Changing Knowledge and Attitudes towards Bariatric Surgery in Primary Care: a 10-Year Cross-Sectional Survey.

BACKGROUND: Some 28% of the Scottish population suffer from obesity. Bariatric procedures per population carried out in England when compared to Scotland (NBSR 2018) are significantly higher. Primary care practitioners (PCP) influence equality of access to secondary care bariatrics and frequently manage post-operative bariatric patients. Examining changes in PCP knowledge and attitude could improve access to bariatric procedures in Scotland. METHODS: Following a sample pilot, all PCPs within three Scottish NHS health boards were emailed a questionnaire-based survey (2011; n = 902). A subsequent 10-year follow-up encompassed a greater scope of practice, additionally distributed to all PCPs in five further health boards (2021; n = 2049). RESULTS: Some 452 responses were achieved (2011, 230; 2021, 222). PCPs felt bariatric surgery offered a greater impact in both weight management and that of obesity-related diseases (p < .0001). More PCPs were aware of local bariatric surgical referral criteria (2011, 43%; 2021, 57% (p = .003)), and more made referrals (2011, 60%; 2021, 72% (p = .018)) but were less familiar with national bariatric surgical guidelines (2011, 70%; 2021, 48% (p < .001)). Comfort at managing post-operative bariatric surgical patients were unchanged (2011, 24%; 2021, 27% (p = .660)). Minimal progress through dietetic-lead weight management services, plus rejection of patients thought to be good candidates, was reasons for referral hesitancy. CONCLUSION: Over 10 years, PCPs were more aware of local referral criteria, making increased numbers of referrals. Knowledge deficits of national guidelines remain, and overwhelmingly PCPs do not feel comfortable looking after post-operative bariatric surgical patients. Further research into PCP educational needs, in addition to improving the primary to secondary care interface, is required.

Removing hospital-based triage from suspected colorectal cancer pathways: the impact and learning from a primary care-led electronic straight-to-test pathway.

BACKGROUND: The 2-week wait referral pathway for suspected colorectal cancer was introduced in England to improve time from referral from a general practitioner (GP) to diagnosis and treatment. Patients are required to be seen by a hospital clinician within 2 weeks if their symptoms meet the criteria set by the National Institute for Health and Care Excellence (NICE) and to start cancer treatment within 62 days. To achieve this, many hospitals have introduced a straight-to-test (STT) strategy requiring hospital-based triage of referrals. We describe the impact and learning from a new pathway which has removed triage and moved the process of requesting tests from hospital to GPs in primary care. METHOD: An electronic STT pathway was introduced allowing GPs to book tests supported by a decision aid based on NICE guidance eliminating the need for a standard referral form or triage process. The hospital identified referrals as being on a cancer pathway and dealt with all ongoing management. Routinely collected cancer data were used to identify time to cancer diagnosis compared with national data RESULTS: 11357 patients were referred via the new pathway over 3 years. Time from referral to diagnosis reduced from 39 to 21 days and led to a dramatic improvement in patients starting treatment within 62 days. Challenges included adapting to a change in referral criteria and developing a robust hospital system to monitor the pathway. CONCLUSION: We have changed the way patients with suspected colorectal cancer are managed within the National Health Service by giving GPs the ability to order tests electronically within a monitored cancer pathway halving time from referral to diagnosis.

Patient preferences for surgical techniques: should we invest in new approaches?

BACKGROUND: The face of surgery has changed over the past two decades with the introduction of laparoscopic techniques. The majority of surgical specialties now perform minimally invasive procedures hence decreasing the scarring, pain, and infection historically associated with open surgery. To further reduce the invasiveness of surgery, new surgical techniques like Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Single-Port Surgery (SPS) are under development. Despite investment from the medical device industry and enthusiasm from medical professionals, we must analyse patient preferences and expectations of these novel techniques. This analysis will help us establish the demand for such techniques and guide future resource allocation. METHODS: A questionnaire-based study was derived to identify whether the concepts of innovative techniques are acceptable to the general population. Their preferences between different available surgical options were recorded along with their choices for new innovative techniques. This study was carried out face-to-face and by using an online survey. It comprised four questions based upon a hypothetical scenario of an acute appendicitis. All the data were captured in a prospective database and analysed using statistical software. RESULTS: A total of 750 participants from variable backgrounds took part in the study. NOTES or SPS without an established safety profile was accepted by 34.3% of patients. SPS was the most popular method followed by conventional laparoscopy. Open surgery and NOTES were the least preferred (ranked 1.78, 1.98, 2.94, and 3.27, respectively). Choosing between SPS and NOTES only, 80.6% opted for SPS, 11.8% NOTES, and 5.6% declined surgery. The most popular route of access for NOTES is oral (37.7%). CONCLUSION: Single-port surgery was the most preferred method and NOTES was the least preferred technique. This shows general acceptance of the concept of virtually scarless surgery but without using the natural orifices.

Endoscopic Electrohydraulic Lithotripsy for Large Bowel Obstruction Secondary to Colonic Gallstone Impaction.

Large bowel obstruction secondary to colonic gallstone impaction is rare. We report an elderly patient who presented with colonic obstruction secondary to impaction of a gallstone in a diverticular segment of his sigmoid colon. He had severe comorbidities that precluded surgery, and it was not possible to remove the gallstone using standard endoscopic techniques. Endoscopic electrohydraulic lithotripsy (EHL) was performed to fracture the gallstone, and fragments were successfully removed. For comorbid patients who are not fit for general anesthesia, endoscopic stone retrieval should be considered. When faced with large or impacted stones, EHL can be utilized to fracture the stone.

eAppendicitis: Diagnostic uncertainty in appendicitis and the role of ehealth - does IT help?

The availability of medical information on the World Wide Web has grown as information technology has become more accessible. Patients seeking online information may be able to selfselect conditions having been adequately informed. This study evaluates the effect of eHealth information on those presenting to hospital with a suspected appendicitis and its effect on their management and clinical outcome. Patients who had performed online reading were more likely to go to theatre but were less likely to have a confirmed histological diagnosis of appendicitis.

Cost awareness of disposable surgical equipment and strategies for improvement: cross sectional survey and literature review.

A significant healthcare funding gap has been predicted over the coming years. NHS England has made transparency and cost efficiency a key priority. Healthcare technology accounts for a large portion of healthcare expenditure. The aim of the study was to establish the cost awareness of theatre staff for disposable surgical equipment and to review the current evidence around improving cost awareness. A cross sectional survey was performed. A questionnaire was distributed to consultants, registrars, core surgical trainees and theatre scrub practitioners within an NHS foundation trust and analysed using Microsoft excel 2010. Following the results, which indicated poor cost awareness amongst theatre staff, a literature review was performed to identify strategies to improving cost awareness in healthcare. The results showed that only 22% of all participants (n = 48) were able to estimate cost correctly. There was no significant difference in cost accuracy between surgeons or scrub practitioners. Strategies for improvement in cost awareness were identified. A lack of cost awareness was identified amongst theatre healthcare professionals for common disposable surgical equipment. This is an area which must improve through the use of proven strategies such as national programs, education, visible pricing and price feedback, as highlighted in this paper.