BACKGROUND: Blood tests used to identify patients at increased risk of undiagnosed cancer are commonly used in isolation, primarily by monitoring whether results fall outside the normal range. Some prediction models incorporate changes over repeated blood tests (or trends) to improve individualized cancer risk identification, as relevant trends may be confined within the normal range. OBJECTIVE: Our aim was to critically appraise existing diagnostic prediction models incorporating blood test trends for the risk of cancer. METHODS: MEDLINE and EMBASE were searched until April 3, 2025 for diagnostic prediction model studies using blood test trends for cancer risk. Screening was performed by 4 reviewers. Data extraction for each article was performed by 2 reviewers independently. To critically appraise models, we narratively synthesized studies, including model building and validation strategies, model reporting, and the added value of blood test trends. We also reviewed the performance measures of each model, including discrimination and calibration. We performed a random-effects meta-analysis of the c-statistic for a trends-based prediction model if there were at least 3 studies validating the model. The risk of bias was assessed using the PROBAST (prediction model risk of bias assessment tool). RESULTS: We included 16 articles, with a total of 7 models developed and 14 external validation studies. In the 7 models derived, full blood count (FBC) trends were most commonly used (86%, n=7 models). Cancers modeled were colorectal (43%, n=3), gastro-intestinal (29%, n=2), nonsmall cell lung (14%, n=1), and pancreatic (14%, n=1). In total, 2 models used statistical logistic regression, 2 used joint modeling, and 1 each used XGBoost, decision trees, and random forests. The number of blood test trends included in the models ranged from 1 to 26. A total of 2 of 4 models were reported with the full set of coefficients needed to predict risk, with the remaining excluding at least one coefficient from their article or were not publicly accessible. The c-statistic ranged 0.69-0.87 among validation studies. The ColonFlag model using trends in the FBC was commonly externally validated, with a pooled c-statistic=0.81 (95% CI 0.77-0.85; n=4 studies) for 6-month colorectal cancer risk. Models were often inadequately tested, with only one external validation study assessing model calibration. All 16 studies scored a low risk of bias regarding predictor and outcome details. All but one study scored a high risk of bias in the analysis domain, with most studies often removing patients with missing data from analysis or not adjusting the derived model for overfitting. CONCLUSIONS: Our review highlights that blood test trends may inform further investigation for cancer. However, models were not available for most cancer sites, were rarely externally validated, and rarely assessed calibration when they were externally validated.
\n \n\n \n \nBACKGROUND: Social prescribing link workers have become part of primary health care in recent years. They help patients to recognise non-medical factors affecting their health and identify sources of support, often in the voluntary, community and social enterprise sector. They form part of wider work to strengthen person-centred care, which actively seeks to engage individuals in decision-making about their health, taking into account their medical, social, psychological, financial and spiritual circumstances. OBJECTIVE: To understand how buy-in to social prescribing and the link worker role is established for a patient, and how this relates to person-centred care. DESIGN: A realist evaluation. SETTING: Patients engaging with link workers in seven different parts of England were involved. METHODS: As part of data collection, we observed link workers interacting with 35 patients. We also interviewed 61 patients and re-interviewed 41 of them 9-12 months later. Data were coded and developed into context-mechanism-outcome configurations, which were used to produce a programme theory. RESULTS: Data highlighted how patients might be uncertain about the link worker role but agree to a referral as they sought assistance with their non-medical issues. Patients talked about experiencing a sense of hope through the trust they developed in a link worker. This trust was established through the communication skills and knowledge demonstrated by a link worker, and by their ability to act as an anchor point when required - a reliable, consistent source of support to whom patients could offload. The link worker role also involved connecting patients to external support, which called for sensitivity around how ready someone was to move forward; this was shaped by a patient's motivation but also their capacity to make changes given other demands in their life. Connecting patients to external support could be affected by structural factors outside the link workers' control (e.g. housing options or employment opportunities). LIMITATIONS: We did not interview patients who had rejected the offer of social prescribing, and most had a positive view of meeting with a link worker. CONCLUSIONS: Person-centred care is engendered by link workers through their skills, knowledge and ability to respond to the individual readiness of patients to engage with external support. It can be curtailed by structural factors outside link workers' sphere of control, such as access to housing or caring responsibilities of patients. This can hinder patients' ability to 'connect to', leaving link workers to continue 'connecting with' patients as they act as an anchor point. FUTURE WORK: Exploration is required of factors affecting patients who interact with a link worker but do not access external support. Longitudinal work with a cohort of patients, speaking to them on a regular basis, may provide further understanding in this respect. FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.
\n \n\n \n \nINTRODUCTION: Secure Extended Care Units (SECU) offer low-secure, long-term inpatient rehabilitation for patients with severe mental illnesses. Limited research is available about the profile of patients referred to such units. OBJECTIVE: This study aimed to explore the sociodemographic and clinical characteristics of patients referred to Austin Health SECU over a 5-year period in Australia. METHODS: A retrospective study design was used to investigate 121 consecutive referrals. The 98 first-time patient referrals were included in the primary analysis. Descriptive statistics were used with non-parametric comparisons (Chi-square and Fisher's exact test where appropriate). RESULTS: Most of the total sample were single males of European ancestry, between 25 and 34\u2009years old, with 10\u2009years or less of education and receiving disability benefits. Schizophrenia was the predominant diagnosis, with 50% having a comorbid personality trait/disorder; substance use was high (82.6%). More than three-fourths had a history of trauma. Physical comorbidity was high (80%), with hepatitis C positivity at 20%. Treatments like Clozapine and Electroconvulsive therapy (ECT) were low. The Median Health of Nations Outcome Scale (HoNOS) was 20 (IQR: 14, 23) and the Life Skills Profile (LSP) was 22.5 (IQR: 16.25, 27). CONCLUSIONS: Referrals showed a high level of psychosocial-physical complexity, with a range of patient needs, service goals, and high psychiatric and interpersonal risk before the referral. The study discusses the need for medium and high-secure beds and a new model of care that integrates Community Care Units (CCU). A trauma-informed approach that creates holistic treatment plans and includes patients and families is indicated. The study makes a case for Universal screening of patients for Bloodborne Hepatitis and treatment for this cohort in an inpatient setting.
\n \n\n \n \nBackground\u00a0The integration of diagnostic services presents a critical opportunity to improve health outcomes in low- and middle-income countries (LMICs), potentially averting up to 1 million premature deaths annually. Antenatal care provides a critical platform for diagnosing multiple diseases in an integrated manner.Aim\u00a0This study explored the experiences of healthcare providers and pregnant women using integrated diagnostic services at a primary care facility in Zimbabwe.Setting\u00a0A qualitative case study was conducted at Mabvuku Polyclinic in Harare, Zimbabwe.Methods\u00a0Using purposive sampling, 14 healthcare workers and 22 pregnant women participated in interviews. Observations and semi-structured interviews were recorded, transcribed and analysed using NVivo software. Thematic analysis was applied to identify key themes related to access, patient-provider interactions and systemic barriers.Results\u00a0According to the interviewees' reports, challenges such as limited resources, medical equipment and staff hinder efforts to integrate diagnostic services. The women strongly preferred integrated diagnosis, even if it meant enduring long waiting times, and valued the convenience of receiving all necessary services in a single visit. The study highlighted the hidden socio-economic barriers to 'free' healthcare and underscored the importance of addressing systemic inefficiencies.Conclusion\u00a0The insights gained from this study are transferable and contribute to the understanding of integrated diagnostic services in maternal healthcare contexts.Contribution:\u00a0They offer practical recommendations for improving service delivery and health outcomes in similar settings.
\n \n\n \n \nSlide presentation \nPillar 3: Practice and Policy
\n \n\n \n \nSlide Presentation \n Pillar 2: Interventions and Evidence
\n \n\n \n \nObjectives: Evidence from clinical trials suggests that antihypertensive treatment is associated with an increased risk of common electrolyte abnormalities. We aimed to develop and validate two clinical prediction models to estimate the risk of hyperkalaemia and hyponatraemia, respectively, to facilitate targeted treatment and monitoring strategies for individuals indicated for antihypertensive therapy. Design and methods: Participants aged at least 40 years, registered to an English primary care practice within the Clinical Practice Research Datalink (CPRD), with a systolic blood pressure reading between 130 and 179 mmHg were included the study. The primary outcomes were first hyperkalaemia or hyponatraemia event recorded in primary or secondary care. Model development used a Fine-Gray approach with death from other causes as competing event. Model performance was assessed using C-statistic, D-statistic, and Observed/Expected (O/E) ratio upon external validation. Results: The development cohort included 1 773 224 patients (mean age 59 years, median follow-up 6 years). The hyperkalaemia model contained 23 predictors and the hyponatraemia model contained 29 predictors, with all antihypertensive medications associated with the outcomes. Upon external validation in a cohort of 3 805 366 patients, both models calibrated well (O/E ratio: hyperkalaemia 1.16, 95% CI 1.13-1.19; hyponatraemia 1.00, 95% CI 0.98-1.02) and showed good discrimination at 10 years (C-statistic: 0.69, 95% CI 0.69-0.69; 0.80, 95% CI 0.80-0.80, respectively). Conclusion: Current clinical guidelines recommend monitoring serum electrolytes after initiating antihypertensive treatment. These clinical prediction models predicted individuals' risk of electrolyte abnormalities associated with antihypertensive treatment and could be used to target closer monitoring for individuals at a higher risk, where resources are limited.
\n \n\n \n \nObjectives: This study investigates how prior home blood pressure monitoring (HBPM) experience affects blood pressure variability and evaluates if reduced HBPM regimens could be recommended for experienced patients. Methods: This posthoc analysis of the TASMINH4 trial included self-monitored blood pressure (BP) data from 225 patients. The standard deviation of systolic BP recordings was calculated for each patient-week to assess how BP variability changes with HBPM duration. A subgroup of 84 patients, who submitted at least 1 reading a day for 7days at months 1, 3, and 6, was analysed to assess the impact of reduced HBPM regimens on BP estimates. Results: Day 1 readings were significantly higher than day 2\u20137 in the first 3months of HBPM: 1.1 (95% CI 1.8, 0.4) day 1 vs. day 2. This effect diminished after 6months: 1.0 (95% CI -0.8, 2.8) day 1 vs. 2. Long term monitoring significantly reduced intra-week BP variability, with the standard deviation of systolic BP recordings within each patient-week significantly reduced after 6months. After 6months of HBPM, the inclusion of day 1 readings or use of an abbreviated monitoring regimen had a reduced impact on estimates of mean systolic and diastolic blood pressure. Conclusions: Long-term HBPM reduces intra-week BP variability, making day 1 readings insignificantly raised after 6months of HBPM. This provides rationale for different HBPM recommendations: longer regimes, excluding day one readings, for diagnosis and short-term monitoring; and abbreviated regimes including day 1 for longer term monitoring in those with HBPM experience.
\n \n\n \n \nBACKGROUND: Social prescribing is increasingly used to support well-being through non-clinical, community-based interventions. However, there is limited understanding of how cultural activities can be tailored for older people from global majority groups. The TOUS study (Tailoring cultural Offers with and for diverse older Users of Social prescribing) explores how cultural offers can be adapted to meet the needs of these communities. AIM: This study aims to understand how storytelling can be used within a realist evaluation to explore the role of cultural activities in enhancing well-being among older adults from global majority groups. METHOD: Storytelling was used as a key method of data collection in two case studies. This approach involves four open-ended questions that allow participants to share experiences in their own words. Each transcript is condensed into a two-page narrative, approved by the participant, and used in collaborative discussions with stakeholders. This method aligns with the patient-centred ethos of social prescribing and complements realist evaluation by highlighting mechanisms of change and barriers to participation. RESULTS: Preliminary findings suggest cultural institutions can foster inclusion, connection, and identity among participants. Storytelling revealed the importance of culturally relevant, welcoming spaces and captured the nuanced experiences of individuals often overlooked in traditional research. CONCLUSION: Storytelling enriches realist evaluation by offering a participant-led, less extractive method of data collection. It bridges individual experiences with broader programme outcomes and provides a valuable approach for researchers aiming to centre voices from underrepresented communities in primary care research.
\n \n\n \n \nINTRODUCTION: Forms of combustible tobacco, such as shisha and pipe tobacco, are popular in the Middle East. Poly use of combustible tobacco products increases exposure to the harmful toxicants in them. Little is known about patterns of tobacco use behaviors in Middle Eastern countries and the potential harms due to particular types and concurrent versus single-use. METHODS: We analyzed data on tobacco use from 7,535 Emirati adults as part of the UAE Healthy Future Study, a longitudinal cohort study in the United Arab Emirates. We examined associations between single, dual, or poly combustible tobacco use and sociodemographic and clinical factors, including markers of cardiovascular disease (CVD). We also examined associations between the type of tobacco used and markers of CVD. RESULTS: Age-adjusted prevalence of combustible tobacco use was 34%. Single, dual, and poly use were 47%, 35%, and 18%, respectively. Parental tobacco use was associated with any kind of combustible tobacco use, and was strongly associated with poly use (RRRp=4.4, 95% CI=1.2, 16.8). Those who used one or more combustible tobacco products had higher levels of some CVD markers, notably HDL and Apolipoprotein A. Use of any type of tobacco was associated with increased risk for markers of CVD. CONCLUSIONS: Any amount of tobacco used was associated with differences in CVD markers. Associations were strongest for poly tobacco users. Future studies are needed to understand relationships between single, dual and poly combustible tobacco use, different combustible tobacco types, and disease risk. IMPLICATIONS: All forms of tobacco were associated with markers of CVD, signaling that there is no safer form of combustible tobacco. The study is one of the largest to characterize tobacco use behaviors in a Middle Eastern population, and should provide an important benchmark for further research on different, and sometimes co-occurring, forms of tobacco use.
\n \n\n \n \nBACKGROUND: Social prescribing addresses non-medical factors affecting health and well-being. Link workers are key to its delivery by connecting people to relevant support, often in the voluntary, community and social enterprise sector. Funding from the National Health Service means that link workers are becoming a common part of primary care in England. OBJECTIVE: To explore and understand the implementation of link workers in primary care in England. DESIGN: A realist evaluation addressed the question - When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? SETTING: Link workers and staff associated with seven primary care sites across England. METHODS: Researchers spent 3 weeks with each link worker, going to meetings with them, watching them interact with patients, with healthcare staff and with voluntary, community and social enterprise organisations. In addition, interviews were conducted with 61 patients and 93 professionals (voluntary, community and social enterprise representatives and healthcare staff, including link workers). Follow-up interviews were conducted with 41 patients and with link workers 9-12 months later. Data were coded and developed into statements to identify how context around the link worker triggers mechanisms that lead to intended and unintended outcomes. RESULTS: We found that link workers exercise micro-discretions in their role - actions and advice-giving based on personal judgement of a situation, which may not always reflect explicit guidance or protocols. Our analysis highlighted that micro-discretions engender positive connections (with patients, healthcare staff, the voluntary, community and social enterprise sector) and promote buy-in to the link worker role in primary care. Micro-discretions supported delivery of person-centred care and enhanced job satisfaction. Data also highlighted that lack of boundaries could place link workers at risk of overstepping their remit. LIMITATIONS: Our research focused on link workers attached to primary care; findings may not be applicable to those working in other settings. Data were collected around seven link worker cases, who were selected purposively for variation in terms of geographical spread and how/by whom link workers were employed. However, these link workers were predominately white females. CONCLUSIONS: Enabling link workers to exercise micro-discretions allows for responsiveness to individual patient needs but can result in uncertainty and to link workers feeling overstretched. FUTURE WORK: Poor link worker retention may, in part, be associated with a lack of clarity around their role. Research to explore how this shapes intention to leave their job is being conducted by authors of this paper. FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.
\n \n\n \n \nBackground Following the 2019 NHS Long Term Plan, link workers have been employed across primary care in England to deliver social prescribing. Aim To understand and explain how the link worker role is being implemented in primary care in England. Design and setting This was a realist evaluation undertaken in England, focusing on link workers based in primary care. Method The study used focused ethnographies around seven link workers from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from health care and the voluntary, community, and social enterprise sector. We reinterviewed 41 patients, seven link workers, and a link worker manager 9\u201312 months after their first interview. Results We developed four concepts from the codes developed during the project on the topic around how link workers are integrated (or not) within primary care: (or not) within primary care: centralising or diffusing power; forging an identity in general practice; demonstrating effect; and building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of link workers into primary care \u2014 from being \u2018bolted on\u2019 to existing provision, without much consideration, to \u2018fitting in\u2019, shaping what is delivered to be accommodating, through to \u2018belonging\u2019, whereby they are accepted as a legitimate source of support, making a valued contribution to patients\u2019 broader wellbeing. Conclusion Social prescribing was introduced into primary care to promote greater attention to the full range of factors affecting patients\u2019 health and wellbeing, beyond biomedicine. For that to happen, our analysis highlights the need for a whole-system approach to defining, delivering, and maintaining this new part of practice.
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