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Background Inflammatory bowel disease [IBD] is a risk factor for colorectal cancer [CRC]. The aim of this study is to determine whether stage at diagnosis and survival differ between sporadic, ulcerative colitis [UC]- and Crohn’s disease [CD]-related CRC. Methods The English National Cancer Registry [NCIN], Hospital Episode Statistics [HES] and Office for National Statistics [ONS] datasets between 2000 and 2010 were linked, providing data on comorbidities, stage and date of death. A logistic regression model determined whether IBD was associated with an early [I/II] or late [III/IV] cancer. Cox regression analysis was used to examine survival differences between sporadic, UC- and CD-related cancers. Results A total of 234 009 patients with CRC were included, of whom 985 [0.4%] and 1922 [0.8%] had CD and UC, respectively. UC, but not CD, was associated with an earlier stage compared with sporadic cancers (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.79 to 0.98, p = 0.02). CD had a significantly worse survival compared with sporadic patients for stage II [HR = 1.71, CI 1.26 to 2.31 p Conclusions Patients with IBD are diagnosed at an earlier stage but tend to have a worse survival compared with sporadic cases of CRC, in particular for nodal disease [stage III].Specifically, patients with CD-related CRC appear to fare worst in terms of survival compared with both the sporadic and UC groups.

Summary Background & aims Sarcopenia occurs in patients with intestinal failure (IF) and has been associated with poorer survival in several chronic diseases. CT can measure sarcopenia through a L3 skeletal muscle index (LSMI). We aim to describe the prevalence of sarcopenia in a section of our IF population using LSMI, & evaluate the effect of home parenteral support (PS) on LSMI & survival. Additionally, we aim to assess any association between LSMI, BMI & other anthropometric measurements. Methods IF patients on PS treated at St Mark's Hospital between 1/1/2006-1/10/2016 were identified from a prospectively maintained database. Patients were included if they were on PS & had 2 CTs: the first ≤30 days before start of HPN (pre-PS); the second ≥100 days from PS start (post-PS). Patient records were reviewed to obtain clinical & demographic information & date of death. Anthropometric measurements & BMI contemporaneous to CT scans were recorded. Results 64 patients met inclusion criteria (M:F 1:1). 83% of our cohort had LSMI below previously published thresholds for sarcopenia. Mean (SD) pre-PS LSMI was 36.5 (6.8)cm2/m2. Mean BMI pre-PS was 22.1 (4.8) kg/m2. Both BMI (22.1 kg/m2 to 23.5 kg/m2) p Conclusions This study is the first to look at sarcopenia & survival using CT defined LSMI (CT-LSMI) in the IF population. 83% of our cohort had a pre-PS LSMI below previously published thresholds, yet we found no relationship between lower baseline LSMI & survival. This may reflect the heterogeneity of the prognoses of the IF population, or that parenteral nutrition itself affects survival. Our study showed that LSMI & BMI improved following PS but demonstrated that other anthropometric measurements had poor correlation with LSMI & showed no significant improvement overall after PS, confirming the known problems of inter-operator & patient variability of these measurements. Whilst we found significant correlation between LSMI & BMI, BMI significantly underestimated the presence & degree of sarcopenia. LSMI has the potential to provide an objective & reproducible measure of sarcopenia in IF. Future larger studies should be performed to evaluate associations with patient outcomes & utility in clinical decision making.

ObjectivesAssess whether impactibility modelling is being used to refine risk stratification for preventive health interventions.DesignSystematic review.SettingPrimary and secondary healthcare populations.PapersArticles published from 2010 to 2020 on the use or implementation of impactibility modelling in population health management, reported with the terms ‘intervenability’, ‘amenability’, and ‘propensity to succeed’ (PTS) and associated with the themes ‘care sensitivity’, ‘characteristic responders’, ‘needs gap’, ‘case finding’, ‘patient selection’ and ‘risk stratification’.InterventionsQualitative synthesis to identify themes for approaches to impactibility modelling.ResultsOf 1244 records identified, 20 were eligible for inclusion. Identified themes were ‘health conditions amenable to care’ (n=6), ‘PTS modelling’ (n=8) and ‘comparison or combination with clinical judgement’ (n=6). For the theme ‘health conditions amenable to care’, changes in practice did not reduce admissions, particularly for ambulatory care sensitive conditions, and sometimes increased them, with implementation noted as a possible issue. For ‘PTS modelling’, high costs and needs did not necessarily equate to high impactibility and targeting a larger number of individuals with disorders associated with lower costs had more potential. PTS modelling seemed to improve accuracy in care planning, estimation of cost savings, engagement and/or care quality. The ‘comparison or combination with clinical judgement’ theme suggested that models can reach reasonable to good discriminatory power to detect impactable patients. For instance, a model used to identify patients appropriate for proactive multimorbid care management showed good concordance with physicians (c-statistic 0.75). Another model employing electronic health record scores reached 65% concordance with nurse and physician decisions when referring elderly hospitalised patients to a readmission prevention programme. However, healthcare professionals consider much wider information that might improve or impede the likelihood of treatment impact, suggesting that complementary use of models might be optimum.ConclusionsThe efficiency and equity of targeted preventive care guided by risk stratification could be augmented and personalised by impactibility modelling.

Background: frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. Objectives: to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of comorbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). Design: observational study. Setting: primary care in England. Subjects: all adult patients diagnosed with HF in primary care between 2010 and 2013. Methods: we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. Results: of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, comorbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. Conclusions: this study suggests that frailty has predictive power beyond its comorbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.

ObjectivesPeriprosthetic 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.DesignA national, observational study.SettingEngland.ParticipantsAll individuals admitted to hospital with periprosthetic fractures between 1 April 2015 and 31 December 2018.Primary and secondary outcome measuresMortality, length of stay, change in rate of admissions.MethodsWe 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.ResultsBetween 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%.ConclusionsThe 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 funded in a similar manner to that successfully employed for people sustaining hip fractures, using national standards and data collection to monitor and improve performance.

Rationale: Heart failure (HF) is a common comorbidity in the chronic obstructive pulmonary disease (COPD) population, but previous research has shown underrecognition.Objectives: The objectives of this study were to determine the incidence of HF in a prevalent COPD cohort and to determine the association of incident HF with short- and long-term mortality of patients with COPD.Methods: Crude incidence of HF in the HF-naive primary care COPD population was calculated for each year from 2006 to 2016 using UK data from the Clinical Practice Research Datalink (CPRD). Patients with COPD were identified using a validated code list and were required to be >35 years old at COPD diagnosis, have a history of smoking, and have documented airflow obstruction. The Office of National Statistics provided mortality data for England. Adjusted mortality rate ratios (aMRRs) from Poisson regression were calculated for patients with COPD and incident HF (COPD-iHF) in 2006, 2011, and 2015, and compared temporally with patients with COPD and without incident HF (COPD-no HF) in those years. Regression was adjusted for age, sex, body mass index, severity of airflow limitation, smoking status, history of cardiovascular disease, and diabetes.Results: We identified 95,987 HF-naive patients with COPD. Crude incidence of HF was steady from 2006 to 2016 (1.18 per 100 person-years; 95% confidence interval [CI], 1.09-1.27). Patients with COPD-iHF experienced greater than threefold increase in 1-year mortality and twofold increase in 5-year and 10-year mortality compared with patients with COPD-no HF, with no change on the basis of year of HF diagnosis. Mortality of patients with COPD-iHF did not improve over time, comparing incident HF in 2011 (1-yr aMRR, 1.26; 95% CI, 0.83-1.90; 5-yr aMRR, 1.26; 95% CI, 0.98-1.61) and 2015 (1-yr aMRR, 1.63; 95% CI, 0.98-2.70) with incident HF in 2006.Conclusions: The incidence of HF in the UK COPD population was stable in the last decade. Survival of patients with COPD and incident HF has not improved over time in England. Bespoke guidelines for the diagnosis and management of HF in the COPD population are needed to improve identification and survival of patients.

Background The ideal thromboprophylaxis regime following lower limb arthroplasty and proximal femur fractures remains controversial. Guidelines disagree on the type of chemical prophylaxis, its dose or duration. This article describes a method of monitoring venous thromboembolism (VTE) rates following Total Hip (THA), Total Knee Arthroplasty (TKA) and surgery for hip fractures (NOF#). Methods Over 3 years, all patients investigated for VTE were analysed using Picture Archiving Communications System (PACS). All positive scans were then cross-referenced using PACS and local registry data to see if they had undergone THA, TKA or NOF# in the preceding 90 days. Mortality data were obtained from the national administrative database, Hospital Episode Statistics. Results Five thousand seven hundred eighty-eight patients underwent investigation for VTE and there were 29 diagnoses of PE and 24 of DVT. There was a 0.77% rate of symptomatic DVT after THA, 0.05% after TKA and 0.55% after NOF #. The rate of confirmed symptomatic PE for THA was 0.46, 0.27% for TKA and 0.96% for NOF #. Mortality at one-year post-THA was 0.6, 0.6% for TKA and 25.9% after NOF#. All patients contacted either remained within the catchment area for the minimum 90 postoperative days or died within the catchment area. Conclusions The 90 day post-operative prevalence of symptomatic VTE of 1.2, 0.3 and 1.5% in THA, TKA and NOF # respectively are similar to other studies using symptomatic and imaging positive VTE as their endpoint. The study uses a method of collecting data which can be utilised in centres where PACS is available.

Rationale: Black adults have worse health outcomes compared with white adults in certain chronic diseases, including chronic obstructive pulmonary disease (COPD). Objectives: To determine to what degree disadvantage by individual and neighborhood socioeconomic status (SES) may contribute to racial disparities in COPD outcomes. Methods: Individual and neighborhood-scale sociodemographic characteristics were determined in 2,649 current or former adult smokers with and without COPD at recruitment into SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study). We assessed whether racial differences in symptom, functional, and imaging outcomes (St. George’s Respiratory Questionnaire, COPD Assessment Test score, modified Medical Research Council dyspnea scale, 6-minute-walk test distance, and computed tomography [CT] scan metrics) and severe exacerbation risk were explained by individual or neighborhood SES. Using generalized linear mixed model regression, we compared respiratory outcomes by race, adjusting for confounders and individual-level and neighborhood-level descriptors of SES both separately and sequentially. Measurements and Main Results: After adjusting for COPD risk factors, Black participants had significantly worse respiratory symptoms and quality of life (modified Medical Research Council scale, COPD Assessment Test, and St. George’s Respiratory Questionnaire), higher risk of severe exacerbations and higher percentage of emphysema, thicker airways (internal perimeter of 10 mm), and more air trapping on CT metrics compared with white participants. In addition, the association between Black race and respiratory outcomes was attenuated but remained statistically significant after adjusting for individual-level SES, which explained up to 12–35% of racial disparities. Further adjustment showed that neighborhood-level SES explained another 26–54% of the racial disparities in respiratory outcomes. Even after accounting for both individual and neighborhood SES factors, Black individuals continued to have increased severe exacerbation risk and persistently worse CT outcomes (emphysema, air trapping, and airway wall thickness). Conclusions: Disadvantages by individual- and neighborhood-level SES each partly explain disparities in respiratory outcomes between Black individuals and white individuals. Strategies to narrow the gap in SES disadvantages may help to reduce race-related health disparities in COPD; however, further work is needed to identify additional risk factors contributing to persistent disparities.

ObjectiveTimely 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.MethodsWe 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.Results36 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.ConclusionsPatients 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.

BackgroundJoint 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.MethodsNational 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.ResultsFrom 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 pConclusionRTT90 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.

Patients undergoing emergency colorectal cancer (CRC) surgery are at higher risk of poor outcome than those managed electively. The aim of this national study is to identify groups at high risk of undergoing unplanned CRC surgery and assess short and long-term outcome in this cohort subsequent morbidity and mortality as well as quantify their long-term survival. The aim of this national study is to identify groups at high risk of undergoing unplanned CRC surgery and assess short and long-term outcome, subsequent morbidity and mortality as well as quantify their long-term survival.The Hospital Episode Statistics (HES) database between the years of 1997-2012 was used to identify all patients that had undergone surgery for colorectal cancer. Multivariable logistic regression analysis and cox regression analyses were undertaken to identify patient factors predictive of undergoing emergency and quantify their long-term survival.A total of 286,591 patients underwent resection for CRC between April 1997 and April 2012, of which 24.3% (69,718 patients) were admitted as emergencies and underwent emergency surgery. Independent predictors of undergoing emergency surgery were female gender (OR 1.23, CI: 1.21-1.25, p 0.001), older age (79 years old OR 1.55, CI: 1.50-1.60, p 0.001), social deprivation (most deprived quintile, OR 1.64, CI: 1.50-1.80, p 0.001) and Black African/Caribbean ethnicity (OR 1.36, CI: 1.21-1.66, p 0.001). All cause 30- and 90-day mortality within the emergency group was significantly higher than that for the electively managed patients group (13.3% versus compared with 3.4% at 30-days) as was 90-day (20.0% versus compared with 5.8% at 90-days). Amongst patients eligible for bowel screening there was an approximate 40% significant reduction in the proportion of patients requiring emergency surgery before and after its introduction in 2006 (23.4%-14.9%, p 0.001). This reduction in emergency surgery included both proximal and distal cancer resections.Older, socially deprived and ethnic minority patients with colorectal cancer are more likely to present as emergencies requiring CRC surgery. Public health initiatives, such as bowel cancer screening, appear to have concomitantly reduced emergency and increased elective surgical rates within the eligible cohort. This is likely to have a beneficial impact on population survival. Strategies aimed at preventing emergency presentation by identifying patients at specific risk could improve survival outcome for colorectal cancer surgery in England.

Objective: To investigate adverse event free admissions as a potential, patient-centered indicator aligned directly with the goal of patient safety— freedom from harm. Background: Preventable adverse event rates in healthcare could be further reduced. These are generally measured separately, one adverse event at a time. However, this does not reveal whether different patients are affected or the same patients are experiencing multiple events. Methods: We examined Medicare inpatient hospital administrative datasets for 2009 to 2011, processed using standard criteria. Events were (i) death within 30 days, (ii) unplanned readmissions within 30 days, (iii) long length of stay, (iv) healthcare acquired infections, and (v) established patient safety indicators not present on admission. We defined adverse event free admissions as those without record of any of these events. National rates were calculated by diagnosis group. Risk-adjusted hospital-specific rates of adverse event free admissions were calculated using colorectal procedures as an example. Results: There were 23,991,193 admissions after exclusions. Approximately, 64% went through the acute inpatient Medicare system without record of anything untoward. Multiple events were recorded in 227% admissions; 15% of these experienced more than 2 adverse events. Risk-adjusted hospitalspecific rates of adverse event free admissions for colorectal procedures showed 131 out of 3786 hospitals below the 998% lower control limit of the national upper quartile. Conclusions: Overall, only 60% of admissions were recorded as adverse event free. Multiple adverse events were common. Even if events are under recorded, this measure could provide an easily understandable and useful baseline for clinicians and managers.

Tumour staging at time of presentation is an important factor in determining survival in colorectal cancer. The aim of this paper is to investigate the relationship between ethnicity and deprivation in late (Stage IV) presentation of colorectal cancer.Data from the Thames Cancer Registry comprising 77,057 colorectal cancer patients between the years 2000 and 2012 were analysed.A total of 17,348 patients were identified with complete data, of which 53.9% were male. Patients from a Black Afro/Caribbean background were diagnosed with CRC at a much younger age than the White British group (median age 67 compared with 72, p0.001). In multiple regression, ethnicity, deprivation and age were positive predictors of presenting with advanced tumour stage at time of diagnosis. Black patients were more likely to present with Stage IV tumours than white patients (OR 1.37, 95% CI 1.18-1.59, p0.001). Social deprivation was also a predictor of Stage IV cancer presentation, with the most deprived group (Quintile 5) 1.26 times more likely to be diagnosed with Stage IV cancer compared with the most affluent group (CI 1.13-1.40, p0.001). Sub-group analyses demonstrated that BlackAffluent patients were still at greater risk of Stage IV CRC than their WhiteAffluent counterparts (OR 1.24, 95% CI 1.11-1.45, p=0.023). Patients with rectal cancer were less likely to present with Stage IV CRC (OR 0.66, 95% CI 0.61-0.71, p0.001).Racial and age related disparities exist in tumour presentation in the United Kingdom. Patients from black and socially deprived backgrounds as well as the elderly are more likely to present with advanced tumours at time of diagnosis.

Background The objective was to evaluate incidence, risk factors and impact of postoperative symptoms following esophagogastric cancer resection in primary care. Methods Patients undergoing esophagogastrectomy for cancer from 1998 to 2010 with linked records in Clinical Practice Research Datalink, Hospital Episodes Statistics and Office of National Statistics databases were studied. The recording of codes for reflux, dysphagia, dyspepsia, nausea, vomiting, dumping, diarrhea, steatorrhea, appetite loss, weight loss, pain and fatigue were identified up to 12 months postoperatively. Psychiatric morbidity was also examined and its risk evaluated by logistic regression analysis. Results Overall, 58.6% (1029/1755) of patients were alive 2 years after surgery. Of these, 41.1% had recorded postoperative symptoms. Reflux, dysphagia, dyspepsia and pain were more frequent following esophagectomy compared with gastrectomy (p < 0.05). Complications (OR = 1.40 95%CI 1.00–1.95) and surgical procedure predicted postoperative symptoms (p < 0.05). When compared with partial gastrectomy, esophagectomy (OR = 2.03 95%CI 1.26–3.27), total gastrectomy (OR = 2.44 95%CI 1.57–3.79) and esophagogastrectomy (OR = 2.66 95%CI 1.85–2.86) were associated with postoperative symptoms (p < 0.05). The majority of patients with postoperative psychiatric morbidity had depression or anxiety (98%). Predictors of postoperative depression/anxiety included younger age (OR = 0.97 95%CI 0.96–0.99), complications (OR = 2.40 95%CI 1.51–3.83), psychiatric history (OR = 6.73 95%CI 4.25–10.64) and postoperative symptoms (OR = 1.78 95%CI 1.17–2.71). Conclusions Over 40% of patients had symptoms related to esophagogastric cancer resection recorded in primary care, and were associated with an increase in postoperative depression and anxiety.

Background Smokers are less likely to develop ulcerative colitis (UC) but the impact of smoking and subsequent cessation on clinical outcomes in UC is unclear. Aim To evaluate the effect of smoking status and smoking cessation on disease outcomes. Methods Using a nationally representative clinical research database, we identified incident cases of UC during 2005-2016. Patients were grouped as never-smokers, ex-smokers and smokers based on smoking status recorded in the 2 years preceding UC diagnosis. We defined subgroups of persistent smokers and smokers who quit within 2 years after diagnosis. We compared the rates of overall corticosteroid use, corticosteroid-requiring flares, corticosteroid dependency, thiopurine use, hospitalisation and colectomy between these groups. Results We identified 6754 patients with a new diagnosis of UC over the study period with data on smoking status, of whom 878 were smokers at diagnosis. Smokers had a similar risk of corticosteroid-requiring flares (OR 1.16, 95% CI 0.92-1.25), thiopurine use (HR 0.84, 95% CI 0.62-1.14), corticosteroid dependency (HR 0.85, 95% CI 0.60-1.11), hospitalisation (HR 0.92, 95% CI 0.72-1.18) and colectomy (HR 0.78, 95% CI 0.50-1.21) in comparison with never-smokers. Rates of flares, thiopurine use, corticosteroid dependency, hospitalisation and colectomy were not significantly different between persistent smokers and those who quit smoking after a diagnosis of UC. Conclusions Smokers and never-smokers with UC have similar outcomes with respect to flares, thiopurine use, corticosteroid dependency, hospitalisation and colectomy. Smoking cessation was not associated with worse disease course. The risks associated with smoking outweigh any benefits. UC patients should be counselled against smoking.

Aim The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients. Method We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records. Results The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific. Conclusion Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.

ObjectivesThis study aimed to examine the prevalence of frailty coding within the Dr Foster Global Comparators (GC) international database. We then aimed to develop and validate a risk prediction model, based on frailty syndromes, for key outcomes using the GC data set.DesignA retrospective cohort analysis of data from patients over 75 years of age from the GC international administrative data. A risk prediction model was developed from the initial analysis based on seven frailty syndrome groups and their relationship to outcome metrics. A weighting was then created for each syndrome group and summated to create the Dr Foster Global Frailty Score. Performance of the score for predictive capacity was compared with an established prognostic comorbidity model (Elixhauser) and tested on another administrative database Hospital Episode Statistics (2011-2015), for external validation.Setting34 hospitals from nine countries across Europe, Australia, the UK and USA.ResultsOf 6.7 million patient records in the GC database, 1.4 million (20%) were from patients aged 75 years or more. There was marked variation in coding of frailty syndromes between countries and hospitals. Frailty syndromes were coded in 2% to 24% of patient spells. Falls and fractures was the most common syndrome coded (24%). The Dr Foster Global Frailty Score was significantly associated with in-hospital mortality, 30-day non-elective readmission and long length of hospital stay. The score had significant predictive capacity beyond that of other known predictors of poor outcome in older persons, such as comorbidity and chronological age. The score’s predictive capacity was higher in the elective group compared with non-elective, and may reflect improved performance in lower acuity states.ConclusionsFrailty syndromes can be coded in international secondary care administrative data sets. The Dr Foster Global Frailty Score significantly predicts key outcomes. This methodology may be feasibly utilised for case-mix adjustment for older persons internationally.

Background We aimed to compare the characteristics and types of heart failure (HF) patients termed “high-impact users”, with high long-term readmission rates, in different regions in England. This will allow clinical factors to be identified in areas with potentially poor quality of care. 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 and followed up for 5 years. Group-based trajectory models and sequence analysis were applied to their readmissions. Results In each of the 8 NHS England regions, multiple discrete groups were identified. All the regions had high-impact users. The group with an initially high readmission rate followed by a rapid decline in the rate ranged from 2.5 to 11.3% across the regions. The group with constantly high readmission rate compared with other groups ranged from 1.9 to 12.1%. Covariates that were commonly found to have an association with high-impact users among most of the regions were chronic respiratory disease, chronic renal disease, stroke, anaemia, mood disorder, and cardiac arrhythmia. Respiratory tract infection, urinary infection, cardiopulmonary signs and symptoms and exacerbation of heart failure were common causes in the sequences of readmissions among high-impact users in all regions. Conclusion There is regional variation in England in readmission and mortality rates and in the proportions of HF patients who are high-impact users.

SUMMARYNICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier.By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management.1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68–0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67–0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21–0.35 p < 0.0001) were more likely to be referred earlier.This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.

AimsTo identify predictors of early revision (within 3 years of the index operation) for hip and knee replacement (HR, KR) from both surgeon and population perspectives.Patients and methodsHierarchical logistic regression on national administrative data for England for index procedures between April 2009 and March 2014.ResultsThere were 315,273 index HR procedures and 374,530 index KR procedures for analysis. Three-year revision rates were 2.1% for HR and 2.2% for KR. The highest odds ratios for HR were for 3+ previous emergency admissions, drug abuse, Parkinson's disease, resurfacing and ages under 60; for KR these were patellofemoral or partial joint replacement, 3+ previous emergency admissions, paralysis and ages under 60. Smaller effects were found for other comorbidities such as obesity (HR) and diabetes (KR). From a population perspective, the only population attributable fractions over 5% were for male gender, uncemented total hip replacements and partial knee or patellofemoral replacements.ConclusionsMeeting the rising demand for revision surgery is a challenge for healthcare leaders and policymakers. Our findings suggest optimising patients pre-operatively and improving patient selection for primary arthroplasty may reduce the burden of early revision of arthroplasty. Our study gives useful information on the additional risks of various comorbidities and procedures, which enables a more informed consent process.Clinical relevanceSurgeons should make patients with certain risk factors such as age and procedure type aware of their higher revision risk as part of shared decision-making.

AIM Historically, postoperative deaths have been reported up to 30 days following surgery. There is, however, emerging evidence that deaths attributable to surgery continue to occur much later than this time frame. This aim of this study was to analyse the timing and causes of mortality following colorectal resection. METHOD Data were obtained from the Hospital Episode Statistics database with linkage to mortality data from the Office for National Statistics. Patients who underwent colorectal resection between April 2001 and February 2007 were included. Causes of death were classified into colorectal cancer (CRC), other malignancy, cardiac, respiratory, gastrointestinal, neurological and other. RESULTS During the study period 171 791 patients underwent a colorectal resection. Thirty-day mortality rates for elective procedures were 1.3, 3.5, 7.0 and 12.1% for the ≤ 65, 66-75, 76-85 and > 85 year age groups, respectively, compared with 2.2, 5.4, 9.8 and 16.7% at 90 days. For elective operations, at 30 days, 38.6% of patients who died had CRC recorded as the primary cause of death, whilst 25.4% died of cardiac causes. In the younger population undergoing a resection, deaths due to cardiac causes were significantly higher than the national average for the same age group even beyond 30 days (13.5% at 30 days, 11.1% at 90 days and 5.7% at 1 year). CONCLUSION This study shows that deaths attributable to colorectal surgery occur beyond the conventionally utilized 30-day period. Information presented to patients on the basis of 30-day mortality estimates is likely to underestimate the true risk of surgical intervention.

BackgroundA small proportion of patients referred to as ‘frequent attenders’ account for a large proportion of hospital activity such as ED attendances and admissions. There is a 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.MethodWe included all attendances at all major EDs across England in the financial year 2016–2017. Patients who attended three 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.Results14 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 three times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended six 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.ConclusionOne in 10 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.

BACKGROUND: All-cause 30-day readmission after total knee arthroplasty (TKA) is currently used as a measure of hospital performance in the United States and elsewhere. Readmissions from surgical causes may more accurately reflect preventability and costs. However, little is known about whether predictors of each type of readmission differ. METHODS: All primary TKAs recorded in England's National Health Service administrative database from 2006 to 2015 were included. Multilevel logistic regression analysis was used to describe the effects of patient-related factors on 30-day readmission risk using 3 different readmission metrics: all-cause, surgical (defined using International Classification of Disease-10 primary admission diagnoses), and those resulting in return to theater (RTT). RESULTS: In total, 566,323 procedures were recorded. The comorbidity with the highest odds ratio (OR) for all types of readmission was psychoses (RTT OR 2.52, P < .001). Obesity was a strong independent predictor of RTT (OR 1.36, P < .001) and had the highest population attributable fraction of any comorbidity (4.7%). Unicompartmental arthroplasty was associated with a significantly lower risk of all types of readmission when compared with TKA, with the effect being most pronounced for surgical readmission (OR 0.66, P < .001). RTT in the index episode increased the risk of RTT readmission (OR 2.80, P < .001), as did any emergency admission to hospital in the preceding 12 months (for >2 emergency admissions, all-cause OR 2.38, P < .001). Length of stay either more than or less than 2 days was associated with an increased risk of all-cause and surgical readmission but not RTT readmission. CONCLUSION: Patient-related predictors of surgical and RTT readmission following TKA differ from those for all-cause readmission, but only the latter metric is in widespread use.

ObjectiveClinical guidelines on heart failure (HF) suggest timings for investigation and referral in primary care. We calculated the time for patients to achieve key elements in the recommended pathway to diagnosis of HF.MethodsIn this observational study, we used linked primary and secondary care data (Clinical Practice Research Datalink, a database of anonymised electronic records from UK general practices) between 2010 and 2013. Records were examined for presenting symptoms (breathlessness, fatigue, ankle swelling) and key elements of the National Institute for Health and Care Excellence-recommended pathway to diagnosis (serum natriuretic peptide (NP) test, echocardiography, specialist referral).Results42 403 patients were diagnosed with HF, of whom 16 597 presented in primary care with suggestive symptoms. 6464 (39%) had recorded NP or echocardiography, and 6043 (36%) specialist referral. Median time from recorded symptom(s) to investigation (NP or echocardiography) was 292 days (IQR 34–844) and to referral 236 days (IQR 42–721). Median time from symptom(s) to diagnosis was 972 days (IQR 337–1468) and to treatment with HF-relevant medication 803 days (IQR 230–1364). Factors significantly affecting timing of referral, treatment and diagnosis included patients’ sex (p=0.001), age (pConclusionsMedian times to investigation or referral of patients presenting in primary care with symptoms suggestive of HF considerably exceeded recommendations. There is a need to support clinicians in the diagnosis of HF in primary care, with improved access to investigation and specialist assessment to support timely management.

Purpose This study aimed to determine changes in absolute and relative socioeconomic inequalities in hospital admissions for major cardiovascular causes among patients with diabetes in England. Methods We identified all patients with diabetes aged ≥45 years admitted to the hospital in England between 2004-2005 and 2014-2015 for acute myocardial infarction, stroke, percutaneous coronary intervention, or coronary artery bypass graft. We measured socioeconomic status using the Index of Multiple Deprivation. Diabetes-specific admission rates were calculated for each year by deprivation quintile. We assessed temporal changes using negative binomial regression models. Results Most admissions occurred among patients aged ≥65 years (71%) and men (63.3%). The number of admissions increased steadily from the least quintile to the most deprived quintile. Patients in the most deprived quintile had a 1.94-fold increased risk of acute myocardial infarction (95% confidence interval [CI], 1.79-2.10), 1.92-fold increased risk of stroke (95% CI, 1.78-2.07), 1.66-fold increased risk of coronary artery bypass graft (95% CI, 1.50-1.74), and 1.76-fold increased risk of percutaneous coronary intervention (95% CI, 1.64-1.89) compared with the least deprived group. Absolute differences in rates between the least and most deprived quintiles did not change significantly for acute myocardial infarction (P = .29) and were reduced for stroke, coronary artery bypass graft, and percutaneous coronary intervention (by 17.5, 15, and 11.8 per 100,000 patients with diabetes, respectively, P ≤ .01 for all). Conclusions Socioeconomic inequalities persist in diabetes-related hospital admissions for major cardiovascular events in England. Besides improved risk stratification strategies that consider socioeconomically defined needs, wide-reaching population-based policy interventions are required to reduce inequalities in diabetes outcomes.

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 and results Patients with a primary diagnosis of heart failure (HF) in the period 2008-09 were identified using nationally representative primary care data linked to national hospital data, which contain information on 10.5 million patients. Heart failure patients were followed up for 5 years. Group-based trajectory models and sequence analysis were applied. The model categorised the HF population (n = 9466) into five 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

Background Hospital mortality, readmission and length of stay (LOS) are commonly used measures for quality of care. We aimed to disentangle the correlations between these interrelated measures and propose a new way of combining them to evaluate the quality of hospital care. Methods We analyzed administrative data from the Global Comparators Project from 26 hospitals on patients discharged between 2007 and 2012. We correlated standardized and risk-adjusted hospital outcomes on mortality, readmission and long LOS. We constructed a composite measure with 5 levels, based on literature review and expert advice, from survival without readmission and normal LOS (best) to mortality (worst outcome). This composite measure was analyzed using ordinal regression, to obtain a standardized outcome measure to compare hospitals. Results Overall, we observed a 3.1% mortality rate, 7.8% readmission rate (in survivors) and 20.8% long LOS rate among 4,327,105 admissions. Mortality and LOS were correlated at the patient and the hospital level. A patient in the upper quartile LOS had higher odds of mortality (odds ratio = 1.45, 95% confidence interval 1.43–1.47) than those in the lowest quartile. Hospitals with a high standardized mortality had higher proportions of long LOS (r = 0.79, p

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.

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

Objective To examine the association of consultants’ experience with mortality by day of the week when elective surgery was performed. Design Retrospective observational study using English hospital administrative data. Setting All acute and specialist English National Health Service (NHS) hospitals carrying out elective surgery between financial years 2008–2009 and 2010–2011. Participants Patients undergoing elective surgical procedures. Main outcome measures Death in or out of hospital within 30 days of the surgical procedure taking place. Results We examined 3 922 091 (26 409 deaths) elective procedures with valid consultant information between 2008–2009 and 2010–2011 in English hospitals; there were 21 196 consultants in charge of these procedures, which took place in 163 NHS hospitals. Consultant seniority had no significant impact in predicting mortality (p=0.345). Patients undergoing elective surgery under junior consultants had slightly lower odds of 30-day death when compared with patients under more experienced consultants (OR 0.95, 95% CI 0.91 to 0.99). We found significant mortality variation among consultants in charge of elective procedures within hospitals, with only moderate variation between hospitals. The adjusted odds of death remained higher for Friday (OR 1.48, 95% CI 1.42 to 1.54), Saturday (OR 1.97, 95% CI 1.83 to 2.12) and Sunday (OR 1.67, 95% CI 1.50 to 1.85) after adjusting for consultant seniority and patient characteristics. Consultant experience is significantly lower (p

Objective To examine the association of mortality by day of the week for emergency and elective patients. Design Retrospective observational study using the international dataset from the Global Comparators (GC) project consisting of hospital administrative data. Setting 28 hospitals from England, Australia, USA and the Netherlands during 2009–2012. Participants Emergency and surgical-elective patients. Main outcome measures In-hospital deaths within 30 days of emergency admission or of elective surgery. Results We examined 2 982 570 hospital records; adjusted odds of 30-day death were higher for weekend emergency admissions to 11 hospitals in England (OR 1.08, 95% CI 1.04 to 1.13 on Sunday), 5 hospitals in USA (OR 1.13, 95% CI 1.04 to 1.24 on Sunday) and 6 hospitals in the Netherlands (OR 1.20, 95% CI 1.09 to 1.33 on Saturday). Emergency admissions to the six Australian hospitals showed no daily variation in adjusted 30-day mortality, but showed a weekend effect at 7 days post emergency admission (OR 1.12, 95% CI 1.04 to 1.22 on Saturday). All weekend elective patients showed higher adjusted odds of 30-day postoperative death; we observed a ‘Friday effect’ for elective patients in the six Dutch hospitals. Conclusions We show that mortality outcomes for our sample vary within each country and per day of the week in agreement with previous studies of the ‘weekend effect’. Due to limitations of administrative datasets, we cannot determine the reasons for these findings; however, the international nature of our database suggests that this is a systematic phenomenon affecting healthcare providers across borders. Further investigation is needed to understand the factors that give rise to the weekend effect. The participating hospitals represent varied models of service delivery, and there is a potential to learn from best practice in different healthcare systems.

ObjectiveTo 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 participantsRisk-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 outcomesMortality difference between weekend and weekday emergency stroke admissions.ResultsWe 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.ConclusionsThere was a steady reduction in weekend/weekday differences in mortality in stroke admissions across England. It appears statistically unrelated to the centralisation of stroke services in Greater London, and is consistent with an overall national focus on improving stroke services.

Aims There are no national studies evaluating the epidemiology of non-alcoholic steatohepatitis (NASH) in England. NASH is becoming an increasingly important health issue given the inexorable rise in obesity and diabetes. We evaluated the rates of NASH in people with and without diabetes from 2004–2005 to 2014–2015. Methods We identified cases of biopsy-proven NASH in people with and without diabetes in England over an eleven-year period using Hospital Episode Statistics. We estimated incidence rates for each year. Negative binomial regression models were fitted to test trends. Results Over the study period, people without diabetes recorded a 3% reduction in admission rates per year (incidence rate ratio (IRR) (95% CI) 0.97 (0.96–0.98), p < 0.001), whilst there was an increase in admission rates in people with diabetes (IRR (95% CI) 1.01 (1.00–1.02), p = 0.04). In people with diabetes, this upward trend was driven by people over 65 years (IRR (95% CI) 1.03 (1.02–1.04), p < 0.001) and men (IRR (95% CI) 1.01 (1.0–1.02), p = 0.03). Inpatient mortality declined for people with diabetes by 2% per year after adjusting for age, sex and year (IRR (95% CI) 0.98 (0.95–0.99), p = 0.03). The 2% decline per year in inpatient mortality for people without diabetes did not achieve statistical significance after adjustment (IRR (95% CI) 0.98 (0.95–1.01), p = 0.175). Conclusions There was a decline in NASH-related hospital admissions amongst people without diabetes over eleven years, whilst rates increased in people with diabetes. These observations highlight the increasing burden of NASH.

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 2 emergency readmissions, OR, 2.33; 95% CI, 2.11-2.57; P

Objective To 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. Design A retrospective cohort study of patients with cerebrovascular conditions. Settings Secondary care of all patients with cerebrovascular conditions admitted to English National Hospital Service hospitals. Participants All patients with cerebrovascular conditions identified through national administrative data (Hospital Episode Statistics) and subsequent emergency hospital admissions followed up for 4 years. Main outcome measure Annual number of emergency hospital readmissions. Results GBTM model classified patients with intracranial haemorrhage (n=2605) into five subgroups, whereas ischaemic stroke (n=34 208) and transient ischaemic attack (TIA) (n=20 549) 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%) among intracranial haemorrhage were strongly associated with thromboembolic event (OR 20.3) and inversely related to older age (OR 0.58). Conclusion GBTM effectively assessed trends in the use of hospital care by the subgroups of patients with cerebrovascular conditions. High-impact users persistently had higher annual readmission during the follow-up period.

Background Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past decade but controversies persist on cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England. Methods We identified all hospital admissions for cardiovascular disease causes among people aged 17 years and above between 2004 and 2014 in England. We calculated diabetes-specific and non-diabetes-specific rates for study outcomes by gender. To assess temporal changes, we fitted negative binomial regression models. Results Diabetes-related admission rates remained unchanged for AMI (incidence rate ratio (IRR) 0.99 [95% CI 0.98–1.01]), increased for stroke by 2% (1.02 [1.01–1.03]) and PCI by 3% (1.03 [1.01–1.04]) and declined for CABG by 3% (0.97 [0.96–0.98]) annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI (IRR 0.46 [95% CI 0.40–0.53]) and stroke (0.73 [0.63–0.84]) compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group. While diabetes tripled admission rates for AMI in men (IRR 3.15 [95% CI 2.72–3.64]), it increased it by over fourfold among women (4.27 [3.78–4.93]). Furthermore, while the presence of diabetes was associated with a threefold increased rates for PCI and fivefold increased rates for CABG (IRR 3.14 [2.83–3.48] and 5.01 [4.59–5.05], respectively) in men, among women diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG (4.37 [3.93–4.85] and 6.24 [5.66–6.88], respectively). Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions unchanged. Conclusions Diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets and treatment intensity to be aligned with levels of CVD risk.

IntroductionReadmissions are a recognised challenge for providers of healthcare and incur financial penalties in a growing number of countries. However, the scale of unscheduled hospital contacts including attendances at emergency departments that do not result in admission is not well known. In addition, little is known about the route to readmission for patients recently discharged from an emergency hospital stay.MethodsThis is an observational study of national hospital administration data for England. In this retrospective cohort study, we tracked patients for 30 days after discharge from an emergency admission for heart failure (HF) or chronic obstructive pulmonary disorder (COPD).ResultsThe majority of patients (COPD:79%; HF:75%) had no unscheduled contact with secondary health care within 30 days of discharge. Of those who did have unscheduled contact, the most common first unscheduled contact was emergency department (ED) attendance (COPD:16%; HF:18%). A further 5% of COPD patients and 4% of HF patients were admitted for an emergency inpatient stay, but not through the ED. A small percentage of patients (COPD:ConclusionWhile the majority of patients did not have unscheduled contact with secondary care in the 30 days after index discharge, many patients attended the ED, often multiple times, and many were admitted to hospital, not always via the ED. More frail patients were more likely to be admitted through the ED, suggesting a possible area of focus as discharge bundles are developed.

This study aimed to evaluate using national data the role of surgeon laparoscopic caseload in determining outcome following elective laparoscopic colorectal cancer resection.All patients who underwent an elective laparoscopic primary colorectal cancer resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Surgeon teams were divided into tertiles according to the mean laparoscopic caseload per year. High volume corresponded to more than 12 laparoscopic procedures per year and low volume corresponded to seven or fewer procedures per year. Outcome measures were 30-day in-hospital mortality, return to theatre (RTT), 30-day medical morbidity, 365-day medical morbidity, length of stay (LOS), and unplanned 28-day readmission.There was a significant increase in the number of surgeons selecting patients for the laparoscopic approach between 2002-2003 and 2007-2008. In 2002-2003, a total of 41 surgeon teams performed laparoscopic resections whereas in 2007-2008 there were 398 surgeon teams. The patients of high-volume surgeon teams had a shorter LOS [OR 0.88 (0.85-0.91), p0.0001]. Patients of medium-volume surgeon teams had the highest medical morbidity rates [30-day medical morbidity: OR 1.24 (1.04-1.48), p = 0.015; 365-day medical morbidity: OR 1.22 (1.04-1.45), p = 0.018]. There were no differences between the high- and low-volume groups in terms of mortality, morbidity, RTT, or readmission.Although there has been a significant increase in the number of surgeon teams offering the minimal access approach, this study has not found a consistent relationship between surgeon laparoscopic cancer surgery caseload and outcome.This is the first national study to explore the role of surgical volume in determining outcome following laparoscopic surgery. This study questions the impact of surgeon caseload on laparoscopic surgical outcome.

Background: Data are lacking on the optimal scheduling of coronary artery bypass grafting (CABG) surgery after stroke. The authors investigated the preoperative predictors of adverse outcomes in patients undergoing CABG, with a focus on the importance of the time interval between prior stroke and CABG. Methods: The Hospital Episode Statistics database (April 2006–March 2010) was analyzed for elective admissions for CABG. Independent preoperative patient factors influencing length of stay, postoperative stroke, and mortality, were identified by logistic regression and presented as adjusted odds ratios (OR). Results: In all, 62,104 patients underwent CABG (1.8% mortality). Prior stroke influenced mortality (OR 2.20 [95% CI 1.47–3.29]), postoperative stroke (OR 1.99 [1.39–2.85]), and prolonged length of stay (OR 1.31 [1.11–1.56]). The time interval between stroke and CABG did not influence mortality or prolonged length of stay. However, a longer time interval between stroke and CABG surgery was associated with a small increase in risk of postoperative stroke (OR per month elapsed 1.02 [1.00–1.04]; P = 0.047). An interaction was evident between prior stroke and myocardial infarction for death (OR 5.50 [2.84–10.8], indicating the importance of the combination of comorbidities. Prominent effects on mortality were also exerted by liver disease (OR 20.8 [15.18–28.51]) and renal failure (OR 4.59 [3.85–5.46]). Conclusions: The authors found no evidence that more recent preoperative stroke predisposed patients undergoing CABG surgery to suffer postoperative stroke, death, or prolonged length of stay. The combination of prior stroke and myocardial infarction substantially increased perioperative risk.

IMPORTANCE: Gastroesophageal cancer resections are associated with significant reintervention and perioperative mortality rates. OBJECTIVE: To compare outcomes following operative and nonoperative reinterventions between high- and low-mortality gastroesophageal cancer surgical units in England. DESIGN: All elective esophageal and gastric resections for cancer between 2000 and 2010 in English public hospitals were identified from a national administrative database. Units were divided into low- and high-mortality units (LMUs and HMUs, respectively) using a threshold of 5% or less for 30-day adjusted mortality. The groups were compared for reoperations and nonoperative reinterventions following complications. SETTING: Both LMUs and HMUs. PARTICIPANTS: Patients who underwent esophageal and gastric resections for cancer. EXPOSURE: Elective esophageal and gastric resections for cancer, with reoperations and nonoperative reinterventions following complications. MAIN OUTCOMES AND MEASURES: Failure to rescue is defined as the death of a patient following a complication; failure to rescue-surgical is defined as the death of a patient following reoperation for a surgical complication. RESULTS: There were 14 955 esophagectomies and 10 671 gastrectomies performed in 141 units. For gastroesophageal resections combined, adjusted mortality rates were 3.0% and 8.3% (P < .001) for LMUs and HMUs, respectively. Complications rates preceding reoperation were similar (5.4% for LMUs vs. 4.9% for HMUs; P = .11). The failure to rescue-surgical rates were lower in LMUs than in HMUs (15.3% vs. 24.1%; P < .001). The LMUs performed more nonoperative reinterventions than the HMUs did (6.7% vs. 4.7%; P < .001), with more patients surviving in LMUs than in HMUs (failure to rescue rate, 7.0% vs. 12.5%; P < .001). Overall, LMUs reintervened more than HMUs did (12.2% vs 9.6%; P < .001), and LMUs had lower failure to rescue rates following reintervention than HMUs did (9.0% vs. 18.3%; P = .001). All P values stated refer to 2-sided values. CONCLUSIONS AND RELEVANCE: Overall, LMUs were more likely to reintervene and rescue patients following gastroesophageal cancer resections in England. Patients were more likely to survive following both reoperations and nonsurgical interventions in LMUs.

BACKGROUND: To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care. METHODS: Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF). RESULTS: There were 639,064 patients with a first-time admission for cancer, with 139,351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15-44 years) to 44.9% (patients aged 85 years and older, P

Summary Background Little is known about the acquisition of Clostridium difficile infection (CDI) and whether it represents hospital- or community-acquired infection. Aim To test the feasibility and value of using national hospital admissions data from Hospital Episode Statistics to examine trends in CDI in England. Methods Hospital Episode Statistics from the period 1997/98 to 2009/10 were used. Time trends were analysed using two different denominators of hospital activity: total admissions and total bed-days. We explored the impact of sociodemographic factors, comorbidity and healthcare pathways on the risk of CDI. Findings CDI rates per admission and per bed-days increased from 1997/98 to 2006/07, then decreased significantly by >50% from 2008/9 and 2009/10. This pattern was similar for patients regardless of probable source of infection but the proportion of probable community-acquired CDI cases rose steadily from 7% in 1997/98 to 13% in 2009/10. CDI rates were higher among older patients (odds ratio: >65 years, 10.9), those with more comorbid conditions (odds ratio for Charlson index: >5, 5.6), and among patients admitted as an emergency compared with elective admissions, but no relationship was found with deprivation score. Conclusion Our findings support not only the falling trend in CDI found in the national mandatory surveillance scheme from the Health Protection Agency, but a growing proportion of CDI presenting on admission with no evidence of prior hospital exposure in the previous 90 days. We suggest that these may be community-acquired CDI cases.

The aim of the study was to evaluate the impact of transfer status and distance on in-hospital mortality for acute myocardial infarction (AMI) patients undergoing angioplasty on the same or next day of hospital admission.Retrospective analysis of English hospital administrative data using logistic regression modelling.After risk adjustment for the patient baseline characteristics, transferred patients had a higher in-hospital mortality rate than those admitted directly to hospital for angioplasty performed on the same or next day: OR=1.25 (95% confidence interval: 1.02-1.52), P=0.029. There was no statistically significant increased risk of in-hospital mortality with increasing distance between home and angioplasty centre (OR=0.98 (0.84-1.16), P=0.842 for 6-15 km and 1.03 (0.87-1.22), P=0.768 for15 km when compared with6 km) or with increasing inter-hospital transfer distance for angioplasty (OR=0.84 (0.55-1.29), P=0.435 for 16-34 km and 0.88 (0.58-1.35), for34 km when compared with16 km).Transfer status is associated with in-hospital mortality rate for AMI patients undergoing angioplasty on the same or next day of hospital admission. No relation between in-hospital mortality and the distance from home to angioplasty centre or inter-hospital transfer distance for angioplasty was found in these patients.

Background: Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management. Methods: We conducted a retrospective opencohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154 945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA1c) levels and total cholesterol. Results: We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA 1c level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19). Interpretation: We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-forperformance programs appear to benefit both large and small practices to a similar extent.

BACKGROUND: The UK is embarking on a national cardiovascular risk assessment programme called NHS Health Checks; in order to be effective, high and equitable uptake is paramount. METHODS: A cross-sectional study, using data extracted from electronic medical records of persons aged 35-74 years estimated to be at a high risk of developing cardiovascular disease, to examine the uptake of the Health Checks using logistic regression and statin prescribing. RESULTS: A total of 44.8% of high risk patients invited for a Health Check attended. Uptake was lower among younger men but higher among patients from south Asian (AOR = 1.71 [1.29-2.27] compared with white) or mixed ethnic backgrounds (AOR = 2.42 [1.50-3.89]), and patients registered with smaller practices (AOR = 2.53 [1.09-5.84]

Background The aim of the study was to identify outcome differences amongst patients undergoing resection of colorectal cancer at English National Health Service trusts using Hospital Episode Statistics (HES). A comparison was undertaken of trusts that submitted and those that did not submit, or submitted only poorly, voluntarily to a colorectal clinical registry, the National Bowel Cancer Audit Programme (NBOCAP). Methods The NBOCAP data set was used to classify trusts according to submitter status. HES data were used for outcome analysis. Data for major resections of colorectal cancer performed between 1 August 2007 and 31 July 2008 were obtained from HES. Trusts not submitting data to NBOCAP and those submitting less than 10 per cent of their total workload were termed ‘non-submitters’. HES data for 30-day mortality, length of stay and readmission rates were compared according to submitter and non-submitter status in multifactorial analyses. Results A total of 17 722 patients were identified from HES for inclusion. Unadjusted 30-day in-hospital mortality rates were higher in non-submitting than in submitting trusts (5·2 versus 4·0 per cent; P = 0·005). Submitter status was independently associated with reduced 30-day mortality (odds ratio 0·76, 95 per cent confidence interval 0·61 to 0·96; P = 0·021) in regression analysis. Conclusion A higher postoperative mortality rate following resection of colorectal cancer was found in trusts that do not voluntarily report data to NBOCAP. Implications regarding the voluntary nature of submission to such registries should be reviewed if they are to be used for outcome benchmarking.

Strategies to reduce the burden of cardiovascular disease (CVD) in the UK have emphasized improved management of high-risk individuals rather than population-based approaches.This 10-year retrospective cohort study examined blood pressure (BP) monitoring and control among patients with and without CVD in general practices in Wandsworth, London between 1998 and 2007. Logistic regression was used to assess associations among age, gender, ethnicity, deprivation and BP control.The percentage of patients with elevated BP (140/90 mm Hg) decreased at a slower rate in patients without CVD (31.0-25.3%) compared with those with CVD (56.8-36.0%) (P0.001). Mean systolic BP decreased from 146.1 to 136.4 mm Hg in patients with CVD and from 133.7 to 130.1 in patients without CVD. Mean diastolic BP decreased from 84.2 to 78.4 mm Hg in patients with CVD and from 80.5 to 79.0 in patients without CVD. Inequalities in BP control decreased among age, ethnic and deprivation groups but increased between men and women without CVD.Measurement and control of BP among those with CVD has improved much more rapidly compared with those without CVD. Inequalities in BP control appeared to increase between men and women without CVD, but decreased among age, ethnicity and deprivation groups.

We examined the impact of a major pay-for-performance initiative introduced into UK primary care in 2004 on disparities in diabetes management between age, sex, and socioeconomic groups in this retrospective cohort study. We used data from the General Practice Research Database enrolling 422 family practices. Existing disparities in risk factor management (HbA1c, blood pressure, cholesterol) narrowed between men and women. Younger patients (

OBJECTIVE To describe recent trends in the incidence of nontraumatic amputations among individuals with and without diabetes and estimate the relative risk of amputations among individuals with diabetes in England. RESEARCH DESIGN AND METHODS We identified all patients aged >16 years who underwent any nontraumatic amputation in England between 2004 and 2008 using national hospital activity data from all National Health Service hospitals. Age- and sex-specific incidence rates were calculated using the total diabetes population in England every year. To test for time trend, we fitted Poisson regression models. RESULTS The absolute number of diabetes-related amputations increased by 14.7%, and the incidence decreased by 9.1%, from 27.5 to 25.0 per 10,000 people with diabetes, during the study period (P > 0.2 for both). The incidence of minor and major amputations did not significantly change (15.7–14.9 and 11.8–10.2 per 10,000 people with diabetes; P = 0.66 and P = 0.29, respectively). Poisson regression analysis showed no statistically significant change in diabetes-related amputation incidence over time (0.98 decrease per year [95% CI 0.93–1.02]; P = 0.12). Nondiabetes-related amputation incidence decreased from 13.6 to 11.9 per 100,000 people without diabetes (0.97 decrease by year [0.93–1.00]; P = 0.059). The relative risk of an individual with diabetes undergoing a lower extremity amputation was 20.3 in 2004 and 21.2 in 2008, compared with that of individuals without diabetes. CONCLUSIONS This national study suggests that the overall population burden of amputations increased in people with diabetes at a time when the number and incidence of amputations decreased in the aging nondiabetic population.

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 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.