General Practice Research Articles

Trends in clinical encounters and management for infertility among women attending Australian general practice: a national longitudinal study using MedicineInsight, 2011 to 2021

ObjectiveTo examine longitudinal trends in infertility management in women attending general practice.DesignCohort study using the national general practice dataset, MedicineInsight.SettingAustralian general practice.Intervention(s)Not applicable.ParticipantsThe cohort included 2 552 339 women aged...

How Can We Make Information on Equity in Clinical Guidelines More Usable for Clinicians? A Case Study Methodology of General Practitioners.

Clinical practice guidelines (CPGs) are moving toward greater consideration of population-level differences, like health inequities, when creating management recommendations. CPGs have the potential to reduce or perpetuate health inequities. The intrinsic design factors of electronic interfaces that contain CPGs are known barriers to guideline use. There is little existing guidance on supporting the uptake of equity-specific recommendations within CPGs by end users. To investigate (1) How do General Practitioners (GPs) use Therapeutic Guidelines to adapt their clinical management for disadvantaged populations and do they support equity recommendations in this CPG? (2) How could Therapeutic Guidelines embed health equity information into their guidelines? The Therapeutic Guidelines was used as a case study as it is the most frequently used CPG in Australian healthcare settings. We employed descriptive qualitative methods, focused on semistructured interviews with 17 eligible GPs. Interviews were structured around four case studies that initially explored the management of a patient from the general population, with their details then changed so they belonged to a disadvantaged population. We used a 'think aloud' interview technique to explore the clinician's application of CPGs. Three themes were developed relating to: (1) GPs agree that health equity information needs to be intentionally included in guidelines and should focus on disadvantaged subgroups to support their clinical decision-making, (2) GPs want CPGs to include equity information which is relevant to the purpose and use of each guideline, acknowledging that other clinical aids could provide additional information when needed, (3) GPs want clearer signposting of information within guidelines to help navigation of key sections, highlighting the utility of symbols, colours and dropdown functions. This research extends existing literature by showing that including equity information tailored to the articulated purpose of each CPG, as perceived by end users, may maximise uptake. Our outlined strategies could be used by CPG developers to make equity-focused management recommendations more accessible. This may increase the implementation of equity-focused recommendations by clinicians, supporting current primary care strategies in achieving more equitable outcomes.

Characteristics, risk factors and clinical impact of penicillin and other antibiotic allergies in adults in the UK General Practice: A population-based cohort study.

To assess the characteristics, risk factors and clinical impact of penicillin and other antibiotic allergy labels in general practice in the UK. Population-based cohort study. Primary care in the UK, 2000-2018. Adults aged 18-100 years who were registered with their general practice for at least 12 months between 01-Jan-2000 and 31-Dec-2018 and followed until 25-Sep-2019. The main outcomes include the annual prevalence and incidence of penicillin and other antibiotic allergy labels. Multinominal logistic regression was used to examine the characteristics associated with receiving an allergy label to different antibiotics. Cox regression modelling was used to compare the risk of resistant infections (methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci) as well as Clostridioides difficile (C.difficile) infection between patients with and without allergy labels. The monthly proportion of patients who had a penicillin allergy test, either before their allergy label was recorded or within one year, was calculated to assess any impact of NICE penicillin allergy assessment recommendations (Clinical guideline [CG183]) in September 2014. Both the prevalence and incidence of penicillin allergy label showed a pattern of initial growth followed by a decline. The prevalence reached a maximum of 8.25% in 2011, and the incidence peaked at 0.46% in 2004. Older age, being female, living in less deprived areas, belonging to a larger general practice, and having co-morbidities were associated with a higher chance of receiving a penicillin or other antibiotic allergy label. Patients with antibiotic allergy labels were more likely to receive alternative broad-spectrum antibiotics and had a higher risk of MRSA and C.difficile infections. The introduction of NICE drug allergy guideline did not alter the proportion of patients undergoing penicillin allergy assessment. Penicillin and other antibiotic allergy labels are common and lead to radical change in the antibiotic prescribing practices and are associated with resistant and healthcare associated infections.

On Lateness: The Ethics of Running Behind Schedule in General Practice.

GPs, at least in the United Kingdom, often run behind schedule in their clinics. This lateness is an inherently ethical problem due to the negative consequences it generates. The paper outlines these negative consequences, attempts to classify the major reasons for such lateness, explores the ethical status of each of these reasons, and offers suggestions for how the negative consequences might be managed. The major reasons for lateness can be classified as GP-related, patient-related, and third party-related. The major negative consequences of lateness in general practice might be classified as the potential disturbance to quality and safe care, the dissatisfaction of and inconvenience to subsequent patients, and the disruption of timely care. These negative consequences must be burdened by some party-either the patient who is related to the reason for the lateness, or other patients who are not. While a strict equality approach to managing such lateness does not consider patients' clinical needs, GPs compensating by actively 'catching up' in their clinics threatens quality and safety of care. The paper argues for minimising the negative consequences of lateness for all parties, while simultaneously promoting equity with regard to patients' clinical needs. The ethical status of each major reason for lateness in general practice is explored, and suggestions are offered for how each might be managed to minimise the negative consequences and promote equity.

Experiences With End-of-Life Care for Patients With Pre-Existing Severe Mental Disorders, Their Relatives, and Healthcare Professionals.

Knowledge is needed about end-of-life care among patients with pre-existing severe mental disorders: Schizophrenia, bipolar disorder, and depression. This study aimed to explore the experiences with end-of-life care for patients with severe mental disorders, their relatives, specialised palliative care nurses and physicians, and general practitioners. Twenty semi-structured interviews were conducted and analysed using reflexive thematic analysis, hereby six interviews with patients, three with relatives, five with general practitioners, and six with specialised palliative healthcare professionals. Patients were selected with help from healthcare professionals. Four main themes were produced: thoughts about the future, healthy relations in end-of-life, changes in psychiatric condition in end-of-life, and the role of openness. Patients with severe mental disorders had wishes and fears for the future, and all participants expressed that healthy relations were crucial for patients at the end-of-life. However, sometimes this was challenged by prior complex relationships. It differed whether patients experienced a change in their psychiatric condition after having a terminal disease. Openness about severe mental disorders and end-of-life were regarded as important. Having the opportunity to openly discuss both wishes, fears, and mental disorders with healthcare professionals and having healthy relations are important for patients with severe mental disorders at the end-of-life. Insecurity about severe mental disorders among specialised palliative care professionals may lead to less openness about severe mental disorders. To optimise end-of-life care, patients need professionals to be present and available to discuss problems related to social, physical, existential, and psychiatric conditions.

Development of a supportive cancer care model for patients with CAncer and pre-existing SEvere MEntal Disorders

BackgroundCancer patients with pre-existing severe mental disorders (SMD), including moderate to severe depression, bipolar disorder and schizophrenia, have reduced life expectancy and are less likely to get optimal cancer treatment. The aim of this study is to develop and pilot test a supportive care model, to enhance cancer care. MethodsThe model was developed through three phases. In phase I, a barrier analysis and prototype of the model were conducted form reviewing the literature and through 162 informal interviews with healthcare professionals, patients and patient representatives. In phase II, the prototype was refined through four workshops with a total of five cancer nurses, four clinical oncologists, three psychiatrists, two general practitioners, one psychologist, and 16 patient representatives. Thereafter, a pilot test with 13 patients was carried out, where continuous adaptations to the prototype from phase II, were made. The quantitative and qualitative data were analysed focusing on components which were prominent and able to fit into the clinical setting. ResultsThe final CASEMED supportive cancer care model included: Early identification of psychiatric comorbidity, engagement of significant caregivers, education of the oncological HCPs, securing continuity among staff and enhanced collaboration between sectors. The latter was achieved through an online psychiatric multidisciplinary team conference where the patient’s general practitioner, a psychiatrist and the patient’s oncologist participated. ConclusionThis study indicates that the model can be implemented in practice and has the potential to optimize cancer care for patients with cancer and pre-existing SMD. A larger feasibility study is currently being conducted.

The challenges faced by early-career international medical graduates in general practice and the opportunities for support: a mixed methods study

ABSTRACT Background Recruiting and retaining International Medical Graduates (IMGs) has been identified as a key component in addressing the ongoing workforce crisis in general practice. However, research shows IMG General Practitioners (GPs) face unique challenges compared to their UK-trained counterparts, impacting their welfare, retention in the workforce, and ability to provide patient care. Aim This study examined the challenges facing early-career IMG GPs, the help and support they access and want to access, and their perceptions and utilisation of the help and support available. Design and setting A mixed-methods study that collected primary data in an online survey and interviews between March and May 2023. Method Early-career IMG GPs based in South West England were invited to complete an online survey consisting of 5-point Likert-scale and free-text questions. Interviews were completed with key informants and some survey respondents. Qualitative data were analysed thematically. Data from the survey and interviews were analysed and merged using a convergent parallel design. Results Based on 29 survey replies and 9 interviews, four interrelated themes were identified: (i) communication and language, (ii) racism, unequal treatment, and developing coping mechanisms (iii), exclusion and being ‘othered’, and (iv) adapting to new ways of living and working. Although some IMG GPs access help and support, many feel this is insufficient and poorly accessible. Conclusion IMG GPs face interrelated and unique challenges in their personal and professional lives and do not feel adequately supported by the NHS. Addressing this disconnect will be vital to sustaining the general practice workforce.

The Management of Chronic Insomnia in Young Children: A Survey of UK General Practice

ABSTRACT Objectives Chronic insomnia (CI), the most common sleep disorder in young children, is associated with negative outcomes for the child and family. This study explores the beliefs, current practice, and understanding of UK primary health care professionals (PCPs) regarding CI in children under 5 years. Method An online survey of UK PCPs (e.g. general practitioners (GPs), practice nurses) recruited through Clinical Research Networks. The survey consisted of Likert-style and closed- questions regarding beliefs, current practice, and training/knowledge. Data were analyzed descriptively. Results Two hundred and ninety-five PCPs took part (mostly GPs, n = 244). Respondents believe that CI has a large impact on children and family. 80% agreed that CI should be managed in health care and 66.3% in primary care. However, consultations with families regarding CI were reported as infrequent. 91.6% agreed that CI should be managed with behavioral approaches, and more than 85% of respondents recommend positive bedtime routines. Respondents had varied confidence and knowledge about management. They had received little to no professional education about CI. Conclusions PCPs recognize the importance of CI and understand some principles of management, though they lack training and confidence. Improved training and awareness of evidence-based resources for support would improve management in primary care.

Abstract TP158: Collaboration Between Neurology and Endocrine Improves Uncontrolled Diabetes for Patients with Acute Ischemic Stroke

Background: Research suggests that the absolute number of strokes among people with diabetes is increasing as the population with diabetes grows. Stroke patients with poorly controlled diabetes are more likely to experience poor functional recovery, longer recovery times, recurrent stroke, and higher risk of death. In response to a finding from the 2021 Joint Commission survey for not addressing an HbA1c=9.3, we launched a quality improvement project to enhance diabetic management among patients admitted for ischemic stroke. Methods: This interdisciplinary collaboration involved endocrinology, hospital medicine, and neurology. For patients admitted to our Thrombectomy-Capable Stroke Center for ischemic stroke with an HbA1c ≥ 9.0% or blood glucose glucoses≥250mg/dl, a mandatory inpatient endocrine consult would be provided, in addition to diabetic educator consult. The patient’s HbA1c levels were followed every 3 months for a year. Results: A total of 66 patients were admitted in 2022 (n=32) and 2023 (n= 34) for ischemic stroke with HbA1c ≥ 9.0%. The median HbA1C for 2022 cohort dropped from 11.2% (range 9.0% – 16.6%) to 8.5% (range 5.0% - 14.1%) in a year (p<0.05); and 10.3% (range 9.0% - 14.6%) to 7.75% (range 6.0% - 11.7%) in a year (p<0.05). 2024 data showed similar improvement with drop of HbA1c from 10.55% to 9.75% at 3 months and 9.45% at 6 months. Conclusion: Inpatient endocrinology involvement for high-risk stroke patients with previously uncontrolled diabetes improves diabetic control over time. Endocrinologists can offer personalized treatment plans considering various factors such as comorbid conditions, patient lifestyle, and specific diabetes complications. This single center intervention is congruent with published data showing that patients under specialist care often experience HbA1c reductions of 0.5% to 1.0% or more compared to those managed by general practitioners. In high risk and high complexity cases, this improvement may potentially lead to reduced risk of stroke recurrence and complications. We postulate that this improvement is attributed to the endocrinologist’s expertise in complex diabetes management, advanced treatment options, personalized care approaches, and resources in post-discharge management. If confirmed in a multicenter clinical study, it can become a generalizable approach to improve the quality of care and outcomes of high-risk stroke patients.

Exploring the acceptability of a risk prediction tool for cardiometabolic risk (gestational diabetes and hypertensive disorders of pregnancy) for use in early pregnancy: A qualitative study.

The acceptability of providing women with personalised cardiometabolic risk information using risk prediction tools early in pregnancy is not well understood. To explore women's and healthcare professionals' perspectives of the acceptability of a prognostic, composite risk prediction tool for cardiometabolic risk (gestational diabetes and/or hypertensive disorders of pregnancy) for use in early pregnancy. Semi-structured interviews were conducted to explore the acceptability of cardiometabolic risk prediction tools, preferences for risk communication and considerations for implementation into antenatal care. The Theoretical Framework of Acceptability informed interview questions. Transcripts were thematically analysed. Women ≤24 weeks' gestation (n = 13) and healthcare professionals (n = 8), including midwives (n = 2), general practitioners (n = 2), obstetricians (n = 2), an endocrinologist (n = 1) and cardiologist (n = 1) participated. Participants indicated that providing personalised risk information is only appropriate when preventative measures can be initiated to mitigate risks. Differentiating the risk for each condition (single risk outputs) was often preferred to composite risk outputs to enable targeted monitoring and management. Defining conditions and risks to mother/baby, visually depicting personalised risk scores, and providing clear, patient-centred clinical management plans were recommended. Supportive clinical policy changes, staff engagement/training, and integration into electronic health records were suggested to facilitate uptake into routine antenatal care. Women and healthcare professionals suggested that early pregnancy cardiometabolic risk prediction tools may be acceptable when preventative interventions are available to reduce risks. Risk prediction tools with integrated patient-centred education materials may promote timely access and engagement with preventative interventions to optimise women's current and future health.

Stigma and patient work: Understanding cumulative inequities for gay and bisexual men in accessing HIV healthcare services.

Patient work refers to the quotidian labour undertaken by individuals to manage health, often unrecognised by health systems. This article argues that anticipated and received stigma and inclusivity labour comprise additional forms of patient work specific to minority populations. We draw on a case study of gay and bisexual men's experiences accessing healthcare services related to HIV prevention and testing in New South Wales (NSW), Australia's most populous state. Although new HIV diagnoses have reduced in NSW, these declines have not been uniformly observed. This study aimed to understand experiences of stigma related to accessing healthcare amongst two priority populations identified in the state's HIV strategy: gay and bisexual men who are young or who are living in regional and outer metropolitan suburbs. We interviewed 32 participants in 2023, recruited via social media advertisements and email invitations, and analysed data thematically. Our findings emphasise how disclosure of sexual orientation and/or HIV status operates as a form of inclusivity labour, in which patients look for cues from health providers that disclosure will be safe and respected. Other forms of patient work required to navigate access to HIV prevention services included finding appropriate providers likely to prescribe HIV pre-exposure prophylaxis (PrEP) and managing service refusal from general practitioners. Patient work appeared to also be compounded by intersecting issues of anticipated and vicarious stigma, unavailability of sexual health services in regional areas, long waiting times, and increased costs of healthcare services. Although experiences of enacted stigma in healthcare were infrequently reported, interview accounts suggested that participants undertook extensive patient work to minimise or avoid stigmatising encounters with health providers. Focusing on patient work in the context of stigma illuminates the labour of underserved populations required to access safe and culturally competent healthcare services (including HIV prevention and testing), suggesting areas of unmet need from health systems.

Information Provision for Patients Who Undergo Resection of Colorectal Liver Metastases.

Information provision to patients is helpful prior to and during cancer treatment. However, the level of information required or warranted varies, and no studies have examined this in patients who have had resection of colorectal liver metastases (CRLM). The aims of this study are to assess how patients perceive information received from different healthcare providers and to examine factors that might be associated with the quality and satisfaction of the information received. This was a cross-sectional study of patients with a potentially curative resection for CRLM between 2010 and June 2021. Patients completed the European Organisation for Research and Treatment of Cancer QLQ-INFO25 questionnaire. In total, 121 patients underwent resection. Of these, 85 were alive and were sent the questionnaire, and 52 (61%) responded. Overall, patients were very satisfied with the information they received and found it helpful (median score 100). No specific patient or disease-related factors were associated with the degree of satisfaction. This study demonstrates excellent overall satisfaction with the information provided to patients with CRLM. Areas of improvement include information about other supportive services outside the hospital. This information may be given by the specialists providing the care but may also be provided by the patient's general practitioners and the cancer nurse coordinators.

New-onset double vision in general practice.

New-onset double vision in general practice.

Crossing the Rubicon: assisted dying in general practice.

Crossing the Rubicon: assisted dying in general practice.

Results of a multicenter retrospective cohort study evaluating the safety and efficacy of FTD/TPI plus ramucirumab in advanced gastric cancer (HGCSG2302).

351 Background: In advanced gastric cancer, trifluridine/tipiracil (FTD/TPI) is one of the standard treatments for later-line chemotherapy. Ramucirumab (RAM), an anti-VEGFR-2 monoclonal antibody, has shown promising efficacy in combination with FTD/TPI in phase II studies conducted in Japan, suggesting that this combination could improve treatment outcomes. However, there remains a paucity of real-world clinical data comparing the efficacy and safety of FTD/TPI monotherapy and FTD/TPI plus RAM combination therapy in general clinical practice. Methods: This retrospective analysis to evaluate safety and efficacy included patients with gastric cancer who were received FTD/TPI plus RAM combination therapy or FTD/TPI monotherapy between August 2019 and March 2023 at 21 institutions. Results: 164 patients were analyzed, 38 patients in the RAM combination group and 126 in the FTD/TPI monotherapy group. The distribution of treatment lines (third/fourth/fifth) was 10/13/15 in the RAM group and 26/54/46 in the monotherapy group, respectively. RAM had been previously administered to 34 patients (89.5%) in the RAM group. Objective response rate and disease control rate were 11.1% / 55.6% (OR 2.0, 95% C.I. 0.84-4.77, p=0.126) in the RAM group and 5.5% /38.5% (OR 2.0, 95% C.I. 0.84-4.77, p=0.126) in the monotherapy group, respectively. Median progression-free survival (PFS) was 3.5 months in the RAM group and 2.1 months in the monotherapy group (HR 0.69, 95% C.I. 0.49-1.02, p=0.06), respectively. Median overall survival (OS) was 8.4 months in the RAM group and 5.8 months in the monotherapy group (HR 0.82, 95% C.I. 0.54-1.25, p=0.350), respectively. Grade 3 neutropenia was reported in 48.6%/52.4% (p=0.707), and there were no significant differences in other adverse event profiles between the two groups. Additionally, in the RAM group, a comparison between patients receiving standard dosing (2 weeks on/2 weeks off; n=7) and those on biweekly dosing (1 week on/1 week off; n=24) showed no notable differences in efficacy or safety. Conclusions: FTD/TPI plus RAM combination therapy showed a trend toward prolonged PFS compared to FTD/TPI monotherapy, but no significant difference in OS.

Proposed macroscopic quality indicators of antimicrobial stewardship in primary care: An observational study

ObjectiveThe objective of this study was to evaluate the ability of two macroscopic quality indicators to guide antibiotic stewardship strategies. MethodsSetting: Bourgogne-Franche-Comté region (eight departments).Antibiotic reimbursement data, expressed in defined daily doses, were used to calculate two macroscopic quality indicators from 2015 to 2020. Urinary tract infection indicator: (fosfomycin + nitrofurantoin + pivmecillinam) / (ciprofloxacin + ofloxacin + norfloxacin) calculated in women aged 15 to 64. Indicator for ear, nose, throat and respiratory tract infections: (amoxicillin/ (amoxicillin-clavulanate + oral 3GC) calculated in children under 15 years of age. ResultsIn 2020, global antibiotic consumption varied from 22.2 to 26.6 defined daily doses per 1000 inhabitants per day, depending on the department. The macroscopic quality indicators were lowest in the departments of Nièvre and Yonne. The scores for the urinary tract infection indicator were 0.55 and 0.74, respectively, while those for the ear, nose and throat and respiratory tract infection indicators were 1.85 and 2.12, respectively. Both scores continuously increased in all departments of the region during the survey, except in 2020 for the urinary tract infection indicator, due to a nitrofurantoin shortage. ConclusionEven in departments with low antibiotic consumption, our macroscopic quality indicators help to identify antibiotic stewardship targets for the most common community-based infections,. They are easy to calculate from quantitative data without requiring any information on diagnosis. Complementarily to other indicators, they provide messages specifically addressed to general practitioners regarding population, molecules and diagnostic elements.

Physical Health Views Among Individuals Experiencing Mental Illness: A Mixed-Methods Study of Self-Reported Health and Contributing Factors.

Severe mental illness is linked to poor physical health and shorter life expectancy, yet research on how individuals experiencing mental illness view and on improve their physical health is limited. This study investigates the perceptions of individuals experiencing mental illness regarding their physical health, utilising a mixed-methods approach. Phase I involved quantitative and qualitative data from an online Qualtrics survey, which included the 12-item Short Form (SF-12) survey to measure participants' quality of life and assess self-reported physical and mental health. Key findings from Phase I revealed significant relationships between lower Physical Component Summary (PCS) scores and factors such as the frequency of GP visits. Additionally, exercise preferences were found to significantly impact Mental Component Summary (MCS) scores, with individuals who preferred a mix of exercise settings reporting higher MCS scores compared to those who exercised alone or with a training partner. Phase II explored these findings further through semi-structured interviews, where participants discussed themes including physical health perceptions, the role of medication and the importance of the general practitioner relationship. Thematic analysis revealed five main barriers to improving physical health: accessibility and availability of services, motivation, staff attitudes, medication side effects and the experience of diagnostic overshadowing. Participants reported viewing physical and mental health as interconnected and expressed a desire for more collaborative care. The results suggest that strengthening the relationship with GPs and increasing awareness of medication side effects may improve physical health outcomes for individuals experiencing mental illness. Mental health nurses can play a pivotal role in enhancing physical health outcomes by monitoring, supporting health-improving strategies and facilitating access to primary care services.

Successful Linkage of Electronic Medical Records and National Health Data System in Type 2 Diabetes Research: Methodological Insights and Implications.

This study assesses success and methodological implications of linking IQVIA's Electronic Medical Records (EMR) of type 2 diabetes (T2D) patients with the National Health Data System (SNDS) database, a cornerstone process in healthcare research. The OREOT cohort was constituted by T2D patients identified in the IQVIA EMR from 2014 to 2018 and linked indirectly to SNDS database. The EMR database contains clinical records from general practitioner consultations, representing ~2.8% of the French population and the SNDS claims database covers over 99% of the French population's healthcare activities. Linkage success was evaluated by the linkage rate. Baseline patients' characteristics were described for both linked and non-linked patients. Of the 291 408 T2D patients identified in the EMR, 244 656 (84%) were successfully linked. After technical data cleaning, 239 141 (82%) were finally linked. Linked and non-linked patients (n = 52,267) were aged 65 years and more frequently male (57% and 59%); half were obese, and most of comorbidities were consistent. Linked patients had more EMR consultations (median 32 vs 16), and more cardiovascular events (12% vs 7%) or chronic kidney disease (10% vs 7%). The successful linkage of EMR and SNDS databases provides valuable insights for future research in T2D and other chronic diseases requiring clinical data. This study demonstrates the feasibility of such data alignments, particularly in patients with complex health profiles or extensive medical records, and linkage potential to enhance real-world research quality. Despite higher prevalence of baseline comorbidities among linked patients, patients' characteristics were consistent with French T2D population.

The Building Blocks for Successful Hub Implementation for Migrant and Refugee Families and Their Children in the First 2000 Days of Life.

Migrant and refugee women, families, and their children can experience significant language, cultural, and psychosocial barriers to engage with child and family services. Integrated child and family health Hubs are increasingly promoted as a potential solution to address access barriers; however, there is scant literature on how to best implement them with migrant and refugee populations. Our aim was to explore with service providers and consumers the barriers, enablers, and experiences with Hubs and the resulting building blocks required for acceptable Hub implementation for migrant and refugee families. This project was undertaken in Sydney, New South Wales, in communities characterised by cultural diversity. In this qualitative study, we used semi-structured interviews guided by the consolidated framework for implementation research, with service providers from health and social services (32 participants) and migrant and refugee parents (14 parents) of children who had accessed Hubs. Our initial qualitative data themes were developed into step-by-step building blocks, representing a way to address contextual determinants to establish and sustain a Hub that can support migrant and refugee families. These include the setting-up phase activities of buy-in and partnership development, which outlines mechanisms to foster collective action and collaboration between health and social services. Following this, our orientation model articulates the need to establish Hub coordination and navigation, activities that enhance a Hub's relevance for migrant and refugee families and ongoing integration mechanisms, such as engagement of same-language general practitioners. This is the first study to explore the building blocks required for acceptable Hub implementation to meet the needs of migrant and refugee families in the first 2000 days of a child's life-a critical time to optimise child development and health. The research questions were developed based on qualitative research undertaken with Hub participants, community members, and service providers. The original investigator team had a consumer representative who has since relocated and consultation was undertaken with local Hub partner services. The researchers also consulted multicultural health services, including cultural support workers, to ensure research materials were culturally nuanced. Patients or participants have not directly been involved in the current study design. This trial was registered with the Australian New Zealand Clinical Trials (ACTRN12621001088831).

Perioperative versus adjuvant therapy in resectable pancreas cancer.

703 Background: Pancreatic ductal adenocarcinoma (PDAC) is the third-leading cause of cancer death in the United States with a 5-year survival rate of 13%. Recurrence rates are high following resection and optimization of neoadjuvant and adjuvant therapy remains under investigation, with the hypothesis that neoadjuvant/perioperative therapy may convert borderline resectable tumors to resectable and prevent progression of micro-metastases in the postoperative setting. Our study evaluates patient outcomes and models predictive and prognostic markers to assist with clinical decision-making in consideration of neoadjuvant therapy for resectable and borderline resectable pancreatic cancers. Methods: We performed a single-institution retrospective analysis of patients who underwent pancreatic resection between January 1, 2016 and December 31, 2020 (n=532). We excluded patients with unresectable disease or a non-PDAC diagnosis. Analysis of the remaining patients (n=175) was performed using automated and manual chart review, basic statistical comparisons with T-tests or Chi-squared tests, Kaplan-Meier Survival analyses, and Cox Proportional Hazard Testing using intention to treat analysis. Results: There were no significant differences (p>0.05) the presenting demographics between the adjuvant (AJ, n=97) and neoadjuvant/perioperative (NP, n=76) groups. Patients were more likely to have a history of pancreatitis, a risk factor for PDAC development, in the NP group (p=0.0153). Patients in the AJ group included patients who ultimately did not receive the recommended adjuvant therapy for various reasons (n=25) and had overall worse performance status (p=0.004) and received less chemotherapy overall compared to the NP cohort (p=0.0003). Adjuvant therapy was more likely to be gemcitabine with capecitabine (n=37, p=0.0007) in the AJ group and gemcitabine with nab-paclitaxel (n=11, p=0.0018) in the NP group. In the neoadjuvant setting, 62% of patients received FOLFIRINOX and 28% received gemcitabine with nab-paclitaxel. Patients in the NP group were more likely to receive radiation (p=0016), including 6 patients who received neoadjuvant radiation. Median overall survival (33.9 [28.8-43.8] versus 38.2 [28.2-47.8] months) and progression free survival (21.1 [18.1-34.2] versus 16.6 [11.7-23.6] months) were not significantly different between the AJ and NP groups, respectively. Conclusions: These results demonstrate similar presenting characteristics between patients with resectable PDAC treated in a period when general practice shifted from adjuvant therapy to a neoadjuvant/perioperative approach. Although patients treated neoadjuvantly received more chemotherapy overall and the chemotherapy regimens differed between the groups, patients had similar outcomes in the two groups.