365 results found
Blackwell J, Saxena S, Petersen I, et al., 2021, Depression in individuals who subsequently develop inflammatory bowel disease: a population-based nested case-control study, GUT, Vol: 70, Pages: 1642-1648, ISSN: 0017-5749
Roshanghalb A, Mazzali C, Lettieri E, et al., 2021, Stability over time of the "hospital effect" on 30-day unplanned readmissions: Evidence from administrative data., Health Policy
Past studies showed that hospital characteristics affect hospital performance in terms of 30-day unplanned readmissions, proving the existence of a "hospital effect". However, the stability over time of this effect has been under-investigated. This study offers new evidence about the stability over time of the hospital effect on 30-day unplanned readmissions. Using 78,907 heart failure (HF) records collected from 116 hospitals in the Lombardy Region (Northern Italy) over three years (2010-2012), this study analysed hospital performance in terms of 30-day unplanned readmissions. Hospitals with unusually high and low readmission rates were identified through multi-level regression that combined both patient and hospital covariates in each year. Our results confirm that although hospital covariates - and the connected managerial choices - affect the 30-day unplanned readmissions of a specific year, their effect is not stable in the short-term (3 years). This has important implications for pay-for-performance schemes and quality improvement initiatives.
Axson E, Bottle R, Cowie M, et al., 2021, The relationship between heart failure and the risk of acute exacerbation of COPD, Thorax, Vol: 76, Pages: 807-814, ISSN: 0040-6376
Rationale: Heart failure (HF) management in chronic obstructive pulmonary disease (COPD) is often delayed or suboptimal.Objectives: To examine the effect of HF and HF medication use on moderate-to-severe COPD exacerbations.Methods and Measurements: Retrospective cohort studies from 2006-2016 using nationally-representative English primary care electronic healthcare records linked to national hospital and mortality data. COPD patients with diagnosed and possible HF were identified. Possible HF defined as continuous loop diuretic use in the absence of a non-cardiac indication. Incident exposure to HF medications was defined as ≥2 prescriptions within 90 days with no gaps >90 days during ≤6 months of continuous use; prevalent exposure as 6+ months continuous use. HF medications investigated were angiotensin receptor blockers, angiotensin converting enzyme inhibitors, beta-blockers, loop diuretics, and mineralocorticoid receptor antagonists. Cox regression, stratified on sex and age; further adjusted for patient characteristics, was used to determine the association of HF on exacerbation risk.Main Results: 86,795 COPD patients were categorized as; no evidence of HF (n=60,047); possible HF (n=8,476); newly diagnosed HF (n=2,066). Newly diagnosed HF (adjusted hazard ratio (aHR): 1.45, 95% confidence interval (CI): 1.30, 1.62) and possible HF (aHR: 1.65, 95%CI: 1.58, 1.72) similarly increased exacerbation risk. Incident and prevalent use of all HF medications were associated with increased exacerbation risk. Prevalent use was associated with reduced exacerbation risk compared with incident use.Conclusions: Earlier opportunities to improve diagnosis and management of HF in the COPD population are missed. Managing HF may reduce exacerbation risk in the longer term.
Coughlan CH, Ruzangi J, Neale FK, et al., 2021, Social and ethnic group differences in healthcare use by children aged 0-14 years: a population-based cohort study in England from 2007 to 2017., Archives of Disease in Childhood, ISSN: 0003-9888
OBJECTIVE: To describe social and ethnic group differences in children's use of healthcare services in England, from 2007 to 2017. DESIGN: Population-based retrospective cohort study. SETTING/PATIENTS: We performed individual-level linkage of electronic health records from general practices and hospitals in England by creating an open cohort linking data from the Clinical Practice Research Datalink and Hospital Episode Statistics. 1 484 455 children aged 0-14 years were assigned to five composite ethnic groups and five ordered groups based on postcode mapped to index of multiple deprivation. MAIN OUTCOME MEASURES: Age-standardised annual general practitioner (GP) consultation, outpatient attendance, emergency department (ED) visit and emergency and elective hospital admission rates per 1000 child-years. RESULTS: In 2016/2017, children from the most deprived group had fewer GP consultations (1765 vs 1854 per 1000 child-years) and outpatient attendances than children in the least deprived group (705 vs 741 per 1000 child-years). At the end of the study period, children from the most deprived group had more ED visits (447 vs 314 per 1000 child-years) and emergency admissions (100 vs 76 per 1000 child-years) than children from the least deprived group.In 2016/2017, children from black and Asian ethnic groups had more GP consultations than children from white ethnic groups (1961 and 2397 vs 1824 per 1000 child-years, respectively). However, outpatient attendances were lower in children from black ethnic groups than in children from white ethnic groups (732 vs 809 per 1000 child-years). By 2016/2017, there were no differences in outpatient, ED and in-patient activity between children from white and Asian ethnic groups. CONCLUSIONS: Between 2007 and 2017, children living in more deprived areas of England made greater use of emergency services and received less scheduled care than children from affluent neighbourhoods. Children from Asian and black ethnic grou
Bottle A, Faitna P, Aylin PP, 2021, Patient-level and hospital-level variation and related time trends in COVID-19 case fatality rates during the first pandemic wave in England: multilevel modelling analysis of routine data., BMJ Qual Saf
BACKGROUND: A report suggesting large between-hospital variations in mortality after admission for COVID-19 in England attracted much media attention but used crude rates. We aimed to quantify these variations between hospitals and over time during England's first wave (March to July 2020) and assess available patient-level and hospital-level predictors to explain those variations. METHODS: We used administrative data for England, augmented by hospital-level information. Admissions were extracted with COVID-19 codes. In-hospital death was the primary outcome. Risk-adjusted mortality ratios (standardised mortality ratios) and interhospital variation were calculated using multilevel logistic regression. Early-wave (March to April) and late-wave (May to July) periods were compared. RESULTS: 74 781 admissions had a primary diagnosis of COVID-19, with 21 984 in-hospital deaths (29.4%); the 30-day total mortality rate was 28.8%. The crude in-hospital death rate fell in all ages and overall from 32.9% in March to 13.4% in July. Patient-level predictors included age, male gender, non-white ethnic group (early period only) and several comorbidities (obesity early period only). The only significant hospital-level predictor was daily COVID-19 admissions in the late period; we did not find a relation with staff absences for COVID-19, mechanical ventilation bed occupancies, total bed occupancies or bed occupancies for COVID-19 admissions in either period. Just 4 (3%) and 2 (2%) hospitals were high, and 5 (4%) and 0 hospitals were low funnel plot mortality outliers at 3 SD for early and late periods, respectively, after risk adjustment. We found no strong correlation between early and late hospital-level mortality (r=0.17, p=0.06). CONCLUSIONS: There was modest variation in mortality following admission for COVID-19 between English hospitals after adjustment for risk and random variation, in marked contrast to early media reports. Early-period mortality did not pred
Deputy M, Rao C, Worley G, et al., 2021, Effect of the SARS-CoV-2 pandemic on mortality related to high-risk emergency and major elective surgery, BRITISH JOURNAL OF SURGERY, Vol: 108, Pages: 754-759, ISSN: 0007-1323
Cecil E, Bottle A, Majeed A, et 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.
Balinskaite V, Aylin P, Bottle R, 2021, Assessing the impact of a shadowing programme on in-hospital mortality following trainee doctors’ changeover, BMC Health Services Research, Vol: 21, Pages: 1-7, ISSN: 1472-6963
BackgroundTo assess the impact on seven-day in-hospital mortality following the introduction in 2012 of a shadowing programme for new UK medical graduates requiring them to observe the doctor they are replacing for at least 4 days before starting work.MethodsData on emergency admissions were derived from Hospital Episode Statistics between 2003 and 2019. A generalised estimating equation model was used to examine whether the introduction of the programme was associated with a change in mortality.ResultsThere were 644,018 emergency admissions, of which 1.8% (7612) ended in death in hospital within a week following the admission. Throughout the study period, there was an annual increase in the number of emergency admissions during July and August, though in-hospital mortality rates declined. The generalised estimating equation analysis found no significant change in the odds of death within 7 days after admission for patients admitted on the first Wednesday in August compared with patients admitted on the last Wednesday in July (OR = 1.03, 95% CI 0.94–1.13, p = 0.53). Furthermore, there was no significant change observed for any clinical diagnosis category following the introduction of the shadowing programme.ConclusionThere was a rising trend in the number of emergency admissions over the study period, though mortality was decreasing. We found no significant association between the introduction of shadowing programme and in-hospital mortality; however, lack of power means that we cannot rule out a small effect on mortality. There are other outcomes that might have changed but were not examined in this study.
Rao A, Razzaq H, Panamarenko B, et al., 2021, Online application for self-referral of the patients with breast symptoms, Annals of Medicine and Surgery, Vol: 66, ISSN: 2049-0801
IntroductionThe study aimed to devise a self-referral mobile/web application for patients with new breast symptoms, giving them an outcome, thus bypassing the need for primary care consultation.MethodsThe online application was designed on the automated algorithm based on evidence-based guidelines for referral to breast onco-plastic units. A retrospective questionnaire-based anonymous survey was carried out at the breast unit in Southend University Hospital (January 2019 to March 2020). The outcome of the patients was recorded, the same data was entered in the software and its outcome was compared with their clinic outcome to assess and validate the software. Chi-square and t-test were used in formulating results.ResultsData was collected for 366 patients who were referred urgently to the clinic. Only 50.5% (n = 186) were appropriately referred, with the main complaint being breast lump (94.1%). 39.6% of referred patients did not require a secondary care referral. Sensitivity and specificity for identifying patients requiring urgent referral was 100% and 98%, respectively.ConclusionA significant number of urgent referrals to breast units do not require urgent specialist referral, and this results in a big strain on the hospital service. The discussed self-referral pathway is a promising alternative with the potential to reduce workload in primary and secondary care and improve patient satisfaction.
Blackwell J, Alexakis C, Saxena S, et al., 2021, The association between antidepressant medication use and steroid dependency in patients with ulcerative colitis: a population-based study, BMJ Open Gastroenterology, Vol: 8, ISSN: 2054-4774
Background: Animal studies indicate a potential protective role of antidepressant medication (ADM) in models of colitis but the effect of their use in humans with ulcerative colitis (UC) remains unclear. Objective: To study the relationship between ADM use and corticosteroid dependency in UC. Design: Using the Clinical Practice Research Datalink we identified patients diagnosed with UC between 2005-2016. We grouped patients according to serotonin selective reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) exposure in the 3 years following diagnosis: 'continuous users', 'intermittent users' and 'non users'. We used logistic regression to estimate the adjusted risk of corticosteroid dependency between ADM exposure groups. Results: We identified 6373 patients with UC. 5,230 (82%) use no ADMs, 627 (10%) were intermittent SSRI users and 282 (4%) were continuous SSRI users, 246 (4%) were intermittent TCA users and 63 (1%) were continuous TCA users. Corticosteroid dependency was more frequent in continuous SSRI and TCA users compared with non-users (19% vs. 24% vs. 14%, respectively, χ2 p=0.002). Intermittent SSRI and TCA users had similar risks of developing corticosteroid dependency to non-users (SSRI: OR 1.19, 95%CI 0.95-1.50, TCA: OR 1.14, CI 0.78-1.66). Continuous users of both SSRIs and TCAs had significantly higher risks of corticosteroid dependency compared to non-users (SSRI: OR 1.62, CI 1.15-2.27, TCA: OR 2.02, CI 1.07-3.81). Conclusions: Continuous ADM exposure has no protective effect in routine clinical practice in UC and identifies a population of patients requiring more intensive medical therapy. ADM use is a flag for potentially worse clinical outcomes in UC.
Bottle R, Faitna P, Aylin P, et al., 2021, Five-year outcomes following left ventricular assist device implantation in England, Open Heart, Vol: 8, Pages: 1-6, ISSN: 2053-3624
Objective Implant rates of mechanical circulatory supports such as left ventricular assist devices (LVAD) have steadily increased in the last decade. We assessed the utility of administrative data to provide information on hospital use and outcomes.Methods Using 2 years of national hospital administrative data for England linked to the death register, we identified all patients with an LVAD and extracted hospital activity for 5 years before and after the LVAD implantation date.Results In the two index years April 2011 to March 2013, 157 patients had an LVAD implanted. The mean age was 50.9 (SD 15.4), and 78.3% were men. After 5 years, 92 (58.6%) had died; the recorded cause of death was noncardiovascular in 67.4%. 42 (26.8%) patients received a heart±lung transplantation. Compared with the 12 months before implantation, the 12 months after but not including the month of implantation saw falls in total inpatient and day case admissions, a fall in admissions for heart failure (HF), a rise in non-HF admissions, a fall in emergency department visits not ending in admission and a rise in outpatient appointments (all per patient at risk). Postimplantation complications were common in the subsequent 5 years: 26.1% had a stroke, 23.6% had a device infection and 13.4% had a new LVAD implanted.Conclusions Despite patients’ young age, their mortality is high and their hospital use and complications are common in the 5 years following LVAD implantation. Administrative data provide important information on resource use in this patient group.
Bottle A, Faitna P, Aylin P, et al., 2021, Five-year survival and use of hospital services following ICD and CRT implantation: comparing real-world data with RCTs, ESC HEART FAILURE, Vol: 8, Pages: 2438-2447, ISSN: 2055-5822
Christen P, D'Aeth J, Lochen A, et al., 2021, The J-IDEA pandemic planner: a framework for implementing hospital provision interventions during the COVID-19 pandemic, Medical Care, Vol: 59, Pages: 371-378, ISSN: 0025-7079
Background : Planning for extreme surges in demand for hospital care of patientsrequiring urgent life-saving treatment for COVID-19, whilst retaining capacity for otheremergency conditions, is one of the most challenging tasks faced by healthcareproviders and policymakers during the pandemic. Health systems must be wellpreparedto cope with large and sudden changes in demand by implementinginterventions to ensure adequate access to care. We developed the first planning toolfor the COVID-19 pandemic to account for how hospital provision interventions (suchas cancelling elective surgery, setting up field hospitals, or hiring retired staff) will affectthe capacity of hospitals to provide life-saving care.Methods : We conducted a review of interventions implemented or considered in 12 European countries in March-April 2020, an evaluation of their impact on capacity, anda review of key parameters in the care of COVID-19 patients. This information wasused to develop a planner capable of estimating the impact of specific interventions ondoctors, nurses, beds and respiratory support equipment. We applied this to ascenario-based case study of one intervention, the set-up of field hospitals in England,under varying levels of COVID-19 patients.Results : The J-IDEA pandemic planner is a hospital planning tool that allows hospitaladministrators, policymakers and other decision-makers to calculate the amount ofcapacity in terms of beds, staff and crucial medical equipment obtained byimplementing the interventions. Flexible assumptions on baseline capacity, the numberof hospitalisations, staff-to-beds ratios, and staff absences due to COVID-19 make theplanner adaptable to multiple settings. The results of the case study show that whilefield hospitals alleviate the burden on the number of beds available, this intervention isfutile unless the deficit of critical care nurses is addressed first.Discussion : The tool supports decision-makers in delivering a fast and effectiveresponse to
Quint JK, Bottle A, 2021, The Role of Individual and Neighborhood Factors on Racial Disparity in Respiratory Outcomes Won't You Be My Neighbor?, AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, Vol: 203, Pages: 939-940, ISSN: 1073-449X
Vamos EP, Lai H, Sharabiani M, et al., 2021, 20-year trajectories of cardiometabolic factors among patients with type 2 diabetes before diagnosis of dementia in England, DUK, Publisher: WILEY, ISSN: 0742-3071
Arhi C, Askari A, Nachiappan S, et al., 2021, Stage at Diagnosis and Survival of Colorectal Cancer With or Without Underlying Inflammatory Bowel Disease: A Population-based Study, JOURNAL OF CROHNS & COLITIS, Vol: 15, Pages: 375-382, ISSN: 1873-9946
Bottle A, Quint J, 2021, COPD: still an unpredictable journey, EUROPEAN RESPIRATORY JOURNAL, Vol: 57, ISSN: 0903-1936
Ali AM, Loeffler MD, Aylin P, et al., 2021, Timing of Readmissions After Elective Total Hip and Knee Arthroplasty: Does a 30-Day All-Cause Rate Capture Surgically Relevant Readmissions?, JOURNAL OF ARTHROPLASTY, Vol: 36, Pages: 728-733, ISSN: 0883-5403
Blackwell J, Saxena S, Jayasooriya N, et al., 2021, Prevalence and duration of gastrointestinal symptoms before diagnosis of Inflammatory Bowel Disease and predictors of timely specialist review: a population-based study, Journal of Crohn's and Colitis, Vol: 15, Pages: 203-211, ISSN: 1873-9946
Background and AimsLack of timely referral and significant waits for specialist review amongst individuals with unresolved gastrointestinal (GI) symptoms can result in delayed diagnosis of Inflammatory Bowel Disease (IBD).AimsTo determine the frequency and duration of GI symptoms and predictors of timely specialist review before the diagnosis of both Crohn’s Disease (CD) and ulcerative colitis (UC).MethodsCase-control study of IBD matched 1:4 for age and sex to controls without IBD using the Clinical Practice Research Datalink from 1998-2016.ResultsWe identified 19,555 cases of IBD, and 78,114 controls. 1 in 4 cases of IBD reported gastrointestinal symptoms to their primary care physician more than 6 months before receiving a diagnosis. There is a significant excess prevalence of GI symptoms in each of the 10 years before IBD diagnosis. GI symptoms were reported by 9.6% and 10.4% at 5 years before CD and UC diagnosis respectively compared to 5.8% of controls. Amongst patients later diagnosed with IBD, <50% received specialist review within 18 months from presenting with chronic GI symptoms. Patients with a previous diagnosis of irritable bowel syndrome or depression were less likely to receive timely specialist review (IBS: HR=0.77, 95%CI 0.60-0.99, depression: HR=0.77, 95%CI 0.60-0.98).ConclusionsThere is an excess of GI symptoms 5 years before diagnosis of IBD compared to the background population which are likely attributable to undiagnosed disease. Previous diagnoses of IBS and depression are associated with delays in specialist review. Enhanced pathways are needed to accelerate specialist referral and timely IBD diagnosis.
Greenfield G, Blair M, Aylin P, et al., 2021, Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data, Emergency Medicine Journal, Vol: 38, Pages: 146-150, ISSN: 1472-0205
BACKGROUND:Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs. AIM:To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals. METHOD:We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups. RESULTS:One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively). CONCLUSION:One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.
Dewa L, Crandell C, Choong E, et al., 2021, CCopeY: a mixed-methods co-produced study on the mental health status and coping strategies of young people during COVID-19 UK lockdown, Journal of Adolescent Health, ISSN: 1054-139X
PurposeExploring the impact of COVID-19 pandemic on young people’s mental health is an increasing priority. Studies to date are largely surveys and lack meaningful involvement from service users in their design, planning and delivery. The study aimed to examine the mental health status and coping strategies of young people during the first UK COVID-19 lockdown using co-production methodology.MethodsThe mental health status of young people (aged 16-24) in April 2020 was established utilising a sequential explanatory co-produced mixed methods design. Factors associated with poor mental health status including coping strategies were also examined using an online survey and semi-structured interviews.Results30.3% had poor mental health and 10.8% had self-harmed since lockdown. Young people identifying as Black/Black-British ethnicity had the highest increased odds of experiencing poor mental health (odds ratio [OR] 3.688, 95% CI 0.54-25.40). Behavioural disengagement (OR 1.462, 95% CI 1.22-1.76), self-blame (OR 1.307 95% CI 1.10-1.55), and substance use (OR 1.211 95% CI 1.02-1.44) coping strategies, negative affect (OR 1.109, 95% CI 1.07-1.15), sleep problems (OR 0.915 95% CI 0.88-0.95) and conscientiousness personality trait (OR 0.819 95% CI 0.69-0.98) were significantly associated with poor mental health. Three qualitative themes were identified: (1) pre-existing/developed helpful coping strategies employed, (2) mental health difficulties worsened and (3) mental health and non-mental health support needed during and after lockdown.ConclusionPoor mental health is associated with dysfunctional coping strategies. Innovative coping strategies can help other young people cope during and after lockdowns, with digital and school promotion and application.
Blackwell J, Saxena S, Jayasooriya N, et al., 2020, Stoma Formation in Crohn's Disease and the Likelihood of Antidepressant Use: A Population-Based Cohort Study., Clin Gastroenterol Hepatol
BACKGROUND & AIMS: The impact of a temporary or permanent stoma on mental health in Crohn's Disease (CD) is unknown. The aim was to examine the association between intestinal surgery and stoma formation and subsequent antidepressant medication (ADM) use. METHODS: Using the Clinical Practice Research Datalink, we identified individuals with CD who underwent intestinal surgery between 1998-2018. We excluded individuals with a prescription for an ADM in the 6 months before surgery. Individuals were stratified into three groups: no stoma, temporary stoma, and permanent stoma. We used Kaplan-Meier curves to examine initiation of ADM after intestinal surgery and Cox regression to identify risk factors for ADM use after intestinal surgery. RESULTS: We identified 1,272 cases of CD undergoing their first intestinal surgery. Of these, 871 (68.5%) had no stoma, 191 (15.0%) had a temporary stoma and 210 (16.5%) had a permanent stoma. The 10-year cumulative incidence of ADM use was 26.4%, 33.4% and 37.3% respectively. Individuals with a permanent stoma were 71% more likely to receive an ADM than those with no stoma (HR 1.71, 95% CI 1.20-2.44). Individuals with a temporary stoma reversed within 12 months had a similar likelihood of ADM use to those without stoma formation (HR 0.99, 95% CI 0.64-1.53) whereas temporary stoma formation with late reversal after 12 months was associated with significantly greater likelihood of ADM use (HR 1.85, 95% CI 1.15-2.96). CONCLUSIONS: Permanent stomas and temporary stomas with late reversal surgery are associated with increased ADM use after intestinal surgery, likely associated with increased anxiety and depression.
Bottle R, Griffiths R, White S, et al., 2020, Periprosthetic fractures: the next fragility fracture epidemic? A national observational study, BMJ Open, Vol: 10, ISSN: 2044-6055
Objectives Periprosthetic fractures have considerable clinical implications for patients and financial implications for healthcare systems. This study aims to determine the burden of periprosthetic fractures of the lower and upper limbs in England and identify any factors associated with differences in treatment and outcome.Design A national, observational study.Setting England.Participants All individuals admitted to hospital with periprosthetic fractures between 1 April 2015 and 31 December 2018.Primary and secondary outcome measures Mortality, length of stay, change in rate of admissions.Methods We analysed Hospital Episode Statistics data using the International Classification of Diseases 10th Revision code M96.6 (Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate) to identify periprosthetic fractures recorded between April 2013 and December 2018. We determined the demographics, procedures performed, mortality rates and discharge destinations. Patient characteristics associated with having a procedure during the index admission were estimated using logistic regression. The annual rate of increase in admissions was estimated using Poisson regression.Results Between 1 April 2015 and 31 December 2018, there were 13 565 patients who had 18 888 admissions (89.5% emergency) with M96.6 in the primary diagnosis field. There was a 13% year-on-year increase in admissions for periprosthetic fracture in England during that period. Older people, people living in deprived areas and those with heart failure or neurological disorders were less likely to receive an operation. 14.4% of patients did not return home after hospital discharge. The overall inpatient mortality was 4.3% and total 30-day mortality was 3.3%.Conclusions The clinical and operational burden of periprosthetic fractures is considerable and increasing rapidly. We suggest that the management of people with periprosthetic fractures should be undertaken and f
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 JOURNAL OF SURGERY, Vol: 45, Pages: 347-355, ISSN: 0364-2313
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
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
Ma R, Cecil E, Bottle A, et 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
Ma R, Cecil E, French R, et al., 2020, Impact of financial incentives for primary care to give long acting reversible contraceptive advice, Publisher: OXFORD UNIV PRESS, ISSN: 1101-1262
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
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.
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