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Sammut-Powell C, Sisk R, Silva-Tinoco R, de la Pena G, Almeda-Valdes P, Juarez Comboni SC, Goncalves S, Cameron R. External validation of a minimal-resource model to predict reduced estimated glomerular filtration rate in people with type 2 diabetes without diagnosis of chronic kidney disease in Mexico: a comparison between country-level and regional performance. Front Endocrinol (Lausanne) 2024; 15:1253492. [PMID: 38586458 PMCID: PMC10998449 DOI: 10.3389/fendo.2024.1253492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/19/2024] [Indexed: 04/09/2024] Open
Abstract
Background Patients with type 2 diabetes are at an increased risk of chronic kidney disease (CKD) hence it is recommended that they receive annual CKD screening. The huge burden of diabetes in Mexico and limited screening resource mean that CKD screening is underperformed. Consequently, patients often have a late diagnosis of CKD. A regional minimal-resource model to support risk-tailored CKD screening in patients with type 2 diabetes has been developed and globally validated. However, population heath and care services between countries within a region are expected to differ. The aim of this study was to evaluate the performance of the model within Mexico and compare this with the performance demonstrated within the Americas in the global validation. Methods We performed a retrospective observational study with data from primary care (Clinic Specialized in Diabetes Management in Mexico City), tertiary care (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán) and the Mexican national survey of health and nutrition (ENSANUT-MC 2016). We applied the minimal-resource model across the datasets and evaluated model performance metrics, with the primary interest in the sensitivity and increase in the positive predictive value (PPV) compared to a screen-everyone approach. Results The model was evaluated on 2510 patients from Mexico (primary care: 1358, tertiary care: 735, ENSANUT-MC: 417). Across the Mexico data, the sensitivity was 0.730 (95% CI: 0.689 - 0.779) and the relative increase in PPV was 61.0% (95% CI: 52.1% - 70.8%). These were not statistically different to the regional performance metrics for the Americas (sensitivity: p=0.964; relative improvement: p=0.132), however considerable variability was observed across the data sources. Conclusion The minimal-resource model performs consistently in a representative Mexican population sample compared with the Americas regional performance. In primary care settings where screening is underperformed and access to laboratory testing is limited, the model can act as a risk-tailored CKD screening solution, directing screening resources to patients who are at highest risk.
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Affiliation(s)
| | - Rose Sisk
- Gendius Ltd, Alderley Edge, United Kingdom
| | - Ruben Silva-Tinoco
- Clinic Specialized in the Diabetes Management of the Mexico City Government, Public Health Services of the Mexico City Government, Mexico, City, Mexico
| | - Gustavo de la Pena
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), Mexico City, Mexico
| | - Paloma Almeda-Valdes
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), Mexico City, Mexico
- Metabolic Diseases Research, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Sisk R, Cameron R, Tahir W, Sammut-Powell C. Diagnosis codes underestimate chronic kidney disease incidence compared with eGFR-based evidence: a retrospective observational study of patients with type 2 diabetes in UK primary care. BJGP Open 2024:BJGPO.2023.0079. [PMID: 37709350 DOI: 10.3399/bjgpo.2023.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/03/2023] [Accepted: 08/11/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Type two diabetes (T2D) is a leading cause of both chronic kidney disease (CKD) and onward progression to end-stage renal disease. Timely diagnosis coding of CKD in patients with T2D could lead to improvements in quality of care and patient outcomes. AIM To assess the consistency between estimated glomerular filtration rate (eGFR)-based evidence of CKD and CKD diagnosis coding in UK primary care. DESIGN & SETTING A retrospective analysis of electronic health record data in a cohort of people with T2D from 60 primary care centres within England between 2012 and 2022. METHOD We estimated the incidence rate of CKD per 100 person-years using eGFR-based CKD and diagnosis codes. Logistic regression was applied to establish which attributes were associated with diagnosis coding. Time from eGFR-based CKD to entry of a diagnosis code was summarised using the median and interquartile range. RESULTS The overall incidence of CKD was 2.32 (95% confidence interval [CI] = 2.24 to 2.41) and significantly higher for eGFR-based criteria than diagnosis codes: 1.98 (95% CI = 1.90 to 2.05) versus 1.06 (95% CI = 1.00 to 1.11), respectively; P<0.001. Only 45.4% of CKD incidences identified using eGFR-based criteria had a corresponding diagnosis code. Patients who were younger, had a higher CKD stage (G4), had an observed urine albumin-to-creatinine ratio (A1), or no observed HbA1c in the past year were more likely to have a diagnosis code. CONCLUSION Diagnosis coding of patients with eGFR-based evidence of CKD in UK primary care is poor within patients with T2D, despite CKD being a well-known complication of diabetes.
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Affiliation(s)
| | | | - Waqas Tahir
- Affinity Care, National Health Service, Bradford, UK
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Sammut-Powell C, Williams R, Sperrin M, Thomas O, Peek N, Grant SW. Healthcare utilisation in patients with long-term conditions during the COVID-19 pandemic: a population-based observational study of all patients across Greater Manchester, UK. BMJ Open 2023; 13:e066873. [PMID: 37419643 PMCID: PMC10335594 DOI: 10.1136/bmjopen-2022-066873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/15/2023] [Indexed: 07/09/2023] Open
Abstract
OBJECTIVES Data on population healthcare utilisation (HCU) across both primary and secondary care during the COVID-19 pandemic are lacking. We describe primary and secondary HCU stratified by long-term conditions (LTCs) and deprivation, during the first 19 months of COVID-19 pandemic across a large urban area in the UK. DESIGN A retrospective, observational study. SETTING All primary and secondary care organisations that contributed to the Greater Manchester Care Record throughout 30 December 2019 to 1 August 2021. PARTICIPANTS 3 225 169 patients who were registered with or attended a National Health Service primary or secondary care service during the study period. PRIMARY OUTCOMES Primary care HCU (incident prescribing and recording of healthcare information) and secondary care HCU (planned and unplanned admissions) were assessed. RESULTS The first national lockdown was associated with reductions in all primary HCU measures, ranging from 24.7% (24.0% to 25.5%) for incident prescribing to 84.9% (84.2% to 85.5%) for cholesterol monitoring. Secondary HCU also dropped significantly for planned (47.4% (42.9% to 51.5%)) and unplanned admissions (35.3% (28.3% to 41.6%)). Only secondary care had significant reductions in HCU during the second national lockdown. Primary HCU measures had not recovered to prepandemic levels by the end of the study. The secondary admission rate ratio between multi-morbid patients and those without LTCs increased during the first lockdown by a factor of 2.40 (2.05 to 2.82; p<0.001) for planned admissions and 1.25 (1.07 to 1.47; p=0.006) for unplanned admissions. No significant changes in this ratio were observed in primary HCU. CONCLUSION Major changes in primary and secondary HCU were observed during the COVID-19 pandemic. Secondary HCU reduced more in those without LTCs and the ratio of utilisation between patients from the most and least deprived areas increased for the majority of HCU measures. Overall primary and secondary care HCU for some LTC groups had not returned to prepandemic levels by the end of the study.
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Affiliation(s)
- Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Science, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- National Institute for Health Research Applied Research Collaboration Greater Manchester, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Richard Williams
- Division of Informatics, Imaging and Data Science, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- National Institute for Health Research Applied Research Collaboration Greater Manchester, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | | | - N Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
- National Institute for Health Research Applied Research Collaboration Greater Manchester, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
- National Institute for Health Research Manchester Biomedical Research Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Stuart W Grant
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
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Sammut-Powell C, Sisk R, Budd J, Patel N, Edge M, Cameron R. Development of minimal resource pre-screening tools for chronic kidney disease in people with type 2 diabetes. Future Healthc J 2022; 9:305-309. [PMID: 36561833 PMCID: PMC9761456 DOI: 10.7861/fhj.2022-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Regular chronic kidney disease (CKD) screening can facilitate earlier diagnosis of CKD and preventative action to reduce the risk of CKD progression. People with type 2 diabetes are at a higher risk of developing CKD; hence, it is recommended that they undergo annual screening. However, resources may be limited, particularly in lower-to-middle income countries, and those at the highest risk of having an abnormal CKD screening result should be prioritised for screening. We have developed models to determine which patients are at a high risk of renal impairment. We have shown that, for people with type 2 diabetes and no previous diagnosis of CKD stage 3-5, it is possible to use age, gender, body mass index, duration of type 2 diabetes and blood pressure information to detect those at a higher risk of a reduced glomerular filtration rate. When blood measurements are available, triglyceride and cholesterol measurements can be used to improve the estimate of the risk. Even though risk factors were associated with an increased urine albumin:creatinine ratio, we found no clinical benefit of using the model over a screen-all approach.
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Affiliation(s)
- Camilla Sammut-Powell
- AGendius, Alderley Edge, UK;,Address for correspondence: Dr Camilla Sammut-Powell, Gendius, The Glasshouse, Alderley Park, Alderley Edge SK10 4ZE, UK. Twitter: @cjmspowell
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5
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Ahmed FZ, Sammut-Powell C, Martin GP, Callan P, Cunnington C, Kale M, Gerritse B, Lanctin D, Soken N, Campbell NG, Taylor JK. Use of a device-based remote management heart failure care pathway is associated with reduced hospitalization and improved patient outcomes: TriageHF Plus real-world evaluation. Eur Heart J 2022. [PMCID: PMC9619664 DOI: 10.1093/eurheartj/ehac544.2814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Heart failure (HF) is a leading cause of hospital admission. However, prompt identification of worsening HF using implantable device data and proactive intervention may reduce hospitalizations. The validated TriageHF algorithm in enabled ICD/CRT devices uses sensor data to risk stratify patients for HF hospitalization in the next 30 days. TriageHF Plus is a novel device-based HF care pathway (DHFP) that uses “high” risk status as the trigger for remote intervention (see Figure 1 for pathway overview). Outcomes after DHFP implementation in a clinical setting have not been examined. Purpose To evaluate the impact of TriageHF Plus clinical pathway on hospitalisation rates. Methods A prospective, multi-center evaluation comparing monthly hospitalization rates for patients enrolled in a DHFP with a concurrent standard of care (SoC) cohort and characterizing staffing resources necessary to implement the DHFP. The DHFP cohort received telephonic assessment and guideline-directed clinical care upon transition to high-risk status. Propensity scores (PS) were applied to DHFP and SoC cohorts to allow unbiased comparison. A negative binomial model was fitted to the monthly number of all-cause hospitalizations with treatment group (DHFP vs. SoC) as a covariate, using PS as weights. Results Between 09/11/2019 and 06/24/2021, 758 patients were included in the study (443 DHFP, 315 SoC). Proportion CRT 76%/ 89% and LVEF <50% 78%/ 66% for DHFP/ SoC, respectively. 196 high risk transmissions prompted telephone assessment, with successful contact in 182; of which, 79 (43%) identified an explanatory acute medical issue. A secondary intervention was undertaken in 44/79 (56%). High risk transmissions took on average 19 minutes per clinical assessment (initial telephone triage and 30 day follow up). The rate of hospitalizations was 58% lower in the DHFP group, compared with SoC, after PS adjustment (IRR 0.42, 95% CI: 0.23, 0.76, p=0.004), see Figure 2. Sensitivity analyses showed Covid-19 had little effect on results. Conclusions This is the first prospective, real-world evaluation of a device-based HF care pathway to report a reduction in hospitalizations and does so with minimal staffing time. Integrated into existing HF services, device-based remote monitoring of HF patients can improve outcomes. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic
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Affiliation(s)
- F Z Ahmed
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - C Sammut-Powell
- University of Manchester, Division of Informatics, Imaging and Data Science , Manchester , United Kingdom
| | - G P Martin
- University of Manchester, Division of Informatics, Imaging and Data Science , Manchester , United Kingdom
| | - P Callan
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - C Cunnington
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - M Kale
- North Manchester General Hospital , Manchester , United Kingdom
| | - B Gerritse
- Medtronic, Inc. , Minneapolis , United States of America
| | - D Lanctin
- Medtronic, Inc. , Minneapolis , United States of America
| | - N Soken
- Medtronic, Inc. , Minneapolis , United States of America
| | - N G Campbell
- Manchester University NHS Foundation Trust , Manchester , United Kingdom
| | - J K Taylor
- University of Manchester, Division of Informatics, Imaging and Data Science , Manchester , United Kingdom
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Sammut-Powell C, Reynard C, Allen J, McDermott J, Braybrook J, Parisi R, Lasserson D, Body R. Examining the effect of evaluation sample size on the sensitivity and specificity of COVID-19 diagnostic tests in practice: a simulation study. Diagn Progn Res 2022; 6:12. [PMID: 35468850 PMCID: PMC9035779 DOI: 10.1186/s41512-021-00116-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In response to the global COVID-19 pandemic, many in vitro diagnostic (IVD) tests for SARS-CoV-2 have been developed. Given the urgent clinical demand, researchers must balance the desire for precise estimates of sensitivity and specificity against the need for rapid implementation. To complement estimates of precision used for sample size calculations, we aimed to estimate the probability that an IVD will fail to perform to expected standards after implementation, following clinical studies with varying sample sizes. METHODS We assumed that clinical validation study estimates met the 'desirable' performance (sensitivity 97%, specificity 99%) in the target product profile (TPP) published by the Medicines and Healthcare products Regulatory Agency (MHRA). To estimate the real-world impact of imprecision imposed by sample size we used Bayesian posterior calculations along with Monte Carlo simulations with 10,000 independent iterations of 5,000 participants. We varied the prevalence between 1 and 15% and the sample size between 30 and 2,000. For each sample size, we estimated the probability that diagnostic accuracy would fail to meet the TPP criteria after implementation. RESULTS For a validation study that demonstrates 'desirable' sensitivity within a sample of 30 participants who test positive for COVID-19 using the reference standard, the probability that real-world performance will fail to meet the 'desirable' criteria is 10.7-13.5%, depending on prevalence. Theoretically, demonstrating the 'desirable' performance in 90 positive participants would reduce that probability to below 5%. A marked reduction in the probability of failure to hit 'desirable' specificity occurred between samples of 100 (19.1-21.5%) and 160 (4.3-4.8%) negative participants. There was little further improvement above sample sizes of 160 negative participants. CONCLUSION Based on imprecision alone, small evaluation studies can lead to the acceptance of diagnostic tests which are likely to fail to meet performance targets when deployed. There is diminished return on uncertainty surrounding an accuracy estimate above a total sample size of 250 (90 positive and 160 negative).
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Affiliation(s)
- Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Science, School of Health Sciences, University of Manchester, Manchester, UK
| | - Charles Reynard
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.
| | - Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - John McDermott
- Department of Genetics, Manchester University NHS Foundation Trust, Manchester, UK
| | - Julian Braybrook
- National Measurement Laboratory, LGC, Queens Road, Teddington, Middlesex, TW11 0LY, UK
| | - Rosa Parisi
- Division of Informatics, Imaging and Data Science, School of Health Sciences, University of Manchester, Manchester, UK
| | - Daniel Lasserson
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
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Brunton L, Sammut-Powell C, Birleson E, Boaden R, Knowles SE, McQuaker C, Cross S, Greaves N, Paroutoglou K, Alzouabi O, Patel HC, Suman A, Kawafi K, Parry-Jones AR. Scale-up of ABC care bundle for intracerebral haemorrhage across two hyperacute stroke units in one region in England: a mixed methods evaluation of a quality improvement project. BMJ Open Qual 2022; 11:bmjoq-2021-001601. [PMID: 35428671 PMCID: PMC9014063 DOI: 10.1136/bmjoq-2021-001601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/17/2022] [Indexed: 12/03/2022] Open
Abstract
Background Intracerebral haemorrhage (ICH) accounts for 10%–15% of strokes in the UK, but is responsible for half of all annual global stroke deaths. The ABC bundle for ICH was developed and implemented at Salford Royal Hospital, and was associated with a 44% reduction in 30-day case fatality. Implementation of the bundle was scaled out to the other hyperacute stroke units (HASUs) in the region from April 2017. A mixed methods evaluation was conducted alongside to investigate factors influencing implementation of the bundle across new settings, in order to provide lessons for future spread. Methods A harmonised quality improvement registry at each HASU captured consecutive patients with spontaneous ICH from October 2016 to March 2018 to capture process and outcome measures for preimplementation (October 2016 to March 2017) and implementation (April 2017 to March 2018) time periods. Statistical analyses were performed to determine differences in process measures and outcomes before and during implementation. Multiple qualitative methods (interviews, non-participant observation and project document analysis) captured how the bundle was implemented across the HASUs. Results HASU1 significantly reduced median anticoagulant reversal door-to-needle time from 132 min (IQR: 117–342) preimplementation to 76 min (64–113.5) after implementation and intensive blood pressure lowering door to target time from 345 min (204–866) preimplementation to 84 min (60–117) after implementation. No statistically significant improvements in process targets were observed at HASU2. No significant change was seen in 30-day mortality at either HASU. Qualitative evaluation identified the importance of facilitation during implementation and identified how contextual changes over time impacted on implementation. This identified the need for continued implementation support. Conclusion The findings show how the ABC bundle can be successfully implemented into new settings and how challenges can impede implementation. Findings have been used to develop an implementation strategy to support future roll out of the bundle outside the region.
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Affiliation(s)
- Lisa Brunton
- Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Sciences, The University of Manchester, Manchester, UK
| | - Emily Birleson
- Stroke Department, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Ruth Boaden
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Sarah E Knowles
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Clare McQuaker
- Stroke Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Stephen Cross
- Stroke Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Natalie Greaves
- Stroke Department, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | - Omran Alzouabi
- Stroke Department, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Hiren C Patel
- Neurosurgical Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Appukuttan Suman
- Stroke Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Khalil Kawafi
- Stroke Department, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
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Lauder J, Harris J, Layton B, Heire P, Sorani A, DeSancha M, Davison AK, Sammut-Powell C, Lindner C. A fully automatic system to assess foot collapse on lateral weight-bearing foot radiographs: A pilot study. Comput Methods Programs Biomed 2022; 213:106507. [PMID: 34794087 PMCID: PMC8674729 DOI: 10.1016/j.cmpb.2021.106507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Foot collapse is primarily diagnosed and monitored using lateral weight-bearing foot x-ray images. There are several well-validated measurements which aid assessment. However, these are subject to inter- and intra-user variability. OBJECTIVE To develop and validate a software system for the fully automatic assessment of radiographic changes associated with foot collapse; automatically generating measurements for calcaneal tilt, cuboid height and Meary's angle. METHODS This retrospective study was approved by the Health Research Authority (IRAS 244852). The system was developed using lateral weight-bearing foot x-ray images, and evaluated against manual measurements from five clinical experts. The system has two main components: (i) a Random Forest-based point-finder to outline the bones of interest; and (ii) a geometry-calculator to generate the measurements based on the point positions from the point-finder. The performance of the point-finder was assessed using the point-to-point error (i.e. the mean absolute distance between each found point and the equivalent ground truth point, averaged over all points per image). For assessing the performance of the geometry-calculator, linear mixed models were fitted to estimate clinical inter-observer agreement and to compare the performance of the software system to that of the clinical experts. RESULTS A total of 200 images were collected from 79 subjects (mean age: 56.4 years ±12.9 SD, 30/49 females/males). There was good agreement among all clinical experts with intraclass correlation estimates between 0.78 and 0.86. The point-finder achieved a median point-to-point error of 2.2 mm. There was no significant difference between the clinical and automatically generated measurements using the point-finder points, suggesting that the fully automatically obtained measurements are in agreement with the manually obtained measurements. CONCLUSIONS The proposed system can be used to support and automate radiographic image assessment for diagnosing and managing foot collapse, saving clinician time, and improving patient outcomes.
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Affiliation(s)
- J Lauder
- Salford Royal NHS Foundation Trust, United Kingdom; East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, United Kingdom
| | - J Harris
- Salford Royal NHS Foundation Trust, United Kingdom
| | - B Layton
- Salford Royal NHS Foundation Trust, United Kingdom; East Lancashire Hospitals NHS Trust, Royal Blackburn Teaching Hospital, United Kingdom
| | - P Heire
- Salford Royal NHS Foundation Trust, United Kingdom
| | - A Sorani
- Salford Royal NHS Foundation Trust, United Kingdom
| | - M DeSancha
- Division of Informatics, Imaging and Data Sciences, The University of Manchester, United Kingdom
| | - A K Davison
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, United Kingdom
| | - C Sammut-Powell
- Division of Informatics, Imaging and Data Sciences, The University of Manchester, United Kingdom
| | - C Lindner
- Division of Informatics, Imaging and Data Sciences, The University of Manchester, United Kingdom.
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Ahmed FZ, Sammut-Powell C, Kwok CS, Tay T, Motwani M, Martin GP, Taylor JK. Remote monitoring data from cardiac implantable electronic devices predicts all-cause mortality. Europace 2021; 24:245-255. [PMID: 34601572 PMCID: PMC8824524 DOI: 10.1093/europace/euab160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Indexed: 11/13/2022] Open
Abstract
Aims To determine if remotely monitored physiological data from cardiac implantable electronic devices (CIEDs) can be used to identify patients at high risk of mortality. Methods and results This study evaluated whether a risk score based on CIED physiological data (Triage-Heart Failure Risk Status, ‘Triage-HFRS’, previously validated to predict heart failure (HF) events) can identify patients at high risk of death. Four hundred and thirty-nine adults with CIEDs were prospectively enrolled. Primary observed outcome was all-cause mortality (median follow-up: 702 days). Several physiological parameters [including heart rate profile, atrial fibrillation/tachycardia (AF/AT) burden, ventricular rate during AT/AF, physical activity, thoracic impedance, therapies for ventricular tachycardia/fibrillation] were continuously monitored by CIEDs and dynamically combined to produce a Triage-HFRS every 24 h. According to transmissions patients were categorized into ‘high-risk’ or ‘never high-risk’ groups. During follow-up, 285 patients (65%) had a high-risk episode and 60 patients (14%) died (50 in high-risk group; 10 in never high-risk group). Significantly more cardiovascular deaths were observed in the high-risk group, with mortality rates across groups of high vs. never-high 10.3% vs. <4.0%; P = 0.03. Experiencing any high-risk episode was associated with a substantially increased risk of death [odds ratio (OR): 3.07, 95% confidence interval (CI): 1.57–6.58, P = 0.002]. Furthermore, each high-risk episode ≥14 consecutive days was associated with increased odds of death (OR: 1.26, 95% CI: 1.06–1.48; P = 0.006). Conclusion Remote monitoring data from CIEDs can be used to identify patients at higher risk of all-cause mortality as well as HF events. Distinct from other prognostic scores, this approach is automated and continuously updated.
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Affiliation(s)
- Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Oxford Rd, Manchester, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chun Shing Kwok
- School of Primary, Community and Social Care, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tricia Tay
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manish Motwani
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Cardiology, Manchester University Hospitals NHS Foundation Trust, Oxford Rd, Manchester, UK
| | - Glen P Martin
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Joanne K Taylor
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Roberts T, Hirst R, Sammut-Powell C, Reynard C, Daniels J, Horner D, Lyttle MD, Samuel K, Graham B, Barrett MJ, Foley J, Cronin J, Umana E, Vinagre J, Carlton E. Psychological distress and trauma during the COVID-19 pandemic: survey of doctors practising anaesthesia, intensive care medicine, and emergency medicine in the United Kingdom and Republic of Ireland. Br J Anaesth 2021; 127:e78-e80. [PMID: 34176596 PMCID: PMC9339913 DOI: 10.1016/j.bja.2021.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 01/12/2023] Open
Affiliation(s)
- Tom Roberts
- Royal College of Emergency Medicine, London, UK; Emergency Department, North Bristol NHS Trust, Bristol, UK.
| | - Robert Hirst
- Royal College of Emergency Medicine, London, UK; Emergency Department, Musgrove Park Hospital, Somerset NHS, Somerset, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Charles Reynard
- Department of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Jo Daniels
- Department of Psychology, University of Bath, Bath, UK
| | - Daniel Horner
- Royal College of Emergency Medicine, London, UK; Department of Intensive Care and Emergency Department, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Mark D Lyttle
- Bristol Royal Hospital for Children, Bristol, UK; Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Katie Samuel
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - Blair Graham
- Faculty of Health, University of Plymouth, Plymouth, UK; Emergency Department, University Hospitals Plymouth, UK
| | - Michael J Barrett
- Department of Emergency Medicine, Children's Health Ireland at Crumlin, Crumlin, Ireland; School of Medicine, Women's and Children's Health, University College Dublin, Dublin, Ireland
| | - James Foley
- Emergency Department, University Hospital Waterford, Waterford, Ireland
| | - John Cronin
- School of Medicine, Women's and Children's Health, University College Dublin, Dublin, Ireland; Department of Emergency Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Etimbuk Umana
- Emergency Department, Connolly Hospital Blanchardstown, Dublin, Ireland
| | - Joao Vinagre
- College of Anaesthesiologists of Ireland, Dublin, Ireland
| | - Edward Carlton
- Royal College of Emergency Medicine, London, UK; Emergency Department, North Bristol NHS Trust, Bristol, UK
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11
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Sammut-Powell C, Ashton C, Paroutoglou K, Parry-Jones A. Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU). Front Neurol 2021; 12:646015. [PMID: 34040576 PMCID: PMC8143189 DOI: 10.3389/fneur.2021.646015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background: In Greater Manchester (GM), prehospital clinicians use the Face Arm Speech Test (FAST) to identify suspected stroke patients alongside pathway exclusions. Within the centralized stroke service, patients with a suspected stroke are taken directly to a Hyper Acute Stroke Unit (HASU), often bypassing their local emergency department (ED). However, many of these patients are experiencing an illness that looks like a stroke but is not a stroke. The data collected in the prehospital setting is rarely used in research yet could give valuable insights into the performance of the pathway. Aim: To evaluate the presenting symptoms and final diagnoses of prehospital suspected strokes and to evaluate the adherence of prehospital stroke pathway exclusions. Methods: We analyzed data from all patients brought in by ambulance and admitted on the stroke pathway between 01/09/15 and 28/02/17. Patient demographics and all data recorded in the prehospital setting were evaluated to identify differences in stroke, TIA, and mimic patients. Pathway adherence was assessed according to whether the patient was local or out-of-area (OOA) and bypassed their local ED. Results: A total of 4,216 suspected strokes were identified: 2,213 (52.5%) had a final diagnosis of stroke, 492 (11.7%) experienced a transient ischemic attack (TIA), and 1,511 (35.8%) were stroke mimics. There were 714 (16.9%) patients that were identified as having at least one pathway exclusion or were FAST negative, of which 270 (37.8%) experienced a stroke. The proportion of strokes was significantly lower in those with a pathway exclusion (41.8 vs. 53.5%; p < 0.001) and the proportion of breaches tended to be comparable or higher in the local population. Discussion: There are high volumes of stroke mimics but identified differences indicate there is an opportunity to better utilize prehospital data. Ambulance clinicians were able to correctly overrule FAST negative results and the volume of these suggest that FAST alone may be too restrictive.
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Affiliation(s)
- Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Christopher Ashton
- Salford Royal NHS Foundation Trust, Greater Manchester Integrated Stroke Delivery Network, Salford, United Kingdom
| | | | - Adrian Parry-Jones
- Salford Royal NHS Foundation Trust, Salford, United Kingdom.,Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, United Kingdom.,Division of Cardiovascular Science, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
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12
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Ashton C, Sammut-Powell C, Birleson E, Mayoh D, Sperrin M, Parry-Jones AR. Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system. BMJ Open Qual 2021; 9:bmjoq-2019-000883. [PMID: 32423973 PMCID: PMC7239536 DOI: 10.1136/bmjoq-2019-000883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/14/2020] [Accepted: 02/01/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | - Emily Birleson
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Duncan Mayoh
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
| | - Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK .,Division of Cadiovascular Sciences, The University of Manchester, Manchester, UK
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13
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Minhas JS, Sammut-Powell C, Birleson E, Patel HC, Parry-Jones AR. Are do-not-resuscitate orders associated with limitations of care beyond their intended purpose in patients with acute intracerebral haemorrhage? Analysis of the ABC-ICH study. BMJ Open Qual 2021; 10:bmjoq-2020-001113. [PMID: 33547153 PMCID: PMC7871257 DOI: 10.1136/bmjoq-2020-001113] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022] Open
Abstract
Implementation of an acute bundle of care for intracerebral haemorrhage (ICH) was associated with a marked improvement in survival at our centre, mediated by a reduction in early (<24 hours) do-not-resuscitate (DNR) orders. The aim of this study was to identify possible mechanisms for this mediation. We retrospectively extracted additional data on resuscitation attempts and supportive care. This observational study utilised existing data collected for the Acute Bundle of Care for ICH (ABC-ICH) quality improvement project between from 2013 to 2017. The primary outcome was whether a patient received an early (<24 hours) DNR order. We used multivariable logistic regression to estimate the adjusted association between clinically meaningful factors, including an indicator for a change in treatment on the introduction of the ABC care bundle. Early DNR orders were associated with a reduced odds of escalation to critical care (OR: 0.07, 95% CI: 0.03 to 0.17, p<0.001). Commencement of palliative care within 72 hours was far more likely (OR: 8.76, 95% CI: 4.74 to 16.61, p<0.001) if an early DNR was in place. The cardiac arrest team were not called for an ICH patient before implementation but were called on five occasions overall during and after implementation. Further qualitative evaluation revealed that on only one occasion was there a cardiac or respiratory arrest with cardiopulmonary resuscitation performed. We found no significant increase in resuscitation attempts after bundle implementation but early DNR orders were associated with less admission to critical care and more early palliation. Early DNR orders are associated with less aggressive supportive care and should be judiciously used in acute ICH.
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Affiliation(s)
| | - Camilla Sammut-Powell
- Centre for Health Informatics, The University of Manchester, Manchester, Manchester, UK
| | - Emily Birleson
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, Salford, UK
| | - Hiren C Patel
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
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14
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Martin GP, Jenkins DA, Bull L, Sisk R, Lin L, Hulme W, Wilson A, Wang W, Barrowman M, Sammut-Powell C, Pate A, Sperrin M, Peek N. Toward a framework for the design, implementation, and reporting of methodology scoping reviews. J Clin Epidemiol 2020; 127:191-197. [PMID: 32726605 DOI: 10.1016/j.jclinepi.2020.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/12/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE In view of the growth of published articles, there is an increasing need for studies that summarize scientific research. An increasingly common review is a "methodology scoping review," which provides a summary of existing analytical methods, techniques and software that have been proposed or applied in research articles to address an analytical problem or further an analytical approach. However, guidelines for their design, implementation, and reporting are limited. METHODS Drawing on the experiences of the authors, which were consolidated through a series of face-to-face workshops, we summarize the challenges inherent in conducting a methodology scoping review and offer suggestions of best practice to promote future guideline development. RESULTS We identified three challenges of conducting a methodology scoping review. First, identification of search terms; one cannot usually define the search terms a priori, and the language used for a particular method can vary across the literature. Second, the scope of the review requires careful consideration because new methodology is often not described (in full) within abstracts. Third, many new methods are motivated by a specific clinical question, where the methodology may only be documented in supplementary materials. We formulated several recommendations that build upon existing review guidelines. These recommendations ranged from an iterative approach to defining search terms through to screening and data extraction processes. CONCLUSION Although methodology scoping reviews are an important aspect of research, there is currently a lack of guidelines to standardize their design, implementation, and reporting. We recommend a wider discussion on this topic.
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Affiliation(s)
- Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Lucy Bull
- Manchester Epidemiology Centre Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Rose Sisk
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lijing Lin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - William Hulme
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Anthony Wilson
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Adult Critical Care, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Wenjuan Wang
- Department of Population Health Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Michael Barrowman
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Alexander Pate
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
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15
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Parry-Jones AR, Sammut-Powell C, Paroutoglou K, Birleson E, Rowland J, Lee S, Cecchini L, Massyn M, Emsley R, Bray B, Patel H. An Intracerebral Hemorrhage Care Bundle Is Associated with Lower Case Fatality. Ann Neurol 2019; 86:495-503. [PMID: 31291031 PMCID: PMC6771716 DOI: 10.1002/ana.25546] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/08/2019] [Accepted: 07/08/2019] [Indexed: 11/24/2022]
Abstract
Objective Anticoagulation reversal, intensive blood pressure lowering, neurosurgery, and access to critical care might all be beneficial in acute intracerebral hemorrhage (ICH). We combined and implemented these as the “ABC” hyperacute care bundle and sought to determine whether the implementation was associated with lower case fatality. Methods The ABC bundle was implemented from June 1, 2015 to May 31, 2016. Key process targets were set, and a registry captured consecutive patients. We compared 30‐day case fatality before, during, and after bundle implementation with multivariate logistic regression and used mediation analysis to determine which care process measures mediated any association. Difference‐in‐difference analysis compared 30‐day case fatality with 32,295 patients with ICH from 214 other hospitals in England and Wales using Sentinel Stroke National Audit Programme data. Results A total of 973 ICH patients were admitted in the study period. Compared to before implementation, the adjusted odds of death by 30 days were lower in the implementation period (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38–0.97, p = 0.03), and this was sustained after implementation (OR = 0.40, 95% CI = 0.24–0.61, p < 0.0001). Implementation of the bundle was associated with a 10.8 percentage point (95% CI = −17.9 to −3.7, p = 0.003) reduction in 30‐day case fatality in difference‐in‐difference analysis. The total effect of the care bundle was mediated by a reduction in do‐not‐resuscitate orders within 24 hours (52.8%) and increased admission to critical care (11.1%). Interpretation Implementation of the ABC care bundle was significantly associated with lower 30‐day case fatality after ICH. ANN NEUROL 2019;86:495–503
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Affiliation(s)
- Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester.,Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
| | - Camilla Sammut-Powell
- Greater Manchester Connected Health Cities, Centre for Health Informatics, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester
| | - Kyriaki Paroutoglou
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
| | - Emily Birleson
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
| | - Joshua Rowland
- Division of Cardiovascular Sciences, School of Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester
| | - Stephanie Lee
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
| | - Luca Cecchini
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
| | - Mark Massyn
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
| | - Richard Emsley
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester
| | - Benjamin Bray
- Department of Population Health Sciences, King's College London, London, United Kingdom
| | - Hiren Patel
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford
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