What are medical students taught about persistent physical symptoms? A scoping review of the literature.

BACKGROUND: Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management. METHODS: The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings. RESULTS: A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners' experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS. CONCLUSION: Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients.

Pro-judge study: Nurses' professional judgement in nurse staffing systems.

AIMS: Aim of this study is to better understand the role of nurses' professional judgment in nurse staffing systems. DESIGN: Qualitative comparative case study design of nurse staffing systems in England and Wales. METHODS: Data will be collected through a variety of sources: individual interviews, observations of relevant meetings and analysis of key documents. Ethical approval for the study was granted in August 2020 from The Healthcare Research Ethics Committee (SREC reference: REC741). Data generation will be informed by science and technology studies and practice theories. DISCUSSION: Ensuring adequate numbers of nurses are available to care for patients in response to shifting demand is an international policy priority. Emerging evidence on the use of formal workforce planning methodologies across the developed world highlights both the centrality of nurses' professional judgement in nurse staffing methodologies and the urgent need for theoretically informed research to better understand and conceptualise its contribution to decision-making. This study is designed to address this gap in understanding. It takes advantage of nurses' experiences of managing the service and staffing impacts of the Covid-19 pandemic and differences in strategic approaches to nurse staffing systems between England and Wales. IMPACT: The research will: make visible the knowledge and skills that underpin professional judgement in nurse staffing decisions and provide a conceptual language with which to articulate this; lay the foundations for evidence-based programmes of nurse education and continuing professional development; furnish the evidence to inform the development of nurse-led decision support tools to augment professional judgement; and generate wider insights into the effectiveness of nurse staffing systems in practice.

Core Outcome Domains for Clinical Trials on Somatic Symptom Disorder, Bodily Distress Disorder, and Functional Somatic Syndromes: European Network on Somatic Symptom Disorders Recommendations.

OBJECTIVE: The harmonization of core outcome domains in clinical trials facilitates comparison and pooling of data, and simplifies the preparation and review of research projects and comparison of risks and benefits of treatments. Therefore, we provide recommendations for the core outcome domains that should be considered in clinical trials on the efficacy and effectiveness of interventions for somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. METHODS: The European Network on Somatic Symptom Disorders group of more than 20 experts in the field met twice in Hamburg to discuss issues of assessment and intervention research in somatic symptom disorder, bodily distress disorder, and functional somatic syndromes. The consensus meetings identified core outcome domains that should be considered in clinical trials evaluating treatments for somatic symptom disorder and associated functional somatic syndromes. RESULTS: The following core domains should be considered when defining ascertainment methods in clinical trials: a) classification of somatic symptom disorder/bodily distress disorder, associated functional somatic syndromes, and comorbid mental disorders (using structured clinical interviews), duration of symptoms, medical morbidity, and prior treatments; b) location, intensity, and interference of somatic symptoms; c) associated psychobehavioral features and biological markers; d) illness consequences (quality of life, disability, health care utilization, health care costs; e) global improvement and treatment satisfaction; and f) unwanted negative effects. CONCLUSIONS: The proposed criteria are intended to improve synergies of clinical trials and to facilitate decision making when comparing different treatment approaches. These recommendations should not result in inflexible guidelines, but increase consistency across investigations in this field.

GPs' experience of difficult decisions in patients with dementia and an acute illness.

BACKGROUND: GPs are often required to make decisions about the management of acute illness in people living with dementia. These decisions are often complex and involve multiple informants. AIM: We aimed to explore how GPs made decisions about acute illness in people with dementia using a micropolitics approach. DESIGN & SETTING: Qualitative, semi-structured interviews with 13 GPs with a range of years of experience working in South Yorkshire, UK. METHOD: Interviews were conducted by phone. Interviews focused on GPs' accounts to reflect their own perceptions and choices as portrayed to the interviewer. The analysis used the lens of micro-politics in the analysis and interpretation of the themes, with a focus on decisions between GP, patient, family and carers, other health and social care providers about the management of acute illness in a person with dementia. RESULTS: The results showed that GPs act as street-level bureaucrats while carrying out their role, using discretion during decision-making in an environment characterised by uncertainties and work pressures. In addition, GPs use the "soft power" skills of diplomacy such as negotiation, persuasion and engagement in navigating through difficult decision-making situations, while building relationships and partnerships with various actors in the health system. CONCLUSION: GPs possess and express power and influence decision-making in people living with dementia when navigating biomedical, social, economic and psychological factors. This power comes in the form of soft power (street level diplomacy) and the more formal power of street level bureaucracy.

Stigmatisation in clinical consultations for persistent physical symptoms/functional disorders: A best fit framework synthesis.

INTRODUCTION: Stigma is a social attribute that links a person to an undesirable characteristic and leads to actions that increase the social distance from that person. This includes different or discriminatory treatment. Stigma is common in healthcare, particularly in people with persistent physical symptoms (PPS) and functional disorders (FD). The aim of this study is to create a new actionable framework to aid understanding of stigmatisation in consultations about PPS/FD and to improve the consultation experiences. METHODS: This framework development used the Best Fit Framework approach to data collected for a scoping review of stigma in functional disorders. The stages included selection of an initial framework from existing conceptual models, mapping quote data from published papers to the framework and an iterative process of revision and re-mapping. The final framework was tested by re-mapping all the quote data to the framework following classification rules. RESULTS: 253 quotes were obtained from the results sections of qualitative studies from a previous scoping review. The framework comprises of prejudice, stereotypes and actions to increase social distance. Stereotype refers to the focus of stigma: this may be the condition, the patient, or their behaviour. Actions that increase social distance include: othering; denial; non-explanation; minimising, norm-breaking; and psychologising. By breaking down stigma into recognisable components, the framework provides a way to understand the difficulties that patients and clinicians face during consultations and a way to develop intervention materials. CONCLUSIONS: This new framework for stigma in clinical consultations for PPS/FDs provides a useful tool for the study of stigma in clinical consultations.

Participatory design of bodysymptoms.org: An interactive web resource to explain multisystem functional somatic symptoms.

OBJECTIVE: There is a lack of trustworthy information about Functional Somatic Symptoms (FSS) on the internet. This means integrative bio-psycho-social explanations of FSS and related health advice are not readily available to the public. To explore and address this problem, we carried out the bodysymptoms project, with the aim to build a website which presents current widely accepted explanations for FSS and shows how different explanations are inter-connected. METHODS: Bodysymptoms was set up as a research-in-action project with a diverse range of international stakeholder-participants, combining approaches from patient and public involvement in healthcare with participatory design. 7 participants with lived experience of multi-system functional symptoms took part in the project and measures of meaningful engagement throughout the project were rated highly. This manuscript describes the methodology by which the website was developed. RESULTS: Through iterative cycles we determined the requirements for an interactive explanatory model and co-created a novel online health interactive resource with integrated actionable health advice. The target end user are young adults with persistent physical symptoms, maintained by functional mechanisms. The overall aim is to empower people at risk of developing functional disorders to seek better health outcomes. The website is intended to be used prior to or alongside engagement with healthcare. CONCLUSION: Bringing lived experience and multi-disciplinary perspectives into dialogue through participatory design can harness the power of research to create immediate shared value. This project has resulted in a usable open access website, bodysymptoms.org, which provides education about FSS for patients, healthcare professionals and members of the public looking to understand FSS.

A qualitative study of primary care professionals' views of case finding for depression in patients with diabetes or coronary heart disease in the UK.

BACKGROUND: Routinely conducting case finding (also commonly referred to as screening) in patients with chronic illness for depression in primary care appears to have little impact. We explored the views and experiences of primary care nurses, doctors and managers to understand how the implementation of case finding/screening might impact on its effectiveness. METHODS: Two complementary qualitative focus group studies of primary care professionals including nurses, doctors and managers, in five primary care practices and five Community Health Partnerships, were conducted in Scotland. RESULTS: We identified several features of the way case finding/screening was implemented that may lead to systematic under-detection of depression. These included obstacles to incorporating case finding/screening into a clinical review consultation; a perception of replacing individualised care with mechanistic assessment, and a disconnection for nurses between management of physical and mental health. Far from being a standardised process that encouraged detection of depression, participants described case finding/screening as being conducted in a way which biased it towards negative responses, and for nurses, it was an uncomfortable task for which they lacked the necessary skills to provide immediate support to patients at the time of diagnosis. CONCLUSION: The introduction of case finding/screening for depression into routine chronic illness management is not straightforward. Routinized case finding/screening for depression can be implemented in ways that may be counterproductive to engagement (particularly by nurses), with the mental health needs of patients living with long term conditions. If case finding/screening or engagement with mental health problems is to be promoted, primary care nurses require more training to increase their confidence in raising and dealing with mental health issues and GPs and nurses need to work collectively to develop the relational work required to promote cognitive participation in case finding/screening.

"It's not just about the numbers": Inside the black box of nurses' professional judgement in nurse staffing systems in England and Wales: Insights from a qualitative cross-case comparative study.

BACKGROUND: Whether implicit or explicit, professional judgement is a central component of the many nurse staffing systems implemented in high-income countries to inform workforce planning and staff deployment. Whilst a substantial body of research has evaluated the technical and operational elements of nurse staffing systems, no studies have systematically examined the role of professional judgement and its contribution to decision-making. OBJECTIVE: To explore nurses' use of professional judgement in nurse staffing systems in England and Wales. METHODS: A cross-case comparative design centred on adult in-patient services in three University Health Boards in Wales and three National Health Service Trusts in England. Data generation was undertaken between January 2021 and March 2023 through stakeholder interviews, observations of staffing meetings, and analysis of documents and artefacts. Observations were undertaken in clinical areas but limited to three cases by COVID-19 restrictions. Analysis was informed by translational mobilisation theory. FINDINGS: Two kinds of professional judgement were deployed in the nurse staffing systems: the judgement of clinical nurses and the judgement of senior nurse managers. The research highlighted the reflexive relationship between professional judgement and data, and the circumstances in which organisations placed trust in people and when they placed trust in numbers. Nurses' professional judgement was central to the generation of data, its interpretation and contextualisation. Healthcare organisations relied on the professional judgements of clinical nurses and senior nurse managers in making operational decisions to mitigate risk, where real-world understanding of the status of the organisation was privileged over formal data. Professional judgement had attenuated authority for the purposes of workforce planning, where data was a master actor. Nurses expressed concerns that strategic decision-making prioritised safety and efficiency, and formal measurement systems did not capture important aspects of care quality or staff wellbeing, which made it difficult to articulate their professional judgement. CONCLUSIONS: The implementation of staffing systems is resource intensive. Given limited evidence on which to recommend any specific methodology, the priority for future research is to optimise existing systems. If nurses are to deploy their professional judgement to proactively influence the conditions for care, as well as responding to the challenges of risk mitigation, there is a need for robust systems of nursing measurement aligned with agreed standards of care and a vocabulary through which these judgements can be articulated. TWEETABLE ABSTRACT: Health systems depend on nurses' professional judgement for operational staffing decisions, but data is privileged over professional judgement for workforce planning.

Using arts-based research in applied health care: An example from an evaluation of NHS dental contract reform in Wales.

OBJECTIVE: Arts-based research (ABR) refers to the use of art in the research process to help generate, interpret and/or communicate knowledge. We used ABR principles to adapt a centre-staging method to complement a more traditional qualitative approach to evaluate participants' views on dental service reform. METHODS: We asked five individuals in the dental health sector in the National Health Service in Wales to select objects to depict their views on the current reform process and their ideal reform process. This process took place alongside traditional semi-structured interviews with the participants. RESULTS: There were three marked differences in the centre-staging process as compared to the interviews: (1) there was a greater use of symbolism by the participants, (2) the participants put a greater focus on the process of change and (3) the participants were more likely to reveal the emotions underlying their assessments of the reform process. CONCLUSIONS: The arts-based approach adopted appeared to be highly accessible and has the potential to be used in a wide range of applications.

Explanations for functional somatic symptoms across European treatment settings: A mixed methods study.

OBJECTIVE: Engaging patients in treatment for functional somatic symptoms (FSS) relies on a shared understanding of the mechanisms underlying the complaints. Despite this, little is known about the explanatory models used in daily clinical practice. We aim to examine the approaches healthcare professionals use to explain FSS across European healthcare settings. METHODS: This is an exploratory mixed methods study, combining sequential qualitative and quantitative analyses. 3 types of data were collected: a survey of Health-Care Professionals (HCPs) with special interest in FSS from 16 European countries (n = 186), Patient Education Material collected systematically from survey respondents (n = 72) and semi-structured Interviews with HCPs (n = 14). Survey results are summarized descriptively. Qualitative data was thematically coded following template analysis methods. Findings were integrated through mixed-methods triangulation. RESULTS: Five main explanatory models for FSS that are used across treatment settings and diagnostic constructs were represented in the data. The 'Multisystem Stress' Approach explains FSS through physiological stress responses within a bio-psycho-social paradigm. 'Sensitized Alarm' and 'Malfunctioning software' are both approaches derived from the neurosciences. Explanations related to 'Embodied Experience' are often used within integrated psychosomatic therapies. In the person-centred 'Symptoms' approach, HCPs aim for co-constructed, individualized explanations. These approaches, which rely on different models of mind-body-environment are complementary and are used flexibly by skilled HCPs. CONCLUSION: Taken together the explanatory models described might form the basis of a curriculum of medical explanation with the potential to equip clinicians to form more collaborative relationships with patients across healthcare.

A cluster randomised controlled trial of an occupational therapy intervention for residents with stroke living in UK care homes (OTCH): study protocol.

BACKGROUND: The occupational therapy (OT) in care homes study (OTCH) aims to investigate the effect of a targeted course of individual OT (with task training, provision of adaptive equipment, minor environmental adaptations and staff education) for stroke survivors living in care homes, compared to usual care. METHODS/DESIGN: A cluster randomised controlled trial of United Kingdom (UK) care homes (n = 90) with residents (n = 900) who have suffered a stroke or transient ischaemic attack (TIA), and who are not receiving end-of-life care. Homes will be stratified by centre and by type of care provided and randomised (50:50) using computer generated blocked randomisation within strata to receive either the OT intervention (3 months intervention from an occupational therapist) or control (usual care). Staff training on facilitating independence and mobility and the use of adaptive equipment, will be delivered to every home, with control homes receiving this after the 12 month follow-up.Allocation will be concealed from the independent assessors, but the treating therapists, and residents will not be masked to the intervention. Measurements are taken at baseline prior to randomisation and at 3, 6 and 12 months post randomisation. The primary outcome measure is independence in self-care activities of daily living (Barthel Activities of Daily Living Index). Secondary outcome measures are mobility (Rivermead Mobility Index), mood (Geriatric Depression Scale), preference based quality of life measured from EQ-5D and costs associated with each intervention group. Quality adjusted life years (QALYs) will be derived based on the EQ-5D scores. Cost effectiveness analysis will be estimated and measured by incremental cost effectiveness ratio. Adverse events will be recorded. DISCUSSION: This study will be the largest cluster randomised controlled trial of OT in care homes to date and will clarify the currently inconclusive literature on the efficacy of OT for stroke and TIA survivors residing in care homes. TRIAL REGISTRATION: ISRCTN00757750.

Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study.

BACKGROUND: Annual recording of the Royal College of Physicians three questions (RCP3Q) morbidity score is rewarded within the UK 'pay-for-performance' Quality and Outcomes Framework. AIMS: To investigate the performance of the RCP3Qs for assessing control in real-life practice compared with the validated Asthma Control Questionnaire (ACQ) administered by self-completed questionnaire. METHODS: We compared the RCP3Q score extracted from a patient's computerised medical record with the ACQ self-completed after the consultation. The anonymous data were paired by practice, age, sex, and dates of completion. We calculated the sensitivity and specificity of the RCP3Q scale compared with the threshold for good/poor asthma control (ACQ ≥1). RESULTS: Of 291 ACQ questionnaires returned from 12 participating practices, 129 could be paired with complete RCP3Q data. Twenty-five of 27 patients who scored zero on the RCP3Q were well controlled (ACQ <1). An RCP3Q score ≥1 predicted inadequate control (ACQ ≥1) with a sensitivity of 0.96 and specificity of 0.34. Comparable values for RCP3Q≥2 were sensitivity 0.50 and specificity 0.94. The intraclass correlation coefficient of 0.13 indicated substantial variability between practices. Exacerbations and use of reliever inhalers were moderately correlated with ACQ (Spearman's rho 0.3 and 0.35) and may reflect different aspects of control. CONCLUSIONS: In routine practice, an RCP3Q score of zero indicates good asthma control and a score of 2 or 3 indicates poor control. An RCP3Q score of 1 has good sensitivity but poor specificity for suboptimal control and should provoke further enquiry and consideration of other aspects of control such as exacerbations and use of reliever inhalers.

Vocal characteristics of pygmy blue whales and their change over time.

Vocal characteristics of pygmy blue whales of the eastern Indian Ocean population were analyzed using data from a hydroacoustic station deployed off Cape Leeuwin in Western Australia as part of the Comprehensive Nuclear-Test-Ban Treaty monitoring network, from two acoustic observatories of the Australian Integrated Marine Observing System, and from individual sea noise loggers deployed in the Perth Canyon. These data have been collected from 2002 to 2010, inclusively. It is shown that the themes of pygmy blue whale songs consist of ether three or two repeating tonal sounds with harmonics. The most intense sound of the tonal theme was estimated to correspond to a source level of 179 ± 2 dB re 1 µPa at 1 m measured for 120 calls from seven different animals. Short-duration calls of impulsive downswept sound from pygmy blue whales were weaker with the source level estimated to vary between 168 to 176 dB. A gradual decrease in the call frequency with a mean rate estimated to be 0.35 ± 0.3 Hz/year was observed over nine years in the frequency of the third harmonic of tonal sound 2 in the whale song theme, which corresponds to a negative trend of about 0.12 Hz/year in the call fundamental frequency.

Extended use or reuse of single-use surgical masks and filtering face-piece respirators during the coronavirus disease 2019 (COVID-19) pandemic: A rapid systematic review.

BACKGROUND: Shortages of personal protective equipment during the coronavirus disease 2019 (COVID-19) pandemic have led to the extended use or reuse of single-use respirators and surgical masks by frontline healthcare workers. The evidence base underpinning such practices warrants examination. OBJECTIVES: To synthesize current guidance and systematic review evidence on extended use, reuse, or reprocessing of single-use surgical masks or filtering face-piece respirators. DATA SOURCES: We used the World Health Organization, the European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and Public Health England websites to identify guidance. We used Medline, PubMed, Epistemonikos, Cochrane Database, and preprint servers for systematic reviews. METHODS: Two reviewers conducted screening and data extraction. The quality of included systematic reviews was appraised using AMSTAR-2. Findings were narratively synthesized. RESULTS: In total, 6 guidance documents were identified. Levels of detail and consistency across documents varied. They included 4 high-quality systematic reviews: 3 focused on reprocessing (decontamination) of N95 respirators and 1 focused on reprocessing of surgical masks. Vaporized hydrogen peroxide and ultraviolet germicidal irradiation were highlighted as the most promising reprocessing methods, but evidence on the relative efficacy and safety of different methods was limited. We found no well-established methods for reprocessing respirators at scale. CONCLUSIONS: Evidence on the impact of extended use and reuse of surgical masks and respirators is limited, and gaps and inconsistencies exist in current guidance. Where extended use or reuse is being practiced, healthcare organizations should ensure that policies and systems are in place to ensure these practices are carried out safely and in line with available guidance.

The social life of self-harm in general practice.

Research engaging qualitatively with clinical practitioners' understanding of, and response to, self-harm has been limited. Self-harm offers a particularly compelling case through which to examine the enduring challenges faced by practitioners in treating patients whose presenting symptoms are not clearly biomedical in nature. In this paper, we present an analysis of 30 General Practitioners' (GPs') accounts of treating patients who had self-harmed. Our analysis demonstrates the complex ways in which GPs seek to make sense of self-harm. Illustrated through three common 'types' of patients (the 'good girl', the 'problem patient' and the 'out of the blue'), we show how GPs grapple with ideas of 'social' and 'psychological' causes of self-harm. We argue that these tensions emerge in different ways according to the social identities of patients, with accounts shaped by local contexts, including access to specialist services, as well as by cultural understandings regarding the legitimacy of self-harming behaviour. We suggest that studying the social life of self-harm in general practice extends a sociological analysis of self-harm more widely, as well as contributing to sociological theorisation on the doctor-patient relationship.

Towards safe nurse staffing in England's National Health Service: Progress and pitfalls of policy evolution.

In 2013, a national inquiry into care failings at a large public hospital in England resulted in major healthcare reforms that included targeting policy aimed at ensuring the adequacy of nurse staffing levels on hospital wards within NHS England. This paper uses a review of publicly available documents to provide a contextual account of the evolution of nurse staffing policy development prior to and following the inquiry. We found that securing safe staffing policy has been impacted by caveats and competing policy, evidence gaps, lack of coordination, and the absence of readily implementable solutions. Consequently, five years on, safe staffing policy for NHS England is described in aspirational terms that ascribes accountability to providers, but fails to adequately address barriers to delivery. Kingdon's 'policy windows' model is used to explain why policy, even when driven by strong public concern and with high inter-sector support, may struggle to gain traction when the conditions necessary for success are not present, and in the face of practical or political constraints. The progress and pitfalls encountered are not unique and the experience of safe staffing policy in England may have lessons for other countries grappling with policy development or implementation in this area.

Professional resilience in GPs working in areas of socioeconomic deprivation: a qualitative study in primary care.

BACKGROUND: GPs working in areas of high socioeconomic deprivation face particular challenges, and are at increased risk of professional burnout. Understanding how GPs working in such areas perceive professional resilience is important in order to recruit and retain a GP workforce in these areas. AIM: To understand how GPs working in areas of high socioeconomic deprivation consider professional resilience. DESIGN AND SETTING: A qualitative study of GPs practising in deprived areas within one primary care region of England. METHOD: In total, 14 individual interviews and one focus group of eight participants were undertaken, with sampling to data saturation. A framework approach was used for data analysis. RESULTS: Participants described three key themes relating to resilience. First, resilience was seen as involving flexibility and adaptability. This involved making trade-offs in order to keep going, even if this was imperfect. Second, resilience was enacted through teams rather than through individual strength. Third, resilience required the integration of personal and professional values rather than keeping the two separate. This dynamic adaptive view, with an emphasis on the importance of individuals within teams rather than in isolation, contrasts with the discourse of resilience as a personal characteristic, which should be strengthened at the individual level. CONCLUSION: Professional resilience is about more than individual strength. Policies to promote professional resilience, particularly in settings such as areas of high socioeconomic deprivation, must recognise the importance of flexibility, adaptability, working as teams, and successful integration between work and personal values.

Influences of socioeconomic deprivation on GPs' decisions to refer patients to cardiology: a qualitative study.

BACKGROUND: Variation in GP referral practice may be a factor contributing to the lower uptake of cardiology specialist services for people living in socioeconomic deprivation. Cardiology referrals were chosen for this study due to higher rates of premature death and emergency admissions resulting from coronary heart disease for patients living in more deprived areas. AIM: To find out how socioeconomic deprivation influences GP referral practice. DESIGN AND SETTING: A qualitative study of GPs working in affluent and deprived areas of one large city in the UK. METHOD: The authors used purposive and snowball sampling to recruit 17 GP participants to interviews and a focus group. Participants were asked to reflect on their own experience of making referrals. The authors used a framework approach to the analysis, with differences in themes for GPs working in least and most deprived areas being highlighted. RESULTS: The authors identified four main themes by which socioeconomic deprivation influenced GP referral practice: identifying problems; making decisions about referral; navigating the healthcare system; and external pressures. Using a published framework of consultation complexity, the authors then examined the data in relation to a fifth theme of complexity. Referrals from areas of high socioeconomic deprivation involved greater complexity in the majority of the domains of this framework. CONCLUSION: Socioeconomic deprivation influences GP referral decisions and navigation of the healthcare system in multiple ways. Referral practice for GPs working in deprived areas is more complex than for their peers working in more affluent areas.

Bayesian hierarchical vector autoregressive models for patient-level predictive modeling.

Predicting health outcomes from longitudinal health histories is of central importance to healthcare. Observational healthcare databases such as patient diary databases provide a rich resource for patient-level predictive modeling. In this paper, we propose a Bayesian hierarchical vector autoregressive (VAR) model to predict medical and psychological conditions using multivariate time series data. Compared to the existing patient-specific predictive VAR models, our model demonstrated higher accuracy in predicting future observations in terms of both point and interval estimates due to the pooling effect of the hierarchical model specification. In addition, by adopting an elastic-net prior, our model offers greater interpretability about the associations between variables of interest on both the population level and the patient level, as well as between-patient heterogeneity. We apply the model to two examples: 1) predicting substance use craving, negative affect and tobacco use among college students, and 2) predicting functional somatic symptoms and psychological discomforts.