Intercontinental translatability of a peer-led GP education model from New Zealand to the United Kingdom: a pilot study.

BACKGROUND: Pegasus Small Group education for General Practitioners (GPs) is a professional development programme that has been delivered in Canterbury, New Zealand for over 30 years. Peer developed content is delivered in small groups supporting interactive discussions informed by evidence and locally relevant data. AIM: An international collaboration between South Tyneside Clinical Commissioning Group (CCG) in the UK and Pegasus Health in Canterbury New Zealand aimed to determine whether the Canterbury model of Small Group (SG) professional development for GPs was transferrable to the South Tyneside context. DESIGN & SETTING: This was a pilot qualitative study testing proof of concept for the Pegasus Small Group GP education model of professional development in another country. METHOD: To test the concept, three pilot sessions on Persistent Pain, Screening, and Optimising Treatment were delivered between November 2021, and March 2022. Four UK GPs were trained as SG leaders and a member of the Pegasus team liaised with various UK GPs in South Tyneside to adapt topics for the local context. The use of videoconferencing (MSTeams, Zoom) to deliver support, training, and the programme itself had been developed and refined in the pandemic so that it could be run entirely online without losing its core components or interactive nature. RESULTS: Thirty-one, 50 and 61 GPs respectively from the 68 registered GPs attended the three sessions, 90% of whom rated the overall quality as good or excellent. These results and other positive feedback from attendees provided a mandate for a further extension over the following months. CONCLUSION: The pilot proved the potential for health systems to collaborate globally despite geographical distance. A wider evaluation to assess the impact of the education initiative is needed to determine the impact on patient care and to demonstrate the benefits of supporting the small group peer education model.

Patient perceptions of barriers to attending annual diabetes review and foot assessment in general practice: a qualitative study.

Introduction Regular diabetic foot checks, at least annually, are important for early identification of risk factors and prevention of ulceration and amputation. To ensure this, most general practices in Aotearoa New Zealand (NZ) offer free annual diabetes reviews (ADRs) which include a comprehensive foot evaluation. However, attendance rates at these ADRs are low. Aim To explore patients' perspectives on the barriers to attending ADRs and foot checks. Methods Semi-structured interviews with people with type 2 diabetes who were overdue their ADR (n = 13; 7 women, 6 Maori) from two urban practices were conducted. Interviews were audio recorded and transcribed verbatim and then analysed using an inductive thematic analysis approach. Results We identified three key themes demonstrating barriers to attendance: healthcare-associated factors (suboptimal clinician-patient relationship, not having a consistent general practitioner (GP)); patient-related factors (co-morbid health conditions, issues surrounding identity, and logistical issues); and systemic factors (COVID-19 pandemic, travel distance to the practice, unawareness of available foot care services). Participants' feedback focused on patient-centred approaches for improvements to service delivery, for example using online educational materials, and utilising culturally appropriate models of health including Te Whare Tapa Wha and Whanau Ora approach. Discussion We identified several barriers to attendance, some of which are potentially modifiable. Addressing modifiable barriers and incorporating suggestions made by participants may improve access to the ADR and reduce non-attendance. Further participatory action research could explore these insights in ways that facilitate tino rangatiratanga (self-determination) and palpable action.

Developing a generic business case for an advanced chronic liver disease support service.

Introduction: Liver disease deaths are rising, but specialist palliative care services for hepatology are limited. Expansion across the NHS is required. Methods: We surveyed clinicians, patients and carers to design an 'ideal' service. Using standard NHS tariffs, we calculated the cost of this service. In hospitals where specialist palliative care was available for liver disease, patient-level costs and bed utilisation in last year of life (LYOL) were compared between those seen by specialist palliative care before death and those not. Results: The 'ideal' service was described. Costs were calculated as whole time equivalent for a minimal service, which could be scaled up. From a hospital with an existing service, patients seen by specialist palliative care had associated costs of £14 728 in LYOL, compared with £18 558 for those dying without. Savings more than balanced the costs of introducing the service. Average bed days per patient in LYOL were reduced (19.4 vs 25.7) also intensive care unit bed days (1.1 vs 1.8). Despite this, time from first admission in LYOL to death was similar in both groups (6 months for the specialist palliative care group vs 5 for those not referred). Conclusions: We have produced a template business case for an 'ideal' advanced liver disease support service, which self-funds and saves many bed days. The model can be easily adapted for local use in other trusts. We describe the methodology for calculating patient-level costs and the required service size. We present a financially compelling argument to expand a service to meet a growing need.

Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand.

AIMS: Cervical cancer remains a burden within Aotearoa New Zealand, with 2022 screening rates sitting 12.7% below target. The National Cervical Screening Programme has changed to primary human papillomavirus (HPV) testing for all screen-eligible people, with the aim for home self-testing. Little is known about the readiness of primary care for the change to self-testing and its associated challenges. A pilot HPV cervical cancer screening programme is being conducted in 17 practice centres. The aim of this study is to explore smear-taker knowledge at these centres about the use of primary HPV testing for cervical cancer screening. METHODS: This is an ethically approved questionnaire study, with data from a structured web-based questionnaire sent to all smear-takers at the pilot centres. RESULTS: We achieved a total completion rate of 57.8%. The average score for "Knowledge of HPV" was 56.5% (range=20-100%). The challenges to patient home HPV self-testing were felt to be overall "not at all" to "mildly challenging". Up to 73.3% of participants identified ongoing needs for further education. CONCLUSIONS: The findings indicate knowledge deficits regarding HPV testing for cervical cancer screening and a desire for the provision of further education. Overall, respondents felt that no major barriers to implementing HPV self-testing would occur.

Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results.

OBJECTIVE: The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. DESIGN: Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. RESULTS: Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. CONCLUSION: Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. TRIAL REGISTRATION NUMBER: ISRCTN41353774.

Development and validation of cardiovascular risk prediction equations in 76 000 people with known cardiovascular disease.

AIMS: Multiple health administrative databases can be individually linked in Aotearoa New Zealand, using encrypted identifiers. These databases were used to develop cardiovascular risk prediction equations for patients with known cardiovascular disease (CVD). METHODS AND RESULTS: Administrative health databases were linked to identify all people aged 18-84 years with known CVD, living in Auckland and Northland, Aotearoa New Zealand, on 1 January 2014. The cohort was followed until study outcome, death, or 5 years. The study outcome was death or hospitalization due to ischaemic heart disease, stroke, heart failure, or peripheral vascular disease. Sex-specific 5-year CVD risk prediction equations were developed using multivariable Fine and Gray models. A total of 43 862 men {median age: 67 years [interquartile range (IQR): 59-75]} and 32 724 women [median age: 70 years (IQR: 60-77)] had 14 252 and 9551 cardiovascular events, respectively. Equations were well calibrated with good discrimination. Increasing age and deprivation, recent cardiovascular hospitalization, Mori ethnicity, smoking history, heart failure, diabetes, chronic renal disease, atrial fibrillation, use of blood pressure lowering and anti-thrombotic drugs, haemoglobin A1c, total cholesterol/HDL cholesterol, and creatinine were statistically significant independent predictors of the study outcome. Fourteen per cent of men and 23% of women had predicted 5-year cardiovascular risk <15%, while 28 and 24% had ≥40% risk. CONCLUSION: Robust cardiovascular risk prediction equations were developed from linked routine health databases, a currently underutilized resource worldwide. The marked heterogeneity demonstrated in predicted risk suggests that preventive therapy in people with known CVD would be better informed by risk stratification beyond a one-size-fits-all high-risk categorization.

Using regionwide New Zealand health databases, methods of predicting hospitalization risk in patients with existing heart disease were developed. Using only data from health databases, it was possible to predict the risk accurately.Among patients with existing heart disease, the predicted risk varied markedly which could help improve preventive strategies.

A cross-sectional study of inequalities in digital air pollution information access and exposure reducing behavior uptake in the UK.

Air pollution is a pervasive global environmental challenge that presents substantial and differential risk across populations. Individual-level pollution exposure is a function of varying factors, including but not limited to geographic location, proximity to point sources, ventilation, and behavioral patterns. Mounting evidence suggests that informational interventions can play a substantial role in mediating exposures for specific population subgroups and reduce downstream adverse health outcomes. The literature has yet to address whether access to air quality information is sociodemographically stratified, and whether such access correlates with increased uptake of exposure reducing behaviors at the population level. This study represents a first step in answering these questions by analysing responses from the "Clean Air Public Insight Tracker" nationally representative survey (n = 1,993) of the UK population, administered by UK charity Global Action Plan. Results from logistic regression and zero-inflated negative binomial models estimate 28% of the population have accessed air pollution information, while the odds of younger individuals (ages 18-36), men, and non-white individuals of accessing digitally available air quality information are greater that those outside these categories. Additionally, the odds of behavior uptake is greater if an individual accesses digital information sources like the internet, mobile apps or social media, has a higher education qualification or cares for someone with a health condition. These findings contribute to the growing literature surrounding which population groups engage with environmental and health-relevant information channels, and what connects engagement with air quality channels and uptake of exposure reducing behaviors. These results reinforce the need for additional research around air pollution informational alerts and exploring causal links between specific exposure reducing behaviours and improved health outcomes. It can also help inform the flow of resources and targeting of informational campaigns towards sociodemographic groups that are less likely to engage with air quality information.

Incorporating faecal haemoglobin measurement using the faecal immunochemical test (FIT) in the referral, triage and prioritisation pathway for patients with colorectal symptoms.

Incorporating faecal haemoglobin (FHb) measurement using the faecal immunochemical test (FIT) in the investigation pathway for patients with colorectal symptoms may improve access to colonoscopy for those at greatest risk of significant disease. AIM: To derive a colorectal symptom pathway incorporating standard clinical and FIT data to guide referral, triage, and prioritisation of cases in New Zealand. METHOD: Diagnostic accuracy of FIT to rule out colorectal cancer (CRC) was determined by meta-analysis. Thereafter, the risk of CRC after FIT was estimated for common clinical presentations by Bayesian methodology, using a specifically collated retrospective cohort of symptomatic cases. A symptom/FIT pathway was developed iteratively following multi-disciplinary engagement. RESULTS: Eighteen studies were included in meta-analysis. The sensitivity and specificity for CRC were 89.0% (95%CI 87.0-90.9%) and 80.1% (95%CI 77.7-82.4%) respectively, at a FHb threshold of >10mcg haemoglobin per gram stool, and 95.7% (95%CI 93.2-97.7%) and 60.5% (95%CI 53.8-67.0%) respectively, at the limit of detection. The final pathway was 97% sensitive for CRC, compared with 90% for the current direct access criteria, and requires 47% fewer colonoscopies. Estimated prevalence of CRC among those declined investigation was 0.23%. CONCLUSION: Incorporating FIT in the new patient symptomatic pathway as presented appears feasible, safe, and allows for resources to be targeted to those at greatest risk of disease. Further work is needed to ensure equity for Maori if this pathway were introduced nationally.

Primary care experiences in the 'Let's test for HPV' study: a qualitative analysis.

Introduction The National Cervical Screening Programme (NCSP) will switch from cervical cytology to Human Papillomavirus (HPV) testing as the primary cervical screening modality in 2023. To prepare for rollout an implementation study of HPV testing in primary care commenced in August 2022 in three different geographic regions in NZ. Aims This study explores Primary Care Staff's experience of using the HPV testing pathway in the 'Let's test for HPV' study so that recommendations can be made to improve the testing process before nationwide roll-out. Method Thirty-nine primary care staff were interviewed across all 17 practices in the Capital and Coast, Canterbury and Whanganui region participating in the 'Let's Test For HPV' study. In total 19 interviews took place which followed a semi-structured approach. These interviews were recorded and transcribed. Template analysis was carried out on transcripts to aid in identifying themes. Results Three key themes, with additional subthemes, were identified. Staff were strongly supportive of the new testing regime. Interviewees identified some issues with the new pathway. Educational needs for both patients and clinicians were identified. Conclusion Primary care staff described the experience of using the HPV testing pathway positively; however, there were requests for ongoing additional support and nationwide rollout to be supported by practitioner and patient education programmes. With the right support this new pathway for cervical cancer screening has the potential to improve access for previously underserved and unserved groups.

Reducing the burden of knee osteoarthritis through community pharmacy: Protocol for a randomised controlled trial of the Knee Care for Arthritis through Pharmacy Service.

INTRODUCTION: Knee osteoarthritis (OA) negatively impacts the health outcomes and equity, social and employment participation, and socio-economic wellbeing of those affected. Little community-based support is offered to people with knee OA in Aotearoa New Zealand. Identifying Maori and non-Maori with knee OA in community pharmacy and providing co-ordinated, evidence- and community-based care may be a scalable, sustainable, equitable, effective and cost-effective approach to improve health and wellbeing. AIM: Assess whether the Knee Care for Arthritis through Pharmacy Service (KneeCAPS) intervention improves knee-related physical function and pain (co-primary outcomes). Secondary aims assess impacts on health-related quality of life, employment participation, medication use, secondary health care utilisation, and relative effectiveness for Maori. METHODS AND ANALYSIS: A pragmatic randomised controlled trial will compare the KneeCAPS intervention to the Pharmaceutical Society of New Zealand Arthritis Fact Sheet and usual care (active control) at 12 months for Maori and non-Maori who have knee OA. Participants will be recruited in community pharmacies. Knee-related physical function will be measured using the function subscale of the Short Form of the Western Ontario and McMaster Universities Osteoarthritis Index. Knee-related pain will be measured using an 11-point numeric pain rating scale. Primary outcome analyses will be conducted on an intention-to-treat basis using linear mixed models. Parallel within-trial health economic analysis and process evaluation will also be conducted. ETHICS AND TRIAL DISSEMINATION: Ethical approval was obtained from the Central Health and Ethics Committee (2022-EXP-11725). The trial is registered with ANZCTR (ACTRN12622000469718). Findings will be submitted for publication and shared with participants.

Exploring the current and future osteoarthritis health service delivery needs in Aotearoa New Zealand.

AIM: Osteoarthritis (OA) affects the wellbeing of one in 10 people in Aotearoa New Zealand, yet current healthcare delivery for these people is fragmented, un-coordinated and inconsistent. How current and future needs should be addressed has not been systematically explored. This study aimed to describe the views of interested people from the health sector regarding current and future OA health service delivery in the public health system in Aotearoa New Zealand. METHOD: Data were collected via a co-design approach within an interprofessional workshop at the Taupuni Hao Huatau Kaikoiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium and analysed using direct qualitative content analysis. RESULTS: The results highlighted several promising current healthcare delivery initiatives. Health literacy and obesity prevention policies featured in the thematic analysis suggesting a lifespan or systemwide approach is needed. Data highlighted a need for reformed systems that enhances hauora/wellbeing, promotes physical activity, facilitates interprofessional service delivery and collaborates across care settings. CONCLUSION: Participants identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Public health policy initiatives are needed to reduce osteoarthritis risk factors. Developing future care pathways should support the diverse needs within Aotearoa New Zealand, coordinate and stratify care, value interprofessional collaboration and practice, and improve health literacy and self-management.

Longitudinal trends in community antibiotic consumption in the Waitaha Canterbury Region of Aotearoa New Zealand over 10 years (2012-2021): an observational study.

AIMS: To investigate community antibiotic consumption in the Waitaha Canterbury Region of Aotearoa New Zealand across 2012-2021. METHODS: This observational study was based on antibiotic dispensing data from Waitaha Canterbury. Outcome measures included number of dispensings/1,000 inhabitants per year and defined daily doses/1,000 inhabitants per day (DIDs), expressed as average annual change (AAC). We stratified antibiotic dispensing per antibiotic group, and per the World Health Organization (WHO) AWaRE (Access, Watch, Reserve) classification. RESULTS: Across 2012-2021, antibiotic dispensing decreased from 867 to 601 dispensings/1,000 inhabitants (AAC -4.2% [95%CI -4.3 to -4.2]). In the pre-COVID period of 2012 to 2019, antibiotic dispensings decreased with AAC of -3.5% (95%CI -3.6 to -3.5). Considering number of dispensings, the largest reductions were observed in quinolones (-14.6%), macrolides/lincosamides (-8.5%) and penicillins with extended spectrum (-4.8%). The number of dispensings increased for nitrofurans (6.0%) and first generation cephalosporins (28.1%), of which 98% comprised cefalexin dispensing. The proportion of Watch antibiotics decreased from 22.0% to 11.9%. CONCLUSIONS: Community antibiotic consumption decreased in Waitaha Canterbury Aotearoa New Zealand from 2012 to 2021, as did use of Watch antibiotics. These changes concord with increasing antimicrobial stewardship guidance for more judicious use of antibiotics. Further research should investigate the factors driving the observed 10-fold rise in cefalexin dispensing.

Knee osteoarthritis and the knowledgeable, trustworthy pharmacist: Patient and pharmacist perceptions of community pharmacy-based education and support.

BACKGROUND: Osteoarthritis (OA) clinical guidelines recommend self-management education, but education is often not included in primary care consultations. OBJECTIVE: To explore pharmacists' and patients' perceptions of a pharmacist-led model of service delivery for knee OA that was integrated within pharmacies' day-to-day workflow. METHODS: Cross-sectional qualitative design using Thematic Analysis. Community pharmacies were recruited in New Zealand and Australia. Pharmacy patients were screened for knee OA and offered tailored explanations, self-management information and referral for further support. Pharmacist focus groups and patient 1:1 interviews explored perceptions of the service delivery model. RESULTS: Nineteen pharmacists and 12 patients with knee OA participated. Pharmacist and patient data were analysed separately, with themes compared and contrasted to derive three meta-themes. Meta-theme 1: 'Welcome Engagement' included two pharmacist themes ('putting my broad skill set to use' and 'we're here and happy to help') and two patient themes ('information delivered well' and 'a welcome offer of help'). Meta-theme 2: 'The Knowledgeable and Trustworthy Pharmacist' included two pharmacist themes ('professional knowledge to help all sorts of patients' and 'managing time to help my patients') and one patient theme ('the accessible professional who I know and trust'). Meta-theme 3: 'The Opportunity for More Support' included one pharmacist theme ('this is not the end of the story') and one patient theme ('more help is available'). CONCLUSION: Community pharmacists are well-positioned to provide information and support to people with knee OA. Pharmacists appreciate the opportunity to better use their skills and accessibility for OA care, and patients welcome this engagement.

Self-regulation training for people with knee osteoarthritis: a protocol for a feasibility randomised control trial (MiNT trial).

Introduction: Knee osteoarthritis (OA) is a chronic secondary musculoskeletal pain condition resulting in disability, reduced quality of life, and high societal costs. Pain associated with knee OA is linked to increased sensitivity in sensory, cognitive, and emotional areas of the brain. Self-regulation training targeting brain functioning related to pain experience could reduce pain and its associated disability. Self-regulatory treatments such as mindfulness meditation (MM) and electroencephalography neurofeedback (EEG-NF) training improve clinical outcomes in people with knee OA. A feasibility clinical trial can address factors that could inform the design of the full trial investigating the effectiveness of self-regulation training programmes in people with knee OA. This clinical trial will evaluate the feasibility, safety, acceptability, experience and perceptions of the self-regulatory training programmes. Methods: The proposed feasibility trial is based on a double-blind (outcome assessor and investigators), three-arm (MM usual care, EEG-NF + usual care and usual care control group) randomised controlled parallel clinical trial. Participants with knee OA will be recruited from the community and healthcare practices. A research assistant (RA) will administer both interventions (20-min sessions, four sessions each week, and 12 sessions over three successive weeks). Feasibility measures (participant recruitment rate, adherence to interventions, retention rate), safety, and acceptability of interventions will be recorded. An RA blinded to the group allocation will record secondary outcomes at baseline, immediately post-intervention (4th week), and 3 months post-intervention. The quantitative outcome measures will be descriptively summarised. The qualitative interviews will evaluate the participants' experiences and perceptions regarding various aspects of the trial, which includes identifying the barriers and facilitators in participating in the trial, evaluating their opinions on the research procedures, such as their preferences for the study site, and determining the level of acceptability of the interventions as potential clinical treatments for managing knee OA. Maori participant perceptions of how assessment and training practices could be acceptable to a Maori worldview will be explored. The interviews will be audio-recorded and analysed thematically. Discussion: This trial will provide evidence on the feasibility, safety, and acceptability of the MM and EEG-NF training in people with knee OA, thus informing the design of a full randomised clinical control trial.

Feasibility of a randomised controlled trial of two types of written information for people with knee osteoarthritis.

Objective: Test the feasibility of conducting an individually randomised controlled trial recruiting people with knee osteoarthritis (OA) in community pharmacies and evaluate the impacts of a novel information booklet. Design: People with knee OA were identified by pharmacy staff using clinical criteria and randomised to receive a novel information booklet (intervention) or the currently available written OA resource (active control). Mixed-methods process evaluation assessed participant recruitment, retention, and experience. Participant-reported outcome measures, assessing OA illness perceptions, OA knowledge, fear of movement, and pain when walking at baseline and 4-weeks, were analysed using linear regression models (adjusted for baseline). Results: Of 72 eligible people, 64 were randomised to intervention (n â€‹= â€‹33) or control (n â€‹= â€‹31). The randomisation sequence was followed correctly and no protocol deviations identified. Mean recruitment rate was 2.7 participants per pharmacy per week. One-in-five participants had no educational qualifications and one-in-four had not received a knee OA diagnosis prior to the trial. Three meta-themes emerged from pharmacist and participant qualitative analysis: 'pleased to be asked'; 'easy process'; and 'successful process'. Three participants were lost to follow-up. At 4 weeks, intervention arm Knee Osteoarthritis Knowledge Scale scores improved (mean difference â€‹= â€‹3.6, 95%CI 0.7 to 6.5). Brief Illness Perceptions Questionnaire scores were similar between groups (mean difference 0.4, 95%CI -3.7 to 4.5). Conclusion: It is feasible to conduct an individually randomised trial in community pharmacy, a potentially effective setting to initiate accessible OA care. A novel information booklet improved OA knowledge, but is unlikely to affect illness perceptions on its own.

Continuing professional development in the COVID-19 era: evolution of the Pegasus Health Small Group model.

Background and context This paper outlines the process of moving a continuing education programme for primary healthcare professionals from a fully in-person model to fully online so it could continue during coronavirus disease 2019 (COVID-19) lockdowns. The programme uses a peer-led Small Group model with the leader facilitating interactive discussion based on background content researched by a team from Pegasus Health. Assessment of problem When the COVID-19 restrictions were implemented in March 2020, the usual in-person Small Group meetings could not continue. Rather than allowing the programme to lapse, a new format was needed. Strategies for improvement In response, the Pegasus Health team transitioned the programme to an eSmall Group model using Zoom. Training packages were developed and disseminated online and the interactive, real-time nature of the programme retained. eSmall Groups began in May and were evaluated late in 2020. Results The online format was strongly supported, though some attendees missed the collegiality of meeting in-person. From 2021, attendees could opt for either online, in-person, or a summer/winter split between in-person and online. The ability to return to fully online was retained, allowing a seamless transition during the periods of further restrictions that followed in 2021-22. Lessons learnt The Small Group model has evolved to a multi-format programme that suits individual preferences, but can respond to pandemic or emergency situations if needed. It continues to have a high level of engagement among primary healthcare professionals.

Symptom control in advanced chronic liver disease: integrating anticipatory palliative and supportive care.

The number of patients coming to hospital with liver disease is increasing. There was a worrying trend before the pandemic, and this has intensified. Despite improvements in the management of patients with advanced cirrhosis many patients will die within 6-12 months of first presentation, and, despite this, the field of palliative and supportive care in liver disease is still in its infancy. This is a narrative review. Evidence is often thin in this field. Where it exists it is cited, but much of the commentary here is based on the authors own experience and readers are free to consider it and debate it. Most patients who die of liver disease receive palliative care very late in their illness (if at all). There are many barriers to supportive and palliative care in liver disease which are discussed. Symptom control is often poor because of these barriers. Before symptomatic control can be established, patients in need of it must to be identified and conversations had about the severity of their situation and what their wishes would be. Interest in palliative and supportive care for patients liver disease is growing as is the number of hepatologists and palliative care clinicians within the UK with an interest. It is important that this enthusiasm and interest can be rolled out and scaled up across the UK so that all patients, wherever they are, can benefit. The aims of these articles are first to highlight and bring into focus the unmet need for palliative and supportive care in liver disease and second to provide suggestions for its integration into liver services. Ask yourself the question: where would I start in my hospital to help these patients?

Palliative long-term abdominal drains for the management of refractory ascites due to cirrhosis: a consensus document.

Palliative care remains suboptimal in advanced cirrhosis, in part relating to a lack of evidence-based interventions. Ascites remains the most common cirrhosis complication resulting in hospitalisation. Many patients with refractory ascites are not candidates for liver transplantation or transjugular intrahepatic portosystemic shunt, and therefore, require recurrent palliative large volume paracentesis in hospital. We review the available evidence on use of palliative long-term abdominal drains in cirrhosis. Pending results of a national trial (REDUCe 2) and consistent with recently published national and American guidance, long-term abdominal drains cannot be regarded as standard of care in advanced cirrhosis. They should instead be considered only on a case-by-case basis, pending definitive evidence. This manuscript provides consensus to help standardise use of long-term abdominal drains in cirrhosis including patient selection and community management. Our ultimate aim remains to improve palliative care for this under researched and vulnerable cohort.