Publications
62 results found
Boyle JM, Kuryba A, Cowling TE, et al., 2020, Determinants of Variation in the Use of Adjuvant Chemotherapy for Stage III Colon Cancer in England, CLINICAL ONCOLOGY, Vol: 32, Pages: E135-E144, ISSN: 0936-6555
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- Citations: 8
Nossiter J, Sujenthiran A, Cowling TE, et al., 2020, Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England, JOURNAL OF CLINICAL ONCOLOGY, Vol: 38, Pages: 744-+, ISSN: 0732-183X
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- Citations: 12
Parry MG, Cowling TE, Sujenthiran A, et al., 2019, Identifying skeletal-related events for prostate cancer patients in routinely collected hospital data, CANCER EPIDEMIOLOGY, Vol: 63, ISSN: 1877-7821
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- Citations: 8
Cowling TE, Cromwell DA, Sharples LD, et al., 2019, Protocol for an observational study evaluating new approaches to modelling diagnostic information from large administrative hospital datasets
<jats:title>Abstract</jats:title><jats:sec><jats:title>Introduction</jats:title><jats:p>The Charlson and Elixhauser indices define sets of conditions used to adjust for patients’ comorbidities in administrative hospital data. A strength of these indices is the parsimony that results from including only 19 and 30 conditions respectively, but the conditions included may not be the ones most relevant to a specific outcome and population. Our objectives are to: (1) test an approach to developing parsimonious indices for the specific outcome and populations being studied, while comparing performance to the Charlson and Elixhauser indices; and (2) evaluate several approaches that involve models with more diagnosis-related terms and aim to improve prediction performance by capturing more of the information in large datasets.</jats:p></jats:sec><jats:sec><jats:title>Methods and analysis</jats:title><jats:p>This is a modelling study using a linked national dataset of administrative hospital records and death records. The study populations are patients admitted to hospital for acute myocardial infarction, hip fracture, or major surgery for colorectal cancer in England between 1 January 2015 and 31 December 2017. The outcome is death within 365 days of the date of admission (acute myocardial infarction and hip fracture) or procedure (colorectal surgery). In the ‘First analysis’, prognostic indices will be developed based on the presence/absence of individual ICD-10 codes in patients’ medical histories. Logistic regression will be used to estimate associations with a full set of sociodemographic and diagnostic predictors from which reduced models (with fewer diagnostic predictors) will be produced using a step-down approach. In the ‘Second analysis’, models will also account for the timing that each ICD-10 code was last recorded and allow for non-linear relationships and
Parry MG, Sujenthiran A, Cowling TE, et al., 2019, Treatment-Related Toxicity Using Prostate-Only Versus Prostate and Pelvic Lymph Node Intensity-Modulated Radiation Therapy: A National Population-Based Study, JOURNAL OF CLINICAL ONCOLOGY, Vol: 37, Pages: 1828-+, ISSN: 0732-183X
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- Citations: 13
Parry MG, Sujenthiran A, Cowling TE, et al., 2019, Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England, INTERNATIONAL JOURNAL OF CANCER, Vol: 145, Pages: 40-48, ISSN: 0020-7136
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- Citations: 15
Wallace D, Walker K, Charman S, et al., 2019, Assessing the Impact of Suboptimal Donor Characteristics on Mortality After Liver Transplantation: A Time-dependent Analysis Comparing HCC With Non-HCC Patients, TRANSPLANTATION, Vol: 103, Pages: E89-E98, ISSN: 0041-1337
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- Citations: 15
Parry MG, Sujenthiran A, Cowling TE, et al., 2019, Imputation of missing prostate cancer stage in English cancer registry data based on clinical assumptions, CANCER EPIDEMIOLOGY, Vol: 58, Pages: 44-51, ISSN: 1877-7821
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- Citations: 10
Baier N, Geissler A, Bech M, et al., 2019, Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms, HEALTH POLICY, Vol: 123, Pages: 1-10, ISSN: 0168-8510
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- Citations: 45
Hayhoe BWJ, Cowling T, Pillutla V, et al., 2018, Integrating a nationally scaled workforce of community health workers in primary care: a modelling study, Journal of the Royal Society of Medicine, Vol: 111, Pages: 453-461, ISSN: 1758-1095
ObjectiveTo model cost and benefit of a national community health worker workforce.DesignModelling exercise based on all general practices in England.SettingUnited Kingdom National Health Service Primary Care.ParticipantsNot applicable.Data sourcesPublicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake.Main outcome measuresWe estimated numbers of community health workers needed, anticipated workload and likely benefits to patients.ResultsConservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.ConclusionA scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.
Majeed FA, Harris M, 2018, Importance of accessibility and opening hours to overall patient experience of general practice: analysis of repeated cross-sectional data from a national patient survey in England, British Journal of General Practice, Vol: 68, Pages: e469-e477, ISSN: 0960-1643
Background The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients’ overall experiences of general practice.Aim To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours.Design and setting Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011–2012 until 2013–2014. These covered 8289 general practice surgeries in England.Method Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression.Results In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices.
Ahmad A, Laverty AA, Cowling TE, et al., 2018, Changing nationwide trends in endoscopic, medical and surgical admissions for Inflammatory Bowel Disease: 2003-2013, BMJ Open Gastroenterology, Vol: 5, ISSN: 2054-4774
Background and study aims In the last decade, there have been major advances in inflammatory bowel disease (IBD) management but their impact on hospital admissions requires evaluation. We aim to investigate nationwide trends in IBD surgical/medical elective and emergency admissions, including endoscopy and cytokine inhibitor infusions, between 2003 and 2013.Patients and methods We used Hospital Episode Statistics and population data from the UK Office for National Statistics.Results Age-sex standardised admission rates increased from 76.5 to 202.9/100 000 (p<0.001) and from 69.5 to 149.5/100 000 (p<0.001) for Crohn’s disease (CD) and ulcerative colitis (UC) between 2003–2004 and 2012–2013, respectively. Mean length of stay (days) fell significantly for elective (from 2.6 to 0.7 and from 2.0 to 0.7 for CD and UC, respectively) and emergency admissions (from 9.2 to 6.8 and from 10.8 to 7.6 for CD and UC, respectively). Elective lower gastrointestinal (GI) endoscopy rates decreased from 6.3% to 3.7% (p<0.001) and from 18.4% to 17.6% (p=0.002) for CD and UC, respectively. Elective major abdominal surgery rates decreased from 2.8% to 1.0% (p<0.001) and from 4.9 to 2.4 (p=0.010) for CD and UC, respectively, with emergency rates also decreasing significantly for CD. Between 2006-2007 and 2012-2013, elective admission rates for cytokine-inhibitor infusions increased from 11.1 to 57.2/100 000 and from 1.4 to 12.1/100 000 for CD and UC, respectively.Conclusions Rising IBD hospital admission rates in the past decade have been driven by an increase in the incidence and prevalence of IBD. Lower GI endoscopy and surgery rates have fallen, while cytokine inhibitor infusion rates have risen. There has been a concurrent shift from emergency care to shorter elective hospital stays. These trends indicate a move towards more elective medical management and may reflect improvements in disease control.
Cowling T, Majeed F, Harris M, 2018, Patient experience of general practice and use of emergency hospital services in England: regression analysis of national cross-sectional time series data, BMJ Quality and Safety, Vol: 27, Pages: 643-654, ISSN: 2044-5415
Background The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England. Methods The study included 8,124 general practices between 2011-12 and 2013-14. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours, and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification. Results Mean practice-level rates of A&E visits and emergency admissions increased from 2011-12 to 2013-14 (310.3 to 324.4 and 98.8 to 102.9 per 1,000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-12 and 76.6 in 2013-14. In the adjusted regression analysis, a standard deviation increase in experience of making appointments (equal to nine points) predicted decreases of 1.8% (95% CI: -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI: -1.9% to -0.9%) in admission rates. This equalled 301,174 fewer A&E visits and 74,610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses. Conclusions Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E
Cowling TE, Laverty AA, Harris MJ, et al., 2017, Contract and ownership type of general practices and patient experience in England: multilevel analysis of a national cross-sectional survey, Journal of the Royal Society of Medicine, Vol: 110, Pages: 440-451, ISSN: 1758-1095
Objective: To examine associations between the contractand ownership type of general practices and patient experiencein England.Design: Multilevel linear regression analysis of a nationalcross-sectional patient survey (General Practice PatientSurvey).Setting: All general practices in England in 2013–2014(n ¼ 8017).Participants: 903,357 survey respondents aged 18 years orover and registered with a general practice for six monthsor more (34.3% of 2,631,209 questionnaires sent).Main outcome measures: Patient reports of experienceacross five measures: frequency of consulting a preferreddoctor; ability to get a convenient appointment; rating ofdoctor communication skills; ease of contacting the practiceby telephone; and overall experience (measured onfour- or five-level interval scales from 0 to 100). Modelsadjusted for demographic and socioeconomic characteristicsof respondents and general practice populations and arandom intercept for each general practice.Results: Most practices had a centrally negotiated contractwith the UK government (‘General Medical Services’54.6%; 4337/7949). Few practices were limited companieswith locally negotiated ‘Alternative Provider MedicalServices’ contracts (1.2%; 98/7949); these practices providedworse overall experiences than General MedicalServices practices (adjusted mean difference 3.04, 95%CI 4.15 to 1.94). Associations were consistent in directionacross outcomes and largest in magnitude for frequencyof consulting a preferred doctor (12.78, 95% CI15.17 to 10.39). Results were similar for practicesowned by large organisations (defined as having 20 practices)which were uncommon (2.2%; 176/7949).Conclusions: Patients registered to general practicesowned by limited companies, including large organisations,reported worse experiences of their care than otherpatients in 2013–2014.
Cowling TE, Gunning E, 2016, Access to general practice in England: political, theoretical, and empirical considerations, British Journal of General Practice, Vol: 66, Pages: e680-e682, ISSN: 1478-5242
Access to general practice services in England has been a prominent theme in recent issues of the BJGP. Simpson and colleagues1 outlined the historical context of current policy to extend practice opening hours in the evenings and at weekends. Campbell and Salisbury2 examined the conceptual foundations of access to health care. Ford and colleagues3 reported empirical work on patient preferences for additional opening hours, while Scantlebury and colleagues4 modelled general-practice-level determinants of emergency department visits. We extend this discussion below, focusing on the UK government’s controversial commitment for all patients in England to be offered GP appointments between 8 am and 8 pm, 7 days a week, by 2020.
Cowling T, Harris M, Majeed F, 2016, Extended opening hours and patient experience of general practice in England: multilevel regression analysis of a national patient survey, BMJ Quality & Safety, Vol: 26, Pages: 360-371, ISSN: 2044-5423
Background The UK government plans to extend the opening hours of general practices in England. The ‘extended hours access scheme’ pays practices for providing appointments outside core times (08:00 to 18.30, Monday to Friday) for at least 30 min per 1000 registered patients each week.Objective To determine the association between extended hours access scheme participation and patient experience.Methods Retrospective analysis of a national cross-sectional survey completed by questionnaire (General Practice Patient Survey 2013–2014); 903 357 survey respondents aged ≥18 years old and registered to 8005 general practices formed the study population. Outcome measures were satisfaction with opening hours, experience of making an appointment and overall experience (on five-level interval scales from 0 to 100). Mean differences between scheme participation groups were estimated using multilevel random-effects regression, propensity score matching and instrumental variable analysis.Results Most patients were very (37.2%) or fairly satisfied (42.7%) with the opening hours of their general practices; results were similar for experience of making an appointment and overall experience. Most general practices participated in the extended hours access scheme (73.9%). Mean differences in outcome measures between scheme participants and non-participants were positive but small across estimation methods (mean differences ≤1.79). For example, scheme participation was associated with a 1.25 (95% CI 0.96 to 1.55) increase in satisfaction with opening hours using multilevel regression; this association was slightly greater when patients could not take time off work to see a general practitioner (2.08, 95% CI 1.53 to 2.63).Conclusions Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience.
Cecil E, Bottle A, Cowling TE, et al., 2016, Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK, PEDIATRICS, Vol: 137, ISSN: 0031-4005
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- Citations: 56
Cowling TE, Richards EC, Gunning E, et al., 2015, Online data on opening hours of general practices in England: a comparison with telephone survey data, British Journal of General Practice, ISSN: 1478-5242
Laverty AA, Cowling TE, Harris MJ, et al., 2015, Variation in patient experience between general practice contract types: multilevel analysis of a national cross-sectional survey, LANCET, Vol: 386, Pages: S14-S14, ISSN: 0140-6736
Cowling TE, Ramzan F, Ladbrooke T, et al., 2015, Referral outcomes of attendances at general practitioner-led urgent care centres in London, England: retrospective analysis of hospital administrative data, Emergency Medicine Journal, Vol: 33, Pages: 200-207, ISSN: 1472-0213
ABSTRACTObjective To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner-led urgent care centres (UCCs) in northwest London, England.Methods We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables – age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; general practitioner registration; time, day, quarter, year, and UCC of attendance – and the outcome of onwards referral to the co-located EDs or other hospital specialty departments.Results Of 243 042 included attendances, 74.1% were managed solely within the UCCs; without same-day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management, or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a ten year increase in a patient’s age. Males, patients registered with a GP, and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs.Conclusions The majority of patients, across each category of all explanatory variables, were managed solely within the UCCs, though a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.
Cowling TE, Harris M, Watt H, et al., 2015, Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data, BMJ Quality & Safety, Vol: 25, Pages: 432-440, ISSN: 2044-5415
Background The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes.Objective To determine whether primary care access is associated with the route of emergency admission—via a GP versus via an A and E department.Methods Retrospective analysis of national administrative data from English hospitals for 2011–2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access—the percentage of patients able to get a general practice appointment on their last attempt—was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics.Results The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England.Conclusions Among hospital inpatients admitted as an emergency, patients
Cowling TE, Harris MJ, Majeed A, 2015, Evidence and rhetoric about access to UK primary care., BMJ, Vol: 350
Cowling TE, Harris MJ, Majeed A, 2015, Access to primary care in England., JAMA Intern Med, Vol: 175
Cowling TE, Soljak MA, Bell D, et al., 2014, Emergency hospital admissions via accident and emergency departments in England: time trend, conceptual framework and policy implications., J R Soc Med, Vol: 107, Pages: 432-438
Ismail TF, Jabbour A, Gulati A, et al., 2014, Role of Late Gadolinium Enhancement Cardiovascular Magnetic Resonance in the Risk Stratification of Hypertrophic Cardiomyopathy, Heart
Cowling TE, Harris MJ, Watt HC, et al., 2014, Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey., Br J Gen Pract, Vol: 64, Pages: e434-e439
BACKGROUND: The annual number of unplanned attendances at accident and emergency (A&E) departments in England increased by 11% (2.2 million attendances) between 2008-2009 and 2012-2013. A national review of urgent and emergency care has emphasised the role of access to primary care services in preventing A&E attendances. AIM: To estimate the number of A&E attendances in England in 2012-2013 that were preceded by the attending patient being unable to obtain an appointment or a convenient appointment at their general practice. DESIGN AND SETTING: Cross-sectional analysis of a national survey of adults registered with a GP in England. METHOD: The number of general practice consultations in England in 2012-2013 was estimated by extrapolating the linear trend of published data for 2000-2001 to 2008-2009. This parameter was multiplied by the ratio of attempts to obtain a general practice appointment that resulted in an A&E attendance to attempts that resulted in a general practice consultation estimated using the GP Patient Survey 2012-2013. A sensitivity analysis varied the number of consultations by ±12% and the ratio by ±25%. RESULTS: An estimated 5.77 million (99.9% confidence interval = 5.49 to 6.05 million) A&E attendances were preceded by the attending patient being unable to obtain a general practice appointment or a convenient appointment, comprising 26.5% of unplanned A&E attendances in England in 2012-2013. The sensitivity analysis produced values between 17.5% and 37.2% of unplanned A&E attendances. CONCLUSION: A large number of A&E attendances are likely to be preceded by unsuccessful attempts to obtain convenient general practice appointments in England each year.
Calderón-Larrañaga A, Soljak M, Cowling TE, et al., 2014, Association of primary care factors with hospital admissions for epilepsy in England, 2004-10: national observational study, Seizure-European Journal of Epilepsy
Cowling TE, Harris MJ, Soljak MA, et al., 2013, Opening hours of general practices in England, British Medical Journal, Vol: 347
Cowling TE, Ramzan F, Majeed A, et al., 2013, Attendances at Charing Cross and Hammersmith Hospitals’ urgent care centres, 2009-12, BMJ, Vol: 347
Cowling TE, Harris MJ, Majeed A, 2013, What Is Our Plan for Acute Unscheduled Care?, Annals of Internal Medicine, Vol: 159, Pages: 575-576
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