an Irish hospital and compares it to international recommendations. Methods A retrospective chart review of patients who had been referred to the clinic over a three month period was performed. The initial referral date, clinic review date, date of any appropriate investigations and final diagnosis were collected and compared against the current recommendations. Quantitative analysis was performed on this data. Results A total of 43 patients were included, 18 were referred by the emergency department (ED), 25 by general practitioners (GP). On average GP referrals were waiting 5.8 days, and ED referrals 3.5 days, to be seen by a specialist. Current ESO recommendation is for specialist review within 24 hours. Of those referred, 34 underwent the recommended carotid imaging. 7 of the 43 were diagnosed with TIA, highlighting the poor sensitivity of the current risk stratification tool (ABCD2). The average time from symptom onset to referral was 3.7. With 15 patients waiting 35 days prior to seeking medical advice. Conclusion It is clear that, at present, the RASP clinic is not meeting the international recommendations. A number of improvements to the referral process have been proposed. The move to an electronic referral process would reduce unnecessary steps in the current pathway and would ensure the appropriate investigations were carried out, at the time of initial contact. Improved patient education on symptoms of TIA is needed. A repeat audit will take place to review if these changes have had a significant impact.

The use of the integrated cognitive assessment to improve the efficiency of primary care referrals to memory services in the accelerating dementia pathway technologies study.

Current primary care cognitive assessment tools are either crude or time-consuming instruments that can only detect cognitive impairment when it is well established. This leads to unnecessary or late referrals to memory services, by which time the disease may have already progressed into more severe stages. Due to the COVID-19 pandemic, some memory services have adapted to the new environment by shifting to remote assessments of patients to meet service user demand. However, the use of remote cognitive assessments has been inconsistent, and there has been little evaluation of the outcome of such a change in clinical practice. Emerging research has highlighted computerized cognitive tests, such as the Integrated Cognitive Assessment (ICA), as the leading candidates for adoption in clinical practice. This is true both during the pandemic and in the post-COVID-19 era as part of healthcare innovation. The Accelerating Dementias Pathways Technologies (ADePT) Study was initiated in order to address this challenge and develop a real-world evidence basis to support the adoption of ICA as an inexpensive screening tool for the detection of cognitive impairment and improving the efficiency of the dementia care pathway. Ninety-nine patients aged 55-90 who have been referred to a memory clinic by a general practitioner (GP) were recruited. Participants completed the ICA either at home or in the clinic along with medical history and usability questionnaires. The GP referral and ICA outcome were compared with the specialist diagnosis obtained at the memory clinic.Participants were given the option to carry out a retest visit where they were again given the chance to take the ICA test either remotely or face-to-face. The primary outcome of the study compared GP referral with specialist diagnosis of mild cognitive impairment (MCI) and dementia. Of those the GP referred to memory clinics, 78% were necessary referrals, with ~22% unnecessary referrals, or patients who should have been referred to other services as they had disorders other than MCI/dementia. In the same population the ICA was able to correctly identify cognitive impairment in ~90% of patients, with approximately 9% of patients being false negatives. From the subset of unnecessary GP referrals, the ICA classified ~72% of those as not having cognitive impairment, suggesting that these unnecessary referrals may not have been made if the ICA was in use. ICA demonstrated a sensitivity of 93% for dementia and 83% for MCI, with a specificity of 80% for both conditions in detecting cognitive impairment. Additionally, the test-retest prediction agreement for the ICA was 87.5%. The results from this study demonstrate the potential of the ICA as a screening tool, which can be used to support accurate referrals from primary care settings, along with the work conducted in memory clinics and in secondary care. The ICA's sensitivity and specificity in detecting cognitive impairment in MCI surpassed the overall standard of care reported in existing literature.

Diagnosis, treatment, and survival from kidney cancer: real-world National Health Service England data between 2013 and 2019.

To report the NHS Digital (NHSD) data for patients diagnosed with kidney cancer (KC) in England. We explore the incidence, route to diagnosis (RTD), treatment, and survival patterns from 2013 to 2019. Data was extracted from the Cancer Data NHSD portal for International Classification of Diseases, 10th edition coded KC; this included Cancer Registry data, Hospital Episode Statistics, and cancer waiting times data. Registrations included 66 696 individuals with KC. Incidence of new KC diagnoses increased (8998 in 2013, to 10 232 in 2019), but the age-standardised rates were stable (18.7-19.4/100 000 population). Almost half of patients (30 340 [45.5%]) were aged 0-70 years and the cohort were most frequently diagnosed with Stage 1-2 KC (n = 26 297 [39.4%]). Most patients were diagnosed through non-urgent general practitioner referrals (n = 16 814 [30.4%]), followed by 2-week-wait (n = 15 472 [28.0%]) and emergency routes (n = 11 796 [21.3%]), with older patients (aged ≥70 years), Stage 4 KCs, and patients with non-specified renal cell carcinoma being significantly more likely to present through the emergency route (all P < 0.001). Invasive treatment (surgery or ablation), radiotherapy, or systemic anti-cancer therapy use varied with disease stage, patient factors, and treatment network (Cancer Alliance). Survival outcomes differed by Stage, histological subtype, and social deprivation class (P < 0.001). Age-standardised mortality rates did not change over the study duration, although immunotherapy usage is likely not captured in this study timeline. The NHSD resource provides useful insight about the incidence, diagnostic pathways, treatment, and survival of patients with KC in England and a useful benchmark for the upcoming commissioned National Kidney Cancer Audit. The RTD data may be limited by incidental diagnoses, which could confound the high proportion of 'emergency' diagnoses. Importantly, survival outcomes remained relatively unchanged.

Factors that affect GP referral of a child with intellectual disability for a mild illness: A discrete choice experiment.

General practitioners (GP) report multiple challenges when treating individuals with intellectual disabilities which may influence referral rates. The study aimed to establish factors that influence GP's decision-making when referring a child with intellectual disabilities to the emergency department. Discrete choice experiments (DCEs) are increasingly used in health research to further understand complex decision making. A DCE was designed to assess the relative importance of factors that may influence a GP's (N = 157) decision to refer. A random parameters model indicated that perceived limited parental capacity to manage an illness was the most important factor in the decision to refer a child to the ED, followed by a repeat visit, a referral request from the parent, and a Friday afternoon appointment. Understanding the factors that influence referral is important for service improvement and to strengthen primary care provision for this population and their families.

The effect of hospital spending on waiting times.

Long waiting times have been a persistent policy issue in the United Kingdom that the COVID-19 pandemic has exacerbated. This study analyses the causal effect of hospital spending on waiting times in England using a first-differences panel approach and an instrumental variable strategy to deal with residual concerns for endogeneity. We use data from 2014 to 2019 on waiting times from general practitioner referral to treatment (RTT) measured at the level of local purchasers (known as Clinical Commissioning Groups). We find that increases in hospital spending by local purchasers of 1% reduce median RTT waiting time for patients whose pathway ends with a hospital admission (admitted pathway) by 0.6days but the effect is not statistically significant at 5% level (only at the 10% level). We also find that higher hospital spending does not affect the RTT waiting time for patients whose pathway ends with a specialist consultation (non-admitted pathway). Nor does higher spending have a statistically significant effect on the volume of elective activity for either pathway. Our findings suggest that higher spending is no guarantee of higher volumes and lower waiting times, and that additional mechanisms need to be put in place to ensure that increased spending benefits elective patients.

Has COVID-19 affected dementia diagnosis rates in England?

The COVID-19 pandemic impacted on the provision of care and routine activity of all National Health Service (NHS) services. While General Practitioner referrals to memory services in England have returned to pre-pandemic levels, the estimated dementia diagnosis rate (DDR) fell by 5.4% between March 2020 and February 2023. In this paper we explore whether this reduction is accurate or is an artefact of the way the NHS collects data. We explore the processes that may have affected national dementia diagnosis rates during and following the COVID-19 pandemic. We discuss what action could be taken to improve the DDR in the future.