Publications
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Skirrow H, Foley K, Bedford H, et al., 2024, Impact of pregnancy vaccine uptake and socio-demographic determinants on subsequent childhood Measles, Mumps and Rubella vaccine uptake: a UK birth cohort study, Vaccine, Vol: 42, Pages: 322-331, ISSN: 0264-410X
BACKGROUND: We examined the association between socio-demographic determinants and uptake of childhood Measles, Mumps & Rubella (MMR) vaccines and the association between pregnant women's pertussis vaccine uptake and their children's MMR vaccine uptake. METHODS: We used nationally-representative linked mother-baby electronic records from the United Kingdom's Clinical-Practice-Research-Datalink. We created a birth cohort of children born between 01.01.2000 and 12.12.2020. We estimated the proportion vaccinated with first MMR vaccine by age 2 years and first and second MMR vaccines by age 5 years. We used survival-analysis and Cox proportional hazard models to examine the association between deprivation, ethnicity and maternal age and pertussis vaccination in pregnancy and children's MMR uptake. RESULTS: Overall, 89.4 % (710,797/795,497) of children had first MMR by age 2 years and 92.6 % (736,495/795,497) by age 5 years. Among children still in the cohort when second MMR was due, 85.9 % (478,480/557,050) had two MMRs by age 5 years. Children from the most-deprived areas, children of Black ethnicity and children of mothers aged < 20 years had increased risk of being unvaccinated compared with children from the least-deprived areas, White children and children of mothers aged 31-40 years: first MMR by 5 years, adjusted Hazard Ratios (HR):0.86 (CI:0.85-0.87), HR:0.87 (CI:0.85-0.88) & HR:0.89 (CI:0.88-0.90) respectively. Deprivation was the determinant associated with the greatest risk of missed second MMR: adjusted HR:0.82 (CI:0.81-0.83). Children of mothers vaccinated in pregnancy were more likely than children of unvaccinated mothers to have MMR vaccines after adjusting for ethnicity, deprivation, and maternal age (First and Second MMRs adjusted HRs:1.43 (CI:1.41-1.45), 1.49 (CI:1.45-1.53). CONCLUSION: Children from most-deprived areas are less likely to have MMR vaccines compared with childre
Kerr G, Greenfield G, Hayhoe B, et al., 2023, Attendance at remote versus in-person outpatient appointments in an NHS Trust, Journal of Telemedicine and Telecare, Pages: 1357633X231216501-1357633X231216501, ISSN: 1357-633X
INTRODUCTION: With the growing use of remote appointments within the National Health Service, there is a need to understand potential barriers of access to care for some patients. In this observational study, we examined missed appointments rates, comparing remote and in-person appointments among different patient groups. METHODS: We analysed adult outpatient appointments at Imperial College Healthcare NHS Trust in Northwest London in 2021. Rates of missed appointments per patient were compared between remote versus in-person appointments using negative binomial regression models. Models were stratified by appointment type (first or a follow-up). RESULTS: There were 874,659 outpatient appointments for 189,882 patients, 29.5% of whom missed at least one appointment. Missed rates were 12.5% for remote first appointments and 9.2% for in-person first appointments. Remote and in-person follow-up appointments were missed at similar rates (10.4% and 10.7%, respectively). For remote and in-person appointments, younger patients, residents of more deprived areas, and patients of Black, Mixed and 'other' ethnicities missed more appointments. Male patients missed more in-person appointments, particularly at younger ages, but gender differences were minimal for remote appointments. Patients with long-term conditions (LTCs) missed more first appointments, whether in-person or remote. In follow-up appointments, patients with LTCs missed more in-person appointments but fewer remote appointments. DISCUSSION: Remote first appointments were missed more often than in-person first appointments, follow-up appointments had similar attendance rates for both modalities. Sociodemographic differences in outpatient appointment attendance were largely similar between in-person and remote appointments, indicating no widening of inequalities in attendance due to appointment modality.
Alturkistani A, Greenfield G, Beaney T, et al., 2023, Cross-sectional analyses of online appointment booking and repeat prescription ordering user characteristics in General Practices of England in the years 2018-2020, BMJ Open, Vol: 13, ISSN: 2044-6055
Objectives To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England’s National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage.Design Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression.Participants Survey respondents of the GPPS 2018–2020.Primary outcome measures Online appointment booking and online repeat prescription ordering.Results 1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups.Conclusions Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the differen
Sukriti KC, Tewolde S, Laverty AA, et al., 2023, Uptake and adoption of the NHSApp in England: an observational study, BRITISH JOURNAL OF GENERAL PRACTICE, ISSN: 0960-1643
Mendelsohn E, Honeyford K, Brittin A, et al., 2023, The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study, Scientific Reports, Vol: 13, ISSN: 2045-2322
The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl–Hirschman index. We explored the impact of ‘regular transfers’ between pairs of wards with shared specialities, ‘atypical transfers’ between pairs of wards with no shared specialities and ‘site transfers’ between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56–3.12), compared to regular transfers, 1.92 days (95% CI 1.82–2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a s
KC S, Reidy C, Laverty AA, et al., 2023, Adoption and Use of the NHS App in England: a mixed-methods evaluation, BJGP
Sukriti KC, Reidy C, Laverty AA, et al., 2023, Adoption and Use of the NHS App in England: a mixed-methods evaluation, BRITISH JOURNAL OF GENERAL PRACTICE, Vol: 73, ISSN: 0960-1643
Honeyford K, Nwosu A-P, Lazzarino R, et al., 2023, Prevalence of electronic screening for sepsis in National Health Service acute hospitals in England, BMJ Health & Care Informatics, Vol: 30, ISSN: 2632-1009
UNLABELLED: Sepsis is a worldwide public health problem. Rapid identification is associated with improved patient outcomes-if followed by timely appropriate treatment. OBJECTIVES: Describe digital sepsis alerts (DSAs) in use in English National Health Service (NHS) acute hospitals. METHODS: A Freedom of Information request surveyed acute NHS Trusts on their adoption of electronic patient records (EPRs) and DSAs. RESULTS: Of the 99 Trusts that responded, 84 had an EPR. Over 20 different EPR system providers were identified as operational in England. The most common providers were Cerner (21%). System C, Dedalus and Allscripts Sunrise were also relatively common (13%, 10% and 7%, respectively). 70% of NHS Trusts with an EPR responded that they had a DSA; most of these use the National Early Warning Score (NEWS2). There was evidence that the EPR provider was related to the DSA algorithm. We found no evidence that Trusts were using EPRs to introduce data driven algorithms or DSAs able to include, for example, pre-existing conditions that may be known to increase risk.Not all Trusts were willing or able to provide details of their EPR or the underlying algorithm. DISCUSSION: The majority of NHS Trusts use an EPR of some kind; many use a NEWS2-based DSA in keeping with national guidelines. CONCLUSION: Many English NHS Trusts use DSAs; even those using similar triggers vary and many recreate paper systems. Despite the proliferation of machine learning algorithms being developed to support early detection of sepsis, there is little evidence that these are being used to improve personalised sepsis detection.
Hayhoe B, Tonkin-Crine S, McLeod M, et al., 2022, Implementing antibiotic stewardship in high prescribing English general practices: a mixed-methods study, British Journal of General Practice, Vol: 73, Pages: e164-e175, ISSN: 0960-1643
Background: Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. We co-developed an implementation intervention to improve use of three AMS strategies; enhanced communication strategies, delayed prescriptions, and point-of-care C-Reactive Protein testing (POC-CRPT). Aim: To investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing. Design and setting: Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an ‘Antibiotic Champion’. Methods: We compared routinely collected prescribing data between intervention and 45 matched control practices using a difference-in-differences analysis. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention. Results: There was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual Champions’ preconceptions of strategies and opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPT; one practice chose all three. POC-CRPT was used more when allocated to one person. Conclusions: Clinicians need detailed information on exactly how to adopt AMS strategies. Strategies may be used more when allocated to one or two individuals. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and sub-optimal use.
Alturkistani A, Greenfield G, Beaney T, et al., 2022, Ethnicity, deprivation, and the use of patient portals in England's general practices 2018-2020, Publisher: OXFORD UNIV PRESS, ISSN: 1101-1262
Venkatraman T, Honeyford C, Ram B, et al., 2022, Identifying local authority need for, and uptake of, school-based physical activity promotion in England – a cluster analysis, Journal of Public Health, Vol: 44, Pages: 694-703, ISSN: 1741-3842
Background:School-based physical activity interventions such as The Daily Mile (TDM) are widely promoted in children’s physical activity guidance. However, targeting such interventions to areas of greatest need is challenging since determinants vary across geographical areas. Our study aimed to identify local authorities in England with the greatest need to increase children’s physical activity and assess whether TDM reaches school populations in areas with the highest need.Methods:This was a cross-sectional study using routinely collected data from Public Health England. Datasets on health, census and the built environment were linked. We conducted a hierarchical cluster analysis to group local authorities by ‘need’ and estimated the association between ‘need’ and registration to TDM.Results:We identified three clusters of high, medium and low need for physical activity interventions in 123 local authorities. Schools in high-need areas were more likely to be registered with TDM (incidence rate ratio 1.25, 95% confidence interval: 1.12–1.39) compared with low-need areas.Conclusions:Determinants of children’s physical activity cluster geographically across local authorities in England. TDM appears to be an equitable intervention reaching schools in local authorities with the highest needs. Health policy should account for clustering of health determinants to match interventions with populations most in need.
Honeyford K, Expert P, Mendelsohn EE, et al., 2022, Challenges and recommendations for high quality research using electronic health records, Frontiers in Digital Health, Vol: 4, ISSN: 2673-253X
Harnessing Real World Data is vital to improve health care in the 21st Century. Data from Electronic Health Records (EHRs) are a rich source of patient centred data, including information on the patient's clinical condition, laboratory results, diagnoses and treatments. They thus reflect the true state of health systems. However, access and utilisation of EHR data for research presents specific challenges. We assert that using data from EHRs effectively is dependent on synergy between researchers, clinicians and health informaticians, and only this will allow state of the art methods to be used to answer urgent and vital questions for patient care. We propose that there needs to be a paradigm shift in the way this research is conducted - appreciating that the research process is iterative rather than linear. We also make specific recommendations for organisations, based on our experience of developing and using EHR data in trusted research environments.
Jauneikaite E, Honeyford K, Blandy O, et al., 2022, Bacterial genotypic and patient risk factors for adverse outcomes in Escherichia coli bloodstream infections: a prospective molecular-epidemiological study, Journal of Antimicrobial Chemotherapy, Vol: 77, Pages: 1753-1761, ISSN: 0305-7453
Objectives:Escherichia coli bloodstream infections have shown a sustained increase in England, for reasons that are unknown. Furthermore, the contribution of multi-drug resistant lineages such as ST131 to overall E. coli disease burden and outcome is undetermined. Methods:We genome sequenced E. coli blood isolates from all patients with E. coli bacteraemia in north-west London from July 2015 to August 2016 and assigned multi-locus sequence types, virulence factors, and AMR genes to all isolates. Isolate sequence types were then linked to phenotypic antimicrobial susceptibility, patient demographic, and clinical outcome data to explore relationships between the E. coli sequence types, patient factors, and outcomes. Results:A total of 551 E. coli genomes were analysed. Four sequence types (ST131, 21.2%; ST73, 14.5%; ST69, 9.3%; and ST95, 8.2%) accounted for over half of cases. E. coli genotype ST131-C2 was associated with phenotypic non-susceptibility to quinolones, third-generation cephalosporins, amoxicillin, amoxicillin-clavulanic acid, gentamicin, and trimethoprim. Among 300 patients from whom outcome was known, an association between the ST131-C2 lineage and longer length-of-stay was detected, although multivariable regression modelling did not demonstrate an association between E. coli sequence type and mortality. Several unexpected associations were identified between gentamicin non-susceptibility; ethnicity; sex and adverse outcomes, requiring further research.Conclusions:Although E. coli sequence type was associated with defined antimicrobial non-susceptibility patterns and prolonged length-of-stay, E. coli sequence type was not associated with increased mortality. ST131 has outcompeted other lineages in north-west London. Where ST131 is prevalent, caution is required when devising empiric regimens for suspected Gram-negative sepsis, in particular the pairing of beta-lactam agents with gentamicin.
Tonkin-Crine S, McLeod M, Borek A, et al., 2022, O01 Nuances of implementing antibiotic stewardship in high-prescribing English general practices: an implementation study, Publisher: OXFORD UNIV PRESS
Iregbu K, Dramowski A, Milton R, et al., 2022, Combating Childhood Infections in LMICs: Evaluating the Contribution of Big Data 3 Global health systems' data science approach for precision diagnosis of sepsis in early life, LANCET INFECTIOUS DISEASES, Vol: 22, Pages: E143-E152, ISSN: 1473-3099
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Kaura A, Trickey A, Shah A, et al., 2022, Comparing the longer-term effectiveness of a single dose of the Pfizer-BioNTech and Oxford-AstraZeneca COVID-19 vaccines across the age spectrum, EClinicalMedicine, Vol: 46, ISSN: 2589-5370
Background:A single dose strategy may be adequate to confer population level immunity and protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, especially in low- and middle-income countries where vaccine supply remains limited. We compared the effectiveness of a single dose strategy of the Oxford-AstraZeneca or Pfizer-BioNTech vaccines against SARS-CoV-2 infection across all age groups and over an extended follow-up period.Methods:Individuals vaccinated in North-West London, UK, with either the first dose of the Oxford-AstraZeneca or Pfizer-BioNTech vaccines between January 12, 2021 to March 09, 2021, were matched to each other by demographic and clinical characteristics. Each vaccinated individual was additionally matched to an unvaccinated control. Study outcomes included SARS-CoV-2 infection of any severity, COVID-19 hospitalisation, COVID-19 death, and all-cause mortality. Findings:Amongst matched individuals, 63,608 were in each of the vaccine groups and 127,216 were unvaccinated. Between 14-84 days of follow-up after matching, there were 534 SARS-CoV-2 infections, 65 COVID-19 hospitalisations, and 190 deaths, of which 29 were categorized as due to COVID-19. The incidence rate ratio (IRR) for SARS-CoV-2 infection was 0.85 (95% confidence interval [CI], 0.69 to 1.05) for Oxford-Astra-Zeneca, and 0.69 (0.55 to 0.86) for Pfizer-BioNTech. The IRR for both vaccines was the same at 0.25 (0.09 to 0.55) and 0.14 (0.02 to 0.58) for reducing COVID-19 hospitalization and COVID-19 mortality, respectively. The IRR for all-cause mortality was 0.25 (0.15 to 0.39) and 0.18 (0.10 to 0.30) for the Oxford-Astra-Zeneca and Pfizer-BioNTech vaccines, respectively. Age was an effect modifier of the association between vaccination and SARS-CoV-2 infection of any severity; lower hazard ratios for increasing age. Interpretation: A single dose strategy, for both vaccines, was effective at reducing COVID-19 mortality and hospitalization rates. The mag
Tewolde S, Costelloe C, PowelI J, et al., 2022, An observational study of uptake and adoption of the NHS App in England
<jats:title>Abstract</jats:title><jats:sec><jats:title>Objectives</jats:title><jats:p>This study aimed to evaluate patterns of uptake and adoption of the NHS App. Data metrics from the NHS App were used to assess acceptability by looking at total app downloads, registrations, appointment bookings, GP health records viewed, and prescriptions ordered. The impact of the UK COVID-19 lockdown and introduction of the <jats:italic>COVID Pass</jats:italic> were also explored to assess App usage and uptake.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>Descriptive statistics and an interrupted time series analysis were used to look at monthly NHS App metrics at a GP practice level from January 2019-May 2021 in the population of England. Interrupted time series models were used to identify changes in level and trend among App usage and the different functionalities before and after the first COVID-19 lockdown. The <jats:italic>Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)</jats:italic> guidelines were used for reporting and analysis.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Between January 2019 and May 2021, there were a total of 8,524,882 NHS App downloads and 4,449,869 registrations. There was a 4-fold increase in app downloads from April 2021 (650,558 downloads) to May 2021 (2,668,535 downloads) when the COVID Pass feature was introduced. Areas with the highest number of App registrations proportional to the GP patient population occurred in Hampshire, Southampton and Isle of Wight CCG, and the lowest in Blackburn with Darwen CCG. After the announcement of the first lockdown (March 2020), a positive and significant trend in the number of login sessions was observed at 602,124 (p=0.004)** logins a month. National NHS App appointment bookings ranged from 298 to 42
Kadirvelu B, Burcea G, Costello C, et al., 2022, Variation in global COVID-19 symptoms by geography and by chronic disease: a global survey using the COVID-19 Symptom Mapper, EClinicalMedicine, Vol: 45, Pages: 1-15, ISSN: 2589-5370
BackgroundCOVID-19 is typically characterised by a triad of symptoms: cough, fever and loss of taste and smell, however, this varies globally. This study examines variations in COVID-19 symptom profiles based on underlying chronic disease and geographical location.MethodsUsing a global online symptom survey of 78,299 responders in 190 countries between 09/04/2020 and 22/09/2020, we conducted an exploratory study to examine symptom profiles associated with a positive COVID-19 test result by country and underlying chronic disease (single, co- or multi-morbidities) using statistical and machine learning methods.FindingsFrom the results of 7980 COVID-19 tested positive responders, we find that symptom patterns differ by country. For example, India reported a lower proportion of headache (22.8% vs 47.8%, p<1e-13) and itchy eyes (7.3% vs. 16.5%, p=2e-8) than other countries. As with geographic location, we find people differed in their reported symptoms if they suffered from specific chronic diseases. For example, COVID-19 positive responders with asthma (25.3% vs. 13.7%, p=7e-6) were more likely to report shortness of breath compared to those with no underlying chronic disease. InterpretationWe have identified variation in COVID-19 symptom profiles depending on geographic location and underlying chronic disease. Failure to reflect this symptom variation in public health messaging may contribute to asymptomatic COVID-19 spread and put patients with chronic diseases at a greater risk of infection. Future work should focus on symptom profile variation in the emerging variants of the SARS-CoV-2 virus. This is crucial to speed up clinical diagnosis, predict prognostic outcomes and target treatment.
Aliabadi S, Jauneikaite E, Muller-Pebody B, et al., 2022, Exploring temporal trends and risk factors for resistance in <i>Escherichia coli</i>-causing bacteraemia in England between 2013 and 2018: an ecological study, JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY, Vol: 77, Pages: 782-792, ISSN: 0305-7453
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Mongru R, Rose D, Costelloe C, et al., 2022, Retrospective analysis of North-West London Healthcare Utilisation by children during the COVID-19 pandemic, BMJ Paediatrics Open, Vol: 6, ISSN: 2399-9772
Objective:To explore the impact of the measures taken to combat COVID-19 on the patterns of acute illness in children presenting to primary and secondary care for North-West London.Design / Setting / Participants:Retrospective analysis of 8,309,358 primary and secondary healthcare episodes of children <16 years registered with a North-West London primary care practice between 2015 and 2021.Main outcome measures: Numbers of primary care consultations, emergency department attendances (ED) and emergency admissions during the pandemic were compared with those in the preceding five years. Trends were examined by age and for ICD10-coded diagnoses of: infectious diseases, and injuries and poisonings for admitted children.Results:Comparing 2020 to the 2015-19 mean, primary care consultations were 22% lower, ED attendances were 38% lower and admissions 35% lower. Following the first national lockdown in April 2020, primary care consultations were 39% lower compared to the April 2015-19 mean, ED attendances were 72% lower, and unscheduled hospital admissions were 63% lower. Admissions >48 hours were on average 13% lower overall during 2020, and 36% lower during April 2020. The reduction in admissions for infections (61% lower than 2015-19 mean) between April-August 2020 was greater than for injuries (31% lower).Conclusion:The COVID-19 pandemic was associated with an overall reduction in childhood illness presentations to health services in North-West London, most prominent during periods of national lockdown, and with a greater impact on infections than injuries. These reductions demonstrate the impact on children of measures taken to combat COVID-19 across the health system.
Aliabadi S, Anyanwu P, Beech E, et al., 2021, Do antibiotic stewardship interventions in primary care have an effect on antimicrobial resistance of Escherichia coli bacteraemia in England? An ecological analysis of national data between 2013-2018, The Lancet Infectious Diseases, Vol: 21, ISSN: 1473-3099
Background: We sought to evaluate the effectiveness of a national antimicrobial stewardship intervention, the Quality Premium (QP), on broad-spectrum antibiotic prescribing and Escherichia coli bacteraemia resistance to broad-spectrum antibiotics in England. Methods: We used longitudinal data on patients registered with a general practitioner in the English National Health Service and patients with E. coli bacteraemia notified to the national mandatory surveillance programme between January 2013-December 2018.We conducted an ecological analysis using interrupted time series (ITS) analyses and generalised estimating equations (GEE) to estimate the change in broad-spectrum antibiotics prescribing over time and change in the proportion of E. coli bacteraemia cases where the causative bacteria were resistant to each antibiotic individually or to at least one of the five antibiotics, after implementation of the QP. Findings: Following the implementation of the QP in April 2015, we observed an immediate downward step-change in broad-spectrum antibiotic prescribing incidence rate of 0.867per 1000 patients (95% CI: 0.837 to 0.898, p<0·001). We found that the pre-intervention slope for total antibiotic usage was an IRR of 1.002(CI: 1.000to 1.004, p-value=0.046). The change in slope for total antibiotic usage was an IRR of 0.993(CI: 0.991to 0.995, p<0·001). We also observed a downward step-change in resistance rate of 0.947 per 1000 E. coli isolates tested (95% CI: 0.918 to 0.977, p<0·001).We found that the pre-intervention slope for total antibiotic resistance was an IRR of 1.001 (CI: 0.999 to 1.003, p-value=0.346). The change in slope level for total antibiotic usage was an IRR of 0.999 (CI: 0.997 to 1.000, p=0.112). On examination of the long-term effect following implementation of the QP, there was an increase in the number of isolates resistant to at least one of the five broad-spectrum antibiotics tested.134Interpretati
Borek AJ, Maitland K, McLeod M, et al., 2021, Impact of the COVID-19 pandemic on community antibiotic prescribing and stewardship: a qualitative interview study with general practitioners in England
<jats:title>Abstract</jats:title><jats:p>The COVID-19 pandemic has had a profound impact on the delivery of primary care services. We aimed to identify general practitioners’ (GPs’) perceptions and experiences of how the COVID-19 pandemic influenced antibiotic prescribing and antimicrobial stewardship (AMS) in general practice in England. Twenty-four semi-structured interviews were conducted with 18 GPs at two time-points: autumn 2020 (14 interviews) and spring 2021 (10 interviews). Interviews were audio-recorded, transcribed and analysed thematically, taking a longitudinal approach. Participants reported a lower threshold for antibiotic prescribing (and fewer consultations) for respiratory infections and COVID-19 symptoms early in the pandemic, then returning to more usual (pre-pandemic) prescribing. They perceived less impact on antibiotic prescribing for urinary and skin infections. Participants perceived the changing ways of working and consulting (e.g., proportions of remote and in-person consultations), and the changing patient presentations and GP workload as influencing the fluctuations in antibiotic prescribing. This was compounded by decreased engagement with, and priority of, AMS due to COVID-19-related urgent priorities. Re-engagement with AMS is needed, e.g., through reviving antibiotic prescribing feedback and targets/incentives. While the pandemic disrupted the usual ways of working, it also produced opportunities, e.g., for re-organising ways of managing infections and AMS in the future.</jats:p>
Venkatraman T, Honeyford K, van Sluijs EMF, et al., 2021, Are children at schools registered to The Daily Mile™ more physically active?, Publisher: OXFORD UNIV PRESS, Pages: 81-81, ISSN: 1101-1262
Vollmer MAC, Radhakrishnan S, Kont MD, et al., 2021, The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: an observational study, BMC Health Services Research, Vol: 21, Pages: 1-9, ISSN: 1472-6963
Background Hospitals in England have undergone considerable change to address the surgein demand imposed by the COVID-19 pandemic. The impact of this on emergencydepartment (ED) attendances is unknown, especially for non-COVID-19 related emergencies.Methods This analysis is an observational study of ED attendances at the Imperial CollegeHealthcare NHS Trust (ICHNT). We calibrated auto-regressive integrated moving averagetime-series models of ED attendances using historic (2015-2019) data. Forecasted trendswere compared to present year ICHNT data for the period between March 12, 2020 (whenEngland implemented the first COVID-19 public health measure) and May 31, 2020. Wecompared ICHTN trends with publicly available regional and national data. Lastly, wecompared hospital admissions made via the ED and in-hospital mortality at ICHNT duringthe present year to the historic 5-year average.Results ED attendances at ICHNT decreased by 35% during the period after the firstlockdown was imposed on March 12, 2020 and before May 31, 2020, reflecting broadertrends seen for ED attendances across all England regions, which fell by approximately 50%for the same time frame. For ICHNT, the decrease in attendances was mainly amongst thoseaged <65 years and those arriving by their own means (e.g. personal or public transport) andnot correlated with any of the spatial dependencies analysed such as increasing distance frompostcode of residence to the hospital. Emergency admissions of patients without COVID-19after March 12, 2020 fell by 48%; we did not observe a significant change to the crudemortality risk in patients without COVID-19 (RR 1.13, 95%CI 0.94-1.37, p=0.19).Conclusions Our study findings reflect broader trends seen across England and give anindication how emergency healthcare seeking has drastically changed. At ICHNT, we findthat a larger proportion arrived by ambulance and that hospitalisation outcomes of patientswithout COVID-19 did not differ from previous years. The ext
Borek AJ, Campbell A, Dent E, et al., 2021, Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice., Implementation Science Communications, Vol: 2, ISSN: 2662-2211
BACKGROUND: Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. METHODS: We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified 'guiding principles' with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. RESULTS: Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an 'implementation support' website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and materi
Venkatraman T, Honeyford K, Ram B, et al., 2021, IDENTIFYING LOCAL AUTHORITY NEED FOR, AND UPTAKE OF, SCHOOL-BASED PHYSICAL ACTIVITY INTERVENTIONS IN ENGLAND - A CLUSTER ANALYSIS USING ROUTINE DATA, Publisher: BMJ PUBLISHING GROUP, Pages: A24-A25, ISSN: 0143-005X
Hayhoe B, 2021, Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: a choice experiment, PLoS Medicine, Vol: 18, Pages: 1-20, ISSN: 1549-1277
Delayed (or ‘back-up’) antibiotic prescription, where the patient is given a prescription but advised todelay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care.However, this strategy is not widely used in the UK. This study aimed to identify factors influencingpreferences among the UK public for delayed prescription, and understand their relative importance,to help increase appropriate use of this prescribing option.Methods and FindingsWe conducted an online choice experiment in two UK general population samples: adults, and parentsof children under 18 years. Respondents were presented with twelve scenarios in which they, or theirchild, might need antibiotics for a respiratory tract infection, and asked to choose either an immediateor a delayed prescription. Scenarios were described by seven attributes. Data were collected betweenNovember 2018 and February 2019. Respondent preferences were modelled using mixed-effectslogistic regression.The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). Thesamples reflected the UK population in age, sex, ethnicity and country of residence. The mostimportant determinant of respondent choice was symptom severity, especially for cough-relatedsymptoms. In the adult sample the probability of choosing delayed prescription was 0.53 (95% CI 0.50-0.56, p<.001) for a chesty cough and runny nose, compared to 0.30 (0.28-0.33, p<.001) for a chestycough with fever, 0.47 (0.44-0.50, p<.001) for sore throat with swollen glands and 0.37 (0.34-0.39,p<.001) for sore throat, swollen glands and fever. Respondents were less likely to choose delayedprescription with increasing duration of illness (odds ratio 0.94 (0.92-0.96, p<0.001)). Probabilities ofchoosing delayed prescription were similar for parents considering treatment for a child (44% ofchoices vs. 42% for adults, p=0.04). However, parents differed from the adult sample in showing
Aliabadi S, Anyanwu P, Beech E, et al., 2021, Effect of antibiotic stewardship interventions in primary care on antimicrobial resistance of Escherichia coli bacteraemia in England (2013-18): a quasi-experimental, ecological, data linkage study, Lancet Infectious Diseases, Vol: 21, ISSN: 1473-3099
BACKGROUND: Antimicrobial resistance is a major global health concern, driven by overuse of antibiotics. We aimed to assess the effectiveness of a national antimicrobial stewardship intervention, the National Health Service (NHS) England Quality Premium implemented in 2015-16, on broad-spectrum antibiotic prescribing and Escherichia coli bacteraemia resistance to broad-spectrum antibiotics in England. METHODS: In this quasi-experimental, ecological, data linkage study, we used longitudinal data on bacteraemia for patients registered with a general practitioner in the English National Health Service and patients with E coli bacteraemia notified to the national mandatory surveillance programme between Jan 1, 2013, and Dec 31, 2018. We linked these data to data on antimicrobial susceptibility testing of E coli from Public Health England's Second-Generation Surveillance System. We did an ecological analysis using interrupted time-series analyses and generalised estimating equations to estimate the change in broad-spectrum antibiotics prescribing over time and the change in the proportion of E coli bacteraemia cases for which the causative bacteria were resistant to each antibiotic individually or to at least one of five broad-spectrum antibiotics (co-amoxiclav, ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin), after implementation of the NHS England Quality Premium intervention in April, 2015. FINDINGS: Before implementation of the Quality Premium, the rate of antibiotic prescribing for all five broad-spectrum antibiotics was increasing at rate of 0·2% per month (incidence rate ratio [IRR] 1·002 [95% CI 1·000-1·004], p=0·046). After implementation of the Quality Premium, an immediate reduction in total broad-spectrum antibiotic prescribing rate was observed (IRR 0·867 [95% CI 0·837-0·898], p<0·0001). This effect was sustained until the end of the study period; a 57% reduction in rate of antibiotic pr
Coughlan C, Rahman S, Honeyford K, et al., 2021, Developing useful early warning and prognostic scores for COVID-19., Postgrad Med J, Vol: 97, Pages: 477-480
Coughlan C, Rahman S, Honeyford K, et al., 2021, Developing useful early warning and prognostic scores for COVID-19, Postgraduate Medical Journal, Vol: 97, Pages: 477-480, ISSN: 0032-5473
Abstract Early recognition of high-risk or deteriorating patients with COVID-19 allows timely treatment escalation and optimises allocation of scarce resources across overstretched healthcare systems. Since the late 1990s, physiological scoring systems have been used in hospital settings to provide an objective signal of clinical deterioration prompting urgent clinical review. Several early warning scores (EWS) accurately predict the need for intensive care unit admission and survival in hospitalised patients with sepsis and other acute illnesses, and their routine use is now recommended in secondary care settings in high and low income countries alike. However, there are widespread concerns that existing EWS, which place a premium on the cardiovascular instability seen in severe sepsis, may fail to identify the deteriorating COVID-19 patient. Dozens of research groups have now assessed the predictive value of existing EWS in hospitalised adults with COVID-19, and used sophisticated statistical methods to develop novel early warning and prognostic scores incorporating vital signs, laboratory tests and imaging results. However, many of these novel scores are at high risk of bias and few have been adopted in routine clinical practice.In this education and learning article, we will discuss key pitfalls of existing prognostic and EWS in hospitalised adults with COVID-19; outline promising novel scores for this patient group; and describe the ideal properties of scoring systems suitable for use in low and middle income settings.
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