333 results found
Dewa L, Lawrence-Jones A, Kalorkoti C, et al., 2020, Reflections and impact of a co-produced qualitative study with young people with experience of mental health difficulties, Publisher: Health Expectations
Greenfield G, Blair M, Aylin P, et al., 2020, Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data, Emergency Medicine Journal, ISSN: 1472-0205
Bottle R, Griffiths R, White S, et al., 2020, Periprosthetic fractures – the next fragility fracture epidemic? A national observational study, BMJ Open, ISSN: 2044-6055
Byrne BE, Faiz OD, Bottle A, et al., 2020, A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery., World J Surg
BACKGROUND: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. METHODS: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15. RESULTS: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. CONCLUSIONS: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.
Hanna GB, Mackenzie H, Miskovic D, et al., 2020, Laparoscopic colorectal surgery outcomes improved after national training program (LAPCO) for specialists in England., Annals of Surgery, ISSN: 0003-4932
OBJECTIVE: To examine the impact of The National Training Programme for Laparoscopic Colorectal Surgery (Lapco) on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. SUMMERY BACKGROUND DATA: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. METHODS: We compared the rate of laparoscopic surgery, mortality and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. RESULTS: 108 Lapco delegates performed 4586 elective colorectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% (95% CI, 18.5 to 23.3, p<0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, p = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, p = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56% respectively. CONCLUSIONS: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.
McCabe R, Schmit N, Christen P, et al., 2020, Adapting hospital capacity to meet changing demands during the COVID-19 pandemic, BMC Medicine, Vol: 18, Pages: 1-12, ISSN: 1741-7015
BackgroundTo calculate hospital surge capacity, achieved via hospital provision interventions implemented for the emergency treatment of coronavirus disease 2019 (COVID-19) and other patients through March to May 2020; to evaluate the conditions for admitting patients for elective surgery under varying admission levels of COVID-19 patients.MethodsWe analysed National Health Service (NHS) datasets and literature reviews to estimate hospital care capacity before the pandemic (pre-pandemic baseline) and to quantify the impact of interventions (cancellation of elective surgery, field hospitals, use of private hospitals, deployment of former medical staff and deployment of newly qualified medical staff) for treatment of adult COVID-19 patients, focusing on general and acute (G&A) and critical care (CC) beds, staff and ventilators.ResultsNHS England would not have had sufficient capacity to treat all COVID-19 and other patients in March and April 2020 without the hospital provision interventions, which alleviated significant shortfalls in CC nurses, CC and G&A beds and CC junior doctors. All elective surgery can be conducted at normal pre-pandemic levels provided the other interventions are sustained, but only if the daily number of COVID-19 patients occupying CC beds is not greater than 1550 in the whole of England. If the other interventions are not maintained, then elective surgery can only be conducted if the number of COVID-19 patients occupying CC beds is not greater than 320. However, there is greater national capacity to treat G&A patients: without interventions, it takes almost 10,000 G&A COVID-19 patients before any G&A elective patients would be unable to be accommodated.ConclusionsUnless COVID-19 hospitalisations drop to low levels, there is a continued need to enhance critical care capacity in England with field hospitals, use of private hospitals or deployment of former and newly qualified medical staff to allow some or all elective surge
Arhi C, Askari A, Nachiappan S, et al., 2020, Stage at diagnosis and survival of colorectal cancer with or without underlying inflammatory bowel disease: a population-based study., J Crohns Colitis
BACKGROUND: Inflammatory Bowel Disease(IBD) is a risk factor for colorectal cancer(CRC). The aim of this study is to determine whether stage at diagnosis and survival differ between sporadic, ulcerative colitis (UC) and Crohn's disease(CD) related CRC. METHOD: The English National Cancer Registry (NCIN), Hospital Episode Statistics(HES) and Office for National Statistics(ONS) datasets between 2000-2010 were linked, providing data on co-morbidities, stage and date of death. A logistic regression model determined whether IBD was associated with an early(I/II) or late (III/IV)cancer. Cox regression analysis was used to examine survival differences between sporadic, UC and CD. RESULTS: A total of 234009 patients with CRC were included, of which 985(0.4%) and 1,922(0.8%) had CD and UC respectively. UC, but not CD, was associated with an earlier stage compared with sporadic cancers (OR 0.88 CI 0.79-0.98 p=0.02). CD had a significantly worse survival compared with sporadic patients for stage II(HR=1.71, CI 1.26-2.31 p<0.005) and III(1.53, CI 1.20-1.96 p<0.005) cancer. UC patients were associated with worse survival compared with the sporadic group for both stage III(1.38, CI 1.17-1.63 p<0.0005)and IV(1.13, CI 1.01-1.28 p=0.04)cancer. After excluding sporadic patients, UC was associated with improved survival compared with CD(0.62, CI 0.43-0.90 p=0.01) for stage II cancer. CONCLUSION: Patients with IBD are diagnosed at an earlier stage but tend to have a worse survival compared with sporadic cases of CRC, in particular for nodal disease(stage III).Specifically, patients with CD related CRC appear to fare worst in terms of survival compared with both the sporadic and UC group.
Greenfield G, Blair M, Aylin P, et al., 2020, Frequent attendances at emergency departments in England, Emergency Medicine Journal, Vol: 37, Pages: 597-599, ISSN: 1472-0205
Background: A small proportion of patients referred to as ‘frequent attenders’ account for a large proportion of hospital activity such as emergency departments (ED) attendances and admissions. There is lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals.Method: We included all attendances at all major EDs across England in the financial year 2016–2017. Patients who attended 3 times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group.Results: 14,829,519 attendances were made by 10,062,847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended 3 times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended 6 times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30-59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had.Conclusion: One in ten patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.
Dewa L, Crandell C, Choong E, et al., 2020, CCopeY: a mixed-methods co-produced study on the mental health status and coping strategies of young people during COVID-19 UK lockdown
Ali AM, Loeffler MD, Aylin P, et al., 2020, Timing of Readmissions After Elective Total Hip and Knee Arthroplasty: Does a 30-Day All-Cause Rate Capture Surgically Relevant Readmissions?, J Arthroplasty
BACKGROUND: The 30-day all-cause readmission rate is a widely used metric of hospital performance. However, there is lack of clarity as to whether 30 days is an appropriate time frame following surgical procedures. Our aim is to determine whether a 90-day time window is superior to a 30-day time window in capturing surgically relevant readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We analyzed readmissions following all primary THAs and TKAs recorded in the English National Health Service Hospital Episode Statistics database from 2008 to 2018. We compared temporal patterns of 30- and 90-day readmission rates for the following types of readmission: all-cause, surgical, return to theater, and those related to specific surgical complications. RESULTS: A total of 1.47 million procedures were recorded. After THA and TKA, over three-quarters of 90-day surgical readmissions took place within the first 30 days (78.5% and 75.7%, respectively). All-cause and surgical readmissions both peaked at day 4 and followed a similar temporal course thereafter. The ratio of surgical to medical readmissions was greater for THA than for TKA, with THA dislocation both being one of the most common surgical complications and clustering early after discharge, with 73.5% of 90-day dislocations occurring within the first 30 days. CONCLUSION: The 30-day all-cause readmission rate is a good reflection of surgically relevant readmissions that take place in the first 90 days after THA and TKA.
Perez Guzman PN, Daunt A, Mukherjee S, et al., 2020, Clinical characteristics and predictors of outcomes of hospitalized patients with COVID-19 in a multi-ethnic London NHS Trust: a retrospective cohort study, Clinical Infectious Diseases, ISSN: 1058-4838
Background: Emerging evidence suggests ethnic minorities are disproportionatelyaffected by COVID-19. Detailed clinical analyses of multi-cultural hospitalized patientcohorts remain largely undescribed.Methods: We performed regression, survival andcumulative competing risk analyses to evaluate factors associated with mortality inpatients admitted for COVID-19 in three large London hospitals between February 25and April 5, censored as of May 1, 2020.Results: Of 614 patients (median age 69years, (IQR 25) and 62% male), 381 (62%) had been discharged alive, 178 (29%)died and 55 (9%) remained hospitalized at censoring. Severe hypoxemia (aOR 4.25,95%CI 2.36-7.64), leukocytosis (aOR 2.35, 95%CI 1.35-4.11), thrombocytopenia (aOR1.01, 95%CI 1.00-1.01, increase per 10x9decrease), severe renal impairment (aOR5.14, 95%CI 2.65-9.97), and low albumin (aOR 1.06, 95%CI 1.02-1.09, increase per gdecrease) were associated with death. Forty percent (244) were from black, Asian andother minority ethnic (BAME) groups, 38% (235) white and for 22% (135) ethnicity wasunknown. BAME patients were younger and had fewer comorbidities. Whilst theunadjusted odds of death did not differ by ethnicity, when adjusting for age, sex andcomorbidities, black patients were at higher odds of death compared to whites (aOR1.69, 95%CI 1.00-2.86). This association was stronger when further adjusting foradmission severity (aOR 1.85 95% CI 1.06-3.24). Conclusions: BAME patients were over-represented in our cohort and, whenaccounting for demographic and clinical profile of admission, black patients were atincreased odds of death. Further research is needed into biologic drivers of differencesin COVID-19 outcomes by ethnicity.
Kim D, Hayhoe B, Aylin P, et al., 2020, Health service use by patients with heart failure living in a community setting: a cross-sectional analysis in North West London, BRITISH JOURNAL OF GENERAL PRACTICE, Vol: 70, Pages: E563-E572, ISSN: 0960-1643
Vollmer M, Radhakrishnan S, Kont M, et al., 2020, Report 29: The impact of the COVID-19 epidemic on all-cause attendances to emergency departments in two large London hospitals: an observational study
The health care system in England has been highly affected by the surge in demand due to patients afflicted by COVID-19. Yet the impact of the pandemic on the care seeking behaviour of patients and thus on Emergency department (ED) services is unknown, especially for non-COVID-19 related emergencies. In this report, we aimed to assess how the reorganisation of hospital care and admission policies to respond to the COVID-19 epidemic affected ED attendances and emergency hospital admissions. We performed time-series analyses of present year vs historic (2015-2019) trends of ED attendances between March 12 and May 31 at two large central London hospitals part of Imperial College Healthcare NHS Trust (ICHNT) and compared these to regional and national trends. Historic attendances data to ICHNT and publicly available NHS situation reports were used to calibrate time series auto-regressive integrated moving average (ARIMA) forecasting models. We thus predicted the (conterfactual) expected number of ED attendances between March 12 (when the first public health measure leading to lock-down started in England) to May 31, 2020 (when the analysis was censored) at ICHNT, at all acute London Trusts and nationally. The forecasted trends were compared to observed data for the same periods of time. Lastly, we analysed the trends at ICHNT disaggregating by mode of arrival, distance from postcode of patient residence to hospital and primary diagnosis amongst those that were subsequently admitted to hospital and compared these data to an average for the same period of time in the years 2015 to 2019.During the study period (January 1 to May 31, 2020) there was an overall decrease in ED attendances of 35% at ICHNT, of 50% across all London NHS Trusts and 53% nationally. For ICHNT, the decrease in attendances was mainly amongst those aged younger than 65 and those arriving by their own means (e.g. personal or public transport). Increasing distance (km) from postcode of residence to hospi
Arhi CS, Burns EM, Bottle A, et al., 2020, Delays in referral from primary care worsen survival for patients with colorectal cancer: a retrospective cohort study, BRITISH JOURNAL OF GENERAL PRACTICE, Vol: 70, Pages: E463-E471, ISSN: 0960-1643
Forchini G, Lochen A, Hallett T, et al., 2020, Report 28: Excess non-COVID-19 deaths in England and Wales between 29th February and 5th June 2020
There were 189,403 deaths from any cause reported in England from 29th February to 5th June 2020 inclusive, and 11,278 all-cause deaths in Wales over the same period. Of those deaths, 44,736 (23.6%) registered COVID-19 on the death certificate in England, and 2,294 (20.3%) in Wales, while 144,667 (76.4%) were not recorded as having been due to COVID-19 in England, and 8,984 (79.7%) in Wales. However, it could be that some of the ‘non-COVID-19’ deaths have in fact also been caused by COVID-19, either as the direct cause of death, or indirectly through provisions for the pandemic impeding access to care for other conditions. There is uncertainty in how many of the non-COVID-19 deaths were directly or indirectly caused by the pandemic. We estimated the excess deaths that were not recorded as associated with COVID-19 in the death certificate (excess non-COVID-19 deaths) as the deaths for which COVID-19 was not reported as the cause, compared to those we would have expected to occur had the pandemic not happened. Expected deaths were forecast with an analysis of historic trends in deaths between 2010 and April 2020 using data by the Office of National Statistics and a statistical time series model. According to the model, we expected 136,294 (95% CI 133,882 - 138,696) deaths in England, and 8,983 (CI 8,051 - 9,904) in Wales over this period, significantly fewer than the number of deaths reported. This means that there were 8,983 (95% CI 5,971 - 10,785) total excess non-COVID-19 deaths in England. For every 100 COVID-19 deaths during the period from 29th February to 5th June 2020 there were between 13 and 24 cumulative excess non-COVID-19 deaths. The proportion of cumulative excess non-COVID-19 deaths of all reported deaths during this period was 4.4% (95% CI 3.2% - 5.7%) in England, with small regional variations. Excess deaths were highest in the South East at 2,213 (95% CI 327 - 4,047) and in London at 1,937 (95% CI 896 - 3,010), respectively. There is no e
McCabe R, Schmit N, Christen P, et al., 2020, Report 27 Adapting hospital capacity to meet changing demands during the COVID-19 pandemic
To meet the growing demand for hospital care due to the COVID-19 pandemic, England implemented a range of hospital provision interventions including the procurement of equipment, the establishment of additional hospital facilities and the redeployment of staff and other resources. Additionally, to further release capacity across England’s National Health Service (NHS), elective surgery was cancelled in March 2020, leading to a backlog of patients requiring care. This created a pressure on the NHS to reintroduce elective procedures, which urgently needs to be addressed. Population-level measures implemented in March and April 2020 reduced transmission of SARS-CoV-2, prompting a gradual decline in the demand for hospital care by COVID-19 patients after the peak in mid-April. Planning capacity to bring back routine procedures for non-COVID-19 patients whilst maintaining the ability to respond to any potential future increases in demand for COVID-19 care is the challenge currently faced by healthcare planners.In this report, we aim to calculate hospital capacity for emergency treatment of COVID-19 and other patients during the pandemic surge in April and May 2020; to evaluate the increase in capacity achieved via five interventions (cancellation of elective surgery, field hospitals, use of private hospitals, and deployment of former and newly qualified medical staff); and to determine how to re-introduce elective surgery considering continued demand from COVID-19 patients. We do this by modelling the supply of acute NHS hospital care, considering different capacity scenarios, namely capacity before the pandemic (baseline scenario) and after the implementation of capacity expansion interventions that impact available general and acute (G&A) and critical care (CC) beds, staff and ventilators. Demand for hospital care is accounted for in terms of non-COVID-19 and COVID-19 patients. Our results suggest that NHS England would not have had sufficient daily capacity
Dewa L, Lawrence-Jones A, Kalorkoti C, et al., 2020, Reflections, impact and recommendations of a co-produced qualitative study with young people who have experience of mental health difficulties, Health Expectations, ISSN: 1369-6513
Perez Guzman PN, Daunt A, Mukherjee S, et al., 2020, Report 17: Clinical characteristics and predictors of outcomes of hospitalised patients with COVID-19 in a London NHS Trust: a retrospective cohort study
Clinical characteristics and determinants of outcomes for hospitalised COVID-19 patients in the UK remain largely undescribed and emerging evidence suggests ethnic minorities might be disproportionately affected. We describe the characteristics and outcomes of patients hospitalised for COVID-19 in three large London hospitals with a multi-ethnic catchment population.We performed a retrospective cohort study on all patients hospitalised with laboratory-confirmed SARS-CoV-2 infection at Imperial College Healthcare NHS Trust between February 25 and April 5, 2020. Outcomes were recorded as of April 19, 2020. Logistic regression models, survival analyses and cumulative competing risk analyses were performed to evaluate factors associated with COVID-19 hospital mortality.Of 520 patients in this cohort (median age 67 years, (IQR 26) and 62% male), 302 (68%) had been discharged alive, 144 (32%) died and 74 (14%) were still hospitalised at the time of censoring. Increasing age (adjusted odds ratio [aOR] 2·16, 95%CI 1·50-3·12), severe hypoxia (aOR 3·75, 95%CI 1·80-7·80), low platelets (aOR 0·65, 95%CI 0.49·0·85), reduced estimated glomerular filtration rate (aOR 4·11, 95%CI 1·58-10·69), bilirubin >21mmol/L (aOR 2·32, 95%CI 1·05-5·14) and low albumin (aOR 0·77, 9%%CI 0·59-1·01) were associated with increased risk of in-hospital mortality. Individual comorbidities were not independently associated with risk of death. Regarding ethnicity, 209 (40%) were from a black and Asian minority, for 115 (22%) ethnicity was unknown and 196 (38%) patients were white. Compared to the latter, black patients were significantly younger and had less comorbidities. Whilst the crude OR of death of black compared to white patients was not significant (1·14, 95%CI 0·69-1·88, p=0.62), adjusting for age and comorbidity showed a trend towards significance
Bottle R, Cohen C, Lucas A, et al., 2020, How an electronic health record became a real-world research resource: comparison between London’s Whole Systems Integrated Care database and the Clinical Practice Research Datalink, BMC Medical Informatics and Decision Making, Vol: 20, ISSN: 1472-6947
BackgroundIn the UK, several initiatives have resulted in the creation of local data warehouses of electronic patient records. Originally developed for commissioning and direct patient care, they are potentially useful for research, but little is known about them outside their home area. We describe one such local warehouse, the Whole Systems Integrated Care (WSIC) database in NW London, and its potential for research as the “Discover” platform. We compare Discover with the Clinical Practice Research Datalink (CPRD), a popular UK research database also based on linked primary care records.MethodsWe describe the key features of the Discover database, including scope, architecture and governance; descriptive analyses compare the population demographics and chronic disease prevalences with those in CPRD.ResultsAs of June 2019, Discover held records for a total of 2.3 million currently registered patients, or 95% of the NW London population; CPRD held records for over 11 million. The Discover population matches the overall age-sex distribution of the UK and CPRD but is more ethnically diverse. Most Discover chronic disease prevalences were comparable to the national rates. Unlike CPRD, Discover has identifiable care organisations and postcodes, allowing mapping and linkage to healthcare provider variables such as staffing, and includes contacts with social, community and mental health care. Discover also includes a consent-to-contact register of over 3000 volunteers to date for prospective studies.ConclusionsLike CPRD, Discover has been a number of years in the making, is a valuable research tool, and can serve as a model for other areas developing similar data warehouses.
Christen P, D'Aeth J, Lochen A, et al., 2020, Report 15: Strengthening hospital capacity for the COVID-19 pandemic
Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for COVID-19, and other conditions, is one of the most challenging tasks facing healthcare commissioners and care providers during the pandemic. Due to uncertainty in expected patient numbers requiring care, as well as evolving needs day by day, planning hospital capacity is challenging. Health systems that are well prepared for the pandemic can better cope with large and sudden changes in demand by implementing strategies to ensure adequate access to care. Thereby the burden of the pandemic can be mitigated, and many lives saved. This report presents the J-IDEA pandemic planner, a hospital planning tool to calculate how much capacity in terms of beds, staff and ventilators is obtained by implementing healthcare provision interventions affecting the management of patient care in hospitals. We show how to assess baseline capacity, and then calculate how much capacity is gained by various healthcare interventions using impact estimates that are generated as part of this study. Interventions are informed by a rapid review of policy decisions implemented or being considered in 12 European countries over the past few months￼ , an evaluation of the impact of the interventions on capacity using a variety of research methods, and by a review of key parameters in the care of COVID-19 patients.The J-IDEA planner is publicly available, interactive and adaptable to different and changing circumstances and newly emerging evidence. The planner estimates the additional number of beds, medical staff and crucial medical equipment obtained under various healthcare interventions using flexible inputs on assumptions of existing capacities, the number of hospitalisations, beds-to-staff ratios, and staff absences due to COVID-19. A detailed user guide accompanies the planner. The planner was developed rapidly and has limitations which we will address in future iterations. It support
Dewa L, Thibaut B, Pattison N, et al., 2020, Treating insomnia in prisoners: a feasibility study of a multi-component treatment pathway, Publisher: Journal of Sleep Research
Giuliani S, Honeyford K, Chang C-Y, et al., 2020, Outcomes of Primary versus Multiple-Staged Repair in Hirschsprung's Disease in England, EUROPEAN JOURNAL OF PEDIATRIC SURGERY, Vol: 30, Pages: 104-110, ISSN: 0939-7248
Kim D, Hayhoe B, Aylin P, et al., 2020, Health service use by community-dwelling heart failurepatients in a large urban population in NW London, British Journal of General Practice, ISSN: 0960-1643
Background: The complex nature of heart failure (HF) management, often involving multidimensional care, is widely recognised, but overall health service utilisation by HF patients has not previously been described.Aim: To describe overall health service use by community-dwelling adults with HF.Design and Setting: Cross-sectional analysis of prevalent HF cases between 2015 and 2018 using an administrative dataset covering primary care, secondary care, and ‘other’ (community, mental health, and social care) services in North West London (NWL).Methods: Healthcare use of each service was described overall and by individual components of secondary care (e.g. outpatient appointments) and ‘other’ services (e.g. nursing contacts). Usage patterns were identified using k-means cluster analysis using all distinct contacts for the whole study period and visualised by a heatmap. Results: There were 39 301 patients with a prevalent diagnosis of HF between 1 January 2015 and 31 December 2018. 90% used health services during the study period, most commonly outpatient services, GP consultations, unplanned A&E visits and community services. Use of cardiology-specific services ranged from around 3% (cardiology-related community care) to around 20% (outpatient cardiology visits). GP consultations decreased by 11% over our study period. Five clusters of patients were identified, each with significantly different care usage patterns and patient characteristics.Conclusions: HF patients make heavy but heterogeneous use of services. Relatively low and falling use of GP consultations, and apparently low uptake of community rehabilitation services by patients with HF, is concerning and suggests challenges in primary care access and integration of care.
Cecil E, Bottle R, Vincent C, et al., 2020, What is the relationship between mortality alerts and other indicators of quality of care? A national cross-sectional study, Journal of Health Services Research and Policy, Vol: 25, Pages: 13-21, ISSN: 1355-8196
Objective: To assess whether mortality alerts, triggered by sustained higher than expected hospital mortality, are associated with other potential indicators of hospital quality relating to factors of hospital structure, clinical process and patient outcomes.Study Design: Cross sectional study of National Health Service hospital trusts in England (2011-2013).Data collection/extraction methods: Publicly available hospital measures chosen a-prior to reflect 1) Organisational structure (mean acute bed occupancy, nurse/bed ratios, training satisfaction and proportion of trusts with low NHS Litigation Authority risk assessment or in financial deficit), 2) Process (mean % of eligible patients who receive percutaneous coronary intervention within 90 minutes) and 3) Outcome (mean patient satisfaction scores, summary measures of hospital mortality (SHMI and HSMR) and % of patient harmed). Mortality alerts were based on hospital administrative data.Principal Findings: Mortality alerts were associated with structural indicators and outcome indicators of quality. There was insufficient data to detect an association between mortality alerts and our process indicator.Conclusion:Mortality alerts appear to reflect aspects of quality within an English hospital setting, suggesting that there may be value in a mortality alerting system in highlighting poor hospital quality.
Cecil E, Bottle A, Majeed A, et al., 2019, Patient and health-care factors associated with potentially missed acute deterioration in primary care: a retrospective observational study of linked primary and secondary care data, National Conference on Public Health Science Dedicated to New Research in UK Public Health, Publisher: Elsevier, Pages: 30-30, ISSN: 0140-6736
Arhi CS, Ziprin P, Bottle A, et al., 2019, Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population-based study, Colorectal Disease, Vol: 21, Pages: 1270-1278, ISSN: 1462-8910
AIM: The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients. METHOD: We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records. RESULTS: The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific. CONCLUSION: Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.
Ghafur S, Kristensen S, honeyford K, et al., 2019, A retrospective impact analysis of the WannaCry cyber-attack on the NHS, npj Digital Medicine, Vol: 2, ISSN: 2398-6352
A systematic analysis of Hospital Episodes Statistics (HES) data was done to determine the effects of the 2017 WannaCry attack on the National Health Service (NHS) by identifying the missed appointments, deaths, and fiscal costs attributable to the ransomware attack. The main outcomes measured were: outpatient appointments cancelled, elective and emergency admissions to hospitals, Accident & Emergency (A&E) attendances, and deaths in A&E. Compared with the baseline, there was no significant difference in the total activity across all trusts during the week of the WannaCry attack. Trusts had 1% more emergency admissions and 1% fewer A&E attendances per day during the WannaCry week compared with baseline. Hospitals directly infected with the ransomware, however, had significantly fewer emergency and elective admissions: a decrease of about 6% in total admissions per infected hospital per day was observed, with 4% fewer emergency admissions and 9% fewer elective admissions. No difference in mortality was noted. The total economic value of the lower activity at the infected trusts during this time was £5.9m including £4m in lost inpatient admissions, £0.6m from lost A&E activity, and £1.3m from cancelled outpatient appointments. Among hospitals infected with WannaCry ransomware, there was a significant decrease in the number of attendances and admissions, which corresponded to £5.9m in lost hospital activity. There was no increase in mortality reported, though this is a crude measure of patient harm. Further work is needed to appreciate the impact of a a cyber attack or IT failure on care delivery and patient safety.
Arhi CS, Markar S, Burns EM, et al., 2019, Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer, Diseases of the Esophagus, Vol: 32, Pages: 1-11, ISSN: 1120-8694
NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.
Kim D, Hayhoe B, Aylin P, et al., 2019, Route to heart failure diagnosis in English primary care: a retrospective cohort study of variation, British Journal of General Practice, Vol: 69, Pages: e697-e705, ISSN: 0960-1643
BACKGROUND: Despite the existence of evidence-based guidelines supporting the identification of heart failure (HF) in primary care, the proportion of patients diagnosed in this setting remains low. Understanding variation in patients' routes to diagnosis will better inform HF management. AIM: To identify the factors associated with variation in patients' routes to HF diagnosis in primary care. DESIGN AND SETTING: A retrospective cohort study of 13 897 patients diagnosed with HF between 1 January 2010 and 31 March 2013 in English primary care. METHOD: This study used primary care electronic health records to identify routes to HF diagnosis, defined using the National Institute for Health and Care Excellence (NICE) guidelines, and adherence to the NICE-recommended guidelines. Multilevel logistic regression was used to investigate factors associated with the recommended route to HF diagnosis, and funnel plots were used to visualise variation between practices. RESULTS: Few patients (7%, n = 976) followed the recommended route to HF diagnosis. Adherence to guidelines was significantly associated with younger age (P = 0.001), lower deprivation level (P = 0.007), HF diagnosis source (P<0.001), not having chronic pulmonary disease (P<0.001), receiving further consultation for symptom(s) suggestive of HF (P<0.001), and presenting with breathlessness (P<0.001). Route to diagnosis also varied significantly between GP practices (P<0.001). CONCLUSION: The significant association of certain patient characteristics with route to HF diagnosis and the variation between GP practices raises concerns about equitable HF management. Further studies should investigate reasons for this variation to improve the diagnosis of HF in primary care. However, these must consider the complexities of a patient group often affected by frailty and multiple comorbidities.
Dewa L, Lavelle M, Pickles K, et al., 2019, Young adults’ perceptions of using wearables, social media and other technologies to detect worsening mental health: a qualitative study, PLoS One, Vol: 14, ISSN: 1932-6203
BackgroundTechnological interventions may help support and improve mental health. However young peoples’ perspectives on using different technologies to detect deteriorating mental health in those already diagnosed with a mental health condition is lacking. The study aim was to explore the perspectives of young patients on the feasibility and acceptability of using wearables, social media and technologies to detect mental health deterioration. Methods The study was co-produced with young adults with past mental health difficulties. Semi-structured interviews were conducted with young adults with a severe mental health condition in a private room at a community mental health site. Data was triangulated by comparing codes and ideas across the two co-researchers and two researchers over two virtual meetings. Themes were finalised and presented in a thematic map. ResultsSixteen participants were interviewed (81% female). There were four main themes: dealing with mental health symptoms, signs of mental health deterioration, technology concerns and technological applications to identify worsening mental health. Wearables and mobile apps were considered acceptable and feasible to detect mental health deterioration in real-time if they could measure changes in sleep patterns, mood or activity levels as signs of deterioration. Getting help earlier was deemed essential particularly in reference to dissatisfaction with the current non-technological mental health services. However, patients identified issues to consider before implementation including practicality, safeguarding and patient preference. ConclusionWearables and mobile apps could be viable technological options to help detect deterioration in young people in order to intervene early and avoid delay in accessing mental health services. However, immediate action following detection is required for the patient to trust and use the intervention.
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