Publications
409 results found
Arhi C, Burns E, Bottle A, et al., 2018, Delays in primary care are associated with a late stage and worse prognosis for colorectal cancer patients: A population based study, National-Cancer-Research-Institute (NCRI) Cancer Conference, Publisher: NATURE PUBLISHING GROUP, Pages: 4-4, ISSN: 0007-0920
Arhi C, Ziprin P, Bottle A, et al., 2018, Young colorectal cancer patients experience referral delays in primary care leading to emergency diagnoses, National-Cancer-Research-Institute (NCRI) Cancer Conference, Publisher: NATURE PUBLISHING GROUP, Pages: 4-4, ISSN: 0007-0920
Shather Z, Laverty A, Bottle RA, et al., 2018, Sustained socio-economic inequalities in hospital admissions for cardiovascular events among people with diabetes in England, The American Journal of Medicine, Vol: 131, Pages: 1340-1348, ISSN: 0002-9343
ObjectiveThis study aimed to determine changes in absolute and relative socio-economic inequalities in hospital admissions for major cardiovascular events and procedures among people with diabetes in England.MethodsWe identified all patients with diagnosed diabetes aged ≥45 years admitted to hospital in England between 2004-2005 and 2014-2015 for acute myocardial infarction, stroke, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Socio-economic status was measured using Index of Multiple Deprivation. Diabetes-specific admission rates were calculated for each year by deprivation quintile. We assessed temporal changes using negative binomial regression models.ResultsMost admissions for cardiovascular causes occurred among people aged ≥65 years (71%) and men (63.3%), and the number of admissions increased steadily from the least to the most deprived quintile. People with diabetes in the most deprived quintile had 1.94-fold increased risk of acute myocardial infarction (95% CI 1.79-2.10), 1.92-fold risk of stroke (95% CI 1.78-2.07), 1.66-fold risk of CABG (95% CI 1.50-1.74), and 1.76-fold risk of PCI (95% CI 1.64-1.89) compared with the least deprived group. Absolute differences in rates between the least and most deprived quintiles did not significantly change for acute myocardial infarction (P=0.29) and were reduced for stroke, CABG and PCI (by 17.5, 15 and 11.8 per 100,000 people with diabetes, respectively, P≤0.01 for all).ConclusionsSocio-economic inequalities persist in diabetes-related hospital admissions for major cardiovascular events in England. Besides improved risk stratification strategies considering socio-economically defined needs, wide-reaching population-based policy interventions are required to reduce inequalities in diabetes outcomes.
Kim D, Hayhoe B, Aylin P, et al., 2018, Variation in route to diagnosis of heart failure in primary care in England: analysis of a retrospective cohort between 2010 and 2013, Public Health Science Conference, Publisher: ELSEVIER SCIENCE INC, Pages: 13-13, ISSN: 0140-6736
Rao AM, Bottle A, Bicknell C, et al., 2018, Trajectory modelling to assess trends in long-term readmission rate among abdominal aortic aneurysm patients, Surgery Research and Practice, Vol: 2018, ISSN: 2356-7759
Introduction. The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. Results. Based on the trends in readmission rates, GBTM classified elective AAA repair () patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex () undergoing other vascular procedures (), poor socioeconomic status index (), older age (), and higher comorbidity score (). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair () had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (), heart failure (P = 0.01), peripheral vascular disease (), female sex (P = 0.02), open repair (), and undergoing other related procedures (). The AUC for c-statistics was 0.71. Conclusion. Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbiditie
Vamos E, Shather Z, Laverty A, et al., 2018, Socio-economic inequalities in hospital admissions for major cardiovascular events in people with diabetes in England, 54th Annual Meeting of the European-Association-for-the-Study-of-Diabetes (EASD), Publisher: SPRINGER, Pages: S576-S576, ISSN: 0012-186X
Cecil E, Bottle RA, Ma R, et al., 2018, Impact of preventive primary care on children’s unplanned hospital admissions; population-based birth cohort study of UK children 2000-2013, BMC Medicine, Vol: 16, ISSN: 1741-7015
BackgroundUniversal health coverage (UHC) aims to improve child health through preventive primary care and vaccine coverage. Yet, in many developed countries with UHC, unplanned and ambulatory care sensitive (ACS) hospital admissions in childhood continue to rise. We investigated the relation between preventive primary care and risk of unplanned and ACS admission in children in a high-income country with UHC.MethodsWe followed 319,780 children registered from birth with 363 English practices in Clinical Practice Research Datalink linked to Hospital Episodes Statistics, born between January 2000 and March 2013. We used Cox regression estimating adjusted hazard ratios (HR) to examine subsequent risk of unplanned and ACS hospital admissions in children who received preventive primary care (development checks and vaccinations), compared with those who did not.ResultsOverall, 98% of children had complete vaccinations and 87% had development checks. Unplanned admission rates were 259, 105 and 42 per 1000 child-years in infants (aged < 1 year), preschool (1–4 years) and primary school (5–9 years) children, respectively.Lack of preventive care was associated with more unplanned admissions. Infants with incomplete vaccination had increased risk for all unplanned admissions (HR 1.89, 1.79–2.00) and vaccine-preventable admissions (HR 4.41, 2.59–7.49). Infants lacking development checks had higher risk for unplanned admission (HR 4.63, 4.55–4.71). These associations persisted across childhood. Children who had higher consulting rates with primary care providers also had higher risk of unplanned admission (preschool children: HR 1.17, 1.17–1.17). One third of all unplanned admissions (62,154/183,530) were for ACS infectious illness. Children with chronic ACS conditions, asthma, diabetes or epilepsy had increased risk of unplanned admission (HR 1.90, 1.77–2.04, HR 11.43, 8.48–15.39, and HR 4.82, 3.93–5.91, respective
Bottle A, Kim D, Aylin P, et al., 2018, National Clinical Guidelines for Diagnosing Heart Failure in Primary Care: How Often are they Followed and for which Patients?, Publisher: OXFORD UNIV PRESS, Pages: 9-10, ISSN: 1353-4505
Kim D, Hayhoe BWJ, Aylin P, et al., 2018, Variation in route to diagnosis of heart failure in primary care in England, Public Health Science: A National Conference Dedicated to New Research in UK Public Health, Publisher: Elsevier, ISSN: 0140-6736
Axson E, Sundaram V, Gayle A, et al., 2018, P67 Temporal trends in heart failure incidence among patients with COPD and all-cause mortality of patients with comorbid COPD and heart failure in UK primary care, 2006–2016, BTS Winter Meeting, Publisher: BMJ Publishing Group, ISSN: 1468-3296
Balinskaite V, Bottle A, Shaw LJ, et al., 2018, Reorganisation of stroke care and impact on mortality in patients admitted during weekends: a national descriptive study based on administrative data, BMJ Quality and Safety, Vol: 27, Pages: 611-618, ISSN: 2044-5415
OBJECTIVE: To evaluate mortality differences between weekend and weekday emergency stroke admissions in England over time, and in particular, whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference. DESIGN, SETTING AND PARTICIPANTS: Risk-adjusted difference-in-difference time trend analysis using hospital administrative data. All emergency patients with stroke admitted to English hospitals from 1 January 2008 to 31 December 2014 were included. MAIN OUTCOMES: Mortality difference between weekend and weekday emergency stroke admissions. RESULTS: We identified 507 169 emergency stroke admissions: 26% of these occurred during the weekend. The 7-day in-hospital mortality difference between weekend and weekday admissions declined across England throughout the study period. In Greater London, where the reorganisation of stroke services took place, an adjusted 28% (relative risk (RR)=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant. In the rest of England, an 11% (RR=1.11, 95% CI 1.07 to 1.15) higher weekend/weekday 30-day mortality ratio declined to a non-significant 4% higher risk (RR=1.04, 95% CI 0.99 to 1.09) in 2014. We found no statistically significant association between decreases in the weekend/weekday admissions difference in mortality and the centralisation of stroke services in Greater London. CONCLUSIONS: There was a steady reduction in weekend/weekday differences i
Bottle A, Honeyford K, Chowdhury F, et al., 2018, Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study, Health and Social Care Delivery Research, Vol: 6, Pages: 1-84, ISSN: 2755-0060
Background: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplannedhospital activity, but our understanding of what drives this is incomplete.Objectives: To model patient, primary care and hospital factors associated with readmission and mortalityfor patients with HF and COPD, to assess the statistical performance of post-discharge emergencydepartment (ED) attendance compared with readmission metrics and to compare all the results for thetwo conditions.Design: Observational study.Setting: English NHS.Participants: All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.Interventions: None.Main outcome measures: One-year mortality and 30-day emergency readmission following the patient’sfirst unplanned admission (‘index admission’) for HF or COPD.Data sources: Patient-level data from Hospital Episodes Statistics were combined with publicly availablepractice- and hospital-level data on performance, patient and staff experience and rehabilitationprogramme website information.Results: One-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factorspredicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long)index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS andcomorbidities also predicted readmission. Of the practice and hospital factors we considered, only moredoctors per 10 beds [odds ratio (OR) 0.95 per doctor; p < 0.001] was significant for both cohorts for mortality,with staff recommending to friends and family (OR 0.80 per unit increase; p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP; p = 0.004) important for COPD. For readmission,only hospital size [OR per 100 beds = 2.16, 95% confidence interval (
Ali AM, Bottle A, 2018, How do we interpret readmission rates?, BMJ-BRITISH MEDICAL JOURNAL, Vol: 362, ISSN: 1756-1833
Rao A, Bicknell C, Bottle R, et al., 2018, Common sequences of emergency readmissions among high-impact users following AAA repair, Surgery Research and Practice, Vol: 2018, ISSN: 2356-7759
IntroductionThe aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate. MethodsThe patient cohort (2006-2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data. ResultsFrom a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among rAAA repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastro-intestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%) and ischaemic heart disease (3.3%).ConclusionA significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community.
Bottle A, Loeffler MD, Aylin P, et al., 2018, Comparison of 3 types of readmission rates for measuring hospital and surgeon performance after primary total hip and knee arthroplasty, Journal of Arthroplasty, Vol: 33, Pages: 2014-2019.e2, ISSN: 0883-5403
BACKGROUND: All-cause 30-day hospital readmission is in widespread use for monitoring and incentivizing hospital performance for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, little is known on the extent to which all-cause readmission is influenced by hospital or surgeon performance and whether alternative measures may be more valid. METHODS: This is an observational study using multilevel modeling on English administrative data to determine the interhospital and intersurgeon variation for 3 readmission metrics: all-cause, surgical, and return-to-theater. Power calculations estimated the likelihood of identifying whether the readmission rate for a surgeon or hospital differed from the national average by a factor of 1.25, 1.5, 2, or 3 times, for both average and high-volume providers. RESULTS: About 259,980 THAs and 311,033 TKAs were analyzed. Variations by both surgeons and hospitals were smaller for the all-cause measure than for the surgical or return-to-theater metrics, although statistical power to detect differences was higher. Statistical power to detect surgeon-level rates of 1.25 or 1.5 times the average was consistently low. However, at the hospital level, the surgical readmission measure showed more variation by hospital while maintaining excellent power to detect differences in rates between hospitals performing the average number of THA or TKA cases per year in England. In practice, more outliers than expected from purely random variation were found for all-cause and surgical readmissions, especially at hospital level. CONCLUSION: The 30-day surgical readmission rate should be considered as an adjunctive measure to 30-day all-cause readmission rate when assessing hospital performance.
Rao A, Kim D, Darzi A, et al., 2018, Long-term trends of use of health service among heart failure patients, European Heart Journal - Quality of Care and Clinical Outcomes, Vol: 4, Pages: 220-231, ISSN: 2058-5225
Aims: We aimed to identify subgroups in the patient population with different trajectories of long-term readmission rates. The study also aimed to assess common causes and their sequences of readmissions for each subgroup. Methods: Patients with a primary diagnosis of heart failure (HF) in the period 2008-2009 were identified using nationally representative primary care data linked to national hospital data, which contain information on 10.5 million patients. HF patients were followed up for 5 years. Group-based trajectory models and sequence analysis were applied. Results: The model categorised the HF population (n = 9466) into 5 subgroups: low-impact (66.9%); two intermediate ones (27.4%); chronic high-impact (2.3%) with steady high annual readmission rates; and short-term high-impact (3.4%) with rapid decline in readmission rates. The groups were defined by their trends of yearly number of readmissions. The all-cause 5-year mortality was highest in the short-term high-impact group (n = 185, 72.8%), followed by group 2 (intermediate users) (n = 744, 58.8%), low-impact (n = 4244, 56.9%), chronic high-impact (n = 88, 37.6%) and group 1 (intermediate users) (n = 401, 30.3%) (p < 0.01). Compared with low-impact users, high-impact users were associated with higher mortality, bereavement episodes, and more out-of-hours GP visits. The chronic high-impact users had distinct sequences of causes of emergency admissions most often consisting of chest infection, ischaemic heart disease, and cardio-pulmonary signs and/or symptoms. Conclusion: Chronic high-impact users constitute a small proportion of total patients, but they have increasingly high use of healthcare services. Short-term high-impact users represent largely end of life patients. They require prompt involvement of the palliative care team to reduce unnecessary readmissions to hospital.
Axson EL, Sundaram V, Bloom C, et al., 2018, Hospitalisation and mortality outcomes of patients with comorbid COPD and heart failure: a systematic review protocol, BMJ Open, Vol: 8, ISSN: 2044-6055
Introduction Chronic obstructive pulmonary disease (COPD) and heart failure (HF) often coexist in patients. Many studies have explored the short-term and long-term outcomes of patients with comorbid COPD and HF; however, there have been discrepancies in their findings.Methods and analysis In this systematic review, MEDLINE and Embase will be searched using a prespecified search strategy. Randomised controlled trials and studies conducted in the general population that employ analytical or descriptive (longitudinal or case–control) study designs that report odds ratios (ORs), hazard ratios (HRs), or risk ratios (RRs) of mortality or hospitalisation, comparing patients with comorbid COPD and HF with patients with just COPD, will be selected. Screening by title and abstract, then full-text screening will be conducted by two reviewers. The Population, Exposure, Comparator, Outcomes, Study (PECOS) characteristics framework will be used to systemise the data extraction from selected studies. Study quality will be assessed using an adapted version of the Newcastle-Ottawa risk of bias tool. Data extraction and the risk of bias will also be conducted by two reviewers. Given sufficient homogeneity of selected studies, a meta-analysis will be conducted. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria will be used to assess the quality of cumulative evidence.Dissemination With this review, we hope to improve the understanding of clinical outcomes of patients with comorbid COPD and HF. We intend to publish the results of our review in a peer-reviewed journal and to present our findings at national and international meetings and conferences.
Woringer M, Dharmayat KI, Greenfield G, et al., 2018, American Heart Association’s Cholesterol CarePlan as a Smartphone-Delivered Web App for Patients Prescribed Cholesterol-Lowering Medication: Protocol for an Observational Feasibility Study (Preprint), JMIR Research Protocols, ISSN: 1929-0748
<sec> <title>BACKGROUND</title> <p>Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.</p> </sec> <sec> <title>OBJECTIVE</title> <p>The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.</p> </sec> <sec> <title>METHODS</title> <p>A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usa
Bottle A, Ventura CM, Dharmarajan K, et al., 2018, Regional variation in hospitalisation and mortality in heart failure: comparison of England and Lombardy using multistate modelling, Health Care Management Science, Vol: 21, Pages: 292-304, ISSN: 1386-9620
Heart failure (HF) is a common, serious chronic condition with high morbidity, hospitalisation and mortality. The healthcare systems of England and the northern Italian region of Lombardy share important similarities and have comprehensive hospital administrative databases linked to the death register. We used them to compare admission for HF and mortality for patients between 2006 and 2012 (n = 37,185 for Lombardy, 234,719 for England) with multistate models. Despite close similarities in age, sex and common comorbidities of the two sets of patients, in Lombardy, HF admissions were longer and more frequent per patient than in England, but short- and medium-term mortality was much lower. English patients had more very short stays, but their very elderly also had longer stays than their Lombardy counterparts. Using a three-state model, the predicted total time spent in hospital showed large differences between the countries: women in England spent an average of 24 days if aged 65 at first admission and 19 days if aged 85; in Lombardy these figures were 68 and 27 days respectively. Eight-state models suggested disease progression that appeared similar in each country. Differences by region within England were modest, with London patients spending more time in hospital and having lower mortality than the rest of England. Whilst clinical practice differences plausibly explain these patterns, we cannot confidently disentangle the impact of alternatives such as coding, casemix, and the availability and use of non-hospital settings. We need to better understand the links between rehospitalisation frequency and mortality.
Oke SM, Rye B, Malietzis G, et al., 2018, SURVIVAL AND CT DEFINED SARCOPENIA IN PATIENTS WITH INTESTINAL FAILURE ON HPN, Annual General Meeting of the British-Society-of-Gastroenterology, Publisher: BMJ PUBLISHING GROUP, Pages: A159-A160, ISSN: 0017-5749
Cecil E, Bottle A, Esmail A, et al., 2018, Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis, BMJ Quality and Safety, Vol: 27, Pages: 965-973, ISSN: 2044-5415
OBJECTIVE: To investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality. BACKGROUND: There is increasing interest in performance monitoring in the NHS. Since 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied. METHODS: We investigated alerts sent to Acute National Health Service hospital trusts in England in 2011-2013. We examined risk-adjusted mortality (relative risk) for all monitored diagnosis and procedure groups at a hospital trust level for 12 months prior to an alert and 23 months post alert. We used an interrupted time series design with a 9-month lag to estimate a trend prior to a mortality alert and the change in trend after, using generalised estimating equations. RESULTS: On average there was a 5% monthly increase in relative risk of mortality during the 12 months prior to an alert (95% CI 4% to 5%). Mortality risk fell, on average by 61% (95% CI 56% to 65%), during the 9-month period immediately following an alert, then levelled to a slow decline, reaching on average the level of expected mortality within 18 months of the alert. CONCLUSIONS: Our results suggest an association between an alert notification and a reduction in the risk of mortality, although with less lag time than expected. It is difficult to determine any causal association. A proportion of alerts may be triggered by random variation alone and subsequent falls could simply reflect regression to the mean. Findings could also indicate that some hospitals are monitoring their own mortality statistics or other performance information, taking action prior to alert notification.
Bottle A, Kim D, Aylin P, et al., 2018, Routes to diagnosis of heart failure: observational study using linked data in England, Heart, Vol: 104, Pages: 600-605, ISSN: 1355-6037
OBJECTIVE: Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management. METHODS: We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis. RESULTS: 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral. CONCLUSIONS: Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.
Lingsma HF, Bottle A, Middleton S, et al., 2018, Evaluation of hospital outcomes: the relation between length-of-stay, readmission, and mortality in a large international administrative database, BMC Health Services Research, Vol: 18, ISSN: 1472-6963
Background:Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care.Methods:We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged between 2007 and 2012. We correlated standardized and risk-adjusted hospital outcomes on mortality, readmission and long LOS. We constructed a composite measure with 5 levels, based on literature review and expert advice, from survival without readmission and normal LOS (best) to mortality (worst outcome). This composite measure was analyzed using ordinal regression, to obtain a standardized outcome measure to compare hospitals.Results:Overall, we observed a 3.1% mortality rate, 7.8% readmission rate (in survivors) and 20.8% long LOS rate among 4,327,105 admissions. Mortality and LOS were correlated at the patient and the hospital level. A patient in the upper quartile LOS had higher odds of mortality (odds ratio = 1.45, 95% confidence interval 1.43–1.47) than those in the lowest quartile. Hospitals with a high standardized mortality had higher proportions of long LOS (r = 0.79, p < 0.01). Readmission rates did not correlate with either mortality or long LOS rates. The interquartile range of the standardized ordinal composite outcome was 74–117. The composite outcome had similar or better reliability in ranking hospitals than individual outcomes.Conclusions:Correlations between different outcome measures are complex and differ between hospital- and patient-level. The proposed composite measure combines three outcomes in an ordinal fashion for a more comprehensive and reliable view of hospital performance than its component indicators.
Furnivall D, Bottle R, Aylin P, 2018, Retrospective analysis of the national impact of industrial action by English junior doctors in 2016, BMJ Open, Vol: 8, ISSN: 2044-6055
Objectives: To examine the impacts of the four episodes of industrial action by English junior doctors in early 2016.Design: Descriptive retrospective study of admitted patient care, accident and emergency (A&E) and outpatient activity in English hospitals.Setting: All hospitals across England.Participants: All patients who attended A&E or outpatient appointments, or those who were admitted to hospital during the three week period surrounding each of the four strikes (January 12th, February 10th, March 9th-10th and April 26th-27th, excluding weekends.)Main outcome measures: Raw numbers and percentage changes of outpatient appointments and cancellations, A&E visits, admitted patients and all in-hospital mortality on strike days compared with patient activity on the same weekday in the weeks before and after the strikes.Results: There were 3.4 million admissions, 27 million outpatient appointments and 3.4 million A&E attendances over the four 3-week periods analysed. Across the four strike days, there were 31,651 fewer admissions (-9.1%), 23,895 fewer A&E attendances (-6.8%) and 173,462 fewer outpatient appointments (-6.0%) than expected. Additionally, 101,109 more outpatient appointments were cancelled by hospitals than expected (+52%). The April 26th-27th strike, where emergency services were also affected, showed the largest impacts on regular service. Mortality did not measurably increase on strike days. Regional analysis showed that services in the Yorkshire and the Humber region were disproportionately more affected by the industrial action. Conclusions: Industrial action by junior doctors during early 2016 caused a significant impact on the provision of healthcare provided by English hospitals. We also observed regional variations in how these strikes affected providers.
Ali AM, Loeffler MD, Aylin P, et al., 2017, Correction: Factors Associated With 30-Day Readmission After Primary Total Hip Athroplasty: Analysis of 514455 Procedures in the UK National Health Service, JAMA Surgery, Vol: 152, Pages: 1184-1184, ISSN: 2168-6254
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.
Ali AM, Loeffler MD, Aylin P, et al., 2017, Factors associated with 30-day readmission after primary total hip arthroplasty: analysis of 514 455 procedures in the UK National Health Service, JAMA Surgery, Vol: 152, Pages: E1-E6, ISSN: 2168-6254
Importance: Thirty-day readmission to hospital after total hip arthroplasty (THA) has significant direct costs and is used as a marker of hospital performance. All-cause readmission is the only metric in current use, and risk factors for surgical readmission and those resulting in return to theater (RTT) are poorly understood. Objective: To determine whether patient-related predictors of all-cause, surgical, and RTT readmission after THA differ and which predictors are most significant. Design, Setting, and Participants: Analysis of all primary THAs recorded in the National Health Service (NHS) Hospital Episode Statistics database from 2006 to 2015. The effect of patient-related factors on 30-day readmission risk was evaluated by multilevel logistic regression analysis. The analysis comprised all acute NHS hospitals in England and all patients receiving primary THA. Main Outcomes and Measures: Thirty-day readmission rate for all-cause, surgical (defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision primary admission diagnoses), and readmissions resulting in RTT. Results: Across all hospitals, 514 455 procedures were recorded. Seventy-nine percent of patients were older than 60 years, 40.3% were men, and 59.7% were women. There were 30 489 all-cause readmissions (5.9%), 16 499 surgical readmissions (3.2%), and 4286 RTT readmissions (0.8%); 54.1% of readmissions were for surgical causes. Comorbidities with the highest odds ratios (ORs) of RTT included those likely to affect patient behavior: drug abuse (OR, 2.22; 95% CI, 1.34-3.67; P = .002), psychoses (OR, 1.83; 95% CI, 1.16-2.87; P = .009), dementia (OR, 1.57; 95% CI, 1.11-2.22; P = .01), and depression (OR, 1.52; 95% CI, 1.31-1.76; P < .001). Obesity had a strong independent association with RTT (OR, 1.46; 95% CI, 4.45-6.43; P < .001), with one of the highest population
Rann O, Sharland M, Long P, et al., 2017, Did the accuracy of oral amoxicillin dosing of children improve after British National Formulary dose revisions in 2014?: national cross sectional survey in England, BMJ Open, Vol: 7, ISSN: 2044-6055
Objectives Inaccurate antibiotic dosing can lead to treatment failure, fuel antimicrobial resistance and increase side effects. The British National Formulary for Children (BNFC) guidance recommends oral antibiotic dosing according to age bands as a proxy for weight. Recommended doses of amoxicillin for children were increased in 2014 ‘after widespread concerns of under dosing’. However, the impact of dose changes on British children of different weights is unknown, particularly given the rising prevalence of childhood obesity in the UK. We aimed to estimate the accuracy of oral amoxicillin dosing in British children before and after the revised BNFC guidance in 2014.Setting and participants We used data on age and weights for 1556 British children (aged 2–18 years) from a nationally representative cross-sectional survey, the Health Survey for England 2013.Interventions We calculated the doses each child would receive using the BNFC age band guidance, before and after the 2014 changes, against the ‘gold standard’ weight-based dose of amoxicillin, as per its summary of product characteristics.Primary outcome measure Assuming children of different weights were equally likely to receive antibiotics, we calculated the percentage of the children who would be at risk of misdosing by the BNFC age bands.Results Before 2014, 54.6% of children receiving oral amoxicillin would have been underdosed and no child would have received more than the recommended dose. After the BNFC guidance changed in 2014, the number of children estimated as underdosed dropped to 5.8%, but 0.5% of the children would have received too high a dose.Conclusions Changes to the BNFC age-banded amoxicillin doses in 2014 have significantly reduced the proportion of children who are likely to be underdosed, with only a minimal rise in the number of those above the recommended range.
Chowdhury FS, Elkin S, Bell D, et al., 2017, How many hospital websites provide information to attract patients to attend cardiac/pulmonary rehabilitation across England?, ISQua 34th International Conference, Publisher: Oxford University Press, Pages: 7-8, ISSN: 1353-4505
Cecil E, Bottle A, Aylin P, 2017, ARE MORTALITY ALERTS ASSOCIATED WITH OTHER INDICATORS OF HOSPITAL QUALITY IN ENGLAND? A NATIONAL CROSS-SECTIONAL STUDY, Publisher: OXFORD UNIV PRESS, Pages: 14-14, ISSN: 1353-4505
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