To explore whether routine electronic healthcare records can be used to identify triggers for initiating advance care planning (ACP) and the optimal time window to initiate ACP. We aimed to assess the prevalence of triggers for initiating ACP as defined for use in routine data, whether their presence is associated with death, and what their position is relative to a previously identified ‘optimal time window for ACP’.

Nested case-control study within a large dynamic population cohort dataset.

Primary care population-based, anonymised data extracted from GP centres in the South Holland province, The Netherlands.

We selected records of individuals aged ≥65 registered with their general practice from 1 Jan 2014 to 1 Jan 2017. Cases were individuals who died between 1 Jan 2017 and 1 Jan 2020. Controls were individuals who remained alive. Cases were matched by age to controls in a 1:4 ratio.

Outcomes include prevalence of triggers for ACP in the records of deceased and living individuals; association of the triggers’ presence with death; timing of the identified triggers in deceased individuals relative to the ‘optimal time window for ACP’.

We included 17098 records, 4139 from deceased individuals (mean age 81) and 12959 from living individuals (mean age 79). Triggers most strongly associated with death were consultations concerning malignancy (OR 8.35, 95% CI 7.42 to 9.41), hospital admissions (OR 7.32, 95% CI 6.75 to 7.94), emergency department referrals (OR 7.11, 95% CI 6.52 to 7.75), registered home visits (OR 5.97, 95% CI 5.51 to 6.47), consultations concerning heart failure (OR 5.25, 95% CI 4.59 to 5.99), dementia (OR 4.75, 95% CI 3.99 to 6.56), opioid prescriptions (OR 4.58 (4.25–4.93), consultations concerning general decline/feeling old (OR 4.15, 95% CI 3.72 to 4.64) and skin ulcers/pressure sores (OR 4.04, 95% CI 3.55 to 4.61). Those closest to the median of the optimal time window for ACP were consultations regarding dyspnoea, general decline/feeling old, heart failure, skin ulcers/pressure sores and fever, opioid prescriptions, emergency department referrals, registered home visits and hospital admissions.

Clinical triggers for initiating ACP in general practice can be recognised within the routine electronic health records and they align well with the ‘window of opportunity’ to initiate ACP.

Our objective was to examine the barriers and facilitators encountered by primary and secondary healthcare professionals when collaborating at the care continuum between primary and secondary care. We aimed to identify specific challenges, observed benefits and proposed changes. By analysing these experiences and identifying opportunities for redesign, we aimed to define specific domains that could improve collaboration, thereby supporting sustainable access to and quality of care in the face of rising demand and constrained resources.

A qualitative exploratory study using semi-structured interview data guided by two domains of the Consolidated Framework for Implementation Research (CFIR), including Inner Setting—Tension for Change and Individual Characteristics, as well as selected implementation outcomes defined by Proctor et al, all viewed through a service (re)design lens.

Consultation and communication between primary and secondary healthcare professionals in a Dutch urbanised area.

37 users of collaboration services (eg, telephone, correspondence) were interviewed between August 2021 and October 2022, including 14 general practitioners (GPs) (10 females, 4 males) and 23 specialists (10 females, 13 males).

Four key domains with subthemes, subdivided per operation and CFIR domain, were identified as central to optimising the collaboration of professionals within the primary-secondary care continuum: (1) software and record integration; (2) seamless personal interaction; (3) eliminating a sense of ‘us vs them’ and (4) gaps in continuity of care.

This study reveals that healthcare professionals in both primary and secondary care face similar collaboration challenges due to system-level issues and inadequate collaboration tools, leading to increased workload, miscommunication and reduced quality of care. Improving collaboration between GPs and specialists requires not only adjustments to individual services, but a comprehensive overhaul of the referral and back-referral process. A more integrated approach, addressing key domains, is crucial for enhancing care quality, streamlining workflows and improving health outcomes.

‘Hotspotters’ are patients with complex care needs, defined by problems in multiple life domains and high acute care use. These patients often receive mismatched care, resulting in overuse of care and increased healthcare costs. As reliable data on effective interventions for this population are scarce, the goal of this study is to assess the cost-effectiveness of proactive, personalised, integrated care for this group.

The Hotspotters Project is planned as a stepped wedge cluster randomised controlled trial in 20 primary care practices in the Netherlands. All practices and participants will begin with standard care during the control period (2–8 months), followed by an intervention (12 months) consisting of a positive health intake with goal setting, multidisciplinary meetings, a personalised care plan and proactive care management. The study will conclude with a follow-up (2–8 months), resulting in a total study duration of 22 months. We plan to include 200 patients with (a) problems on two or more life domains and (b) at least two acute care encounters in the previous year. Possible Hotspotters are identified using an Adjusted Clinical Groups-based algorithm or via a local primary healthcare team.

Questionnaires and routine care data will be used to gather data on cost-effectiveness, which will then be assessed using multilevel analysis, with levels for the individual, cluster and duration of control period. Secondary outcomes will include psychological outcomes on self-regulation (proactive coping, patient activation, self-efficacy and intention), experience of care (satisfaction, perceived autonomy support and qualitative data from focus groups) and quality of life, qualitative analysis of the Positive Health approach, implementation outcomes and process evaluation including integration of care.

The Ethics Committee of Leiden University Medical Centre granted approval (METC-LDD, P21.123). Results will be shared through peer-reviewed publication and (inter)national conference presentations.

NCT05878054.