Challenges of monitoring use of secondary care at local level: a study based in London, UK

Comparison of UK’s Minor Ailments Scheme and US’s retail clinic model: a narrative review

There is a raising demand for unscheduled care in the United Kingdom. Minor Ailments Schemes (MAS) were introduced to reduce the burden of minor ailments on higher cost settings such as general practices and emergency departments. The number of visits for minor ailments at GPs often declined following the implementation of MAS. Retail clinics in America employ nurse practitioners (NPs) and physician assistants (PAs) who can diagnose and treat minor illness, and minor injuries. Similar to the retail clinics, MAS can merge with walk-in centres. PAs and NPs can take over some primary care workload from pharmacists to prevent the pharmacists from being overwhelmed with all their current duties. MAS can also initiate the development of telehealth service to accommodate the home-bound patients. MAS must continue to change and evolve to meet the current and future demands of health care.

Charlson scores based on ICD-10 administrative data were valid in assessing comorbidity in patients undergoing urological cancer surgery

BACKGROUND AND OBJECTIVES

Adjustment for comorbidity is an essential component of any observational study comparing outcomes. We evaluated the validity of the Charlson comorbidity score based on ICD-10 codes in patients undergoing urological cancer surgery within an English administrative database.

STUDY DESIGN AND SETTING

Patients who underwent radical urological cancer surgery between 1998 and 2002 in the English National Health Service were identified from the Hospital Episode Statistics database (N = 20,138). ICD-9-CM codes defining comorbid diseases according to the Deyo and Dartmouth-Manitoba adaptations of the Charlson comorbidity score were translated into ICD-10 codes.

RESULTS

Charlson scores derived by the ICD-10 translation of the Deyo and Dartmouth-Manitoba adaptations were identical in 16,623 patients (83%; kappa = .63). For both adaptations, ICD-10 scores increased with age, were higher in patients admitted on an emergency basis, and predicted short-term outcome. Addition of either the ICD-10 Charlson Deyo or Dartmouth-Manitoba score to risk models containing age and sex to predict in-hospital mortality resulted in a better model fit but only in small improvements of the predictive power.

CONCLUSION

The ICD-10 translations of the Deyo and Dartmouth-Manitoba adaptations performed similarly in risk models predicting hospital mortality following urological cancer surgery. Adjustment for comorbidity over and above age and sex alone does not seem to provide a large improvement.

The value of in-patient dermatology: a survey of in-patients in Scotland and Northern England

Dermatology in-patient units are frequently threatened with reduction or closure, yet there are few objective data regarding the nature and use of in-patient management with which to assess their value. We have surveyed 300 patients admitted during March 1997 to dermatology units throughout Scotland and Northern England, to establish their clinical and social profile, and the outcome of admission. All departments provided phototherapy and out-patient treatment services, and 84% of those admitted lived within an hour's travel of one of these. Three diagnostic groups (psoriasis, eczema and leg ulcers) accounted for 83% of in-patient days. Patients were admitted principally because of disease severity but many, including half of those with psoriasis, had concurrent medical problems such as alcohol abuse, psychiatric disorder or arthropathy. Many patients with psoriasis and leg ulcers were from socially deprived areas, as defined by low Carstairs index scores, and a similar proportion received income support. Eighteen per cent of patients, mainly those with acute disorders, would have needed admission irrespective of dermatology bed availability. Out-patient management was considered the next best alternative for only 28% of patients, and many patients would have been expected to treat themselves. By contrast, 84% of patients admitted were cleared or substantially improved, or had procedures completed as planned, and another 12% were partially improved. Outcomes were particularly good in psoriasis, eczema and infection groups. We have demonstrated that in-patient management is highly effective in providing remission in chronic skin disease, and our survey also suggests that concomitant disability or social factors mean that for many such patients ambulatory care cannot replace this service.

Using routine data to evaluate quality of care in British hospitals

OBJECTIVES

As part of the process of developing an international comparative study of the outcome of hospital care it has been necessary to understand what data on hospital activity are available and how they compare with those in other countries. The authors describe the administrative data collected in British National Health Service Hospitals, with emphasis on how they differ from that available in the United States.

METHODS

A description of the content of administrative data and a selective review of published literature related to their uses.

RESULTS

Administrative data in the United Kingdom resembles that available in the United States, but it also has some important differences. These include a different system of procedure classification, the use of International Classification of Diseases, 10th Revision (rather than International Classification of Diseases, Ninth Revision, Clinical Modification), and the use of a different denominator ("finished consultant episodes," rather than admission spells). There also are important differences in the completeness and precision of the data that are collected.

CONCLUSIONS

British administrative data can be used to describe patterns of care and have the potential to identify possible differences in outcome that can then be subjected to more detailed scrutiny. They are substantially less detailed than US data but are also somewhat less costly to collect.

Informing the market: the strengths and weaknesses of information in the British National Health Service

Many countries are experimenting with planned (or quasi-) markets to discover if they can efficiently deliver health care in keeping with societal objectives. This paper examines the information requirements of this approach. Information is necessary in order to compare the performance of providers, to support billing, and to monitor access to care. It should be accurate, unambiguous, and resistant to manipulation. We draw on a project to find out how information on hospitalisation could be used in contracting in the British National Health Service. We conclude that the existing British system fails to provide robust measures of how many patients are treated, for what conditions, and with what treatments. We identify some promising remedies, others that are more difficult, and some which may be impossible to implement in any planned market, given the uncertainty of clinical practice.