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ReportBalinskaite V, Aylin P, Bennett P, et al., 2016,
Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study
, Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study, Publisher: NIHR Journals LibraryBackground:Previous research suggests that non-obstetric surgery is carried out in 1–2% of allpregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of theevidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelinesregarding non-obstetric surgery in pregnant women.Objectives:To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgerywas or was not carried out. To further analyse common procedure groups.Data Source:Hospital Episode Statistics (HES) maternity data collected between 2002–3 and 2011–12.Main outcomes:Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, longinpatient stay, stillbirth and low birthweight.Methods:We utilised HES, an administrative database that includes records of all patient admissions andday cases in all English NHS hospitals. We analysed HES maternity data collected between 2002–3 and2011–12, and identified pregnancies in which non-obstetric surgery was carried out. We used logisticregression models to determine the adjusted relative risk and attributable risk of non-obstetric surgicalprocedures for adverse birth outcomes and the number needed to harm.Results:We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out.In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgerywas associated with a higher risk of adverse birth outcomes, although the attributable risk was generallylow. We estimated that for every 287 pregnancies in which a surgical operation was carried out there wasone additional stillbirth; for every 31 operations there was one additional preterm delivery; for every25 operations there was one additional caesarean section; for every 50 operations there was oneadditional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby.Limitations:We
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Journal articleTudor Car L, Papachristou N, Bull A, et al., 2016,
Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study
, BMC Family Practice, Vol: 17, ISSN: 1471-2296Background: Delayed diagnosis in primary care is a common, harmful and costly patient safety incident. Its measurement and monitoring are underdeveloped and underutilised. We created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. Methods: We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were thematically grouped and synthesized into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the Average Expert Agreement.Results: The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients’ medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts.Conclusions: The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their vie
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Journal articlePinder EM, Bottle A, Aylin P, et al., 2016,
Does laminar flow ventilation reduce the rate of infection? an observational study of trauma in England.
, Bone and Joint Journal, Vol: 98-B, Pages: 1262-1269, ISSN: 2049-4408AIMS: To determine whether there is any difference in infection rate at 90 days between trauma operations performed in laminar flow and plenum ventilation, and whether infection risk is altered following the installation of laminar flow (LF). PATIENTS AND METHODS: We assessed the impact of plenum ventilation (PV) and LF on the rate of infection for patients undergoing orthopaedic trauma operations. All NHS hospitals in England with a trauma theatre(s) were contacted to identify the ventilation system which was used between April 2008 and March 2013 in the following categories: always LF, never LF, installed LF during study period (subdivided: before, during and after installation) and unknown. For each operation, age, gender, comorbidity, socio-economic deprivation, number of previous trauma operations and surgical site infection within 90 days (SSI90) were extracted from England's national hospital administrative Hospital Episode Statistics database. Crude and adjusted odds ratios (OR) were used to compare ventilation groups using hierarchical logistic regression. Subanalysis was performed for hip hemiarthroplasties. RESULTS: A total of 803 065 trauma operations were performed during this time; 19 hospitals installed LF, 124 already had LF, 13 had PV and the type of ventilation was unknown in 28. Patient characteristics were similar between the groups. The rate of SSI90 was similar for always LF and PV (2.7% and 2.4%). For hemiarthroplasties of the hip, the rates of SSI90 were significantly higher for LF compared with PV (3.8% and 2.6%, OR 1.45, p = 0·001). Hospitals installing LF did not see any statistically significant change in the rate of SSI90. CONCLUSION: The results of this observational study imply that infection rate is similar when orthopaedic trauma surgery is performed in LF and PV, and is unchanged by installing LF in a previously PV theatre. Cite this article: Bone Joint J 2016;98-B:1262-9.
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Journal articleBouras G, Markar SR, Burns EM, et al., 2016,
Linked Hospital and Primary Care Database Analysis of the Incidence and Impact of Psychiatric Morbidity Following Gastrointestinal Cancer Surgery in England
, Annals of Surgery, Vol: 264, Pages: 93-99, ISSN: 1528-1140 -
Journal articleAylin P, Bennett P, Bottle A, et al., 2016,
The risk of adverse pregnancy outcomes following non-obstetric surgery during pregnancy: An observational study
, BJOG-An International Journal of Obstetrics and Gynaecology, Vol: 123, Pages: 84-84, ISSN: 1471-0528 -
Journal articleBottle RA, Goudie R, Bell D, et al., 2016,
Use of hospital services by age and comorbidity after an index heart failure admission in England: an observational study
, BMJ Open, Vol: 6, ISSN: 2044-6055Objectives: To describe hospital inpatient, emergency department (ED) and outpatient department (OPD) activity for patients in the year following their first emergency admission for heart failure (HF). To assess the proportion receiving specialist assessment within two weeks of hospital discharge, as now recommended by guidelines.Design: Observational study of national administrative data.Setting: all acute NHS hospitals in England.Participants: 82,241 patients with an index emergency admission between April 2009 and March 2011 with a primary diagnosis of HF.Main outcome measures: cardiology OPD appointment within two weeks and within a year of discharge from the index admission; emergency department (ED) and inpatient use within a yearResults: 15.1% died during the admission. Of the 69,848 survivors, 19.7% were readmitted within 30 days and half within a year, the majority for non-HF diagnoses. 6.7% returned to the ED within a week of discharge, of whom the majority (77.6%) were admitted. The two most common OPD specialties during the year were cardiology (24.7% of the total appointments) and anticoagulant services (12.5%). Although half of all patients had a cardiology appointment within a year, the proportion within the recommended two weeks of discharge was just 6.8% overall and varied by age, from 2.4% in those aged 90+ to 19.6% in those aged 18-45 (p<0.0001); appointments in other specialties made up only some of the shortfall. More comorbidity at any age was associated with higher rates of cardiology OPD follow-up. Conclusion: patients with HF are high users of hospital services. Post-discharge cardiology OPD follow-up rates fell well below current NICE guidelines, particularly for the elderly and those with less comorbidity.
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Journal articleMamidanna R, Nachiappan S, Bottle A, et al., 2016,
Defining the timing and causes of death amongst patients undergoing colorectal resection in England
, Colorectal Disease, Vol: 18, Pages: 586-593, ISSN: 1463-1318 -
Journal articleKing AS, Bottle R, Faiz O, et al., 2016,
Investigating adverse event free admissions in Medicare inpatients as a patient safety indicator
, Annals of Surgery, Vol: 265, Pages: 910-915, ISSN: 1528-1140Objective: 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 furtherreduced. These are generally measured separately, one adverse event at a time.However, this does not reveal whether different patients are affected or thesame patients are experiencing multiple events.Methods: We examined Medicare inpatient hospital administrative datasetsfor 2009 to 2011, processed using standard criteria. Events were (i) deathwithin 30 days, (ii) unplanned readmissions within 30 days, (iii) long length ofstay, (iv) healthcare acquired infections, and (v) established patient safetyindicators not present on admission. We defined adverse event free admissionsas those without record of any of these events. National rates were calculatedby diagnosis group. Risk-adjusted hospital-specific rates of adverse event freeadmissions 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 ofanything untoward. Multiple events were recorded in 227% admissions; 15%of these experienced more than 2 adverse events. Risk-adjusted hospitalspecificrates of adverse event free admissions for colorectal proceduresshowed 131 out of 3786 hospitals below the 998% lower control limit of thenational upper quartile.Conclusions: Overall, only 60% of admissions were recorded as adverseevent free. Multiple adverse events were common. Even if events are underrecorded, this measure could provide an easily understandable and usefulbaseline for clinicians and managers.
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Journal articleAskari A, Nachiappan S, Currie A, et al., 2016,
Selection for laparoscopic resection confers a survival benefit in colorectal cancer surgery in England.
, Surgical Endoscopy, ISSN: 0930-2794INTRODUCTION: Laparoscopic surgery is being increasingly used in colorectal cancer resections. The aim of this national study was to determine whether laparoscopy confers a long-term survival advantage in colorectal cancer. METHODS: A national administrative data set (Hospital Episode Statistics-HES) encompassing all elective hospital admissions in England between 2001 and 2011 was analysed. All patients that had a colorectal cancer resection (open or laparoscopic) were identified. Cox hazard regression was used to determine differences in overall survival (10 year) between the open and laparoscopy groups. RESULTS: A total of 141,682 patients underwent elective surgery for colorectal cancer, of which 20.9 % (n = 29,550) had a laparoscopic procedure. The median 5-year survival in the open group was 36.1 months compared with 46.1 months in the laparoscopic group (p = <0.001). Survival analysis demonstrated laparoscopy to be an independent predictor of survival. Patients who underwent laparoscopic resection were 18 % less likely to die than patients who had an open CRC resection (HR 0.82, CI 0.79-0.83, p < 0.001). This survival benefit persisted even when initial post-operative mortality (90 day) was excluded (HR 0.87, CI 0.85-0.90, p < 0.001). Subgroup analysis, exploring the effect of CRC laparoscopic surgery on survival in the elderly (>79 years old), demonstrated similar survival benefit amongst patients treated using laparoscopy (HR 0.90, CI 0.86-0.94, p < 0.001). Patients not undergoing adjuvant chemotherapy were more likely to survive if they underwent laparoscopic resection (HR 0.81, CI 0.78-0.83, p < 0.001). Similarly, patients undergoing adjuvant chemotherapy demonstrated a survival benefit if a minimal access surgical approach was utilised (HR 0.86, CI 0.81-0.91, p < 0.001). CONCLUSION: Laparoscopy confers a survival benefit, irrespec
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Journal articleMamidanna R, Ni Z, Anderson O, et al., 2016,
Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England
, Annals of Surgery, Vol: 263, Pages: 727-732, ISSN: 1528-1140Objective: The aim of the study was to assess whether there is a proficiency curve-like relationship between surgeon volume and operative mortality and determine the minimum surgeon volume for optimum operative mortality.Background: The inverse relationship between hospital volume and operative mortality is well-established for esophageal, gastric, and pancreatic cancer. The recommended minimum surgeon volumes are however uncertain.Methods: We retrieved data on esophagectomies, gastrectomies, and pancreatectomies for cancer from the NHS Hospital Episodes Statistics database from April 2000 to March 2010. We defined mortality as in-hospital death within 30 days of surgery. We determined whether there was a proficiency curve relationship by inspecting surgeon volume-mortality graphs after adjusting for patient age, sex, socioeconomic, and comorbidity indices. We then statistically determined the minimum surgeon volume that produced a mortality rate insignificantly different from the optimum of the curve.Results: Sixteen thousand five hundred seventy-two esophagectomies, 12,622 gastrectomies, and 9116 pancreatectomies were examined. Surgeon volume ranged from 2 to 29 esophagectomies, from 1 to 14 gastrectomies, and from 2 to 31 pancreatectomies per surgeon per year. We demonstrated a proficiency relationship between surgeon volume and mortality in esophageal, gastric, and pancreatic cancer surgery. Each additional case of esophagectomy, gastrectomy, and pancreatectomy would reduce 30-day mortality odds by 3.4%, 7.2%, and 4.1%, respectively. However, as surgeon volume increased, mortality rate continued to improve. Therefore, we were unable to recommend minimum surgeon volume.Conclusions: Mortality after resections for esophageal, gastric, and pancreatic cancer falls as surgeon volume rises up to 30 cases. Within this range, we did not demonstrate any statistical threshold that could be recommended as a minimum volume target.
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