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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.
Sangkaew S, Ming D, Boonyasiri A, et al., 2021, Risk predictors of progression to severe disease during the febrile phase of dengue: a systematic review and meta-analysis, Lancet Infectious Diseases, Vol: 21, Pages: 1014-1026, ISSN: 1473-3099
BACKGROUND: The ability to accurately predict early progression of dengue to severe disease is crucial for patient triage and clinical management. Previous systematic reviews and meta-analyses have found significant heterogeneity in predictors of severe disease due to large variation in these factors during the time course of the illness. We aimed to identify factors associated with progression to severe dengue disease that are detectable specifically in the febrile phase. METHODS: We did a systematic review and meta-analysis to identify predictors identifiable during the febrile phase associated with progression to severe disease defined according to WHO criteria. Eight medical databases were searched for studies published from Jan 1, 1997, to Jan 31, 2020. Original clinical studies in English assessing the association of factors detected during the febrile phase with progression to severe dengue were selected and assessed by three reviewers, with discrepancies resolved by consensus. Meta-analyses were done using random-effects models to estimate pooled effect sizes. Only predictors reported in at least four studies were included in the meta-analyses. Heterogeneity was assessed using the Cochrane Q and I2 statistics, and publication bias was assessed by Egger's test. We did subgroup analyses of studies with children and adults. The study is registered with PROSPERO, CRD42018093363. FINDINGS: Of 6643 studies identified, 150 articles were included in the systematic review, and 122 articles comprising 25 potential predictors were included in the meta-analyses. Female patients had a higher risk of severe dengue than male patients in the main analysis (2674 [16·2%] of 16 481 vs 3052 [10·5%] of 29 142; odds ratio [OR] 1·13 [95% CI 1·01-1·26) but not in the subgroup analysis of studies with children. Pre-existing comorbidities associated with severe disease were diabetes (135 [31·3%] of 431 with vs 868 [16·0%] of 5421 witho
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.
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
Powell N, Honeyford K, Sandoe J, 2020, Impact of penicillin allergy records on antibiotic costs and length of hospital stay: a single-centre observational retrospective cohort, JOURNAL OF HOSPITAL INFECTION, Vol: 106, Pages: 35-42, ISSN: 0195-6701
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
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.
Honeyford CE, Aylin P, Bottle R, 2019, Should emergency department attendances be used with or instead of readmission rates as a performance metric? Comparison of statistical properties using national data, Medical Care, Vol: 57, Pages: e1-e8, ISSN: 1537-1948
Background: Hospital readmissions are common and are viewed as unfavorable. They are commonly used as a measure of quality of care and, in the United States and England, are associated with financial penalties. Readmissions are not the only possible return-to-acute-care metric; patients may also attend emergency departments (ED).Objective: To assess hospital-level return-to-acute-care metrics using statistical criteria.Research Design: Patient readmissions and/or ED attendances were aggregated to produce risk-standardized hospital rates. Return-to-acute-care rates at 7, 30, 90, and 365 days were assessed using key statistical properties: (i) variability between hospitals; (ii) the relative contribution of patient and nonpatient factors to variation; and (iii) the statistical power to detect performance differences.Subjects: We had pseudonymized administrative data on all inpatient hospital admissions and ED attendances in National Health Service hospitals in England between April 2009 and March 2011. Patients with an inpatient stay for chronic obstructive pulmonary disorder or heart failure were eligible for inclusion.Measures: ED attendances and readmissions for patients discharged from an inpatient stay for chronic obstructive pulmonary disorder or heart failure.Results: Interhospital variation was greatest for ED attendance; in addition, readmission was more strongly determined by patient characteristics than was ED attendance or both combined. Because of smaller numbers, the statistical power to detect differences in rates at 7 days for any indicator was limited.Conclusions: Despite the current emphasis on readmissions, we found that ED attendance within 30 days has more desirable statistical properties and therefore the potential to be a useful metric when comparing hospitals.
Honeyford C, Cecil E, Lo M, et al., 2018, The weekend effect: does hospital mortality differ by day of the week? A systematic review and meta-analysis, BMC Health Services Research, Vol: 18, ISSN: 1472-6963
BackgroundThe concept of a weekend effect, poorer outcomes for patients admitted to hospitals at the weekend is not new, but is the focus of debate in England. Many studies have been published which consider outcomes for patients on admitted at the weekend. This systematic review and meta-analysis aims to estimate the effect of weekend admission on mortality in UK hospitals.MethodsThis is a systematic review and meta-analysis of published studies on the weekend effect in UK hospitals. We used EMBASE, MEDLINE, HMIC, Cochrane, Web of Science and Scopus to search for relevant papers. We included systematic reviews, randomised controlled trials and observational studies) on patients admitted to hospital in the UK and published after 2001. Our outcome was death; studies reporting mortality were included. Reviewers identified studies, extracted data and assessed the quality of the evidence, independently and in duplicate. Discrepancy in assessment was considered by a third reviewer. All meta-analyses were performed using a random-effects meta-regression to incorporate the heterogeneity into the weighting.ResultsForty five articles were included in the qualitative synthesis. 53% of the articles concluded that outcomes for patients either undergoing surgery or admitted at the weekend were worse. We included 39 in the meta-analysis which contributed 50 separate analyses. We found an overall effect of 1.07 [odds ratio (OR)] (95%CI:1.03–1.12), suggesting that patients admitted at the weekend had higher odds of mortality than those admitted during the week. Sub-group analyses suggest that the weekend effect remained when measures of case mix severity were included in the models (OR:1.06 95%CI:1.02–1.10), but that the weekend effect was not significant when clinical registry data was used (OR:1.03 95%CI: 0.98–1.09). Heterogeneity was high, which may affect generalisability.ConclusionsDespite high levels of heterogeneity, we found evidence of a weekend effect in
Aylin PP, Bou-Antoun S, Costelloe CE, et al., 2018, Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis, Journal of Antimicrobial Chemotherapy, Vol: 73, Pages: 2883-2892, ISSN: 0305-7453
Objectives: To assess the impact of the 2015/16 NHS England Quality Premium (which provided a financial incentive for Clinical Commissioning Groups to reduce antibiotic prescribing in primary care) on antibiotic prescribing by General Practitioners (GPs) for respiratory tract infections (RTIs).Method: Interrupted time series analysis using monthly patient-level consultation and prescribing data obtained from the Clinical Practice Research Datalink (CPRD), between April 2011 and March 2017. The study population comprised patients consulting a GP who were diagnosed with an RTI. We assessed the rate of antibiotic prescribing in patients (both aggregate and stratified by age) with a recorded diagnosis of uncomplicated RTI, before and after the implementation of the Quality Premium.Results: Prescribing rates decreased over the six year study period, with evident seasonality. Notably, there was a 3% drop in the rate of antibiotic prescribing (equating to 14.65 prescriptions per 1,000 RTI consultations) (p<0.05) in April 2015, coinciding with the introduction of the Quality Premium. This reduction was sustained, such that after two years there was a 3% decrease in prescribing relative to that expected had the pre-intervention trend continued. There was also a concurrent 2% relative reduction in the rate of broad-spectrum antibiotic prescribing. Antibiotic prescribing for RTIs diagnosed in children showed the greatest decline with a 6% relative change two years after the intervention. Of the RTI indications studied, the greatest reductions in antibiotic prescribing were seen for patients with sore throats.Conclusions: Community prescribing of antibiotics for RTIs significantly decreased following the introduction of the Quality Premium, with the greatest reduction seen in younger patients.
Honeyford K, Greaves F, Aylin P, et al., 2017, Secondary analysis of hospital patient experience scores across England's National Health Service - How much has improved since 2005?, PLoS ONE, Vol: 12, ISSN: 1932-6203
OBJECTIVE: To examine trends in patient experience and consistency between hospital trusts and settings. METHODS: Observational study of publicly available patient experience surveys of three hospital settings (inpatients (IP), accident and emergency (A&E) and outpatients (OP)) of 130 acute NHS hospital trusts in England between 2004/05 and 2014/15. RESULTS: Overall patient experience has been good, showing modest improvements over time across the three hospital settings. Individual questions with the biggest improvement across all three settings are cleanliness (IP: +7.1, A&E: +6.5, OP: +4.7) and information about danger signals (IP: +3.8, A&E: +3.9, OP: +4.0). Trust performance has been consistent over time: 71.5% of trusts ranked in the same cluster for more than five years. There is some consistency across settings, especially between outpatients and inpatients. The lowest-scoring questions, regarding information at discharge, are the same in all years and all settings. CONCLUSIONS: The greatest improvement across all three settings has been for cleanliness, which has seen national policies and targets. Information about danger signals and medication side-effects showed least consistency across settings and scores have remained low over time, despite information about danger signals showing a big increase in score. Patient experience of aspects of access and waiting have declined, as has experience of discharge delay, likely reflecting known increases in pressure on England's NHS.
Honeyford CE, Bell D, Aylin P, et al., 2017, The relation between length of stay, a&e attendance and readmission for heart failure patients, Heart, Vol: 103, Pages: A3-A3, ISSN: 1355-6037
Levene LS, Walker N, Baker R, et al., 2016, Rationalising data use for general practice: a missed opportunity?, British Journal of General Practice, Vol: 66, Pages: e603-e605, ISSN: 0960-1643
Honeyford K, 2016, Data and performance: can education and health learn from each other?, British Journal of General Practice, Vol: 66, Pages: e365-e367, ISSN: 0960-1643
Baker R, Honeyford K, Levene LS, et al., 2016, Population characteristics, mechanisms of primary care and premature mortality in England: a cross-sectional study, BMJ Open, Vol: 6, ISSN: 2044-6055
Objectives: Health systems with strong primary care tend to have better population outcomes, but in many countries demand for care is growing. We sought to identify mechanisms of primary care that influence premature mortality.Design: We developed a conceptual model of the mechanisms by which primary care influences premature mortality, and undertook a cross-sectional study in which population and primary care variables reflecting the model were used to explain variations in mortality of those aged under 75 years. The premature standardised mortality ratios (SMRs) for each practice, available from the Department of Health, had been calculated from numbers of deaths in the 5 years from 2006 to 2010. A regression model was undertaken with explanatory variables for the year 2009/2010, and repeated to check stability using data for 2008/2009 and 2010/2011.Setting: All general practices in England were eligible for inclusion and, of the total of 8290, complete data were available for 7858.Results: Population variables, particularly deprivation, were the most powerful predictors of premature mortality, but the mechanisms of primary care depicted in our model also affected mortality. The number of GPs/1000 population and detection of hypertension were negatively associated with mortality. In less deprived practices, continuity of care was also negatively associated with mortality.Conclusions: Greater supply of primary care is associated with lower premature mortality even in a health system that has strong primary care (England). Health systems need to sustain the capacity of primary care to deliver effective care, and should assist primary care providers in identifying and meeting the needs of socioeconomically deprived groups.
Honeyford K, Baker R, Bankart MJG, et al., 2014, Estimating smoking prevalence in general practice using data from the Quality and Outcomes Framework (QOF), BMJ Open, Vol: 4, ISSN: 2044-6055
Objectives: To determine to what extent underlyingdata published as part of Quality and OutcomesFramework (QOF) can be used to estimate smokingprevalence within practice populations and localareas and to explore the usefulness of theseestimates.Design: Cross-sectional, observational study of QOFsmoking data. Smoking prevalence in generalpractice populations and among patients with chronicconditions was estimated by simple manipulation ofQOF indicator data. Agreement between estimatesfrom the integrated household survey (IHS) andaggregated QOF-based estimates was calculated. Theimpact of including smoking estimates in negativebinomial regression models of counts of prematurecoronary heart disease (CHD) deaths was assessed.Setting: Primary care in the East Midlands.Participants: All general practices in the area ofstudy were eligible for inclusion (230). 14 practiceswere excluded due to incomplete QOF data for theperiod of study (2006/2007–2012/2013). Onepractice was excluded as it served a restrictedpractice list.Measurements: Estimates of smoking prevalence ingeneral practice populations and among patients withchronic conditions.Results: Median smoking prevalence in the practicepopulations for 2012/2013 was 19.2% (range5.8–43.0%). There was good agreement (meandifference: 0.39%; 95% limits of agreement (−3.77,4.55)) between IHS estimates for local authoritydistricts and aggregated QOF register estimates.Smoking prevalence estimates in those with chronicconditions were lower than for the general population(mean difference −3.05%), but strongly correlated(Rp=0.74, p<0.0001). An important positiveassociation between premature CHD mortality andsmoking prevalence was shown when smokingprevalence was added to other population and servicecharacteristics.Conclusions: Published QOF data allow usefulestimation of smoking prevalence within practicepopulations and in those with chronic conditions; thelatter estimates may sometimes be useful in place o
Honeyford K, Baker R, Bankart MJG, et al., 2013, Modelling factors in primary care quality improvement: a cross-sectional study of premature CHD mortality, BMJ Open, Vol: 3, ISSN: 2044-6055
Objectives: To identify features of primary care qualityimprovement associated with improved health outcomesusing premature coronary heart disease (CHD) mortalityas an example, and to determine impacts of differentmodelling approaches.Design: Cross-sectional study of mortality rates in 229general practices.Setting: General practices from three East Midlandsprimary care trusts.Participants: Patients registered to the practices abovebetween April 2006 and March 2009.Main outcome measures: Numbers of CHD deaths inthose aged under 75 (premature mortality) and at allages in each practice.Results: Population characteristics and markers ofquality of primary care were associated with variations inpremature CHD mortality. Increasing levels ofdeprivation, percentages of practice populations onpractice diabetes registers, white, over 65 and male wereall associated with increasing levels of premature CHDmortality. Control of serum cholesterol levels in thosewith CHD and the percentage of patients recalling accessto their preferred general practitioner were bothassociated with decreased levels of premature CHDmortality. Similar results were found for all-age mortality.A combined measure of quality of primary care for CHDcomprising 12 quality outcomes framework indicatorswas associated with decreases in both all-age andpremature CHD mortality. The selected models suggestthat practices in less deprived areas may have up to 20%lower premature CHD mortality than those with mediandeprivation and that improvement in the CHD care qualityfrom 83% (lower quartile) to 86% (median) could reducepremature CHD mortality by 3.6%. Different modellingapproaches yielded qualitatively similar results.Conclusions: High-quality primary care, includingaspects of access to and continuity of care, detection andmanagement, appears to be associated with reducingCHD mortality. The impact on premature CHD mortality isgreater than on all-age CHD mortality. Determining themost useful measures of quality of p
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