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Atkins E, Birmpili P, Kellar I, Johal AS, Li Q, Waton S, Boyle JR, Pherwani AD, Chetter I, Cromwell DA. Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours. J Foot Ankle Res 2024; 17:e12015. [PMID: 38703396 DOI: 10.1002/jfa2.12015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/15/2024] [Indexed: 05/06/2024] Open
Abstract
INTRODUCTION Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI. METHODS Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance. RESULTS Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour. CONCLUSION We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.
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Affiliation(s)
- Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | | | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Jonathan R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - Arun D Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Pherwani AD, Johal AS, Cromwell DA, Boyle JR, Szeberin Z, Venermo M, Beiles B, Khashram M, Lattmann T, Altreuther ME, Laxdal E, Behrendt CA, Mani K, Budtz-Lilly J. Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 - 2019. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00178-3. [PMID: 38382695 DOI: 10.1016/j.ejvs.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To determine the peri-operative mortality rate for intact and ruptured abdominal aortic aneurysm (AAA) repair in 10 countries and to compare practice and outcomes over a six year period by age, sex, and geographic location. METHODS This VASCUNET study used prospectively collected data from vascular registries in 10 countries on primary repair of intact and ruptured AAAs undertaken between January 2014 and December 2019. The primary outcome was peri-operative death (30 day or in hospital). Logistic regression models were used to estimate the association between peri-operative death, patient characteristics, and type of procedure. Factors associated with the use of endovascular aortic aneurysm repair (EVAR) were also evaluated. RESULTS The analysis included 50 642 intact and 9 453 ruptured AAA repairs. The proportion of EVARs for intact repairs increased from 63.4% in 2014 to 67.3% in 2016 before falling to 62.3% in 2019 (p < .001), but practice varied between countries. EVAR procedures were more common among older patients (p < .001) and men (p < .001). Overall peri-operative mortality after intact AAA repair was 1.4% (95% confidence interval [CI] 1.3 - 1.5%) and did not change over time. Mortality rates were stable within countries. Among ruptured AAA repairs, the proportion of EVARs increased from 23.7% in 2014 to 35.2% in 2019 (p < .001). The average aortic diameter was 7.8 cm for men and 7.0 cm for women (p < .001). The overall peri-operative mortality rate was 31.3% (95% CI 30.4 - 32.2%); the rates were 36.0% (95% CI 34.9 - 37.2%) for open repair and 19.7% (95% CI 18.2 - 21.3%) for EVAR. This difference and shift to EVAR reduced peri-operative mortality from 32.6% (in 2014) to 28.7% (in 2019). CONCLUSION The international practice of intact AAA repair was associated with low mortality rates in registry reported data. There remains variation in the use of EVAR for intact AAAs across countries. Overall peri-operative mortality remains high after ruptured AAA, but an increased use of EVAR has reduced rates over time.
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Affiliation(s)
- Arun D Pherwani
- Keele University School of Medicine, Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Amundeep S Johal
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK. http://www.twitter.com/vsqip
| | | | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust and Department of Surgery, University of Cambridge, Cambridge, UK. http://www.twitter.com/Jonnyboyle1
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. http://www.twitter.com/VenerMa
| | - Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Manar Khashram
- University of Auckland, Waikato Hospital, Hamilton, New Zealand. http://www.twitter.com/ManarKhashram
| | - Thomas Lattmann
- Swissvasc Registry, Clinic for Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland. http://www.twitter.com/LattmannThomas
| | - Martin E Altreuther
- Section of Vascular Surgery, Department of Surgery, St Olavs Hospital, and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elin Laxdal
- Department of Vascular Surgery, Landspitalinn University Hospital, Reykjavik, Iceland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany. http://www.twitter.com/VASCevidence
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden. http://www.twitter.com/KevinMani7
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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Atkins E, Kellar I, Birmpili P, Waton S, Li Q, Johal AS, Boyle JR, Pherwani AD, Chetter I, Cromwell DA. The symptom to assessment pathway for suspected chronic limb-threatening ischaemia (CLTI) affects quality of care: a process mapping exercise. BMJ Open Qual 2024; 13:e002605. [PMID: 38267216 PMCID: PMC10824038 DOI: 10.1136/bmjoq-2023-002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Delays in the pathway from first symptom to treatment of chronic limb-threatening ischaemia (CLTI) are associated with worse mortality and limb loss outcomes. This study examined the processes used by vascular services to provide urgent care to patients with suspected CLTI referred from the community. METHODS Vascular surgery units from various regions in England were invited to participate in a process mapping exercise. Clinical and non-clinical staff at participating units were interviewed, and process maps were created that captured key staff and structures used to create processes for referral receipt, triage and assessment at the units. RESULTS Twelve vascular units participated, and process maps were created after interviews with 45 participants. The units offered multiple points of access for urgent referrals from general practitioners and other community clinicians. Triage processes were varied, with units using different mixes of staff (including medical staff, podiatrists and s) and this led to processes of varying speed. The organisation of clinics to provide slots for 'urgent' patients was also varied, with some adopting hot clinics, while others used dedicated slots in routine clinics. Service organisation could be further complicated by separate processes for patients with and without diabetes, and because of the organisation of services regionally into vascular networks that had arterial and non-arterial centres. CONCLUSIONS For referred patients with symptoms of CLTI, the points of access, triage and assessment processes used by vascular units are diverse. This reflects the local context and ingenuity of vascular units but can lead to complex processes. It is likely that benefits might be gained from simplification.
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Affiliation(s)
- Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England, UK
- Hull York Medical School, Hull, England, UK
| | - Ian Kellar
- University of Sheffield, Sheffield, England, UK
| | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England, UK
- Hull York Medical School, Hull, England, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England, UK
| | - Jon R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals, Cambridge, England, UK
| | - Arun D Pherwani
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, England, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
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Cromwell DA, Johnston C. Emergency laparotomy and short-term mortality: a reply. Anaesthesia 2023; 78:1526. [PMID: 37669773 DOI: 10.1111/anae.16123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/07/2023]
Affiliation(s)
- D A Cromwell
- London School of Hygiene and Tropical Medicine, London, UK
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Eugene N, Kuryba A, Martin P, Oliver CM, Berry M, Moppett IK, Johnston C, Hare S, Lockwood S, Murray D, Walker K, Cromwell DA. Development and validation of a prognostic model for death 30 days after adult emergency laparotomy. Anaesthesia 2023; 78:1262-1271. [PMID: 37450350 DOI: 10.1111/anae.16096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.
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Affiliation(s)
- N Eugene
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - P Martin
- Department of Applied Health Research, University College London, London, UK
| | - C M Oliver
- UCL Division of Surgery and Interventional Science, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Berry
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - I K Moppett
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Repair, University of Nottingham, Nottingham, UK
| | - C Johnston
- Department of Anaesthesia, St George's Hospital, London, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | - S Lockwood
- Colorectal Surgery Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - D Murray
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - K Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Wahba AJ, Cromwell DA, Hutchinson PJ, Mathew RK, Phillips N. Assessing national patterns and outcomes of pituitary surgery: is hospital administrative data good enough? Br J Neurosurg 2023; 37:1135-1142. [PMID: 36727284 DOI: 10.1080/02688697.2023.2170982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 01/03/2023] [Indexed: 02/03/2023]
Abstract
PURPOSE Patterns of surgical care, outcomes, and quality of care can be assessed using hospital administrative databases but this requires accurate and complete data. The aim of this study was to explore whether the quality of hospital administrative data was sufficient to assess pituitary surgery practice in England. METHODS The study analysed Hospital Episode Statistics (HES) data from April 2013 to March 2018 on all adult patients undergoing pituitary surgery in England. A series of data quality indicators examined the attribution of cases to consultants, the coding of sellar and parasellar lesions, associated endocrine and visual disorders, and surgical procedures. Differences in data quality over time and between neurosurgical units were examined. RESULTS A total of 5613 records describing pituitary procedures were identified. Overall, 97.3% had a diagnostic code for the tumour or lesion treated, with 29.7% (n = 1669) and 17.8% (n = 1000) describing endocrine and visual disorders, respectively. There was a significant reduction from the first to the fifth year in records that only contained a pituitary tumour code (63.7%-47.0%, p < .001). The use of procedure codes that attracted the highest tariff increased over time (66.4%-82.4%, p < .001). Patterns of coding varied widely between the 24 neurosurgical units. CONCLUSION The quality of HES data on pituitary surgery has improved over time but there is wide variation in the quality of data between neurosurgical units. Research studies and quality improvement programmes using these data need to check it is of sufficient quality to not invalidate their results.
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Affiliation(s)
- Adam J Wahba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Research, Royal College of Surgeons of England, London, UK
| | - Ryan K Mathew
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nick Phillips
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Atkins E, Kellar I, Birmpili P, Boyle JR, Pherwani AD, Chetter I, Cromwell DA. Hospital clinicians' perceptions and experiences of care pathways for chronic limb-threatening ischaemia: a qualitative study. J Foot Ankle Res 2023; 16:62. [PMID: 37726754 PMCID: PMC10507819 DOI: 10.1186/s13047-023-00664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Chronic limb-threatening ischaemia (CLTI) is a condition associated with significant risks of lower limb loss and mortality, which increase with delays in management. Guidance recommends urgent referral and assessment, but delays are evident at every stage of the CLTI patient pathway. This study uses qualitative methods to explore hospital clinicians' experiences and perceptions of the existing CLTI pathway. METHODS A qualitative interview study was conducted. Semi-structured interviews were undertaken with 13 clinicians involved in the assessment of patients referred to hospital with suspected CLTI, identified via purposive sampling from English vascular surgery units. Clinicians included podiatrists, vascular specialist nurses and doctors. Reflexive thematic analysis was performed on the data from a critical realist position. RESULTS The need for speed was the single overarching theme identified. Four linked underlying themes were also identified; 1. Vascular surgery as the poor relation (compared to cancer and other specialties), with a sub-theme of CLTI being a challenging diagnosis. 2. Some patients are more equal than others, with sub-themes of diabetes vs. non-diabetes, hub vs. spoke and frailty vs. non-frail. 3. Life in the National Health Service (NHS) is tough, with sub-themes of lack of resource and we're all under pressure. 4. Non-surgeons can help. CONCLUSIONS The underlying themes generated from the rich interview data describe barriers to timely referral, assessment and management of CLTI, as well as the utility of non-surgical roles such as podiatrists and vascular specialist nurses as a potential solution for delays. The overarching theme of the need for speed highlights the meaning given to adverse consequences of delays in management of CLTI by clinicians involved in its assessment. Future improvement projects aimed at the CLTI pathway should take these findings into account.
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Affiliation(s)
- Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 38-43 Lincoln's Inn Fields, Holborn, London, WC2A 3PE, UK.
- Hull York Medical School, Hull, UK.
| | | | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 38-43 Lincoln's Inn Fields, Holborn, London, WC2A 3PE, UK
- Hull York Medical School, Hull, UK
| | - Jonathan R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals, Cambridge, UK
| | - Arun D Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-On-Trent, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 38-43 Lincoln's Inn Fields, Holborn, London, WC2A 3PE, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Miller K, Gannon MR, Medina J, Clements K, Dodwell D, Horgan K, Park MH, Cromwell DA. Variation in Rates of Post-Mastectomy Radiotherapy Among Women with Early Invasive Breast Cancer in England and Wales: A Population-Based Cohort Study. Clin Oncol (R Coll Radiol) 2023; 35:e549-e560. [PMID: 37321887 DOI: 10.1016/j.clon.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/28/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
AIMS This study examined whether patterns of post-mastectomy radiotherapy (PMRT) among women with early invasive breast cancer (EIBC) varied within England and Wales and explored the role of different patient factors in explaining any variation. MATERIALS AND METHODS The study used national cancer data on women aged ≥50 years diagnosed with EIBC (stage I-IIIa) in England and Wales between January 2014 and December 2018 who had a mastectomy within 12 months of diagnosis. A multilevel mixed-effects logistic regression model was used to calculate risk-adjusted rates of PMRT for geographical regions and National Health Service acute care organisations. The study examined the variation in these rates within subgroups of women with different risks of recurrence (low: T1-2N0; intermediate: T3N0/T1-2N1; high: T1-2N2/T3N1-2) and investigated whether the variation was linked to patient case-mix within regions and organisations. RESULTS Among 26 228 women, use of PMRT increased with greater recurrence risk (low: 15.0%; intermediate: 59.4%; high: 85.1%). In all risk groups, use of PMRT was more common among women who had received chemotherapy and decreased among women aged ≥80 years. There was weak or no evidence of an association between use of PMRT and comorbidity or frailty, for each risk group. In women with an intermediate risk, unadjusted rates of PMRT varied substantially between geographical regions (range 40.3-77.3%), but varied less for the high-risk (range 77.1-91.6%) and low-risk groups (range 4.1-32.9%). Adjusting for patient case-mix reduced the variation in regional and organisational PMRT rates to a small degree. CONCLUSIONS Rates of PMRT are consistently high across England and Wales among women with high-risk EIBC, but variation exists across regions and organisations for women with intermediate-risk EIBC. Effort is required to reduce unwarranted variation in practice for intermediate-risk EIBC.
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Affiliation(s)
- K Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - M R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - J Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - K Clements
- National Cancer Registration and Analysis Service, NHS Digital, Birmingham, UK
| | - D Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - M H Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Birmpili P, Cromwell DA, Li Q, Johal AS, Atkins E, Waton S, Pherwani AD, Williams R, Richards T, Nandhra S. The Impact of Pre-Operative Anaemia on One Year Amputation Free Survival and Re-Admissions in Patients Undergoing Vascular Surgery for Peripheral Arterial Disease: a National Vascular Registry Study. Eur J Vasc Endovasc Surg 2023; 66:204-212. [PMID: 37169135 DOI: 10.1016/j.ejvs.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 02/27/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Anaemia is common among patients undergoing surgery, but its association with post-operative outcomes in patients with peripheral arterial disease (PAD) is unclear. The aim of this observational population based study was to examine the association between pre-operative anaemia and one year outcomes after surgical revascularisation for PAD. METHODS This study used data from the National Vascular Registry, linked with an administrative database (Hospital Episode Statistics), to identify patients who underwent open surgical lower limb revascularisation for PAD in English NHS hospitals between January 2016 and December 2019. The primary outcome was one year amputation free survival. Secondary outcomes were one year re-admission rate, 30 day re-intervention rate, 30 day ipsilateral major amputation rate and 30 day death. Flexible parametric survival analysis and generalised linear regression were performed to assess the effect of anaemia on one year outcomes. RESULTS The analysis included 13 641 patients, 57.9% of whom had no anaemia, 23.8% mild, and 18.3% moderate or severe anaemia. At one year follow up, 80.6% of patients were alive and amputation free. The risk of one year amputation or death was elevated in patients with mild anaemia (adjusted HR 1.3; 95% CI 1.15 - 1.41) and moderate or severe anaemia (aHR 1.5; 1.33 - 1.67). Patients with moderate or severe anaemia experienced more re-admissions over one year (adjusted IRR 1.31; 1.26 - 1.37) and had higher odds of 30 day re-interventions (aOR 1.22; 1.04 - 1.45), 30 day ipsilateral major amputation (aOR 1.53; 1.17 - 2.01), and 30 day death (aOR 1.39; 1.03 - 1.88) compared with patients with no anaemia. CONCLUSION Pre-operative anaemia is associated with lower one year amputation free survival and higher one year re-admission rates following surgical revascularisation in patients with PAD. Research is required to evaluate whether interventions to correct anaemia improve outcomes after lower limb revascularisation.
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Affiliation(s)
- Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Hull York Medical School, Hull, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Hull York Medical School, Hull, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arun D Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Robin Williams
- Department of Interventional Radiology, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle upon Tyne, UK
| | - Toby Richards
- Department of Vascular Surgery, University of Western Australia, Perth, Australia
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle upon Tyne, UK; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
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10
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Birmpili P, Li Q, Johal AS, Atkins E, Waton S, Chetter I, Boyle JR, Pherwani AD, Cromwell DA. Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study. Br J Surg 2023; 110:958-965. [PMID: 37216910 PMCID: PMC10361679 DOI: 10.1093/bjs/znad134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/12/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Patients with diabetes and peripheral arterial disease are at increased risk of minor amputation. The aim of study was to assess the rate of re-amputations and death after an initial minor amputation, and to identify associated risk factors. METHODS Data on all patients aged 40 years and over with diabetes and/or peripheral arterial disease, who underwent minor amputation between January 2014 and December 2018, were extracted from Hospital Episode Statistics. Patients who had bilateral index procedures or an amputation in the 3 years before the study were excluded. Primary outcomes were ipsilateral major amputation and death after the index minor amputation. Secondary outcomes were ipsilateral minor re-amputations, and contralateral minor and major amputations. RESULTS In this study of 22 118 patients, 16 808 (76.0 per cent) were men and 18 473 (83.5 per cent) had diabetes. At 1 year after minor amputation, the estimated ipsilateral major amputation rate was 10.7 (95 per cent c.i. 10.3 to 11.1) per cent. Factors associated with a higher risk of ipsilateral major amputation included male sex, severe frailty, diagnosis of gangrene, emergency admission, foot amputation (compared with toe amputation), and previous or concurrent revascularization. The estimated mortality rate was 17.2 (16.7 to 17.7) per cent at 1 year and 49.4 (48.6 to 50.1) per cent at 5 years after minor amputation. Older age, severe frailty, comorbidity, gangrene, and emergency admission were associated with a significantly higher mortality risk. CONCLUSION Minor amputations were associated with a high risk of major amputation and death. One in 10 patients had an ipsilateral major amputation within the first year after minor amputation and half had died by 5 years.
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Affiliation(s)
- Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Ian Chetter
- Hull York Medical School, Hull, UK
- Academic Vascular Surgical Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arun D Pherwani
- Staffordshire and South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Fowler AJ, Wahedally MAH, Abbott TEF, Prowle JR, Cromwell DA, Pearse RM. Long-term disease interactions amongst surgical patients: a population cohort study. Br J Anaesth 2023:S0007-0912(23)00237-4. [PMID: 37400340 PMCID: PMC10375505 DOI: 10.1016/j.bja.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND The average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described. METHODS We included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations. RESULTS We identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9-4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0-3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs. CONCLUSION One in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.
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Affiliation(s)
- Alexander J Fowler
- School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal College of Surgeons of England, London, UK.
| | | | - Tom E F Abbott
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John R Prowle
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - David A Cromwell
- Royal College of Surgeons of England, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - Rupert M Pearse
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
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12
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Wahba AJ, Phillips N, Mathew RK, Hutchinson PJ, Helmy A, Cromwell DA. Benchmarking short-term postoperative mortality across neurosurgery units: is hospital administrative data good enough for risk-adjustment? Acta Neurochir (Wien) 2023:10.1007/s00701-023-05623-5. [PMID: 37243824 DOI: 10.1007/s00701-023-05623-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/02/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Surgical mortality indicators should be risk-adjusted when evaluating the performance of organisations. This study evaluated the performance of risk-adjustment models that used English hospital administrative data for 30-day mortality after neurosurgery. METHODS This retrospective cohort study used Hospital Episode Statistics (HES) data from 1 April 2013 to 31 March 2018. Organisational-level 30-day mortality was calculated for selected subspecialties (neuro-oncology, neurovascular and trauma neurosurgery) and the overall cohort. Risk adjustment models were developed using multivariable logistic regression and incorporated various patient variables: age, sex, admission method, social deprivation, comorbidity and frailty indices. Performance was assessed in terms of discrimination and calibration. RESULTS The cohort included 49,044 patients. Overall, 30-day mortality rate was 4.9%, with unadjusted organisational rates ranging from 3.2 to 9.3%. The variables in the best performing models varied for the subspecialties; for trauma neurosurgery, a model that included deprivation and frailty had the best calibration, while for neuro-oncology a model with these variables plus comorbidity performed best. For neurovascular surgery, a simple model of age, sex and admission method performed best. Levels of discrimination varied for the subspecialties (range: 0.583 for trauma and 0.740 for neurovascular). The models were generally well calibrated. Application of the models to the organisation figures produced an average (median) absolute change in mortality of 0.33% (interquartile range (IQR) 0.15-0.72) for the overall cohort model. Median changes for the subspecialty models were 0.29% (neuro-oncology, IQR 0.15-0.42), 0.40% (neurovascular, IQR 0.24-0.78) and 0.49% (trauma neurosurgery, IQR 0.23-1.68). CONCLUSIONS Reasonable risk-adjustment models for 30-day mortality after neurosurgery procedures were possible using variables from HES, although the models for trauma neurosurgery performed less well. Including a measure of frailty often improved model performance.
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Affiliation(s)
- Adam J Wahba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK.
- Leeds Institute of Medical Research, School of Medicine, Worsley Building, University of Leeds, Leeds, LS2 9JT, UK.
| | - Nick Phillips
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, UK
| | - Ryan K Mathew
- Leeds Institute of Medical Research, School of Medicine, Worsley Building, University of Leeds, Leeds, LS2 9JT, UK
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, UK
| | - Peter J Hutchinson
- Department of Research, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Adel Helmy
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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13
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Viviani L, White IR, Williamson EJ, Carpenter J, van der Meulen J, Cromwell DA. The DetectDeviatingCells algorithm was a useful addition to the toolkit for cellwise error detection in observational data. J Clin Epidemiol 2023; 157:35-45. [PMID: 36806732 PMCID: PMC7615728 DOI: 10.1016/j.jclinepi.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES We evaluated the error detection performance of the DetectDeviatingCells (DDC) algorithm which flags data anomalies at observation (casewise) and variable (cellwise) level in continuous variables. We compared its performance to other approaches in a simulated dataset. STUDY DESIGN AND SETTING We simulated height and weight data for hypothetical individuals aged 2-20 years. We changed a proportion of height values according to predetermined error patterns. We applied the DDC algorithm and other error-detection approaches (descriptive statistics, plots, fixed-threshold rules, classic, and robust Mahalanobis distance) and we compared error detection performance with sensitivity, specificity, likelihood ratios, predictive values, and receiver operating characteristic (ROC) curves. RESULTS At our chosen thresholds error detection specificity was excellent across all scenarios for all methods and sensitivity was higher for multivariable and robust methods. The DDC algorithm performance was similar to other robust multivariable methods. Analysis of ROC curves suggested that all methods had comparable performance for gross errors (e.g., wrong measurement unit), but the DDC algorithm outperformed the others for more complex error patterns (e.g., transcription errors that are still plausible, although extreme). CONCLUSIONS The DDC algorithm has the potential to improve error detection processes for observational data.
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Affiliation(s)
- Laura Viviani
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
| | - Ian R White
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, UK
| | - Elizabeth J Williamson
- Faculty of Epidemiology and Population Health, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - James Carpenter
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, London WC1V 6LJ, UK; Faculty of Epidemiology and Population Health, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Jan van der Meulen
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - David A Cromwell
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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14
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Miller K, Gannon MR, Medina J, Clements K, Dodwell D, Horgan K, Park MH, Cromwell DA. The Association Between Survival and Receipt of Post-mastectomy Radiotherapy According to Age at Diagnosis Among Women With Early Invasive Breast Cancer: A Population-Based Cohort Study. Clin Oncol (R Coll Radiol) 2023; 35:e265-e277. [PMID: 36764877 DOI: 10.1016/j.clon.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/08/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023]
Abstract
AIMS Clinical trials of post-mastectomy radiotherapy (PMRT) for early invasive breast cancer (EIBC) have included few older women. This study examined whether the association between overall survival or breast cancer-specific survival (BCSS) and receipt of PMRT for EIBC altered with age. MATERIALS AND METHODS The study used patient-level linked cancer registration, routine hospital and radiotherapy data for England and Wales. It included 31 243 women aged ≥50 years diagnosed between 2014 and 2018 with low- (T1-2N0), intermediate- (T3N0/T1-2N1) or high-risk (T1-2N2/T3N1-2) EIBC who received a mastectomy within 12 months from diagnosis. Patterns of survival were analysed using a landmark approach. Associations between overall survival/BCSS and PMRT in each risk group were analysed with flexible parametric survival models, which included patient and tumour factors; whether the association between PMRT and overall survival/BCSS varied by age was assessed using interaction terms. RESULTS Among 4711 women with high-risk EIBC, 86% had PMRT. Five-year overall survival was 70.5% and BCSS was 79.3%. Receipt of PMRT was associated with improved overall survival [adjusted hazard ratio (aHR) 0.75, 95% confidence interval 0.64-0.87] and BCSS (aHR 0.78, 95% confidence interval 0.65-0.95) compared with women who did not have PMRT; associations did not vary by age (overall survival, P-value for interaction term = 0.141; BCSS, P = 0.077). Among 10 814 women with intermediate-risk EIBC, 59% had PMRT; 5-year overall survival was 78.4% and BCSS was 88.0%. No association was found between overall survival (aHR 1.01, 95% confidence interval 0.92-1.11) or BCSS (aHR 1.16, 95% confidence interval 1.01-1.32) and PMRT. There was statistical evidence of a small change in the association with age for overall survival (P = 0.007), although differences in relative survival were minimal, but not for BCSS (P = 0.362). CONCLUSIONS The association between PMRT and overall survival/BCSS does not appear to be modified by age among women with high- or intermediate-risk EIBC and, thus, treatment recommendations should not be modified on the basis of age alone.
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Affiliation(s)
- K Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - M R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - J Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - K Clements
- National Cancer Registration and Analysis Service, NHS Digital, Birmingham, UK
| | - D Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - M H Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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15
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Atkins E, Birmpili P, Glidewell L, Li Q, Johal AS, Waton S, Boyle JR, Pherwani AD, Chetter I, Cromwell DA. Effectiveness of quality improvement collaboratives in UK surgical settings and barriers and facilitators influencing their implementation: a systematic review and evidence synthesis. BMJ Open Qual 2023; 12:bmjoq-2022-002241. [PMID: 37037588 PMCID: PMC10106059 DOI: 10.1136/bmjoq-2022-002241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/14/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND High-quality surgical care is vital to deliver the excellent outcomes patients deserve following surgical treatment. Quality improvement collaboratives (QICs) are based on a multicentre model for improving healthcare. They are increasingly used but their effectiveness in the context of surgical services is unclear. This review assessed effectiveness of QICs in National Health Service (NHS) surgical settings, and identified factors that influenced implementation. METHODS A systematic search of MEDLINE and EMBASE, as well as grey literature, was conducted in January 2022 to identify evaluations of QICs in NHS surgical settings. Data were extracted on the intervention, setting, study results and factors that were identified as facilitators or barriers. These were coded using the Consolidated Framework for Implementation Research (CFIR). The quality of study reports was assessed using Quality Improvement Minimum Criteria Set. RESULTS Fifteen reports on 10 QICs met inclusion criteria. The evaluations used study designs of different strength, with one using a stepped-wedge randomised controlled trial (RCT). Eight studies reported the QIC had been successful in achieving their principal aims, which covered a mix of patient outcomes and process indicators. The study based on the RCT found the QIC was not successful (no improvement in patient outcomes). Each article reported a range of facilitators and barriers to effectiveness of implementation of the QIC, which were spread across the CFIR domains (intervention, outer setting, inner setting, individuals and process). There were few barriers reported in the intervention domain that related to the QIC. There was no clear relationship between numbers of facilitators and barriers reported and effectiveness. CONCLUSIONS Studies have reported QICs to be effective in increasingly complex contexts, but their results must be treated with caution. The evaluations often used weak study designs and the quality of reports was variable. Evaluation with strong study design should be integral to future QICs. PROSPERO REGISTRATION NUMBER CRD42022324970.
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Affiliation(s)
- Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | | | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Jon R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals, Cambridge, UK
| | - Arun D Pherwani
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, School of Hygiene and Tropical Medicine, London, UK
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16
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Pucher PH, Park MH, Cromwell DA, Crosby TC, Thomas B, Trudgill N, Wahedally M, Maynard N, Gossage JA. Diagnosis and treatment for gastro-oesophageal cancer in England and Wales: analysis of the National Oesophago-Gastric Cancer Audit (NOGCA) database 2012–2020. Br J Surg 2023; 110:701-709. [PMID: 36972221 PMCID: PMC10364547 DOI: 10.1093/bjs/znad065] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/26/2023] [Accepted: 02/13/2023] [Indexed: 03/29/2023]
Abstract
Abstract
Background
The National Oesophago-Gastric Cancer Audit (NOGCA) captures patient data from diagnosis to end of primary treatment for all patients with oesophagogastric (OG) cancer in England and Wales. This study assessed changes in patient characteristics, treatments received, and outcomes for OG cancer surgery for the period 2012–2020, and examined which factors may have led to changes in clinical outcomes over this time.
Methods
Patients diagnosed with OG cancer between April 2012 and March 2020 were included. Descriptive statistics were used to summarize patient demographics, disease site, type, and stage, patterns of care, and outcomes over time. The treatment variables of unit case volume, surgical approach, and neoadjuvant therapy were included. Regression models were used to examine associations between surgical outcomes (duration of stay and mortality), and patient and treatment variables.
Results
In total, 83 393 patients diagnosed with OG cancer during the study period were included. Patient demographics and cancer stage at diagnosis showed little change over time. Altogether, 17 650 patients underwent surgery as part of radical treatment. These patients had increasingly more advanced cancers, and a greater likelihood of pre-existing comorbidity in more recent years. Significant decreases in mortality rates and duration of stay were noted, along with improvements in oncological outcomes (nodal yields and margin positivity rates). Following adjustment for patient and treatment variables, increasing audit year and trust volume were associated, respectively, with improved postoperative outcomes: lower 30-day mortality (odds ratio (OR) 0.93 (95 per cent c.i. 0.88 to 0.98) and OR 0.99 (95 per cent c.i. 0.99–0.99)) and lower 90-day mortality (OR 0.94 (95 per cent c.i. 0.91 to 0.98) and OR 0.99 (95 per cent c.i. 0.99–0.99)), and a reduction in duration of postoperative stay (incidence rate ratio (IRR) 0.98 (95 per cent c.i. 0.97 to 0.98) and IRR 0.99 (95 per cent c.i. 0.99 to 0.99)).
Conclusion
Outcomes of OG cancer surgery have improved over time, despite little evidence of improvements in early diagnosis. The underlying drivers for improvements in outcome are multifactorial.
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Birmpili P, Li Q, Johal AS, Waton S, Atkins E, Boyle JR, Chetter I, Williams R, Pherwani AD, Cromwell DA. Outcomes of Surgery for Patients with Peripheral Arterial Disease During the COVID-19 Pandemic in the United Kingdom: A Population Based Study. Eur J Vasc Endovasc Surg 2023; 65:738-746. [PMID: 36774995 PMCID: PMC9912811 DOI: 10.1016/j.ejvs.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/24/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE There is limited information on changes in the patterns of care and outcomes for patients who had vascular procedures after the first wave of the COVID-19 pandemic. The aim of this population based study was to examine the patterns of care and outcomes for vascular lower limb procedures in the UK during the COVID-19 pandemic. METHODS Lower limb revascularisations and major amputations performed from January 2019 to April 2021 in the UK and entered in the National Vascular Registry were included in the study. The primary outcome was in hospital post-operative mortality and secondary outcomes were complications and re-interventions. The study was divided into Pre-pandemic (1 January 2019 - 29 February 2020), Wave 1 (1 March - 30 June 2020), Respite (1 July - 31 October 2020), Wave 2/3 (1 November 2020 - 30 April 2021). RESULTS The study included 36 938 procedures (7 245 major amputations, 16 712 endovascular, 12 981 open revascularisations), with 15 501 procedures after March 2020, a 27.7% reduction compared with pre-pandemic. The proportion of open surgical procedures performed under general anaesthetic was lower in Wave 1 and after compared with pre-pandemic (76.7% vs. 81.9%, p < .001). Only 4.6% of patients in the cohort had SARS-CoV-2 infection (n = 708), but their in hospital post-operative mortality was 25.0% (n = 177), six times higher than patients without SARS-CoV-2 (adjusted odds ratio 5.88; 95% CI 4.80 - 7.21, p < .001). The in hospital mortality rate was higher during the pandemic than pre-pandemic after elective open and endovascular revascularisation (respectively 1.6% vs. 1.1%, p = .033, and 0.9% vs. 0.5%, p = .005) and major amputations (10.4% during Wave 2/3 vs. 7.7% pre-pandemic, p = .022). CONCLUSION There was excess post-operative mortality for patients undergoing lower limb vascular procedures during the pandemic, which was associated with SARS-CoV-2 infections. Further research should be conducted on long-term outcomes of patients operated on during the COVID-19 pandemic period.
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Affiliation(s)
- Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Hull York Medical School, Hull, UK.
| | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S. Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK,Hull York Medical School, Hull, UK
| | - Jonathan R. Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Ian Chetter
- Hull York Medical School, Hull, UK,Academic Vascular Surgical Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Robin Williams
- Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Arun D. Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - David A. Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Rahman SA, Walker RC, Maynard N, Trudgill N, Crosby T, Cromwell DA, Underwood TJ. The AUGIS Survival Predictor: Prediction of Long-Term and Conditional Survival After Esophagectomy Using Random Survival Forests. Ann Surg 2023; 277:267-274. [PMID: 33630434 PMCID: PMC9831040 DOI: 10.1097/sla.0000000000004794] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of this study was to develop a predictive model for overall survival after esophagectomy using pre/postoperative clinical data and machine learning. SUMMARY BACKGROUND DATA For patients with esophageal cancer, accurately predicting long-term survival after esophagectomy is challenging. This study investigated survival prediction after esophagectomy using a RandomSurvival Forest (RSF) model derived from routine data from a large, well-curated, national dataset. METHODS Patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales who underwent an esophagectomy were included. Prediction models for overall survival were developed using the RSF method and Cox regression from 41 patient and disease characteristics. Calibration and discrimination (time-dependent area under the curve) were validated internally using bootstrap resampling. RESULTS The study analyzed 6399 patients, with 2625 deaths during follow-up. Median follow-up was 41 months. Overall survival was 47.1% at 5 years. The final RSF model included 14 variables and had excellent discrimination with a 5-year time-dependent area under the receiver operator curve of 83.9% [95% confidence interval (CI) 82.6%-84.9%], compared to 82.3% (95% CI 81.1%-83.3%) for the Cox model. The most important variables were lymph node involvement, pT stage, circumferential resection margin involvement (tumor at < 1 mm from cut edge) and age. There was a wide range of survival estimates even within TNM staging groups, with quintiles of prediction within Stage 3b ranging from 12.2% to 44.7% survival at 5 years. CONCLUSIONS An RSF model for long-term survival after esophagectomy exhibited excellent discrimination and well-calibrated predictions. At a patient level, it provides more accuracy than TNM staging alone and could help in the delivery of tailored treatment and follow-up.
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Affiliation(s)
- Saqib A Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Robert C Walker
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Nigel Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Timothy J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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Birmpili P, Atkins E, Li Q, Johal AS, Waton S, Williams R, Pherwani AD, Cromwell DA. Evaluation of the ICD-10 system in coding revascularisation procedures in patients with peripheral arterial disease in England: A retrospective cohort study using national administrative and clinical databases. EClinicalMedicine 2023; 55:101738. [PMID: 36386037 PMCID: PMC9661515 DOI: 10.1016/j.eclinm.2022.101738] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many studies evaluating care in hospitals in England use the Hospital Episode Statistics (HES) administrative database. The aim of this study was to explore whether the International Classification of Diseases 10th Revision (ICD-10) system used by HES supported the evaluation of care received by patients with peripheral arterial disease (PAD) who had revascularisation. METHODS This retrospective cohort study used records on patients who had revascularisation for PAD between 1st January 2017 and 31st December 2019 in England, collected prospectively in the National Vascular Registry (NVR) and linked to HES. Patients were excluded if their NVR record did not have a match in HES, due to lack of consent or different admission and procedure dates. Agreement between different presentations of PAD recorded in the NVR and the ICD-10 diagnostic codes recorded in HES was evaluated using the unweighted Kappa statistic and sensitivity and specificity. Agreement between the NVR and HES was also assessed for gender, age, comorbidities, mode of admission, and procedure type and side. FINDINGS In total, 20,603 patients who had 24,621 admissions were included in the study. Agreement between NVR and HES on patient gender (Kappa = 0.98), age (Kappa = 0.98), mode of admission (Kappa = 0.80), and procedure type and side (Kappa = 0.92 and 0.87, respectively) was excellent. When all diagnostic fields in HES were explored, substantial agreement was observed for chronic ischaemia with tissue loss (Kappa = 0.63), but it was lower for chronic ischaemia without tissue loss (Kappa = 0.32) and acute limb ischaemia (Kappa = 0.15). Agreement on comorbidities was mixed; excellent for diabetes (Kappa = 0.82), moderate for chronic lung disease (Kappa = 0.56), chronic kidney disease (Kappa = 0.56), and ischaemic heart disease (Kappa = 0.45) and fair for chronic heart failure (Kappa = 0.35). INTERPRETATION The diagnostic ICD-10 codes currently used in HES cannot accurately differentiate between stages of PAD. Therefore, studies using HES to examine patterns of care and outcomes for patients with PAD are likely to suffer from misclassification bias. Adopting an extended ICD-10 system or the ICD-11 version released to the World Health Organisation member states in 2022, may overcome this problem. FUNDING Healthcare Quality Improvement Partnership (HQIP).
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Affiliation(s)
- Panagiota Birmpili
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
- Corresponding author. Clinical Effectiveness Unit, The Royal College of Surgeons of England, Holborn, London, WC2A 3PE, UK.
| | - Eleanor Atkins
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S. Johal
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Robin Williams
- Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Arun D. Pherwani
- Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - David A. Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Wahba AJ, Cromwell DA, Hutchinson PJ, Mathew RK, Phillips N. Mortality as an indicator of quality of neurosurgical care in England: a retrospective cohort study. BMJ Open 2022; 12:e067409. [PMID: 36332948 PMCID: PMC9639111 DOI: 10.1136/bmjopen-2022-067409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Postoperative mortality is a widely used quality indicator, but it may be unreliable when procedure numbers and/or mortality rates are low, due to insufficient statistical power. The objective was to investigate the statistical validity of postoperative 30-day mortality as a quality metric for neurosurgical practice across healthcare providers. DESIGN Retrospective cohort study. SETTING Hospital Episode Statistics data from all neurosurgical units in England. PARTICIPANTS Patients who underwent neurosurgical procedures between April 2013 and March 2018. Procedures were grouped using the National Neurosurgical Audit Programme classification. OUTCOMES MEASURED National 30-day postoperative mortality rates were calculated for elective and non-elective neurosurgical procedural groups. The study estimated the proportion of neurosurgeons and NHS trusts in England that performed sufficient procedures in 3-year and 5-year periods to detect unusual performance (defined as double the national rate of mortality). The actual difference in mortality rates that could be reliably detected based on procedure volumes of neurosurgeons and units over a 5-year period was modelled. RESULTS The 30-day mortality rates for all elective and non-elective procedures were 0.4% and 6.1%, respectively. Only one neurosurgeon in England achieved the minimum sample size (n=2402) of elective cases in 5 years needed to detect if their mortality rate was double the national average. All neurosurgical units achieved the minimum sample sizes for both elective (n=2402) and non-elective (n=149) procedures. In several neurosurgical subspecialties, approximately 80% of units (or more) achieved the minimum sample sizes needed to detect if their mortality rate was double the national rate, including elective neuro-oncology (baseline mortality rate=2.3%), non-elective neuro-oncology (rate=5.7%), neurovascular (rate=6.7%) and trauma (rate=11%). CONCLUSION Postoperative mortality lacks statistical power as a measure of individual neurosurgeon performance. Neurosurgical units in England performed sufficient procedure numbers overall and in several subspecialty areas to support the use of mortality as a quality indicator.
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Affiliation(s)
- Adam J Wahba
- Clinical Effectiveness Unit, Royal College of Surgeons, London, UK
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons, London, UK
- Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter J Hutchinson
- Academic Neurosurgery, University of Cambridge, Cambridge, UK
- Clinical Research, Royal College of Surgeons, London, UK
| | - Ryan K Mathew
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nick Phillips
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Clinical Lead for Cranial Neurosurgery, Getting It Right First Time (GIRFT), London, UK
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21
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Li Q, Birmpili P, Johal AS, Waton S, Pherwani AD, Boyle JR, Cromwell DA. Delays to revascularization for patients with chronic limb-threatening ischaemia. Br J Surg 2022; 109:717-726. [PMID: 35543274 PMCID: PMC10364726 DOI: 10.1093/bjs/znac109] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/07/2022] [Accepted: 03/21/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Vascular services in England are organized into regional hub-and-spoke models, with hubs performing arterial surgery. This study examined time to revascularization for chronic limb-threatening ischaemia (CLTI) within and across different care pathways, and its association with postrevascularization outcomes. METHODS Three inpatient and four outpatient care pathways were identified for patients with CLTI undergoing revascularization between April 2015 and March 2019 using Hospital Episode Statistics data. Differences in times from presentation to revascularization across care pathways were analysed using Cox regression. The relationship between postoperative outcomes and time to revascularization was evaluated by logistic regression. RESULTS Among 16 483 patients with CLTI, 9470 had pathways starting with admission to a hub or spoke hospital, whereas 7013 (42.5 per cent) were first seen at outpatient visits. Among the inpatient pathways, patients admitted to arterial hubs had shorter times to revascularization than those admitted to spoke hospitals (median 5 (i.q.r. 2-10) versus 12 (7-19) days; P < 0.001). Shorter times to revascularization were also observed for patients presenting to outpatient clinics at arterial hubs compared with spoke hospitals (13 (6-25) versus 26 (15-35) days; P < 0.001). Within most care pathways, longer delays to revascularizsation were associated with increased risks of postoperative major amputation and in-hospital death, but the effect of delay differed across pathways. CONCLUSION For patients with CLTI, time to revascularization was influenced by presentation to an arterial hub or spoke hospital. Generally, longer delays to revascularization were associated with worse outcomes, but the impact of delay differed across pathways.
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Affiliation(s)
- Qiuju Li
- Correspondence to: Qiuju Li, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK (e-mail: )
| | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arun D Pherwani
- Vascular Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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Gannon MR, Dodwell D, Miller K, Horgan K, Clements K, Medina J, Kunkler I, Cromwell DA. Change in the Use of Fractionation in Radiotherapy Used for Early Breast Cancer at the Start of the COVID-19 Pandemic: A Population-Based Cohort Study of Older Women in England and Wales. Clin Oncol (R Coll Radiol) 2022; 34:e400-e409. [PMID: 35691761 PMCID: PMC9151525 DOI: 10.1016/j.clon.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/28/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022]
Abstract
Aims Adjuvant radiotherapy is recommended for most patients with early breast cancer (EBC) receiving breast-conserving surgery and those at moderate/high risk of recurrence treated by mastectomy. During the first wave of COVID-19 in England and Wales, there was rapid dissemination of randomised controlled trial-based evidence showing non-inferiority for five-fraction ultra-hypofractionated radiotherapy (HFRT) regimens compared with standard moderate-HFRT, with guidance recommending the use of five-fraction HFRT for eligible patients. We evaluated the uptake of this recommendation in clinical practice as part of the National Audit of Breast Cancer in Older Patients (NABCOP). Materials and methods Women aged ≥50 years who underwent surgery for EBC from January 2019 to July 2020 were identified from the Rapid Cancer Registration Dataset for England and from Wales Cancer Network data. Radiotherapy details were from linked national Radiotherapy Datasets. Multivariate mixed-effects logistic regression models were used to assess characteristics influential in the use of ultra-HFRT. Results Among 35 561 women having surgery for EBC, 71% received postoperative radiotherapy. Receipt of 26 Gy in five fractions (26Gy5F) increased from <1% in February 2020 to 70% in April 2020. Regional variation in the use of 26Gy5F during April to July 2020 was similar by age, ranging from 49 to 87% among women aged ≥70 years. Use of 26Gy5F was characterised by no known nodal involvement, no comorbidities and initial breast-conserving surgery. Of those patients receiving radiotherapy to the breast/chest wall, 85% had 26Gy5F; 23% had 26Gy5F if radiotherapy included regional nodes. Among 5139 women receiving postoperative radiotherapy from April to July 2020, nodal involvement, overall stage, type of surgery, time from diagnosis to start of radiotherapy were independently associated with fractionation choice. Conclusions There was a striking increase in the use of 26Gy5F dose fractionation regimens for EBC, among women aged ≥50 years, within a month of guidance published at the start of the COVID-19 pandemic in England and Wales.
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Affiliation(s)
- M R Gannon
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - D Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Miller
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - K Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - K Clements
- National Cancer Registration and Analysis Service, NHS Digital, Birmingham, UK
| | - J Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - I Kunkler
- University of Edinburgh, Edinburgh, UK
| | - D A Cromwell
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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Miller K, Gannon MR, Medina J, Clements K, Horgan K, Dodwell D, Park MH, Cromwell DA. Does the association between survival and receipt of post-mastectomy radiotherapy vary by age at diagnosis among women with early invasive breast cancer? European Journal of Surgical Oncology 2022. [DOI: 10.1016/j.ejso.2022.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wahba AJ, Cromwell DA, Hutchinson PJ, Mathew RK, Phillips N. Patterns and outcomes of neurosurgery in England over a five-year period: A national retrospective cohort study. Int J Surg 2022; 99:106256. [PMID: 35150923 DOI: 10.1016/j.ijsu.2022.106256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neurosurgical practice has seen major changes over several decades. There are no recent evaluations of national neurosurgical practice. The aim of this observational study was to describe neurosurgical practice in England and to use outcomes to assess and benchmark the quality of care in neurosurgery. MATERIAL AND METHODS This national retrospective cohort study analysed Hospital Episode Statistics (HES) data from April 2013 to March 2018 for all adult admissions with a specialty code for neurosurgery. The epidemiology of patients and RCS Charlson comorbidities were derived and procedure incidence rates per 100,000 person-years calculated. Post-operative outcomes for elective and non-elective patients included: median length of stay, the proportion of patients requiring additional inpatient neurosurgical procedures, the proportion of patients discharged to their usual address, and in-hospital mortality rates. RESULTS During the 5-year study period, there were 371,418 admissions to neurosurgery. The proportion of admissions involving a neurosurgical procedure was 77.3% (n = 287,077). Of these, 45% were for cranial surgery and 37% for spinal. Overall, 68.3% were elective procedures. The incidence rates of most procedures were low (<20 per 100,000 person-years). Following elective neurosurgical procedures, in-hospital mortality rates for cranial and spinal surgery were 0.5% (95% CI, 0.5-0.6) and 0.1% (95% CI, 0.04-0.1), respectively. After non-elective neurosurgery, mortality rates were 7.4% (95% CI, 7.2-7.6) and 1.3% (95% CI, 1.2-1.5) for cranial and spinal surgery, respectively. Approximately 1 in 4 patients had additional procedures following non-elective cranial surgery (24%; 95% CI, 23.6-24.3). Outcomes were highly variable across different subspecialty areas. CONCLUSIONS The incidence rates of neurosurgical procedures are low within England, and neurosurgical units have a high volume of non-surgical admissions. In-hospital mortality rates after elective neurosurgery are low but there may be opportunities for quality improvement programmes to improve outcomes for non-elective surgery as well as ensuring equitable access to treatment.
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Affiliation(s)
- Adam J Wahba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK School of Medicine, Worsley Building, University of Leeds, Leeds, LS2 9JT, UK Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, LS1 3EX, UK Vice President, Society of British Neurological Surgeons, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, UK
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25
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Miller K, Kreis IA, Gannon MR, Medina J, Clements K, Horgan K, Dodwell D, Park MH, Cromwell DA. The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review. Cancer Treat Rev 2022; 104:102353. [PMID: 35152157 DOI: 10.1016/j.ctrv.2022.102353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age. METHODOLOGY MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis. RESULTS Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age. CONCLUSIONS Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.
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Affiliation(s)
- Katie Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Irene A Kreis
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Melissa R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jibby Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Karen Clements
- National Cancer Registration and Analysis Service, NHS Digital, 2(nd) Floor, 23 Stephenson Street, Birmingham, UK
| | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Min Hae Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Rahman S, Thomas B, Maynard N, Park MH, Wahedally M, Trudgill N, Crosby T, Cromwell DA, Underwood TJ. Impact of postoperative chemotherapy on survival for oesophagogastric adenocarcinoma after preoperative chemotherapy and surgery. Br J Surg 2022; 109:227-236. [PMID: 34910129 PMCID: PMC10364695 DOI: 10.1093/bjs/znab427] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Perioperative chemotherapy is widely used in the treatment of oesophagogastric adenocarcinoma (OGAC) with a substantial survival benefit over surgery alone. However, the postoperative part of these regimens is given in less than half of patients, reflecting uncertainty among clinicians about its benefit and poor postoperative patient fitness. This study estimated the effect of postoperative chemotherapy after surgery for OGAC using a large population-based data set. METHODS Patients with adenocarcinoma of the oesophagus, gastro-oesophageal junction or stomach diagnosed between 2012 and 2018, who underwent preoperative chemotherapy followed by surgery, were identified from a national-level audit in England and Wales. Postoperative therapy was defined as the receipt of systemic chemotherapy within 90 days of surgery. The effectiveness of postoperative chemotherapy compared with observation was estimated using inverse propensity treatment weighting. RESULTS Postoperative chemotherapy was given to 1593 of 4139 patients (38.5 per cent) included in the study. Almost all patients received platinum-based triplet regimens (4004 patients, 96.7 per cent), with FLOT used in 3.3 per cent. Patients who received postoperative chemotherapy were younger, with a lower ASA grade, and were less likely to have surgical complications, with similar tumour characteristics. After weighting, the median survival time after postoperative chemotherapy was 62.7 months compared with 50.4 months without chemotherapy (hazard ratio 0.84, 95 per cent c.i. 0.77 to 0.94; P = 0.001). CONCLUSION This study has shown that postoperative chemotherapy improves overall survival in patients with OGAC treated with preoperative chemotherapy and surgery.
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Affiliation(s)
- Saqib Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Betsan Thomas
- Department of Oncology, Velindre University NHS Trust, Cardiff, UK
| | - Nick Maynard
- Department of Upper Gastrointestinal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Min Hae Park
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Muhammad Wahedally
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Nigel Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Tom Crosby
- Department of Oncology, Velindre University NHS Trust, Cardiff, UK
| | - David A. Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Tim J. Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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Fowler AJ, Wahedally MAH, Abbott TEF, Smuk M, Prowle JR, Pearse RM, Cromwell DA. Death after surgery among patients with chronic disease: prospective study of routinely collected data in the English NHS. Br J Anaesth 2021; 128:333-342. [PMID: 34949439 DOI: 10.1016/j.bja.2021.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/08/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Five million surgeries take place in the NHS each year. Little is known about the prevalence of chronic diseases among these patients, and the association with postoperative outcomes. METHODS Analysis of routine data from all NHS hospitals in England including patients aged ≥18 yr undergoing non-obstetric surgery between January 1, 2010 and December 31, 2015. The primary outcome was death within 90 days after surgery. For each chronic disease, we adjusted for age, sex, presence of other diseases, emergency surgery, and year using logistic regression models. We defined high-risk diseases as those with an adjusted odds ratio (OR) for death ≥2 and report associated 2-yr survival. RESULTS We included 8 624 611 patients (median age, 53 [36-68] yr), of whom 6 913 451 (80.2%) underwent elective surgery and 1 711 160 (19.8%) emergency surgery. Overall, 2 311 600 (26.8%) patients had a chronic disease, of whom 109 686 (4.7%) died within 90 days compared with 24 136 (0.4%) of 6 313 011 without chronic disease. Respiratory disease (1 002 281 [11.6%]), diabetes mellitus (662 706 [7.7%]), and cancer (310 363; 3.6%) were the most common. Four chronic diseases accounted for 7.7% of patients but 59.0% of deaths: cancer (37 693 deaths [12.1%]; OR=8.3 [8.2-8.5]), liver disease (8638 deaths [10.3%]; OR=4.5 [4.4-4.7]), cardiac failure (26 604 deaths [12.6%]; OR=2.4 [2.4-2.5]), and dementia (19 912 deaths [17.9%]; OR=2.0 [1.9-2.0]). Two-year survival was 67.7% among patients with high-risk chronic disease, compared with 97.1% without. CONCLUSION One in four surgical patients has a chronic disease with an associated 10-fold increase in risk of postoperative death. Two-thirds of all deaths after surgery occur among patients with high-risk diseases (cancer, cardiac failure, liver disease, dementia).
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Affiliation(s)
- Alexander J Fowler
- Barts & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal College of Surgeons of England, London, UK.
| | | | - Tom E F Abbott
- Barts & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Melanie Smuk
- London School of Hygiene and Tropical Medicine, London, UK
| | - John R Prowle
- Barts & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rupert M Pearse
- Barts & the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - David A Cromwell
- Royal College of Surgeons of England, London, UK; London School of Hygiene and Tropical Medicine, London, UK
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Rahman SA, Maynard N, Trudgill N, Crosby T, Park M, Wahedally H, Underwood TJ, Cromwell DA. Prediction of long-term survival after gastrectomy using random survival forests. Br J Surg 2021; 108:1341-1350. [PMID: 34297818 PMCID: PMC10364915 DOI: 10.1093/bjs/znab237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND No well validated and contemporaneous tools for personalized prognostication of gastric adenocarcinoma exist. This study aimed to derive and validate a prognostic model for overall survival after surgery for gastric adenocarcinoma using a large national dataset. METHODS National audit data from England and Wales were used to identify patients who underwent a potentially curative gastrectomy for adenocarcinoma of the stomach. A total of 2931 patients were included and 29 clinical and pathological variables were considered for their impact on survival. A non-linear random survival forest methodology was then trained and validated internally using bootstrapping with calibration and discrimination (time-dependent area under the receiver operator curve (tAUC)) assessed. RESULTS The median survival of the cohort was 69 months, with a 5-year survival of 53.2 per cent. Ten variables were found to influence survival significantly and were included in the final model, with the most important being lymph node positivity, pT stage and achieving an R0 resection. Patient characteristics including ASA grade and age were also influential. On validation the model achieved excellent performance with a 5-year tAUC of 0.80 (95 per cent c.i. 0.78 to 0.82) and good agreement between observed and predicted survival probabilities. A wide spread of predictions for 3-year (14.8-98.3 (i.q.r. 43.2-84.4) per cent) and 5-year (9.4-96.1 (i.q.r. 31.7-73.8) per cent) survival were seen. CONCLUSIONS A prognostic model for survival after a potentially curative resection for gastric adenocarcinoma was derived and exhibited excellent discrimination and calibration of predictions.
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Affiliation(s)
- S A Rahman
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - N Maynard
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - N Trudgill
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - T Crosby
- Velindre Cancer Centre, Cardiff, UK
| | - M Park
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - H Wahedally
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - T J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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Boyle JR, Mao J, Beck AW, Venermo M, Sedrakyan A, Behrendt CA, Szeberin Z, Eldrup N, Schermerhorn M, Beiles B, Thomson I, Cassar K, Altreuther M, Debus S, Johal AS, Waton S, Scali ST, Cromwell DA, Mani K. Editor's Choice - Variation in Intact Abdominal Aortic Aneurysm Repair Outcomes by Country: Analysis of International Consortium of Vascular Registries 2010 - 2016. Eur J Vasc Endovasc Surg 2021; 62:16-24. [PMID: 34144883 DOI: 10.1016/j.ejvs.2021.03.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Outcomes for intact abdominal aortic aneurysm (AAA) repair vary over time and by healthcare system, country, and surgeon. The aim of this study was to analyse peri-operative mortality for intact AAA repair in 11 countries over time and compare outcomes by gender, age, and geographical location. METHODS Prospective data on primary repair of intact AAA were collected from 11 countries through the International Consortium of Vascular Registries (ICVR) and analysed for two time periods, 2010 - 2013 and 2014 - 2016. The primary outcome was peri-operative mortality after endovascular aneurysm repair (EVAR) and open surgical repair (OSR). Multivariable logistic regression models were used to adjust for differences in patient characteristics. RESULTS A total of 103 715 patients were included. The percentage of patients undergoing EVAR increased from 63.6% to 71.2% (p < .001) over the study period. This proportion varied by country from 35% in Hungary to 81% in the United States. Overall peri-operative mortality decreased from 2.1% to 1.6 % (p < .001). Mortality also declined significantly over time for both OSR 4.2% to 3.6 % (p = .002) and EVAR 1.0% to 0.7% (p = .002). Mortality was significantly higher for female than male patients (3.0% vs. 1.6% p < .001). The percentage of patients > 80 years old undergoing AAA repair remained constant at 23.6% (p = .91). Peri-operative mortality was higher for patients > 80 years than for those < 80 years old (2.7% vs. 1.6% p < .001). Forty-six per cent (n = 275) of all EVAR deaths occurred in the over 80s. CONCLUSION The proportion of AAA repairs performed using EVAR has increased over time. Peri-operative mortality continues to decline for both OSR and EVAR. Outcomes however were significantly worse for both women and those aged over 80, so efforts should be focused on these patient groups to further reduce elective AAA mortality rates.
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Affiliation(s)
- Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK.
| | - Jialin Mao
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Art Sedrakyan
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Working Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Zoltan Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Marc Schermerhorn
- Division of Vascular Surgery and Endovascular Therapy, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Barry Beiles
- Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia
| | - Ian Thomson
- Department of Surgery, University of Otago, Dunedin, New Zealand
| | - Kevin Cassar
- Department of Surgery, Faculty of Medicine and Surgery, University of Malta, Malta
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Sebastian Debus
- Department of Vascular Medicine, Working Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, United Kingdom
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, United Kingdom
| | - Salvatore T Scali
- University of Florida College of Medicine, Division of Vascular Surgery & Endovascular Therapy, Gainesville, FL, USA
| | - David A Cromwell
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, United Kingdom
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Johal AS, Naylor AR, Pherwani AD, Li Q, Birmpili P, Waton S, O'Neill R, Boyle JR, Cromwell DA. Carotid Endarterectomy Following Intravenous Thrombolysis in the UK. Eur J Vasc Endovasc Surg 2021; 62:9-15. [PMID: 34088616 DOI: 10.1016/j.ejvs.2021.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of pre-operative intravenous thrombolytic therapy (ivTT) on short term outcomes after carotid endarterectomy (CEA) among patients who presented with ischaemic stroke. METHODS A retrospective study using a large population based dataset from the National Vascular Registry in the United Kingdom (UK-NVR). The cohort included adult patients who underwent CEA for ischaemic stroke between 1 January 2014 and 31 December 2019. NVR records provided information on patient demographics, Rankin score, medication, time from onset of symptoms to surgery and whether the patient received ivTT prior to surgery. Logistic regression was used to evaluate the relationship between ivTT and rates of any stroke at 30 days after CEA and in hospital complication rates for neck haematoma. Secondary outcomes included in hospital cardiac and respiratory complications, and cranial nerve injury. RESULTS Between 2014 and 2019, 9 030 patients presented with a stroke and underwent CEA, of whom 1 055 (11.7%) had received pre-operative ivTT. Those receiving ivTT were younger (mean 70.6 vs. 72.0 years, p < .001). The median (IQR) time from symptom to CEA was 10 days (6 - 17) for ivTT patients and 11 days (7 - 20) for CEA patients not receiving ivTT. Post-operative rates of 30 day stroke were similar between the no ivTT (2.1%) and ivTT (1.8%) cohorts (p = .48). In hospital neck haematomas were statistically significantly more common in CEA patients receiving ivTT (3.7%) vs. no ivTT (2.3%) (p = .006). There was no statistically significant association between 30 day stroke and neck haematoma complications when stratified for delays from symptom onset to CEA, but the overall cohort contained few adverse events for analysis during the very early time period. CONCLUSION The use of ivTT before CEA in stroke patients was not associated with an increased risk of 30 day stroke, but there was an increase in the risk of neck haematoma.
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Affiliation(s)
- Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
| | - Arun D Pherwani
- Royal Stoke Vascular Unit, Royal Stoke University Hospital, Stoke-On-Trent, UK
| | - Qiuju Li
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Panagiota Birmpili
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Richard O'Neill
- Interventional Radiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - David A Cromwell
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Rahman SA, Walker RC, Crosby T, Maynard N, Cromwell DA, Underwood TJ. O14: RANDOM FOREST MODELS FOR PREDICTING SURVIVAL AFTER OESOPHAGECTOMY. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
For patients with oesophageal cancer, producing accurate prediction models for survival after oesophagectomy has proved challenging. We investigated whether Random Survival Forests (RSF), a novel machine learning method, could produce an accurate prognostic model for overall survival after oesophagectomy.
Method
The study used data from the National Oesophago-Gastric Cancer Audit and included patients diagnosed with oesophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales and who underwent a curative oesophagectomy with adequate lymphadenectomy (15 LN) and survived to discharge (n=6198). Missing data was handled using multiple imputation and the data was split into training and validation cohorts. 13 variables were selected for inclusion using Random Forest variable importance and used to train the final model. The same variables were used to develop a traditional Cox regression model.
Result
Median survival was 53 months in both cohorts. The final RSF model had good discrimination in the validation cohort with a C-index of 0.757(0.755-0.759), exceeding the Cox model; 0.748(0.746-0.750). At 3 years post-surgery, overall survival was 56.2%. The RSF yielded a mean predicted survival of 55.8%(IQR 29.5%-81.7%) compared to 55.4%(40.0%-77.7%) for the Cox model. The most important variables were lymph node involvement and pT/ypT stage, however other variables including neoadjuvant treatment completion and surgical complications were also found to be important.
Conculsion
A Random Forest survival model provided better performance in predicting survival after curative oesophagectomy. This will allow more personalised predictions to be delivered clinicians and patients.
Take-home message
Random Forest survival models can accurately predict post-operative prognosis after oesophagectomy.
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Affiliation(s)
- SA Rahman
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton
| | - RC Walker
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton
| | | | - N Maynard
- Oxford University Hospitals NHS Foundation Trust
| | - DA Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England
| | - TJ Underwood
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton
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Jauhari Y, Gannon MR, Dodwell D, Horgan K, Clements K, Medina J, Cromwell DA. Surgical decisions in older women with early breast cancer: patient and disease factors. Br J Surg 2021; 108:160-167. [PMID: 33711149 PMCID: PMC7954278 DOI: 10.1093/bjs/znaa042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/27/2020] [Accepted: 09/19/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Studies reporting lower rates of surgery for older women with early invasive breast cancer have focused on women with oestrogen receptor (ER)-positive tumours. This study examined the factors that influence receipt of breast surgery in older women with ER-positive and ER-negative early invasive breast cancer . METHODS Women aged 50 years or above with unilateral stage 1-3A early invasive breast cancer diagnosed in 2014-2017 were identified from linked English and Welsh cancer registration and routine hospital data sets. Logistic regression analysis was used to evaluate the influence of tumour and patient factors on receipt of surgery. RESULTS Among 83 188 women, 86.8 per cent had ER-positive and 13.2 per cent had ER-negative early invasive breast cancer. These proportions were unaffected by age at diagnosis. Compared with women with ER-negative breast cancer, a higher proportion of women with ER-positive breast cancer presented with low risk tumour characteristics: G1 (20.0 versus 1.5 per cent), T1 (60.8 versus 44.2 per cent) and N0 (73.9 versus 68.8 per cent). The proportions of women with any recorded co-morbidity (13.7 versus 14.3 per cent) or degree of frailty (25 versus 25.8 per cent) were similar among women with ER-positive and ER-negative disease respectively. In women with ER-positive early invasive breast cancer aged 70-74, 75-79 and 80 years or above, the rate of no surgery was 5.6, 11.0 and 41.9 per cent respectively. Among women with ER-negative early invasive breast cancer, the corresponding rates were 3.8, 3.7 and 12.3 per cent. The relatively lower rate of surgery for ER-positive breast cancer persisted in women with good fitness. CONCLUSION The reasons for the observer differences should be further explored to ensure consistency in treatment decisions.
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Affiliation(s)
- Y Jauhari
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - M R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Horgan
- Department of Breast Surgery, St James’s University Hospital, Leeds, UK
| | - K Clements
- National Disease Registration Service, Public Health England, Birmingham, UK
| | - J Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Cowling TE, Cromwell DA, Sharples LD, van der Meulen J. A novel approach selected small sets of diagnosis codes with high prediction performance in large healthcare datasets. J Clin Epidemiol 2020; 128:20-28. [DOI: 10.1016/j.jclinepi.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 12/23/2022]
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Jeevan R, Browne JP, Gulliver-Clarke C, Pereira J, Caddy CM, van der Meulen JHP, Cromwell DA. Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer. Eur J Cancer Care (Engl) 2020; 30:e13362. [PMID: 33171000 DOI: 10.1111/ecc.13362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 08/27/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Mastectomy patients' satisfaction with reconstructive options has not been examined. METHODS A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability. RESULTS Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001). CONCLUSIONS Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.
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Affiliation(s)
- Ranjeet Jeevan
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Manchester University NHS Foundation Trust, Wythenshawe Hospital, Wythenshawe, Manchester, UK
| | - John P Browne
- Health Services Research Unit, Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Carmel Gulliver-Clarke
- Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Worthing, West Sussex, UK
| | - Jerome Pereira
- James Paget University Hospitals NHS Foundation Trust, Gorleston, Norfolk, UK.,University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Christopher M Caddy
- Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Jan H P van der Meulen
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Health Services Research Unit, Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Health Services Research Unit, Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Schoenweger P, Miller F, Cromwell DA, Waton S, Johal AS, Boyle JR, Heikkila K. Outcomes of Lower Limb Angioplasty Vary by Area Deprivation in England. Eur J Vasc Endovasc Surg 2020; 60:784-785. [DOI: 10.1016/j.ejvs.2020.07.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/03/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
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Heikkilä K, Loftus IM, Waton S, Johal AS, Boyle JR, Cromwell DA. Association of neighbourhood deprivation with risks of major amputation and death following lower limb revascularisation. Atherosclerosis 2020; 306:11-14. [DOI: 10.1016/j.atherosclerosis.2020.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/31/2020] [Accepted: 06/17/2020] [Indexed: 01/18/2023]
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Jauhari Y, Gannon MR, Dodwell D, Horgan K, Clements K, Medina J, Tsang C, Robinson T, Tang SSK, Pettengell R, Cromwell DA. Construction of the secondary care administrative records frailty (SCARF) index and validation on older women with operable invasive breast cancer in England and Wales: a cohort study. BMJ Open 2020; 10:e035395. [PMID: 32376755 PMCID: PMC7223146 DOI: 10.1136/bmjopen-2019-035395] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/28/2020] [Accepted: 03/31/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Studies that use national datasets to evaluate the management of older women with breast cancer are often constrained by a lack of information on patient fitness. This study constructed a frailty index for use with secondary care administrative records and evaluated its ability to improve models of treatment patterns and overall survival in women with breast cancer. DESIGN Retrospective cohort study. PARTICIPANTS Women aged ≥50 years with oestrogen receptor (ER) positive early invasive breast cancer diagnosed between 2014 and 2017 in England. METHODS The secondary care administrative records frailty (SCARF) index was based on the cumulative deficit model of frailty, using International Statistical Classification of Diseases, Injuries and Causes of Death, 10th revision codes to define a set of deficits. The index was applied to administrative records that were linked to national cancer registry datasets. The ability of the SCARF index to improve the performance of regression models to explain observed variation in the rate of surgery and overall survival was evaluated using Harrell's c-statistic and decision curve analysis. External validation was performed on a dataset of similar women diagnosed in Wales. RESULTS The SCARF index captured 32 deficits that cover functional impairment, geriatric syndromes, problems with nutrition, cognition and mood, and medical comorbidities. In the English dataset (n=67 925), the prevalence of frailty in women aged 50-69, 70-79 and ≥80 years was 15%, 28% and 47%, respectively. Adding a frailty measure to regression models containing age, tumour characteristics and comorbidity improved their ability to: (1) discriminate between whether a woman was likely to have surgery and (2) predict overall survival. Similar results were obtained when the models were applied to the Welsh cohort (n=4 230). CONCLUSION The SCARF index provides a simple and consistent method to identify frailty in population level data and could help describe differences in breast cancer treatments and outcomes.
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Affiliation(s)
- Yasmin Jauhari
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Melissa Ruth Gannon
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David Dodwell
- Nuffield Department of Population Health, Oxford University, Oxford, Oxfordshire, UK
| | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, W Yorks, UK
| | - Karen Clements
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Jibby Medina
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Carmen Tsang
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, Leicestershire, UK
| | | | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Bielicki JA, Sharland M, Heath PT, Walker AS, Agarwal R, Turner P, Cromwell DA. Evaluation of the Coverage of 3 Antibiotic Regimens for Neonatal Sepsis in the Hospital Setting Across Asian Countries. JAMA Netw Open 2020; 3:e1921124. [PMID: 32049298 DOI: 10.1001/jamanetworkopen.2019.21124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE High levels of antimicrobial resistance in neonatal bloodstream isolates are being reported globally, including in Asia. Local hospital antibiogram data may include too few isolates to meaningfully examine the expected coverage of antibiotic regimens. OBJECTIVE To assess the coverage offered by 3 antibiotic regimens for empirical treatment of neonatal sepsis in Asian countries. DESIGN, SETTING, AND PARTICIPANTS A decision analytical model was used to estimate coverage of 3 prespecified antibiotic regimens according to a weighted-incidence syndromic combination antibiogram. Relevant data to parameterize the models were identified from a systematic search of Ovid MEDLINE and Embase. Data from Asian countries published from 2014 onward were of interest. Only data on blood culture isolates from neonates with sepsis, bloodstream infection, or bacteremia reported from the relevant setting were included. Data analysis was performed from April 2019 to July 2019. EXPOSURES The prespecified regimens of interest were aminopenicillin-gentamicin, third-generation cephalosporins (cefotaxime or ceftriaxone), and meropenem. The relative incidence of different bacteria and their antimicrobial susceptibility to antibiotics relevant for determining expected concordance with these regimens were extracted. MAIN OUTCOMES AND MEASURES Coverage was calculated on the basis of a decision-tree model incorporating relative bacterial incidence and antimicrobial susceptibility of relevant isolates. Data on 7 bacteria most commonly reported in the included studies were used for estimating coverage, which was reported at the country level. RESULTS Data from 48 studies reporting on 10 countries and 8376 isolates were used. Individual countries reported 51 (Vietnam) to 6284 (India) isolates. Coverage varied considerably between countries. Meropenem was generally estimated to provide the highest coverage, ranging from 64.0% (95% credible interval [CrI], 62.6%-65.4%) in India to 90.6% (95% CrI, 86.2%-94.4%) in Cambodia, followed by aminopenicillin-gentamicin (from 35.9% [95% CrI, 27.7%-44.0%] in Indonesia to 81.0% [95% CrI, 71.1%-89.7%] in Laos) and cefotaxime or ceftriaxone (from 17.9% [95% CrI, 11.7%-24.7%] in Indonesia to 75.0% [95% CrI, 64.8%-84.1%] in Laos). Aminopenicillin-gentamicin coverage was lower than that of meropenem in all countries except Laos (81.0%; 95% CrI, 71.1%-89.7%) and Nepal (74.3%; 95% CrI, 70.3%-78.2%), where 95% CrIs for aminopenicillin-gentamicin and meropenem were overlapping. Third-generation cephalosporin coverage was lowest of the 3 regimens in all countries. The coverage difference between aminopenicillin-gentamicin and meropenem for countries with nonoverlapping 95% CrIs ranged from -15.9% in China to -52.9% in Indonesia. CONCLUSIONS AND RELEVANCE This study's findings suggest that noncarbapenem antibiotic regimens may provide limited coverage for empirical treatment of neonatal sepsis in many Asian countries. Alternative regimens must be studied to limit carbapenem consumption.
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Affiliation(s)
- Julia A Bielicki
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Paediatric Pharmacology and Paediatric Infectious Diseases, University of Basel Children's Hospital, Basel, Switzerland
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
| | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Ramesh Agarwal
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Poulton TE, Moonesinghe R, Raine R, Martin P, Anderson ID, Bassett MG, Cromwell DA, Davies E, Eugene N, Grocott MP, Johnston C, Kuryba A, Lockwood S, Lourtie J, Murray D, Oliver C, Peden C, Salih T, Walker K. Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study. Br J Anaesth 2020; 124:73-83. [DOI: 10.1016/j.bja.2019.08.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/05/2019] [Accepted: 08/22/2019] [Indexed: 11/28/2022] Open
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Johal AS, Loftus IM, Boyle JR, Heikkila K, Waton S, Cromwell DA. Long-term survival after endovascular and open repair of unruptured abdominal aortic aneurysm. Br J Surg 2019; 106:1784-1793. [DOI: 10.1002/bjs.11215] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/07/2019] [Accepted: 03/24/2019] [Indexed: 11/10/2022]
Abstract
Abstract
Background
The aim of this study was to examine patterns of 10-year survival after elective repair of unruptured abdominal aortic aneurysms (AAAs) in different patient groups.
Methods
Patients having open repair or endovascular aneurysm repair (EVAR) in the English National Health Service between January 2006 and December 2015 were identified from Hospital Episode Statistics data. Postoperative survival among patients of different age and Royal College of Surgeons of England (RCS) modified Charlson co-morbidity score profiles were analysed using flexible parametric survival models. The relationship between patient characteristics and risk of rupture after repair was also analysed.
Results
Some 37 138 patients underwent elective AAA repair, of which 15 523 were open and 21 615 were endovascular. The 10-year mortality rate was 38·1 per cent for patients aged under 70 years, and the survival trajectories for open repair and EVAR were similar when patients had no RCS-modified Charlson co-morbidity. Among older patients or those with co-morbidity, the 10-year mortality rate rose, exceeding 70 per cent for patients aged 80 years. Mean survival times over 10 years for open repair and EVAR were often similar in subgroups of older and more co-morbid patients, but their survival trajectories became increasingly dissimilar, with open repair showing greater short-term risk within 6 months but lower 10-year mortality rates. The risk of rupture over 9 years was 3·4 per cent for EVAR and 0·9 per cent for open repair, and was weakly associated with patient factors.
Conclusion
Long-term survival patterns after elective open repair and EVAR for unruptured AAA vary markedly across patients with different age and co-morbidity profiles.
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Affiliation(s)
- A S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - I M Loftus
- St George's University Hospitals NHS Foundation Trust Vascular Institute, London, UK
| | - J R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Heikkila
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Bamber JR, Stephens TJ, Cromwell DA, Duncan E, Martin GP, Quiney NF, Abercrombie JF, Beckingham IJ. Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy. BJS Open 2019; 3:802-811. [PMID: 31832587 PMCID: PMC6887703 DOI: 10.1002/bjs5.50221] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/01/2019] [Indexed: 12/21/2022] Open
Abstract
Background Acute gallstone disease is a high‐volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. Methods Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole‐QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. Results Of 13 sites invited to join Chole‐QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole‐QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8‐day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. Conclusion A surgeon‐led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.
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Affiliation(s)
- J R Bamber
- Practicality Consulting Queen Mary University of London London UK
| | - T J Stephens
- William Harvey Research Institute Queen Mary University of London London UK
| | - D A Cromwell
- Department of Health Services Research and Policy London School of Hygiene and Tropical Medicine London UK
| | - E Duncan
- Department of Professional Standards Royal College of Surgeons of England London UK
| | - G P Martin
- The Healthcare Improvement Studies (THIS) Institute University of Cambridge Cambridge UK
| | - N F Quiney
- Department of Anaesthesia Royal Surrey County Hospital Guildford UK
| | - J F Abercrombie
- Departments of Colorectal Surgery Queen's Medical Centre Nottingham UK
| | - I J Beckingham
- Hepatobiliary and Pancreatic Surgery Queen's Medical Centre Nottingham UK
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Johal AS, Loftus IM, Boyle JR, Naylor AR, Waton S, Heikkila K, Cromwell DA. Changing Patterns of Carotid Endarterectomy Between 2011 and 2017 in England. Stroke 2019; 50:2461-2468. [DOI: 10.1161/strokeaha.119.025231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Carotid endarterectomy (CEA) reduces the risk of stroke in recently symptomatic patients and less so in asymptomatic patients. Recent evidence suggests that the number of CEAs may be declining. The aim of this study was to investigate annual patterns of CEA in asymptomatic and symptomatic patients in England from 2011 to 2017.
Methods—
Data from the National Vascular Registry were used to describe (1) the number of CEA procedures in England and its 9 geographic regions from 2011 to 2017, (2) the characteristics of patients undergoing CEA, and (3) whether rates of CEA correlated with the number of vascular arterial units within each region. Annual stroke incidence for each region was derived from official population figures and the number of index stroke admissions per year.
Results—
The overall number of CEAs performed in England fell from 4992 in 2011 to 3482 in 2017, a 30% decline. Among symptomatic patients, there was a 25% decline, the number of CEAs falling from 4270 to 3217. In asymptomatic patients, there were 722 CEAs performed in 2011 and 265 in 2017, a 63% decline. CEAs per 100 000 adults within all regions declined over time but the size of change varied across the regions (range, 1.7–5.5 per 100 000). The regional numbers of CEAs per year were associated with changes in the regional stroke incidence, the proportion of CEAs performed in asymptomatic patients, and the number of hospitals performing CEA.
Conclusions—
This population-based study revealed a 63% decline in CEAs among asymptomatic patients between 2011 and 2017, possibly because of changing attitudes in the role of CEA. Reasons for the 25% decline in CEAs among symptomatic patients are unclear as UK guidelines on CEA have not changed for these patients. Whether the proportion of symptomatic patients with 50% to 99% ipsilateral stenosis has changed requires investigation.
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Affiliation(s)
- Amundeep S. Johal
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Ian M. Loftus
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom (I.M.L.)
| | - Jonathan R. Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke’s Hospital, Cambridge University Hospital Trust, United Kingdom (J.R.B.)
| | - A. Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, United Kingdom (A.R.N.)
| | - Sam Waton
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Katriina Heikkila
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
| | - David A. Cromwell
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
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Knight HE, Oddie SJ, Harron KL, Aughey HK, van der Meulen JH, Gurol-Urganci I, Cromwell DA. Establishing a composite neonatal adverse outcome indicator using English hospital administrative data. Arch Dis Child Fetal Neonatal Ed 2019; 104:F502-F509. [PMID: 30487299 PMCID: PMC6703994 DOI: 10.1136/archdischild-2018-315147] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 10/06/2018] [Accepted: 10/19/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We adapted a composite neonatal adverse outcome indicator (NAOI), originally derived in Australia, and assessed its feasibility and validity as an outcome indicator in English administrative hospital data. DESIGN We used Hospital Episode Statistics (HES) data containing information infants born in the English National Health Service (NHS) between 1 April 2014 and 31 March 2015. The Australian NAOI was mapped to diagnoses and procedure codes used within HES and modified to reflect data quality and neonatal health concerns in England. To investigate the concurrent validity of the English NAOI (E-NAOI), rates of NAOI components were compared with population-based studies. To investigate the predictive validity of the E-NAOI, rates of readmission and death in the first year of life were calculated for infants with and without E-NAOI components. RESULTS The analysis included 484 007 (81%) of the 600 963 eligible babies born during the timeframe. 114/148 NHS trusts passed data quality checks and were included in the analysis. The modified E-NAOI included 23 components (16 diagnoses and 7 procedures). Among liveborn infants, 5.4% had at least one E-NAOI component recorded before discharge. Among newborns discharged alive, the E-NAOI was associated with a significantly higher risk of death (0.81% vs 0.05%; p<0.001) and overnight hospital readmission (15.7% vs 7.1%; p<0.001) in the first year of life. CONCLUSIONS A composite NAOI can be derived from English hospital administrative data. This E-NAOI demonstrates good concurrent and predictive validity in the first year of life. It is a cost-effective way to monitor neonatal outcomes.
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Affiliation(s)
- Hannah Ellin Knight
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine Faculty of Public Health and Policy, London, UK,Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Sam J Oddie
- Bradford Neonatology, Bradford Royal Infirmary, West Yorkshire, UK
| | - Katie L Harron
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Harriet K Aughey
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK,University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jan H van der Meulen
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Ipek Gurol-Urganci
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - David A Cromwell
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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Mamza JB, Geary RS, El-Hamamsy D, Cromwell DA, Duckett J, Monga A, Toozs-Hobson P, Mahmood T, Wilson A, Tincello DG, van der Meulen JH, Gurol Urganci I. Geographical variation in rates of surgical treatment for female stress urinary incontinence in England: a national cohort study. BMJ Open 2019; 9:e029878. [PMID: 31462480 PMCID: PMC6720135 DOI: 10.1136/bmjopen-2019-029878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS). DESIGN National cohort study. SETTING NHS hospitals. PARTICIPANTS 27 997 women aged 20 years or older who had a first SUI surgery in an English NHS Hospital between April 2013 and March 2016 and a diagnosis of SUI at the same time as the procedure. METHODS Multilevel Poisson regression was used to adjust for geographic differences in age, ethnicity, prevalence of long-term illness and socioeconomic deprivation. PRIMARY OUTCOME MEASURE Rate of surgery for SUI per 100 000 women/year at two geographic levels: Clinical Commissioning Group (CCG; n=209) and Sustainability and Transformation Partnership (STP; n=44). RESULTS The rate of surgery for SUI was 40 procedures per 100 000 women/year. Risk-adjusted rates ranged from 20 to 106 procedures per 100 000 women/year across CCGs and 24 to 69 procedures per 100 000 women/year across the STP areas. These regional differences were only partially explained by demographic characteristics as adjustment reduced variance of surgery rates by 16% among the CCGs and 35% among the STPs. CONCLUSIONS Substantial geographic variation exists in the use of surgery for female SUI in the English NHS, suggesting that women in some areas are more likely to be treated compared with women with the same condition in other areas. The variation reflects differences in how national guidelines are being interpreted in the context of the ongoing debate about the safety of SUI surgery.
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Affiliation(s)
- Jil B Mamza
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Rebecca S Geary
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Dina El-Hamamsy
- Obstetrics and Gynaecology Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | | | - Ash Monga
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Jan H van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Ipek Gurol Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
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Geary RS, Gurol-Urganci I, Kiran A, Cromwell DA, Bansi-Matharu L, Shakespeare J, Mahmood T, van der Meulen J. Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit. BMJ Open 2019; 9:e024260. [PMID: 30782899 PMCID: PMC6377553 DOI: 10.1136/bmjopen-2018-024260] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To examine the factors associated with receiving surgery for heavy menstrual bleeding (HMB) in England and Wales. DESIGN National cohort study. SETTING National Health Service hospitals. PARTICIPANTS Women with HMB aged 18-60 who had a new referral to secondary care. METHODS Patient-reported data linked to administrative hospital data. Risk ratios (RR) estimated using multivariable Poisson regression. PRIMARY OUTCOME MEASURE Surgery within 1 year of first outpatient clinic visit. RESULTS 14 545 women were included. At their first clinic visit, mean age was 42 years, mean symptom severity score was 62 (scale ranging from 0 (least) to 100 (most severe)), 73.9% of women reported having symptoms for >1 year and 30.4% reported no prior treatment in primary care. One year later, 42.6% had received surgery. Of these, 57.8% had endometrial ablation and 37.2% hysterectomy. Women with more severe symptoms were more likely to have received surgery (most vs least severe quintile, 33.1% vs 56.0%; RR 1.6, 95% CI 1.5 to 1.7). Surgery was more likely among those who reported prior primary care treatment compared with those who did not (48.0% vs 31.1%; RR 1.5, 95% CI 1.4 to 1.6). Surgery was less likely among Asian and more likely among black women, compared with white women. Surgery was not associated with socioeconomic deprivation. CONCLUSIONS Receipt of surgery for HMB depends on symptom severity and prior treatment in primary care. Referral pathways should be locally audited to ensure women with HMB receive care that addresses their individual needs and preferences, especially for those who do not receive treatment in primary care.
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Affiliation(s)
- Rebecca Sally Geary
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Tahir Mahmood
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
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Neuburger J, Currie C, Wakeman R, Georghiou T, Boulton C, Johansen A, Tsang C, Wilson H, Cromwell DA, van der Meulen J. Safe working in a 7-day service. Experience of hip fracture care as documented by the UK National Hip Fracture Database. Age Ageing 2018; 47:741-745. [PMID: 29796590 DOI: 10.1093/ageing/afy074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 11/12/2022] Open
Abstract
Objective to describe differences in care and 30-day mortality of patients admitted with hip fracture on weekends (Saturday-Sunday) compared to weekdays (Monday-Friday), and their relationship to the organisation of care. Methods data came from the National Hip Fracture Database (NHFD) linked to ONS mortality data on 52,599 patients presenting to 162 units in England between 1 January and 31 December 2014. This was combined with information on geriatrician staffing and major trauma centre (MTC) status. 30-day mortality and care were compared for patients admitted at weekends and weekdays; separately for patients treated in units grouped by the mean level of input by geriatricians, weekend geriatrician clinical cover and MTC status. Differences were adjusted for variation in patients' characteristics. Results there was no evidence of differences in 30-day mortality between patients admitted at weekends compared to weekdays (7.2 vs 7.5%, P = 0.3) before or after adjusting for patient characteristics in either MTCs or general hospitals. The proportion receiving a preoperative geriatrician assessment was lower at weekends (42.8 vs 60.7%, P < 0.001). 30-day mortality was lower in units with higher levels of geriatrician input, but there was no weekend mortality effect associated with lower levels of input or absence of weekend cover. Conclusion there was no evidence of a weekend mortality effect among patients treated for hip fracture in the English NHS. It appears that clinical teams provide comparably safe and effective care throughout the week. However, greater geriatrician involvement in teams was associated with overall lower mortality.
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Affiliation(s)
- Jenny Neuburger
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK
- The Nuffield Trust, London, UK
| | - Colin Currie
- Formerly of Geriatric Medicine Unit, School of Clinical Sciences and Community Health, College of Medicine and Veterinary Medicine, Edinburgh University, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, UK
| | - Robert Wakeman
- Royal College of Physicians, 11 St Andrews Place, London, UK
| | | | - Chris Boulton
- Royal College of Physicians, 11 St Andrews Place, London, UK
| | | | - Carmen Tsang
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - Helen Wilson
- Royal Surrey County Hospital, Guildford, Surrey, UK
| | - David A Cromwell
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, UK
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, 34-43 Lincoln’s Inn Fields, London, UK
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Harron KL, Doidge JC, Knight HE, Gilbert RE, Goldstein H, Cromwell DA, van der Meulen JH. A guide to evaluating linkage quality for the analysis of linked data. Int J Epidemiol 2018; 46:1699-1710. [PMID: 29025131 PMCID: PMC5837697 DOI: 10.1093/ije/dyx177] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/14/2022] Open
Abstract
Linked datasets are an important resource for epidemiological and clinical studies, but linkage error can lead to biased results. For data security reasons, linkage of personal identifiers is often performed by a third party, making it difficult for researchers to assess the quality of the linked dataset in the context of specific research questions. This is compounded by a lack of guidance on how to determine the potential impact of linkage error. We describe how linkage quality can be evaluated and provide widely applicable guidance for both data providers and researchers. Using an illustrative example of a linked dataset of maternal and baby hospital records, we demonstrate three approaches for evaluating linkage quality: applying the linkage algorithm to a subset of gold standard data to quantify linkage error; comparing characteristics of linked and unlinked data to identify potential sources of bias; and evaluating the sensitivity of results to changes in the linkage procedure. These approaches can inform our understanding of the potential impact of linkage error and provide an opportunity to select the most appropriate linkage procedure for a specific analysis. Evaluating linkage quality in this way will improve the quality and transparency of epidemiological and clinical research using linked data.
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Affiliation(s)
- Katie L Harron
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - James C Doidge
- Administrative Data Research Centre for England, UCL Great Ormond Street Institute of Child Health, UCL, London, UK.,Centre for Population Health Research, University of South Australia, Adelaide, Australia
| | - Hannah E Knight
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ruth E Gilbert
- Administrative Data Research Centre for England, UCL Great Ormond Street Institute of Child Health, UCL, London, UK
| | - Harvey Goldstein
- Administrative Data Research Centre for England, UCL Great Ormond Street Institute of Child Health, UCL, London, UK.,Graduate School of Education, University of Bristol, Bristol, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jan H van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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48
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Bielicki JA, Sharland M, Versporten A, Goossens H, Cromwell DA. Using risk adjustment to improve the interpretation of global inpatient pediatric antibiotic prescribing. PLoS One 2018; 13:e0199878. [PMID: 29979795 PMCID: PMC6034826 DOI: 10.1371/journal.pone.0199878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/15/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives Assessment of regional pediatric last-resort antibiotic utilization patterns is hampered by potential confounding from population differences. We developed a risk-adjustment model from readily available, internationally used survey data and a simple patient classification to aid such comparisons. Design We investigated the association between pediatric conserve antibiotic (pCA) exposure and patient / treatment characteristics derived from global point prevalence surveys of antibiotic prescribing, and developed a risk-adjustment model using multivariable logistic regression. The performance of a simple patient classification of groups with different expected pCA exposure levels was compared to the risk model. Setting 226 centers in 41 countries across 5 continents. Participants Neonatal and pediatric inpatient antibiotic prescriptions for sepsis/bloodstream infection for 1281 patients. Results Overall pCA exposure was high (35%), strongly associated with each variable (patient age, ward, underlying disease, community acquisition or nosocomial infection and empiric or targeted treatment), and all were included in the final risk-adjustment model. The model demonstrated good discrimination (c-statistic = 0.83) and calibration (p = 0.38). The simple classification model demonstrated similar discrimination and calibration to the risk model. The crude regional pCA exposure rates ranged from 10.3% (Africa) to 67.4% (Latin America). Risk adjustment substantially reduced the regional variation, the adjusted rates ranging from 17.1% (Africa) to 42.8% (Latin America). Conclusions Greater comparability of pCA exposure rates can be achieved by using a few easily collected variables to produce risk-adjusted rates.
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Affiliation(s)
- Julia A. Bielicki
- Paediatric Infectious Diseases Research Group, Infection and Immunity, St George’s University of London, London, United Kingdom
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Paediatric Pharmacology Group, University of Basel Children’s Hospital, Basel, Switzerland
- * E-mail:
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Ann Versporten
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - David A. Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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49
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Geary RS, Knight HE, Carroll FE, Gurol‐Urganci I, Morris E, Cromwell DA, van der Meulen JH. A step-wise approach to developing indicators to compare the performance of maternity units using hospital administrative data. BJOG 2018; 125:857-865. [PMID: 29105913 PMCID: PMC6001534 DOI: 10.1111/1471-0528.15013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
Hospital administrative data are attractive for comparing performance of maternity units because of their often large sample sizes, lack of selection bias and the relatively low costs of accessing these data compared with conducting primary data collection. However, using administrative data to develop indicators can also present challenges including varying data quality, the limited detail on clinical risk factors and a lack of structural and user experience measures. This review illustrates how to develop performance indicators for maternity units using hospital administrative data, including methods to address the challenges that administrative data pose. TWEETABLE ABSTRACT How to develop maternity indicators from administrative data.
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Affiliation(s)
- RS Geary
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - HE Knight
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - FE Carroll
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - I Gurol‐Urganci
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - E Morris
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
- Norfolk and Norwich University HospitalNorwichUK
| | - DA Cromwell
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Surgeons of EnglandClinical Effectiveness UnitLondonUK
| | - JH van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
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50
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Heikkila K, Loftus IM, Mitchell DC, Johal AS, Waton S, Cromwell DA. Population-based study of mortality and major amputation following lower limb revascularization. Br J Surg 2018; 105:1145-1154. [DOI: 10.1002/bjs.10823] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 12/08/2017] [Accepted: 12/18/2017] [Indexed: 11/11/2022]
Abstract
Abstract
Background
The aim of this study was to estimate separate risks of major lower limb amputation and death following revascularization for peripheral artery disease (PAD) using competing risks analysis.
Methods
Routinely collected data from Hospital Episode Statistics (HES) were used to identify patients who underwent endovascular or open lower limb revascularization for PAD in England from 2005 to 2015. The primary outcomes were major lower limb amputation and death within 5 years of revascularization. Cox proportional hazards and Fine–Gray competing risks regression were used to examine the competing risks of these outcomes.
Results
Some 164 845 patients underwent their first lower limb revascularization for PAD during the study interval. Most were men (64·6 per cent) and the median age was 71 (i.q.r. 62–78) years. Following endovascular revascularization, the 5-year cumulative incidence of amputation was 4·2 per cent in patients with intermittent claudication and 18·0 per cent in those with a record of tissue loss. The corresponding rates were 10·8 and 25·3 per cent respectively after open revascularization, and 8·1 and 25·0 per cent after combined procedures. The 5-year cumulative incidence of death varied from 24·5 to 39·8 per cent, depending on procedure type. Competing risks methods consistently produced lower estimates than standard methods.
Conclusion
The 5-year risk of major amputation following lower limb revascularization for PAD appears lower than estimated previously. Patients undergoing revascularization for tissue loss and those who require an open procedure are at highest risk of limb loss.
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Affiliation(s)
- K Heikkila
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - I M Loftus
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - D C Mitchell
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - A S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - S Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - D A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
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