Association of Digoxin Use With Transplant-Free Interstage Survival in Infants Palliated With a Stage 1 Hybrid Procedure.

Background Digoxin prescription in patients with single-ventricle physiology after stage 1 palliation is associated with reduced interstage death. Prior literature has primarily included patients having undergone the Norwood procedure. We sought to determine if digoxin prescription at discharge in infants following hybrid stage 1 palliation was associated with improved transplant-free interstage survival. Methods and Results A retrospective multicenter cohort analysis was conducted using data from the National Pediatric Cardiology Quality Improvement Collaborative registry data from 2008 to 2021. Infants with functional single ventricles and aortic arch obstruction discharged home after the hybrid stage 1 palliation hospitalization were included. Patients were excluded if they had supraventricular tachycardia or conversion to Norwood operation. The primary outcome was transplant-free survival. Multivariable logistic regression analysis including a propensity score for digoxin use identified associations between digoxin use and interstage death or transplant. Of 259 included infants from 45 sites, 158 (61%) had hypoplastic left heart syndrome. Forty-nine percent had a gestational age ≤38 weeks, 18% had a birth weight <2.5 kg, and 58% had a preoperative risk factor. Of the 259 subjects, 129 (50%) were discharged on digoxin. Interstage death or transplant occurred in 30 (23%) patients in the no-digoxin group compared with 18 (14%) in the digoxin group (P=0.06). With multivariate analysis, discharge digoxin prescription was associated with a lower risk of interstage death or transplant (adjusted odds ratio, 0.48 [95% CI, 0.24-0.93]; P=0.03). Conclusions In infants with single-ventricle physiology who underwent hybrid stage 1 palliation, digoxin prescription at hospital discharge was associated with improved interstage transplant-free survival.

Mycobacterium abscessus Causes Highly Resistant Infection as a Breast Abscess.

Mycobacterium abscessus is an increasing threat to public health due to its multi-drug resistance and increasing prevalence. The pathogen most commonly causes chronic respiratory infections, but it may also invade locally through the skin and soft tissue damage caused by trauma, piercings, or tattoos. A 58-year-old African American female presented with a five-month history of recurrent abscesses in the right breast. She had previously been treated with doxycycline and ceftriaxone injections at an outside clinic with minimal improvement. Following incision and drainage, cultures and susceptibilities showed M. abscessus infection with a high level of drug resistance. Due to financial barriers, the patient received a suboptimal antibiotic regimen and required multiple surgical procedures, resulting in only temporary wound healing. At the time of this report, the patient is recovering from her fourth incision and drainage, with cultures and susceptibilities pending and discussions of a total mastectomy. M. abscessus is a highly resistant bacteria capable of causing skin and soft tissue infections of the breast. Such infections may occur without an inciting event and require extensive surgical and antimicrobial management.

Medication work among nonagenarians: a qualitative study of the Newcastle 85+ cohort participants at 97 years old.

BACKGROUND: People aged ≥85 years are the fastest growing section of our population across most high-income countries. A majority live with multiple long-term conditions and frailty, but there is limited understanding of how the associated polypharmacy is experienced by this group. AIM: To explore the experiences of medication management among nonagenarians and the implications for primary care practice. DESIGN AND SETTING: Qualitative analysis of medication work in nonagenarians from a purposive sample of survivors of the Newcastle 85+ study (a longitudinal cohort study). METHOD: Semi-structured interviews (n = 20) were conducted, transcribed verbatim, and analysed using a thematic approach. RESULTS: In most cases, although considerable work is associated with self-management of medication use, it is generally not experienced as problematic by the older people themselves. Taking medications is habitualised into everyday routines and practices, and is experienced in much the same way as other activities of daily living. For some, the work associated with medications has been relinquished (either partially or wholly) to others, minimising the burden experienced by the individual. Exceptions to this were found when disruptions to these steady states occurred, for example, following a new medical diagnosis with associated medication changes or a major life event. CONCLUSION: This study has shown a high level of acceptance of the work associated with medications among this group and trust in the prescribers to provide the most appropriate care. Medicines optimisation should build on this trust and be presented as personalised, evidence-based care.

The effects of single and a combination of determinants of anaemia in the very old: results from the TULIPS consortium.

BACKGROUND AND OBJECTIVES: Nutritional deficiencies, renal impairment and chronic inflammation are commonly mentioned determinants of anaemia. The aim of this study was to investigate the effects of these determinants, singly and in combination, on anaemia in the very old. METHOD: The TULIPS Consortium consists of four population-based studies in oldest-old individuals: Leiden 85-plus Study, LiLACS NZ, Newcastle 85+ study, and TOOTH. Five selected determinants (iron, vitamin B12, and folate deficiency; low estimated glomerular filtration rate (eGFR); and high C-reactive protein (CRP)) were summed. This sum score was used to investigate the association with the presence and onset of anaemia (WHO definition). The individual study results were pooled using random-effects models. RESULTS: In the 2216 participants (59% female, 30% anaemia) at baseline, iron deficiency, low eGFR and high CRP were individually associated with the presence of anaemia. Low eGFR and high CRP were individually associated with the onset of anaemia. In the cross-sectional analyses, an increase per additional determinant (adjusted OR 2.10 (95% CI 1.85-2.38)) and a combination of ≥2 determinants (OR 3.44 (95% CI 2.70-4.38)) were associated with the presence of anaemia. In the prospective analyses, an increase per additional determinant (adjusted HR 1.46 (95% CI 1.24-1.71)) and the presence of ≥2 determinants (HR 1.95 (95% CI 1.40-2.71)) were associated with the onset of anaemia. CONCLUSION: Very old adults with a combination of determinants of anaemia have a higher risk of having, and of developing, anaemia. Further research is recommended to explore causality and clinical relevance.

Changes in Serum Thyroid Function Predict Cognitive Decline in the Very Old: Longitudinal Findings from the Newcastle 85+ Study.

Background: Low serum thyrotropin (TSH) has been associated with an increased risk of cognitive impairment in observational studies of older individuals, but the mechanism underlying this is unclear. We investigated the association between changes in thyroid status and cognitive impairment in very old adults, using prospective data from the Newcastle 85+ study. Method: A cohort of 85-year-old individuals was assessed for health status and thyroid function. Complete data from a comprehensive multidimensional measure of health and repeat thyroid function were available for 642 participants with normal free thyroid hormones and TSH levels ranging between 0.1 and 10 mU/L. Cognitive performance, assessed using Mini-Mental State Examination (MMSE) and Cognitive Drug Research battery was examined by using linear mixed, logistic regression, and Cox proportional hazard models in relation to baseline and 3-year changes in serum TSH, free thyroxine (fT4), and free triiodothyronine (fT3). Results: Over 3 years, declining serum TSH was associated with reductions in fT4 and fT3, and an increased risk of incident cognitive impairment by 5 years (odds ratio1.77 [95% confidence interval: 1.19-2.61]; p = 0.004). A greater reduction in MMSE score was associated with larger TSH decline, at 3 (p = 0.001) and 5 years (p < 0.001), respectively. Steady fT4 concentrations were found in participants with rising TSH. Conclusions: In contrast to physiological expectation, in this group of 85-year-olds, a declining serum TSH was associated with reductions in free thyroid hormones over time. A decreasing serum TSH trajectory over time anticipated cognitive decline in later life. Declining TSH concentrations are a biomarker for cognitive impairment in later life.

Anaemia and physical and mental health in the very old: An individual participant data meta-analysis of four longitudinal studies of ageing.

OBJECTIVE: To determine the physical and mental health of very old people (aged 80+) with anaemia. METHODS: Individual level meta-analysis from five cohorts of octogenarians (n = 2,392): LiLACS NZ Maori, LiLACS NZ non-Maori, Leiden 85-plus Study, Newcastle 85+ Study, and TOOTH. Mixed models of change in functional ability, cognitive function, depressive symptoms, and self-rated health over time were separately fitted for each cohort. We combined individual cohort estimates of differences according to the presence of anaemia at baseline, adjusting for age at entry, sex, and time elapsed. Combined estimates are presented as differences in standard deviation units (i.e. standardised mean differences-SMDs). RESULTS: The combined prevalence of anaemia was 30.2%. Throughout follow-up, participants with anaemia, on average, had: worse functional ability (SMD -0.42 of a standard deviation across cohorts; CI -0.59,-0.25); worse cognitive scores (SMD -0.27; CI -0.39,-0.15); worse depression scores (SMD -0.20; CI -0.31,-0.08); and lower ratings of their own health (SMD -0.36; CI -0.47,-0.25). Differential rates of change observed were: larger declines in functional ability for those with anaemia (SMD -0.12 over five years; CI -0.21,-0.03) and smaller mean difference in depression scores over time between those with and without anaemia (SMD 0.18 over five years; CI 0.05,0.30). CONCLUSION: Anaemia in the very old is a common condition associated with worse functional ability, cognitive function, depressive symptoms, and self-rated health, and a more rapid decline in functional ability over time. The question remains as to whether anaemia itself contributes to worse outcomes or is simply a marker of chronic diseases and nutrient deficiencies.

The Association between 25-Hydroxyvitamin D Concentration and Disability Trajectories in Very Old Adults: The Newcastle 85+ Study.

Background: Low vitamin D status is common in very old adults which may have adverse consequences for muscle function, a major predictor of disability. Aims: To explore the association between 25-hydroxyvitamin D [25(OH)D] concentrations and disability trajectories in very old adults and to determine whether there is an 'adequate' 25(OH)D concentration which might protect against a faster disability trajectory. Methodology: A total of 775 participants from the Newcastle 85+ Study for who 25(OH)D concentration at baseline was available. Serum 25(OH)D concentrations of <25 nmol/L, 25-50 nmol/L and >50 nmol/L were used as cut-offs to define low, moderate and high vitamin D status, respectively. Disability was defined as difficulty in performing 17 activities of daily living, at baseline, after 18, 36 and 60 months. Results: A three-trajectory model was derived (low-to-mild, mild-to-moderate and moderate-to-severe). In partially adjusted models, participants with 25(OH)D concentrations <25 nmol/L were more likely to have moderate and severe disability trajectories, even after adjusting for sex, living in an institution, season, cognitive status, BMI and vitamin D supplement use. However, this association disappeared after further adjustment for physical activity. Conclusions: Vitamin D status does not appear to influence the trajectories of disability in very old adults.

Natural History of Social Participation in the Very Old: Findings from the Newcastle 85+ Study.

Objective: To describe the natural history of social participation in people aged 85 years and over. Methods: Prospective cohort study; Newcastle 85+ study. Data were collected at baseline (n = 850) and at 18-, 36- and 60-month follow-ups (n = 344). Participation in 19 social activities (e.g. playing bingo, doing volunteer work and watching television) was measured at each time point. Results: The mean number of activities reported at baseline was 8.7 (SD 2.6). The number of activities was higher in those with higher educational attainment and intact walking ability (both p < .001). Social participation decreased significantly over time (p < .001) and at a similar rate in both sexes and for those with/without limited walking ability but at a higher rate in those with higher than lower educational attainment (p = .019). Discussion: Social participation seems to decrease significantly between ages 85 and 90 years; ways of encouraging social participation in this age group are needed.

Transitions between frailty states in the very old: the influence of socioeconomic status and multi-morbidity in the Newcastle 85+ cohort study.

BACKGROUND: Using Newcastle 85+ Study data, we investigated transitions between frailty states from age 85 to 90 years and whether multi-morbidities and socioeconomic status (SES) modify transitions. METHODS: The Newcastle 85+ Study is a prospective, longitudinal cohort study of all people born in 1921 in Newcastle and North Tyneside. Data included: a multidimensional health assessment; general practice record review (GPRR) and date of death. Using the Fried phenotype (participants defined as robust, pre-frail or frail), frailty was measured at baseline, 18, 36 and 60 months. RESULTS: Frailty scores were available for 82% (696/845) of participants at baseline. The prevalence of frailty was higher in women (29.7%, 123/414) than men (17.7%, 50/282) at baseline and all subsequent time points. Of those robust at baseline, 44.6% (50/112) remained robust at 18 months and 28% (14/50) at age 90. Most (52%) remained in the same state across consecutive interviews; only 6% of the transitions were recovery (from pre-frail to robust or frail to pre-frail), and none were from frail to robust. Four or more diseases inferred a greater likelihood of progression from robust to pre-frail even after adjustment for SES. SES did not influence the likelihood of moving from one frailty state to another. CONCLUSIONS: Almost half the time between age 85 and 90, on average, was spent in a pre-frail state; multi-morbidity increased the chance of progression from robust and to frail; greater clinical intervention at the onset of a first chronic illness, to prevent transition to multi-morbidity, should be encouraged.

Relative prevalence and distribution of knee, hand and foot symptomatic osteoarthritis subtypes in an English population.

In this brief report, we used data from a series of three related cohorts on pain and osteoarthritis (OA) of the knee, hand and foot, which were conducted in North Staffordshire, England. We used a common approach for sampling, data collection and coding, to estimate the relative prevalence of 10 different symptomatic radiographic OA subtypes in the knee, hand and foot and to compare their association with age, sex, socioeconomic position and body mass index. Overall, symptomatic hand OA was more common than knee or foot OA (22.4% vs 17.4% vs 16.5%), due mainly to the high prevalence of nodal interphalangeal joint OA among women. The first carpometacarpal joint OA was the most frequent subtype, with patellofemoral, tibiofemoral, (nodal) interphalangeal and midfoot OA also common. Of the risk factors examined, the greatest differences between subtypes appeared to be their associations with sex and obesity: sex differences were noticeably greater for all forms of hand OA except non-nodal interphalangeal joint OA, while obesity appeared most strongly associated with forms of knee OA. The prevalence of all subtypes was higher among older ages, and among those with lower educational attainment.

Frailty, hospital use and mortality in the older population: findings from the Newcastle 85+ study.

BACKGROUND: Frailty is a significant determinant of health care utilisation and associated costs, both of which also increase with proximity to death. What is not known is how the relationships between frailty, proximity to death, hospital use and costs develop in a population aged 85 years and over. METHODS: This study used data from a prospective observational cohort, the Newcastle 85+ Study, linked with hospital episode statistics and death registrations. Using the Rockwood frailty index (cut off <0.25), we analysed the relationship between frailty and mortality, proximity to death, hospital use and hospital costs over 2, 5 and 7 years using descriptive statistics, Kaplan-Meier survival curves, Cox's proportional hazards and negative binomial regression models. RESULTS: Baseline frailty was associated with a more than two-fold increased risk of mortality after 7 years, compared to people who were non-frail. Participants classified as frail spent more time in hospital over 7 years than the non-frail, but this difference declined over time. Baseline frailty was not associated with increased time spent in hospital during the last 90 days of life. CONCLUSION: Evidence continues to accrue on the impact of frailty on emergency health care use. Hospital and community services need to adapt to meet the challenge of introducing new proactive and preventative approaches, designed to achieve benefits in clinical and/or cost effectiveness of frailty management.

A meta-analysis of genome-wide association studies identifies multiple longevity genes.

Human longevity is heritable, but genome-wide association (GWA) studies have had limited success. Here, we perform two meta-analyses of GWA studies of a rigorous longevity phenotype definition including 11,262/3484 cases surviving at or beyond the age corresponding to the 90th/99th survival percentile, respectively, and 25,483 controls whose age at death or at last contact was at or below the age corresponding to the 60th survival percentile. Consistent with previous reports, rs429358 (apolipoprotein E (ApoE) ε4) is associated with lower odds of surviving to the 90th and 99th percentile age, while rs7412 (ApoE ε2) shows the opposite. Moreover, rs7676745, located near GPR78, associates with lower odds of surviving to the 90th percentile age. Gene-level association analysis reveals a role for tissue-specific expression of multiple genes in longevity. Finally, genetic correlation of the longevity GWA results with that of several disease-related phenotypes points to a shared genetic architecture between health and longevity.

Factors associated with change in self-reported physical activity in the very old: The Newcastle 85+ study.

BACKGROUND: Higher physical activity (PA) has been linked to better health and functioning. Trajectories of PA and associated factors have been studied in older adults aged ≥65, but less is known about influences on PA change in the very old (aged ≥85). OBJECTIVE: To investigate factors associated with self-reported PA and PA change over time in very old adults. METHODS: 845 participants in the Newcastle 85+ Study were followed for health and functioning at 1.5-, 3-, and 5-year follow-up (wave 2 to 4). PA scores (range 0-18) and PA levels (low (PA scores 0-1), medium (2-6) and high (7-18)) were determined using a purpose-designed PA questionnaire. We used linear mixed models (LMM) to investigate factors associated with 5-year change in PA scores. RESULTS: Overall, men had higher mean PA scores than women (up to 2.27 points). The highest proportion of participants (42-48%) had medium levels of PA across the waves. Although most experienced decline-stability in moderate and increases in high PA levels were also observed. The fully adjusted LMM revealed a curvilinear annual decline in PA scores of 0.52 (0.13) (ß (SE), p<0.001), which decelerated by 0.07 (0.02) points (p<0.01) over time. The factors associated with low PA scores at baseline were female gender, higher waist-hip ratio, and no alcohol intake. Better self-rated and cognitive health and having fewer diseases were associated with higher PA scores. None were associated with the rate of change in PA over time. CONCLUSION: We observed a curvilinear trend and deceleration in PA scores decline in the very old. Men and those in better health and who drank alcohol were more physically active at baseline. None of the factors were associated with the rate of PA decline. Investigating those who maintain or increase levels of PA may inform interventions for at risk groups with PA decline.

Care home services at the vanguard: a qualitative study exploring stakeholder views on the development and evaluation of novel, integrated approaches to enhancing healthcare in care homes.

OBJECTIVES: To explore stakeholders' understanding of novel integrated approaches to enhancing care in care homes (a care home 'vanguard') and identify priorities for evaluation. DESIGN: A qualitative study, using semistructured interviews with commissioners and service providers to/within care homes, and third sector organisations with thematic analysis. SETTING: A Clinical Commissioning Group (CCG) area in England. PARTICIPANTS: Thirty interviewees from care homes, the National Health Service (NHS; England) and local authority, third sector (10 care home managers, 5 general practitioners, 4 CCG employees, 4 local authority employees, 1 national (NHS England) vanguard lead, 2 specialist nurses, 2 geriatricians, 1 third sector and 1 health manager). RESULTS: Four higher level themes emerged from the data: understanding of proposed changes, communication, evaluation of outcome measures of success, and trust and complexity. The vision for the new programme was shared by stakeholders, with importance attached to equitable access to high-quality care. Support for the programme was described as being 'the right thing to do', inferring a moral imperative. However, the practical implications of key aspects, such as integrated working, were not clearly understood and the programme was perceived by some as being imposed, top down, from the health service. Barriers and facilitators to change were identified across themes of communication, outcomes, trust and complexity. Importance was attached to the measurement of intangible aspects of success, such as collaboration. Interviewees understood that outcome-based commissioning was one element of the new programme, but discussion of their aspirations and practices revealed values and beliefs more compatible with a system based on trust. CONCLUSIONS: Innovation in service delivery requires organisations to adopt common priorities and share responsibility for success. The vanguard programme is working to ensure health and local authorities have this commitment, but engaging care homes that may feel isolated from the welfare system needs sustained dialogue over the longer term. Evaluation of the programme needs to measure what is important to stakeholders, and not focus too closely on resource consumption.

Use of primary care and other healthcare services between age 85 and 90 years: longitudinal analysis of a single-year birth cohort, the Newcastle 85+ study.

OBJECTIVE: To describe, using data from the Newcastle 85+ cohort study, the use of primary care and other healthcare services by 85-year-olds as they age. DESIGN: Longitudinal population-based cohort study. SETTING: Newcastle on Tyne and North Tyneside, UK. PARTICIPANTS: Community dwelling and institutionalised men and women recruited through general practices (n=845, 319 men and 526 women). RESULTS: Contact was established with 97% (n=1409/1459) of eligible 85-year-olds, consent obtained from 74% (n=1042/1409) and 851 agreed to undergo the multidimensional health assessment and a general practice medical records review. A total of 845 participants had complete data at baseline for this study (319 male, 526 female), with 344 (118 male, 226 female) reinterviewed at 60 months. After adjusting for confounders, all consultations significantly increased over the 5 years (incidence rate ratio, IRR=1.03, 95% CI 1.01 to 1.05, P=0.001) as did general practitioner (GP) consultations (IRR=1.03, 95% CI 1.01 to 1.05, P=0.006). Significant increases were also observed in inpatient and day hospital use over time, though these disappeared after adjustment for confounders. CONCLUSIONS: Our study of primary, secondary and community care use by the very old reveals that, between the ages of 85 and 90 years, older people are much more likely to consult their GP than any other primary healthcare team members. With a rapidly ageing society, it is essential that both current and future GPs are appropriately skilled, and adequately supported by specialist colleagues, as the main healthcare provider for a population with complex and challenging needs.

Assessing the need for arthritis training among paid carers in UK residential care homes: A focus group and interview study.

OBJECTIVE: The aim of the study was to perform an educational and training needs assessment for arthritis care in residential homes. METHODS: Qualitative data were collected from three purposively selected residential homes: one independent, one in a regional chain and one in a national chain. Three researcher-led focus groups were conducted with paid carers (N = 22) using vignette exercises; interviews were undertaken with 12 residents with joint pain (N = 12), five managerial staff and two general practitioners (GPs). Data were compared and analysed thematically around care practices, communication and training. RESULTS: There is a lack of arthritis awareness among paid carers, although they regularly identify and manage arthritic symptoms. Residents rely on paid carers to recognize when pain and mobility problems are treatable. Senior staff and GPs rely on carers to identify arthritic problems. However, paid carers themselves undervalued the health significance of their activities and lacked the confidence to communicate important information to healthcare professionals. Few of the paid carers had received training in arthritis and many expressed a strong desire to learn about it, to improve their ability to provide better care. CONCLUSIONS: Education for paid carers regarding arthritis is lacking and lags behind education about conditions such as dementia and diabetes. To meet the expectations of their care roles fully, paid carers require an awareness of what arthritis is and how to recognize symptoms. We suggest that training should be aimed at improving confidence in communicating with colleagues, residents and health professionals, with senior care staff receiving more in-depth training.

Clinical Significance of Medial Versus Lateral Compartment Patellofemoral Osteoarthritis: Cross-Sectional Analyses in an Adult Population With Knee Pain.

OBJECTIVE: To determine the comparative prevalence, associations with selected patient characteristics, and clinical outcomes of medial and lateral compartment patellofemoral (PF) joint osteoarthritis (OA). METHODS: Information was collected by questionnaires, clinical assessment, and radiographs from 745 eligible community-dwelling symptomatic adults age ≥50 years. PF joint space narrowing (JSN) and osteophytes were scored from skyline radiographs using the Osteoarthritis Research Society International atlas. Multilevel models were used to assess associations of compartmental PF joint OA with age, sex, body mass index (BMI) and varus-valgus malalignment, while median regression was used to examine associations with clinical outcomes (current pain intensity on a numeric rating scale [0-10] and the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [0-68]). RESULTS: Isolated lateral PF joint OA was more common than isolated medial PF joint OA, particularly at higher severity thresholds. Irrespective of severity threshold, age (≥2 odds ratio [OR] 1.19 [95% confidence interval (95% CI) 1.12, 1.26]), BMI (≥2 OR 1.15 [95% CI 1.07, 1.24]), and valgus malalignment (≥2 OR 2.58 [95% CI 1.09, 6.07]) were associated with increased odds of isolated lateral JSN, but isolated medial JSN was only associated with age (≥2 OR 1.20 [95% CI 1.14, 1.27]). The pattern of association was less clear for PF joint osteophytes. Isolated lateral PF joint OA, defined by JSN or osteophytes, was associated with higher pain scores than isolated medial PF joint OA, but these differences were modest and were not significant. A similar pattern of association was seen for functional limitation but only when PF joint OA was defined by JSN. CONCLUSION: Isolated lateral PF joint OA is more common than isolated medial PF joint OA, and it is more consistently associated with established OA risk factors. It is also associated with higher, but clinically nonsignificant, pain and function scores than isolated medial PF joint OA, particularly when PF joint OA is defined using JSN.

Patients' experiences of a multidisciplinary team-led community case management programme: a qualitative study.

OBJECTIVES: To explore the views and experiences of patients on the care they have received while enrolled on the Northumberland High Risk Patient Programme (NHRPP). This programme involved case finding of frail patients using a multidisciplinary team (MDT)-led community case management programme, and support of patients through care planning and regular reviews using primary, community, secondary and social care professionals. DESIGN: A qualitative study using semistructured interviews, which were digitally recorded, transcribed and subject to thematic analysis. SETTING: Community patients receiving primary care in the county of Northumberland, England. PARTICIPANTS: 23 participants took part, of which 16 were patients enrolled on the NHRPP, and 7 carers. GP practices were selected purposively by size, deprivation and location, and patients identified and invited by General Practitioners to participate. RESULTS: 4 main themes emerged from the data: awareness and understanding of the NHRPP, confidence in the primary healthcare team, limitations of home care and the active role of being a patient. Despite having a low level of awareness of the details of the NHRPP, participants did think that its broad aim made sense. Participants discussed their high level of satisfaction with their care and access to team members. However, some limitations of alternatives to hospital care were identified, including the need to consider psychological as well as medical needs, the importance of overnight care and the needs of those without informal carers. Finally, participants discussed the active nature of being a patient under the NHRPP if they were to contribute fully to planning and managing their own care. CONCLUSIONS: This study has identified that a programme of MDT-led case management was generally very well received by patients and their families. However, a number of factors were identified that could improve the implementation of the programme and further research needs to be undertaken to address these.