Objectives:To examine trends and variation in the use of advice and guidance compared with direct referrals in primary care, and to assess potential inequalities across population groups. Design:Population based study. Setting:Clinical Practice Research Datalink (CPRD) Aurum, an anonymised UK primary care database, 1 January 2015 to 31 December 2023. Participants:16 340 696 patients with electronic health record data registered in CPRD; 671 894 (4% of the registered population) had advice and guidance recorded and 9 719 796 (59% of the registered population) had a direct referral recorded. Main outcome measures:Annual prevalence of advice and guidance, and direct referrals, in each calendar year, grouped by age, sex, social deprivation, locality, and ethnic group. Mapping of clinical codes to determine target specialities for advice and guidance. Proportion of individuals recorded with advice and guidance and a direct referral within ±4 months. Results:16 340 696 registered patients were analysed between 2015 and 2023; 671 894 patients (4%) had advice and guidance recorded and 9.7 million (59%) had a direct referral. Use of advice and guidance increased 19-fold from 0.10% to 1.97% of the registered population, doubling between 2019 and 2020 during the covid-19 pandemic. Direct referral rates decreased from 23-25% before the pandemic to 18% in 2020, before recovering to 24% by 2023. Cardiology (21%), dermatology (7%) and ear, nose, and throat (5%) were the most common specialties linked to advice and guidance. Most patients receiving advice and guidance (86%) also had a direct referral within ±4 months. Inequities were evident: use of advice and guidance was higher among older, white, and less deprived patients, whereas minority ethnic and more deprived groups had slower recovery of direct referral rates after the pandemic. Conclusions:The study showed that the use of advice and guidance has increased substantially since 2015, accelerated by the covid-19 pandemic and maintained after, but has not displaced direct referrals. Direct referral often preceded advice and guidance, raising questions about efficiency and equity. Use of advice and guidance was higher among older, white, and less deprived individuals, whereas minority ethnic and more socially deprived groups were more likely to have direct referrals after advice and guidance, suggesting potential delays in access to specialist care. Policy should prioritise dealing with these inequalities and evaluate whether advice and guidance reduces unnecessary referrals or delays access to specialist care.

ABSTRACT Background and Aims Healthcare research is an essential driver of evidence‐based practice, leading to improved service delivery and outcomes. Despite being integral to pharmacy (e.g., in driving safe and effective use of medicines), research engagement is relatively low. This service evaluation study aimed to assess pharmacy professionals' research engagement inclusive of capacity (opportunity and time) and ability (skills and knowledge), and to explore potential barriers and facilitators to research engagement. Methods The study was conducted at a single Mental Health and Community Trust in the UK between February and June in 2024. Data were collected in two phases: phase 1: an online survey assessed current research engagement, and phase 2: virtual individual interviews and a focus group explored in‐depth views on research engagement. All practising pharmacists and pharmacy technicians were eligible to participate and were invited via email through a senior pharmacist. Quantitative data were descriptively analysed, and qualitative data were audio‐recorded, transcribed and thematically analysed. As a service evaluation, no ethical approval was required. Results Of the 62 invited pharmacy professionals, 32 responded (52%, n = 20 pharmacists). Around 47% (n = 15) reported prior involvement in research activity/training. Most viewed research as relevant (63%, n = 20) and extremely valuable (72%, n = 23) to practice, and 47% (n = 15) expressed interest in engaging in future research. However, few expressed having confidence across a range of research skills. Seven interviews and one focus group were conducted. Three main themes were identified: research‐related views and experience, barriers to research engagement, and strategies to improve research engagement. Conclusion Overall, positive views on research were reflected. Current research involvement rate is low, as is the confidence in applying research to practice. Several barriers were identified, which require addressing to enhance research activity. Organisations therefore should assess research capacity and ability of their staff to identify encountered barriers to enhance research engagement.

Background Where available, Advice and Guidance (A&G) can enable primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs’ (primary care clinicians’) decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Results Four overarching themes encapsulate clinicians’ decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care.

Background Adherence to oral bisphosphonates for osteoporosis is poor; the challenges and complexity of follow-up reviews in general practice are implicated as a contributory cause. Clinical pharmacists in general practice are an expanding professional group within the UK NHS workforce and could provide person-centred medicines optimisation interventions. Aim To explore clinician and patient perceptions towards a pharmacist-led osteoporosis review, including identifying current practice, care gaps, and implementation barriers and facilitators. Design & setting Qualitative interview study with patients, clinical pharmacists, GPs, osteoporosis specialists, and service commissioners. Method Semi-structured interviews were transcribed verbatim and analysed thematically, informed by a normalisation process theory approach. Results In total, 32 participants were interviewed in 22 one-to-one interviews and four small group interviews. Three themes relevant to the design and implementation of a pharmacist-led osteoporosis follow-up review were identified: dissonant views among patients and healthcare professionals about current provision and needs; pharmacists' suitability for, and role in, osteoporosis care and training needs; and contextual issues affecting implementation of a new pharmacist-led osteoporosis review. Conclusion Our study found that current practice with respect to following-up patients initiated on oral bisphosphonate treatment in primary care is variable. Although pharmacists were highlighted as well-placed to conduct osteoporosis reviews, varying views about the need for this were highlighted along with a number of contextual barriers, including lack of financial and policy drivers in primary care, workload challenges, varying pharmacist skills and autonomy, and lack of coordination across the health system.

Background Opioids offer limited long-term benefits and carry significant risks. We developed the PROMPPT intervention to address challenges in implementing effective person-centred review and safe opioid tapering in UK primary care. PROMPPT comprises a primary care review, led by clinical pharmacists working in general practices as part of the multidisciplinary team, and an associated training package. This trial will evaluate (1) the effectiveness of PROMPPT in supporting people with persistent non-cancer pain to safely reduce opioids, where appropriate, without increasing pain/pain-related interference, and (2) cost-effectiveness compared with usual primary care. Methods Design and setting: cluster randomised controlled trial, with internal pilot, in 38 general practices across England. Participants: patients ≥18 years prescribed one or more opioids ≥6 months for persistent pain who consent to participate in a questionnaire study. Exclusions: acute pain, cancer pain, end-of-life care, dementia, severe mental illness or otherwise vulnerable, and current substance misuse treatment. Practices are randomly allocated (1:1) to either: invite participants for a PROMPPT review with a trained practice pharmacist, and follow-up as needed, or continue usual primary care review for patients who are prescribed opioids. Co-primary outcomes, measured at 12 months, are (1) reduction in self-reported opioid use (≥25% reduction in daily morphine equivalent dose from their baseline) and (2) non-inferiority of the Brief Pain Inventory total score. The trial includes an economic evaluation (within trial and longer-term cost-utility analyses) and a mixed methods process evaluation. Analysis of consultation audio-recordings, case report forms (including an intervention delivery template), acceptability questionnaires and semi-structured interviews will explore how PROMPPT was delivered and received, and how context affected implementation and outcomes. Conclusion The PROMPPT trial will assess whether review by trained clinical pharmacists working in general practices can support safe opioid reduction without compromising pain management and quality of life. Trial registration ISRCTN 45616481, 13/05/2022 https://doi.org/10.1186/ISRCTN45616481

OBJECTIVES:Assess individual hospital-based pharmacy professionals' (PP) research readiness (experience, skills, knowledge, capacity, capability). METHODS:A cross-sectional service evaluation study was conducted with practicing PPs across four NHS mental health trusts within the West and East Midlands region of England between February and June 2024. Each participating trust administered an identical online survey (adapted from a previous published research readiness survey) to their pharmacy teams. The survey captured participant characteristics, included mixed open and closed questions, and data related to research skills/knowledge, experience, confidence, and barriers to research engagement. This paper presents pooled analysis of these surveys with data descriptively analysed using SPSS software, and free text data analysed using content analysis by NVivo software. KEY FINDINGS:A total of 164 PPs were eligible to participate, with 88 professionals (54%) completing the surveys. Most reflected positive views on the value and relevance of research to pharmacy practice, with 74% agreeing that research should be incorporated into professional development. However, only 33% reported research experience and low confidence was expressed in the ability to conduct research-related activities. Free text responses identified four themes focusing on the benefits and relevance of research to practice, questions about research, and barriers to research engagement. CONCLUSIONS:Participants acknowledged the value, relevance, and benefits of research to pharmacy practice. However, several barriers were identified with gaps in research skills and confidence that should be addressed. Organizations need to work with their teams to develop strategies to overcome barriers and to instill a research supportive culture.

Background Often, people living with persistent non-cancer pain are prescribed opioids long term, despite a lack of evidence for their long-term effectiveness and safety. This study informed the design of a new practice pharmacist-led review (the PROMPPT review) for people prescribed opioids for persistent pain in UK primary care. Aim To explore the perspectives of pharmacists working in UK general practice regarding the proposed PROMPPT review, and to identify barriers to and facilitators of its delivery in practice, including supporting opioid deprescribing where appropriate. Design & setting Multi-method qualitative study conducted with pharmacists working in primary care, who were recruited via professional networks predominantly in the East Midlands and West Midlands, UK. Method Pharmacists with experience of consulting in primary care participated in semi-structured interviews ( n = 13) and two focus groups ( n = 16) to explore attitudes to, beliefs about, and experiences of the proposed PROMPPT review for people living with persistent pain. The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis. Facilitators and barriers were mapped to components of the Capability Opportunity Motivation — Behaviour (COM-B) model. Results In total, 16 facilitators and barriers relating to the delivery of the PROMPPT review were identified across 10 domains of the TDF. Factors included access to evidence-based patient-facing resources, receiving professional colleagues’ peer support, and having a therapeutic alliance with patients. These mapped to the COM-B model components as follows: capability (knowledge, skills), opportunity (environmental context and resources, social influences), and motivation (social or professional role and identity, beliefs about capabilities, beliefs about consequences, intentions, goals, emotions). Conclusion This study provides theoretically based evidence of factors influencing pharmacists’ delivery of the proposed PROMPPT review in relation to pharmacist capability, motivation, and opportunity. This work informed the co-design of both the intervention and the pharmacist training package.

Background: Nyaope increasing use has become a major public health concern, not only because of its detrimental health effects but also because of its far-reaching social consequences. This situation has caused distress for families, communities and the users themselves, contributing to ongoing cycles of dependency and instability at the social, family and individual levels. The aim of this study is to explore the perspectives of users regarding the factors underlying their use of and dependency on nyaope. Methods: An exploratory descriptive qualitative design was employed. Data were gathered from 10 nyaope users through semi-structured interviews. Results: Nyaope was widely and easily available, and purchases could be made with impunity. Factors such as peer pressure, boredom, poverty, unemployment and escapism all contributed to the initiation of nyaope use. Participants financed their habit through personal earnings, criminal activities and even support from family members. There was a pervasive sense of lawlessness associated with nyaope use, coupled with the stigmatisation and marginalisation of users by both their families and communities. Many users ultimately became part of a street-level nyaope brotherhood that perpetuated the use. Conclusion: Multisectoral and multifaceted interventions will be necessary to reduce the use of nyaope. Further research could quantify these factors and inform more effective prevention and treatment strategies. Contribution: These findings, along with input from community and family members, provide a comprehensive understanding of the factors related to nyaope use.

Objectives To investigate the anatomical locations of pain and stiffness in people with polymyalgia rheumatica (PMR) and how these compare with the general population. Methods A total of 739 people with PMR were invited to complete a postal survey at the time of their diagnosis. Respondents were sent further questionnaires after 1, 4, 8, 12, 18, 24 and 60 months. All questionnaires included a body manikin on which participants shaded areas of pain or stiffness lasting >1 day in the last month. The prevalence of pain was calculated in 44 mutually exclusive areas. Responses were compared with similar manikins completed at a single time point by an age- and gender-matched sample from a general population survey. Results Completed surveys were received from 652 people with PMR at diagnosis, 244 at 24 months and 197 at 60 months. Pain was reported in a median of 16 sites at diagnosis, with the majority reporting bilateral shoulder (81%) and hip (59%) pain. After 1 month, the median number of pain areas in people with PMR was four—the same as the general population sample—but those with PMR continued to report more bilateral shoulder and hip pain. The converse was true for unilateral pain. Conclusion Bilateral pain remains more common in people with PMR than their age- and gender-matched counterparts through the disease course. Causes of this pain could not be attributed but likely include residual disease activity, treatment sequelae and comorbidities. This knowledge will help to direct future investigations to improve quality of life for people with PMR.

Objectives To examine the number of patients screening positive for depression, while self-completing an automated check-in screen prior to a general practice consultation.Design A descriptive cross-sectional study.Setting 10 general practices in the West Midlands, England. Recruitment commenced in March 2023 and concluded in June 2023.Participants All patients aged 18 years and over, self-completing an automated check-in screen for any general practice prebooked appointment, were invited to participate during a 3-week recruitment period.Primary and secondary outcome measures The number of patients screening positive for depression using the Whooley case finding research questions was the primary outcome measure. Secondary outcome measures included: demographic and (general practice level) deprivation differences in completion responses.Results 73.5% (n=3666) of patients self-completing an automated check-in screen participated in the CAse-fInding foR depressiOn in primary care (CAIRO) study, (61.1% (n=2239) female, mean age 55.0 years (18–96 years, SD=18.5)).28.3% (n=1039) of participants provided a positive response to at least one of the two Whooley research questions (31.2% female and 23.8% male). Significantly more positive responses were obtained from females, those aged between 35 years and 49 years and those from more deprived practices.Conclusions Over a quarter of CAIRO participants provided a positive response to at least one of the two Whooley questions, suggesting possible unmet need in the population studied. A follow-up study could investigate whether responses provided at the point of check-in are raised and addressed in the subsequent consultation.

Given the poor long-term effectiveness of opioids for persistent non-cancer pain, and their potential for harm, evidence-based interventions to address opioid overprescribing for persistent pain are needed. This study aimed to explore the acceptability and feasibility of a primary care practice pharmacist-led intervention (PROMPPT review) for patients prescribed opioids for persistent pain and the feasibility of evaluating PROMPPT in a definitive trial. A single-arm study, with mixed methods process evaluation, was conducted in four English primary care practices. Adults prescribed opioids for ≥ 6 months were invited to participate in the Management of Opioids and Persistent Pain (MOPP) study by completing baseline and 3-month follow-up questionnaires. Practices invited a representative sample of MOPP participants to schedule a PROMPPT review, eight of which were audio-recorded. Following the review, pharmacists completed intervention delivery templates, and participants were sent an Acceptability Questionnaire and invited to consent to an interview. Between November 2020 and May 2021, 148 participants were recruited to the MOPP study. Of these, 123 (83 ISRCTN87628403 , registered 31 July 2020

AIM:The aim of this study was to determine whether the causes of emergency department (ED) attendance and clinical outcomes vary by frailty status. METHODS:Using the Nationwide ED Sample, causes of attendance were stratified by Hospital Frailty Risk Score (HFRS). Logistic regression was used to determine adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) of ED and overall mortality. RESULTS:A total of 155 497 048 ED attendances were included, of which 125 809 960 (80.9%) had a low HFRS (<5), 27 205 257 (17.5%) had an intermediate HFRS (5-15), and 2 481 831 (1.6%) had a high HFRS (>15). The most common cause of ED attendance in the high-HFRS group was infectious diseases (43.0%), followed by cardiovascular diseases (CVD) (24.0%) and respiratory diseases (10.2%). For the low-HFRS group, musculoskeletal disease was the most common cause (21.2%), followed by respiratory diseases (20.6%) and gastrointestinal diseases (18.5%). On adjusted analysis, high-HFRS attendances had increased overall mortality (combined ED and in-hospital) across most attendance causes, compared with their low-risk counterparts (P < 0.001). High-HFRS attendances with infectious diseases, CVD, and respiratory diseases had an increased risk of overall mortality, compared with their low-risk counterparts (aOR 23.88, 95% CI 23.42-24.34 for the infectious disease cohort; aOR 2.58, 95% CI 2.55-2.61 for the CVD cohort; and aOR 36.90, 95% CI 36.18-37.62 for the respiratory disease cohort). CONCLUSIONS:Frailty is present in a significant proportion of ED attendances, with the cause varying by frailty status. Frailty is associated with decreased ED and increased overall mortality across most attendance causes. Geriatr Gerontol Int 2025; 25: 1350-1358.

INTRODUCTION:Over the last two decades, nyaope use has evolved to become a prominent substance use disorder in South Africa, posing a significant public health burden. The majority of users are young people who are solely concerned with their next nyaope joint. This study aimed to explore the perception of family members on the factors associated with the use of and dependency on nyaope. METHODS:This was a descriptive exploratory qualitative study conducted in Tshwane, South Africa. Data were collected from 32 family members of Nyaope users via three focus group interviews conducted by a retired psychologist nurse in the three townships of Tshwane. RESULTS:The findings revealed a complex and interconnected web of elements that shape the journey of individuals from the onset of nyaope use to the point of dependence and eventual departure from their family homes. Rather than following a linear path of events, this pathway is characterised by a dynamic interplay of seven distinct themes, namely concealed nyaope use, family concerns and suspicions regarding nyaope use, confirmation of nyaope use, possible reasons for using nyaope, barriers to obtaining assistance for nyaope users, family distress, and the transition from home to a life on the streets. CONCLUSION:Most users ended up being disconnected from their families. Family members' opinions noted that the problem is perceived to be a web of elements working together rather than a linear path of events. The findings have implications for substance use services, social services, health and police services as well as schools.

BackgroundThe use of digital health (DH) interventions has increased over the past 2 decades, providing patients with alternative remote pathways for receiving health care services. Patients with major trauma frequently require long-term access to health care services to support their mental and physical health and their overall quality of life. DH interventions can help patients stay connected to rehabilitation services, thereby enhancing their health condition and helping them regain their independence, which will enable them to return to the workplace or regain a role in society. There is a need to explore existing evidence on the effectiveness of DH interventions for improving health-related outcomes in patients with major trauma. ObjectiveThis review aims to identify DH interventions that support the physical, functional, or psychological rehabilitation of patients who have experienced major physical trauma. MethodsThis review targets randomized controlled trials. Studies investigating DH interventions in adult patients with major traumatic physical injuries (end users of the interventions) are considered eligible for inclusion. Digital interventions that are delivered remotely and studies that report the impact of DH interventions on patients’ health-related outcomes will be included. The search will be limited to publications since 2000 and peer-reviewed journals. No language restrictions will be applied, and articles not written in English will be translated. The search will be conducted in MEDLINE, Embase, AMED, CINAHL Plus, and PsycInfo. Grey literature and bibliographies of included studies and relevant reviews will also be searched for potentially relevant articles. A minimum of two reviewers will independently screen retrieved references. Data extraction will be conducted by 1 reviewer and independently checked by another reviewer. Quality assessment of the included studies will be conducted using the Cochrane Risk of Bias 2 tool. Any disagreements arising at any stage of the review will be resolved through discussion or by consulting a third reviewer, if required. A meta-analysis will be performed where possible, and a descriptive analysis of the included studies will be reported. ResultsAs of January 2025, the systematic review is in the data extraction stage. Seven studies have been identified as eligible for inclusion. The findings are expected to be published in a peer-reviewed journal by December 2025. ConclusionsThe review findings will help identify existing evidence regarding DH interventions used to support the physical, functional, or psychological rehabilitation needs of patients with major trauma. This would help guide practitioners and policy makers to implement effective interventions to better support patient outcomes. The evidence synthesized from this review will also identify existing gaps and direct future research. Trial RegistrationPROSPERO CRD42023485748; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023485748 International Registered Report Identifier (IRRID)DERR1-10.2196/67675

BACKGROUND:Stakeholder involvement is a core element of the Medical Research Council (MRC) framework for developing and evaluating complex interventions, but approaches to involve stakeholders are not well-reported. We outline how stakeholders contributed to co-designing a Proactive clinical Review of patients taking Opioid Medicines long-term for persistent Pain led by Pharmacists working in primary care Teams (the PROMPPT intervention-a review and pharmacist training package). METHODS:We brought key stakeholders together to co-design the PROMPPT intervention using a person-based approach, alongside evidence from best practice guidance. We established a community of practice comprising three complementary groups: a patient advisory group, a pharmacist advisory group and a mixed stakeholder group. Patient stakeholders were identified from an existing patient involvement group. Professional stakeholders were identified using networks and social media. The three groups met in iterative workshops with predefined aims. We offered reimbursement for the stakeholders' time. OUTCOMES:The patient advisory group (n = 10), pharmacist advisory group (n = 6) and mixed stakeholder group (n = 16) each met for 2 or 3 workshops between April 2019 and February 2020. Stakeholders had expertise, often cross-cutting, in lived experience, persistent pain, opioids, delivering primary healthcare and/or promoting behaviour change. Patient stakeholders provided their perspectives of consulting about their pain and opioids. Pharmacist stakeholders provided their perspectives on how pain reviews were happening in practice and on considerations for training (e.g., vignettes and experiential learning were considered important). The mixed stakeholder group provided a breadth of views highlighting current practice, including the value of engaging the wider GP practice team, issues around clinical responsibility for prescribing and the fact that international clinical guidance was not always relevant to UK primary care. CONCLUSIONS:By understanding the context of the PROMPPT intervention, stakeholders worked to develop a new pharmacist-led primary care review ahead of feasibility testing. We make recommendations for future developers of complex interventions. PATIENT AND PUBLIC CONTRIBUTION:Patient stakeholders, including a lay co-applicant (C.S.) supported by a PPI support worker (A.H.), helped develop and refine the intervention. C.S. and A.H. read and contributed to the initial manuscript and approved the final manuscript.

INTRODUCTION:Long COVID (LC) is characterised by fatigue, muscle weakness and impaired concentration among other symptoms. No standardised diagnostic or treatment pathway is yet available, though a holistic, person-centred approach to symptom management is recommended. The LC Optimal Health Programme (LC-OHP) is a psychoeducational programme designed to support the mental and physical health of people with LC. This study aimed to examine the feasibility of delivering the LC-OHP to people with LC. METHODS:This was a feasibility randomised controlled trial of the LC-OHP conducted across the UK. Adults diagnosed with LC were recruited and randomised to control (usual care) or to intervention (LC-OHP) groups; follow-up questionnaires were completed at three- and 6-months (December 2021 to May 2023). RESULTS:Sixty participants were recruited with a completion rate of 83% (n = 50). Most participants in the LC-OHP group completed programme sessions (n = 19, 68%), rated the programme positively (n = 23, 87%); and felt that it had potential to improve health outcomes (n = 42, 70%). Initial findings demonstrate improvements across all variables at 3- and 6-months, and more so for the LC-OHP group than the control group in the short-term. CONCLUSION:Findings support the feasibility of delivering the LC-OHP to people with LC. Further, initial data demonstrate potential for the programme to improve most outcomes at three and 6 months. Data from this feasibility trial will be used as an evidence base to support a fully powered RCT of the LC-OHP on patients with LC. PATIENT OR PUBLIC CONTRIBUTION:The LC-OHP programme was adapted from the original OHP. Taking into account the various symptoms that people with LC experience, including fatigue and brain fog, public members were not directly involved in the design of the study; however, several approaches were considered to obtain ongoing support from public members while conducting the study, to suit people with LC. This included consulting with practitioners who care for people with LC and implementing their feedback, implementing prior feedback from patients with other chronic health conditions who used the OHP in previous studies, and collecting and implementing feedback from participants receiving this programme in this study. Additionally, two public members with lived LC experience were members of the data management committee that overviewed the study progress and provided continuous support. Public members and practitioners provided advice and guidance on different aspects related to the LC-OHP programme and to the process of delivering it to study participants. This included making the programme concise, visual, colourful, and more user-friendly, and adjusting and adapting the mode and timing of delivering the programme sessions (i.e., reduce the session duration, use convenient delivery methods) as preferred by study participants. TRIAL REGISTRATION:ISRCTN trial register: registration number 38746119, https://doi.org/10.1186/ISRCTN38746119.

Objective: to examine trends and variation in the use of Advice and Guidance (A&G) compared with direct referrals in primary care, and to assess potential disparities across population groups. Design: Observational study using routinely collected electronic health records Setting: Clinical Practice Research Datalink (CPRD) Aurum, 2015-2023. Main Outcome Measures: annual prevalence of A&G and direct referrals, stratified by age, gender, deprivation, locality, and ethnicity. Mapping of clinical codes was used to determine target specialities for A&G. The proportion of individuals recorded with A&G and a direct referral within ±4 months was calculated. Results: Between 2015-2023, 671,894 patients (4%; 59% female) had A&G recorded and 9.7 million (59%; 46% female) had a direct referral. A&G use increased 19-fold from (0.10% to 1.97%), doubling between 2019 and 2020 during the COVID-19 pandemic. Direct referral rates fell from 23%-25% pre-pandemic to 18% in 2020 before recovering to 24% by 2023. Cardiology (21%), Dermatology (7%) and Ear, Nose and Throat (5%) were the most common specialties linked to A&G. Most patients receiving A&G (86%) also had a direct referral within ±4 months. Inequities were evident: A&G use was higher among older, white, and less deprived patients, while minority ethnic and more deprived groups had slower recovery of direct referral rates post-pandemic. Conclusion: A&G use has increased substantially since 2015, accelerated by the pandemic and maintained after, but has not displaced direct referrals. Instead, direct referral often precedes A&G, raising questions about efficiency and equity. The system appears to benefit older, white, and less deprived individuals while minority ethnic and more deprived groups remain disadvantaged. Policy should prioritise addressing these disparities and evaluate whether A&G reduces unnecessary referrals or delays access to specialist care. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This project is funded by NIHR Health and Social Care Delivery Research (HSDR) Programme (reference number NIHR158681), and NIHR Applied Research Collaboration (ARC) West Midlands (reference number NIHR200165). CB is funded by a National Institute for Health and Care Research (NIHR) Academic Clinical Lectureship CL-2020-10-002. CJ, KPJ and CDM are part funded by the NIHR ARC West Midlands (NIHR200165). CDM is a NIHR Senior Investigator. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Clinical Practice Research Datalink (CPRD) has Health Research Authority approval to support research using anonymised patient data. This study was approved by the CPRD Research Data Governance Process (reference 24_0040223 – protocol made available to this manuscriptU+2019s reviewers). Under CPRDU+2019s ethical approval from the UK Health Research Authority to support research using anonymised patient data, individual patient consent is not required as patients contributing data to CPRD cannot be identified from the data made available to researchers. Data from CPRD adheres to the ethical principles outlined in the Declaration of Helsinki. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data may be obtained from a third party and are not publicly available. The data were obtained from the Clinical Practice Research Datalink. Clinical Practice Research Datalink data governance does not allow us to distribute patient data to other parties. Researchers may apply for data access at http://www.CPRD.com/. Code lists are openly available at https://doi.org/10.21252/t55f-vr93

OBJECTIVE:To identify the effectiveness of remote digital health (DH) interventions in supporting physical and/or psychosocial rehabilitation in patients with major physical trauma. DATA SOURCES:This review was conducted between 2000 and 2023 following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to identify relevant studies by searching 5 databases: MEDLINE, EMBASE, AMED, CINAHL Plus, and PsycInfo. Searches were limited to randomized controlled trials and peer-reviewed journals. Bibliographies of included studies and relevant reviews were searched for relevant articles. STUDY SELECTION:Inclusion criteria consisted of randomized controlled trials that investigated remote DH interventions to enhance physical, and/or psychosocial rehabilitation of adults subjected to major physical trauma (eg, traumatic brain injury or spinal cord injury [SCI]). Screening of retrieved studies was conducted by 2 reviewers. Disagreements were resolved by discussion or by consulting a third reviewer. DATA EXTRACTION:Data were extracted by one reviewer and independently checked by another. Risk of bias (ROB) was independently conducted by 2 reviewers using ROB2 tool. Disagreements were resolved by discussion or by consulting a third reviewer. DATA SYNTHESIS:Results were reported following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Seven studies were included, of which 5 had adequate power to detect a significant treatment effect. Studies included mostly men of White race. Included interventions targeted traumatic brain injuries or SCIs, and were delivered using numerous pathways (eg, video conferencing, virtual reality), with/without human support. Positive findings were generally reported with significant effects only reported by 3 studies targeting people with SCIs, reflecting improvements in physical and psychosocial outcomes. ROB ranged from low (n=3); some concern (n=2), and high (n=2). CONCLUSIONS:Overall positive findings were reported with strong evidence only reported by 3 studies targeting SCIs. Future studies should be adequately powered and include diverse populations to measure the effectiveness and cost effectiveness of DH interventions in comparison with usual care.

to examine trends and variation in the use of Advice and Guidance (A&G) compared with direct referrals in primary care, and to assess potential disparities across population groups. Observational study using routinely collected electronic health records Clinical Practice Research Datalink (CPRD) Aurum, 2015-2023. annual prevalence of A&G and direct referrals, stratified by age, gender, deprivation, locality, and ethnicity. Mapping of clinical codes was used to determine target specialities for A&G. The proportion of individuals recorded with A&G and a direct referral within ±4 months was calculated. Between 2015-2023, 671,894 patients (4%; 59% female) had A&G recorded and 9.7 million (59%; 46% female) had a direct referral. A&G use increased 19-fold from (0.10% to 1.97%), doubling between 2019 and 2020 during the COVID-19 pandemic. Direct referral rates fell from 23%-25% pre-pandemic to 18% in 2020 before recovering to 24% by 2023. Cardiology (21%), Dermatology (7%) and Ear, Nose and Throat (5%) were the most common specialties linked to A&G. Most patients receiving A&G (86%) also had a direct referral within ±4 months. Inequities were evident: A&G use was higher among older, white, and less deprived patients, while minority ethnic and more deprived groups had slower recovery of direct referral rates post-pandemic. A&G use has increased substantially since 2015, accelerated by the pandemic and maintained after, but has not displaced direct referrals. Instead, direct referral often precedes A&G, raising questions about efficiency and equity. The system appears to benefit older, white, and less deprived individuals while minority ethnic and more deprived groups remain disadvantaged. Policy should prioritise addressing these disparities and evaluate whether A&G reduces unnecessary referrals or delays access to specialist care. – Advice & Guidance (A&G) was introduced to support outpatient reform and manage NHS waiting lists. – Evidence on its usage patterns and equity across patient groups is limited. – A&G use increased 19-fold between 2015 and 2023, particularly post-pandemic. – Disparities were identified with higher uptake in older, white and less deprived groups. – Direct referrals have recovered to pre-pandemic levels, suggesting A&G is not replacing traditional pathways.

IntroductionAdherence to medicines in osteoporosis is poor, with estimated 1 year persistence rates between 16% and 60%. Poor adherence is complex, relating to combinations of fear of side effects, beliefs about medication being unnecessary, doubts about effectiveness and the burden of medication management. This is compounded by an absence of monitoring, as many patients are effectively discharged from ongoing care following the initial prescription. Clinical pharmacists in general practice are a relatively new workforce in the UK NHS; this is an unexplored professional group that could provide person-centred, adherence-focused interventions in an osteoporosis context.A model consultation intervention to be delivered by clinical pharmacists in general practice for patients already prescribed fracture prevention medications will be developed using existing evidence and theory and empirical qualitative work outlined in this protocol.Methods and analysisWe will investigate the current practice and barriers and facilitators to a clinical pharmacist-led osteoporosis intervention, including exploring training needs, through focus groups with people living with osteoporosis, pharmacists, general practitioners, osteoporosis specialists and service designers/commissioners. Framework analysis will identify and prioritise salient themes, followed by mapping codes to the theoretical domains framework and normalisation process theory to understand integration and implementation issues.We will further develop the content and model of care for the new consultation intervention through co-design workshops with stakeholder and patient and public involvement and engagement group members. The intervention in practice will be refined in a sequential process with workshops and in-practice testing with people prescribed fracture prevention medication, pharmacists and the multidisciplinary team.Ethics and disseminationEthical approval was obtained from NHS North West—Greater Manchester South Research Ethics Committee (Ref 23/NW/0199). Dissemination and knowledge mobilisation will be facilitated through a range of national bodies/stakeholders. Impact and implementation plans will accelerate this research towards a future clinical trial to determine cost and clinical effectiveness.