Body mass index and survival in people with heart failure.

AIMS: In people with heart failure (HF), a high body mass index (BMI) has been linked with better outcomes ('obesity paradox'), but there is limited evidence in community populations across long-term follow-up. We aimed to examine the association between BMI and long-term survival in patients with HF in a large primary care cohort. METHODS: We included patients with incident HF aged ≥45 years from the Clinical Practice Research Datalink (2000-2017). We used Kaplan-Meier curves, Cox regression and penalised spline methods to assess the association of pre-diagnostic BMI, based on WHO classification, with all-cause mortality. RESULTS: There were 47 531 participants with HF (median age 78.0 years (IQR 70-84), 45.8% female, 79.0% white ethnicity, median BMI 27.1 (IQR 23.9-31.0)) and 25 013 (52.6%) died during follow-up. Compared with healthy weight, people with overweight (HR 0.78, 95% CI 0.75 to 0.81, risk difference (RD) -4.1%), obesity class I (HR 0.76, 95% CI 0.73 to 0.80, RD -4.5%) and class II (HR 0.76, 95% CI 0.71 to 0.81, RD -4.5%) were at decreased risk of death, whereas people with underweight were at increased risk (HR 1.59, 95% CI 1.45 to 1.75, RD 11.2%). In those underweight, this risk was greater among men than women (p value for interaction=0.02). Class III obesity was associated with increased risk of all-cause mortality compared with overweight (HR 1.23, 95% CI 1.17 to 1.29). CONCLUSION: The U-shaped relationship between BMI and long-term all-cause mortality suggests a personalised approach to identifying optimal weight may be needed for patients with HF in primary care. Underweight people have the poorest prognosis and should be recognised as high-risk.

Diagnostic accuracy of natriuretic peptide screening for left ventricular systolic dysfunction in the community: systematic review and meta-analysis.

AIMS: Heart failure (HF) is a global health burden and new strategies to achieve timely diagnosis and early intervention are urgently needed. Natriuretic peptide (NP) testing can be used to screen for left ventricular systolic dysfunction (LVSD), but evidence on test performance is mixed, and international HF guidelines differ in their recommendations. Our aim was to summarize the evidence on diagnostic accuracy of NP screening for LVSD in general and high-risk community populations and estimate optimal screening thresholds. METHODS: We searched relevant databases up to August 2020 for studies with a screened community population of over 100 adults reporting NP performance to diagnose LVSD. Study inclusion, quality assessment, and data extraction were conducted independently and in duplicate. Diagnostic test meta-analysis used hierarchical summary receiver operating characteristic curves to obtain estimates of pooled accuracy to detect LVSD, with optimal thresholds obtained to maximize the sum of sensitivity and specificity. RESULTS: Twenty-four studies were identified, involving 26 565 participants: eight studies in high-risk populations (at least one cardiovascular risk factor), 12 studies in general populations, and four in both high-risk and general populations combined. For detecting LVSD in screened high-risk populations with N-terminal prohormone brain natriuretic peptide (NT-proBNP), the pooled sensitivity was 0.87 [95% confidence interval (CI) 0.73-0.94] and specificity 0.84 (95% CI 0.55-0.96); for BNP, sensitivity was 0.75 (95% CI 0.65-0.83) and specificity 0.78 (95% CI 0.72-0.84). Heterogeneity between studies was high with variations in positivity threshold. Due to a paucity of high-risk studies that assessed NP performance at multiple thresholds, it was not possible to calculate optimal thresholds for LVSD screening in high-risk populations alone. To provide an indication of where the positivity threshold might lie, the pooled accuracy for LVSD screening in high-risk and general community populations were combined and gave an optimal cut-off of 311 pg/mL [sensitivity 0.74 (95% CI 0.53-0.88), specificity 0.85 (95% CI 0.68-0.93)] for NT-proBNP and 49 pg/mL [sensitivity 0.68 (95% CI 0.45-0.85), specificity 0.81 (0.67-0.90)] for BNP. CONCLUSIONS: Our findings suggest that in high-risk community populations NP screening may accurately detect LVSD, potentially providing an important opportunity for diagnosis and early intervention. Our study highlights an urgent need for further prospective studies, as well as an individual participant data meta-analysis, to more precisely evaluate diagnostic accuracy and identify optimal screening thresholds in specifically defined community-based populations to inform future guideline recommendations.

Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study.

BACKGROUND: Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis. AIM: To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds. DESIGN AND SETTING: Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018). METHOD: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed. RESULTS: In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8). CONCLUSION: At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

Natriuretic peptide level at heart failure diagnosis and risk of hospitalisation and death in England 2004-2018.

OBJECTIVE: Heart failure (HF) is a malignant condition requiring urgent treatment. Guidelines recommend natriuretic peptide (NP) testing in primary care to prioritise referral for specialist diagnostic assessment. We aimed to assess association of baseline NP with hospitalisation and mortality in people with newly diagnosed HF. METHODS: Population-based cohort study of 40 007 patients in the Clinical Practice Research Datalink in England with a new HF diagnosis (48% men, mean age 78.5 years). We used linked primary and secondary care data between 1 January 2004 and 31 December 2018 to report one-year hospitalisation and 1-year, 5-year and 10-year mortality by NP level. RESULTS: 22 085 (55%) participants were hospitalised in the year following diagnosis. Adjusted odds of HF-related hospitalisation in those with a high NP (NT-proBNP >2000 pg/mL) were twofold greater (OR 2.26 95% CI 1.98 to 2.59) than a moderate NP (NT-proBNP 400-2000 pg/mL). All-cause mortality rates in the high NP group were 27%, 62% and 82% at 1, 5 and 10 years, compared with 19%, 50% and 77%, respectively, in the moderate NP group and, in a competing risks model, risk of HF-related death was 50% higher at each timepoint. Median time between NP test and HF diagnosis was 101 days (IQR 19-581). CONCLUSIONS: High baseline NP is associated with increased HF-related hospitalisation and poor survival. While healthcare systems remain under pressure from the impact of COVID-19, research to test novel strategies to prevent hospitalisation and improve outcomes-such as a mandatory two-week HF diagnosis pathway-is urgently needed.

Long term trends in natriuretic peptide testing for heart failure in UK primary care: a cohort study.

AIMS: Heart failure (HF) is a malignant condition with poor outcomes and is often diagnosed on emergency hospital admission. Natriuretic peptide (NP) testing in primary care is recommended in international guidelines to facilitate timely diagnosis. We aimed to report contemporary trends in NP testing and subsequent HF diagnosis rates over time. METHODS AND RESULTS: Cohort study using linked primary and secondary care data of adult (≥45 years) patients in England 2004-18 (n = 7 212 013, 48% male) to report trends in NP testing (over time, by age, sex, ethnicity, and socioeconomic status) and HF diagnosis rates. NP test rates increased from 0.25 per 1000 person-years [95% confidence interval (CI) 0.23-0.26] in 2004 to 16.88 per 1000 person-years (95% CI 16.73-17.03) in 2018, with a significant upward trend in 2010 following publication of national HF guidance. Women and different ethnic groups had similar test rates, and there was more NP testing in older and more socially deprived groups as expected. The HF detection rate was constant over the study period (around 10%) and the proportion of patients without NP testing prior to diagnosis remained high [99.6% (n = 13 484) in 2004 vs. 76.7% (n = 12 978) in 2017]. CONCLUSION: NP testing in primary care has increased over time, with no evidence of significant inequalities, but most patients with HF still do not have an NP test recorded prior to diagnosis. More NP testing in primary care may be needed to prevent hospitalization and facilitate HF diagnosis at an earlier, more treatable stage.

Risks of and From SARS-CoV-2 Infection and COVID-19 in People With Diabetes: A Systematic Review of Reviews.

BACKGROUND: This review was commissioned by the World Health Organization and presents a summary of the latest research evidence on the impact of coronavirus disease 2019 (COVID-19) on people with diabetes (PWD). PURPOSE: To review the evidence regarding the extent to which PWD are at increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and/or of suffering its complications, including associated mortality. DATA SOURCES: We searched the Cochrane COVID-19 Study Register, Embase, MEDLINE, and LitCOVID on 3 December 2020. STUDY SELECTION: Systematic reviews synthesizing data on PWD exposed to SARS-CoV-2 infection, reporting data on confirmed SARS-CoV-2 infection, admission to hospital and/or to intensive care unit (ICU) with COVID-19, and death with COVID-19 were used. DATA EXTRACTION: One reviewer appraised and extracted data; data were checked by a second. DATA SYNTHESIS: Data from 112 systematic reviews were narratively synthesized and displayed using effect direction plots. Reviews provided consistent evidence that diabetes is a risk factor for severe disease and death from COVID-19. Fewer data were available on ICU admission, but where available, these data also signaled increased risk. Within PWD, higher blood glucose levels both prior to and during COVID-19 illness were associated with worse COVID-19 outcomes. Type 1 diabetes was associated with worse outcomes than type 2 diabetes. There were no appropriate data for discerning whether diabetes was a risk factor for acquiring SARS-CoV-2 infection. LIMITATIONS: Due to the nature of the review questions, the majority of data contributing to included reviews come from retrospective observational studies. Reviews varied in the extent to which they assessed risk of bias. CONCLUSIONS: There are no data on whether diabetes predisposes to infection with SARS-CoV-2. Data consistently show that diabetes increases risk of severe COVID-19. As both diabetes and worse COVID-19 outcomes are associated with socioeconomic disadvantage, their intersection warrants particular attention.

Email Consultations Between Patients and Doctors in Primary Care: Content Analysis.

BACKGROUND: Increasingly, consultations in health care settings are conducted remotely using a range of communication technologies. Email allows for 2-way text-based communication, occurring asynchronously. Studies have explored the content and nature of email consultations to understand the use, structure, and function of email consultations. Most previous content analyses of email consultations in primary care settings have been conducted in North America, and these have shown that concerns and assumptions about how email consultations work have not been realized. There has not been a UK-based content analysis of email consultations. OBJECTIVE: This study aims to explore and delineate the content of consultations conducted via email in English general practice by conducting a content analysis of email consultations between general practitioners (GPs) and patients. METHODS: We conducted a content analysis of anonymized email consultations between GPs and patients in 2 general practices in the United Kingdom. We examined the descriptive elements of the correspondence to ascertain when the emails were sent, the number of emails in an email consultation, and the nature of the content. We used a normative approach to analyze the content of the email consultations to explore the use and function of email consultation. RESULTS: We obtained 100 email consultations from 85 patients, which totaled 262 individual emails. Most email users were older than 40 years, and over half of the users were male. The email consultations were mostly short and completed in a few days. Emails were mostly sent and received during the day. The emails were mostly clinical in content rather than administrative and covered a wide range of clinical presentations. There were 3 key themes to the use and function of the email consultations: the role of the GP and email consultation, the transactional nature of an email consultation, and the operationalization of an email consultation. CONCLUSIONS: Most cases where emails are used to have a consultation with a patient in general practice have a shorter consultation, are clinical in nature, and are resolved quickly. GPs approach email consultations using key elements similar to that of the face-to-face consultation; however, using email consultations has the potential to alter the role of the GP, leading them to engage in more administrative tasks than usual. Email consultations were not a replacement for face-to-face consultations.

In-vitro diagnostic point-of-care tests in paediatric ambulatory care: A systematic review and meta-analysis.

INTRODUCTION: Paediatric consultations form a significant proportion of all consultations in ambulatory care. Point-of-care tests (POCTs) may offer a potential solution to improve clinical outcomes for children by reducing diagnostic uncertainty in acute illness, and streamlining management of chronic diseases. However, their clinical impact in paediatric ambulatory care is unknown. We aimed to describe the clinical impact of all in-vitro diagnostic POCTs on patient outcomes and healthcare processes in paediatric ambulatory care. METHODS: We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science from inception to 29 January 2020 without language restrictions. We included studies of children presenting to ambulatory care settings (general practice, hospital outpatient clinics, or emergency departments, walk-in centres, registered drug shops delivering healthcare) where in-vitro diagnostic POCTs were compared to usual care. We included all quantitative clinical outcome data across all conditions or infection syndromes reporting on the impact of POCTs on clinical care and healthcare processes. Where feasible, we calculated risk ratios (RR) with 95% confidence intervals (CI) by performing meta-analysis using random effects models. RESULTS: We included 35 studies. Data relating to at least one outcome were available for 89,439 children of whom 45,283 had a POCT across six conditions or infection syndromes: malaria (n = 14); non-specific acute fever 'illness' (n = 7); sore throat (n = 5); acute respiratory tract infections (n = 5); HIV (n = 3); and diabetes (n = 1). Outcomes centred around decision-making such as prescription of medications or hospital referral. Pooled estimates showed that malarial-POCTs (Plasmodium falciparum) better targeted antimalarial treatment by reducing over-treatment by a third compared to usual care (RR 0.67; 95% CI [0.58 to 0.77], n = 36,949). HIV-POCTs improved initiating earlier antiretroviral therapy compared to usual care (RR, 3.11; 95% CI [1.55 to 6.25], n = 912). Across the other four conditions, there was limited evidence for the benefit of POCTs in paediatric ambulatory care except for acute respiratory tract infections (RTI) in low-and-middle-income countries (LMICs), where POCT C-Reactive Protein (CRP) may reduce immediate antibiotic prescribing by a third (risk difference, -0.29 [-0.47, -0.11], n = 2,747). This difference was shown in randomised controlled trials in LMICs which included guidance on interpretation of POCT-CRP, specific training or employed a diagnostic algorithm prior to POC testing. CONCLUSION: Overall, there is a paucity of evidence for the use of POCTs in paediatric ambulatory care. POCTs help to target prescribing for children with malaria and HIV. There is emerging evidence that POCT-CRP may better target antibiotic prescribing for children with acute RTIs in LMIC, but not in high-income countries. Research is urgently needed to understand where POCTs are likely to improve clinical outcomes in paediatric settings worldwide.

Diabetes and COVID-19: Risks, Management, and Learnings From Other National Disasters.

Evidence relating to the impact of COVID-19 in people with diabetes (PWD) is limited but continuing to emerge. PWD appear to be at increased risk of more severe COVID-19 infection, though evidence quantifying the risk is highly uncertain. The extent to which clinical and demographic factors moderate this relationship is unclear, though signals are emerging that link higher BMI and higher HbA1c to worse outcomes in PWD with COVID-19. As well as posing direct immediate risks to PWD, COVID-19 also risks contributing to worse diabetes outcomes due to disruptions caused by the pandemic, including stress and changes to routine care, diet, and physical activity. Countries have used various strategies to support PWD during this pandemic. There is a high potential for COVID-19 to exacerbate existing health disparities, and research and practice guidelines need to take this into account. Evidence on the management of long-term conditions during national emergencies suggests various ways to mitigate the risks presented by these events.

Impact of point-of-care panel tests in ambulatory care: a systematic review and meta-analysis.

OBJECTIVES: This article summarises all the available evidence on the impact of introducing blood-based point-of-care panel testing (POCT) in ambulatory care on patient outcomes and healthcare processes. DESIGN: Systematic review and meta-analysis of randomised-controlled trials and before-after studies. DATA SOURCES: Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, Database of Abstracts of Reviews and Effects, Science Citation Index from inception to 22 October 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included studies were based in ambulatory care and compared POCT with laboratory testing. The primary outcome was the time to decision regarding disposition that is, admission/referral termed disposition decision (DD) time. Secondary outcomes included length of stay (LOS) at the ambulatory care unit/practice and mortality. RESULTS: 19 562 patients from nine studies were included in the review, eight of these were randomised-controlled trials, and one was a before-after study. All the studies were based in either emergency departments or the ambulance service; no studies were from primary care settings. General panel tests performed at the POCT resulted in DDs being made 40 min faster (95% CI -42.2 to -36.6, I2=0%) compared with the group receiving usual care, including central laboratory testing. This in turn resulted in a reduction in LOS for patients who were subsequently discharged by 34 min (95% CI -63.7 to -5.16). No significant difference in mortality was reported. DISCUSSION: Although statistical and clinical heterogeneity is evident and only a small number of studies were included in the meta-analysis, our results suggest that POCTs might lead to faster discharge decisions. Future research should be performed in primary care and identify how POCTs can contribute meaningful changes to patient care rather than focusing on healthcare processes. PROSPERO REGISTRATION NUMBER: CRD42016035426.

The role of informal carers in the diagnostic process of heart failure: a secondary qualitative analysis.

BACKGROUND: Heart failure (HF) is a common clinical syndrome, particularly in older people, and symptoms can develop gradually. The aim of this study was to explore the role of informal carers in the HF diagnostic process. METHODS: Secondary analysis of qualitative interviews with 16 participants with a new diagnosis of HF. Original interviews were conducted in the participant's home, with carers present in some cases. Interview transcripts were re-analysed using the Framework Method for themes pertaining to informal carers and how they were involved in the diagnostic process. RESULTS: Informal carers often noticed symptoms, such as breathlessness, before participants. In some cases, carers colluded with participants in normalising symptoms but over time, when symptoms failed to resolve or got worse, they encouraged participants to seek medical help. Adult children of participants commonly initiated help-seeking behaviour. During the diagnostic process, carers coordinated participants' healthcare through advocacy and organisation. Carers were keen to be informed about the diagnosis, but both participants and carers struggled to understand some aspects of the term 'heart failure'. CONCLUSIONS: Carers play a crucial role in HF diagnosis, particularly in initiating contact with healthcare services, and should be empowered to encourage people with HF symptoms to seek medical help. Improving public awareness of HF could mean informal carers are more likely to notice symptoms. The important role of carers in supporting the patient's route to diagnosis should be incorporated into future care pathways and explored in further research.

Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis.

OBJECTIVE: The aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care. DESIGN: This was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied. DATA EXTRACTION: Data were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool. RESULTS: 11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission. CONCLUSIONS: Performing a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes. PROSPERO REGISTRATION NUMBER: CRD42016035426; Results.

The Clinical Utility of Point-of-Care Tests for Influenza in Ambulatory Care: A Systematic Review and Meta-analysis.

BACKGROUND: Point-of-care tests (POCTs) for influenza are diagnostically superior to clinical diagnosis, but their impact on patient outcomes is unclear. METHODS: A systematic review of influenza POCTs versus usual care in ambulatory care settings. Studies were identified by searching six databases and assessed using the Cochrane risk of bias tool. Estimates of risk ratios (RR), standardised mean differences, 95% confidence intervals and I2 were obtained by random effects meta-analyses. We explored heterogeneity with sensitivity analyses and meta-regression. RESULTS: 12,928 citations were screened. Seven randomized studies (n = 4,324) and six non-randomized studies (n = 4,774) were included. Most evidence came from paediatric emergency departments. Risk of bias was moderate in randomized studies and higher in non-randomized studies. In randomized trials, POCTs had no effect on admissions (RR 0.93, 95% CI 0.61-1.42, I2 = 34%), returning for care (RR 1.00 95% CI = 0.77-1.29, I2 = 7%), or antibiotic prescribing (RR 0.97, 95% CI 0.82-1.15, I2 = 70%), but increased prescribing of antivirals (RR 2.65, 95% CI 1.95-3.60; I2 = 0%). Further testing was reduced for full blood counts (FBC) (RR 0.80, 95% CI 0.69-0.92 I2 = 0%), blood cultures (RR 0.82, 95% CI 0.68-0.99; I2 = 0%) and chest radiography (RR 0.81, 95% CI 0.68-0.96; I2 = 32%), but not urinalysis (RR 0.91, 95% CI 0.78-w1.07; I2 = 20%). Time in the emergency department was not changed. Fewer non-randomized studies reported these outcomes, with some findings reversed or attenuated (fewer antibiotic prescriptions and less urinalysis in tested patients). CONCLUSIONS: Point-of-care testing for influenza influences prescribing and testing decisions, particularly for children in emergency departments. Observational evidence shows challenges for real-world implementation.

Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data.

BACKGROUND: It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained. AIM: To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions. DESIGN AND SETTING: A secondary analysis of survey data from the International Cancer Benchmarking Partnership. METHOD: The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach. RESULTS: PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility. CONCLUSION: The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

BACKGROUND: Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area. AIM: To ascertain the key learning points from GPs' experiences of diagnostic errors and approaches to clinical decision making associated with these. DESIGN AND SETTING: Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK. METHOD: Two datasets of semi-structured interviews were combined. Questions focused on GPs' experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. RESULTS: Learning points include GPs' reliance on 'pattern recognition' and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a 'restricted rule out' approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed. CONCLUSION: Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors.

Email for clinical communication between healthcare professionals.

BACKGROUND: Email is one of the most widely used methods of communication, but its use in healthcare is still uncommon. Where email communication has been utilised in health care, its purposes have included clinical communication between healthcare professionals, but the effects of using email in this way are not well known. We updated a 2012 review of the use of email for two-way clinical communication between healthcare professionals. OBJECTIVES: To assess the effects of email for clinical communication between healthcare professionals on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information. SEARCH METHODS: We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9 2013), MEDLINE (OvidSP) (1946 to August 2013), EMBASE (OvidSP) (1974 to August 2013), PsycINFO (1967 to August 2013), CINAHL (EbscoHOST) (1982 to August 2013), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched November 2013). We used additional search methods: examining reference lists and contacting authors. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised trials, controlled before and after studies, and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information in the form of: 1) unsecured email, 2) secure email, or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information and have reported all measures as per the study report. MAIN RESULTS: The previous version of this review included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment versus usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement or osteoporosis medication, or both) when compared with usual care. The evidence for its impact on patient behaviours or actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively (patients had a higher calcium intake), and two found no difference between the two groups. The study did not assess health service outcomes or harms.No new studies were identified for this update. AUTHORS' CONCLUSIONS: Only one study was identified for inclusion, providing insufficient evidence for guiding clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research should aim to utilise high-quality study designs that use the most recent developments in information technology, with consideration of the complexity of email as an intervention.