Publications
398 results found
Kim D, Hayhoe BWJ, Aylin P, et al., 2018, Variation in route to diagnosis of heart failure in primary care in England, Public Health Science: A National Conference Dedicated to New Research in UK Public Health, Publisher: Elsevier, ISSN: 0140-6736
Lishman H, Costelloe C, Hopkins S, et al., 2018, Exploring the relationship between primary care antibiotic prescribing for urinary tract infections, Escherichia coli bacteraemia incidence and antibiotic resistance: an ecological study, International Journal of Antimicrobial Agents, ISSN: 0924-8579
Dewa LH, Cecil E, Eastwood L, et 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
Balinskaite V, Bottle A, Shaw LJ, et al., 2018, Reorganisation of stroke care and impact on mortality in patients admitted during weekends: a national descriptive study based on administrative data, BMJ Quality and Safety, Vol: 27, Pages: 611-618, ISSN: 2044-5415
OBJECTIVE: To evaluate mortality differences between weekend and weekday emergency stroke admissions in England over time, and in particular, whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference. DESIGN, SETTING AND PARTICIPANTS: Risk-adjusted difference-in-difference time trend analysis using hospital administrative data. All emergency patients with stroke admitted to English hospitals from 1 January 2008 to 31 December 2014 were included. MAIN OUTCOMES: Mortality difference between weekend and weekday emergency stroke admissions. RESULTS: We identified 507 169 emergency stroke admissions: 26% of these occurred during the weekend. The 7-day in-hospital mortality difference between weekend and weekday admissions declined across England throughout the study period. In Greater London, where the reorganisation of stroke services took place, an adjusted 28% (relative risk (RR)=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant. In the rest of England, an 11% (RR=1.11, 95% CI 1.07 to 1.15) higher weekend/weekday 30-day mortality ratio declined to a non-significant 4% higher risk (RR=1.04, 95% CI 0.99 to 1.09) in 2014. We found no statistically significant association between decreases in the weekend/weekday admissions difference in mortality and the centralisation of stroke services in Greater London. CONCLUSIONS: There was a steady reduction in weekend/weekday differences i
Bottle A, Honeyford K, Chowdhury F, et al., 2018, Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study, Health and Social Care Delivery Research, Vol: 6, Pages: 1-84, ISSN: 2755-0060
Background: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplannedhospital activity, but our understanding of what drives this is incomplete.Objectives: To model patient, primary care and hospital factors associated with readmission and mortalityfor patients with HF and COPD, to assess the statistical performance of post-discharge emergencydepartment (ED) attendance compared with readmission metrics and to compare all the results for thetwo conditions.Design: Observational study.Setting: English NHS.Participants: All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.Interventions: None.Main outcome measures: One-year mortality and 30-day emergency readmission following the patient’sfirst unplanned admission (‘index admission’) for HF or COPD.Data sources: Patient-level data from Hospital Episodes Statistics were combined with publicly availablepractice- and hospital-level data on performance, patient and staff experience and rehabilitationprogramme website information.Results: One-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factorspredicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long)index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS andcomorbidities also predicted readmission. Of the practice and hospital factors we considered, only moredoctors per 10 beds [odds ratio (OR) 0.95 per doctor; p < 0.001] was significant for both cohorts for mortality,with staff recommending to friends and family (OR 0.80 per unit increase; p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP; p = 0.004) important for COPD. For readmission,only hospital size [OR per 100 beds = 2.16, 95% confidence interval (
Rao A, Bicknell C, Bottle R, et al., 2018, Common sequences of emergency readmissions among high-impact users following AAA repair, Surgery Research and Practice, Vol: 2018, ISSN: 2356-7759
IntroductionThe aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate. MethodsThe patient cohort (2006-2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data. ResultsFrom a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among rAAA repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastro-intestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%) and ischaemic heart disease (3.3%).ConclusionA significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community.
Bottle A, Loeffler MD, Aylin P, et al., 2018, Comparison of 3 types of readmission rates for measuring hospital and surgeon performance after primary total hip and knee arthroplasty, Journal of Arthroplasty, Vol: 33, Pages: 2014-2019.e2, ISSN: 0883-5403
BACKGROUND: All-cause 30-day hospital readmission is in widespread use for monitoring and incentivizing hospital performance for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, little is known on the extent to which all-cause readmission is influenced by hospital or surgeon performance and whether alternative measures may be more valid. METHODS: This is an observational study using multilevel modeling on English administrative data to determine the interhospital and intersurgeon variation for 3 readmission metrics: all-cause, surgical, and return-to-theater. Power calculations estimated the likelihood of identifying whether the readmission rate for a surgeon or hospital differed from the national average by a factor of 1.25, 1.5, 2, or 3 times, for both average and high-volume providers. RESULTS: About 259,980 THAs and 311,033 TKAs were analyzed. Variations by both surgeons and hospitals were smaller for the all-cause measure than for the surgical or return-to-theater metrics, although statistical power to detect differences was higher. Statistical power to detect surgeon-level rates of 1.25 or 1.5 times the average was consistently low. However, at the hospital level, the surgical readmission measure showed more variation by hospital while maintaining excellent power to detect differences in rates between hospitals performing the average number of THA or TKA cases per year in England. In practice, more outliers than expected from purely random variation were found for all-cause and surgical readmissions, especially at hospital level. CONCLUSION: The 30-day surgical readmission rate should be considered as an adjunctive measure to 30-day all-cause readmission rate when assessing hospital performance.
Rao A, Kim D, Darzi A, et al., 2018, Long-term trends of use of health service among heart failure patients, European Heart Journal - Quality of Care and Clinical Outcomes, Vol: 4, Pages: 220-231, ISSN: 2058-5225
Aims: We aimed to identify subgroups in the patient population with different trajectories of long-term readmission rates. The study also aimed to assess common causes and their sequences of readmissions for each subgroup. Methods: Patients with a primary diagnosis of heart failure (HF) in the period 2008-2009 were identified using nationally representative primary care data linked to national hospital data, which contain information on 10.5 million patients. HF patients were followed up for 5 years. Group-based trajectory models and sequence analysis were applied. Results: The model categorised the HF population (n = 9466) into 5 subgroups: low-impact (66.9%); two intermediate ones (27.4%); chronic high-impact (2.3%) with steady high annual readmission rates; and short-term high-impact (3.4%) with rapid decline in readmission rates. The groups were defined by their trends of yearly number of readmissions. The all-cause 5-year mortality was highest in the short-term high-impact group (n = 185, 72.8%), followed by group 2 (intermediate users) (n = 744, 58.8%), low-impact (n = 4244, 56.9%), chronic high-impact (n = 88, 37.6%) and group 1 (intermediate users) (n = 401, 30.3%) (p < 0.01). Compared with low-impact users, high-impact users were associated with higher mortality, bereavement episodes, and more out-of-hours GP visits. The chronic high-impact users had distinct sequences of causes of emergency admissions most often consisting of chest infection, ischaemic heart disease, and cardio-pulmonary signs and/or symptoms. Conclusion: Chronic high-impact users constitute a small proportion of total patients, but they have increasingly high use of healthcare services. Short-term high-impact users represent largely end of life patients. They require prompt involvement of the palliative care team to reduce unnecessary readmissions to hospital.
Bou-Antoun S, Costelloe C, Honeyford CE, et al., 2018, Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis, Journal Of Antimicrobial Chemotherapy, ISSN: 0305-7453
ObjectivesTo assess the impact of the 2015/16 NHS England Quality Premium (which provided a financial incentive for Clinical Commissioning Groups to reduce antibiotic prescribing in primary care) on antibiotic prescribing by General Practitioners (GPs) for respiratory tract infections (RTIs).MethodsInterrupted time series analysis using monthly patient-level consultation and prescribing data obtained from the Clinical Practice Research Datalink (CPRD) between April 2011 and March 2017. The study population comprised patients consulting a GP who were diagnosed with an RTI. We assessed the rate of antibiotic prescribing in patients (both aggregate and stratified by age) with a recorded diagnosis of uncomplicated RTI, before and after the implementation of the Quality Premium.ResultsPrescribing rates decreased over the 6 year study period, with evident seasonality. Notably, there was a 3% drop in the rate of antibiotic prescribing (equating to 14.65 prescriptions per 1000 RTI consultations) (P < 0.05) in April 2015, coinciding with the introduction of the Quality Premium. This reduction was sustained, such that after 2 years there was a 3% decrease in prescribing relative to that expected had the pre-intervention trend continued. There was also a concurrent 2% relative reduction in the rate of broad-spectrum antibiotic prescribing. Antibiotic prescribing for RTIs diagnosed in children showed the greatest decline with a 6% relative change 2 years after the intervention. Of the RTI indications studied, the greatest reductions in antibiotic prescribing were seen for patients with sore throats.ConclusionsCommunity prescribing of antibiotics for RTIs significantly decreased following the introduction of the Quality Premium, with the greatest reduction seen in younger patients.
Dunning J, Blankley S, Hoang LT, et al., 2018, Progression of whole-blood transcriptional signatures from interferon-induced to neutrophil-associated patterns in severe influenza, Nature Immunology, Vol: 19, Pages: 625-635, ISSN: 1529-2916
Transcriptional profiles and host-response biomarkers are used increasingly to investigate the severity, subtype and pathogenesis of disease. We now describe whole-blood mRNA signatures and concentrations of local and systemic immunological mediators in 131 adults hospitalized with influenza, from whom extensive clinical and investigational data were obtained by MOSAIC investigators. Signatures reflective of interferon-related antiviral pathways were common up to day 4 of symptoms in patients who did not require mechanical ventilator support; in those who needed mechanical ventilation, an inflammatory, activated-neutrophil and cell-stress or death (‘bacterial’) pattern was seen, even early in disease. Identifiable bacterial co-infection was not necessary for this ‘bacterial’ signature but was able to enhance its development while attenuating the early ‘viral’ signature. Our findings emphasize the importance of timing and severity in the interpretation of host responses to acute viral infection and identify specific patterns of immune-system activation that might enable the development of novel diagnostic and therapeutic tools for severe influenza.
Bottle A, Ventura CM, Dharmarajan K, et al., 2018, Regional variation in hospitalisation and mortality in heart failure: comparison of England and Lombardy using multistate modelling, Health Care Management Science, Vol: 21, Pages: 292-304, ISSN: 1386-9620
Heart failure (HF) is a common, serious chronic condition with high morbidity, hospitalisation and mortality. The healthcare systems of England and the northern Italian region of Lombardy share important similarities and have comprehensive hospital administrative databases linked to the death register. We used them to compare admission for HF and mortality for patients between 2006 and 2012 (n = 37,185 for Lombardy, 234,719 for England) with multistate models. Despite close similarities in age, sex and common comorbidities of the two sets of patients, in Lombardy, HF admissions were longer and more frequent per patient than in England, but short- and medium-term mortality was much lower. English patients had more very short stays, but their very elderly also had longer stays than their Lombardy counterparts. Using a three-state model, the predicted total time spent in hospital showed large differences between the countries: women in England spent an average of 24 days if aged 65 at first admission and 19 days if aged 85; in Lombardy these figures were 68 and 27 days respectively. Eight-state models suggested disease progression that appeared similar in each country. Differences by region within England were modest, with London patients spending more time in hospital and having lower mortality than the rest of England. Whilst clinical practice differences plausibly explain these patterns, we cannot confidently disentangle the impact of alternatives such as coding, casemix, and the availability and use of non-hospital settings. We need to better understand the links between rehospitalisation frequency and mortality.
Cecil E, Bottle A, Esmail A, et al., 2018, Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis, BMJ Quality and Safety, Vol: 27, Pages: 965-973, ISSN: 2044-5415
OBJECTIVE: To investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality. BACKGROUND: There is increasing interest in performance monitoring in the NHS. Since 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied. METHODS: We investigated alerts sent to Acute National Health Service hospital trusts in England in 2011-2013. We examined risk-adjusted mortality (relative risk) for all monitored diagnosis and procedure groups at a hospital trust level for 12 months prior to an alert and 23 months post alert. We used an interrupted time series design with a 9-month lag to estimate a trend prior to a mortality alert and the change in trend after, using generalised estimating equations. RESULTS: On average there was a 5% monthly increase in relative risk of mortality during the 12 months prior to an alert (95% CI 4% to 5%). Mortality risk fell, on average by 61% (95% CI 56% to 65%), during the 9-month period immediately following an alert, then levelled to a slow decline, reaching on average the level of expected mortality within 18 months of the alert. CONCLUSIONS: Our results suggest an association between an alert notification and a reduction in the risk of mortality, although with less lag time than expected. It is difficult to determine any causal association. A proportion of alerts may be triggered by random variation alone and subsequent falls could simply reflect regression to the mean. Findings could also indicate that some hospitals are monitoring their own mortality statistics or other performance information, taking action prior to alert notification.
Friebel R, Hauck K, Aylin P, 2018, Centralisation of acute stroke services in London: Impact evaluation using two treatment groups, Health Economics, Vol: 27, Pages: 722-732, ISSN: 1057-9230
The bundling of clinical expertise in centralised treatment centres is considered an effective intervention to improve quality and efficiency of acute stroke care. In 2010, 8 London Trusts were converted into Hyper Acute Stroke Units. The intention was to discontinue acute stroke services in 22 London hospitals. However, in reality, provision of services declined only gradually, and 2 years later, 15% of all patients were still treated in Trusts without a Hyper Acute Stroke Unit. This study evaluates the impact of centralising London's stroke care on 7 process and outcome indicators using a difference-in-difference analysis with two treatment groups, Hyper Acute and discontinued London Trusts, and data on all stroke patients recorded in the hospital episode statistics database from April 2006 to April 2014. The policy resulted in improved thrombolysis treatment and lower rates of pneumonia in acute units. However, 6 indicators worsened in the Trusts that were meant to discontinue services, including deaths within 7 and 30 days, readmissions, brain scan rates, and thrombolysis treatment. The reasons for these results are difficult to uncover and could be related to differences in patient complexity, data recording, or quality of care. The findings highlight that actual implementation of centralisation policies needs careful monitoring and evaluation.
Bottle A, Kim D, Aylin P, et al., 2018, Routes to diagnosis of heart failure: observational study using linked data in England, Heart, Vol: 104, Pages: 600-605, ISSN: 1355-6037
OBJECTIVE: Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management. METHODS: We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis. RESULTS: 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral. CONCLUSIONS: Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.
Friebel R, Hauck KD, Aylin PP, et al., 2018, National trends in emergency readmission rates: A longitudinal analysis of administrative data for England between 2006 and 2016, BMJ Open, Vol: 18, ISSN: 2044-6055
Objective To assess trends in 30-day emergency readmission rates across England over one decade.Design Retrospective study design.Setting 150 non-specialist hospital trusts in England.Participants 23 069 134 patients above 18 years of age who were readmitted following an initial admission (n=62 584 297) between April 2006 and February 2016.Primary and secondary outcomes We examined emergency admissions that occurred within 30 days of discharge from hospital (‘emergency readmissions’) as a measure of healthcare quality. Presented are overall readmission rates, and disaggregated by the nature of the indexed admission, including whether it was elective or emergency, and by clinical health condition recorded. All rates were risk-adjusted for patient age, gender, ethnicity, socioeconomic status, comorbidities and length of stay.Results The average risk-adjusted, 30-day readmission rate increased from 6.56% in 2006/2007 to 6.76% (P<0.01) in 2012/2013, followed by a small decrease to 6.64% (P<0.01) in 2015/2016. Emergency readmissions for patients discharged following elective procedures decreased by 0.13% (P<0.05), whereas those following emergency admission increased by 1.27% (P<0.001). Readmission rates for hip or knee replacements decreased (−1.29%; P<0.001); for acute myocardial infarction (−0.04%; P<0.49), stroke (+0.62%; P<0.05), chronic obstructive pulmonary disease (+0.41%; P<0.05) and heart failure (+0.15%; P<0.05) remained stable; and for pneumonia (+2.72%; P<0.001), diabetes (+7.09%; P<0.001), cholecystectomy (+1.86%; P<0.001) and hysterectomy (+2.54%; P<0.001) increased.Conclusions Overall, emergency readmission rates in England remained relatively stable across the observation period, with trends of slight increases contained post 2012/2013. However, there were large variations in trends across clinical areas, with some experiencing marked increases in readmission rates. This highlights the need t
Aylin P, Benn J, Bottle A, et 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
Furnivall D, Bottle R, Aylin P, 2018, Retrospective analysis of the national impact of industrial action by English junior doctors in 2016, BMJ Open, Vol: 8, ISSN: 2044-6055
Objectives: To examine the impacts of the four episodes of industrial action by English junior doctors in early 2016.Design: Descriptive retrospective study of admitted patient care, accident and emergency (A&E) and outpatient activity in English hospitals.Setting: All hospitals across England.Participants: All patients who attended A&E or outpatient appointments, or those who were admitted to hospital during the three week period surrounding each of the four strikes (January 12th, February 10th, March 9th-10th and April 26th-27th, excluding weekends.)Main outcome measures: Raw numbers and percentage changes of outpatient appointments and cancellations, A&E visits, admitted patients and all in-hospital mortality on strike days compared with patient activity on the same weekday in the weeks before and after the strikes.Results: There were 3.4 million admissions, 27 million outpatient appointments and 3.4 million A&E attendances over the four 3-week periods analysed. Across the four strike days, there were 31,651 fewer admissions (-9.1%), 23,895 fewer A&E attendances (-6.8%) and 173,462 fewer outpatient appointments (-6.0%) than expected. Additionally, 101,109 more outpatient appointments were cancelled by hospitals than expected (+52%). The April 26th-27th strike, where emergency services were also affected, showed the largest impacts on regular service. Mortality did not measurably increase on strike days. Regional analysis showed that services in the Yorkshire and the Humber region were disproportionately more affected by the industrial action. Conclusions: Industrial action by junior doctors during early 2016 caused a significant impact on the provision of healthcare provided by English hospitals. We also observed regional variations in how these strikes affected providers.
Lishman H, Aylin P, Alividza V, et al., 2017, Investigating the burden of antibiotic resistance in ethnic minority groups in high-income countries: protocol for a systematic review and meta-analysis., Systematic Reviews, Vol: 6, ISSN: 2046-4053
Background: Antibiotic resistance (ABR) is an urgent problem globally, with overuse and misuse of antibioticsbeing one of the main drivers of antibiotic-resistant infections. There is increasing evidence that the burden ofcommunity-acquired infections such as urinary tract infections and bloodstream infections (both susceptible andresistant) may differ by ethnicity, although the reasons behind this relationship are not well defined. It has beendemonstrated that socioeconomic status and ethnicity are often highly correlated with each other; however, it isnot yet known whether accounting for deprivation completely explains any discrepancy seen in infection risk. Therehave currently been no systematic reviews summarising the evidence for the relationship between ethnicity andantibiotic resistance or prescribing.Methods: This protocol will outline how we will conduct this systematic literature review and meta-analysisinvestigating whether there is an association between patient ethnicity and (1) risk of antibiotic-resistant infectionsor (2) levels of antibiotic prescribing in high-income countries. We will search PubMed/MEDLINE, EMBASE, GlobalHealth, Scopus and CINAHL using MESH terms where applicable. Two reviewers will conduct title/abstract screening,data extraction and quality assessment independently. The Critical Appraisal Skills Programme (CASP) checklist will beused for cohort and case-control studies, and the Cochrane collaboration’s risk of bias tool will be used for randomisedcontrol trials, if they are included. Meta-analyses will be performed by calculating the minority ethnic group to majorityethnic group odds ratios or risk ratios for each study and presenting an overall pooled odds ratio for the two outcomes.The Grading of Recommendations, Assessments, Development and Evaluation (GRADE) approach will be used to assessthe overall quality of the body of evidence.Discussion: In this systematic review and meta-analysis, we will aim to collate the avail
Ali AM, Loeffler MD, Aylin P, et al., 2017, Correction: Factors Associated With 30-Day Readmission After Primary Total Hip Athroplasty: Analysis of 514455 Procedures in the UK National Health Service, JAMA Surgery, Vol: 152, Pages: 1184-1184, ISSN: 2168-6254
Honeyford K, Greaves F, Aylin P, et al., 2017, Secondary analysis of hospital patient experience scores across England's National Health Service - How much has improved since 2005?, PLoS ONE, Vol: 12, ISSN: 1932-6203
OBJECTIVE: To examine trends in patient experience and consistency between hospital trusts and settings. METHODS: Observational study of publicly available patient experience surveys of three hospital settings (inpatients (IP), accident and emergency (A&E) and outpatients (OP)) of 130 acute NHS hospital trusts in England between 2004/05 and 2014/15. RESULTS: Overall patient experience has been good, showing modest improvements over time across the three hospital settings. Individual questions with the biggest improvement across all three settings are cleanliness (IP: +7.1, A&E: +6.5, OP: +4.7) and information about danger signals (IP: +3.8, A&E: +3.9, OP: +4.0). Trust performance has been consistent over time: 71.5% of trusts ranked in the same cluster for more than five years. There is some consistency across settings, especially between outpatients and inpatients. The lowest-scoring questions, regarding information at discharge, are the same in all years and all settings. CONCLUSIONS: The greatest improvement across all three settings has been for cleanliness, which has seen national policies and targets. Information about danger signals and medication side-effects showed least consistency across settings and scores have remained low over time, despite information about danger signals showing a big increase in score. Patient experience of aspects of access and waiting have declined, as has experience of discharge delay, likely reflecting known increases in pressure on England's NHS.
Ali AM, Loeffler MD, Aylin P, et al., 2017, Factors associated with 30-day readmission after primary total hip arthroplasty: analysis of 514 455 procedures in the UK National Health Service, JAMA Surgery, Vol: 152, Pages: E1-E6, ISSN: 2168-6254
Importance: Thirty-day readmission to hospital after total hip arthroplasty (THA) has significant direct costs and is used as a marker of hospital performance. All-cause readmission is the only metric in current use, and risk factors for surgical readmission and those resulting in return to theater (RTT) are poorly understood. Objective: To determine whether patient-related predictors of all-cause, surgical, and RTT readmission after THA differ and which predictors are most significant. Design, Setting, and Participants: Analysis of all primary THAs recorded in the National Health Service (NHS) Hospital Episode Statistics database from 2006 to 2015. The effect of patient-related factors on 30-day readmission risk was evaluated by multilevel logistic regression analysis. The analysis comprised all acute NHS hospitals in England and all patients receiving primary THA. Main Outcomes and Measures: Thirty-day readmission rate for all-cause, surgical (defined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision primary admission diagnoses), and readmissions resulting in RTT. Results: Across all hospitals, 514 455 procedures were recorded. Seventy-nine percent of patients were older than 60 years, 40.3% were men, and 59.7% were women. There were 30 489 all-cause readmissions (5.9%), 16 499 surgical readmissions (3.2%), and 4286 RTT readmissions (0.8%); 54.1% of readmissions were for surgical causes. Comorbidities with the highest odds ratios (ORs) of RTT included those likely to affect patient behavior: drug abuse (OR, 2.22; 95% CI, 1.34-3.67; P = .002), psychoses (OR, 1.83; 95% CI, 1.16-2.87; P = .009), dementia (OR, 1.57; 95% CI, 1.11-2.22; P = .01), and depression (OR, 1.52; 95% CI, 1.31-1.76; P < .001). Obesity had a strong independent association with RTT (OR, 1.46; 95% CI, 4.45-6.43; P < .001), with one of the highest population
King A, Mullish B, Williams H, et al., 2017, Comparative epidemiology of Clostridium difficile infection in England and the US, International Journal for Quality in Health Care, Vol: 29, Pages: 785-791, ISSN: 1353-4505
Objective: To examine whether there is an epidemiological difference between Clostridium difficile infection (CDI) inpatient populations in England and the United States.Design: A cross-sectional study.Setting: National administrative inpatient discharge data from England (Hospital Episode Statistics) and the United States (National Inpatient Sample) in 2012.Participants: De-identifiable non-obstetric inpatient discharges from the national datasets were used to estimate national CDI incidence in the United States and England using ICD9-CM(008.45) and ICD10(A04.7) respectively. Main outcome measures: The rate of CDI was calculated per 100,000 population using national population estimates. Rate per 100,000 inpatient discharges was also calculated separated by primary and secondary diagnosis of CDI. Age, sex and Elixhauser comorbidities profiles were examined. Results: The US had a higher rate of CDI compared to England: 115.1/100,000 vs. 19.3/100,000 population (p<0.001). CDI age profiles differed between the countries (p<0.001): in England, patients ≥75years constitute a larger proportion of CDI cases, whilst those aged 25-70 constitute more cases in the US(p<0.001). Overall adjusted odds of CDI in females compared to males was elevated in both England (OR1.26 95%CI[1.21,1.31] p<0.001) and the US (OR1.20 95%CI[1.18,1.22] p<0.001). The proportion of CDI patients with comorbidities was greater in the US compared to England apart from dementia, which was greater in England (9.63% vs. 1.25%,p<0.0001).Conclusions: The 2012 inpatient CDI rate within the US was much higher than in England. Age and co-morbidity profiles also differed between CDI patients in both countries. The reasons for this are likely multi-factorial but may reflect national infection control policy.
Bottle A, Dharmarajan K, Aylin P, et al., 2017, COMPARISON OF HOSPITALISATION AND MORTALITY FOR PATIENTS WITH HEART FAILURE IN ENGLAND AND LOMBARDY REGION (NORTHERN ITALY), Publisher: OXFORD UNIV PRESS, Pages: 13-14, ISSN: 1353-4505
Cecil E, Bottle A, Aylin P, 2017, ARE MORTALITY ALERTS ASSOCIATED WITH OTHER INDICATORS OF HOSPITAL QUALITY IN ENGLAND? A NATIONAL CROSS-SECTIONAL STUDY, Publisher: OXFORD UNIV PRESS, Pages: 14-14, ISSN: 1353-4505
Bottle RA, Chase HE, Aylin P, et al., 2017, Does early return to theatre add value to rates of revision at 3 years in assessing surgeon performance for elective hip and knee arthroplasty? A national observational study, BMJ Quality & Safety, Vol: 27, Pages: 373-379, ISSN: 2044-5423
Background Joint replacement revision is the most widely used long-term outcome measure in elective hip and knee surgery. Return to theatre (RTT) has been proposed as an additional outcome measure, but how it compares with revision in its statistical performance is unknown.Methods National hospital administrative data for England were used to compare RTT at 90 days (RTT90) with revision rates within 3 years by surgeon. Standard power calculations were run for different scenarios. Funnel plots were used to count the number of surgeons with unusually high or low rates.Results From 2006 to 2011, there were 297 650 hip replacements (HRs) among 2952 surgeons and 341 226 knee replacements (KRs) among 2343 surgeons. RTT90 rates were 2.1% for HR and 1.5% for KR; 3-year revision rates were 2.1% for HR and 2.2% for KR. Statistical power to detect surgeons with poor performance on either metric was particularly low for surgeons performing 50 cases per year for the 5 years. The correlation between the risk-adjusted surgeon-level rates for the two outcomes was +0.51 for HR and +0.20 for KR, both p<0.001. There was little agreement between the measures regarding which surgeons had significantly high or low rates.Conclusion RTT90 appears to provide useful and complementary information on surgeon performance and should be considered alongside revision rates, but low case loads considerably reduce the power to detect unusual performance on either metric.
Balinskaite V, Bottle R, Sodhi V, et al., 2017, The risk of adverse pregnancy outcomes following non-obstetric surgery during pregnancy. Estimates from a retrospective cohort study of 6.5 million pregnancies, Annals of Surgery, Vol: 266, Pages: 260-266, ISSN: 1528-1140
Objective. To estimate the risk of adverse birth outcomes for women who underwent non-obstetric surgery during pregnancy compared with those who did not. Background. Previous research suggests that non-obstetric surgery occurs during 1%-2% of pregnancies. However, there is limited evidence quantifying risks to the mother or pregnancy of such surgery. Methods. We examined maternity admissions using hospital administrative data collected between 1st April 2002 and 31st March 2012 and identified pregnancies where non-obstetric surgery occurred. We used logistic regression models to determine the adjusted relative risk, attributable risk and number needed to harm of non-obstetric surgical procedures for adverse birth outcomes.Results. We identified 6,486,280 pregnancies. In 47,628 of these pregnancies, non-obstetric surgery had occurred. We found that non-obstetric surgery during pregnancy was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that every 287 surgical operations were associated with one additional stillbirth, every 31 operations associated with one additional preterm delivery, every 39 operations associated with one additional low birth weight baby, every 25 operations associated with one additional caesarean section, and every 50 operations associated with one additional long inpatient stay.Conclusions. Although we have no means of disentangling the effect of the surgery from the effect of the underlying condition, we found that the risk associated with non-obstetric surgery was relatively low, confirming that surgical procedures during pregnancy are generally safe. We believe that our findings improve upon previous research, and are useful reference points for any discussion of risk with prospective patients.
Nouraei SAR, Allen J, Kaddour H, et al., 2017, Vocal palsy increases the risk of lower respiratory tract infection in low-risk, low-morbidity patients undergoing thyroidectomy for benign disease: A big data analysis., Clinical Otolaryngology, Vol: 42, Pages: 1259-1266, ISSN: 1749-4478
OBJECTIVES: Thyroidectomy is the commonest operation that places normally functioning laryngeal nerves at risk of injury. Vocal palsy is a major risk factor for dysphonia, dysphagia, and less commonly, airway obstruction. We investigated the association between post-thyroidectomy vocal palsy and long-term risks of pneumonia and laryngeal failure. DESIGN: An N=near-all analysis of the English administrative dataset using a previously validated informatics algorithm to identify young and otherwise low-risk patients undergoing first-time elective thyroidectomy for benign disease. Information about age, sex, morbidities, social deprivation and post-operative and late complications were derived. MAIN OUTCOME MEASURES: Between 2004 and 2012, 43 515 patients between the ages of 20 and 69 who had no history of cancer, neurological, or respiratory disease underwent elective total or hemithyroidectomy without concomitant or late neck dissection, parathyroidectomy or laryngotracheal surgery for benign thyroid disease for the first and only time. Information about age, sex, morbidities and in-hospital and late complications was recorded. RESULTS: Mean age at surgery was 46±12. There was a strong female preponderance (85%), and most patients (89%) had no recorded Charlson comorbidities Most patients (65%) underwent hemithyroidectomy. Late vocal palsy was recorded in 449 (1.03%) patients, and its occurrence was an independent risk factor for emergency hospital readmission (n=7113; Hazard Ratio 1.52; 95% confidence interval 1.21-1.91), hospitalisation for lower respiratory tract infection (n=944; HR 2.04; 95% CI 1.07-3.75), dysphagia (n=564; HR 3.47; 95% CI 1.57-7.65) and gastrostomy/tracheostomy placement (n=80; HR 20.8; 95% CI 2.5-171.2). Independent risk factors for late vocal palsy were age, burden of morbidities, total thyroidectomy, post operative bleeding, male sex, and annual surgeon volume <30. CONCLUSIONS: There is a significant association between post-th
Rao AM, jones A, Bottle R, et al., 2017, A retrospective cohort study of high-impact users among patients with cerebrovascular conditions, BMJ Open, Vol: 7, ISSN: 2044-6055
ObjectiveTo apply group-based trajectory modelling (GBTM) to the hospital administrative data to evaluate, model and visualise trends and changes in the frequency of long-term hospital care use of the subgroups of patients with cerebrovascular conditions.DesignA retrospective cohort study of patients with cerebrovascular conditions.SettingsSecondary care of all patients with cerebrovascular conditions admitted to English National Hospital Service hospitals.ParticipantsAll patients with cerebrovascular conditions identified through national administrative data (Hospital Episode Statistics) and subsequent emergency hospital admissions followed up for 4 years.Main outcome measureAnnual number of emergency hospital readmissions.ResultsGBTM model classified patients with intracranial haemorrhage (n=2605) into five subgroups, whereas ischaemic stroke (n=34208) and transientischaemic attack (TIA) (n=20549) patients were shown to have two conventional groups, low and high impact. The covariates with significant association with high-impact users (17.1%) among ischaemic stroke were epilepsy (OR 2.29), previous stroke (OR 2.18), anxiety/depression (OR 1.63), procedural complication (OR 1.43), admission to intensive therapy unit (ITU) or high dependency unit (HDU) (OR 1.42), comorbidity score (OR 1.36), urinary tract infections (OR 1.32), vision loss (OR 1.32), chest infections (OR 1.25), living alone (OR 1.25), diabetes (OR 1.23), socioeconomic index (OR 1.20), older age (OR 1.03) and prolonged length of stay (OR 1.00). The covariates associated with high-impact users among TIA (20.0%) were thromboembolic event (OR 3.67), previous stroke (OR 2.51), epilepsy (OR 2.25), hypotension (OR 1.86), anxiety/depression (OR 1.63), amnesia (OR 1.62), diabetes (OR 1.58), anaemia (OR 1.55), comorbidity score (OR 1.39), atrial fibrillation (OR 1.27), living alone (OR 1.25), socioeconomic index (OR 1.13), older age (OR 1.04) and prolonged length of stay (OR 1.02). The high-impact users (0.5%
Honeyford CE, Bell D, Aylin P, et al., 2017, The relation between length of stay, a&e attendance and readmission for heart failure patients, Heart, Vol: 103, Pages: A3-A3, ISSN: 1355-6037
Rao AM, Bottle R, Darzi A, et al., 2017, Sequence analysis of long-term readmissions among high-impact users of cerebrovascular patients, Stroke Research and Treatment, Vol: 2017, ISSN: 2090-8105
Objective. Understanding the chronological order of the causes of readmissions may help us assess any repeated chain of events among high-impact users, those with high readmission rate. We aim to perform sequence analysis of administrative data to identify distinct sequences of emergency readmissions among the high-impact users. Methods. A retrospective cohort of all cerebrovascular patients identified through national administrative data and followed for 4 years. Results. Common discriminating subsequences in chronic high-impact users () of ischaemic stroke () were “urological conditions-chest infection,” “chest infection-urological conditions,” “injury-urological conditions,” “chest infection-ambulatory condition,” and “ambulatory condition-chest infection” (). Among TIA patients (), common discriminating () subsequences among chronic high-impact users were “injury-urological conditions,” “urological conditions-chest infection,” “urological conditions-injury,” “ambulatory condition-urological conditions,” and “ambulatory condition-chest infection.” Among the chronic high-impact group of intracranial haemorrhage () common discriminating subsequences () were “dementia-injury,” “chest infection-dementia,” “dementia-dementia-injury,” “dementia-urine infection,” and “injury-urine infection.” Conclusion. Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.
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