71 results found
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, 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
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, 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, 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.
You J, Expert P, Costelloe C, 2021, Using text mining to track outbreak trends in global surveillance of emerging diseases: ProMED-mail, Journal of the Royal Statistical Society Series A: Statistics in Society, ISSN: 0964-1998
ProMED-mail (Program for Monitoring Emerging Disease) is an international disease outbreak monitoring and early warning system. Every year, users contribute thousands of reports that include reference to infectious diseases and toxins. However, due to the uneven distribution of the reports for each disease, traditional statistics-based text mining techniques, represented by term frequency-related algorithm, are not suitable. Thus, we conducted a study in three steps (i) report filtering, (ii) keyword extraction from reports and finally (iii) word co-occurrence network analysis to fill the gap between ProMED and its utilization. The keyword extraction was performed with the TextRank algorithm, keywords co-occurrence networks were then produced using the top keywords from each document and multiple network centrality measures were computed to analyse the co-occurrence networks. We used two major outbreaks in recent years, Ebola, 2014 and Zika 2015, as cases to illustrate and validate the process. We found that the extracted information structures are consistent with World Health Organisation description of the timeline and phases of the epidemics. Our research presents a pipeline that can extract and organize the information to characterize the evolution of epidemic outbreaks. It also highlights the potential for ProMED to be utilized in monitoring, evaluating and improving responses to outbreaks.
Jauneikaite E, Honeyford K, Blandy O, et al., 2021, Bacterial genotypic and patient risk factors for adverse outcomes in Escherichia coli bloodstream infections: a prospective molecular-epidemiological study
<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p><jats:italic>Escherichia coli</jats:italic> bloodstream infections have increased rapidly in the UK, for reasons that are unclear. The relevance of highly fit, or multi-drug resistant lineages such as ST131 to overall <jats:italic>E. coli</jats:italic> disease burden remains to be fully determined. We set out to characterise the prevalence of <jats:italic>E. coli</jats:italic> multi-locus sequence types (MLST) and determine if these were associated with adverse outcomes in an urban population of <jats:italic>E. coli</jats:italic> bacteraemia patients.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We undertook whole genome sequencing of <jats:italic>E. coli</jats:italic> blood isolates from all patients with diagnosed <jats:italic>E. coli</jats:italic> bacteraemia in north-west London from July 2015 to August 2016 and assigned multi-locus sequence types to all isolates. Isolate sequence types were linked to routinely collected antimicrobial susceptibility, patient demographic, and clinical outcome data to explore relationships between the <jats:italic>E. coli</jats:italic> sequence types, patient factors, and outcomes.</jats:p></jats:sec><jats:sec><jats:title>Findings</jats:title><jats:p>A total of 551 <jats:italic>E. coli</jats:italic> genomes were available for analysis. More than half of these cases were caused by four <jats:italic>E. coli</jats:italic> sequence types: ST131 (21%), ST73 (15%), ST69 (9%) and ST95 (8%). <jats:italic>E. coli</jats:italic> genotype ST131-C2 was associated with non-susceptibility to quinolones and third-generation cephalosporins, and also to amoxicillin, augmentin, gentamicin and trimethoprim. An associat
Boncea E, Expert P, Mitchell C, et al., 2021, Association between intrahospital transfer and hospital-acquired infection in the elderly: A retrospective case-control study in a UK hospital network, BMJ Quality & Safety, Vol: 30, Pages: 457-466, ISSN: 2044-5415
Background Intrahospital transfers have become more common as hospital staff balance patient needs with bed availability. However, this may leave patients more vulnerable to potential pathogen transmission routes via increased exposure to contaminated surfaces and contacts with individuals.Objective This study aimed to quantify the association between the number of intrahospital transfers undergone during a hospital spell and the development of a hospital-acquired infection (HAI).Methods A retrospective case–control study was conducted using data extracted from electronic health records and microbiology cultures of non-elective, medical admissions to a large urban hospital network which consists of three hospital sites between 2015 and 2018 (n=24 240). As elderly patients comprise a large proportion of hospital users and are a high-risk population for HAIs, the analysis focused on those aged 65 years or over. Logistic regression was conducted to obtain the OR for developing an HAI as a function of intrahospital transfers until onset of HAI for cases, or hospital discharge for controls, while controlling for age, gender, time at risk, Elixhauser comorbidities, hospital site of admission, specialty of the dominant healthcare professional providing care, intensive care admission, total number of procedures and discharge destination.Results Of the 24 240 spells, 2877 cases were included in the analysis. 72.2% of spells contained at least one intrahospital transfer. On multivariable analysis, each additional intrahospital transfer increased the odds of acquiring an HAI by 9% (OR=1.09; 95% CI 1.05 to 1.13).Conclusion Intrahospital transfers are associated with increased odds of developing an HAI. Strategies for minimising intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.
Honeyford K, Coughlan C, Nijman R, et al., 2021, Changes in emergency department activity and the first COVID-19 lockdown; a cross sectional study, Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health, Vol: 22, Pages: 603-607, ISSN: 1936-900X
BackgroundEmergency Department (ED) attendances fell across the UK after the ‘lockdown’ introduced on 23rd March 2020 to limit the spread of coronavirus disease 2019 (COVID-19). We hypothesised that reductions would vary by patient age and disease type. We examined pre- and in-lockdown ED attendances for two COVID-19 unrelated diagnoses; one likely to be affected by lockdown measures (gastroenteritis) and one likely to be unaffected (appendicitis). MethodsRetrospective cross-sectional study conducted across two EDs in one London hospital Trust. We compared all adult and paediatric ED attendances, before (January 2020) and during lockdown (March/April 2020). Key patient demographics, method of arrival and discharge location were compared. We used SNOMED codes to define attendances for gastroenteritis and appendicitis. ResultsED attendances fell from 1129 per day before lockdown to 584 in-lockdown; 51.7% of pre-lockdown rates. In-lockdown attendances were lowest for under-18s (16.0% of pre-lockdown). The proportion of patients admitted to hospital increased from 17.3% to 24.0% and the proportion admitted to intensive care increased four-fold. Attendances for gastroenteritis fell from 511 to 103; 20.2% of pre-lockdown rates. Attendances for appendicitis also decreased, from 144 to 41; 28.5% of pre-lockdown rates.ConclusionED attendances fell substantially following lockdown implementation. The biggest reduction was for under-18s. We observed reductions in attendances for gastroenteritis and appendicitis. This may reflect lower rates of infectious disease transmission, though the fall in appendicitis-related attendances suggests that behavioural factors are also important. Larger studies are urgently needed to understand changing patterns of ED use and access to emergency care during the COVID-19 pandemic.
Venkatraman T, Honeyford C, Ram B, et al., 2021, Identifying local authority need for, and uptake of, school-based physical activity promotion in England – a cluster analysis, Journal of Public Health, 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.
Kadirvelu B, Burcea G, Quint JK, et al., 2021, Covid-19 does not look like what you are looking for: Clustering symptoms by nation and multi-morbidities reveal substantial differences to the classical symptom triad
<jats:title>ABSTRACT</jats:title><jats:p>COVID-19 is by convention characterised by a triad of symptoms: cough, fever and loss of taste/smell. The aim of this study was to examine clustering of COVID-19 symptoms based on underlying chronic disease and geographical location. Using a large global symptom survey of 78,299 responders in 190 different countries, we examined symptom profiles in relation to geolocation (grouped by country) and underlying chronic disease (single, co- or multi-morbidities) associated with a positive COVID-19 test result using statistical and machine learning methods to group populations by underlying disease, countries, and symptoms. Taking the responses of 7980 responders with a COVID-19 positive test in the top 5 contributing countries, we find that the most frequently reported symptoms differ across the globe: For example, fatigue 4108(51.5%), headache 3640(45.6%) and loss of smell and taste 3563(44.6%) are the most reported symptoms globally. However, symptom patterns differ by continent; India reported a significantly lower proportion of headache (22.8% vs 45.6%, p<0.05) and itchy eyes (7.0% vs. 15.3%, p<0.05) than other countries, as does Pakistan (33.6% vs 45.6%, p<0.05 and 8.6% vs 15.3%, p<0.05). Mexico and Brazil report significantly less of these symptoms. As with geographic location, we find people differed in their reported symptoms, if they suffered from specific underlying diseases. For example, COVID-19 positive responders with asthma or other lung disease were more likely to report shortness of breath as a symptom, compared with COVID-19 positive responders who had no underlying disease (25.3% vs. 13.7%, p<0.05, and 24.2 vs.13.7%, p<0.05). Responders with no underlying chronic diseases were more likely to report loss of smell and tastes as a symptom (46%), compared with the responders with type 1 diabetes (21.3%), Type 2 diabetes (33.5%) lung disease (29.3%), or hype
Pi L, Expert P, Clarke JM, et al., 2021, Electronic health record enabled track and trace in an urban hospital network: implications for infection prevention and control
<jats:title>ABSTRACT</jats:title><jats:p>Healthcare-associated infections represent one of the most significant challenges for modern medicine as they can significantly impact patients’lives. Carbapenemase-producing Enterobacteriaceae (CPE) pose the greatest clinical threat, given the high levels of resistance to carbapenems, which are considered as agents of ‘last resort’ against life-threatening infections. Understanding patterns of CPE infection spreading in hospitals is paramount to design effective infection control protocols to mitigate the presence of CPE in hospitals. We used patient electronic health records from three urban hospitals to: i) track microbiologically confirmed carbapenemase producing <jats:italic>Escherichia coli</jats:italic> (CP-Ec) carriers and ii) trace the patients they shared place and time with until their identification. We show that yearly contact networks in each hospital consistently exhibit a core-periphery structure, highlighting the presence of a core set of wards where most carrier-contact interactions occured before being distributed to peripheral wards. We also identified functional communities of wards from the general patient movement network. The contact networks projected onto the general patient movement community structure showed a comprehensive coverage of the hospital. Our findings highlight that infections such as CP-Ec infections can reach virtually all parts of hospitals through first-level contacts.</jats:p>
Honeyford C, Costelloe C, Expert P, et al., 2021, Changes in Emergency Department attendances before and after COVID-19 lockdown implementation: a cross sectional study of one urban NHS Hospital Trust, Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health, ISSN: 1936-900X
Borek AJ, Campbell A, Dent E, et al., 2021, Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices, BMC Family Practice, Vol: 22, ISSN: 1471-2296
BackgroundTrials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use.MethodsThis was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically.ResultsNine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience – participants viewed the strategies as having limited value as ‘clinical tools’, perceiving them as useful only in ‘rare’ instances of clinical uncertainty and/or for those less experienced. Strategies as ‘social tools’ – participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities – participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context – various other situational and practical issues were raised with implementing the strategies.ConclusionsHigh-prescribing practices do not view DPs and POC-CRPT as sufficiently useful ‘clinical tools’ in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as ‘social tools’ to reduce unnecessary antibio
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, 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
Venkatraman T, Honeyford K, Costelloe C, et al., 2021, Sociodemographic profiles, educational attainment and physical activity associated with The Daily Mile™ registration in primary schools in England – a national cross-sectional linkage study, Journal of Epidemiology and Community Health, Vol: 75, Pages: 137-144, ISSN: 0143-005X
ObjectiveTo examine primary school and local authority characteristics associated with registrationfor The Daily Mile (TDM), an active mile initiative aimed at increasing physical activity inchildren.DesignA cross-sectional linkage study using routinely collected data.SettingAll state funded primary schools in England from 2012-2018(n=15,815).Results3,502 of all 15,815(22.1%) state funded primary schools in England were registered to doTDM, ranging from 16% in the East Midlands region to 31% in Inner London.Primary schools registered for TDM had larger mean pupil numbers compared with schoolsthat had not registered (300 vs 269 respectively). There was a higher proportion of TDMregistered schools in urban areas compared with non-urban areas. There was local authorityvariation in the likelihood of school registration (ICC: 0.094).After adjusting for school and local authority characteristics, schools located in a majorurban conurbation (OR 1.46 (95%CI:1.24-1.71) urban vs. rural) and schools with a higherproportion of disadvantaged pupils had higher odds of being registered to the TDM (OR 1.16(95%CI:1.02-1.33)). Area based physical activity and schools’ educational attainment wasnot significantly associated with registration to TDM.ConclusionOne in five primary schools in England has registered for The Daily Mile since 2012. TDMappears to be a wide-reaching school based physical activity intervention that is reachingmore disadvantaged primary school populations in urban areas where obesity prevalence ishighest. TDM registered schools include those with both high and low educationalattainment and are in areas with high and low physical activity
Miller L, Costelloe CE, Robotham JV, et al., 2021, Overuse of antibiotics: can viral vaccinations help stem the tide?, British Journal of Clinical Pharmacology, Vol: 87, Pages: 87-89, ISSN: 0306-5251
Pouwels KB, Vansteelandt S, Batra R, et al., 2020, Estimating the effect of healthcare-associated infections on excess length of hospital stay using inverse probability-weighted survival curves, Clinical Infectious Diseases, Vol: 71, Pages: e415-e420, ISSN: 1058-4838
BACKGROUND: Studies estimating excess length of stay (LOS) attributable to nosocomial infections have failed to address time-varying confounding, likely leading to overestimation of their impact. We present a methodology based on inverse probability-weighted survival curves to address this limitation. METHODS: A case study focusing on intensive care unit-acquired bacteremia using data from 2 general intensive care units (ICUs) from 2 London teaching hospitals were used to illustrate the methodology. The area under the curve of a conventional Kaplan-Meier curve applied to the observed data was compared with that of an inverse probability-weighted Kaplan-Meier curve applied after treating bacteremia as censoring events. Weights were based on the daily probability of acquiring bacteremia. The difference between the observed average LOS and the average LOS that would be observed if all bacteremia cases could be prevented was multiplied by the number of admitted patients to obtain the total excess LOS. RESULTS: The estimated total number of extra ICU days caused by 666 bacteremia cases was estimated at 2453 (95% confidence interval [CI], 1803-3103) days. The excess number of days was overestimated when ignoring time-varying confounding (2845 [95% CI, 2276-3415]) or when completely ignoring confounding (2838 [95% CI, 2101-3575]). CONCLUSIONS: ICU-acquired bacteremia was associated with a substantial excess LOS. Wider adoption of inverse probability-weighted survival curves or alternative techniques that address time-varying confounding could lead to better informed decision making around nosocomial infections and other time-dependent exposures.
Daunt A, Perez-Guzman PN, Liew F, et al., 2020, Validity of the UK early access to medicines scheme criteria for Remdesivir use in patients with COVID-19 disease, Journal of Infection, Vol: 81, Pages: 666-668, ISSN: 0163-4453
Boyd SE, Vasudevan A, Moore LSP, et al., 2020, Validating a prediction tool to determine the risk of nosocomial multidrug-resistant Gram-negative bacilli infection in critically ill patients: A retrospective case-control study, Journal of Global Antimicrobial Resistance, Vol: 22, Pages: 826-831, ISSN: 2213-7165
BACKGROUND: The Singapore GSDCS score was developed to enable clinicians predict the risk of nosocomial multidrug-resistant Gram-negative bacilli (RGNB) infection in critically ill patients. We aimed to validate this score in a UK setting. METHOD: A retrospective case-control study was conducted including patients who stayed for more than 24h in intensive care units (ICUs) across two tertiary National Health Service hospitals in London, UK (April 2011-April 2016). Cases with RGNB and controls with sensitive Gram-negative bacilli (SGNB) infection were identified. RESULTS: The derived GSDCS score was calculated from when there was a step change in antimicrobial therapy in response to clinical suspicion of infection as follows: prior Gram-negative organism, Surgery, Dialysis with end-stage renal disease, prior Carbapenem use and intensive care Stay of more than 5 days. A total of 110 patients with RGNB infection (cases) were matched 1:1 to 110 geotemporally chosen patients with SGNB infection (controls). The discriminatory ability of the prediction tool by receiver operating characteristic curve analysis in our validation cohort was 0.75 (95% confidence interval 0.65-0.81), which is comparable with the area under the curve of the derivation cohort (0.77). The GSDCS score differentiated between low- (0-1.3), medium- (1.4-2.3) and high-risk (2.4-4.3) patients for RGNB infection (P<0.001) in a UK setting. CONCLUSION: A simple bedside clinical prediction tool may be used to identify and differentiate patients at low, medium and high risk of RGNB infection prior to initiation of prompt empirical antimicrobial therapy in the intensive care setting.
Alturkistani A, Qavi A, Anyanwu PE, et al., 2020, Patient portal functionalities and patient outcomes among diabetes patients: a systematic, Journal of Medical Internet Research, Vol: 22, Pages: 1-9, ISSN: 1438-8871
Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the functionalities such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improve the patient’s self-management of the disease.Objective:To summarise the evidence regarding the use of patient portal (portals that are connected to the electronic healthcare record) or patient portal functionality (e.g. appointment booking or e-messages) and their reported associations with health and healthcare quality outcomes among adult diabetes patients.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data was summarised through narrative synthesis.Results:Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and healthcare quality outcomes. Six studies reported E-messaging or email use associated outcomes and two studies reported prescription refill associated outcomes. Reported associations included the association between patient portal use and blood pressure, LDL cholesterol or BMI. Few studies reported outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Limited number of studies reported overall quality of care for diabetes patients who used patient portals.Conclusions:The included studies mostly r
Alturkistani A, Qavi A, Anyanwu PE, et al., 2020, Patient portal functionalities and patient outcomes among patients with diabetes: systematic review (Preprint), Publisher: JMIR Publications
Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the features such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improved patient self-management of the disease.Objective:To assess health and healthcare quality outcomes associated with the use of tethered (portals that are connected to the electronic healthcare record) patient portals by adult patients (18 years or older) with diabetes.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NIH) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data were summarised through narrative synthesis.Results:Twelve studies were included in this review. Nine studies reported outcomes related to glycaemic control and most of them found statistically significant associations between using a patient portal and glycaemic control. Some studies also found an inverse association or no association between patient portal use and blood pressure, LDL cholesterol or BMI. Studies reported mixed outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Few studies reported overall improved quality of care for diabetes patients who used patient portals.Conclusions:Studies mostly reported improved health outcomes for diabetes patients who used patient portals. However, the limitations of studying the effects of patient portals exist that do not guarantee whether
Alturkistani A, Greenfield G, Greaves F, et al., 2020, Patient portal functionalities and uptake: a systematic review protocol, JMIR Research Protocols, Vol: 9, ISSN: 1929-0748
Background: Patient portals are digital health tools adopted by healthcare organisations. The portals are generally connected to the electronic health record of the healthcare organisation and offer patients functionalities such as access to the medical record, ability to order repeat prescriptions, make appointments or message the healthcare provider. Patient portals may be beneficial for patients and for the healthcare system. Patient portals can widely differ from one context to another due to the differences in the portal functionalities and capabilities and it is anticipated that outcomes associated with the functionalities to differ as well. Current systematic reviews report outcomes associated with patient portal uptake but do not explicitly specify the patient portal functionalities. Objective: The aim of this systematic review is to synthesise the evidence on health and healthcare quality outcomes associated with patient portal use among adult (18 years or older) patients. The review research questions are: What kind of health outcomes do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? and What kind of healthcare quality outcomes including healthcare utilisation outcomes, do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? Methods: The systematic review will be conducted by searching the Medline, Embase, and Scopus databases for relevant literature. The review inclusion criteria will be studies about adult patients (18 years or older), studies only about tethered patient portals and studies with or without a comparator. We will report patient portal-associated health and healthcare quality outcomes based on the patient portal functionalities. All quantitative primary study types will be included. Risk of bias of included studies will be assessed using the Cochrane Collaboration’s tool for assessing risk of bias in randomised
Anyanwu PE, Pouwels K, Walker A, et al., 2020, Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study, BJGP Open, Vol: 4, Pages: 1-12, ISSN: 2398-3795
BACKGROUND: In 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%-23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015-2016. AIM: To investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing. DESIGN & SETTING: Longitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016. METHOD: Linear generalised estimating equations models were fitted, examining the effect of the 2015-2016 QP on the number of antibiotic items per specific therapeutic group age-sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation. RESULTS: Antibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015-2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabet
Vollmer M, Radhakrishnan S, Kont M, et al., 2020, Report 29: The impact of the COVID-19 epidemic on all-cause attendances to emergency departments in two large London hospitals: an observational study
The health care system in England has been highly affected by the surge in demand due to patients afflicted by COVID-19. Yet the impact of the pandemic on the care seeking behaviour of patients and thus on Emergency department (ED) services is unknown, especially for non-COVID-19 related emergencies. In this report, we aimed to assess how the reorganisation of hospital care and admission policies to respond to the COVID-19 epidemic affected ED attendances and emergency hospital admissions. We performed time-series analyses of present year vs historic (2015-2019) trends of ED attendances between March 12 and May 31 at two large central London hospitals part of Imperial College Healthcare NHS Trust (ICHNT) and compared these to regional and national trends. Historic attendances data to ICHNT and publicly available NHS situation reports were used to calibrate time series auto-regressive integrated moving average (ARIMA) forecasting models. We thus predicted the (conterfactual) expected number of ED attendances between March 12 (when the first public health measure leading to lock-down started in England) to May 31, 2020 (when the analysis was censored) at ICHNT, at all acute London Trusts and nationally. The forecasted trends were compared to observed data for the same periods of time. Lastly, we analysed the trends at ICHNT disaggregating by mode of arrival, distance from postcode of patient residence to hospital and primary diagnosis amongst those that were subsequently admitted to hospital and compared these data to an average for the same period of time in the years 2015 to 2019.During the study period (January 1 to May 31, 2020) there was an overall decrease in ED attendances of 35% at ICHNT, of 50% across all London NHS Trusts and 53% nationally. For ICHNT, the decrease in attendances was mainly amongst those aged younger than 65 and those arriving by their own means (e.g. personal or public transport). Increasing distance (km) from postcode of residence to hospi
Peto J, Alwan NA, Godfrey KM, et al., 2020, Universal weekly testing as the UK COVID-19 lockdown exit strategy, The Lancet, Vol: 395, Pages: 1420-1421, ISSN: 0140-6736
Anyanwu P, Costelloe C, Majeed A, et al., 2020, Do variations in primary care practice characteristics explain the effect of a financial incentive scheme on antibiotic prescribing? A longitudinal study of the Quality Premium intervention in NHS England, BJGP Open, ISSN: 2398-3795
BackgroundAbout 73% of antibiotics in England are prescribed from primary care practices.AimTo investigate whether effects of the Quality Premium (QP), which provided performance-related financial incentives to Clinical Commissioning Groups, could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design and settingWe analysed longitudinal monthly prescribing data for 6,251 primary care practices in England from April 2014 to March 2016.MethodWe fitted linear generalised estimating equations models examining the effect of 2015/16 QP on number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation; and examined consistency of effects after further adjustment for variations in practice characteristics, including practice workforce, co-morbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items/STAR-PU (95% CI: -0.180 to -0.171) after 2015/16 QP implementation, with slight increases in the months following April 2015 (+0.014 items/STAR-PU; 95% CI: +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items/STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015/16 QP compared to other practices (interaction p<0.001).ConclusionHigh prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared to other practices, highlighting the need for targeted support of these practices an
Honeyford C, Cooke G, Kinderlerer A, et al., 2020, Evaluating a digital sepsis alert in a London multi-site hospital network: a natural experiment using electronic health record data, Journal of the American Medical Informatics Association, Vol: 27, Pages: 274-283, ISSN: 1067-5027
Objective: To determine the impact of a digital sepsis alert on patient outcomes in a UK multi-site hospital network. Methods:A natural experiment utilising the phased introduction (without randomisation) of a digital sepsis alert into a multi-site hospital network. Sepsis alerts were either visible to clinicans (patients in the ‘intervention’ group) or running silently and not visible (the control group). Inverse probability of treatment weighted multivariable logistic regression was used to estimate the effect of the intervention on individual patient outcomes.Outcomes:In-hospital 30-day mortality (all inpatients), prolonged hospital stay (≥7 days) and timely antibiotics (≤60minutes of the alert) for patients who alerted in the Emergency Department. Results: The introduction of the alert was associated with lower odds of death (OR:0.76; 95%CI:(0.70, 0.84) n=21183); lower odds of prolonged hospital stay ≥7 days (OR:0.93; 95%CI:(0.88, 0.99) n=9988); and in patients who required antibiotics, an increased odds of receiving timely antibiotics (OR:1.71; 95%CI:(1.57, 1.87) n=4622).Discussion: Current evidence that digital sepsis alerts are effective is mixed. In this large UK study a digital sepsis alert has been shown to be associated with improved outcomes, including timely antibiotics. It is not known whether the presence of alerting is responsible for improved outcomes, or whether the alert acted as a useful driver for quality improvement initiatives.Conclusions: These findings strongly suggest that the the introduction of a network-wide digital sepsis alert is associated with improvements in patient outcomes, demonstrating that digital based interventions can be successfully introduced and readily evaluated.
Kyaw BM, Car LT, van Galen LS, et al., 2019, Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration, JOURNAL OF MEDICAL INTERNET RESEARCH, Vol: 21, ISSN: 1438-8871
Anyanwu P, Tonkin-Crine S, Borek A, et al., 2019, Investigating the mechanism of impact of the quality premium initiative on antibiotic prescribing in primary care practices in England: a study protocol, BMJ Open, Vol: 9, ISSN: 2044-6055
IntroductionThe persistent development and spread of resistance to antibiotics remains an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England.Methods and analysisThe study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using Ordinary Least Square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics.Ethics and disseminationThis study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple cha
Saxena S, Skirrow H, Wincott T, et al., 2019, Preschool respiratory hospital admissions following infant bronchiolitis: a birth cohort study, Archives of Disease in Childhood, Vol: 104, Pages: 658-663, ISSN: 1468-2044
Background: Bronchiolitis causes significant infant morbidity worldwide from hospital admissions. However, studies quantifying the subsequent respiratory burden in children under 5 years are lacking.Objective: To estimate the risk of subsequent respiratory hospital admissions in children under 5 years in England following bronchiolitis admission in infancy.Design: Retrospective population-based birth cohort study.Setting: Public hospitals in England.Patients: We constructed a birth cohort of 613,377 infants born between 1.4.2007 and 31.3.2008, followed up until aged 5 years by linking Hospital Episode Statistics (HES) admissions data. Methods: We compared the risk of respiratory hospital admission due to asthma, wheezing and lower and upper respiratory tract infections(LRTI & URTI) in infants who had been admitted for bronchiolitis with those who had not, using Cox proportional hazard regression. We adjusted hazard ratios for known respiratory illness risk factors including living in deprived households, being born preterm or with a comorbid condition.Results: We identified 16,288/613,377 infants(2.7 %) with at least one admission for bronchiolitis. Of these, 21.7% had a further respiratory hospital admission by age 5 years compared with 8% without a previous bronchiolitis admission, (HR(adjusted),2.82, 95%CI 2.72-2.92). The association was greatest for asthma (HR(adjusted), 4.35, 95%CI 4.00-4.73) and wheezing admissions (HR(adjusted), 5.02, 95%CI 4.64-5.44) but were also significant for URTI and LRTI admissions. Conclusions: Hospital admission for bronchiolitis in infancy is associated with a 3-to-5-fold risk of subsequent respiratory hospital admissions from asthma, wheezing and respiratory infections. One in five infants with bronchiolitis hospital admissions will have a subsequent respiratory hospital admission by age 5 years.
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