Publications
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Dewa L, Lawrence-Jones A, Kalorkoti C, et al., 2020, Reflections and impact of a co-produced qualitative study with young people with experience of mental health difficulties, Publisher: Health Expectations
McCabe R, Schmit N, Christen P, et al., 2020, Adapting hospital capacity to meet changing demands during the COVID-19 pandemic, BMC Medicine, Vol: 18, Pages: 1-12, ISSN: 1741-7015
BackgroundTo calculate hospital surge capacity, achieved via hospital provision interventions implemented for the emergency treatment of coronavirus disease 2019 (COVID-19) and other patients through March to May 2020; to evaluate the conditions for admitting patients for elective surgery under varying admission levels of COVID-19 patients.MethodsWe analysed National Health Service (NHS) datasets and literature reviews to estimate hospital care capacity before the pandemic (pre-pandemic baseline) and to quantify the impact of interventions (cancellation of elective surgery, field hospitals, use of private hospitals, deployment of former medical staff and deployment of newly qualified medical staff) for treatment of adult COVID-19 patients, focusing on general and acute (G&A) and critical care (CC) beds, staff and ventilators.ResultsNHS England would not have had sufficient capacity to treat all COVID-19 and other patients in March and April 2020 without the hospital provision interventions, which alleviated significant shortfalls in CC nurses, CC and G&A beds and CC junior doctors. All elective surgery can be conducted at normal pre-pandemic levels provided the other interventions are sustained, but only if the daily number of COVID-19 patients occupying CC beds is not greater than 1550 in the whole of England. If the other interventions are not maintained, then elective surgery can only be conducted if the number of COVID-19 patients occupying CC beds is not greater than 320. However, there is greater national capacity to treat G&A patients: without interventions, it takes almost 10,000 G&A COVID-19 patients before any G&A elective patients would be unable to be accommodated.ConclusionsUnless COVID-19 hospitalisations drop to low levels, there is a continued need to enhance critical care capacity in England with field hospitals, use of private hospitals or deployment of former and newly qualified medical staff to allow some or all elective surge
Greenfield G, Blair M, Aylin P, et al., 2020, Frequent attendances at emergency departments in England, Emergency Medicine Journal, Vol: 37, Pages: 597-599, ISSN: 1472-0205
Background: A small proportion of patients referred to as ‘frequent attenders’ account for a large proportion of hospital activity such as emergency departments (ED) attendances and admissions. There is lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals.Method: We included all attendances at all major EDs across England in the financial year 2016–2017. Patients who attended 3 times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group.Results: 14,829,519 attendances were made by 10,062,847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended 3 times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended 6 times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30-59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had.Conclusion: One in ten patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.
Dewa L, Crandell C, Choong E, et al., 2020, CCopeY: a mixed-methods co-produced study on the mental health status and coping strategies of young people during COVID-19 UK lockdown
Perez Guzman PN, Daunt A, Mukherjee S, et al., 2020, Clinical characteristics and predictors of outcomes of hospitalized patients with COVID-19 in a multi-ethnic London NHS Trust: a retrospective cohort study, Clinical Infectious Diseases, Vol: 2020, Pages: 1-11, ISSN: 1058-4838
Background: Emerging evidence suggests ethnic minorities are disproportionatelyaffected by COVID-19. Detailed clinical analyses of multi-cultural hospitalized patientcohorts remain largely undescribed.Methods: We performed regression, survival andcumulative competing risk analyses to evaluate factors associated with mortality inpatients admitted for COVID-19 in three large London hospitals between February 25and April 5, censored as of May 1, 2020.Results: Of 614 patients (median age 69years, (IQR 25) and 62% male), 381 (62%) had been discharged alive, 178 (29%)died and 55 (9%) remained hospitalized at censoring. Severe hypoxemia (aOR 4.25,95%CI 2.36-7.64), leukocytosis (aOR 2.35, 95%CI 1.35-4.11), thrombocytopenia (aOR1.01, 95%CI 1.00-1.01, increase per 10x9decrease), severe renal impairment (aOR5.14, 95%CI 2.65-9.97), and low albumin (aOR 1.06, 95%CI 1.02-1.09, increase per gdecrease) were associated with death. Forty percent (244) were from black, Asian andother minority ethnic (BAME) groups, 38% (235) white and for 22% (135) ethnicity wasunknown. BAME patients were younger and had fewer comorbidities. Whilst theunadjusted odds of death did not differ by ethnicity, when adjusting for age, sex andcomorbidities, black patients were at higher odds of death compared to whites (aOR1.69, 95%CI 1.00-2.86). This association was stronger when further adjusting foradmission severity (aOR 1.85 95% CI 1.06-3.24). Conclusions: BAME patients were over-represented in our cohort and, whenaccounting for demographic and clinical profile of admission, black patients were atincreased odds of death. Further research is needed into biologic drivers of differencesin COVID-19 outcomes by ethnicity.
Kim D, Hayhoe B, Aylin P, et al., 2020, Health service use by patients with heart failure living in a community setting: a cross-sectional analysis in North West London, British Journal of General Practice, Vol: 70, Pages: e563-e572, ISSN: 0960-1643
Background: The complex nature of heart failure (HF) management, often involving multidimensional care, is widely recognised, but overall health service utilisation by HF patients has not previously been described.Aim: To describe overall health service use by community-dwelling adults with HF.Design and Setting: Cross-sectional analysis of prevalent HF cases between 2015 and 2018 using an administrative dataset covering primary care, secondary care, and ‘other’ (community, mental health, and social care) services in North West London (NWL).Methods: Healthcare use of each service was described overall and by individual components of secondary care (e.g. outpatient appointments) and ‘other’ services (e.g. nursing contacts). Usage patterns were identified using k-means cluster analysis using all distinct contacts for the whole study period and visualised by a heatmap. Results: There were 39 301 patients with a prevalent diagnosis of HF between 1 January 2015 and 31 December 2018. 90% used health services during the study period, most commonly outpatient services, GP consultations, unplanned A&E visits and community services. Use of cardiology-specific services ranged from around 3% (cardiology-related community care) to around 20% (outpatient cardiology visits). GP consultations decreased by 11% over our study period. Five clusters of patients were identified, each with significantly different care usage patterns and patient characteristics.Conclusions: HF patients make heavy but heterogeneous use of services. Relatively low and falling use of GP consultations, and apparently low uptake of community rehabilitation services by patients with HF, is concerning and suggests challenges in primary care access and integration of care.
Vollmer MAC, Radhakrishnan S, Kont MD, et al., 2020, The Impact of the COVID-19 Epidemic on Patterns of Attendance at Emergency Departments in Two Large London Hospitals: An Observational Study
<jats:title>Abstract</jats:title> <jats:p>BackgroundHospitals in England have undergone considerable change to address the surge in demand imposed by the COVID-19 epidemic. The impact of this on emergency department (ED) attendances is unknown, especially for non-COVID-19 related emergencies.MethodsWe calibrated auto-regressive integrated moving average time-series models of ED attendances to Imperial College Healthcare NHS Trust (ICHNT) using historic (2015–2019) data. Forecasted trends were compared to present year ICHNT data for the period between March 12 (when England implemented the first COVID-19 public health measure) and May 31. We compared ICHTN trends with publicly available regional and national data. Lastly, we compared emergency admissions and in-hospital mortality at ICHNT during the present year to a historic 5-year average.ResultsED attendances at ICHNT decreased by 35%, in keeping with the trend for ED attendances across all England regions, which fell by approximately 50%. For ICHNT, the decrease in attendances was mainly amongst those aged < 65 years and those arriving by their own means (e.g. personal or public transport). Increasing distance from postcode of residence to hospital was a significant predictor of reduced attendances. Non-COVID related emergency admissions to hospital after March 12 fell by 48%; there was an indication of a non-significant increase in non-COVID-19 crude mortality risk (RR 1.13, 95%CI 0.94–1.37, p = 0.19).ConclusionsOur study finds strong evidence that emergency healthcare seeking has drastically changed across the population in England. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of non-COVID patients did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital rema
Arhi CS, Burns EM, Bottle A, et al., 2020, Delays in referral from primary care worsen survival for patients with colorectal cancer: a retrospective cohort study, British Journal of General Practice, Vol: 70, Pages: E463-E471, ISSN: 0960-1643
Background Delays in referral for patients with colorectal cancer may occur if the presenting symptom is falsely attributed to a benign condition.Aim To investigate whether delays in referral from primary care are associated with a later stage of cancer at diagnosis and worse prognosis.Design and setting A national retrospective cohort study in England including adult patients with colorectal cancer identified from the cancer registry with linkage to Clinical Practice Research Datalink, who had been referred following presentation to their GP with a ‘red flag’ or ‘non-specific’ symptom.Method The hazard ratios (HR) of death were calculated for delays in referral of between 2 weeks and 3 months, and >3 months, compared with referrals within 2 weeks.Results A total of 4527 (63.5%) patients with colon cancer and 2603 (36.5%) patients with rectal cancer were included in the study. The percentage of patients presenting with red-flag symptoms who experienced a delay of >3 months before referral was 16.9% of those with colon cancer and 13.5% of those with rectal cancer, compared with 35.7% of patients with colon cancer and 42.9% of patients with rectal cancer who presented with non-specific symptoms. Patients referred after 3 months with red-flag symptoms demonstrated a significantly worse prognosis than patients who were referred within 2 weeks (colon cancer: HR 1.53; 95% confidence interval [CI] = 1.29 to 1.81; rectal cancer: HR 1.30; 95% CI = 1.06 to 1.60). This association was not seen for patients presenting with non-specific symptoms. Delays in referral were associated with a significantly higher proportion of late-stage cancers.Conclusion The first presentation to the GP provides a referral opportunity to identify the underlying cancer, which, if missed, is associated with a later stage in diagnosis and worse survival.
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
Forchini G, Lochen A, Hallett T, et al., 2020, Report 28: Excess non-COVID-19 deaths in England and Wales between 29th February and 5th June 2020
There were 189,403 deaths from any cause reported in England from 29th February to 5th June 2020 inclusive, and 11,278 all-cause deaths in Wales over the same period. Of those deaths, 44,736 (23.6%) registered COVID-19 on the death certificate in England, and 2,294 (20.3%) in Wales, while 144,667 (76.4%) were not recorded as having been due to COVID-19 in England, and 8,984 (79.7%) in Wales. However, it could be that some of the ‘non-COVID-19’ deaths have in fact also been caused by COVID-19, either as the direct cause of death, or indirectly through provisions for the pandemic impeding access to care for other conditions. There is uncertainty in how many of the non-COVID-19 deaths were directly or indirectly caused by the pandemic. We estimated the excess deaths that were not recorded as associated with COVID-19 in the death certificate (excess non-COVID-19 deaths) as the deaths for which COVID-19 was not reported as the cause, compared to those we would have expected to occur had the pandemic not happened. Expected deaths were forecast with an analysis of historic trends in deaths between 2010 and April 2020 using data by the Office of National Statistics and a statistical time series model. According to the model, we expected 136,294 (95% CI 133,882 - 138,696) deaths in England, and 8,983 (CI 8,051 - 9,904) in Wales over this period, significantly fewer than the number of deaths reported. This means that there were 8,983 (95% CI 5,971 - 10,785) total excess non-COVID-19 deaths in England. For every 100 COVID-19 deaths during the period from 29th February to 5th June 2020 there were between 13 and 24 cumulative excess non-COVID-19 deaths. The proportion of cumulative excess non-COVID-19 deaths of all reported deaths during this period was 4.4% (95% CI 3.2% - 5.7%) in England, with small regional variations. Excess deaths were highest in the South East at 2,213 (95% CI 327 - 4,047) and in London at 1,937 (95% CI 896 - 3,010), respectively. There is no e
McCabe R, Schmit N, Christen P, et al., 2020, Report 27 Adapting hospital capacity to meet changing demands during the COVID-19 pandemic
To meet the growing demand for hospital care due to the COVID-19 pandemic, England implemented a range of hospital provision interventions including the procurement of equipment, the establishment of additional hospital facilities and the redeployment of staff and other resources. Additionally, to further release capacity across England’s National Health Service (NHS), elective surgery was cancelled in March 2020, leading to a backlog of patients requiring care. This created a pressure on the NHS to reintroduce elective procedures, which urgently needs to be addressed. Population-level measures implemented in March and April 2020 reduced transmission of SARS-CoV-2, prompting a gradual decline in the demand for hospital care by COVID-19 patients after the peak in mid-April. Planning capacity to bring back routine procedures for non-COVID-19 patients whilst maintaining the ability to respond to any potential future increases in demand for COVID-19 care is the challenge currently faced by healthcare planners.In this report, we aim to calculate hospital capacity for emergency treatment of COVID-19 and other patients during the pandemic surge in April and May 2020; to evaluate the increase in capacity achieved via five interventions (cancellation of elective surgery, field hospitals, use of private hospitals, and deployment of former and newly qualified medical staff); and to determine how to re-introduce elective surgery considering continued demand from COVID-19 patients. We do this by modelling the supply of acute NHS hospital care, considering different capacity scenarios, namely capacity before the pandemic (baseline scenario) and after the implementation of capacity expansion interventions that impact available general and acute (G&A) and critical care (CC) beds, staff and ventilators. Demand for hospital care is accounted for in terms of non-COVID-19 and COVID-19 patients. Our results suggest that NHS England would not have had sufficient daily capacity
Perez Guzman PN, Daunt A, Mukherjee S, et al., 2020, Report 17: Clinical characteristics and predictors of outcomes of hospitalised patients with COVID-19 in a London NHS Trust: a retrospective cohort study
Clinical characteristics and determinants of outcomes for hospitalised COVID-19 patients in the UK remain largely undescribed and emerging evidence suggests ethnic minorities might be disproportionately affected. We describe the characteristics and outcomes of patients hospitalised for COVID-19 in three large London hospitals with a multi-ethnic catchment population.We performed a retrospective cohort study on all patients hospitalised with laboratory-confirmed SARS-CoV-2 infection at Imperial College Healthcare NHS Trust between February 25 and April 5, 2020. Outcomes were recorded as of April 19, 2020. Logistic regression models, survival analyses and cumulative competing risk analyses were performed to evaluate factors associated with COVID-19 hospital mortality.Of 520 patients in this cohort (median age 67 years, (IQR 26) and 62% male), 302 (68%) had been discharged alive, 144 (32%) died and 74 (14%) were still hospitalised at the time of censoring. Increasing age (adjusted odds ratio [aOR] 2·16, 95%CI 1·50-3·12), severe hypoxia (aOR 3·75, 95%CI 1·80-7·80), low platelets (aOR 0·65, 95%CI 0.49·0·85), reduced estimated glomerular filtration rate (aOR 4·11, 95%CI 1·58-10·69), bilirubin >21mmol/L (aOR 2·32, 95%CI 1·05-5·14) and low albumin (aOR 0·77, 9%%CI 0·59-1·01) were associated with increased risk of in-hospital mortality. Individual comorbidities were not independently associated with risk of death. Regarding ethnicity, 209 (40%) were from a black and Asian minority, for 115 (22%) ethnicity was unknown and 196 (38%) patients were white. Compared to the latter, black patients were significantly younger and had less comorbidities. Whilst the crude OR of death of black compared to white patients was not significant (1·14, 95%CI 0·69-1·88, p=0.62), adjusting for age and comorbidity showed a trend towards significance
Bottle R, Cohen C, Lucas A, et al., 2020, How an electronic health record became a real-world research resource: comparison between London’s Whole Systems Integrated Care database and the Clinical Practice Research Datalink, BMC Medical Informatics and Decision Making, Vol: 20, ISSN: 1472-6947
BackgroundIn the UK, several initiatives have resulted in the creation of local data warehouses of electronic patient records. Originally developed for commissioning and direct patient care, they are potentially useful for research, but little is known about them outside their home area. We describe one such local warehouse, the Whole Systems Integrated Care (WSIC) database in NW London, and its potential for research as the “Discover” platform. We compare Discover with the Clinical Practice Research Datalink (CPRD), a popular UK research database also based on linked primary care records.MethodsWe describe the key features of the Discover database, including scope, architecture and governance; descriptive analyses compare the population demographics and chronic disease prevalences with those in CPRD.ResultsAs of June 2019, Discover held records for a total of 2.3 million currently registered patients, or 95% of the NW London population; CPRD held records for over 11 million. The Discover population matches the overall age-sex distribution of the UK and CPRD but is more ethnically diverse. Most Discover chronic disease prevalences were comparable to the national rates. Unlike CPRD, Discover has identifiable care organisations and postcodes, allowing mapping and linkage to healthcare provider variables such as staffing, and includes contacts with social, community and mental health care. Discover also includes a consent-to-contact register of over 3000 volunteers to date for prospective studies.ConclusionsLike CPRD, Discover has been a number of years in the making, is a valuable research tool, and can serve as a model for other areas developing similar data warehouses.
Christen P, D'Aeth J, Lochen A, et al., 2020, Report 15: Strengthening hospital capacity for the COVID-19 pandemic
Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for COVID-19, and other conditions, is one of the most challenging tasks facing healthcare commissioners and care providers during the pandemic. Due to uncertainty in expected patient numbers requiring care, as well as evolving needs day by day, planning hospital capacity is challenging. Health systems that are well prepared for the pandemic can better cope with large and sudden changes in demand by implementing strategies to ensure adequate access to care. Thereby the burden of the pandemic can be mitigated, and many lives saved. This report presents the J-IDEA pandemic planner, a hospital planning tool to calculate how much capacity in terms of beds, staff and ventilators is obtained by implementing healthcare provision interventions affecting the management of patient care in hospitals. We show how to assess baseline capacity, and then calculate how much capacity is gained by various healthcare interventions using impact estimates that are generated as part of this study. Interventions are informed by a rapid review of policy decisions implemented or being considered in 12 European countries over the past few months , an evaluation of the impact of the interventions on capacity using a variety of research methods, and by a review of key parameters in the care of COVID-19 patients.The J-IDEA planner is publicly available, interactive and adaptable to different and changing circumstances and newly emerging evidence. The planner estimates the additional number of beds, medical staff and crucial medical equipment obtained under various healthcare interventions using flexible inputs on assumptions of existing capacities, the number of hospitalisations, beds-to-staff ratios, and staff absences due to COVID-19. A detailed user guide accompanies the planner. The planner was developed rapidly and has limitations which we will address in future iterations. It support
Dewa L, Thibaut B, Pattison N, et al., 2020, Treating insomnia in prisoners: a feasibility study of a multi-component treatment pathway, Publisher: Journal of Sleep Research
Giuliani S, Honeyford K, Chang C-Y, et al., 2020, Outcomes of Primary versus Multiple-Staged Repair in Hirschsprung's Disease in England, EUROPEAN JOURNAL OF PEDIATRIC SURGERY, Vol: 30, Pages: 104-110, ISSN: 0939-7248
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Cecil E, Bottle R, Vincent C, et al., 2020, What is the relationship between mortality alerts and other indicators of quality of care? A national cross-sectional study, Journal of Health Services Research and Policy, Vol: 25, Pages: 13-21, ISSN: 1355-8196
Objective: To assess whether mortality alerts, triggered by sustained higher than expected hospital mortality, are associated with other potential indicators of hospital quality relating to factors of hospital structure, clinical process and patient outcomes.Study Design: Cross sectional study of National Health Service hospital trusts in England (2011-2013).Data collection/extraction methods: Publicly available hospital measures chosen a-prior to reflect 1) Organisational structure (mean acute bed occupancy, nurse/bed ratios, training satisfaction and proportion of trusts with low NHS Litigation Authority risk assessment or in financial deficit), 2) Process (mean % of eligible patients who receive percutaneous coronary intervention within 90 minutes) and 3) Outcome (mean patient satisfaction scores, summary measures of hospital mortality (SHMI and HSMR) and % of patient harmed). Mortality alerts were based on hospital administrative data.Principal Findings: Mortality alerts were associated with structural indicators and outcome indicators of quality. There was insufficient data to detect an association between mortality alerts and our process indicator.Conclusion:Mortality alerts appear to reflect aspects of quality within an English hospital setting, suggesting that there may be value in a mortality alerting system in highlighting poor hospital quality.
Cecil E, Bottle A, Majeed A, et al., 2019, Patient and health-care factors associated with potentially missed acute deterioration in primary care: a retrospective observational study of linked primary and secondary care data, National Conference on Public Health Science Dedicated to New Research in UK Public Health, Publisher: Elsevier, Pages: 30-30, ISSN: 0140-6736
Arhi CS, Ziprin P, Bottle A, et al., 2019, Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population-based study, Colorectal Disease, Vol: 21, Pages: 1270-1278, ISSN: 1462-8910
AIM: The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients. METHOD: We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records. RESULTS: The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific. CONCLUSION: Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.
Kim D, Hayhoe B, Aylin P, et al., 2019, Health service use by community-dwelling patients with heart failure in northwest London, 2015-18: a retrospective cohort analysis, National Conference on Public Health Science Dedicated to New Research in UK Public Health, Publisher: ELSEVIER SCIENCE INC, Pages: 64-64, ISSN: 0140-6736
Ghafur S, Kristensen S, honeyford K, et al., 2019, A retrospective impact analysis of the WannaCry cyber-attack on the NHS, npj Digital Medicine, Vol: 2, ISSN: 2398-6352
A systematic analysis of Hospital Episodes Statistics (HES) data was done to determine the effects of the 2017 WannaCry attack on the National Health Service (NHS) by identifying the missed appointments, deaths, and fiscal costs attributable to the ransomware attack. The main outcomes measured were: outpatient appointments cancelled, elective and emergency admissions to hospitals, Accident & Emergency (A&E) attendances, and deaths in A&E. Compared with the baseline, there was no significant difference in the total activity across all trusts during the week of the WannaCry attack. Trusts had 1% more emergency admissions and 1% fewer A&E attendances per day during the WannaCry week compared with baseline. Hospitals directly infected with the ransomware, however, had significantly fewer emergency and elective admissions: a decrease of about 6% in total admissions per infected hospital per day was observed, with 4% fewer emergency admissions and 9% fewer elective admissions. No difference in mortality was noted. The total economic value of the lower activity at the infected trusts during this time was £5.9m including £4m in lost inpatient admissions, £0.6m from lost A&E activity, and £1.3m from cancelled outpatient appointments. Among hospitals infected with WannaCry ransomware, there was a significant decrease in the number of attendances and admissions, which corresponded to £5.9m in lost hospital activity. There was no increase in mortality reported, though this is a crude measure of patient harm. Further work is needed to appreciate the impact of a a cyber attack or IT failure on care delivery and patient safety.
Arhi CS, Markar S, Burns EM, et al., 2019, Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer, Diseases of the Esophagus, Vol: 32, Pages: 1-11, ISSN: 1120-8694
NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.
Kim D, Hayhoe B, Aylin P, et al., 2019, Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation, British Journal of General Practice, Vol: 69, Pages: e697-e705, ISSN: 0960-1643
BACKGROUND: Despite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients' routes to diagnosis will better inform HF management. AIM: To identify the factors associated with variation in patients' routes to HF diagnosis in primary care. DESIGN AND SETTING: A retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care. METHOD: This study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices. RESULTS: Few patients (7%, n = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age (P = 0.001), lower deprivation level (P = 0.007), HF diagnosis source (P<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<0.001). CONCLUSION: The significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.
Dewa L, Lavelle M, Pickles K, et al., 2019, Young adults’ perceptions of using wearables, social media and other technologies to detect worsening mental health: a qualitative study, PLoS One, Vol: 14, ISSN: 1932-6203
BackgroundTechnological interventions may help support and improve mental health. However young peoples’ perspectives on using different technologies to detect deteriorating mental health in those already diagnosed with a mental health condition is lacking. The study aim was to explore the perspectives of young patients on the feasibility and acceptability of using wearables, social media and technologies to detect mental health deterioration. Methods The study was co-produced with young adults with past mental health difficulties. Semi-structured interviews were conducted with young adults with a severe mental health condition in a private room at a community mental health site. Data was triangulated by comparing codes and ideas across the two co-researchers and two researchers over two virtual meetings. Themes were finalised and presented in a thematic map. ResultsSixteen participants were interviewed (81% female). There were four main themes: dealing with mental health symptoms, signs of mental health deterioration, technology concerns and technological applications to identify worsening mental health. Wearables and mobile apps were considered acceptable and feasible to detect mental health deterioration in real-time if they could measure changes in sleep patterns, mood or activity levels as signs of deterioration. Getting help earlier was deemed essential particularly in reference to dissatisfaction with the current non-technological mental health services. However, patients identified issues to consider before implementation including practicality, safeguarding and patient preference. ConclusionWearables and mobile apps could be viable technological options to help detect deterioration in young people in order to intervene early and avoid delay in accessing mental health services. However, immediate action following detection is required for the patient to trust and use the intervention.
Cecil EV, Dewa L, Ma R, et al., 2019, Primary health care professionals views of reminders in electronic patient records, JECH, Publisher: BMJ PUBLISHING GROUP, Pages: A64-A64, ISSN: 0143-005X
Balinskaite V, Johnson AP, Holmes A, et al., 2019, The impact of a national antimicrobial stewardship programme on antibiotic prescribing in primary care: an interrupted time series analysis, Clinical Infectious Diseases, Vol: 69, Pages: 227-232, ISSN: 1058-4838
Background: The Quality Premium was introduced in 2015 to financially reward local commissioners of healthcare in England for targeted reductions in antibiotic prescribing in primary care. Methods: We used a national antibiotic prescribing dataset from April 2013 till February 2017 to examine the number of antibiotic items prescribed, the total number of antibiotic items prescribed per STAR-PU (Specific Therapeutic Group Age-sex Related Prescribing Units), the number of broad-spectrum antibiotic items prescribed and broad-spectrum antibiotic items prescribed expressed as a percentage of the total number of antibiotic items. To evaluate the impact of the Quality Premium on antibiotic prescribing, we used a segmented regression analysis of interrupted time series data. Results: During the study period, over 140 million antibiotic items were prescribed in primary care. Following the introduction of the Quality Premium, antibiotic items prescribed decreased by 8.2%, representing 5,933,563 fewer antibiotic items prescribed during the 23 post-intervention months compared with the expected numbers based on the trend in the pre-intervention period. After adjusting for the age and sex distribution in the population, the segmented regression model also showed a significant relative decrease in antibiotic items prescribed per STAR-PU. A similar effect was found for broad-spectrum antibiotics (comprising 10.1% of total antibiotic prescribing), with an 18.9% reduction in prescribing. Conclusions: This study shows that the introduction of financial incentives for local commissioners of healthcare to improve the quality of prescribing was associated with a significant reduction in both total and broad-spectrum antibiotic prescribing in primary care in England.
Balinskaite V, Bou-Antoun S, Johnson AP, et al., 2019, An assessment of potential unintended consequences following a national antimicrobial stewardship programme in England: an interrupted time series analysis, Clinical Infectious Diseases, Vol: 69, Pages: 233-242, ISSN: 1058-4838
Background: The 'Quality Premium' (QP) introduced in England in 2015 aimed to financially reward local healthcare commissioners for targeted reductions in primary care antibiotic prescribing. We aimed to evaluate possible unintended clinical outcomes related to this QP. Methods: Using Clinical Practice Research Datalink and Hospital Episode Statistics datasets, we examined general practitioner (GP) consultations (visits) and emergency hospital admissions related to a series of pre-defined conditions of unintended consequences of reduced prescribing. Monthly age and sex-standardised rates were calculated using a direct method of standardisation. We used segmented regression analysis of interrupted time series to evaluate the impact of the QP on seasonally adjusted outcome rates. Results: We identified 27,334 GP consultations and over five million emergency hospital admissions with pre-defined conditions. There was no evidence that the QP was associated with changes in GP consultation and hospital admission rates for the selected conditions combined. However, when each condition was considered separately, a significant increase in hospital admission rates was noted for quinsy, and significant decreases were seen for hospital-acquired pneumonia, scarlet fever, pyelonephritis and complicated urinary tract conditions. A significant decrease in GP consultation rates was estimated for empyema and scarlet fever. No significant changes were observed for other conditions. Conclusions: Findings from this study show that overall there was no significant association between the intervention and unintended clinical consequences, with the exception of a few specific conditions, most of which could be explained through other parallel policy changes or should be interpreted with caution due to small numbers.
Honeyford K, Bell D, Chowdhury F, et al., 2019, Unscheduled hospital contacts after inpatient discharge: A national observational study of COPD and heart failure patients in England, PLoS ONE, Vol: 14, ISSN: 1932-6203
IntroductionReadmissions are a recognised challenge for providers of healthcare and incur financial penalties in a growing number of countries. However, the scale of unscheduled hospital contacts including attendances at emergency departments that do not result in admission is not well known. In addition, little is known about the route to readmission for patients recently discharged from an emergency hospital stay.MethodsThis is an observational study of national hospital administration data for England. In this retrospective cohort study, we tracked patients for 30 days after discharge from an emergency admission for heart failure (HF) or chronic obstructive pulmonary disorder (COPD).ResultsThe majority of patients (COPD:79%; HF:75%) had no unscheduled contact with secondary health care within 30 days of discharge. Of those who did have unscheduled contact, the most common first unscheduled contact was emergency department (ED) attendance (COPD:16%; HF:18%). A further 5% of COPD patients and 4% of HF patients were admitted for an emergency inpatient stay, but not through the ED. A small percentage of patients (COPD:<1%, HF:2%) died without any known contact with secondary care. ED conversion rates at first attendance for both COPD and HF were high: 75% and 79% respectively. A quarter of patients who were not admitted during this first ED attendance attended the ED again within the 30-day follow-up period, and around half (COPD:56%; HF:63%) of these were admitted at this point.Patients who live alone, had an index admission which included an overnight stay and were comorbid had higher odds of being admitted through the ED than via other routes.ConclusionWhile the majority of patients did not have unscheduled contact with secondary care in the 30 days after index discharge, many patients attended the ED, often multiple times, and many were admitted to hospital, not always via the ED. More frail patients were more likely to be admitted through the ED, suggesting a
Wang Y, Honeyford K, Aylin P, et al., 2019, One-year outcomes for congenital diaphragmatic hernia, BJS Open, Vol: 3, Pages: 305-313, ISSN: 2474-9842
BackgroundCongenital diaphragmatic hernia (CDH) is a congenital anomaly with high mortality and long‐term morbidity. The aim of this study was to benchmark trends in 1‐year and hospital volume outcomes for this condition.MethodsThis study included all infants born with CDH in England between 2003 and 2016. This was a retrospective analysis of the Hospital Episode Statistics database. The main outcomes were: 1‐year mortality, neonatal length of hospital stay (nLOS), total bed‐days at 1 year and readmission rate. The association between hospital volume and outcomes was assessed for specialist paediatric surgery centres.ResultsA total of 2336 infants were included (incidence 2·5 per 10 000 live births). No significant time trends were found in incidence and main outcomes. Some 1491 infants (63·8 per cent) underwent surgical repair. The 1‐year mortality rate was 31·2 per cent. Median nLOS and total bed‐days were 17 and 19 days respectively. The readmission rate in specialist paediatric centres was 6·3 per cent. Higher mortality was associated with birthweight lower than 1 kg (OR 5·90, 95 per cent c.i. 1·03 to 33·75), gestational age of 36 weeks or less (OR 1·75, 1·12 to 2·75) and black ethnicity (OR 2·13, 1·03 to 4·48). Only 4·0 per cent had extracorporeal membrane oxygenation, which was associated with higher mortality (OR 5·34, 3·01 to 9·46), longer nLOS (OR 3·70, 2·14 to 6·14) and longer total bed‐days (OR 3·87, 2·19 to 6·83). Specialist paediatric centres showed variation in 30‐day mortality (4·6 per cent with 84 per cent coefficient of variation), nLOS (median 25 (i.q.r. 15–42) days) and total bed‐days (median 28 (i.q.r. 16–51) days), but no significant volume–outcome relationship.ConclusionKey outcomes for CDH were similar to those of other develo
Martin G, Clarke J, Liew F, et al., 2019, Evaluating the impact of organisational digital maturity on clinical outcomes in secondary care in England, npj Digital Medicine, Vol: 2, ISSN: 2398-6352
All healthcare systems are increasingly reliant on health information technology to support the delivery of high-quality, efficient and safe care. Data on its effectiveness are however limited. We therefore sought to examine the impact of organisational digital maturity on clinical outcomes in secondary care within the English National Health Service. We conducted a retrospective analysis of routinely collected administrative data for 13,105,996 admissions across 136 hospitals in England from 2015 to 2016. Data from the 2016 NHS Clinical Digital Maturity Index were used to characterise organisational digital maturity. A multivariable regression model including 12 institutional covariates was utilised to examine the relationship between one measure of organisational digital maturity and five key clinical outcome measures. There was no significant relationship between organisational digital maturity and risk-adjusted 30-day mortality, 28-day readmission rates or complications of care. In multivariable analysis risk-adjusted long length of stay and harm-free care were significantly related to aspects of organisational digital maturity; digitally mature hospitals may not only deliver more harm-free care episodes but also may have a significantly increased risk of patients experiencing a long length of stay. Organisational digital maturity is to some extent related to selected clinical outcomes in secondary care in England. Digital maturity is, however, also strongly linked to other institutional factors that likely play a greater role in influencing clinical outcomes. There is a need to better understand how health IT impacts care delivery and supports other drivers of hospital quality.
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