Telephone triage of young adults with chest pain: population analysis of NHS24 calls in Scottish unscheduled care.

BACKGROUND: Telephone triage is increasingly used to manage unscheduled care demand. Younger adults are frequent users, and commonly call with chest pain. We compared pathways of care in younger adults calling with chest pain, and associations of patient characteristics and telephone triage recommendation with hospital admission. METHODS: A retrospective study of all triage calls with chest pain to NHS24 advice line by people aged 15-34 years between 1 January 2015 and 31 December 2017 where chest pain was recorded as the call reason. Recommended outcome and subsequent use of services were determined using the continuous urgent care pathways (CUPs) database which records single episodes of care spanning multiple services. We determined the number of services involved, the proportion of patients with inpatient admission, those with an admission for an 'acute-and-serious' diagnosis, and the association between the triage call recommendation and these outcomes. RESULTS: There were 102 822 CUPs identified, with 1251 different combinations of services. The most common pathway was an NHS24 call then attendance at a primary care out-of-hours (PCOOH) centre, accounting for 38 643 (37.6%) CUPs. 9060 (8.8%) CUPs ended with hospital admission, 3030 (3.0%) the result of an 'acute-and-serious' diagnosis. 8453 (8.2%) were given 'self-care' advice and not referred further, while 46.9% ended at PCOOH and 15.2% at ED. 'Asthma, unspecified' was the most frequent 'acute-and-serious' diagnosis. Compared with people given self-care advice, referral to other services had increased odds of inpatient admission (adjusted OR (aOR) for ambulance called 28.7, 95% CI 22.6 to 36.3; for 1-hour in-home general practitioner (GP) visit arranged aOR 36.8, 95% CI 23.2 to 58.5) and for admission with an 'acute-and-serious' diagnosis (aOR ambulance called 23.9, 95% CI 16.2 to 35.4; aOR 1-hour GP visit 48.3, 95% CI 25.5 to 91.6). CONCLUSION: Chest pain triage by NHS24 appears safe, but care pathways can involve multiple service contacts. While acuity assigned to the call is strongly related to the odds of hospital admission and odds of an 'acute-and-serious' diagnosis, 'overtriage' means few patients are directed to self-care advice.

The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation.

OBJECTIVES: To develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas. METHODS: Six co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients. RESULTS: Participants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients. DISCUSSION: We have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial.

Do multimorbidity and deprivation influence patients' emotional expressions and doctors' responses in primary care consultations?--An exploratory study using multilevel analysis.

OBJECTIVE: To explore whether and how patient multimorbidity and socioeconomic deprivation might influence patients' emotional expression and doctors' responses in the general practice (GP) consultations. METHODS: Video recordings of 107 consultations (eight GPs) were coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). Multilevel logistic regressions modelled the probability of GP providing space response, considering patient multimorbidity, deprivation conditions and other contextual factors. Further multinomial regressions explored the possible impact of multimorbidity and deprivation on expression of and specific responses to patients' emotional distress. RESULTS: It was less likely for GPs to provide space as the consultation proceeded, controlling for multimorbidity and deprivation variables. Patients with multimorbidity were less likely to express emotional distress in an explicit form. GPs were more likely to provide acknowledgement to emotions expressed by patients from more deprived areas. CONCLUSION: Multimorbidity and deprivation may influence the dynamics of the GP consultations in specific ways. Rigorous methodologies using larger samples are required to explore further how these two variables relate to each other and influence cue expression, provider response and subsequent patient outcomes. PRACTICE IMPLICATIONS: Understanding how multimorbidity and deprivation impact on GP consultations may help inform future service improvement programmes.

Prevention of anxiety and depression in Chinese: a randomized clinical trial testing the effectiveness of a stepped care program in primary care.

BACKGROUND: Despite empirical evidence demonstrating the effectiveness of collaborative stepped care program (SCP) in Western countries, such programs have not been evaluated in the east, which has a different services system structure and cultural nuances in seeking help for mental illness. Furthermore, only a few studies have used SCP for depression and anxiety prevention. We conducted a trial to test its effectiveness in preventing major depressive disorder and generalized anxiety disorder among primary care patients with subthreshold depression and/or anxiety in Hong Kong. METHODS: Subthreshold depression and/or anxiety patients were randomized into the SCP group (n=121) or care as usual (CAU) group (n=119). The SCP included watchful waiting, telephone counseling, problem solving therapy, and family doctor treatment within one year. The primary outcome was the onset of major depressive disorder or generalized anxiety disorder in 15 months. The secondary outcomes were depressive and anxiety symptoms, quality of life and time absent from work due to any illness. RESULTS: Survival analysis showed no differences between the SCP and CAU groups (the cumulative probability of onset at 15 month was 23.1% in the SCP group and 20.5% in the CAU group; Hazard Ratio=1.62; 95% Confidence Interval: 0.82-3.18; p=0.16). No significant differences were found in secondary outcomes. LIMITATIONS: Sample size might not have been large enough. CONCLUSIONS: SCP did not show beneficial effect on depression/anxiety prevention compared with CAU in Hong Kong primary care. As a large majority of patients improved overtime without any intervention, we are not able to exclude the possibility that the intervention might be effective. Future studies would need to have a larger sample size and conduct on patients with more severe symptoms or perform a second screening.