Imperial College London

DrElizabethCecil

Faculty of MedicineSchool of Public Health

Honorary Research Fellow
 
 
 
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Contact

 

+44 (0)20 7594 1838e.cecil Website

 
 
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Location

 

328Reynolds BuildingCharing Cross Campus

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Summary

 

Publications

Publication Type
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45 results found

Cecil E, 2021, How equitable is the NHS really for children?, Archives of Disease in Childhood, ISSN: 0003-9888

Journal article

Soley-Bori M, Lingam R, Satherley R-M, Forman J, Cecil L, Fox-Rushby J, Wolfe Iet al., 2021, Children and Young People's Health Partnership Evelina London Model of Care: economic evaluation protocol of a complex system change, BMJ OPEN, Vol: 11, ISSN: 2044-6055

Journal article

Cecil E, Dewa L, Ma R, Majeed F, Aylin Pet al., 2021, General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: A qualitative analysis, BMJ Open, Vol: 11, ISSN: 2044-6055

Objectives Reminders in primary care administrative systems aim to help clinicians provide evidence-based care, prescribe safely and save money. However, increased use of reminders can lead to alert fatigue. Our study aimed to assess general practitioners’ (GPs) and nurse practitioners’ (NPs) views on electronic reminders in primary care.Design A qualitative analysis using semistructured interviews.Setting and participants Fifteen GPs and NP based in general practices located in North-West London and Yorkshire, England.Methods We collected data on participants’ views on: (1) perceptions of the value of information provided; (2) reminder-related behaviours and (3) how to improve reminders. We carried out a thematic analysis.Results Participants were familiar with reminders in their clinical systems and felt many were important to support their clinical work. However, participants reported, on average, 70% of reminders were ignored. Four major themes emerged: (1) reaction to a reminder, which was mixed and varied by situation. (2) Factors influencing the decision to act on reminders, often related to experience, consultation styles and interests of participants. Time constraints, alert design, inappropriate presentation and litigation were also factors. (3) Negative consequences of using reminders were increased workload or costs and compromising GP and NPs behaviour. (4) Factors relating to improving users’ engagement with reminders were prevention of unnecessary reminders through data linkage across healthcare administrative systems or the development of more intelligent algorithms. Participants felt training was vital to effectively manage reminders.Conclusions GPs and NPs believe reminders are useful in supporting the provision of good quality patient care. Improving GPs and NPs’ engagement with reminders centres on further developing their relevance to their clinical practice, which is personalised, considers cognitive workflow and s

Journal article

Cecil E, Bottle A, Majeed A, Aylin Pet al., 2021, Factors associated with potentially missed acute deterioration in primary care, British Journal of General Practice, Vol: 24/6/21, Pages: e547-e554, ISSN: 0960-1643

BACKGROUND: In the UK, the majority of primary care contacts are uncomplicated. However, safety incidents resulting in patient harm occur, such as failure to recognise a patient's deterioration in health. AIM: We aimed to determine patient and healthcare factors associated with potentially missed deterioration. DESIGN AND SETTING: A cohort of patients registered with English CPRD general practices between 01-04-2014 and 31-12-2017 with linked hospital data. METHODS: We defined a potentially missed deterioration as a patient, seen in primary care by a GP in the three days before hospitalisation, having a self-referred admission. We used generalised estimating equations to investigate factors associated with odds of a self-referred admission. We investigated all diagnoses and subsets of commonly reported missed conditions. RESULTS: There were 116,097 patients who contacted a GP three days prior to an emergency admission. Patients with sepsis or urinary tract infections were more likely to self-refer, adjusted odds ratio 1.10 95%CI(1.02-1.19) and 1.09 (1.04-1.14) respectively. GP appointment durations were associated with self-referral. On average, a 5-minute increase resulted in 10% decrease in odds of self-referred admissions, 0.90 (0.89-0.91). Patients having a telephone (compared with face-to-face) consultation 1.13 (1.09-1.16), previous health service use and health status were also associated with self-referred admission. CONCLUSIONS: Differentiating deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, UTI or with long-term conditions. Our findings supports the call for longer GP consultations and cautions reliance on telephone consultations in primary care; however, research is needed to understand the underlying mechanisms.

Journal article

Ma R, Cecil E, Bottle A, French R, Saxena Set al., 2020, Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study, PLoS Medicine, Vol: 17, Pages: e1003333-e1003333, ISSN: 1549-1277

BackgroundLong-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions.Methods and findingsWe examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26–5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34–8.47, p < 0.001) and sustained trend increase (3.14, 3.08–3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of −22.8 (−24.5 to −21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; −15.0, −15.5 to −14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of −2.28 (−2.98 to −1.57, p = 0.002) and sustained decrease in trend of −0.88 (−1.12 to −0.63, p < 0.001). The largest

Journal article

Ruzangi J, Blair M, Cecil E, Greenfield G, Bottle R, Hargreaves D, Saxena Set al., 2020, Trends in healthcare use in children aged less than 15 years; a population-based cohort study in England from 2007 to 2017, BMJ Open, Vol: 10, ISSN: 2044-6055

Objective To describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017Design Population-based retrospective cohort study.Methods We used linked data from the Clinical Practice Research Datalink to study children’s primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists.Results Between 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (−1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017.Conclusions Over the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children’s use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.

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

Cecil EV, Dewa L, Ma R, Majeed A, Aylin Pet al., 2019, Primary health care professionals views of reminders in electronic patient records, JECH, Publisher: BMJ PUBLISHING GROUP, Pages: A64-A64, ISSN: 0143-005X

Conference paper

Saxena S, Cecil E, Majeed A, Blackwell J, Pollok R, Alexakis Cet al., 2019, The impact of smoking and smoking-cessation on disease outcomes in Ulcerative Colitis: a nationwide population-based study, Alimentary Pharmacology and Therapeutics, Vol: 50, Pages: 556-567, ISSN: 0269-2813

BackgroundSmokers are less likely to develop Ulcerative Colitis (UC) but the impact of smoking and subsequentcessation on clinical outcomes in UC is unclear. Aim: To evaluate the effect of smoking status andsmoking cessation on disease outcomes.MethodsUsing a nationally representative clinical research database, we identified incident cases of UCduring 2005-2016. Patients were grouped as never-smokers, ex-smokers and smokers, based onsmoking status recorded in the two years preceding UC diagnosis. We defined subgroups ofpersistent smokers and smokers who quit within 2 years after diagnosis. We compared rates ofoverall corticosteroid use, corticosteroid-requiring flares, corticosteroid dependency, thiopurineuse, hospitalization and colectomy between these groups.ResultsWe identified 6754 patients with a new diagnosis of UC over the study period with data on smokingstatus, of whom 878 were smokers at diagnosis. Smokers had a similar risk of corticosteroidrequiring flares (OR 1.16, 95%CI 0.92-1.25), thiopurine use (HR 0.84, 95%CI 0.62-1.14),corticosteroid dependency (HR 0.85, 95%CI 0.60-1.11), hospitalization (HR 0.92, 95%CI 0.72-1.18),and colectomy (HR 0.78, 95%CI 0.50-1.21) in comparison with never-smokers.Rates of flares, thiopurine use, corticosteroid dependency, hospitalization and colectomy were notsignificantly different between persistent smokers and those who quit smoking after a diagnosis ofUC.ConclusionsSmokers and never-smokers with UC have similar outcomes with respect to flares, thiopurine use,corticosteroid dependency, hospitalization and colectomy. Smoking cessation was not associatedwith worse disease course. The risks associated with smoking outweigh any benefits. UC patientsshould be counselled against smoking.

Journal article

Saxena S, Skirrow H, Wincott T, Cecil E, Bottle A, Costelloe C, Saxena Set al., 2019, Preschool respiratory hospital admissions following infant bronchiolitis: a birth cohort study, Archives of Disease in Childhood, Vol: 104, Pages: 658-663, ISSN: 1468-2044

Background: Bronchiolitis causes significant infant morbidity worldwide from hospital admissions. However, studies quantifying the subsequent respiratory burden in children under 5 years are lacking.Objective: To estimate the risk of subsequent respiratory hospital admissions in children under 5 years in England following bronchiolitis admission in infancy.Design: Retrospective population-based birth cohort study.Setting: Public hospitals in England.Patients: We constructed a birth cohort of 613,377 infants born between 1.4.2007 and 31.3.2008, followed up until aged 5 years by linking Hospital Episode Statistics (HES) admissions data. Methods: We compared the risk of respiratory hospital admission due to asthma, wheezing and lower and upper respiratory tract infections(LRTI & URTI) in infants who had been admitted for bronchiolitis with those who had not, using Cox proportional hazard regression. We adjusted hazard ratios for known respiratory illness risk factors including living in deprived households, being born preterm or with a comorbid condition.Results: We identified 16,288/613,377 infants(2.7 %) with at least one admission for bronchiolitis. Of these, 21.7% had a further respiratory hospital admission by age 5 years compared with 8% without a previous bronchiolitis admission, (HR(adjusted),2.82, 95%CI 2.72-2.92). The association was greatest for asthma (HR(adjusted), 4.35, 95%CI 4.00-4.73) and wheezing admissions (HR(adjusted), 5.02, 95%CI 4.64-5.44) but were also significant for URTI and LRTI admissions. Conclusions: Hospital admission for bronchiolitis in infancy is associated with a 3-to-5-fold risk of subsequent respiratory hospital admissions from asthma, wheezing and respiratory infections. One in five infants with bronchiolitis hospital admissions will have a subsequent respiratory hospital admission by age 5 years.

Journal article

Cecil EV, Wilkinson S, Bottle R, Esmail A, Vincent C, Aylin Pet al., 2018, A national hospital mortality surveillance system: a descriptive analysis, BMJ Quality and Safety, Vol: 27, Pages: 974-981, ISSN: 2044-5415

Objective To provide a description of the Imperial College Mortality Surveillance System and subsequent investigations by the Care Quality Commission (CQC) in National Health Service (NHS) hospitals receiving mortality alerts.Background The mortality surveillance system has generated monthly mortality alerts since 2007, on 122 individual diagnosis and surgical procedure groups, using routinely collected hospital administrative data for all English acute NHS hospital trusts. The CQC, the English national regulator, is notified of each alert. This study describes the findings of CQC investigations of alerting trusts.Methods We carried out (1) a descriptive analysis of alerts (2007–2016) and (2) an audit of CQC investigations in a subset of alerts (2011–2013).Results Between April 2007 and October 2016, 860 alerts were generated and 76% (654 alerts) were sent to trusts. Alert volumes varied over time (range: 40–101). Septicaemia (except in labour) was the most commonly alerting group (11.5% alerts sent). We reviewed CQC communications in a subset of 204 alerts from 96 trusts. The CQC investigated 75% (154/204) of alerts. In 90% of these pursued alerts, trusts returned evidence of local case note reviews (140/154). These reviews found areas of care that could be improved in 69% (106/154) of alerts. In 25% (38/154) trusts considered that identified failings in care could have impacted on patient outcomes. The CQC investigations resulted in full trust action plans in 77% (118/154) of all pursued alerts.Conclusion The mortality surveillance system has generated a large number of alerts since 2007. Quality of care problems were found in 69% of alerts with CQC investigations, and one in four trusts reported that failings in care may have an impact on patient outcomes. Identifying whether mortality alerts are the most efficient means to highlight areas of substandard care will require further investigation.

Journal article

Honeyford C, Cecil E, Lo M, Bottle R, Aylin Pet al., 2018, The weekend effect: does hospital mortality differ by day of the week? A systematic review and meta-analysis, BMC Health Services Research, Vol: 18, ISSN: 1472-6963

BackgroundThe concept of a weekend effect, poorer outcomes for patients admitted to hospitals at the weekend is not new, but is the focus of debate in England. Many studies have been published which consider outcomes for patients on admitted at the weekend. This systematic review and meta-analysis aims to estimate the effect of weekend admission on mortality in UK hospitals.MethodsThis is a systematic review and meta-analysis of published studies on the weekend effect in UK hospitals. We used EMBASE, MEDLINE, HMIC, Cochrane, Web of Science and Scopus to search for relevant papers. We included systematic reviews, randomised controlled trials and observational studies) on patients admitted to hospital in the UK and published after 2001. Our outcome was death; studies reporting mortality were included. Reviewers identified studies, extracted data and assessed the quality of the evidence, independently and in duplicate. Discrepancy in assessment was considered by a third reviewer. All meta-analyses were performed using a random-effects meta-regression to incorporate the heterogeneity into the weighting.ResultsForty five articles were included in the qualitative synthesis. 53% of the articles concluded that outcomes for patients either undergoing surgery or admitted at the weekend were worse. We included 39 in the meta-analysis which contributed 50 separate analyses. We found an overall effect of 1.07 [odds ratio (OR)] (95%CI:1.03–1.12), suggesting that patients admitted at the weekend had higher odds of mortality than those admitted during the week. Sub-group analyses suggest that the weekend effect remained when measures of case mix severity were included in the models (OR:1.06 95%CI:1.02–1.10), but that the weekend effect was not significant when clinical registry data was used (OR:1.03 95%CI: 0.98–1.09). Heterogeneity was high, which may affect generalisability.ConclusionsDespite high levels of heterogeneity, we found evidence of a weekend effect in

Journal article

Saxena S, Alexakis C, Chhaya V, Cecil E, Majeed A, Pollok Ret al., 2018, Smoking status at diagnosis and subsequent smoking cessation: associations with cortic os use and intestinal resection in Crohn's disease, The American Journal of Gastroenterology, Vol: 113, Pages: 1689-1700, ISSN: 1572-0241

BackgroundThe impact of smoking at diagnosis and subsequent smoking cessation on clinical outcomes in Crohn’s disease (CD) has not been evaluated in a population-based cohort.MethodsUsing a nationally representative clinical research database, we identified incident cases of CD between 2005 and 2014. We compared the following outcomes: overall corticosteroid (CS) use; flares requiring CS; CS dependency and intestinal surgery between smokers and non-smokers at time of CD diagnosis. Differences in these outcomes were also compared between persistent smokers and smokers who quit within 2 years of diagnosis.ResultsWe identified 3553 patients with a new CD diagnosis over the study period of whom 1121 (32%) were smokers. Smokers at CD diagnosis had significantly higher CS-use (56 versus 47%, p < 0.0001), proportionally more CS flares (>1 CS flare/year: 9 versus 6%, p < 0.0001), and higher CS dependency (27 versus 21%, p < 0.0001) than non-smokers. Regression analysis identified smoking at diagnosis to be associated with a higher risk of intestinal surgery (HR 1.64, 95% CI 1.16–2.52). There was a significantly higher proportion of ‘quitters’ who remained steroid-free through follow-up in comparison to ‘persistent smokers’ (45.4 versus 37.5%, respectively, p = 0.02). ‘Quitters’ also had lower rates of CS dependency compared to ‘persistent smokers’ (24 versus 33%, p = 0.008).ConclusionsSmokers at CD diagnosis have higher CS-use, CS dependency and higher risk of intestinal surgery. Quitting smoking appears to have beneficial effects on disease related outcomes, including reducing CS dependency highlighting the importance of offering early smoking cessation support.

Journal article

Cecil E, Bottle RA, Ma R, Hargreaves D, Wolfe I, Mainous III AG, Saxena Set 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

Journal article

Dewa LH, Cecil E, Eastwood L, Darzi A, Aylin Pet al., 2018, Indicators of deterioration in young adults with serious mental illness: a systematic review protocol, Systematic Reviews, Vol: 7, ISSN: 2046-4053

BackgroundThe first signs of serious mental illnesses (SMIs) including schizophrenia, bipolar disorder and major depression are likely to occur before the age of 25. The combination of high prevalence of severe mental health symptoms, inability to recognise mental health deterioration and increased likelihood of comorbidity in a complex transitional young group makes detecting deterioration paramount. Whilst studies have examined physical and mental health deterioration in adults, no systematic review has examined the indicators of mental and physical deterioration in young adults with SMI. The study aim is to systematically review the existing evidence from observational studies that examine the indicators of mental and physical deterioration in young adults with SMI and highlight gaps in knowledge to inform future research.MethodsSeven databases including CINHAL, MEDLINE, Embase, PsycINFO, Health Management Information Consortium, Cochrane databases and Web of Science will be searched against five main facets (age, serious mental illness, sign, deterioration and patient) and a subsequent comprehensive list of search terms. Searches will be run individually in each database to reflect each unique set of relevant subject headings and appropriate MeSH terms. Inclusion and exclusion criteria were developed and refined by the research team. Two reviewers will participate in each search stage including abstract/title and full text screening, data extraction and appraisal, to ensure reliability. A narrative synthesis of the data will also be conducted.DiscussionThis systematic review will likely make a significant contribution to the field of mental health and help inform future research pertaining to interventions that help highlight deteriorating patients. This may vary depending on the patient group, mental illness or deterioration type.Systematic review registrationPROSPERO CRD42017075755

Journal article

Cecil E, Bottle A, Esmail A, Wilkinson S, Vincent C, Aylin PPet 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.

Journal article

Mastellos N, Tran T, Dharmayat K, Cecil E, Hsin-yi L, Wong C, Mkandawire W, Ngalande E, Wu JT-S, Hardy V, Chirambo BG, O'Donoghue JMet al., 2018, Training community healthcare workers on the use of information and communication technologies: a randomised controlled trial of traditional versus blended learning in Malawi, Africa, BMC Medical Education, Vol: 18, ISSN: 1472-6920

Background: Despite the increasing uptake of information and communication technologies (ICT) within healthcare services across developing countries, community healthcare workers (CHWs) have limited knowledge to fully utilise computerised clinical systems and mobile apps. The ‘Introduction to Information and Communication Technology and eHealth’ course was developed with the aim to provide CHWs in Malawi, Africa, with basic knowledge and computer skills to use digital solutions in healthcare delivery. The course was delivered using a traditional and a blended learning approach. Methods: Two questionnaires were developed and tested for face validity and reliability in a pilot course with 20 CHWs. Those were designed to measure CHWs’ knowledge of and attitudes towards the use of ICT, before and after each course, as well as their satisfaction with each learning approach. Following validation, a randomised controlled trial was conducted to assess the effectiveness of the two learning approaches. A total of 40 CHWs were recruited, stratified by position, gender and computer experience, and allocated to the traditional or blended learning group using block randomisation. Participants completed the baseline and follow-up questionnaires before and after each course to assess the impact of each learning approach on their knowledge, attitudes, and satisfaction. Per-item, pre-post and between-group, mean differences for each approach were calculated using paired and unpaired t-tests, respectively. Per-item, between-group, satisfaction scores were compared using unpaired t-tests.Results: Scores across all scales improved after attending the traditional and blended learning courses. Self-rated ICT knowledge was significantly improved in both groups with significant differences between groups in seven domains. However, actual ICT knowledge scores were similar across groups. There were no significant differences between groups in attitudinal gains. Satisfaction

Journal article

Aylin P, Benn J, Bottle A, Burnett S, Vincent C, Esmail A, Cecil E, Charles K, D'Lima Det al., 2018, Evaluation of a national surveillance system for mortality alerts: a mixed-methods study. Health Serv Deliv Res 2018;6(7), Evaluation of a national surveillance system for mortality alerts: a mixed-methods study

BackgroundSince 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.ObjectivesTo improve understanding of mortality alerts and evaluate their impact as an intervention to reduce mortality.DesignMixed methods.SettingEnglish NHS acute hospital trusts.ParticipantsEleven trusts were included in the case study. The survey involved 78 alerting trusts.Main outcome measuresRelative risk of mortality and perceived efficacy of the alerting system.Data sourcesHospital Episodes Statistics, published indicators on quality and safety, Care Quality Commission (CQC) reports, interviews and documentary evidence from case studies, and a national evaluative survey.MethodsDescriptive analysis of alerts; association with other measures of quality; associated change in mortality using an interrupted time series approach; in-depth qualitative case studies of institutional response to alerts; and a national cross-sectional evaluative survey administered to describe the organisational structure for mortality governance and perceptions of efficacy of alerts.ResultsA total of 690 mortality alerts generated between April 2007 and December 2014. CQC pursued 75% (154/206) of alerts sent between 2011 and 2013. Patient care was cited as a factor in 70% of all investigations and in 89% of sepsis alerts. Alerts were associated with indicators on bed occupancy, hospital mortality, staffing, financial status, and patient and trainee satisfaction. On average, the risk of death fell by 58% during the 9-month lag following an alert, levelling afterwards and reaching an expected risk within 18 months of the alert. Acute myocardial infarction (AMI) and sepsis alerts instigated institutional responses across all the case study sites, although most sites were undertaking some parallel activities

Report

Woringer M, cecil E, watt H, chang K, hamid F, khunti K, dubois E, evason J, Majeed A, soljak Met al., 2017, Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study, BMC Health Services Research, Vol: 17, ISSN: 1472-6963

Background:Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.Methods:Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively.Results:Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men s

Journal article

Ma RMMN, Saxena S, Cecil E, 2017, Can Clinical Practice Research Datalink (CPRD) be used to study trends in recorded abortions in UK general practice?, Faculty of Sexual and Reproductive Healthcare Annual Scientific Conference

Conference paper

Alexakis C, Saxena S, Chhaya V, Cecil E, Curcin V, Pollok Ret al., 2017, Do Thiopurines Reduce the Risk of Surgery in Elderly Onset Inflammatory Bowel Disease? A 20-Year National Population-Based Cohort Study., Inflammatory Bowel Diseases, Vol: 23, Pages: 672-680, ISSN: 1536-4844

BACKGROUND: Evidence that thiopurines impact on the risk of surgery in elderly onset inflammatory bowel disease (EO-IBD) is lacking. We aimed to compare the rates of surgery in EO-IBD (>60 years at diagnosis) with adult-onset IBD (18-59 yrs), and examine the impact of thiopurines on surgical risk in EO-IBD. METHODS: Using a U.K. database between 1990 and 2010, we compared rates of surgery between adult-onset IBD and EO-IBD using survival analysis. Ulcerative colitis (UC) and Crohn's disease (CD) were analyzed separately. Cox proportional hazard modeling was used to determine the adjusted relative risk of surgery. We further assessed the impact of duration of thiopurine treatment on risk of surgery. RESULTS: We identified 2758 of 9515 patients with UC and 1349 of 6490 patients with CD, with EO-IBD. Cumulative 1, 5, and 10 years risk of colectomy was similar in EO-UC (2.2, 4.5, and 5.8%, respectively) and AO-UC (2.2, 5.0, and 7.3%, respectively; P = 0.15). Cumulative 1, 5, and 10 years risk of first intestinal surgery was lower in EO-CD (9.5, 14.6, and 17.9%, respectively) than AO-CD (12.2, 19.0, and 24.4%, respectively; P < 0.001). Early steroid use, steroid dependency, and thiopurine use was associated with higher risk of colectomy in EO-UC. Among EO-UC receiving thiopurines for >12 months, there was a 70% reduction in risk of colectomy (hazard ratio. 0.30; 95% confidence interval, 0.15-0.58). Thiopurines were not associated with a reduced risk of surgery in EO-CD. CONCLUSIONS: Risk of colectomy in EO-UC does not differ from AO-UC, but the risk of surgery in EO-CD is significantly lower than in AO-CD. Sustained thiopurine use of 12 months or more duration in EO-UC reduces the risk colectomy, but does not impact on the risk of surgery in EO-CD. These findings are important given the greater risk of thiopurine-associated lymphoma in the elderly.

Journal article

Chhaya V, Saxena S, Cecil E, Subramanian V, Curcin V, Majeed A, Pollok RCet al., 2016, Emerging trends and risk factors for perianal surgery in Crohn's disease: a 20-year national population-based cohort study, European Journal of Gastroenterology & Hepatology, Vol: 28, Pages: 890-895, ISSN: 0954-691X

Background: Little is known about the rates of perianal surgery (PAS) in Crohn’s disease (CD). Our aim was to determine trends in PAS, the timing of surgery relative to the diagnosis of CD and to identify subgroups at risk of PAS.Materials and methods: We identified 9391 incident cases of CD between 1989 and 2009. We defined three eras: era 1 (1989–1995), era 2 (1996–2002) and era 3 (2003–2009), and determined trends in procedure type and the time to first PAS relative to the date of diagnosis. We used Kaplan–Meier analysis to calculate the rate of first PAS and performed Cox regression to determine subgroups at risk of PAS.Results: Among the 9391 incident cases of CD, 405 (4.3%) underwent PAS. The overall rate of PAS was 5.5% [95% confidence interval (CI): 4.9–6.2%] 10 years after diagnosis. 34% (n=137) of all patients undergoing PAS had surgery in the 5 years before CD diagnosis. Abscess drainage increased from 34 to 58%, whereas proctectomy decreased from 16 to 6% between eras 1 and 3, respectively. Men [hazard rate (HR) 1.51, 95% CI: 1.24–1.84], those aged 17–40 years (HR 1.69, 95% CI: 1.09–2.02 vs. those aged >40 years) and those with a history of previous intestinal resection (HR 28.5, 95% CI: 22.2–36.5) were more likely to have PAS.Conclusion: Around one-third of patients have a PAS in the 5 years preceding their diagnosis of CD. Surgical practice has changed over 20 years, with a decrease in proctectomy and a concurrent increase in abscess drainage that is likely to reflect improvements in therapeutic practice.

Journal article

Chhaya V, Saxena S, Cecil E, Subramanian V, Curcin V, Majeed A, Pollok RCet al., 2016, Steroid dependency and trends in prescribing for inflammatory bowel disease - a 20-year national population-based study., Alimentary Pharmacology and Therapeutics, Vol: 44, Pages: 482-494, ISSN: 0269-2813

BACKGROUND: It is unclear whether adherence to prescribing standards has been achieved in inflammatory bowel disease (IBD). AIM: To determine how prescribing of 5-aminosalicylates (5-ASAs), steroids and thiopurines has changed in response to emerging evidence. METHODS: We examined trends in oral and topical therapies in 23 509 incident IBD cases (6997 with Crohn's disease and 16 512 with ulcerative colitis) using a nationally representative sample between 1990 and 2010. We created five eras according to the year of diagnosis: era 1 (1990-1993), era 2 (1994-1997), era 3 (1998-2001), era 4 (2002-2005) and era 5 (2006-2010). We calculated the proportion of patients treated with prolonged 5-ASAs (>12 months) and steroid dependency, defined as prolonged steroids (>3 months) or recurrent (restarting within 3 months) steroid exposure. We calculated the cumulative probability of receiving each medication using survival analysis. RESULTS: Half of the Crohn's disease patients were prescribed prolonged oral 5-ASAs during the study, although this decreased between era 3 and 5 from 61.8% to 56.4% (P = 0.002). Thiopurine use increased from 14.0% to 47.1% (P < 0.001) between era 1 and 5. This coincided with a decrease in steroid dependency from 36.5% to 26.8% (P < 0.001) between era 1 and 2 and era 4 and 5 respectively. In ulcerative colitis, 49% of patients were maintained on prolonged oral 5-ASAs. Despite increasing thiopurine use, repeated steroid exposure increased from 15.3% to 17.8% (P = 0.02) between era 1 and 2 and era 4 and 5 respectively. CONCLUSIONS: Prescribing in clinical practice insufficiently mirrors the evidence base. Physicians should direct management towards reducing steroid dependency and optimising 5-ASA use in patients with IBD.

Journal article

Cecil E, Bottle A, Cowling TE, Majeed A, Wolfe I, Saxena Set al., 2016, Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK, PEDIATRICS, Vol: 137, ISSN: 0031-4005

Journal article

Chhaya V, Pollok RCG, Cecil E, Subramanian V, Curcin V, Majeed A, Saxena Set al., 2015, Impact of early thiopurines on surgery in 2770 children and young people diagnosed with inflammatory bowel disease: a national population-based study, ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Vol: 42, Pages: 990-999, ISSN: 0269-2813

Journal article

Saxena S, Atchison C, Cecil E, Sharland M, Koshy E, Bottle Aet al., 2015, Additive impact of pneumococcal conjugate vaccines on pneumonia and empyema hospital admissions in England, JOURNAL OF INFECTION, Vol: 71, Pages: 428-436, ISSN: 0163-4453

Journal article

Cecil E, Bottle A, Sharland M, Saxena Set al., 2015, Impact of UK primary care policy reforms on short-stay unplanned hospital admissions for children with primary care-sensitive conditions, Annals of Family Medicine, Vol: 13, Pages: 214-220, ISSN: 1544-1709

PURPOSE:We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions.METHODS:We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions.RESULTS:There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004.CONCLUSIONS:The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.

Journal article

Chhaya V, Saxena S, Cecil E, Subramanian V, Curcin V, Majeed A, Pollok RCGet al., 2015, Impact of Timing and Duration of Thiopurine Treatment on First Perianal Surgery in Crohn's Disease: UK Population-based Study (1995-2009), INFLAMMATORY BOWEL DISEASES, Vol: 21, Pages: 385-391, ISSN: 1078-0998

Journal article

Mbeledogu CNA, Cecil EV, Millett C, Saxena Set al., 2015, Hospital admissions for unintentional poisoning in preschool children in England; 2000-2011, ARCHIVES OF DISEASE IN CHILDHOOD, Vol: 100, Pages: 180-182, ISSN: 0003-9888

Journal article

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