Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety-netting’ in primary care

Abstract

BackgroundSafety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.ObjectiveTo use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.MethodsFive electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.Results95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient’s personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.ConclusionsWe present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

Faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC): a joint guideline from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG)

“…Safety netting has come to be regarded as ‘best practice’ in relation to cancer diagnosis, especially in non-specialist settings 41 42. Its aim is to ensure patients do not drop through the healthcare net but are monitored until symptoms are explained, defined as a consultation technique to communicate uncertainty, provide patient information on red-flag symptoms and plan for future appointments to ensure timely re-assessment of a patient’s condition 43.…”

Grand rounds in methodology: when are realist reviews useful, and what does a ‘good’ realist review look like?

“…Realist reviews have been used to ‘diagnose’ problems and better understand a wide range of complex practices and interventions in the quality and safety field, from junior doctors’ antimicrobial prescribing1 to ‘safety-netting’ in primary care 2. The ultimate aim in a realist review project is typically focused on identifying solutions to complex problems, by developing theory-informed responses in the form of recommendations or new intervention designs.…”

“…Realist reviews aim to produce a type of theory known as ‘programme theory’—a theory that explains what a programme or intervention is expected to do, and how it is expected to work 4. For example, Friedemann Smith et al ’s programme theory of safety-netting in primary care settings demonstrates the important contexts, mechanisms and range of outcomes involved when this intervention is successful in its aim to ensure patient safety 2. Recommendations for policy, practice and intervention design can be informed by the understanding captured in a programme theory.…”

“…A realist review can also improve the understanding or ‘diagnose’ the causes of an identified ‘problem’, with the aim of developing potential solutions. A programme theory that captures this understanding can be used for a number of purposes, including informing the design of interventions to modify specific contexts,2 considering how a programme might be improved8 or informing the development of new interventions 11. A realist review could enable the hospital managers in our scenario to assess local contexts to identify potential intervention points to improve staff retention, or to identify and create supportive conditions for the successful introduction of new professionals joining the workforce.…”

Safety-netting in the consultation

“…A literature review in 2019 reported the most common type of safety-netting article was an expert opinion (n=25), followed by qualitative studies (n=12), with no completed randomised controlled trial (RCT) 6. An updated realist review in 2022, which produced 15 recommendations to enhance the communication of safety-netting advice, included reference to two randomised trials, but neither had a primary intervention of safety-netting or referred to this term 7…”