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Neill S, Bayes N, Thompson M, Croxson C, Roland D, Lakhanpaul M. Helping parents know when to seek help for an acutely ill child: Evidence based co-development of a mobile phone app using complex intervention methodology. Int J Med Inform 2024; 187:105459. [PMID: 38640593 DOI: 10.1016/j.ijmedinf.2024.105459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Acute illness accounts for the majority of episodes of illness in children under five years of age and is the age group with the highest consultation rate in general practice in the UK. The number of children presenting to emergency care is also steadily increasing, having risen beyond pre-pandemic numbers. Such high, and increasing, rates of consultation have prompted concerns about parents' level of knowledge and confidence in caring for their children when they are ill, and particularly when and how to seek help appropriately. AIM The ASK SNIFF collaboration research programme identified parents' need for accurate and accessible information to help them know when to seek help for a sick child in 2010. This paper presents the resulting programme of research which aimed to co-develop an evidence-based safety netting intervention (mobile app) to help parents know when to seek help for an acutely ill child under the age of five years in the UK. METHODS Our programme used a collaborative six step process with 147 parent and 324 health professional participants over a period of six years including: scoping existing interventions, systematic review, qualitative research, video capture, content identification and development, consensus methodology, parent and expert clinical review. RESULTS Our programme has produced evidence-based content for an app supported by video clips. Our collaborative approach has supported every stage of our work, ensuring that the end result reflects the experiences, perspectives and expressed needs of parents and the clinicians they consult. CONCLUSION We have not found any other resource which has used this type of approach, which may explain why there is no published evaluation data demonstrating the impact of existing UK resources. Future mobile apps should be designed and developed with the service users for whom they are intended.
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Affiliation(s)
- Sarah Neill
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK.
| | - Natasha Bayes
- Faculty of Health, University of Northampton, Northampton, UK.
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, USA.
| | - Caroline Croxson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK; SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK.
| | - Monica Lakhanpaul
- UCL Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK; Community Paediatrics, Whittington Health NHS, London N19 5NF, UK.
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Malcolm C, Hoddinott P, King E, Dick S, Kyle R, Wilson P, France E, Aucott L, Turner SW. Short-stay urgent hospital admissions of children with convulsions: A mixed methods exploratory study to inform out of hospital care pathways. PLoS One 2024; 19:e0301071. [PMID: 38557817 PMCID: PMC10984513 DOI: 10.1371/journal.pone.0301071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE To inform interventions focused on safely reducing urgent paediatric short stay admissions (SSAs) for convulsions. METHODS Routinely acquired administrative data from hospital admissions in Scotland between 2015-2017 investigated characteristics of unscheduled SSAs (an urgent admission where admission and discharge occur on the same day) for a diagnosis of febrile and/or afebrile convulsions. Semi-structured interviews to explore perspectives of health professionals (n = 19) making referral or admission decisions about convulsions were undertaken. Interpretation of mixed methods findings was complemented by interviews with four parents with experience of unscheduled SSAs of children with convulsion. RESULTS Most SSAs for convulsions present initially at hospital emergency departments (ED). In a subset of 10,588 (11%) of all cause SSAs with linked general practice data available, 72 (37%) children with a convulsion contacted both the GP and ED pre-admission. Within 30 days of discharge, 10% (n = 141) of children admitted with afebrile convulsions had been readmitted to hospital with a further convulsion. Interview data suggest that panic and anxiety, through fear that the situation is life threatening, was a primary factor driving hospital attendance and admission. Lengthy waits to speak to appropriate professionals exacerbate parental anxiety and can trigger direct attendance at ED, whereas some children with complex needs had direct access to convulsion professionals. CONCLUSIONS SSAs for convulsions are different to SSAs for other conditions and our findings could inform new efficient convulsion-specific pre and post hospital pathways designed to improve family experiences and reduce admissions and readmissions.
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Affiliation(s)
- Cari Malcolm
- School of Health Sciences, University of Dundee, Dundee, United Kingdom
| | - Pat Hoddinott
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, United Kingdom
| | - Emma King
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, United Kingdom
| | - Smita Dick
- Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Richard Kyle
- Academy of Nursing, Department of Health and Care Professions, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Aberdeen, United Kingdom
- Centre for Research and Education in General Practice, University of Copenhagen, København, Denmark
| | - Emma France
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, United Kingdom
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Stephen W. Turner
- Child Health, University of Aberdeen, Aberdeen, United Kingdom
- Women and Children Division, NHS Grampian, Aberdeen, United Kingdom
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Nicholson E, McDonnell T, Conlon C, De Brún A, Doherty E, Collins C, Bury G, McAuliffe E. Factors that affect GP referral of a child with intellectual disability for a mild illness: A discrete choice experiment. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2023; 36:1241-1250. [PMID: 37489607 DOI: 10.1111/jar.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/26/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND General practitioners (GP) report multiple challenges when treating individuals with intellectual disabilities which may influence referral rates. The study aimed to establish factors that influence GP's decision-making when referring a child with intellectual disabilities to the emergency department. METHOD Discrete choice experiments (DCEs) are increasingly used in health research to further understand complex decision making. A DCE was designed to assess the relative importance of factors that may influence a GP's (N = 157) decision to refer. RESULTS A random parameters model indicated that perceived limited parental capacity to manage an illness was the most important factor in the decision to refer a child to the ED, followed by a repeat visit, a referral request from the parent, and a Friday afternoon appointment. CONCLUSION Understanding the factors that influence referral is important for service improvement and to strengthen primary care provision for this population and their families.
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Affiliation(s)
- Emma Nicholson
- School of Psychology, Dublin City University, Dublin, Ireland
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), UCD School of Nursing, Midwifery and Health Systems, University College Dublin, UCD College of Health and Agricultural Sciences, Dublin, Ireland
| | - Thérèse McDonnell
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), UCD School of Nursing, Midwifery and Health Systems, University College Dublin, UCD College of Health and Agricultural Sciences, Dublin, Ireland
| | - Ciara Conlon
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), UCD School of Nursing, Midwifery and Health Systems, University College Dublin, UCD College of Health and Agricultural Sciences, Dublin, Ireland
| | - Aoife De Brún
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), UCD School of Nursing, Midwifery and Health Systems, University College Dublin, UCD College of Health and Agricultural Sciences, Dublin, Ireland
| | - Edel Doherty
- J.E. Cairnes School of Business & Economics, National University of Ireland Galway, Galway, Ireland
| | | | - Gerard Bury
- UCD School of Medicine, UCD College of Health and Agricultural Sciences, University College Dublin, Dublin, Ireland
| | - Eilish McAuliffe
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS), UCD School of Nursing, Midwifery and Health Systems, University College Dublin, UCD College of Health and Agricultural Sciences, Dublin, Ireland
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King E, Dick S, Hoddinott P, Malcolm C, France E, Kyle RG, Aucott L, Wilson P, Turner S. Regional variations in short stay urgent paediatric hospital admissions: a sequential mixed-methods approach exploring differences through data linkage and qualitative interviews. BMJ Open 2023; 13:e072734. [PMID: 37748848 PMCID: PMC10533722 DOI: 10.1136/bmjopen-2023-072734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/23/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVES The aim of this sequential mixed-methods study was to describe and understand how paediatric short stay admission (SSA) rates vary across Health Board regions of Scotland. DESIGN Exploratory sequential mixed-methods study. Routinely acquired data for the annual (per capita) SSA to hospital were compared across the 11 regions. Five diverse regions with different SSA per capita formed cases for qualitative interviews with health professionals and parents to explore how care pathways, service features and geography may influence decisions to admit. SETTING Scotland. PARTICIPANTS All children admitted to hospital 2015-2017. Healthcare staff (n=48) and parents (n=15) were interviewed. RESULTS Of 171 039 urgent hospital admissions, 92 229 were SSAs, with a fivefold variation between 14 and 69/1000 children/year across regions. SSAs were higher for children in the most deprived compared with the least deprived communities. When expressed as a ratio of highest to lowest SSA/1000 children/year for diagnosed conditions between regions, the ratio was highest (10.1) for upper respiratory tract infection and lowest (2.8) for convulsions. Readmissions varied between 0.80 and 2.52/1000/year, with regions reporting higher SSA rates more likely to report higher readmission rates (r=0.70, p=0.016, n=11). Proximity and ease of access to services, local differences in service structure and configuration, national policy directives and disparities in how an SSA is defined were recognised by interviewees as explaining the observed regional variations in SSAs. Socioeconomic deprivation was seldom spontaneously raised by professionals when reflecting on reasons to refer or admit a child. Instead, greater emphasis was placed on the wider social circumstances and parents' capacity to cope with and manage their child's illness at home. CONCLUSION SSA rates for children vary quantitatively by region, condition and area deprivation and our interviews identify reasons for this. These findings can usefully inform future care pathway interventions.
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Affiliation(s)
- Emma King
- Nursing Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Smita Dick
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Pat Hoddinott
- Nursing Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Cari Malcolm
- School of Health Science, University of Dundee, Dundee, UK
| | - Emma France
- Nursing Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | | | - Lorna Aucott
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Philip Wilson
- Institute of Health and Wellbeing, University of Aberdeen, Aberdeen, UK
| | - Stephen Turner
- Department of Child Health, University of Aberdeen, Aberdeen, UK
- Division of Women and Children, NHS Grampian, Aberdeen, UK
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Dick S, Kyle R, Wilson P, Aucott L, France E, King E, Malcolm C, Hoddinott P, Turner SW. Insights from and limitations of data linkage studies: analysis of short-stay urgent admission referral source from routinely collected Scottish data. Arch Dis Child 2023; 108:300-306. [PMID: 36719837 DOI: 10.1136/archdischild-2022-324171] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/14/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION This study identified the referral source for urgent short-stay admissions (SSAs) and compared characteristics of children with SSA stratified by different referral sources. METHODS Routinely acquired data from urgent admissions to Scottish hospitals during 2015-2017 were linked to data held by the three referral sources: emergency department (ED), out-of-hours (OOH) service and general practice (GP). RESULTS There were 171 039 admissions including 92 229 (54%) SSAs. Only 171 (19%) of all of Scotland's GP practices contributed data. Among the subgroup of 10 588 SSAs where GP data were available (11% all SSA), there was contact with the following referral source on the day of admission: only ED, 1853 (18%); only GP, 3384 (32%); and only OOH, 823 (8%). Additionally, 2165 (20%) had contact with more than one referral source, and 1037 (10%) had contact with referral source(s) on the day before the admission. When all 92 229 SSAs were considered, those with an ED referrer were more likely to be for older children, of white ethnicity, living in more deprived communities and diagnosed with asthma, convulsions or croup. The odds ratio for an SSA for a given condition differed by referral source and ranged from 0.07 to 1.9 (with reference to ED referrals). CONCLUSION This study yielded insights and potential limitations regarding data linkage in a healthcare setting. Data coverage, particularly from primary care, needs to improve further. Evidence from data linkage studies can inform future intervention designed to provide safe integrated care pathways.
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Affiliation(s)
- Smita Dick
- Child Health, University of Aberdeen, Aberdeen, UK
| | - Richard Kyle
- Academy of Nursing, University of Exeter, Exeter, UK
| | - Philip Wilson
- Institute of Health and Wellbeing, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Emma France
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - E King
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Cari Malcolm
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Pat Hoddinott
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
| | - Stephen W Turner
- Child Health, University of Aberdeen, Aberdeen, UK
- Women and Children Division, NHS Grampian, Aberdeen, UK
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Malcolm C, King E, France E, Kyle RG, Kumar S, Dick S, Wilson P, Aucott L, Turner SW, Hoddinott P. Short stay hospital admissions for an acutely unwell child: A qualitative study of outcomes that matter to parents and professionals. PLoS One 2022; 17:e0278777. [PMID: 36525432 PMCID: PMC9757586 DOI: 10.1371/journal.pone.0278777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Numbers of urgent short stay admissions (SSAs) of children to UK hospitals are rising rapidly. This paper reports on experiences of SSAs from the perspective of parents accessing urgent care for their acutely unwell child and of health professionals referring, caring for, or admitting children. METHODS A qualitative interview study was conducted by a multi-disciplinary team with patient and public involvement (PPI) to explore contextual factors relating to SSAs and better understand pre-hospital urgent care pathways. Purposive sampling of Health Board areas in Scotland, health professionals with experience of paediatric urgent care pathways and parents with experience of a SSA for their acutely unwell child was undertaken to ensure maximal variation in characteristics such as deprivation, urban-rural and hospital structure. Interviews took place between Dec 2019 and Mar 2021 and thematic framework analysis was applied. RESULTS Twenty-one parents and forty-eight health professionals were interviewed. In the context of an urgent SSA, the themes were centred around shared outcomes of care that matter. The main outcome which was common to both parents and health professionals was the importance of preserving the child's safety. Additional shared outcomes by parents and health professionals were a desire to reduce worries and uncertainty about the illness trajectory, and provide reassurance with sufficient time, space and personnel to undertake a period of skilled observation to assess and manage the acutely unwell child. Parents wanted easy access to urgent care and, preferably, with input from paediatric-trained staff. Healthcare professionals considered that it was important to reduce the number of children admitted to hospital where safe and appropriate to do so. CONCLUSIONS The shared outcomes of care between parents and health professionals emphasises the potential merit of adopting a partnership approach in identifying, developing and testing interventions to improve the acceptability, safety, efficiency, and cost-effectiveness of urgent care pathways between home and hospital.
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Affiliation(s)
- Cari Malcolm
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom
- * E-mail: (PH); (CM)
| | - Emma King
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, United Kingdom
| | - Emma France
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, United Kingdom
| | - Richard G. Kyle
- Academy of Nursing, College of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Simita Kumar
- Screening and Immunisation, Public Health Scotland, Edinburgh, United Kingdom
| | - Smita Dick
- Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Lorna Aucott
- Centre for Randomised Healthcare Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - Stephen W. Turner
- Child Health, University of Aberdeen, Aberdeen, United Kingdom
- NHS Grampian, Aberdeen, United Kingdom
| | - Pat Hoddinott
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, United Kingdom
- * E-mail: (PH); (CM)
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Etoori D, Harron KL, Mc Grath-Lone L, Verfürden ML, Gilbert R, Blackburn R. Reductions in hospital care among clinically vulnerable children aged 0-4 years during the COVID-19 pandemic. Arch Dis Child 2022; 107:e31. [PMID: 35728939 PMCID: PMC9271837 DOI: 10.1136/archdischild-2021-323681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To quantify reductions in hospital care for clinically vulnerable children during the COVID-19 pandemic. DESIGN Birth cohort. SETTING National Health Service hospitals in England. STUDY POPULATION All children aged <5 years with a birth recorded in hospital administrative data (January 2010-March 2021). MAIN EXPOSURE Clinical vulnerability defined by a chronic health condition, preterm birth (<37 weeks' gestation) or low birth weight (<2500 g). MAIN OUTCOMES Reductions in care defined by predicted hospital contact rates for 2020, estimated from 2015 to 2019, minus observed rates per 1000 child years during the first year of the pandemic (March 2020-2021). RESULTS Of 3 813 465 children, 17.7% (one in six) were clinically vulnerable (9.5% born preterm or low birth weight, 10.3% had a chronic condition). Reductions in hospital care during the pandemic were much higher for clinically vulnerable children than peers: respectively, outpatient attendances (314 vs 73 per 1000 child years), planned admissions (55 vs 10) and unplanned admissions (105 vs 79). Clinically vulnerable children accounted for 50.1% of the reduction in outpatient attendances, 55.0% in planned admissions and 32.8% in unplanned hospital admissions. During the pandemic, weekly rates of planned care returned to prepandemic levels for infants with chronic conditions but not older children. Reductions in care differed by ethnic group and level of deprivation. Virtual outpatient attendances increased from 3.2% to 24.8% during the pandemic. CONCLUSION One in six clinically vulnerable children accounted for one-third to one half of the reduction in hospital care during the pandemic.
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Affiliation(s)
- David Etoori
- Institute of Health Informatics, University College London, London, UK
| | - Katie L Harron
- Department of Population, Policy and Practice, Institute of Child Health, University College London, London, London, UK
| | | | - Maximiliane L Verfürden
- Department of Population, Policy and Practice, Institute of Child Health, University College London, London, London, UK
| | - Ruth Gilbert
- Department of Population, Policy and Practice, Institute of Child Health, University College London, London, London, UK
| | - Ruth Blackburn
- Institute of Health Informatics, University College London, London, UK
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Nath S, Zylbersztejn A, Viner RM, Cortina-Borja M, Lewis KM, Wijlaars LPMM, Hardelid P. Determinants of accident and emergency attendances and emergency admissions in infants: birth cohort study. BMC Health Serv Res 2022; 22:936. [PMID: 35864495 PMCID: PMC9302562 DOI: 10.1186/s12913-022-08319-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited understanding of the drivers of increasing infant accident and emergency (A&E) attendances and emergency hospital admissions across England. We examine variations in use of emergency hospital services among infants by local areas in England and investigate the extent to which infant and socio-economic factors explain these variations. METHODS Birth cohort study using linked administrative Hospital Episode Statistics data in England. Singleton live births between 1-April-2012 and 31-March-2019 were followed up for 1 year; from 1-April-2013 (from the discharge date of their birth admission) until their first birthday, death or 31-March-2019. Mixed effects negative binomial models were used to calculate incidence rate ratios for A&E attendances and emergency admissions and mixed effects logistic regression models estimated odds ratio of conversion (the proportion of infants subsequently admitted after attending A&E). Models were adjusted for individual-level factors and included a random effect for local authority (LA). RESULTS The cohort comprised 3,665,414 births in 150 English LAs. Rates of A&E attendances and emergency admissions were highest amongst: infants born < 32 weeks gestation; with presence of congenital anomaly; and to mothers < 20-years-old. Area-level deprivation was positively associated with A&E attendance rates, but not associated with conversion probability. A&E attendance rates were highest in the North East (916 per 1000 child-years, 95%CI: 911 to 921) and London (876 per 1000, 95%CI: 874 to 879), yet London had the lowest emergency admission rates (232 per 1000, 95%CI: 231 to 234) and conversion probability (25% vs 39% in South West). Adjusting for individual-level factors did not significantly affect variability in A&E attendance and emergency admission rates by local authority. CONCLUSIONS Drivers of A&E attendances and emergency admissions include individual-level factors such being born premature, with congenital anomaly and from socio-economically disadvantaged young parent families. Support for such vulnerable infants and families should be provided alongside preventative health care in primary and community care settings. The impact of these services requires further investigation. Substantial geographical variations in rates were not explained by individual-level factors. This suggests more detailed understanding of local and underlying service-level factors would provide targets for further research on mechanisms and policy priority.
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Affiliation(s)
- Selina Nath
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Ania Zylbersztejn
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Russell M Viner
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Mario Cortina-Borja
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Kate Marie Lewis
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Linda P M M Wijlaars
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Pia Hardelid
- Population, Policy and Practice Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
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9
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Raymond ME, Bird C, van Hecke O, Glogowska M, Hayward G. Point-of-care diagnostic technology in paediatric ambulatory care: a qualitative interview study of English clinicians and stakeholders. BMJ Open 2022; 12:e059103. [PMID: 35672068 PMCID: PMC9174781 DOI: 10.1136/bmjopen-2021-059103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
UNLABELLED Point-of-care (POC) tests have the potential to improve paediatric healthcare. However, both the development and evaluation of POC technology have almost solely been focused on adults. We aimed to explore frontline clinicians' and stakeholders' current experience of POC diagnostic technology in children in England; and to identify areas of unmet need. DESIGN, SETTING AND PARTICIPANTS Qualitative semistructured telephone interviews were carried out with purposively sampled participants from clinical paediatric ambulatory care and charity, industry and policymaking stakeholders. The interviews were audio-recorded, transcribed and analysed thematically. RESULTS We interviewed 19 clinicians and 8 stakeholders. The main perceived benefits of POC tests and technologies were that they aided early decision-making and could be convenient and empowering when used independently by patients and families. Clinicians and stakeholders wanted more POC tests to be available for use in clinical practice. Most recognised that play and reward are important components of successful POC tests for children. Clinicians wanted tests to give them answers, which would result in a change in their clinical management. Detecting acute serious illness, notably distinguishing viral and bacterial infection, was perceived to be an area where tests could add value. POC tests were thought to be particularly useful for children presenting atypically, where diagnosis was more challenging, such as those less able to communicate, and for rare serious diseases. Many participants felt they could be useful in managing chronic disease. CONCLUSIONS This exploratory study found that clinicians and stakeholders supported the use of diagnostic POC technology in paediatric ambulatory care settings in England. Some existing tests are not fit for purpose and could be refined. Industry should be encouraged to develop new child-friendly tests tackling areas of unmet need, guided by the preferred characteristics of those working on the ground.
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Affiliation(s)
- Meriel Elizabeth Raymond
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Chris Bird
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
- Emergency Department, Birmingham Children's Hospital, Birmingham, UK
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, Oxfordshire, UK
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10
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Martínez-González NA, Plate A, Jäger L, Senn O, Neuner-Jehle S. The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners. Antibiotics (Basel) 2022; 11:543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023] Open
Abstract
Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92-98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65-87%). Faced with intermediate CRP results, GPs preferred 3-5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Levy Jäger
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
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11
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Roland D, Wolfe I, Klaber RE, Watson M. Final warning on the need for integrated care systems in acute paediatrics. Arch Dis Child 2022; 107:e9. [PMID: 34531197 DOI: 10.1136/archdischild-2020-320828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/10/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Damian Roland
- Sapphire Group, Health Sciences, University of Leicester, Leicester, UK .,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ingrid Wolfe
- Department of Women and Children's Health, King's College London, London, UK.,Institute for Women and Children's Health, King's Health Partners, London, UK
| | - Robert Edward Klaber
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.,Academic Centre for Paediatrics & Child Health, Imperial College London, London, UK
| | - Mando Watson
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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12
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Dick S, MacRae C, McFaul C, Rasul U, Wilson P, Turner SW. Interventions to reduce acute paediatric hospital admissions: a systematic review. Arch Dis Child 2022; 107:234-243. [PMID: 34340984 DOI: 10.1136/archdischild-2021-321884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/19/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Admission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified. OBJECTIVE To systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives. DATA SOURCES MEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched. STUDY ELIGIBILITY CRITERIA Randomised controlled trials and before-and-after studies. PARTICIPANTS Individuals aged <18 years. STUDY APPRAISAL AND SYNTHESIS METHODS Studies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second. RESULTS Twenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies. CONCLUSIONS AND IMPLICATIONS There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.
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Affiliation(s)
- Smita Dick
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Clare MacRae
- Usher institute, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Claire McFaul
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Usman Rasul
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Philip Wilson
- Institute of Health and Wellbeing, University of Aberdeen, Aberdeen, UK
| | - Stephen W Turner
- Department of Child Health, University of Aberdeen, Aberdeen, UK
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13
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Verbakel JYJ, De Burghgraeve T, Van den Bruel A, Coenen S, Anthierens S, Joly L, Laenen A, Luyten J, De Sutter A. Antibiotic prescribing rate after optimal near-patient C-reactive protein testing in acutely ill children presenting to ambulatory care (ARON project): protocol for a cluster-randomized pragmatic trial. BMJ Open 2022; 12:e058912. [PMID: 34980633 PMCID: PMC8724812 DOI: 10.1136/bmjopen-2021-058912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Children become ill quite often, mainly because of infections, most of which can be managed in the community. Many children are prescribed antibiotics which contributes to antimicrobial resistance and reinforces health-seeking behaviour. Point-of-care C reactive protein (POC CRP) testing, prescription guidance and safety-netting advice can help safely reduce antibiotic prescribing to acutely ill children in ambulatory care as well as save costs at a systems level. METHODS AND ANALYSIS The ARON (Antibiotic prescribing Rate after Optimal Near-patient testing in acutely ill children in ambulatory care) trial is a pragmatic cluster randomized controlled superiority trial with a nested process evaluation and will assess the clinical and cost effectiveness of a diagnostic algorithm, which includes a standardised clinical assessment, a POC CRP test, and safety-netting advice, in acutely ill children aged 6 months to 12 years presenting to ambulatory care. The primary outcome is antibiotic prescribing at the index consultation; secondary outcomes include clinical recovery, reconsultation, referral/admission to hospital, additional testing, mortality and patient satisfaction. We aim to recruit a total sample size of 6111 patients. All outcomes will be analysed according to the intent-to-treat approach. We will use a mixed-effect logistic regression analysis to account for the clustering at practice level. ETHICS AND DISSEMINATION The study will be conducted in compliance with the principles of the Declaration of Helsinki (current version), the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 November 2020 from the Ethics Committee Research of University Hospitals Leuven under reference S62005. We will ensure that the findings of the study will be disseminated to relevant stakeholders other than the scientific world including the public, healthcare providers and policy-makers. The process evaluation that is part of this trial may provide a basis for an implementation strategy. If our intervention proves to be clinically and cost-effective, it will be essential to educate physicians about introducing the diagnostic algorithm including POC CRP testing and safety-netting advice in their daily practice. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT04470518. Protocol V.2.0 date 2 October 2020. (Pre-results).
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Affiliation(s)
- Jan Yvan Jos Verbakel
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
| | - Ann Van den Bruel
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Wilrijk, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Wilrijk, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Louise Joly
- Research Unit Primary Care and Health, Department of General Practice, Department of Clinical Sciences, University of Liege, Liege, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Jeroen Luyten
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Department of Family Medicine & Health Policy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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14
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Turner S, Raja EA. The association between opening a short stay paediatric assessment unit and trends in short stay hospital admissions. BMC Health Serv Res 2021; 21:523. [PMID: 34049553 PMCID: PMC8164232 DOI: 10.1186/s12913-021-06541-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background Many inpatient facilities in Scotland have opened short stay paediatric assessment units (SSPAU) which are clinical areas separate from the usual inpatient ward area and these are where most short stay (also called zero day) admissions are accommodated. Here we describe the effect of opening short stay paediatric assessment units (SSPAU) on the proportion of zero day admissions relative to all emergency admissions. Methods Details of all emergency medical paediatric admissions to Scottish hospitals between 2000 and 2013 were obtained, including the number of zero day admissions per month and health board (i.e. geographic region). The month and year that an SSPAU opened in each health board was provided by local clinicians. Results SSPAUs opened in 7 health boards, between 2004 and 2012. Health boards with an SSPAU had a slower rise in zero day admissions compared to those without SSPAU (0.6% per month [95% CI 0.04, 0.09]. Across all 7 health boards, opening an SSPAU was associated with a 13% [95% CI 10, 15] increase in the proportion of zero day admissions. When considered individually, zero day admissions rose in four health boards after their SSPAU opened, were unchanged in one and fell in two health boards. Independent of SSPAUs opening, there was an increase in the proportion of all admissions which were zero day admissions (0.1% per month), and this accelerated after SSPAUs opened. Conclusion Opening an SSPAU has heterogeneous outcomes on the proportion of zero day admissions in different settings. Zero day admissions could be reduced in some health boards by understanding differences in clinical referral pathways between health boards with contrasting trends in zero day admissions after their SSPAU opens. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06541-x.
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Affiliation(s)
- Steve Turner
- Child Health, University of Aberdeen, Aberdeen, UK. .,Women and Children Division, NHS Grampian, Aberdeen, AB25 2ZG, UK.
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15
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Greenfield G, Blair M, Aylin PP, Saxena S, Majeed A, Bottle A. Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data. Emerg Med J 2020; 38:146-150. [PMID: 33199272 DOI: 10.1136/emermed-2019-209122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/03/2020] [Accepted: 10/04/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs. AIM To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals. METHOD We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups. RESULTS One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively). CONCLUSION One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.
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Affiliation(s)
- Geva Greenfield
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Mitch Blair
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Paul P Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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16
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Nicholson E, McDonnell T, De Brún A, Barrett M, Bury G, Collins C, Hensey C, McAuliffe E. Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review. BMC Health Serv Res 2020; 20:663. [PMID: 32680518 PMCID: PMC7366445 DOI: 10.1186/s12913-020-05527-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 07/09/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?" METHOD Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data. RESULTS Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP. CONCLUSION Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.
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Affiliation(s)
- E. Nicholson
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - T. McDonnell
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - A. De Brún
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - M. Barrett
- Department of Emergency Medicine/National Children’s Research Centre, Children’s Health Ireland at Crumlin, Dublin, Ireland
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - G. Bury
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - C. Collins
- Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2, Ireland
| | - C. Hensey
- Children’s Health Ireland at Temple St, Temple St, Rotunda, Dublin 1, Ireland
| | - E. McAuliffe
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
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In-vitro diagnostic point-of-care tests in paediatric ambulatory care: A systematic review and meta-analysis. PLoS One 2020; 15:e0235605. [PMID: 32628707 PMCID: PMC7337322 DOI: 10.1371/journal.pone.0235605] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 06/19/2020] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Paediatric consultations form a significant proportion of all consultations in ambulatory care. Point-of-care tests (POCTs) may offer a potential solution to improve clinical outcomes for children by reducing diagnostic uncertainty in acute illness, and streamlining management of chronic diseases. However, their clinical impact in paediatric ambulatory care is unknown. We aimed to describe the clinical impact of all in-vitro diagnostic POCTs on patient outcomes and healthcare processes in paediatric ambulatory care. METHODS We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science from inception to 29 January 2020 without language restrictions. We included studies of children presenting to ambulatory care settings (general practice, hospital outpatient clinics, or emergency departments, walk-in centres, registered drug shops delivering healthcare) where in-vitro diagnostic POCTs were compared to usual care. We included all quantitative clinical outcome data across all conditions or infection syndromes reporting on the impact of POCTs on clinical care and healthcare processes. Where feasible, we calculated risk ratios (RR) with 95% confidence intervals (CI) by performing meta-analysis using random effects models. RESULTS We included 35 studies. Data relating to at least one outcome were available for 89,439 children of whom 45,283 had a POCT across six conditions or infection syndromes: malaria (n = 14); non-specific acute fever 'illness' (n = 7); sore throat (n = 5); acute respiratory tract infections (n = 5); HIV (n = 3); and diabetes (n = 1). Outcomes centred around decision-making such as prescription of medications or hospital referral. Pooled estimates showed that malarial-POCTs (Plasmodium falciparum) better targeted antimalarial treatment by reducing over-treatment by a third compared to usual care (RR 0.67; 95% CI [0.58 to 0.77], n = 36,949). HIV-POCTs improved initiating earlier antiretroviral therapy compared to usual care (RR, 3.11; 95% CI [1.55 to 6.25], n = 912). Across the other four conditions, there was limited evidence for the benefit of POCTs in paediatric ambulatory care except for acute respiratory tract infections (RTI) in low-and-middle-income countries (LMICs), where POCT C-Reactive Protein (CRP) may reduce immediate antibiotic prescribing by a third (risk difference, -0.29 [-0.47, -0.11], n = 2,747). This difference was shown in randomised controlled trials in LMICs which included guidance on interpretation of POCT-CRP, specific training or employed a diagnostic algorithm prior to POC testing. CONCLUSION Overall, there is a paucity of evidence for the use of POCTs in paediatric ambulatory care. POCTs help to target prescribing for children with malaria and HIV. There is emerging evidence that POCT-CRP may better target antibiotic prescribing for children with acute RTIs in LMIC, but not in high-income countries. Research is urgently needed to understand where POCTs are likely to improve clinical outcomes in paediatric settings worldwide.
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Shand J, Morris S, Gomes M. Understanding health and care expenditure by setting - who matters to whom? J Health Serv Res Policy 2020; 26:77-84. [PMID: 32605391 PMCID: PMC8013836 DOI: 10.1177/1355819620936721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To assess service use and associated expenditure across a range of care settings in one local authority in London, United Kingdom. Methods An analysis of linked electronic health and council records of adults living in the borough of Barking and Dagenham, east London, for the financial year 2016/17. Unit costs were applied to individual service use to provide expenditure at an individual and population level for five settings of care. Population and expenditure volumes were compared for 32 possible combinations of service use. Results The total expenditure for the cohort (114,393 residents) for 2016/17 was £180.1 million. Almost half (47%) of total expenditure was incurred by community care, social care and mental health services, with hospital care and primary care incurring, respectively, 35% (£63.3 m) and 18% (£32.6 m). The two most common combinations in terms of total population volume and expenditure were primary and hospital care, and primary, hospital and community care. Primary care was present in all combinations. Mental health service use accounted for just over a tenth of all expenditure in the borough, but using mental health services substantially increased mean expenditure per patient. Conclusions A whole system perspective across all settings of care improves understanding of service user patterns. Setting-level analysis remains important, particularly for mental health users.
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Affiliation(s)
- Jenny Shand
- PhD Researcher, Institute of Epidemiology and Health Care, University College London, UK
| | - Stephen Morris
- RAND Professor of Health Services Research, Department of Public Health and Primary Care, University of Cambridge, UK
| | - Manuel Gomes
- Associate Professor in Health Economics, Institute of Epidemiology and Health Care, University College London, UK
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19
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Ruzangi J, Blair M, Cecil E, Greenfield G, Bottle A, Hargreaves DS, Saxena S. Trends in healthcare use in children aged less than 15 years: a population-based cohort study in England from 2007 to 2017. BMJ Open 2020; 10:e033761. [PMID: 32371509 PMCID: PMC7228511 DOI: 10.1136/bmjopen-2019-033761] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017 DESIGN: Population-based retrospective cohort study. METHODS We used linked data from the Clinical Practice Research Datalink to study children's primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists. RESULTS Between 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (-1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017. CONCLUSIONS Over the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children's use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.
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Affiliation(s)
- Judith Ruzangi
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Mitch Blair
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Elizabeth Cecil
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Geva Greenfield
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Dougal S Hargreaves
- Department of Primary Care & Public Health, Imperial College London, London, UK
| | - Sonia Saxena
- Department of Primary Care & Public Health, Imperial College London, London, UK
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Ladhani SN, Henderson KL, Muller-Pebody B, Ramsay ME, Riordan A. Risk of invasive bacterial infections by week of age in infants: prospective national surveillance, England, 2010-2017. Arch Dis Child 2019; 104:874-878. [PMID: 31147318 DOI: 10.1136/archdischild-2018-316191] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 04/04/2019] [Accepted: 04/20/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To estimate the incidence of laboratory-confirmed, invasive bacterial infections (IBIs) by week of age in infants over a 7-year period. DESIGN Analysis of prospective national surveillance data for England. SETTING National Health Service hospitals in England. PATIENTS Infants aged <1 year who were hospitalised with IBI. MAIN OUTCOME MEASURES IBI incidence by week of age, incidence rate ratio (IRR) at 8, 12 and 16 weeks compared with the first week of life, and the main pathogens responsible for IBI. RESULTS There were 22 075 IBI episodes between 2010/2011 and 2016/2017. The lowest annual cases were in 2011/2012 (n=2 799; incidence, 412/100 000 population), increasing year-on-year to 3 698 cases in 2016/2017 (incidence, 552/100 000 population). The incidence was highest in the first week of life and then declined rapidly. In 2016/2017, compared with the first week of life, weekly IBI incidence was 92% lower at 8 weeks (IRR 0.08; 95% CI 0.06 to 0.10) and 96% lower at 16 weeks of age (IRR 0.04; 95% CI 0.03 to 0.06). In 2016/2017, Escherichia coli was the most prevalent pathogen responsible for IBI (n=592, 16.0%), followed by group B Streptococci (n=493, 13.3%), Staphylococcus aureus (n=400, 10.8%) and Enterococci (n=304, 8.2%). The other pathogens were individually responsible for <5% of total cases. There were differences in age distribution of the pathogens with increasing age. CONCLUSION IBI incidence declines rapidly after the first week of life, such that infants have a very low risk of IBI by the time they are eligible for their routine immunisations from 8 weeks of age.
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Affiliation(s)
- Shamez N Ladhani
- Immunisation and Countermeasures Division, Public Health England, London, UK.,Paediatric Infectious Diseases Research Group, St George's, University of London, London, UK
| | - Katherine L Henderson
- Healthcare Associated Infection and Antimicrobial Resistance Division, Public Health England, London, UK
| | - Berit Muller-Pebody
- Healthcare Associated Infection and Antimicrobial Resistance Division, Public Health England, London, UK
| | - Mary E Ramsay
- Immunisation and Countermeasures Division, Public Health England, London, UK
| | - Andrew Riordan
- Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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21
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Hoang U, Liyanage H, Coyle R, Godden C, Jones S, Blair M, Rigby M, de Lusignan S. Determinants of inter-practice variation in childhood asthma and respiratory infections: cross-sectional study of a national sentinel network. BMJ Open 2019; 9:e024372. [PMID: 30679295 PMCID: PMC6347957 DOI: 10.1136/bmjopen-2018-024372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Respiratory infections are associated with acute exacerbations of asthma and accompanying morbidity and mortality. In this study we explore inter-practice variations in respiratory infections in children with asthma and study the effect of practice-level factors on these variations. DESIGN Cross-sectional study. SETTING We analysed data from 164 general practices in the Royal College of General PractitionersResearch and Surveillance Centresentinel network in England. PARTICIPANTS Children 5-12 years. INTERVENTIONS None. In this observational study, we used regression analysis to explore the impact of practice-level determinants on the number of respiratory infections in children with asthma. PRIMARY AND SECONDARY OUTCOME MEASURES We describe the distribution of childhood asthma and the determinants of upper/lower respiratory tract infections in these children. RESULTS 83.5% (137/164) practices were in urban locations; the mean number of general practitioners per practice was 7; and the mean duration since qualification 19.7 years. We found almost 10-fold difference in the rate of asthma (1.5-11.8 per 100 children) and 50-fold variation in respiratory infection rates between practices. Larger practices with larger lists of asthmatic children had greater rates of respiratory infections among these children. CONCLUSION We showed that structural/environmental variables are consistent predictors of a range of respiratory infections among children with asthma. However, contradictory results between measures of practice clinical care show that a purely structural explanation for variability in respiratory infections is limited. Further research is needed to understand how the practice factors influence individual risk behaviours relevant to respiratory infections.
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Affiliation(s)
- Uy Hoang
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Harshana Liyanage
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Rachel Coyle
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | | | - Simon Jones
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Division of Healthcare Delivery Science/ Center for Healthcare Innovation and Delivery Science (CHIDS), Department of Population Health, New York University, Langone Medical Centre, New York, USA
| | - Mitch Blair
- Department of Paediatrics and Child Health, Northwick Park Hospital, Harrow, UK
| | - Michael Rigby
- Section of Paediatrics, School of Medicine, Imperial College London, St. Mary’s Hospital, London, UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Research and Surveillance Centre, Royal College of General Practitioners, London, UK
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22
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Jones E, Taylor B, Rudge G, MacArthur C, Jyothish D, Simkiss D, Cummins C. Hospitalisation after birth of infants: cross sectional analysis of potentially avoidable admissions across England using hospital episode statistics. BMC Pediatr 2018; 18:390. [PMID: 30572847 PMCID: PMC6302406 DOI: 10.1186/s12887-018-1360-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 11/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background Admissions of infants in England have increased substantially but there is little evidence whether this is across the first year or predominately in neonates; and for all or for specific causes. We aimed to characterise this increase, especially those admissions that may be avoidable in the context of postnatal care provision. Methods A cross sectional analysis of 1,387,677 infants up to age one admitted to English hospitals between April 2008 and April 2014 using Hospital Episode Statistics and live birth denominators for England from Office for National Statistics. Potentially avoidable conditions were defined through a staged process with a panel. Results The rate of hospital admission in the first year of life for physiological jaundice, feeding difficulties and gastroenteritis, the three conditions identified as potentially preventable in the context of postnatal care provision, increased by 39% (39.55 to 55.33 per 1000 live births) relative to an overall increase of 6% (334.97 to 354.55 per 1000 live births). Over the first year the biggest increase in admissions occurred in the first 0–6 days (RR 1.26, 95% CI 1.24 to 1.29) and 85% of the increase (12.36 to 18.23 per 1000 live births) in this period was for the three potentially preventable conditions. Conclusions Most of the increase in infant hospital admissions was in the early neonatal period, the great majority being accounted for by three potentially avoidable conditions especially jaundice and feeding difficulties. This may indicate missed opportunities within the postnatal care pathway and given the enormous NHS cost and parental distress from hospital admission of infants, requires urgent attention. Electronic supplementary material The online version of this article (10.1186/s12887-018-1360-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eleanor Jones
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TH, England.
| | - Beck Taylor
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TH, England
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TH, England
| | - Christine MacArthur
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TH, England
| | - Deepthi Jyothish
- Birmingham Women's and Children's NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, England
| | - Doug Simkiss
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TH, England
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23
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Neill S, Roland D, Thompson M, Tavaré A, Lakhanpaul M. Why are acute admissions to hospital of children under 5 years of age increasing in the UK? Arch Dis Child 2018; 103:917-919. [PMID: 29475836 DOI: 10.1136/archdischild-2017-313958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Sarah Neill
- Faculty of Health and Society, University of Northampton, Northampton, UK
| | - Damian Roland
- Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, USA.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alison Tavaré
- West of England Academic Health Science Network, Bristol, UK
| | - Monica Lakhanpaul
- General and Adolescent Paediatrics Unit, UCL Institute of Child Health, London, UK
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24
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Barwise-Munro R, Morgan H, Turner S. Physician and Parental Decision-Making Prior to Acute Medical Paediatric Admission. Healthcare (Basel) 2018; 6:healthcare6030117. [PMID: 30227652 PMCID: PMC6165442 DOI: 10.3390/healthcare6030117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/29/2018] [Accepted: 09/14/2018] [Indexed: 11/16/2022] Open
Abstract
Background: The number of acute medical paediatric emergency admissions is rising. We undertook qualitative interviews with parents and clinicians to better understand what factors, other than the health status of the child, may influence decision making leading to emergency admission. Methods: Semi-structured interviews were conducted with parents; clinicians working in general practice, out-of-hours or the emergency department (referring clinicians); and doctors working in acute medical paediatrics (receiving clinicians). Results: Ten parents, 7 referring clinicians and 10 receiving clinicians were interviewed. Parents described “erring on the side of caution” when seeking medical opinion and one mentioned anxiety. Among themes seen among referring clinicians, “erring on the side of caution” was also identified as was managing “parental anxiety” and acting on “gut instinct”. Among receiving clinicians, themes included managing parental anxiety and increasing parental expectations of the health service. Conclusions: The study of parent and referring clinician decision-making prior to a hospital admission can identify “teachable moments” where interventions might be delivered to slow or even arrest the rise in short-stay acute medical admissions in Britain and other countries. Interventions could assure parents or referring clinicians that hospital referral is not required and help clinicians understand what they perceive as “parental anxiety”.
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Affiliation(s)
| | - Heather Morgan
- Child Health, University of Aberdeen, Aberdeen AB24 3FX, UK.
- Health Services Research Unit, University of Aberdeen, Aberdeen AB24 3FX, UK.
| | - Steve Turner
- Child Health, Royal Aberdeen Children's Hospital, Aberdeen AB25 2ZG, UK.
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25
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Pope I, Ismail S, Bloom B, Jansen G, Burn H, McCoy D, Harris T. Short-stay admissions at an inner city hospital: a cross-sectional analysis. Emerg Med J 2018; 35:238-246. [PMID: 29305379 DOI: 10.1136/emermed-2016-205803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 11/15/2017] [Accepted: 11/21/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs). METHOD This is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission. RESULTS There were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay. CONCLUSION Only a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.
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Affiliation(s)
- Ian Pope
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Sharif Ismail
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Benjamin Bloom
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Gwyneth Jansen
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen Burn
- Department of Emergency Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - David McCoy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
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26
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Al-Mahtot M, Barwise-Munro R, Wilson P, Turner S. Changing characteristics of hospital admissions but not the children admitted-a whole population study between 2000 and 2013. Eur J Pediatr 2018; 177:381-388. [PMID: 29260375 PMCID: PMC5816774 DOI: 10.1007/s00431-017-3064-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED There are increasing numbers of emergency medical paediatric admissions. Our hypothesis was that characteristics of children and details of their emergency admissions are also changing over time. Details of emergency admissions in Scotland 2000-2013 were analysed. There were 574,403 emergency admissions, median age 2.3 years. The age distribution, proportion of boys and socioeconomic status of children admitted were essentially unchanged. Emergency admissions rose by 49% from 36/1000 children per annum to 54/1000 between 2000 and 2013. Emergency admissions that were discharged on the same day rose by 186% from 8.6/1000 to 24.6/1000. The mean duration of emergency admission fell from 1.7 to 1.0 days. The odds for an emergency admission with upper respiratory infection, "viral infection", tonsillitis, bronchiolitis and lower respiratory tract infection all rose. In contrast the odds for an emergency admission with asthma and gastroenteritis fell. CONCLUSIONS The demographics of children with emergency admissions have not changed substantially but characteristics of admissions have changed considerably, in particular admissions which are short stay and due to respiratory infection are much more common. The fall in the absolute number of children with some acute medical diagnoses suggests that the rise in admissions is not necessarily inexorable. What is Known: • Emergency admission prevalence is rising in many countries across Europe. What is New: • Our paper is the first to comprehensively analyse emergency medical paediatric admissions by exploring how characteristics of admissions and the children admitted have changed over time for a whole population. • The "take home message" is that whilst characteristics of emergency admissions have changed (e.g. number, duration of stay, readmissions, diagnoses), the characteristics of the children have not changed.
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Affiliation(s)
- Maryam Al-Mahtot
- Child Health, Royal Aberdeen Children’s Hospital, Aberdeen, AB25 2ZG UK
| | | | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Inverness, UK
| | - Steve Turner
- Child Health, Royal Aberdeen Children's Hospital, Aberdeen, AB25 2ZG, UK.
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27
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Husk K, Berry V, Tozer R, Skipwith G, Radmore R, Ball S, Ukoumunne OC, Logan S. Interventions for reducing unplanned paediatric admissions: an observational study in one hospital. BMJ Paediatr Open 2018; 2:e000235. [PMID: 29637196 PMCID: PMC5887827 DOI: 10.1136/bmjpo-2017-000235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/14/2018] [Accepted: 03/06/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Evidence on how best to intervene to improve paediatric acute care and therefore reduce unplanned hospital admissions is weak. We describe service evaluation work at one hospital to assess interventions at critical clinical and service decision points. DESIGN We conducted an observational study using routine daily-collected data (April 2009-December 2015) from a medium-sized district general hospital in south-west UK, using before-and-after comparisons of admissions-related data to evaluate two interventions implemented in April and November 2014, respectively: (1) an advice and guidance (A&G) phone line, where a senior paediatrician is available for general practitioners (GPs) and emergency department (ED) and (2) a Short Stay Paediatric Assessment Unit (SSPAU). We analysed data on all admitted children (<18 years) in the catchment area (population estimate 27 740 in 2015). Outcomes were GP-referred attendances, ward admissions, less than 1 day admissions and length of stay. RESULTS A&G phone line was associated with a reduction in the mean number of less than 1 day admissions per month (difference in means before and after intervention -16.6 (95% CI -0.2 to -32.9)) and an increase in overall monthly bed-days (difference 72.5 (95% CI 21.0 to 124.0)), but there was little evidence of a change in GP-referred attendances or ward admissions. SSPAU was associated with a reduction in the mean number of monthly ward admissions (difference -34.6 (95% CI -21.3 to -48.0)) and less than 1 day admissions (difference in means -21.7 (95% CI -8.4 to -35.1)) and a reduction in the mean number of overall bed-days per month (difference -50.2 (95% CI -12.1 to -88.3)). CONCLUSIONS Interventions for reducing time taken to senior clinician review may be effective in better managing paediatric acute care. Further work should explore results by age, condition and injury/illness status.
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Affiliation(s)
- Kerryn Husk
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Vashti Berry
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Richard Tozer
- Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, UK
| | - Gina Skipwith
- Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, UK
| | - Robert Radmore
- Torbay and South Devon NHS Foundation Trust, Torbay Hospital, Torquay, UK
| | - Susan Ball
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Stuart Logan
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, Exeter, UK
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28
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Farnham L, Harwood H, Robertson M. Effect of a children's at-home nursing team on reducing emergency admissions. Nurs Child Young People 2017; 29:31-37. [PMID: 29206360 DOI: 10.7748/ncyp.2017.e930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 06/07/2023]
Abstract
This article explores the effect of a children's at-home nursing team, Hospital at Home (H@H), which aimed to reduce demand on acute hospital beds, support families to improve patient experience, and empower parents to care safely for their unwell children and help prevent emergency department (ED) reattendance. Data on demographics and clinical presentation of H@H and ED attendances were collected and compared. A survey measuring parents' confidence in managing their unwell children was also conducted. Of 72 patients treated by the H@H service between May and July 2016, 32 (44%) would have been admitted to hospital from the ED if the H@H service had not existed. This is equivalent to a saving of 64 bed days. Patients treated by the H@H service had similar demographics to those discharged from the ED to usual care. The H@H service took on patients with higher Bedside Paediatric Early Warning System scores before discharge. Parents reported that they would be more confident caring for their children after discharge from the H@H service. The H@H service decreased the number of unnecessary ED admissions. The service promotes a positive patient experience and increases parents' confidence when caring for unwell children at home.
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Affiliation(s)
- Laura Farnham
- King's College Hospital NHS Foundation Trust, London, England
| | - Hannah Harwood
- King's College Hospital NHS Foundation Trust, London, England
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29
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Irwin AD, Grant A, Williams R, Kolamunnage-Dona R, Drew RJ, Paulus S, Jeffers G, Williams K, Breen R, Preston J, Appelbe D, Chesters C, Newland P, Marzouk O, McNamara PS, Diggle PJ, Carrol ED. Predicting Risk of Serious Bacterial Infections in Febrile Children in the Emergency Department. Pediatrics 2017; 140:peds.2016-2853. [PMID: 28679639 DOI: 10.1542/peds.2016-2853] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Improving the diagnosis of serious bacterial infections (SBIs) in the children's emergency department is a clinical priority. Early recognition reduces morbidity and mortality, and supporting clinicians in ruling out SBIs may limit unnecessary admissions and antibiotic use. METHODS A prospective, diagnostic accuracy study of clinical and biomarker variables in the diagnosis of SBIs (pneumonia or other SBI) in febrile children <16 years old. A diagnostic model was derived by using multinomial logistic regression and internally validated. External validation of a published model was undertaken, followed by model updating and extension by the inclusion of procalcitonin and resistin. RESULTS There were 1101 children studied, of whom 264 had an SBI. A diagnostic model discriminated well between pneumonia and no SBI (concordance statistic 0.84, 95% confidence interval 0.78-0.90) and between other SBIs and no SBI (0.77, 95% confidence interval 0.71-0.83) on internal validation. A published model discriminated well on external validation. Model updating yielded good calibration with good performance at both high-risk (positive likelihood ratios: 6.46 and 5.13 for pneumonia and other SBI, respectively) and low-risk (negative likelihood ratios: 0.16 and 0.13, respectively) thresholds. Extending the model with procalcitonin and resistin yielded improvements in discrimination. CONCLUSIONS Diagnostic models discriminated well between pneumonia, other SBIs, and no SBI in febrile children in the emergency department. Improvements in the classification of nonevents have the potential to reduce unnecessary hospital admissions and improve antibiotic prescribing. The benefits of this improved risk prediction should be further evaluated in robust impact studies.
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Affiliation(s)
| | | | | | | | - Richard J Drew
- Department of Microbiology, Rotunda Hospital, Dublin, Ireland.,Department of Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
| | | | | | | | - Rachel Breen
- Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | | | - Duncan Appelbe
- Clinical Trials Research Centre, University of Liverpool, Liverpool, United Kingdom
| | - Christine Chesters
- Biochemistry, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Paul Newland
- Biochemistry, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | | | | | - Peter J Diggle
- Institute of Infection and Global Health.,Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, United Kingdom
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30
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Herbert A, Wijlaars L, Zylbersztejn A, Cromwell D, Hardelid P. Data Resource Profile: Hospital Episode Statistics Admitted Patient Care (HES APC). Int J Epidemiol 2017; 46:1093-1093i. [PMID: 28338941 PMCID: PMC5837677 DOI: 10.1093/ije/dyx015] [Citation(s) in RCA: 386] [Impact Index Per Article: 55.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Annie Herbert
- Population, Policy and Practice Programme, UCL Institute of Child Health
- Department of Behavioural Science and Health, UCL Institute of Epidemiology and Healthcare
| | - Linda Wijlaars
- Population, Policy and Practice Programme, UCL Institute of Child Health
| | - Ania Zylbersztejn
- Population, Policy and Practice Programme, UCL Institute of Child Health
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Pia Hardelid
- Population, Policy and Practice Programme, UCL Institute of Child Health
- Department of Primary Care and Population Health, University College London, London, UK
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31
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Harron K, Gilbert R, Cromwell D, Oddie S, Guttmann A, van der Meulen J. International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England. BMJ Qual Saf 2017; 27:31-39. [PMID: 28607037 PMCID: PMC5750429 DOI: 10.1136/bmjqs-2016-006253] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 04/19/2017] [Accepted: 05/02/2017] [Indexed: 11/25/2022]
Abstract
Objectives To compare emergency hospital use for infants in Ontario (Canada) and England. Methods We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission. Results The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age. Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.
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Affiliation(s)
- Katie Harron
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ruth Gilbert
- Great Ormond Street Institute of Child Health, London, UK
| | - David Cromwell
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sam Oddie
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Astrid Guttmann
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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Heys M, Rajan M, Blair M. Length of paediatric inpatient stay, socio-economic status and hospital configuration: a retrospective cohort study. BMC Health Serv Res 2017; 17:274. [PMID: 28412944 PMCID: PMC5392919 DOI: 10.1186/s12913-017-2171-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Variation in paediatric inpatient length of stay exists - whether this is driven by differences in patient characteristics or health service delivery is unclear. We will test the hypotheses that higher levels of deprivation are associated with prolonged length of stay and that differences in prolonged length of stay across 2 hospitals will be explained by demographic, clinical and process factors. METHODS This is a retrospective cohort study of 2889 children aged less than 16 years admitted from 1st April 2009 to 30th March 2010. Administrative data were used from two UK hospitals whose Accident and Emergency (A&E) departments were paediatric and adult physician led respectively. The main outcome was prolonged length of stay defined as greater than or equal to the mean (1.8 days). Sensitivity analyses defined prolonged length of stay as greater than the median (1 day). Demographic, clinical and process characteristics were examined. Socio-economic position was measured by Income Deprivation Affecting Children Index. Multivariable logistic and linear regression analyses were performed. RESULTS We did not find a consistent association between length of stay and socio-economic position, using a variety of definitions of length of stay. In contrast, adjusted for age, gender, socio-economic position, ethnicity, final diagnosis, number of hospital admissions, source of admission, and timing of admission, admission to the adult led A&E hospital was more strongly associated with prolonged length of stay (Odds Ratio 1.41, 95% Confidence Interval 1.16, 1.71). CONCLUSION Local variation in paediatric inpatient length of stay was not explained by demographic, clinical or process factors, but could have been due to residual confounding by medical complexity. Length of stay was not consistently associated with socio-economic position suggesting that length of stay is a function of health service not the determinants of health. Analyses of these types of data would be strengthened by measures of complexity and adverse events.
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Affiliation(s)
- Michelle Heys
- Child Public Health Group, Imperial College River Island Academic Centre, Paediatric Department, Northwick Park Hospital (NWLH NHS Trust), London, UK. .,Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK. .,Great Ormond Street Institute of Child Health, University College London, 30 Guildford Street, London, WC1N 1EH, UK.
| | - Matthew Rajan
- Child Public Health Group, Imperial College River Island Academic Centre, Paediatric Department, Northwick Park Hospital (NWLH NHS Trust), London, UK.,Imperial College London, London, UK
| | - Mitch Blair
- Child Public Health Group, Imperial College River Island Academic Centre, Paediatric Department, Northwick Park Hospital (NWLH NHS Trust), London, UK.,Imperial College London, London, UK
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Poropat F, Heinz P, Barbi E, Ventura A. Comparison of two European paediatric emergency departments: does primary care organisation influence emergency attendance? Ital J Pediatr 2017; 43:29. [PMID: 28274237 PMCID: PMC5341451 DOI: 10.1186/s13052-017-0339-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 01/20/2017] [Indexed: 11/23/2022] Open
Abstract
Backround To compare paediatric Emergency Department (ED) attendances and admission outcomes in two European hospitals with different paediatric primary care set-up. Methods This is a retrospective prevalence study comparing all paediatric ED attendances during calendar years 2013 in two EDs with similar catchment area: one in Italy (Trieste) where paediatric primary care is provided by office paediatricians, the other, in the UK (Cambridge), where paediatric primary care is provided by general practitioners. Data on reason for presentation, discharge diagnosis and admission rate were collected and sub-group analysis for specific age groups (<1 year, 1–4 years, 5–15 years) was performed. Results Over 12 months, 20.331 children (0–15 years old) were seen in Cambridge and 18.646 in Trieste, with a very similar age distribution in both centres, except for the youngest age group: the percentage of infants seen in comparison with the total number of children attending ED was 1/3 higher in England than in Italy (15.4% vs 11.4%). The reasons for attendance were similar: under 1 year of age, the chief complaints were fever, breathing difficulties and gastrointestinal problems while in the older age groups trauma represented the commonest reason. Among discharge diagnoses, no differences were found between the two hospitals, except for faltering growth and “well child”, more frequently diagnosed in English children under 5 years. The proportion of admissions was three times higher in Cambridge (14.1% vs 4.8%) with most children being admitted for infectious diseases. Conclusions ED attendances in infants are more common in a primary care setting provided by general practicioner and, moreover, admission rates in all age groups are 1/3 reduced by primary care based paediatricians. Due to the methodological limits of this study, it isn't possible to evaluate whether these results depend only on paediatric primary care set-up or be determined by other confounding factors. New studies are needed to confirm this preliminary evidence.
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Affiliation(s)
- F Poropat
- University of Trieste, IRCCS-Burlo Garofolo Trieste (Italy), via dell'Istria 65/1, Trieste, 34137, Italy.
| | - P Heinz
- Emergency Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Barbi
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - A Ventura
- University of Trieste, IRCCS-Burlo Garofolo Trieste (Italy), via dell'Istria 65/1, Trieste, 34137, Italy.,Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
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Bustinduy AL, Chis Ster I, Shaw R, Irwin A, Thiagarajan J, Beynon R, Ladhani S, Sharland M. Predictors of fever-related admissions to a paediatric assessment unit, ward and reattendances in a South London emergency department: the CABIN 2 study. Arch Dis Child 2017; 102:22-28. [PMID: 27551062 DOI: 10.1136/archdischild-2016-310494] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the risk factors for ward and paediatric assessment unit (PAU) admissions from the emergency department (ED). DESIGN Prospective observational study. SETTING AND PATIENTS Febrile children attending a large tertiary care ED during the winter of 2014-2015. MAIN OUTCOME MEASURES Ward and PAU admissions, National Institute for Health and Care Excellence (NICE) guidelines classification, reattendance to the ED within 28 days and antibiotic use. RESULTS A total of 1097 children attending the children's ED with fever were analysed. Risk factors for PAU admission were tachycardia (RR=1.1, 95% CI (1 to 1.1)), ill-appearance (RR=2.2, 95% CI (1.2 to 4.2)), abnormal chest findings (RR=2.1, 95% CI (1.2 to 4.3)), categorised as NICE amber (RR 1.7 95% CI (1.2 to 2.5)). There was a 30% discordance between NICE categorisation at triage and statistical internal validation. Predictors of ward admission were a systemic (RR=6.9, 95% CI (2.4 to 19.8)) or gastrointestinal illness (RR=3.8, 95% (1.4 to 10.4)) and categorised as NICE Red (RR=5.9, 95% CI (2.2 to 15.3)). Only 51 children had probable bacterial pneumonia (4.6%), 52 children had a proven urinary tract infection (4.2%), with just 2 (0.2%) positive blood cultures out of 485 (44%) children who received an antibiotic. 15% of all children reattended by 28 days and were more likely to have been categorised as Amber and had investigations on initial visit. CONCLUSIONS Risk factors for PAU and ward admissions are different in this setting with high reattendance rates and very low proportion of confirmed/probable serious bacterial infections. Future studies need to focus on reducing avoidable admissions and antibiotic treatment.
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Affiliation(s)
- Amaya L Bustinduy
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | - Irina Chis Ster
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Rebecca Shaw
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK.,Children's Emergency Department, St George's NHS trust, London, UK
| | - Adam Irwin
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | | | - Rhys Beynon
- Children's Emergency Department, St George's NHS trust, London, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK.,Immunisation Department, Public Health England, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
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Rees P, Edwards A, Powell C, Hibbert P, Williams H, Makeham M, Carter B, Luff D, Parry G, Avery A, Sheikh A, Donaldson L, Carson-Stevens A. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLoS Med 2017; 14:e1002217. [PMID: 28095408 PMCID: PMC5240916 DOI: 10.1371/journal.pmed.1002217] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting. METHODS AND FINDINGS We undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales' National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions. Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods. CONCLUSIONS This study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.
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Affiliation(s)
- Philippa Rees
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Colin Powell
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Peter Hibbert
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
| | - Huw Williams
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Meredith Makeham
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
| | - Ben Carter
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Donna Luff
- Institute for Professionalism and Ethical Practice, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anesthesia, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
- Institute for Healthcare Improvement, Cambridge, Massachusetts, United States of America
| | - Anthony Avery
- Division of General Practice, University of Nottingham, Nottingham, United Kingdom
| | - Aziz Sheikh
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Liam Donaldson
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew Carson-Stevens
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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Wijlaars LPMM, Gilbert R, Hardelid P. Chronic conditions in children and young people: learning from administrative data. Arch Dis Child 2016; 101:881-5. [PMID: 27246068 PMCID: PMC5050282 DOI: 10.1136/archdischild-2016-310716] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/02/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Linda P M M Wijlaars
- Children's Policy Research Unit, UCL Institute of Child Health, London, UK,Farr Institute of Health Informatics Research London, London, UK
| | - Ruth Gilbert
- Children's Policy Research Unit, UCL Institute of Child Health, London, UK,Farr Institute of Health Informatics Research London, London, UK
| | - Pia Hardelid
- Children's Policy Research Unit, UCL Institute of Child Health, London, UK,Department of Primary Care and Population Health, University College London, London, UK
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Gnani S, Morton S, Ramzan F, Davison M, Ladbrooke T, Majeed A, Saxena S. Healthcare use among preschool children attending GP-led urgent care centres: a descriptive, observational study. BMJ Open 2016; 6:e010672. [PMID: 27288373 PMCID: PMC4908914 DOI: 10.1136/bmjopen-2015-010672] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Urgent care centres' (UCCs) hours were developed with the aim of reducing inappropriate emergency department (ED) attendances in England. We aimed to examine the presenting complaint and outcomes of care in 2 general practitioner (GP)-led UCCs with extended opening times. DESIGN Retrospective observational epidemiological study using routinely collected data. SETTING 2 GP-led UCCs in London, colocated with a hospital ED. PARTICIPANTS All children aged under 5 years, attending 2 GP-led UCCs over a 3-year period. OUTCOMES Outcomes of care for the children including: primary diagnosis; registration status with a GP; destination following review within the UCC; and any medication prescribed. Comparison between GP-led UCC visit rates and routine general practices was also made. RESULTS 3% (n=7747/282 947) of all attenders at the GP-led UCCs were children aged under 5 years. The most common reason for attendance was a respiratory illness (27%), followed by infectious illness (17%). 18% (n=1428) were either upper respiratory tract infections or viral infections. The majority (91%) of children attending were registered with a GP, and over two-thirds of attendances were 'out of hours'. Overall 79% were seen and discharged home. Preschool children were more likely to attend their GP (47.0 per 100) than a GP-led UCC (9.4 per 100; 95% CI 8.9 to 10.0). CONCLUSIONS Two-thirds of preschool children attending GP-led UCCs do so out of hours, despite the majority being registered with a GP. The case mix is comparable with those presenting to an ED setting, with the majority managed exclusively by the GPs in the UCC before discharge home. Further work is required to understand the benefits of a GP-led urgent system in influencing future use of services especially emergency care.
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Affiliation(s)
- S Gnani
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - S Morton
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - F Ramzan
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - M Davison
- North End Medical Centre, London, UK
| | - T Ladbrooke
- London Central and West Unscheduled Care Collaborative, London, UK
| | - A Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - S Saxena
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Neill SJ, Jones CHD, Lakhanpaul M, Roland DT, Thompson MJ. Parents' help-seeking behaviours during acute childhood illness at home: A contribution to explanatory theory. J Child Health Care 2016; 20:77-86. [PMID: 25296933 DOI: 10.1177/1367493514551309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Uncertainty and anxiety surround parents' decisions to seek medical help for an acutely ill child. Consultation rates for children are rising, yet little is known about factors that influence parents' help-seeking behaviours. We used focus groups and interviews to examine how 27 parents of children under five years, from a range of socioeconomic groups in the East Midlands of England, use information to make decisions during acute childhood illness at home. This article reports findings elucidating factors that influence help-seeking behaviours. Parents reported that decision-making during acute childhood illness was influenced by a range of personal, social and health service factors. Principal among these was parents' concern to do the right thing for their child. Their ability to assess the severity of the illness was influenced by knowledge and experience of childhood illness. When parents were unable to access their general practitioner (GP), feared criticism from or had lost trust in their GP, some parents reported using services elsewhere such as Accident and Emergency. These findings contribute to explanatory theory concerning parents' help-seeking behaviours. Professional and political solutions have not reduced demand; therefore, collaborative approaches involving the public and professionals are now needed to improve parents' access to information.
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Affiliation(s)
- Sarah J Neill
- School of Health, University of Northampton, Northampton, UK
| | - Caroline H D Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monica Lakhanpaul
- General and Adolescent Paediatrics Unit, Institute of Child Health, University College London, London, UK
| | - Damian T Roland
- Paediatric Emergency Medicine Leicester Academic Group, Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Matthew J Thompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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40
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Irwin AD, Wickenden J, Le Doare K, Ladhani S, Sharland M. Supporting decisions to increase the safe discharge of children with febrile illness from the emergency department: a systematic review and meta-analysis. Arch Dis Child 2016; 101:259-66. [PMID: 26718814 DOI: 10.1136/archdischild-2015-309056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 11/30/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Despite fewer serious infections presenting to the children's emergency department (ED), hospital admissions of children with febrile illness have increased. We review evidence for the use of decision rules to increase the safe discharge of these children from the ED. METHODS A systematic review of prospective studies of decision rules for the discharge of children with febrile illness, and prediction rules for the diagnosis of serious infections in children presenting to ED. We reviewed the MEDLINE database, Cochrane Library and hand searched the bibliographies of related studies. The search was limited to the English language. RESULTS Thirty-three studies were identified. Fourteen reported low-risk criteria to rule out serious bacterial infection (SBI) in infants less than 3 months of age. In this group, clinical tools such as the Rochester and Philadelphia criteria support the safe discharge of low-risk infants without empirical antibiotics. Seventeen studies reported prediction rules in older children, though only four included children over 3 years. Two impact studies based upon multivariable prediction models failed to demonstrate any impact on rates of discharge from ED. CONCLUSIONS The use of clinical prediction models can improve discrimination between serious and self-limiting infections in children. The application of low-risk thresholds may help to rule out serious infections and discharge children from the ED without empirical antibiotics. A growing evidence base for prediction rules has so far failed to translate into validated rules to aid decision-making. Future work should evaluate decision rules in well designed impact studies, focusing on the need for hospital admission and antibiotic therapy.
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Affiliation(s)
- A D Irwin
- Paediatric Infectious Disease Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Wickenden
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - K Le Doare
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - S Ladhani
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - M Sharland
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
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Cecil E, Bottle A, Cowling TE, Majeed A, Wolfe I, Saxena S. Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK. Pediatrics 2016; 137:e20151492. [PMID: 26791971 DOI: 10.1542/peds.2015-1492] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Demand for unplanned hospital services is rising, and children are frequent users, especially where access to primary care is poor. In England, universal health care coverage entitles parents to see a general practitioner (GP) for first-contact care. However, access to GP appointments is variable, and few patients can see their own regular GP out of hours (OOH). The goal of this study explored the association between access to GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in England. METHODS ED visit and short hospitalization rates were investigated in 9.5 million children aged <15 years registered with English family practices between April 2011 and March 2012 by using administrative hospital data. Six access categories ranked all practices according to patients' reported ability to schedule GP appointments; from national GP Patient Survey data. GP consulting hours were 8:00 am to 6:30 pm on weekdays. RESULTS There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over the 12 months studied. Children registered with practices in the highest access group compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95% confidence interval: 0.89-93]), particularly OOH compared with consulting hours (10% vs 7%). Children in the highest access groups were equally likely to be admitted for a short stay. CONCLUSIONS Increasing GP accessibility might alleviate the burden of ED visits from children, particularly during peak times OOH. Short hospitalizations may be more sensitive to other aspects of health systems.
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Affiliation(s)
- Elizabeth Cecil
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom; and
| | - Alex Bottle
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom; and
| | - Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom; and
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom; and
| | - Ingrid Wolfe
- Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom
| | - Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom; and
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McLaren J, Williams ID. The impact of communicating information about air pollution events on public health. THE SCIENCE OF THE TOTAL ENVIRONMENT 2015; 538:478-491. [PMID: 26318685 DOI: 10.1016/j.scitotenv.2015.07.149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/22/2015] [Accepted: 07/30/2015] [Indexed: 06/04/2023]
Abstract
Short-term exposure to air pollution has been associated with exacerbation of asthma and chronic obstructive pulmonary disease (COPD). This study investigated the relationship between emergency hospital admissions for asthma, COPD and episodes of poor air quality in an English city (Southampton) from 2008-2013. The city's council provides a forecasting service for poor air quality to individuals with respiratory disease to reduce preventable admissions to hospital and this has been evaluated. Trends in nitrogen dioxide, ozone and particulate matter concentrations were related to hospital admissions data using regression analysis. The impacts of air quality on emergency admissions were quantified using the relative risks associated with each pollutant. Seasonal and weekly trends were apparent for both air pollution and hospital admissions, although there was a weak relationship between the two. The air quality forecasting service proved ineffective at reducing hospital admissions. Improvements to the health forecasting service are necessary to protect the health of susceptible individuals, as there is likely to be an increasing need for such services in the future.
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Affiliation(s)
- J McLaren
- Centre for Environment Sciences, Faculty of Engineering and the Environment, University of Southampton, Lanchester Building, University Rd., Highfield, Southampton, Hampshire SO17 1BJ, UK
| | - I D Williams
- Centre for Environment Sciences, Faculty of Engineering and the Environment, University of Southampton, Lanchester Building, University Rd., Highfield, Southampton, Hampshire SO17 1BJ, UK.
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43
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Wijlaars LP, Hardelid P, Woodman J, Allister J, Cheung R, Gilbert R. Contribution of recurrent admissions in children and young people to emergency hospital admissions: retrospective cohort analysis of hospital episode statistics. Arch Dis Child 2015; 100:845-9. [PMID: 25987359 DOI: 10.1136/archdischild-2014-307771] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 04/23/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine the contribution of recurrent admissions to the high rate of emergency admissions among children and young people (CYP) in England, and to what extent readmissions are accounted for by patients with chronic conditions. DESIGN All hospital admissions to the National Health Service (NHS) in England using hospital episode statistics (HES) from 2009 to 2011 for CYP aged 0-24 years. We followed CYP for 2 years from discharge of their first emergency admission in 2009. We determined the number of subsequent emergency admissions, time to next admission, length of stay and the proportion of injury and chronic condition admissions measured by diagnostic codes in all following admissions. RESULTS 869 895 children had an index emergency admission in 2009, resulting in a further 939 710 admissions (of which 600 322, or 64%, were emergency admissions) over the next 2 years. After discharge from the index admission, 32% of 274,986 (32%) children were readmitted within 2 years, 26% of these readmissions occurring within 30 days of discharge. Recurrent emergency admission accounted for 41% of all emergency admissions in the 2-year cohort and 66% of inpatient days. 41% of index admissions, but 76% of the recurrent emergency admissions, were in children with a chronic condition. CONCLUSIONS Recurrent admissions contribute substantially to total emergency admissions. They often occur soon after discharge, and disproportionately affect CYP with chronic conditions. Policies aiming to discourage readmissions should consider whether they could undermine necessary inpatient care for children with chronic conditions.
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Affiliation(s)
- Linda Pmm Wijlaars
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Pia Hardelid
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Jenny Woodman
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Janice Allister
- Clinical Innovation and Research, Royal College of General Practitioners, London, UK
| | - Ronny Cheung
- Department of General Paediatrics, Evelina's Children Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - Ruth Gilbert
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
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Cecil E, Bottle A, Sharland M, Saxena S. Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions. Ann Fam Med 2015; 13:214-20. [PMID: 25964398 PMCID: PMC4427415 DOI: 10.1370/afm.1786] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions. METHODS We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions. RESULTS There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004. CONCLUSIONS The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.
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Affiliation(s)
- Elizabeth Cecil
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
| | - Alex Bottle
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
| | - Mike Sharland
- Paediatric Infectious Disease Unit, St George's Hospital, University of London, United Kingdom
| | - Sonia Saxena
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
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Mellish LC, Dunkley C, Ferrie CD, Pal DK. Antiepileptic drug treatment of rolandic epilepsy and Panayiotopoulos syndrome: clinical practice survey and clinical trial feasibility. Arch Dis Child 2015; 100:62-7. [PMID: 25202134 PMCID: PMC4283698 DOI: 10.1136/archdischild-2013-304211] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The evidence base for management of childhood epilepsy is poor, especially for the most common specific syndromes such as rolandic epilepsy (RE) and Panayiotopoulos syndrome (PS). Considerable international variation in management and controversy about non-treatment indicate the need for high quality randomised controlled trials (RCT). The aim of this study is, therefore, to describe current UK practice and explore the feasibility of different RCT designs for RE and PS. METHODS We conducted an online survey of 590 UK paediatricians who treat epilepsy. Thirty-two questions covered annual caseload, investigation and management practice, factors influencing treatment, antiepileptic drug preferences and hypothetical trial design preferences. RESULTS 132 responded (22%): 81% were paediatricians and 95% at consultant seniority. We estimated, annually, 751 new RE cases and 233 PS cases. Electroencephalography (EEG) is requested at least half the time in approximately 70% of cases; MRI brain at least half the time in 40%-65% cases and neuropsychological evaluation in 7%-8%. Clinicians reported non-treatment in 40%: main reasons were low frequency of seizures and parent/child preferences. Carbamazepine is the preferred older, and levetiracetam the preferred newer, RCT arm. Approximately one-half considered active and placebo designs acceptable, choosing seizures as primary and cognitive/behavioural measures as secondary outcomes. CONCLUSIONS Management among respondents is broadly in line with national guidance, although with possible overuse of brain imaging and underuse of EEG and neuropsychological assessments. A large proportion of patients in the UK remains untreated, and clinicians seem amenable to a range of RCT designs, with carbamazepine and levetiracetam the preferred active drugs.
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Affiliation(s)
| | | | - Colin D Ferrie
- Department of Paediatric Neurology, Leeds General Infirmary, Leeds, UK
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Sepsis and meningitis in hospitalized children: performance of clinical signs and their prediction rules in a case-control study. Pediatr Emerg Care 2014; 30:373-80. [PMID: 24849278 DOI: 10.1097/pec.0000000000000142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Feverish illness is a common presentation to acute pediatric services. Clinical staff faces the challenge of differentiating the few children with meningitis or sepsis from the majority with self-limiting illness. We aimed to determine the diagnostic value of clinical features and their prediction rules (CPR) for identifying children with sepsis or meningitis among those children admitted to a District General Hospital with acute febrile illness. METHODS Acutely ill children admitted to a District General Hospital in England were included in this case-control study between 2000 and 2005. We examined the diagnostic accuracy of individual clinical signs and 6 CPRs, including the National Institute for Clinical Excellence "traffic light" system, to determine clinical utility in identifying children with a diagnosis of sepsis or meningitis. RESULTS Loss of consciousness, prolonged capillary refill, decreased alertness, respiratory effort, and the physician's illness assessment had high positive likelihood ratios (9-114), although with wide confidence intervals, to rule in sepsis or meningitis. The National Institute for Clinical Excellence traffic light system, the modified Yale Observation Scale, and the Pediatric Advanced Warning Score performed poorly with positive likelihood ratios ranging from 1 to 3. CONCLUSIONS The pediatrician's overall illness assessment was the most useful feature to rule in sepsis or meningitis in these hospitalized children. Clinical prediction rules did not effectively rule in sepsis or meningitis. The modified Yale Observation Scale should be used with caution. Single clinical signs could complement these scores to rule in sepsis or meningitis. Further research is needed to validate these CPRs.
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Le Doare K, Nichols AL, Payne H, Wells R, Navidnia S, Appleby G, Calton E, Sharland M, Ladhani SN. Very low rates of culture-confirmed invasive bacterial infections in a prospective 3-year population-based surveillance in Southwest London. Arch Dis Child 2014; 99:526-31. [PMID: 24554055 DOI: 10.1136/archdischild-2013-305565] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To estimate the incidence, clinical characteristics and risk factors for culture-confirmed invasive bacterial infections in England. DESIGN Prospective, observational, study of all children with positive blood and/or cerebrospinal fluid (CSF) culture over a 3-year period (2009-2011). SETTING All five hospitals within a geographically defined region in southwest London providing care for around 600 000 paediatric residents. PATIENTS Children aged 1 month to 15 years MAIN OUTCOME MEASURES Rates of community-acquired and hospital-acquired invasive bacterial infections in healthy children and those with co-morbidities; pathogens by age group, risk group and clinical presentation. RESULTS During 2009-2011, 44 118 children had 46 039 admissions, equivalent to 26 admissions per 1000 children. Blood/CSF cultures were obtained during 44.7% of admissions, 7.4% were positive but only 504 were clinically significant, equivalent to 32.9% of positive blood/CSF cultures, 2.4% of all blood/CSF cultures and 1.1% of hospital admissions. The population incidence of culture-confirmed invasive bacterial infection was 28/100 000. One-third of infections were hospital acquired and, of the community-acquired infections, two-thirds occurred in children with pre-existing co-morbidities. In previously healthy children, therefore, the incidence of community-acquired invasive bacterial infection was only 6.4/100 000. CONCLUSIONS Although infection was suspected in almost half the children admitted to hospital, a significant pathogen was cultured from blood or CSF in only 2.4%, mainly among children with pre-existing co-morbidities, who may require a more broad-spectrum empiric antibiotic regime compared to previously healthy children. Invasive bacterial infection in previously healthy children is now very rare. Improved strategies to manage low-risk febrile children are required.
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Affiliation(s)
- Kirsty Le Doare
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK Wellcome Trust/Imperial Centre for Global Health Research, Imperial College, London, UK
| | - Anna-Louise Nichols
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Helen Payne
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Rosy Wells
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Sonia Navidnia
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Gayle Appleby
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Elizabeth Calton
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK
| | - Shamez N Ladhani
- Paediatric Infectious Diseases Research Group, St. George's Hospital, London, UK Immunisation Department, Public Health England, London, UK
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Murray J, Bottle A, Sharland M, Modi N, Aylin P, Majeed A, Saxena S. Risk factors for hospital admission with RSV bronchiolitis in England: a population-based birth cohort study. PLoS One 2014; 9:e89186. [PMID: 24586581 PMCID: PMC3935842 DOI: 10.1371/journal.pone.0089186] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/16/2014] [Indexed: 11/30/2022] Open
Abstract
Objective To examine the timing and duration of RSV bronchiolitis hospital admission among term and preterm infants in England and to identify risk factors for bronchiolitis admission. Design A population-based birth cohort with follow-up to age 1 year, using the Hospital Episode Statistics database. Setting 71 hospitals across England. Participants We identified 296618 individual birth records from 2007/08 and linked to subsequent hospital admission records during the first year of life. Results In our cohort there were 7189 hospital admissions with a diagnosis of bronchiolitis, 24.2 admissions per 1000 infants under 1 year (95%CI 23.7–24.8), of which 15% (1050/7189) were born preterm (47.3 bronchiolitis admissions per 1000 preterm infants (95% CI 44.4–50.2)). The peak age group for bronchiolitis admissions was infants aged 1 month and the median was age 120 days (IQR = 61–209 days). The median length of stay was 1 day (IQR = 0–3). The relative risk (RR) of a bronchiolitis admission was higher among infants with known risk factors for severe RSV infection, including those born preterm (RR = 1.9, 95% CI 1.8–2.0) compared with infants born at term. Other conditions also significantly increased risk of bronchiolitis admission, including Down's syndrome (RR = 2.5, 95% CI 1.7–3.7) and cerebral palsy (RR = 2.4, 95% CI 1.5–4.0). Conclusions Most (85%) of the infants who are admitted to hospital with bronchiolitis in England are born at term, with no known predisposing risk factors for severe RSV infection, although risk of admission is higher in known risk groups. The early age of bronchiolitis admissions has important implications for the potential impact and timing of future active and passive immunisations. More research is needed to explain why babies born with Down's syndrome and cerebral palsy are also at higher risk of hospital admission with RSV bronchiolitis.
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Affiliation(s)
- Joanna Murray
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
- * E-mail:
| | - Alex Bottle
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Mike Sharland
- Paediatric Infectious Diseases Unit, St. George's Hospital NHS Trust, London, United Kingdom
| | - Neena Modi
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Paul Aylin
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
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Jones CHD, Neill S, Lakhanpaul M, Roland D, Singlehurst-Mooney H, Thompson M. Information needs of parents for acute childhood illness: determining 'what, how, where and when' of safety netting using a qualitative exploration with parents and clinicians. BMJ Open 2014; 4:e003874. [PMID: 24430877 PMCID: PMC3902331 DOI: 10.1136/bmjopen-2013-003874] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the views of parents and clinicians regarding the optimal content, format and delivery of safety netting information for acute childhood illness. DESIGN Qualitative study including semistructured focus groups and interviews. SETTING First contact care settings, community centres, children's centres and nurseries in the Midlands, UK. PARTICIPANTS 27 parents from a travelling community, Asian British community and white British community. Sixteen clinicians including 10 doctors and 6 nurses from a general practice surgery, an out-of-hours service and two emergency departments (paediatric and combined adult and paediatric). RESULTS Participants described a need for safety netting to contain information on signs and symptoms of serious and common illnesses, illness management and where and when to seek help. Resources should be basic, simple to use and contain simple symbols. A key criterion was professional endorsement of resources. Internet-based information was desired which is reliable, consistent and up-to-date. Participants described a need for different types of information: that which could be delivered during consultations, as well as more general information for parents to access before consulting a healthcare professional. Face-to-face education, written materials and digital media were suggested delivery mechanisms. Audiovisual material was preferred by families with low literacy. Participants commonly suggested internet-based and phone-based resources, but the travelling community was less comfortable with these approaches. CONCLUSIONS A multifaceted and tailored approach to safety netting is needed so that effective resources are available for parents with varying information needs, literacy levels and ability to use information technology. We have identified key aspects of content, quality criteria, format and delivery mechanisms for safety netting information from the perspectives of clinicians and parents. Resources should be coproduced with parents and clinicians to ensure that they are valued and utilised by both groups.
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Affiliation(s)
- Caroline H D Jones
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Neill
- School of Health, University of Northampton, Northampton, UK
| | - Monica Lakhanpaul
- General and Adolescent Paediatrics Unit, Institute of Child Health, University College London, London, UK
| | - Damian Roland
- Paediatric Emergency medicine Leicester Academic Group, Department of Cardiovascular Sciences, Leicester University, Leicester, UK
| | | | - Matthew Thompson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Shivaji T, Lee A, Dougall N, McMillan T, Stark C. The epidemiology of hospital treated traumatic brain injury in Scotland. BMC Neurol 2014; 14:2. [PMID: 24386897 PMCID: PMC3893436 DOI: 10.1186/1471-2377-14-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 12/02/2013] [Indexed: 11/10/2022] Open
Abstract
Background Traumatic Brain Injury (TBI) is an important global public health problem made all the more important by the increased likelihood of disability following a hospital admission for TBI. Understanding those groups most at risk will help inform interventions designed to prevent causes of TBI, such as falls prevention measures. This study identifies the rate of hospitalisation episodes of TBI in Scotland, explores causes of TBI admissions, and trends in hospitalisation episodes by age and gender over a twelve year period using routinely collected hospital data. Methods A retrospective analysis of routine hospital episode data identified records relating to TBI for the twelve years between 1998 and 2009. Descriptive and joinpoint regression analysis were used, average annual percentage changes (AAPC) and annual percentage change (APC) in rates were calculated. Results Between 1998 and 2009 there were 208,195 recorded episodes of continuous hospital care in Scotland as a result of TBI. Almost half (47%) of all TBIs were the result of falls, with marked peaks observed in the very young and the oldest groups. The AAPC of hospitalization episode rates over the study period for boys and girls aged 0-14 were -4.9% (95% CI -3.5 to-6.3) and -4.7% (95% CI -2.6 to -6.8) respectively. This reduction was not observed in older age groups. In women aged 65 and over there was an APC of 3.9% (95% CI 1.2 to 6.6) between 2004 and 2009. Conclusions Hospitalisation for TBI is relatively common in Scotland. The rise in the age-adjusted rate of hospitalisation episodes observed in older people indicates that reduction of TBI should be a public health priority in countries with an ageing population. Public health interventions such as falls prevention measures are well advised and evaluations of such interventions should consider including TBI hospitalisation as an alternative or supplementary outcome measure to fractured neck of femur. Further research is needed to advance understanding of the associations of risk factors with increased incidence of TBI hospital episodes in the elderly population.
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Affiliation(s)
| | | | - Nadine Dougall
- NMAHP Research Unit, School of Nursing, Midwifery & Health, Unit 13 Scion House, University of Stirling, Stirling FK9 4NF, Scotland.
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