Secondary Care Research Articles

Background: Although it is known that increased urinary protein excretion is predictive of both end-stage kidney disease and cardiovascular (CV) outcomes, laboratory quantification of urinary albumin is rarely carried out in CV practice. However, dipstick urine testing is often performed in primary and secondary care, although the results may not be routinely inspected or acted upon. Given the renewed emphasis on CV-metabolic-kidney overlap in medicine, we have examined the prognostic value of semiquantitative urine dipstick protein (DP) assessments in patients with heart failure and reduced ejection fraction (HFrEF). Hypothesis: DP predicts clinical outcomes and enables risk stratification in HFrEF. Methods: GALACTIC-HF (Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure) was a randomized, double-blind, multicenter, event-driven trial that evaluated the efficacy and safety of the cardiac myosin activator omecamtiv mecarbil (OM) versus placebo in 8,232 patients with HFrEF. The primary outcome was a time-to-first-event analysis of a composite of worsening HF (hospitalization or urgent visit) or CV death. We assessed associations between baseline DP and clinical outcomes. Results: Baseline DP data were available for 7,790 patients, of whom 5,910 (75.9%) had a negative test or trace proteinuria, 995 (12.8%) had 1+, and 885 (11.4%) had ≥2+ proteinuria. Patients with DP ≥2+ were younger, more often were in NYHA class III/IV and had diabetes, had higher systolic blood pressure, and lower eGFR (Figure). Mean LVEF was 27% across all DP groups. The rate of the primary outcome (per 100 person-years) increased significantly with increasing DP: negative/trace (21.8, 95% confidential interval [CI] 20.8–22.7); 1+ (34.8, 31.8–38.0); and ≥2+ (38.1, 34.7–41.9). Similar trends were seen for the components of the primary outcome and all cause mortality (Figure). Although individual hazard ratios were partially attenuated after adjustment for recognized prognostic variables, including NT-proBNP and eGFR, higher DP remained significantly associated with worse outcomes. The treatment effect of OM compared with placebo on clinical outcomes was not modified by DP category. Conclusions: DP is a simple inexpensive test with prognostic value in HFrEF.

BackgroundOpioid use is associated with increased health care service utilization but home care recipients and patients with dementia have been mostly ignored in earlier studies, although changes in their health status can have dramatic cost consequences. This study examined social and health care utilization and costs among older home care recipients before and after opioid initiation, with persons with dementia as a subgroup of interest.MethodsThis retrospective nationwide register-linkage study included Finnish regular home care recipients aged ≥ 65 years with opioid initiation between 1st March 2015 and 31st December 2016. Recipients with health care contacts due to cancer and palliative care were excluded.Incidence rate ratios of social and health care service use during the observation period starting one year before and ending one year after opioid initiation were calculated using nationwide register data. The utilization costs of various social and health care service categories were compared before and after the opioid initiation. Recipients with and without dementia were analysed separately.ResultsHome care recipients had 1.76 (95% CI 1.75 − 1.78) times more inpatient days, 1.31 (1.26 − 1.36) times more emergency care admissions, and recipients without dementia had more outpatient service use (secondary care 1.10 [1.06 − 1.13], primary care 1.06 [1.04 − 1.07]) after opioid initiation compared to the preceding year. Home care service use decreased (0.85 [0.85 − 0.85]) in recipients with dementia but increased in those without (1.08 [1.08 − 1.08]). Of the recipients, 20.8% were admitted to long-term residential care during the follow-up year. The mean annual total costs per recipient were 21% higher during the year following opioid initiation compared to the preceding year. A peak in the costs, consisting largely of inpatient costs, was observed about a month before opioid initiation, after which costs showed a declining trend but remained above the baseline level.ConclusionsRecipients’ monthly health care resource use started to increase already before opioid initiation, after which monthly expenditures declined steadily, which may reflect mostly recipients’ worsened health status before opioid initiation. Most of the expenditures arose from housing services. The relationship between opioid use and utilization of residential care and home care services should be further examined.Trial registrationNot applicable (a retrospective register-based study).Supplementary InformationThe online version contains supplementary material available at 10.1186/s12877-025-06550-z.

Significant differences in group-level performance have been identified in UK postgraduate medical examinations. However, few examinations have been investigated independently, and those that have, focus on a limited number of sociodemographic factors. This study addresses these gaps by identifying predictors of success in each UK postgraduate medical examination, accounting for prior academic attainment and other sociodemographic differences. Retrospective cohort study. Secondary care. Anonymised pass/fail data at the first attempt held within the General Medical Council Database were analysed for all candidates (UK medical school graduates [UKG] and international, non-UK graduates [IMG]) attempting a postgraduate examination between 2014 and 2020. Multivariate logistic regression models identified independent predictors of success at each postgraduate examination. During the study period, 180,890 examination first-attempts were made by candidates, and 121,745 (67.3%) passed at their first attempt. Multivariate regression models revealed that place of primary qualification, gender, age, ethnicity, religion, sexual orientation, disability and LTFT status were all statistically significant independent predictors of success or failure in written and clinical examinations. The strongest independent predictors of failing written and clinical examinations were being an IMG, being from a minority ethnic background and having a registered disability. This was the largest study to date investigating independent predictors of outcomes at each UK postgraduate medical examination. Significant differences in pass rates were seen according to sociodemographic differences in each examination. These data can be used by Medical Royal Colleges, the GMC and training institutions to guide more granular research and future interventions.

Spinal cord stimulation (SCS) constitutes a treatment option for patients with severe chronic pain responding insufficiently to pharmacological treatment. High device costs and expenses associated with surgical procedures and follow-up constitute a barrier to adoption. However, CNP patients also constitute a significant burden on public finances, with high public costs relating to health care utilisation, medicine, and lost work capacity. We investigated the costs of SCS therapy from a healthcare perspective (primary and secondary healthcare and medicine costs) 3 years before and 3 years after initiation of the SCS therapy in a large, mixed, well-characterised patient cohort derived from a dedicated neuromodulation registry, including patients with different diagnoses and characteristics from three of the four Danish SCS centers. We additionally compared costs of productivity loss for patients under the age of retirement. Data on societal costs were retrieved from public Danish registries. Three hundred and eight-four patients were included. Total healthcare costs 3 years after SCS were significantly higher than 3 years before SCS, with an increase of €29,835. The expenses associated with establishing SCS therapy are reflected in a sharp increase in in-patient secondary health care cost in year one after SCS. Primary health care, secondary out-patient health care and medicine costs all decrease after SCS but not enough to compensate for the cost of establishing treatment. Costs due to productivity loss remain stable throughout the period. Our findings highlight evaluating high-cost interventions within a broader cost framework to inform more efficient resource allocation in chronic pain management. This study analyzes the real-world socioeconomic impact of spinal cord stimulation (SCS) in Denmark. By using data from public Danish registries, we find a sharp increase in in-hospital expenses at the year of implantation, only partially offset by a subsequent reduction in other health care expenses and medicine costs. These findings give unique insights into the financial aspects of SCS, offering a perspective for healthcare providers, policymakers, and patients when evaluating the long-term budgetary implications of this treatment.

Accounting for morbidity in capitation payments: A person-based workload formula for primary medical care in England.

Surgical reconstruction (SR) to treat severe pressure ulcers (SPU) in the UK: a mixed-methods analysis of surveys of healthcare professionals.

Comorbidities as treatable traits of chronic airway diseases.

The aim of this study was to describe the baseline characteristics of patients with a meniscal tear and explore associations with 12-month outcomes. This prospective, national multicentre cohort study recruited patients aged 18 to 55 years presenting to secondary care with MRI-confirmed meniscal tears. All tear types and mechanisms of injury were included. Osteoarthritis severity was assessed using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Outcomes at 12 months were measured using the Western Ontario Meniscal Evaluation Tool (WOMET) and the Knee Injury and Osteoarthritis Outcome Score (KOOS4). Multivariable regression analysis assessed associations between 17 baseline factors (including age, tear type, mechanical symptoms, arthritis severity, and undergoing surgery) and 12-month outcomes. A total of 201 patients were recruited across eight sites, with a mean age of 43.2 years (SD 9.7). WORMS analysis indicated no or early-stage osteoarthritis. Stepwise logistic regression showed that higher baseline WOMET and KOOS4 scores, as well as undergoing surgery, were significantly associated with improved 12-month outcomes (p < 0.001). Surgery led to a mean 18-point improvement in both WOMET and KOOS4 scores (out of 100). Mechanical symptoms were not significantly associated with outcomes (p > 0.05). Post hoc analysis revealed that patients who underwent surgery were significantly younger (p = 0.011), with no other baseline differences between groups. In patients with MRI-confirmed meniscal tears, surgical intervention and higher baseline outcome scores were associated with significantly better 12-month patient-reported outcomes. Mechanical symptoms did not predict outcome, suggesting that they should not be exclusively used to guide treatment decisions. Further exploration of these findings is required through randomized trials using similar inclusion criteria to this study.

Reported penicillin allergy in Israel: Clinical outcomes and antibiotic costs in a nationwide population-based cohort study.

BackgroundN-terminal pro-B-type natriuretic peptides (NT-proBNP) are important in the assessment of suspected heart failure (HF). However, NT-proBNP concentrations are elevated in atrial fibrillation (AF), creating diagnostic uncertainty. The aim of this study was to assess the diagnostic accuracy of NT-proBNP for HF in people with AF, overall and by age, sex and BMI.Methods and findingsRetrospective study of all patients with a NT-proBNP test in their primary care electronic health record among English GP practices provided through the Clinical Practice Research Datalink (2004–2018) and linked to secondary care data. The accuracy of NT-proBNP for diagnosing HF within six months was assessed for people with and without AF at thresholds of 125, 400, 660 and 2,000 pg/mL, including by age, sex and BMI. Among 155,347 people who had an NT-proBNP test organized in primary care (median age 61 years), 17,403 (11.2%) had pre-existing AF. Of the 155,347 people included, 14,585 (9.4%) were subsequently diagnosed with HF, including 4,168/17,403 (23.9%) people with AF (median NT-proBNP = 1,852 pg/mL, interquartile range (IQR) [974, 3,459] pg/mL) and 10,417/137,944 (7.6%) without AF (1,110 pg/mL, IQR [434, 3,108] pg/mL). NT-proBNP discriminated better overall among people without AF (AUC = 0.877 (95% confidence interval (CI) [0.873, 0.881]) than with AF (AUC = 0.743 (95% CI [0.735, 0.751]). Among people with AF, NT-proBNP sensitivity and specificity at a 125 pg/mL threshold was 98.8% (95% CI [98.5%, 99.1]) and 13.2% (95% CI [12.6%, 13.7]) and at 400 pg/mL 93.2% (95% CI [92.4, 93.9]) and 35.5% (95% CI [34.7, 36.3]). Among people without AF the corresponding results were 92.9% (95% CI [92.4, 93.4]) and 53.8% (95% CI [53.6, 54.1]) at 125 pg/mL and 77.1% (95% CI [76.3, 77.9]) and 84.9% (95% CI [84.7, 85.1]) at 400 pg/mL. NT-proBNP discriminated less well among people with AF aged ≥65 years compared to <65years (e.g., AUC in people aged 65–75 years was 0.725, 95% CI [0.712, 0.739]). Increasing the threshold for a positive test among people with AF from 125 pg/mL to 660 pg/mL would reduce the number of false positive results by 26.0%, whilst retaining a negative predictive value of 91.5 (95% CI [90.8, 92.1]), albeit with a 10.6% increase in the proportion of those tested with AF having a missed or delayed HF diagnosis. The main limitation of the study is that it relies on routinely collected primary care data and people with an NT-proBNP result <400 pg/mL may not have been referred for further assessment, impacting upon the diagnostic accuracy below this threshold.ConclusionsNT-proBNP discriminates more accurately for HF among people without AF than with AF. A higher referral threshold could be considered in AF to account for higher median NT-proBNP levels but this would also increase missed HF diagnoses.

IntroductionAcute appendicitis is a common cause of acute abdomen in secondary care. Despite advancements in diagnostics, misdiagnosis and negative appendectomies remain significant. Artificial Intelligence (AI), particularly machine learning (ML) and deep learning, shows promise in improving diagnostic accuracy.Materials and MethodsA literature review using PubMed and Cochrane databases included studies on AI's role in diagnosing and prognosing appendicitis. Studies relying solely on clinical or radiology reports were excluded.ResultsAI models, particularly random forest (RF), logistic regression (LR), and neural networks (NN), demonstrated high diagnostic accuracy, with RF outperforming others. Machine learning methods like SVM and XGBoost (XGB) were effective in predicting appendicitis prognosis, especially in distinguishing complicated cases. AI models outperformed traditional diagnostic scores, such as the Alvarado score.ConclusionAI has significant potential to enhance the diagnosis and prognosis of acute appendicitis, but challenges in data requirements and standardisation must be addressed for widespread clinical use.

Background: We report a case of Peri-Partum Cardiomyopathy in a 28-year-old Primigravida, who came in labor and underwent a Caesarean Section in view of meconium-stained liquor, fetal distress. On day 4 post-partum, she complained of a sudden onset of shortness of breath, cough, and restlessness in the morning. The patient had no prior history of heart disease or respiratory disease. Patient developed sudden onset tachypnoea and tachycardia with bilateral crepitus. On further evaluation, she was diagnosed with Peripartum Cardiomyopathy. Results: The case was successfully managed by a multi-disciplinary team using dobutamine, diuretics, and Angiotensin receptor blockers. Conclusion: The case report aims to present a case of Peripartum cardiomyopathy with early diagnosis and successful management in a secondary care level hospital. Peripartum (postpartum) cardiomyopathy is the most common cardiomyopathy in pregnancy, defined as an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction toward the end of pregnancy or after delivery, in the absence of any other cause of heart failure. It is a diagnosis of exclusion, and the majority are diagnosed postpartum. Although the LV may not be dilated, the ejection fraction is nearly always reduced below 45%. Incidence of PPCM is 1:3000 to 1:15000 pregnancies. It is a major cause of morbidity and mortality if diagnosis gets delayed; therefore, early diagnosis and timely management can affect patients’ long-term prognosis. This case report aims to raise awareness in health professionals about the possibilities of PPCM and its symptoms, as in our case.

The current study was performed to determine the human resources (HR) and infrastructure available for providing ophthalmic services from the existing secondary and tertiary level hospitals in India and to assess the achievement of targets related to HR and infrastructure as per Vision 2020 norms. It was a multi-institutional online survey in which 7901 institutions participated. The inclusion criteria were eyecare institutes that had at least one ophthalmologist (either full-time or part-time) on roll. Hence, vision centers manned by PMOAs were excluded. The institutional data was collected from one ophthalmologist or HR manager from each institute, either telephonically or via Monkey Survey© online. The questionnaire comprised of three sections: general information about HR, speciality ophthalmology services, and pediatric ophthalmology services. A second phase of data collection involved online meetings with SPOs/DPMs to improve the response rate. The primary outcomes were various indicators like the ophthalmologist and optometrist population ratio, eye-bed population ratio, etc. The response rate was 89.9% (7901/8790). The number of ophthalmologists and optometrists in the entire country at secondary/tertiary level was 20,944, and 17,849, respectively (ratio: 0.85). On average, there were 15 ophthalmologists and 74 eye beds per million population. On average, there were three ophthalmologists and two optometrists per eye institute at secondary level eye care and above. There is wide variation and uneven distribution of HR for eye care in the country. The number of ophthalmologists and optometrists in the country needs to be increased to provide the necessary services for universal eye health coverage.

Introduction Cellulitis is a common bacterial skin infection causing significant pain, swelling and impact on daily activities, frequently leading to emergency department presentations and hospital admissions. While antibiotics are the mainstay of treatment, they do not directly address inflammation, often resulting in persisting or worsening symptoms in the initial days. Corticosteroids, with their potent anti-inflammatory effects, have shown benefit in other acute infections but are not currently standard care for patients with cellulitis. This trial aims to determine if adjunctive oral dexamethasone can reduce pain and improve outcomes in adults with cellulitis presenting to UK urgent secondary care settings.Methods and analysisThis is a pragmatic, multicentre, double-blind, placebo-controlled, randomised, parallel group, phase 3 superiority trial, with an internal pilot and parallel health economic evaluation. Adult patients (≥16 years) with a clinical diagnosis of cellulitis (at any body site except the orbit) presenting to urgent secondary care will be screened for eligibility. 450 participants will be randomised (1:1) to receive either two 8 mg doses of oral dexamethasone or matched placebo, administered approximately 24 hours apart, in addition to standard antibiotic therapy. The primary outcome is total pain experienced over the first 3 days postrandomisation, calculated using the standardised area under the curve from pain scores (Numerical Rating Scale 0–10) across up to seven timepoints. Secondary outcomes include health-related quality of life (EuroQol 5 Dimension 5 Level), patient global impression of improvement, analgesia and antibiotic usage, hospital (re)admissions, complications, unscheduled healthcare use, cellulitis recurrence and cost-effectiveness at 90 days. The primary estimand will apply a treatment policy approach to intercurrent events.Ethics and disseminationThe trial has received ethical approval from South Central—Oxford B Research Ethics Committee (reference: 24/SC/0289) and will be conducted in compliance with Good Clinical Practice and applicable regulations. Informed consent will be obtained from all participants. A model consent form can be seen in online supplemental file S1. Findings will be disseminated through peer-reviewed publications and conference presentations, and to patient groups and relevant clinical guideline committees.Trial registration numberISRCTN76873478.

To assess the prevalence of comorbidities, treatment regimens, and employment status before, during, and after getting diagnosed with Ménière disease. Ménière's disease is an inner ear disorder characterized by recurrent episodes of vertigo, hearing loss, tinnitus or aural fullness. Previous studies have reported an overlap between Ménière's disease and various comorbid conditions. Moreover, the unpredictable nature of vertigo attacks may substantially affect some patients' ability to maintain employment. This register-study utilized multiple Danish national health registers. Newly diagnosed patients with Ménière disease were identified in the Danish National Patient Register using ICD10 code H810 and matched 1:4 with controls based on sex, age, municipality, grouped index year, and civil status. The main outcome measures included health care utilization in primary care and secondary care, differences in comorbidities, and differences in employment status in relation to the diagnosis of Ménière disease. Commonly used treatments for Ménière disease were also visualized. A total of 7106 patients with Ménière disease were identified, 54% females. The mean age at diagnosis was 60 years. Patients had more health care visits to general practitioners, ENT specialists, and psychologists than controls. Conditional logistic regression analyses showed statistically significant higher odds of migraine, depression, anxiety, and receiving sickness benefits or disability pension for Ménière disease. Patients with Ménière disease exhibit significantly higher odds of migraine, depression, and anxiety compared with a control group. Patients with Ménière disease have significantly higher odds of being on sickness benefits or disability pensions relative to a control group. These findings underscore the importance of a multidisciplinary approach in the management of patients with Ménière disease.

BackgroundThe emergency department (ED) plays a vital role in providing life-saving services in hospitals worldwide. In Jeddah province, Saudi Arabia, the Ministry of Health introduced the “Door to Disposition” key performance indicator (KPI) to enhance ED service quality by addressing overcrowding, limited bed capacity, delays in patient transfer, and complex logistical inefficiencies. However, little is known about how this initiative has affected the quality of ED care from the perspectives of patients and healthcare professionals.AimTo evaluate the quality of health services in the ED from the patients’ and health professional’s perspectives.MethodsA qualitative design was employed using purposive sampling. Semi-structured interviews were conducted with 32 patients and 24 health professionals across 11 public hospitals (three rural and eight urban) in Jeddah between November 2023 and January 2024. Interviews were conducted face-to-face or by phone in Arabic or English, recorded with consent, and analyzed thematically.FindingsParticipants highlighted the importance of the “Door to Disposition” initiative and its valuable implementation. On the other hand, the primary reported barriers to emergency quality care provision are the absence of an effective triage system, shortage of medical practitioners, long waiting times, lack of dedicated urgent care centers, and lack of resources and logistical support. Thus, participants suggested improving emergency department services by focusing on primary and secondary care centers in terms of essential services and supplies, increasing the physical and human capacity of hospitals, establishing affiliated urgent care centers, providing effective and efficient means of communication between primary and secondary care centers, and finally, continually developing the healthcare providers capabilities.ConclusionThe study helped to identify the barriers and facilitators encountered by patients and health professionals when accessing and utilizing emergency care in Jeddah.

Objective This study aimed to investigate the potential impact of replacing alteplase with a single-bolus fibrinolytic agent, such as tenecteplase, on patient care, secondary care management and resource utilization, from the perspective of healthcare professionals practicing within Acute and Comprehensive Stroke Centers across the UK. Methods Semi-structured interviews were conducted to gather insights from UK-based healthcare professionals (HCPs) with experience in the administration of thrombolytic treatment or the care of acute ischemic stroke patients within the six months prior to the study initiation. Participants shared their perspective on the potential impact of transitioning to a theoretical single bolus fibrinolytic agent. Results Six HCPs participated in the study. All agreed that the introduction of a single-bolus thrombolytic agent could save significant stroke specialist nurse time. Participants also noted potential resource use savings, stemming from reduced use of consumables and equipment. Additionally, participants believed that the new agent was likely to improve clinical outcomes and patient wellbeing. Conclusion The introduction of a single-bolus thrombolytic agent to treat acute ischemic stroke could lead to significant system efficiencies in the UK. These findings are expected to be broadly generalizable to other settings and merit global consideration.

To achieve progression criteria for a definitive phase three randomised controlled trial (RCT). Prospective phase two multicentre parallel-group RCT. Participants recruited from secondary care respiratory clinics in two health boards in Scotland, United Kingdom. 110 adults with moderate-severe COPD and co-morbidities. Tailored Intervention for COPD and Co-morbidities by Pharmacists and Consultant Physicians (TICC-PCP): home visits (for a year) by generalist prescribing pharmacists collaborating with consultant respiratory physicians. Pharmacists assessed, prescribed, de-prescribed, and referred participants to health and social care services as appropriate, in addition to Usual Care (UC). Recruit ≥100 participants; deliver TICC-PCP to ≥70% intervention-arm participants; collect ≥90% in-person data; retain ≥80% participants until 21-months. Secondary outcomes include clinical and health service utilisation. Recruitment, data collection, retention and participant retention targets were achieved over 21 months. TICC-PCP delivery: the median number of contacts, nine per participant in one year, matched the a-priori target although fewer than expected (13 (27%)) received the planned schedule of contacts (monthly for six months then every other month for six months). Secondary outcomes included increased prescribing of bone strengthening medicines, de-prescribing of medicines associated with increasing falls risk; delayed time to emergency health care contacts, fewer exacerbations; improved health related quality of life and longer duration of hospitalisation. A definitive phase three RCT of TICC-PCP may improve outcomes for people with moderate-severe COPD and co-morbidities. Trial registration: The trial is registered with the UK Clinical Trials Registry (10.1186/ISRCTN43508703). Registration date: 3/1/2020.

We aimed to estimate how rheumatology outpatient hospital attendances have changed since the COVID-19 pandemic and determine demographic characteristics associated with observed changes. Using three primary and secondary care electronic health record datasets in England (with the approval of NHS England), Scotland, and Wales, we identified people with a diagnosis of rheumatoid arthritis (RA) before 01/04/2019. We determined the proportion of people with rheumatology hospital outpatient appointments each month (April 2019-December 2022 (Wales and Scotland), November 2023 (England)) and quantified changes using interrupted time-series analysis. We used logistic regression to determine characteristics associated with having fewer appointments compared with 2019. We identified 145 065, 3,813 and 13 637 people coded with RA in England, Scotland, and Wales, respectively. At the start of the COVID-19 pandemic the number of rheumatology outpatient appointments dropped sharply across all nations. In England and Scotland, the percentage of monthly appointments has continued to decline. In Wales, while there was a gradual recovery, rheumatology services have not returned to pre-pandemic levels. In contrast, the number of appointments for other specialties has recovered in all nations. People with no rheumatology outpatient appointments were more often aged over 80, male, and living in rural areas. Ethnic minorities, those living in more deprived, and urban areas had fewer appointments after the start of the pandemic compared with 2019. For the first time, we compared healthcare use across three UK nations and found rheumatology outpatient appointments had not recovered to pre-COVID-19 pandemic levels, particularly in Scotland and England.

Study DesignOnline questionnaire following the CHERRIES framework.ObjectivesDegenerative cervical myelopathy (DCM) is a heterogenous condition with a broad clinical presentation profile. Understanding the adoption of clinical signs and symptoms for both diagnostic and surgical decision-making could inform the development of standardised diagnostic criteria for DCM. Therefore, we sought to survey orthopaedic spine surgeons and neurosurgeons in secondary care across Australasia (New Zealand and Australia).MethodsAn online 19-item questionnaire was distributed to orthopaedic spine surgeons and neurosurgeons across Australasia. It examined factors influencing diagnostic and surgical decision-making, including responses to clinical vignettes. Post-stratification weighting was applied and an exploratory post-hoc pattern analysis was performed.ResultsSeventy-two completed responses were analysed. For diagnosis, gait clumsiness (86.1%), hand clumsiness (76.4%) and reduced hand dexterity (75.0%) were the most frequently selected symptoms, and hyperreflexia (83.3%) and ankle clonus sign (68.1%) were the most commonly selected clinical signs. Symptom severity, myelomalacia, and extent of cord compression were ranked as the top 3 variables influencing surgical decision-making for over 70% of surgeons. In clinical vignettes, most (72.2%) chose serial observation for asymptomatic cord compression; however, accompanying myelomalacia was found to increase the chance of offering surgery from 5.6% to 34.7%.ConclusionsAlthough several signs and symptoms were commonly used to diagnose DCM, a broad range of features were employed, reflecting substantial variability amongst Australasian surgeons. Surgical decision-making also varied, particularly for asymptomatic cord compression with myelomalacia. These findings reinforce the need for standardized diagnostic criteria and referral pathways.