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  • Journal article
    Greenfield G, Blair M, Aylin P, Saxena S, Majeed F, Hoffman M, Bottle Aet 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.

  • Report
    Christen P, D'Aeth J, Lochen A, McCabe R, Rizmie D, Schmit N, Nayagam AS, Miraldo M, White P, Aylin P, Bottle R, Perez Guzman PN, Donnelly C, Ghani A, Ferguson N, Hauck Ket 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

  • Journal article
    Giuliani S, Honeyford K, Chang C-Y, Bottle A, Aylin Pet 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
  • Journal article
    Cecil E, Bottle R, Vincent C, Esmail A, Aylin Pet 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.

  • Journal article
    Ghafur S, Kristensen S, honeyford K, Martin G, Darzi A, Aylin Pet 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.

  • Journal article
    Honeyford K, Bell D, Chowdhury F, Quint J, Aylin P, Bottle Aet 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

  • Journal article
    Wang Y, Honeyford K, Aylin P, Bottle A, Giuliani Set 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

  • Journal article
    Martin G, Clarke J, Liew F, Arora S, King D, Paul A, Darzi Aet 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.

  • Journal article
    Bottle A, Kim D, Hayhoe B, Majeed A, Aylin P, Clegg A, Cowie MRet al., 2019,

    Frailty and comorbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England

    , Age and Ageing, Vol: 48, Pages: 347-354, ISSN: 1468-2834

    Background: frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. Objectives: to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of comorbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). Design: observational study. Setting: primary care in England. Subjects: all adult patients diagnosed with HF in primary care between 2010 and 2013. Methods: we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. Results: of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, comorbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. Conclusions: this study suggests that frailty has predictive power beyond its comorbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.

  • Journal article
    Bottle A, Parikh S, Aylin P, Loeffler Met al., 2019,

    Risk factors for early revision after total hip and knee arthroplasty: National observational study from a surgeon and population perspective

    , PLoS One, Vol: 14, Pages: 1-15, ISSN: 1932-6203

    AimsTo identify predictors of early revision (within 3 years of the index operation) for hip and knee replacement (HR, KR) from both surgeon and population perspectives.Patients and methodsHierarchical logistic regression on national administrative data for England for index procedures between April 2009 and March 2014.ResultsThere were 315,273 index HR procedures and 374,530 index KR procedures for analysis. Three-year revision rates were 2.1% for HR and 2.2% for KR. The highest odds ratios for HR were for 3+ previous emergency admissions, drug abuse, Parkinson’s disease, resurfacing and ages under 60; for KR these were patellofemoral or partial joint replacement, 3+ previous emergency admissions, paralysis and ages under 60. Smaller effects were found for other comorbidities such as obesity (HR) and diabetes (KR). From a population perspective, the only population attributable fractions over 5% were for male gender, uncemented total hip replacements and partial knee or patellofemoral replacements.ConclusionsMeeting the rising demand for revision surgery is a challenge for healthcare leaders and policymakers. Our findings suggest optimising patients pre-operatively and improving patient selection for primary arthroplasty may reduce the burden of early revision of arthroplasty. Our study gives useful information on the additional risks of various comorbidities and procedures, which enables a more informed consent process.

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