At the Alma-Ata conference in 1978, multiple influential organisations gathered to define the core values of primary care.1 At this meeting, it was decided to adopt continuity of care as one of the core values. Continuity of care has several components: relational continuity, which stresses the personal patient–practitioner relationship over time; management continuity, which is about coordination of care across different healthcare professionals (HCPs); and informational continuity, which relates to appropriate transfer of patient data between different HCPs and between primary and secondary care.2

Numerous studies have shown beneficial effects of aiming for continuity of care. It is associated with reductions in emergency department use, hospital admissions and mortality.3–5 Importantly, it is also associated with improvements in patient satisfaction.6 7 Inversely, a reduction in continuity of care is associated with reduced patient satisfaction and higher...

Many patients with cancer are diagnosed in an emergency care context (often also termed ‘emergency presentation’ (EP)), and these patients have markedly worse prognosis and poorer patient experience even after adjustment for stage at diagnosis.1 2 Therefore, reducing the frequency of diagnosis of cancer as an emergency is an important public health and healthcare quality improvement target. Yet the extent to which preventing diagnosis as an emergency leads to improved survival remains unclear, and we do not know whether effective strategies to reduce the frequency of emergency diagnosis exist. Khalaf et al provide important new evidence to help address these critical questions.3

In 2012, Elliss-Brookes et al linked English cancer registration with National Health Service hospital administration and screening programme data to produce the first population-wide study examining the ‘routes to diagnosis’ of cancer.4 The findings were revealing. Across 15 common...

Objective

Relational continuity of care is associated with better patient experience and health outcomes. In England, relational continuity of primary care has been declining over a decade, coinciding with an increase in patient complaints. This study investigates the relationship between relational continuity of care and patient complaints.

Methods

Cross-sectional analysis of linked practice-level data in the English National Health Service (NHS) (2016/2017–2022/2023) obtained from NHS Digital and General Practice Patient Survey (GPPS). A negative binomial model was used to investigate the association between the proportion of patients never or almost never seeing their preferred general practitioner (GP) and new written complaints per 10 000 patients, with adjustment for patient demographics, socioeconomic status, care experiences, practice care capacity and care quality. Mediation analysis was further conducted to examine patients’ lost trust and unmet clinical needs as potential mechanisms.

Results

A 10 percentage point increase in the proportion of patients reporting low continuity was associated with 1.34 more new complaints per 10 000 patients (95% CI 1.23 to 1.46). The association may be stronger after than before the pandemic, among general practices with historically better continuity, and in more deprived areas. The findings were robust in using different measures of relational continuity, adjusting for primary case demand–supply mismatches, implementing a Poisson model with practice fixed effects and excluding ethnicity from the model specification. Mediation analysis showed that neither lost trust nor unmet care needs were important mediators of the effects of low continuity.

Conclusion

Self-reported low continuity of primary care is associated with more patient complaints in England. Future research should explore potential underlying mechanisms and establish whether the same relationship exists between objectively measured relational continuity and patient complaints.

Background

We previously developed a digital quality measure (dQM) of emergency presentations (EPs) in colorectal cancer (CRC) and found it to be associated with worse outcomes. Potentially avoidable EPs were common in this cohort, but identifying them required time-intensive chart reviews. We aimed to enhance the existing dQM to automate the detection of potentially avoidable EPs.

Materials and methods

We defined potentially avoidable EPs as those preceded by a CRC red flag (iron-deficiency anaemia or haematochezia ≥60 days prior, or positive stool-based screening test ≥180 days prior). The enhanced dQM was applied to a national cohort of incident CRC cases diagnosed in the Veterans Affairs healthcare system from 2017 to 2021. We examined associations with cancer stage, treatment and mortality.

Results

The enhanced dQM had a positive predictive value of 92% (95% CI 85.5% to 95.7%) for identifying potentially avoidable EPs. Among 9096 CRC cases, 28.1% were identified as EPs. Of these, 31.6% were classified as potentially avoidable. These patients were more likely to have advanced-stage disease (adjusted OR 1.50; 95% CI 1.27 to 1.78), less likely to receive treatment (adjusted OR 0.58; 95% CI 0.48 to 0.70) and had higher mortality (adjusted HR 1.58; 95% CI 1.40 to 1.79) compared with other patients with CRC.

Conclusions

The enhanced dQM accurately identified potentially avoidable EPs, which were associated with worse outcomes. This measure is unique in its focus on cases of preventable care delays, which can help guide future efforts to improve diagnostic timeliness and reduce EPs among patients with CRC.

Background

Voluntary assisted dying (VAD) in Victoria, Australia, is governed by a stringent legislative framework, designed and enforced by the state, as well as other forms of regulation. However, there remains limited understanding about how these various forms of regulation operate at the frontline or how clinicians themselves can influence regulation.

Objectives

This article explores how clinicians working at the frontline (clinical coalface) may influence the regulation of VAD in Victoria, and how this contributes to the safe and effective delivery of VAD.

Methods

Reflexive thematic analysis of 30 semistructured interviews with 37 ‘regulators’ (defined as those capable of steering and guiding behaviour with respect to VAD).

Results

Data analysis resulted in the generation of three main themes: (1) coalface regulation extends regulations at the clinical level, ensuring adherence to laws while developing new standards and systems for safe and effective practice; (2) coalface regulation guides day-to-day VAD practice; and (3) coalface regulation plays a critical role in quality monitoring and improvement.

Conclusions

Clinicians play a significant role in VAD regulation in Victoria and fulfil what we define as a ‘coalface regulator’ role. These coalface regulators are influential in ensuring the safe and effective delivery of VAD. Understanding how coalface regulation intersects with other forms of VAD regulation and how this regulatory influence can be harnessed is critical for optimising VAD regulation, safety and improving service delivery at a local and system level.

Objective

Quality improvement (QI) practices and scholarship are increasingly concerned with environmental sustainability given the negative health outcomes caused by the ecological crisis, as well as the environmental impacts of healthcare delivery itself. A core component of QI activities is measuring change. How sustainability metrics have been used in QI is unclear. We conducted a scoping review of metrics used in published sustainability-focused QI initiatives.

Data sources

MEDLINE, EMBASE, CINAHL and Scopus from 2000 to 2023.

Eligibility criteria

Published healthcare QI initiatives intended to address environmental sustainability with at least one quantitative sustainability metric.

Data analysis

Publication, study, measurement and QI intervention characteristics were charted from included studies. Data items were synthesised and presented narratively as well as quantitatively.

Results

We screened 6294 studies and included 90 full-text publications. The studies were published from 2000 to 2023, with the majority (61%, 55/90) published since 2020. Publications originated from a wide range of clinical disciplines with most QI projects situated in the inpatient setting (78%, 70/90). Environmental sustainability metrics were subcategorised into activity data and environmental impact indicators. Some papers included more than one category of activity data, with the most common being cost (88%, 79/90), hospital waste (52%, 47/90), anaesthetic gases (49%, 44/90), disposable use (24%, 22/90) and distance travelled (14%, 13/90). Fewer publications included environmental impact indicators, with global warming potential dominating this category (53%, 48/90).

Discussion

There is a need to align QI efforts with environmental sustainability. However, there is limited guidance specific to healthcare QI on how to measure environmental impacts of these efforts. This review illuminates that sustainability-focused QI efforts to date have used a relatively narrow set of sustainability metrics. QI scholars and practitioners can benefit from further education, measurement frameworks and guidelines to effectively incorporate environmental sustainability metrics into QI efforts.

Objectives

With the growing adoption of virtual consultations in primary care, the need for tailored metrics to evaluate their safety became increasingly urgent. This systematic review seeks to identify and review existing safety measures that could be used for safety evaluation of virtual consultations in primary care.

Methods

This has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and followed a published protocol. A systematic literature search was performed in Ovid MEDLINE/PubMed, Embase and Cochrane Library databases from 2014 to 2024. Studies comparing virtual consultations with face-to-face consultations in the primary care setting were included. An inductive thematic analysis was performed to systematically extract and group the safety measures into overarching themes, with a narrative synthesis to summarise the results.

Results

A total of 47 studies (31 experimental and 16 observational studies) were included (n=2 223 697 patients). All studies assessed the safety of virtual versus face-to-face consultations via one or both of the following domains: (1) factors that influence the safety of virtual consultations and (2) tangible outcomes of virtual care safety. The former were categorised into provider-related, patient-related and system-related factors. Tangible outcomes were evident through three subthemes—adverse events, health outcomes and patient perception of safety.

Conclusions

This review provides a systematic synthesis of measures for the safety evaluation of virtual consultations. Further research into patient and physician perspectives is needed to identify aspects and indicators not captured in this study, followed by a consensus study to finalise safety metrics. Ultimately, having a robust methodology for safety evaluation of virtual consultations in place will enable safety monitoring, root cause analyses and safety improvement.

PROSPERO registration number

PROSPERO CRD42023464878.

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