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Boyle JM, van der Meulen J, Kuryba A, Cowling TE, Braun MS, Aggarwal A, Walker K, Fearnhead NS. What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery? Colorectal Dis 2023; 25:1981-1993. [PMID: 37705203 PMCID: PMC10946964 DOI: 10.1111/codi.16745] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/24/2023] [Accepted: 05/30/2023] [Indexed: 09/15/2023]
Abstract
AIM Evidence for a positive volume-outcome relationship for rectal cancer surgery is unclear. This study aims to evaluate the volume-outcome relationship for rectal cancer surgery at hospital and surgeon level in the English National Health Service (NHS). METHOD All patients undergoing a rectal cancer resection in the English NHS between 2015 and 2019 were included. Multilevel multivariable logistic regression was used to model relationships between outcomes and mean annual hospital and surgeon volumes (using a linear plus a quadratic term for volume) with adjustment for patient characteristics. RESULTS A total of 13 858 patients treated in 166 hospitals were included. Six hospitals (3.6%) performed fewer than 10 rectal cancer resections per year, and 381 surgeons (45.0%) performed fewer than five such resections per year. Patients treated by high-volume surgeons had a reduced length of stay (p = 0.016). No statistically significant volume-outcome relationships were demonstrated for 90-day mortality, 30-day unplanned readmission, unplanned return to theatre, stoma at 18 months following anterior resection, positive circumferential resection margin and 2-year all-cause mortality at either hospital or surgeon level (p values > 0.05). CONCLUSION Almost half of colorectal surgeons in England do not meet national guidelines for rectal cancer surgeons to perform a minimum of five major resections annually. However, our results suggest that centralizing rectal cancer surgery with the main focus of increasing operative volume may have limited impact on NHS surgical outcomes. Therefore, quality improvement initiatives should address a wider range of evidence-based process measures, across the multidisciplinary care pathway, to enhance outcomes for patients with rectal cancer.
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Affiliation(s)
- Jemma M. Boyle
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Jan van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Angela Kuryba
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Thomas E. Cowling
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
| | - Michael S. Braun
- Department of OncologyThe Christie NHS Foundation TrustManchesterUK
- School of Medical SciencesUniversity of ManchesterManchesterUK
| | - Ajay Aggarwal
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Department of OncologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Kate Walker
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Clinical Effectiveness UnitRoyal College of Surgeons of EnglandLondonUK
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2
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Fankhauser CD, Parry MG, Ali A, Cowling TE, Nossiter J, Sujenthiran A, Berry B, Morris M, Aggarwal A, Payne H, van der Meulen J, Clarke NW. A low prostate specific antigen predicts a worse outcome in high but not in low/intermediate-grade prostate cancer. Eur J Cancer 2023; 181:70-78. [PMID: 36641896 DOI: 10.1016/j.ejca.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/14/2022] [Accepted: 12/18/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The relationship between prostate-specific antigen (PSA) and prostate cancer (PCa) grade was traditionally thought to be linear but recent reports suggest this is not true in high-grade cancers. We aimed to compare the association between PSA and PCa-specific mortality (PCSM) in clinically localised low/intermediate and high-grade PCa. SUBJECTS/PATIENTS AND METHODS Retrospective cohort study using the National Prostate Cancer Audit database in England of men treated with external beam radiotherapy (EBRT), EBRT and brachytherapy boost (EBRT + BT), radical prostatectomy or no radical local treatment between 2014 and 2018. Multivariable competing-risk regression was used to examine the association between PSA, Gleason, and PCSM. Multivariable restricted cubic spline regression was used to explore the non-linear associations of PSA and PCSM. RESULTS 102,089 men were included, of whom 71,138 had low/intermediate-grade and 22,425 had high-grade PCa. In high-grade, 4-year PCSM was higher with PSA ≤5 than PSA 5.1-10 for men treated with EBRT (hazard ratio 1.96 (95% confidence interval 1.15-3.34) or no radical local treatment (hazard ratio 1.99 (95% confidence interval 1.33-2.98). Restricted cubic spline regression showed that PSA and PCSM have a non-linear association in high-grade but a linear association in low/intermediate-grade PCa. CONCLUSION The low-PSA/high-grade combination in M0 PCa treated with EBRT has a higher PCSM than those with high-grade and intermediate PSA levels. In high-grade disease, the PSA association was non-linear; by contrast, low/intermediate-grade had a linear relationship. This confirms a more aggressive biology in low PSA secreting high-grade PCa and a worse outcome following treatment.
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Affiliation(s)
- Christian D Fankhauser
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK; National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; University of Zurich, Zurich, Switzerland; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland.
| | - Matthew G Parry
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Adnan Ali
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK; GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Thomas E Cowling
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Julie Nossiter
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Arun Sujenthiran
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Brendan Berry
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Melanie Morris
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Ajay Aggarwal
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust
| | - Heather Payne
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Department of Clinical Oncology University College London Hospital NHS Trust, London, United Kingdom
| | - Jan van der Meulen
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK; National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Department of Urology, Salford Royal NHS Foundation Trust, Manchester, UK
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3
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Yang Z, Bou-Antoun S, Gerver S, Cowling TE, Freeman R. Sustained increases in antibiotic prescriptions per primary care consultation for upper respiratory tract infections in England during the COVID-19 pandemic. JAC Antimicrob Resist 2023; 5:dlad012. [PMID: 36789176 PMCID: PMC9921722 DOI: 10.1093/jacamr/dlad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/17/2023] [Indexed: 02/13/2023] Open
Abstract
Background The responsible use of existing antimicrobials is essential in reducing the threat posed by antimicrobial resistance (AMR). With the introduction of restrictions during the COVID-19 pandemic, a substantial reduction in face-to-face appointments in general practice was observed. To understand if this shift in healthcare provision has impacted on prescribing practices, we investigated antibiotic prescribing for upper respiratory tract infections (URTI) consultations. Methods We conducted an interrupted time-series analysis using patient-level primary care data to assess the impact of the COVID-19 pandemic on consultations and antibiotic prescribing for URTI in England. Results We estimated an increase of 105.7 antibiotic items per 1000 URTI consultations (95% CI: 65.6-145.8; P < 0.001) after national lockdown measures in March 2020, with increases mostly sustained to May 2022. Conclusions Overuse of antibiotics is known to be a driver of resistance and it is essential that efforts to reduce inappropriate prescribing continue subsequent to the COVID-19 pandemic. Further work should examine drivers of increased antibiotic prescribing for URTI to inform the development of targeted antibiotic stewardship interventions.
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Affiliation(s)
- Zheyuan Yang
- Real World Solutions, IQVIA, 37 North Wharf Road, London W2 1AF, UK,Faculty of Epidemiology and Population Health, The London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Sabine Bou-Antoun
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Sarah Gerver
- HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Thomas E Cowling
- Faculty of Epidemiology and Population Health, The London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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4
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Boyle JM, van der Meulen J, Kuryba A, Cowling TE, Booth C, Fearnhead NS, Braun MS, Walker K, Aggarwal A. Measuring variation in the quality of systemic anti-cancer therapy delivery across hospitals: A national population-based evaluation. Eur J Cancer 2023; 178:191-204. [PMID: 36459767 DOI: 10.1016/j.ejca.2022.10.017] [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: 08/08/2022] [Revised: 10/10/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
AIM To date, there has been little systematic assessment of the quality of care associated with systemic anti-cancer therapy (SACT) delivery across national healthcare systems. We evaluated hospital-level toxicity rates during SACT treatment as a means of identifying variation in care quality. METHODS All colorectal cancer (CRC) patients receiving SACT within 106 English National Health Service (NHS) hospitals between 2016 and 2019 were included. Severe acute toxicity rates were derived from hospital administrative data using a validated coding framework. Variation in hospital-level toxicity rates was assessed separately in the adjuvant and metastatic settings. Toxicity rates were adjusted for age, sex, comorbidity, performance status, tumour site, and TNM staging. RESULTS Eight thousand one hundred and seventy three patients received SACT in the adjuvant setting, and 7,683 patients in the metastatic setting. Adjusted severe acute toxicity rates varied between hospitals from 11% to 49% for the adjuvant cohort, and from 25% to 67% for the metastatic cohort. Compared to the national mean toxicity rate in the adjuvant cohort, six hospitals were more than two standard deviations (2SD) above, and four hospitals were more than 2SD below. In the metastatic cohort, six hospitals were more than 2SD above, and seven hospitals were more than 2SD below the national mean toxicity rate. Overall, 12 hospitals (12%) had toxicity rates more than 2SD above the national mean, and 11 (10%) had rates more than 2SD below. CONCLUSION There is substantial variation in hospital-level severe acute toxicity rates in both the adjuvant and metastatic settings, despite risk-adjustment. Ongoing reporting of this performance indicator can be used to focus further investigation of toxicity rates and stimulate quality improvement initiatives to improve care.
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Affiliation(s)
- Jemma M Boyle
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | | | - Nicola S Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals, Cambridge, UK
| | - Michael S Braun
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK; School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Department of Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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5
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Parry MG, Skolarus TA, Nossiter J, Sujenthiran A, Morris M, Cowling TE, Berry B, Aggarwal A, Payne H, Cathcart P, Clarke NW, van der Meulen J. Urinary incontinence and use of incontinence surgery after radical prostatectomy: a national study using patient-reported outcomes. BJU Int 2021; 130:84-91. [PMID: 34846770 DOI: 10.1111/bju.15663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate whether patient-reported urinary incontinence and bother scores after radical prostatectomy result in subsequent intervention with incontinence surgery. METHODS Men diagnosed with prostate cancer in the English National Health Service between April 2014 and January 2016 were identified. Administrative data were used to identify men who had undergone a radical prostatectomy and those who subsequently underwent a urinary incontinence procedure. The National Prostate Cancer Audit database was used to identify men who had also completed a post-treatment survey. These surveys included the Expanded Prostate Cancer Composite Index (EPIC-26). The frequency of subsequent incontinence procedures, within 6 months of the survey, was explored according to EPIC-26 urinary incontinence scores. The relationship between "good" (≥75) or "bad" (≤25) EPIC-26 urinary incontinence scores and perceptions of urinary bother was also explored (responses ranging from 'no problem' to 'big problem' with respect to their urinary function). RESULTS We identified 11,290 men who had undergone a radical prostatectomy. The 3-year cumulative incidence of incontinence surgery was 2.5%. After exclusions, we identified 5,165 men who had also completed a post-treatment survey after a median time of 19 months (response rate 74%). 481 men (9.3%) reported a "bad" urinary incontinence score and 207 men (4.0%) also reported that they had a big problem with their urinary function. 47 men went on to have incontinence surgery within 6 months of survey completion (0.9%), of whom 93.6% had a "bad" urinary incontinence score. Of the 71 men with the worst urinary incontinence score (zero), only 11 men (15.5%) subsequently had incontinence surgery. CONCLUSION In England, there is a significant number of men living with severe, bothersome urinary incontinence following radical prostatectomy, and an unmet clinical need for incontinence surgery. The systematic collection of patient-reported outcomes could be used to identify men who may benefit from incontinence surgery.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA.,Flatiron, UK
| | - Melanie Morris
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | | | - Brendan Berry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ajay Aggarwal
- Department of Radiotherapy, NHS Foundation Trust, Guy's & St Thomas, UK.,Department of Cancer Epidemiology, KCL, Population & Global Health, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Paul Cathcart
- Department of Urology, NHS Foundation Trust, Guy's & St Thomas, UK
| | - Noel W Clarke
- Department of Urology, Salford Royal NHS Foundation Trusts, The Christie &, UK
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6
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Wallace D, Cowling TE, Suddle A, Gimson A, Rowe I, Callaghan C, Sapisochin G, Ivanics T, Claasen M, Mehta N, Heaton N, van der Meulen J, Walker K. National time trends in mortality and graft survival following liver transplantation from circulatory death or brainstem death donors. Br J Surg 2021; 109:79-88. [PMID: 34738095 PMCID: PMC10364702 DOI: 10.1093/bjs/znab347] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite high waiting list mortality rates, concern still exists on the appropriateness of using livers donated after circulatory death (DCD). We compared mortality and graft loss in recipients of livers donated after circulatory or brainstem death (DBD) across two successive time periods. METHODS Observational multinational data from the United Kingdom and Ireland were partitioned into two time periods (2008-2011 and 2012-2016). Cox regression methods were used to estimate hazard ratios (HRs) comparing the impact of periods on post-transplant mortality and graft failure. RESULTS A total of 1176 DCD recipients and 3749 DBD recipients were included. Three-year patient mortality rates decreased markedly from 19.6 per cent in time period 1 to 10.4 per cent in time period 2 (adjusted HR 0.43, 95 per cent c.i. 0.30 to 0.62; P < 0.001) for DCD recipients but only decreased from 12.8 to 11.3 per cent (adjusted HR 0.96, 95 per cent c.i. 0.78 to 1.19; P = 0.732) in DBD recipients (P for interaction = 0.001). No time period-specific improvements in 3-year graft failure were observed for DCD (adjusted HR 0.80, 95% c.i. 0.61 to 1.05; P = 0.116) or DBD recipients (adjusted HR 0.95, 95% c.i. 0.79 to 1.14; P = 0.607). A slight increase in retransplantation rates occurred between time period 1 and 2 in those who received a DCD liver (from 7.3 to 11.8 per cent; P = 0.042), but there was no change in those receiving a DBD liver (from 4.9 to 4.5 per cent; P = 0.365). In time period 2, no difference in mortality rates between those receiving a DCD liver and those receiving a DBD liver was observed (adjusted HR 0.78, 95% c.i. 0.56 to 1.09; P = 0.142). CONCLUSION Mortality rates more than halved in recipients of a DCD liver over a decade and eventually compared similarly to mortality rates in recipients of a DBD liver. Regions with high waiting list mortality may mitigate this by use of DCD livers.
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Affiliation(s)
- David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Alex Gimson
- The Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ian Rowe
- Liver Unit, St James' Hospital and University of Leeds, Leeds, UK/Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Renal Unit, Guy's Hospital, London, UK
| | - Gonzalo Sapisochin
- Multi-Organ Transplant, Toronto General Surgery, Toronto, Canada.,Department of General Surgery, University of Toronto, Toronto, Canada
| | - Tommy Ivanics
- Multi-Organ Transplant, Toronto General Surgery, Toronto, Canada.,Department of General Surgery, University of Toronto, Toronto, Canada
| | - Marco Claasen
- Multi-Organ Transplant, Toronto General Surgery, Toronto, Canada.,Department of General Surgery, University of Toronto, Toronto, Canada
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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7
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Boyle JM, Kuryba A, Cowling TE, van der Meulen J, Fearnhead NS, Walker K, Braun MS, Aggarwal A. Survival outcomes associated with completion of adjuvant oxaliplatin-based chemotherapy for stage III colon cancer: A national population-based study. Int J Cancer 2021; 150:335-346. [PMID: 34520572 DOI: 10.1002/ijc.33806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/19/2021] [Accepted: 08/30/2021] [Indexed: 11/06/2022]
Abstract
The impact of cycle completion rates of oxaliplatin-based adjuvant chemotherapy for stage III colon cancer in real-world practice is unknown. We assessed its impact, and that of treatment modification, on 3-year cancer-specific mortality. Four thousand one hundred and forty-seven patients with pathological stage III colon cancer undergoing major resection from 2014 to 2017 in the English National Health Service were included. Chemotherapy data came from linked national administrative datasets. Competing risk regression analysis for 3-year cancer-specific mortality was performed according to completion of <6, 6-11, or 12 5-fluoropyrimidine and oxaliplatin (FOLFOX) cycles, or <4, 4-7, or 8 capecitabine and oxaliplatin (CAPOX) cycles, adjusted for patient, tumour and hospital-level characteristics. Median age was 64 years. Thirty-two per cent of patients had at least one comorbidity. Forty-two per cent of patients had T4 disease, and 40% had N2 disease. Compared to completion of 12 FOLFOX cycles, cancer-specific mortality was higher in patients completing <6 cycles [subdistribution hazard ratios (sHR) 2.17; 95% CI 1.56-3.03] or 6-11 cycles (sHR 1.40; 95% CI 1.09-1.78) (P < .001). Compared to completion of 8 CAPOX cycles, cancer-specific mortality was higher in patients completing <4 cycles (sHR 2.02; 95% CI 1.53-2.67) or 4-7 cycles (sHR 1.63; 95% CI 1.27-2.10) (P < .001). Dose reduction and early oxaliplatin discontinuation did not impact mortality in patients completing all cycles. Completion of all cycles of chemotherapy was associated with improved cancer-specific survival in real-world practice. Poor prognostic factors may have affected findings, however, patients completing <50% of cycles had poor outcomes. Clinicians may wish to facilitate completion with treatment modification in those able to tolerate it.
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Affiliation(s)
- Jemma M Boyle
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Nicola S Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals, Cambridge, UK
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Michael S Braun
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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8
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Wallace D, Cowling TE, Walker K, Suddle A, Gimson A, Rowe I, Callaghan C, Heaton N, van der Meulen J, Bernal W. The Impact of Performance Status on Length of Hospital Stay and Clinical Complications Following Liver Transplantation. Transplantation 2021; 105:2037-2044. [PMID: 33044430 DOI: 10.1097/tp.0000000000003484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Impaired pretransplant performance status (PS) is associated with chronic liver disease (CLD). We studied its impact on hospital length of stay (LOS), complications, and readmissions in the first year after liver transplantation. METHODS The Standard National Liver Transplant Registry was linked to a hospital administrative dataset, and all first-time liver transplant recipients with CLD aged ≥18 years in England were identified. A modified 3-level Eastern Cooperative Oncology Group score was used to assess PS. Linear- and logistic-fixed effect regression models were used to estimate the effect of specific posttransplant complications and readmissions in the first year after transplantation. RESULTS Six thousand nine hundred sixty-eight recipients were included. Impaired PS was associated with an increased LOS in the initial posttransplant period (comparing ECOG 1-3, adjusted difference 7.2 d; 95% confidence [CI], 4.8-9.6; P < 0.001) and in time spent on the ITU (adjusted difference 1.2 d; 95% CI, 0.4-2.0; P < 0.001). There was no significant association between ECOG status and total LOS of later admissions (adjusted difference, 2.5 d; 95% CI, -0.4-5.5; P = 0.23). Those with a poorer ECOG status had an increased incidence of renal failure (odds ratio, 1.5; 95% CI, 1.1-2.0; P = 0.004) and infection (odds ratio, 1.2; 95% CI, 1.1-1.4; P = 0.02) but not an increased incidence of readmission (odds ratio, 1.2; 95% CI, 0.9-1.5; P = 0.13). CONCLUSIONS In liver transplant recipients with CLD, impaired pretransplant PS is associated with prolonged LOS in the immediate posttransplant period but not with LOS of later admissions in the first year after transplantation. Impaired PS increased the risk of renal failure and infection.
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Affiliation(s)
- David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alex Gimson
- The Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Ian Rowe
- Liver Unit, St James' Hospital and University of Leeds, Leeds, United Kingdom
- Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Chris Callaghan
- Department of Transplantation, Renal Unit, Guy's Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - William Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
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9
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Boyle JM, Kuryba A, Braun MS, Aggarwal A, van der Meulen J, Cowling TE, Walker K. Validity of chemotherapy information derived from routinely collected healthcare data: A national cohort study of colon cancer patients. Cancer Epidemiol 2021; 73:101971. [PMID: 34225249 DOI: 10.1016/j.canep.2021.101971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 04/01/2021] [Revised: 06/09/2021] [Accepted: 06/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND We used a structured approach to validate chemotherapy information derived from a national routinely collected chemotherapy dataset and from national administrative hospital data. METHODS 10,280 patients who had surgical resection with stage III colon cancer were included. First, we compared information derived from the national chemotherapy dataset (SACT) and from the administrative hospital dataset (HES) in the English NHS with respect to receipt of adjuvant chemotherapy (ACT). Second, we compared regimen and number of cycles in linked patient-level records. Third, we carried out a sensitivity analysis to establish to what extent the impact of ACT receipt differed according to data source. RESULTS 6,012 patients (58 %) received ACT according to either dataset. Of these patients, 3,460 (58 %) had ACT records in both datasets, 1,649 (27 %) in SACT alone, and 903 (15 %) in HES alone. Of the 3,460 patients with records in both datasets, 3,320 (96 %) had matching regimens. There was good agreement on cycle number with similar proportions of patients recorded with a single cycle (6 % in SACT vs. 7 % in HES) and slightly fewer patients recorded with more than 8 cycles in SACT (32 % in SACT vs. 35 % in HES). 3-year cancer-specific mortality was similar for patients receiving ACT, regardless of whether a patient received ACT according to SACT alone (16.6 %), according to HES alone (16.8 %), or according to either SACT or HES (17.1 %). CONCLUSION Routinely collected national chemotherapy data and administrative hospital data are highly accurate in recording regimen and number of chemotherapy cycles. However, chemotherapy information should ideally be captured from both datasets to avoid under-capture, particularly of oral chemotherapy from administrative hospital data, and to minimise bias.
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Affiliation(s)
- Jemma M Boyle
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Michael S Braun
- Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK.
| | - Ajay Aggarwal
- Department of Oncology, Guy's and St. Thomas' NHS Foundation Trust, London, UK.
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
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10
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Parry MG, Nossiter J, Sujenthiran A, Cowling TE, Patel RN, Morris M, Berry B, Cathcart P, Clarke NW, van der Meulen J, Aggarwal A. In Reply to Langley et al. Int J Radiat Oncol Biol Phys 2021; 110:913-914. [PMID: 34089685 DOI: 10.1016/j.ijrobp.2021.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Julie Nossiter
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Thomas E Cowling
- Department of Health Services Research and Policy, LSHTM, London, England
| | - Rajan N Patel
- Department of Gastroenterology, The Whittington Hospital NHS Trust, London, England
| | - Melanie Morris
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Brendan Berry
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, England; Heather Payne, FRCP FRCR, Department of Oncology, University College London Hospitals, London, England
| | - Jan van der Meulen
- Department of Health Services Research and Policy, LSHTM, London, England
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, LSHTM, London, England; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, England
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11
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Boyle JM, Kuryba A, Cowling TE, van der Meulen J, Fearnhead NS, Walker K, Braun M, Aggarwal A. Real-world survival outcomes associated with completion of adjuvant chemotherapy for stage III colon cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.3596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3596 Background: The optimal duration of adjuvant combination chemotherapy administered to patients with stage III colon cancer is debated. Our study assessed the effect of completed chemotherapy cycles on 3-year colon cancer-specific mortality, as well as the effect of dose reduction and early discontinuation of oxaliplatin in patients with 100% completion, within a real-world population. Methods: 4,147 patients undergoing major resection between 01 June 2014 and 30 April 2017 with pathological stage III colon cancer in the English National Health Service were identified. Chemotherapy data were obtained from linked administrative hospital records and a national chemotherapy dataset. Patients were stratified according to completion of < 50% ( < 6 FOLFOX cycles or < 4 CAPOX cycles), 50-92% (6-11 FOLFOX cycles or 4-7 CAPOX cycles) or 100% of cycles (12 FOLFOX cycles or 8 CAPOX cycles). Competing-risk regression analysis for 3-year colon cancer-specific death was performed with adjustment for patient, tumour and hospital-level characteristics to estimate subdistribution hazard ratios (sHR) as a measure of relative risk. Results: Patients included within our study were less fit and had increased rates of high-risk disease (T4 and/or N2 pathological staging) compared to the IDEA study. For FOLFOX, the 3-year cumulative incidence of colon cancer-specific death in patients completing 100% of cycles was 15.1% (95% CI, 12.8% to 17.6%), 18.2% (95% CI, 15.3% to 21.3%) for 50-92% of cycles and 26.4% (95% CI, 20.6% to 32.5%) for < 50% of cycles. For CAPOX, this was 12.0% (95% CI, 10.2% to 14.0%) for 100% completion of cycles, 18.2% (95% CI, 15.6% to 21.0%) for 50-92% of cycles, and 19.8% (95% CI, 15.8% to 24.1%) for < 50% cycles. Compared to 100% completion of FOLFOX cycles, colon cancer-specific death was higher in patients recorded as completing < 50% (sHR 2.17; 95% CI, 1.56 to 3.03; P = < 0.001) and 50-92% of FOLFOX cycles (sHR 1.40; 95% CI, 1.09 to 1.78; P = 0.007). Compared to 100% completion of CAPOX cycles, colon cancer-specific death was higher in patients recorded as completing < 50% (sHR 2.02; 95% CI 1.53 to 2.67; P< 0.001) and 50-92% of CAPOX cycles (sHR 1.63; 95% CI 1.27 to 2.10; P< 0.001). Dose reduction and early discontinuation of oxaliplatin did not have a statistically significant effect on mortality. Conclusions: Patients within the real world setting were more likely to have poor prognostic factors. Those who completed adjuvant chemotherapy for stage III colon cancer had improved survival rates regardless of dose reduction or early discontinuation of oxaliplatin.
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Affiliation(s)
- Jemma Megan Boyle
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angela Kuryba
- Royal College of Surgeons of England, London, United Kingdom
| | - Thomas E Cowling
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jan van der Meulen
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | | | - Kate Walker
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Braun
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ajay Aggarwal
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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12
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Parry MG, Nossiter J, Sujenthiran A, Cowling TE, Patel RN, Morris M, Berry B, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Impact of High-Dose-Rate and Low-Dose-Rate Brachytherapy Boost on Toxicity, Functional and Cancer Outcomes in Patients Receiving External Beam Radiation Therapy for Prostate Cancer: A National Population-Based Study. Int J Radiat Oncol Biol Phys 2020; 109:1219-1229. [PMID: 33279595 DOI: 10.1016/j.ijrobp.2020.11.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/16/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE External beam radiation therapy (EBRT) with brachytherapy boost reduces cancer recurrence in patients with prostate cancer compared with EBRT monotherapy. However, randomized controlled trials or large-scale observational studies have not compared brachytherapy boost types directly. METHODS AND MATERIALS This observational cohort study used linked national cancer registry data, radiation therapy data, administrative hospital data, and mortality records of 54,642 patients with intermediate-risk, high-risk, and locally advanced prostate cancer in England. The records of 11,676 patients were also linked to results from a national patient survey collected at least 18 months after diagnosis. Competing risk regression analyses were used to compare gastrointestinal (GI) toxicity, genitourinary (GU) toxicity, skeletal-related events (SRE), and prostate cancer-specific mortality (PCSM) at 5 years with adjustment for patient and tumor characteristics. Linear regression was used to compare Expanded Prostate Cancer Index Composite 26-item version domain scores (scale, 0-100, with higher scores indicating better function). RESULTS Five-year GI toxicity was significantly increased after low-dose-rate brachytherapy boost (LDR-BB) (32.3%) compared with high-dose-rate brachytherapy boost (HDR-BB) (16.7%) or EBRT monotherapy (18.7%). Five-year GU toxicity was significantly increased after both LDR-BB (15.8%) and HDR-BB (16.6%), compared with EBRT monotherapy (10.4%). These toxicity patterns were matched by the mean patient-reported bowel function scores (LDR-BB, 77.3; HDR-BB, 85.8; EBRT monotherapy, 84.4) and the mean patient-reported urinary obstruction/irritation function scores (LDR-BB, 72.2; HDR-BB, 78.9; EBRT monotherapy, 83.8). Five-year incidences of SREs and PCSM were significantly lower after HDR-BB (2.4% and 2.7%, respectively) compared with EBRT monotherapy (2.8% and 3.5%, respectively). CONCLUSIONS Compared with EBRT monotherapy, LDR-BB has worse GI and GU toxicity and HDR-BB has worse GU toxicity. HDR-BB has a lower incidence of SREs and PCSM than EBRT monotherapy.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Julie Nossiter
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, LSHTM, London, UK
| | - Rajan N Patel
- Department of Gastroenterology, The Whittington Hospital NHS Trust, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | | | - Ajay Aggarwal
- Department of Health Services Research and Policy, LSHTM, London, UK; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
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13
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Cowling TE, Cromwell DA, Sharples LD, van der Meulen J. A novel approach selected small sets of diagnosis codes with high prediction performance in large healthcare datasets. J Clin Epidemiol 2020; 128:20-28. [DOI: 10.1016/j.jclinepi.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 12/23/2022]
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14
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Zhao Y, Atun R, Oldenburg B, McPake B, Tang S, Mercer SW, Cowling TE, Sum G, Qin VM, Lee JT. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data. Lancet Glob Health 2020; 8:e840-e849. [PMID: 32446349 PMCID: PMC7241981 DOI: 10.1016/s2214-109x(20)30127-3] [Citation(s) in RCA: 165] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 01/28/2023]
Abstract
Background Multimorbidity, the presence of two or more mental or physical chronic non-communicable diseases, is a major challenge for the health system in China, which faces unprecedented ageing of its population. Here we examined the distribution of physical multimorbidity in relation to socioeconomic status; the association between physical multimorbidity, health-care service use, and catastrophic health expenditures; and whether these associations varied by socioeconomic group and social health insurance schemes. Methods In this population-based, panel data analysis, we used data from three waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS) for 2011, 2013, and 2015. We included participants aged 50 years and older in 2015, who had complete follow-up for the three waves. We used 11 physical non-communicable diseases to measure physical multimorbidity and annual per-capita household consumption spending as a proxy for socioeconomic status. Findings Of 17 708 participants in CHARLS, 11 817 were eligible for inclusion in our analysis. The median age of participants was 62 years (IQR 56–69) in 2015, and 5766 (48·8%) participants were male. 7320 (61·9%) eligible participants had physical multimorbidity in China in 2015. The prevalence of physical multimorbidity was increased with older age (odds ratio 2·93, 95% CI 2·71–3·15), among women (2·70, 2·04–3·57), within a higher socioeconomic group (for quartile 4 [highest group] 1·50, 1·24–1·82), and higher educational level (5·17, 3·02–8·83); however, physical multimorbidity was more common in poorer regions than in the more affluent regions. An additional chronic non-communicable disease was associated with an increase in the number of outpatient visits (incidence rate ratio 1·29, 95% CI 1·27–1·31), and number of days spent in hospital as an inpatient (1·38, 1·35–1·41). We saw similar effects in health service use of an additional chronic non-communicable disease in different socioeconomic groups and among those covered by different social health insurance programmes. Overall, physical multimorbidity was associated with a significantly increased likelihood of catastrophic health expenditure (for the overall population: odds ratio 1·29, 95% CI 1·26–1·32, adjusted for sociodemographic variables). The effect of physical multimorbidity on catastrophic health expenditures persisted even among the higher socioeconomic groups and across all health insurance programmes. Interpretation Concerted efforts are needed to reduce health inequalities that are due to physical multimorbidity, and its adverse economic effect in population groups in China. Social health insurance reforms must place emphasis on reducing out-of-pocket spending for patients with multimorbidity to provide greater financial risk protection. Funding None.
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Affiliation(s)
- Yang Zhao
- The Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne, VIC, Australia; The George Institute for Global Health at Peking University Health Science Center, Beijing, China.
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health and Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brian Oldenburg
- The Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne, VIC, Australia
| | - Barbara McPake
- The Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Stewart W Mercer
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Grace Sum
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Vicky Mengqi Qin
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - John Tayu Lee
- The Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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15
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Cowling TE, Bellot A, Boyle J, Walker K, Kuryba A, Galbraith S, Aggarwal A, Braun M, Sharples LD, van der Meulen J. One-year mortality of colorectal cancer patients: development and validation of a prediction model using linked national electronic data. Br J Cancer 2020; 123:1474-1480. [PMID: 32830202 PMCID: PMC7652941 DOI: 10.1038/s41416-020-01034-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/29/2020] [Accepted: 08/06/2020] [Indexed: 12/24/2022] Open
Abstract
Background The existing literature does not provide a prediction model for mortality of all colorectal cancer patients using contemporary national hospital data. We developed and validated such a model to predict colorectal cancer death within 90, 180 and 365 days after diagnosis. Methods Cohort study using linked national cancer and death records. The development population included 27,480 patients diagnosed in England in 2015. The test populations were diagnosed in England in 2016 (n = 26,411) and Wales in 2015–2016 (n = 3814). Predictors were age, gender, socioeconomic status, referral source, performance status, tumour site, TNM stage and treatment intent. Cox regression models were assessed using Brier scores, c-indices and calibration plots. Results In the development population, 7.4, 11.7 and 17.9% of patients died from colorectal cancer within 90, 180 and 365 days after diagnosis. T4 versus T1 tumour stage had the largest adjusted association with the outcome (HR 4.67; 95% CI: 3.59–6.09). C-indices were 0.873–0.890 (England) and 0.856–0.873 (Wales) in the test populations, indicating excellent separation of predicted risks by outcome status. Models were generally well calibrated. Conclusions The model was valid for predicting short-term colorectal cancer mortality. It can provide personalised information to support clinical practice and research.
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Affiliation(s)
- Thomas E Cowling
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK. .,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Alexis Bellot
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK.,Alan Turing Institute, London, UK
| | - Jemma Boyle
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kate Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Angela Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Sarah Galbraith
- Department of Palliative Care, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ajay Aggarwal
- Department of Clinical Oncology, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michael Braun
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Jan van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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16
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Parry MG, Nossiter J, Cowling TE, Sujenthiran A, Berry B, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Toxicity of Pelvic Lymph Node Irradiation With Intensity Modulated Radiation Therapy for High-Risk and Locally Advanced Prostate Cancer: A National Population-Based Study Using Patient-Reported Outcomes. Int J Radiat Oncol Biol Phys 2020; 108:1196-1203. [PMID: 32717261 DOI: 10.1016/j.ijrobp.2020.07.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Little is known about the toxicity of additional pelvic lymph node irradiation in men receiving intensity modulated radiation therapy (IMRT) for prostate cancer. The aim of this study was to compare patient-reported outcomes after IMRT to the prostate only (PO-IMRT) versus the prostate and pelvic lymph nodes (PPLN-IMRT). METHODS AND MATERIALS Patients who received a diagnosis of high-risk or locally advanced prostate cancer in the English National Health Service between April 2014 and September 2016 who were treated with IMRT were mailed a questionnaire at least 18 months after diagnosis. Patient-reported urinary, sexual, bowel, and hormonal functional domains on a scale from 0 to 100, with higher scores indicating better outcomes, and generic health-related quality of life were collected using the Expanded Prostate Cancer Index Composite 26-item version and EQ-5D-5L. We used linear regression to compare PPLN-IMRT versus PO-IMRT with adjustment for patient, tumor, and treatment characteristics. RESULTS Of the 7017 men who received a questionnaire, 5468 (77.9%) responded; 4196 (76.7%) had received PO-IMRT and 1272 (23.3%) PPLN-IMRT. Adjusted differences in the Expanded Prostate Cancer Index Composite 26-item version domain scores were smaller than 1 (P always >.2), except for sexual function, with men who had PPNL-IMRT reporting a lower mean score (adjusted difference, 2.3; 95% confidence interval, 0.9-3.7; P = .002). This did not represent a clinically relevant difference. There was no significant difference in health-related quality of life (P = .5). CONCLUSIONS Additional pelvic lymph node irradiation does not lead to clinically meaningful increases in the toxicity of IMRT for prostate cancer according to patient-reported functional outcomes and health-related quality of life.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom.
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ajay Aggarwal
- Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, United Kingdom
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17
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Parry MG, Cowling TE, Sujenthiran A, Nossiter J, Berry B, Cathcart P, Aggarwal A, Payne H, van der Meulen J, Clarke NW, Gnanapragasam VJ. Risk stratification for prostate cancer management: value of the Cambridge Prognostic Group classification for assessing treatment allocation. BMC Med 2020; 18:114. [PMID: 32460859 PMCID: PMC7254634 DOI: 10.1186/s12916-020-01588-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The five-tiered Cambridge Prognostic Group (CPG) classification is a better predictor of prostate cancer-specific mortality than the traditional three-tiered classification (low, intermediate, and high risk). We investigated radical treatment rates according to CPG in men diagnosed with non-metastatic prostate cancer in England between 2014 and 2017. METHODS Patients diagnosed with non-metastatic prostate cancer were identified from the National Prostate Cancer Audit database. Men were risk stratified according to the CPG classification. Risk ratios (RR) were estimated for undergoing radical treatment according to CPG and for receiving radiotherapy for those treated radically. Funnel plots were used to display variation in radical treatment rates across hospitals. RESULTS A total of 61,999 men were included with 10,963 (17.7%) in CPG1 (lowest risk group), 13,588 (21.9%) in CPG2, 9452 (15.2%) in CPG3, 12,831 (20.7%) in CPG4, and 15,165 (24.5%) in CPG5 (highest risk group). The proportion of men receiving radical treatment increased from 11.3% in CPG1 to 78.8% in CGP4, and 73.3% in CPG5. Men in CPG3 were more likely to receive radical treatment than men in CPG2 (66.3% versus 48.4%; adjusted RR 1.44; 95% CI 1.36-1.53; P < 0.001). Radically treated men in CPG3 were also more likely to receive radiotherapy than men in CPG2 (59.2% versus 43.9%; adjusted RR, 1.18; 95% CI 1.10-1.26). Although radical treatment rates were similar in CPG4 and CPG5 (78.8% versus 73.3%; adjusted RR 1.01; 95% CI 0.98-1.04), more men in CPG5 had radiotherapy than men in CPG4 (79.9% versus 59.1%, adjusted RR 1.26; 95% CI 1.12-1.40). CONCLUSIONS The CPG classification distributes men in five risk groups that are about equal in size. It reveals differences in treatment practices in men with intermediate-risk disease (CPG2 and CPG3) and in men with high-risk disease (CPG4 and CPGP5) that are not visible when using the traditional three-tiered risk classification.
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Affiliation(s)
- M G Parry
- 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, England.
| | - T E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - J Nossiter
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - B Berry
- 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, England
| | - P Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Aggarwal
- Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, UK.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - H Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - J van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - N W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, UK
| | - V J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.,Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Cambridge Urology Translational Research and Clinical Trials Office, Cambridge Biomedical Campus, Cambridge, UK
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18
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Qin VM, McPake B, Raban MZ, Cowling TE, Alshamsan R, Chia KS, Smith PC, Atun R, Lee JT. Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample. BMC Health Serv Res 2020; 20:372. [PMID: 32366235 PMCID: PMC7197140 DOI: 10.1186/s12913-020-05194-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 07/30/2019] [Accepted: 04/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China. Method We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. Findings Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64). Conclusion Our findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.
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Affiliation(s)
- Vicky Mengqi Qin
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Thomas E Cowling
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Riyadh Alshamsan
- Department of Primary Care and Public Health, School of Public Health, Imperial College, London, UK
| | - Kee Seng Chia
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Peter C Smith
- Centre for Health Economics, University of York, York, UK.,Imperial College London, London, UK
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - John Tayu Lee
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Primary Care and Public Health, School of Public Health, Imperial College, London, UK
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19
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Berry B, Parry MG, Sujenthiran A, Nossiter J, Cowling TE, Aggarwal A, Cathcart P, Payne H, van der Meulen J, Clarke N. Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study. BJU Int 2020; 126:97-103. [PMID: 32124525 DOI: 10.1111/bju.15039] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To assess the complications of transrectal (TR) compared to transperineal prostate (TP) biopsies. PATIENTS AND METHODS Men diagnosed with prostate cancer between 1 April 2014 and 31 March 2017 in England were identified in the National Prostate Cancer Audit. Administrative hospital data were then used to categorize the type of prostate biopsy and subsequent complications requiring hospital admission. Administrative hospital data were used to identify patients staying overnight immediately after biopsy and those readmitted separately for hospital admissions because of sepsis, urinary retention or haematuria. Procedure-related mortality and total length of hospital stay within 30 days were also recorded. Generalized linear models were used to calculate adjusted risk differences (aRDs). RESULTS A total of 73 630 patients undergoing prostate biopsy were identified. Those undergoing TP biopsy (n = 13 723) were more likely to have an overnight hospital stay (12.3% vs 2.4%; aRD 9.7%, 95% confidence interval [CI] 7.1-12.3), were less likely to be readmitted because of sepsis (1.0% vs 1.4%; aRD -0.4%, CI -0.6 to -0.2), and were more likely to be readmitted with urinary retention (1.9% vs 1.0%; aRD 1.1%, CI 0.7-1.4) than those undergoing a TR biopsy (n = 59 907). There were no significant differences in the risk of haematuria or mortality. CONCLUSIONS Our results showed that TP biopsy had a lower risk of readmission for sepsis but a higher risk of readmission for urinary retention than TR biopsy. Use of the TP route would prevent one readmission for sepsis in 278 patients at the cost of three additional patients readmitted for urinary retention.
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Affiliation(s)
- Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Ajay Aggarwal
- Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Noel Clarke
- Department of Urology, Christie and Salford Royal Hospitals Manchester NHS Foundation Trust, Manchester, UK
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20
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Wallace D, Cowling TE, Walker K, Suddle A, Gimson A, Rowe I, Callaghan C, Sapisochin G, Mehta N, Heaton N, van der Meulen J. Liver transplantation outcomes after transarterial chemotherapy for hepatocellular carcinoma. Br J Surg 2020; 107:1183-1191. [DOI: 10.1002/bjs.11559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/05/2020] [Accepted: 01/27/2020] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) awaiting liver transplantation is widespread, although evidence that it improves outcomes is lacking and there exist concerns about morbidity. The impact of TACE on outcomes after transplantation was evaluated in this study.
Methods
Patients with HCC who had liver transplantation in the UK were identified, and stratified according to whether they received TACE between 2006 and 2016. Cox regression methods were used to estimate hazard ratios (HRs) for death and graft failure after transplantation adjusted for donor and recipient characteristics.
Results
In total, 385 of 968 patients (39·8 per cent) received TACE. Five-year patient survival after transplantation was similar in those who had or had not received TACE: 75·2 (95 per cent c.i. 68·8 to 80·5) and 75·0 (70·5 to 78·8) per cent respectively. After adjustment for donor and recipient characteristics, there were no differences in mortality (HR 0·96, 95 per cent c.i. 0·67 to 1·38; P = 0·821) or graft failure (HR 1·01, 0·73 to 1·40; P = 0·964). The number of TACE treatments (2 or more versus 1: HR 0·97, 0·61 to 1·55; P = 0·903) or the time of death after transplantation (within or after 90 days; P = 0·291) did not alter the outcome. The incidence of hepatic artery thrombosis was low in those who had or had not received TACE (1·3 and 2·4 per cent respectively; P = 0·235).
Conclusion
TACE delivered to patients with HCC before liver transplant did not affect complications, patient death or graft failure after transplantation.
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Affiliation(s)
- D Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - T E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - K Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Suddle
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - A Gimson
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - I Rowe
- Liver Unit, St James's Hospital and University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - C Callaghan
- Department of Nephrology and Transplantation, Renal Unit, Guy's Hospital, London, UK
| | - G Sapisochin
- Multi-Organ Transplant, Toronto General Surgery, Toronto, Ontario, Canada
- Department of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - N Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - N Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - J van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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21
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Wallace D, Cowling TE, Walker K, Suddle A, Rowe I, Callaghan C, Gimson A, Bernal W, Heaton N, van der Meulen J. Short- and long-term mortality after liver transplantation in patients with and without hepatocellular carcinoma in the UK. Br J Surg 2020; 107:896-905. [DOI: 10.1002/bjs.11451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/01/2019] [Accepted: 11/07/2019] [Indexed: 12/21/2022]
Abstract
Abstract
Background
The increasing demand for liver transplantation has led to considerable changes in characteristics of donors and recipients. This study evaluated the short- and long-term mortality of recipients with and without hepatocellular carcinoma (HCC) in the UK between 1997 and 2016.
Methods
First-time elective adult liver transplant recipients in the UK were identified and four successive eras of transplantation were compared. Hazard ratios (HRs) comparing the impact of era on short-term (first 90 days) and longer-term (from 90 days to 5 years) mortality were estimated, with adjustment for recipient and donor characteristics.
Results
Some 1879 recipients with and 7661 without HCC were included. There was an increase in use of organs donated after circulatory death (DCD), from 0 per cent in era 1 to 35·2 per cent in era 4 for recipients with HCC, and from 0·2 to 24·1 per cent for non-HCC recipients. The 3-year mortality rate decreased from 28·3 per cent in era 1 to 16·9 per cent in era 4 (adjusted HR 0·47, 95 per cent c.i. 0·35 to 0·63) for recipients with HCC, and from 20·4 to 9·3 per cent (adjusted HR 0·44, 0·36 to 0·53) for those without HCC. Comparing era 4 with era 1, improvements were more marked in short-term than in long-term mortality, both for recipients with HCC (0–90 days: adjusted HR 0·20, 0·10 to 0·39; 90 days to 5 years: adjusted HR 0·52, 0·35 to 0·75; P = 0·043) and for non-HCC recipients (0–90 days: adjusted HR 0·32, 0·24 to 0·42; 90 days to 5 years: adjusted HR 0·52, 0·40 to 0·67; P = 0·024).
Conclusion
In the past 20 years, the mortality rate after liver transplantation has more than halved, despite increasing use of DCD donors. Improvements in overall survival can be explained by decreases in short-term and longer-term mortality.
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Affiliation(s)
- D Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Cambridge University Hospitals NHS Foundation Trust, London, UK
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - T E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - K Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - A Suddle
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - I Rowe
- Liver Unit, St James's Hospital and University of Leeds, Cambridge University Hospitals NHS Foundation Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Cambridge University Hospitals NHS Foundation Trust, Leeds, UK
| | - C Callaghan
- Department of Transplantation, Renal Unit, Guy's Hospital, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - A Gimson
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - W Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - N Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, London, UK
| | - J van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Cambridge University Hospitals NHS Foundation Trust, London, UK
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22
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Nossiter J, Sujenthiran A, Cowling TE, Parry MG, Charman SC, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England. J Clin Oncol 2020; 38:744-752. [PMID: 31895608 DOI: 10.1200/jco.19.01538] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The aim of the current study was to determine patient-reported functional outcomes in men with prostate cancer (PCa) undergoing moderately hypofractionated (H-RT) or conventionally fractionated radiation therapy (C-RT) in a national cohort study. PATIENDS AND METHODS All men diagnosed with PCa between April 2014 and September 2016 in the English National Health Service undergoing C-RT or H-RT were identified in the National Prostate Cancer Audit and mailed a questionnaire at least 18 months after diagnosis. We estimated differences in patient-reported urinary, bowel, sexual, and hormonal function-Expanded Prostate Cancer Index Composite short-form 26 domain scores on a 0 to 100 scale-and health-related quality of life-EQ-5D-5L on a 0 to 1 scale-using linear regression with adjustment for patient, tumor, and treatment-related factors in addition to GI and genitourinary baseline function, with higher scores representing better outcomes. RESULTS Of the 17,058 men in the cohort, 77% responded: 8,432 men received C-RT (64.2%) and 4,699 H-RT (35.8%). Men in the H-RT group were older (age ≥ 70 years: 67.5% v 60.9%), fewer men had locally advanced disease (56.5% v 71.3%), were less likely to receive androgen-deprivation therapy (79.5% v 87.8%), and slightly more men had pretreatment genitourinary procedures (24.2% v 21.2%). H-RT was associated with small increases in adjusted mean Expanded Prostate Cancer Index Composite short-form 26 sexual (3.3 points; 95% CI, 2.1 to 4.5; P < .001) and hormonal function scores (3.2 points; 95% CI, 1.8 to 4.6; P < .001). These differences failed to meet established thresholds for a clinically meaningful change. There were no statistically significant differences in urinary or bowel function and quality of life. CONCLUSION This is the first national cohort study comparing functional outcomes after H-RT and C-RT reported by patients. These real-world results further support the use of H-RT as the standard for radiation therapy in men with nonmetastatic PCa.
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Affiliation(s)
- Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew G Parry
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Susan C Charman
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ajay Aggarwal
- Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, United Kingdom.,Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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23
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Parry MG, Cowling TE, Sujenthiran A, Nossiter J, Berry B, Cathcart P, Clarke NW, Payne H, Aggarwal A, van der Meulen J. Identifying skeletal-related events for prostate cancer patients in routinely collected hospital data. Cancer Epidemiol 2019; 63:101628. [DOI: 10.1016/j.canep.2019.101628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/28/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
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24
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Parry MG, Sujenthiran A, Cowling TE, Nossiter J, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Treatment-Related Toxicity Using Prostate-Only Versus Prostate and Pelvic Lymph Node Intensity-Modulated Radiation Therapy: A National Population-Based Study. J Clin Oncol 2019; 37:1828-1835. [PMID: 31163009 DOI: 10.1200/jco.18.02237] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE There is a debate about the effectiveness and toxicity of pelvic lymph node (PLN) irradiation for the treatment of men with high-risk prostate cancer. This study compared the toxicity of intensity-modulated radiation therapy (IMRT) to the prostate and the pelvic lymph nodes (PPLN-IMRT) with prostate-only IMRT (PO-IMRT). MATERIALS AND METHODS Patients with high-risk localized or locally advanced prostate cancer treated with IMRT in the English National Health Service between 2010 and 2013 were identified by using data from the Cancer Registry, the National Radiotherapy Dataset, and Hospital Episode Statistics, an administrative database of all hospital admissions. Follow-up was available up to December 31, 2015. Validated indicators were used to identify patients with severe toxicity according to the presence of both a procedure code and diagnostic code in patient Hospital Episode Statistics records. A competing risks regression analysis, with adjustment for patient and tumor characteristics, estimated subdistribution hazard ratios (sHRs) by comparing GI and genitourinary (GU) complications for PPLN-IMRT versus PO-IMRT. RESULTS Three-year cumulative incidence in the PPLN-IMRT (n = 780) and PO-IMRT (n = 3,065) groups was 14% for both groups for GI toxicity, and 9% and 8% for GU toxicity, respectively. Patients receiving PPLN-IMRT and PO-IMRT had similar levels of severe GI (adjusted sHR, 1.00; 95% CI, 0.80 to 1.24; P = .97) and GU (adjusted sHR, 1.10; 95% CI, 0.83 to 1.46; P = .50) toxicity rates. CONCLUSION Including PLNs in radiation fields for high-risk or locally advanced prostate cancer is not associated with increased GI or GU toxicity at 3 years. Additional follow-up is required to answer questions about its impact on late GU toxicity. Results from ongoing trials will provide insight into the anticancer effectiveness of PLN irradiation.
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Affiliation(s)
- Matthew G Parry
- 1 London School of Hygiene and Tropical Medicine, London, United Kingdom.,2 Royal College of Surgeons of England, London, United Kingdom
| | | | - Thomas E Cowling
- 1 London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Julie Nossiter
- 2 Royal College of Surgeons of England, London, United Kingdom
| | - Paul Cathcart
- 3 Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Noel W Clarke
- 4 The Christie and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Heather Payne
- 5 University College London Hospitals, London, United Kingdom
| | - Jan van der Meulen
- 1 London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ajay Aggarwal
- 3 Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom.,6 King's College London, London, United Kingdom
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25
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Parry MG, Sujenthiran A, Cowling TE, Nossiter J, Cathcart P, Clarke NW, Payne H, Aggarwal A, van der Meulen J. Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England. Int J Cancer 2019; 145:40-48. [PMID: 30549266 PMCID: PMC6590431 DOI: 10.1002/ijc.32068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/30/2018] [Accepted: 11/21/2018] [Indexed: 11/17/2022]
Abstract
In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high‐risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high‐risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co‐ordinating centre (‘hub’), for having surgery by the presence of surgical services on‐site, and for receiving high dose‐rate brachytherapy (HDR‐BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91–1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10–1.40), and more likely to receive additional HDR‐BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94–12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities. What's new? More than one‐quarter of men with high‐risk or locally advanced prostate cancer in England do not receive radical treatment with radiotherapy or surgery, potentially owing to differences in treatment access. Here, prostate cancer service centralisation in England was investigated for potential impacts on treatment access. Among English patients in the National Prostate Cancer Audit database, centralisation had no impact on decisions to use radical treatment. It did, however, affect treatment option availability, with potential consequences for patient outcome. Patients were more likely to undergo surgery or high dose‐rate brachytherapy when diagnosed at hospitals with direct links to these services.
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Affiliation(s)
- Matthew G Parry
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Julie Nossiter
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, England
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, England.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, England
| | - Heather Payne
- Department of Oncology, University College London Hospitals, Department of Cancer, London, England
| | - Ajay Aggarwal
- Epidemiology, Population, and Global Health, King's College London, London, England.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
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Hayhoe B, Cowling TE, Pillutla V, Garg P, Majeed A, Harris M. Integrating a nationally scaled workforce of community health workers in primary care: a modelling study. J R Soc Med 2018; 111:453-461. [PMID: 30286301 PMCID: PMC6295943 DOI: 10.1177/0141076818803443] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 09/07/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To model cost and benefit of a national community health worker workforce. DESIGN Modelling exercise based on all general practices in England. SETTING United Kingdom National Health Service Primary Care. PARTICIPANTS Not applicable. DATA SOURCES Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. MAIN OUTCOME MEASURES We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. RESULTS Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. CONCLUSION A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.
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Affiliation(s)
- Benedict Hayhoe
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK
| | - Thomas E Cowling
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Virimchi Pillutla
- Department of Medicine, School of Clinical Sciences, Monash University, VIC 3168 Australia
| | - Priya Garg
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK
| | - Matthew Harris
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK
- Centre for Health Policy, Institute of Global Health Innovation, St Marys Hospital, London W2 1NY, UK
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Parry MG, Sujenthiran A, Cowling TE, Charman S, Nossiter J, Aggarwal A, Clarke NW, Payne H, van der Meulen J. Imputation of missing prostate cancer stage in English cancer registry data based on clinical assumptions. Cancer Epidemiol 2018; 58:44-51. [PMID: 30463041 DOI: 10.1016/j.canep.2018.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cancer stage can be missing in national cancer registry records. We explored whether missing prostate cancer stage can be imputed using specific clinical assumptions. METHODS Prostate cancer patients diagnosed between 2010 and 2013 were identified in English cancer registry data and linked to administrative hospital and mortality data (n = 139,807). Missing staging items were imputed based on specific assumptions: men with recorded N-stage but missing M-stage have no distant metastases (M0); low/intermediate-risk men with missing N- and/or M-stage have no nodal disease (N0) or metastases; and high-risk men with missing M-stage have no metastases. We tested these clinical assumptions by comparing 4-year survival in men with the same recorded and imputed cancer stage. Multi-variable Cox regression was used to test the validity of the clinical assumptions and multiple imputation. RESULTS Survival was similar for men with recorded N-stage but missing M-stage and corresponding men with M0 (89.5% vs 89.6%); for low/intermediate-risk men with missing M-stage and corresponding men with M0 (92.0% vs 93.1%); and for low/intermediate-risk men with missing N-stage and corresponding men with N0 (90.9% vs 93.7%). However, survival was different for high-risk men with missing M-stage and corresponding men with M0. Imputation based on clinical imputation performs as well as statistical multiple imputation. CONCLUSION Specific clinical assumptions can be used to impute missing information on nodal involvement and distant metastases in some patients with prostate cancer.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, England, United Kingdom; Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, England, United Kingdom.
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, England, United Kingdom.
| | - Thomas E Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, England, United Kingdom; Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, England, United Kingdom.
| | - Susan Charman
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, England, United Kingdom.
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, England, United Kingdom; Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, England, United Kingdom.
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, England, United Kingdom; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, England, United Kingdom; Department of Cancer Epidemiology, Population, and Global Health, King's College London, Strand, London, WC2R 2LS, England, United Kingdom.
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, England, United Kingdom; Department of Urology, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, England, United Kingdom.
| | - Heather Payne
- Department of Oncology, University College London Hospitals, 235 Euston Road, London, NW1 2BU, England, United Kingdom.
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, England, United Kingdom; Clinical Effectiveness Unit, The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London, WC2A 3PE, England, United Kingdom.
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Baier N, Geissler A, Bech M, Bernstein D, Cowling TE, Jackson T, van Manen J, Rudkjøbing A, Quentin W. Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms. Health Policy 2018; 123:1-10. [PMID: 30503764 DOI: 10.1016/j.healthpol.2018.11.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 09/11/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Increasing numbers of hospital emergency department (ED) visits pose a challenge to health systems in many countries. This paper aims to examine emergency and urgent care systems, in six countries and to identify reform trends in response to current challenges. METHODS Based on a literature review, six countries - Australia, Denmark, England, France, Germany and the Netherlands - were selected for analysis. Information was collected using a standardized questionnaire that was completed by national experts. These experts reviewed relevant policy documents and provided information on (1) the organization and planning of emergency and urgent care, (2) payment systems for EDs and urgent primary care providers, and (3) reform initiatives. RESULTS In the six countries four main reform approaches could be identified: (a) extending the availability of urgent primary care, (b) concentrating and centralizing the provision of urgent primary care, (c) improving coordination between urgent primary care and emergency care, and (d) concentrating emergency care provision at fewer institutions. The design of payment systems for urgent primary care and for emergency care is often aligned to support these reforms. CONCLUSION Better guidance of patients and a reconfiguration of emergency and urgent care are the most important measures taken to address the current challenges. Nationwide planning of all emergency care providers, closely coordinated reforms and informing patients can support future reforms.
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Affiliation(s)
- Natalie Baier
- Department of Health Care Management, Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße des 17.Juni 135, 10623, Berlin, Germany.
| | - Alexander Geissler
- Department of Health Care Management, Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße des 17.Juni 135, 10623, Berlin, Germany
| | - Mickael Bech
- University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark; Department of Political Science, Aarhus University, Bartholins Allé 7, 8000, Aarhus, Denmark
| | | | - Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, Kensington, London, SW72AZ, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Terri Jackson
- Melbourne Institute of Applied Economic and Social Research, University of Melbourne, Parkville, 3010, Melbourne, Victoria, Australia
| | - Johan van Manen
- Dutch Health Authority, Postbus 3017, 3502 GA, Utrecht, Netherlands
| | - Andreas Rudkjøbing
- Department of Public Health, University of Copenhagen, Nørregade 10, 1165 Copenhagen, Denmark
| | - Wilm Quentin
- Department of Health Care Management, Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße des 17.Juni 135, 10623, Berlin, Germany
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Cowling TE, Majeed A, Harris MJ. Patient experience of general practice and use of emergency hospital services in England: regression analysis of national cross-sectional time series data. BMJ Qual Saf 2018; 27:643-654. [PMID: 29358314 DOI: 10.1136/bmjqs-2017-007174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 07/17/2017] [Revised: 12/11/2017] [Accepted: 12/19/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England. METHODS The study included 8124 general practices between 2011-2012 and 2013-2014. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification. RESULTS Mean practice-level rates of A&E visits and emergency admissions increased from 2011-2012 to 2013-2014 (310.3-324.4 and 98.8-102.9 per 1000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-2012 and 76.6 in 2013-2014. In the adjusted regression analysis, an SD increase in experience of making appointments (equal to 9 points) predicted decreases of 1.8% (95% CI -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI -1.9% to -0.9%) in admission rates. This equalled 301 174 fewer A&E visits and 74 610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses. CONCLUSIONS Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E visits and emergency admissions.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Matthew J Harris
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Cowling TE, Laverty AA, Harris MJ, Watt HC, Greaves F, Majeed A. Contract and ownership type of general practices and patient experience in England: multilevel analysis of a national cross-sectional survey. J R Soc Med 2017; 110:440-451. [PMID: 29096580 DOI: 10.1177/0141076817738499] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To examine associations between the contract and ownership type of general practices and patient experience in England. Design Multilevel linear regression analysis of a national cross-sectional patient survey (General Practice Patient Survey). Setting All general practices in England in 2013-2014 ( n = 8017). Participants 903,357 survey respondents aged 18 years or over and registered with a general practice for six months or more (34.3% of 2,631,209 questionnaires sent). Main outcome measures Patient reports of experience across five measures: frequency of consulting a preferred doctor; ability to get a convenient appointment; rating of doctor communication skills; ease of contacting the practice by telephone; and overall experience (measured on four- or five-level interval scales from 0 to 100). Models adjusted for demographic and socioeconomic characteristics of respondents and general practice populations and a random intercept for each general practice. Results Most practices had a centrally negotiated contract with the UK government ('General Medical Services' 54.6%; 4337/7949). Few practices were limited companies with locally negotiated 'Alternative Provider Medical Services' contracts (1.2%; 98/7949); these practices provided worse overall experiences than General Medical Services practices (adjusted mean difference -3.04, 95% CI -4.15 to -1.94). Associations were consistent in direction across outcomes and largest in magnitude for frequency of consulting a preferred doctor (-12.78, 95% CI -15.17 to -10.39). Results were similar for practices owned by large organisations (defined as having ≥20 practices) which were uncommon (2.2%; 176/7949). Conclusions Patients registered to general practices owned by limited companies, including large organisations, reported worse experiences of their care than other patients in 2013-2014.
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Affiliation(s)
- Thomas E Cowling
- 1 Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Anthony A Laverty
- 1 Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
- 2 Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London W6 8RP, UK
| | - Matthew J Harris
- 1 Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
- 3 Centre for Health Policy, Imperial College London, London W2 1NY, UK
| | - Hilary C Watt
- 1 Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Felix Greaves
- 1 Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Azeem Majeed
- 1 Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Cowling TE, Harris M, Majeed A. Extended opening hours and patient experience of general practice in England: multilevel regression analysis of a national patient survey. BMJ Qual Saf 2016; 26:360-371. [PMID: 27343274 PMCID: PMC5530331 DOI: 10.1136/bmjqs-2016-005233] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 01/10/2016] [Revised: 05/24/2016] [Accepted: 05/30/2016] [Indexed: 11/26/2022]
Abstract
Background The UK government plans to extend the opening hours of general practices in England. The ‘extended hours access scheme’ pays practices for providing appointments outside core times (08:00 to 18.30, Monday to Friday) for at least 30 min per 1000 registered patients each week. Objective To determine the association between extended hours access scheme participation and patient experience. Methods Retrospective analysis of a national cross-sectional survey completed by questionnaire (General Practice Patient Survey 2013–2014); 903 357 survey respondents aged ≥18 years old and registered to 8005 general practices formed the study population. Outcome measures were satisfaction with opening hours, experience of making an appointment and overall experience (on five-level interval scales from 0 to 100). Mean differences between scheme participation groups were estimated using multilevel random-effects regression, propensity score matching and instrumental variable analysis. Results Most patients were very (37.2%) or fairly satisfied (42.7%) with the opening hours of their general practices; results were similar for experience of making an appointment and overall experience. Most general practices participated in the extended hours access scheme (73.9%). Mean differences in outcome measures between scheme participants and non-participants were positive but small across estimation methods (mean differences ≤1.79). For example, scheme participation was associated with a 1.25 (95% CI 0.96 to 1.55) increase in satisfaction with opening hours using multilevel regression; this association was slightly greater when patients could not take time off work to see a general practitioner (2.08, 95% CI 1.53 to 2.63). Conclusions Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Matthew Harris
- Centre for Health Policy, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Cowling TE, Ramzan F, Ladbrooke T, Millington H, Majeed A, Gnani S. Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data. Emerg Med J 2015; 33:200-7. [PMID: 26396232 DOI: 10.1136/emermed-2014-204603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 08/26/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner (GP) led urgent care centres (UCCs) in northwest London, England. METHODS We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables-age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; GP registration; time, day, quarter, year; and UCC of attendance-and the outcome of onwards referral to the co-located EDs or other hospital specialty departments. RESULTS Of 243 042 included attendances, 74.1% were managed solely within the UCCs without same day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a 10 year increase in a patient's age. Men, patients registered with a GP and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs. CONCLUSIONS The majority of patients, across each category of all explanatory variables, were managed solely within the UCCs, although a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Farzan Ramzan
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Tim Ladbrooke
- London Central and West Unscheduled Care Collaborative, London, UK
| | - Hugh Millington
- Emergency Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Shamini Gnani
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Cowling TE, Harris M, Watt H, Soljak M, Richards E, Gunning E, Bottle A, Macinko J, Majeed A. Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data. BMJ Qual Saf 2015; 25:432-40. [PMID: 26306608 PMCID: PMC4893129 DOI: 10.1136/bmjqs-2015-004338] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [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: 04/28/2015] [Accepted: 07/17/2015] [Indexed: 01/18/2023]
Abstract
Background The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. Objective To determine whether primary care access is associated with the route of emergency admission—via a GP versus via an A and E department. Methods Retrospective analysis of national administrative data from English hospitals for 2011–2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access—the percentage of patients able to get a general practice appointment on their last attempt—was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. Results The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. Conclusions Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Matthew Harris
- Department of Primary Care and Public Health, Imperial College London, London, UK Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York, USA
| | - Hilary Watt
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Michael Soljak
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Emma Richards
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Elinor Gunning
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - James Macinko
- Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York, USA
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Matthew J Harris
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK Department of Nutrition, Food Studies, and Public Health, New York University, New York, USA
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England
| | - Matthew J Harris
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England
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Cowling TE, Soljak MA, Bell D, Majeed A. Emergency hospital admissions via accident and emergency departments in England: time trend, conceptual framework and policy implications. J R Soc Med 2014; 107:432-8. [PMID: 25377736 PMCID: PMC4224646 DOI: 10.1177/0141076814542669] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Michael A Soljak
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Derek Bell
- Department of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Cecil EV, Bottle A, Cowling TE, Saxena S. PP49 Do children registered with English general practices with better patient reported access have fewer emergency department visits in and out of hours? A cross sectional study in 2011/12. Br J Soc Med 2014. [DOI: 10.1136/jech-2014-204726.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ismail TF, Jabbour A, Gulati A, Mallorie A, Raza S, Cowling TE, Das B, Khwaja J, Alpendurada FD, Wage R, Roughton M, McKenna WJ, Moon JC, Varnava A, Shakespeare C, Cowie MR, Cook SA, Elliott P, O'Hanlon R, Pennell DJ, Prasad SK. Role of late gadolinium enhancement cardiovascular magnetic resonance in the risk stratification of hypertrophic cardiomyopathy. Heart 2014; 100:1851-8. [PMID: 24966307 DOI: 10.1136/heartjnl-2013-305471] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Myocardial fibrosis identified by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM) is associated with adverse cardiovascular events, but its value as an independent risk factor for sudden cardiac death (SCD) is unknown. We investigated the role of LGE-CMR in the risk stratification of HCM. METHODS We conducted a prospective cohort study in a tertiary referral centre. Consecutive patients with HCM (n=711, median age 56.3 years, IQR 46.7-66.6; 70.0% male) underwent LGE-CMR and were followed for a median 3.5 years. The primary end point was SCD or aborted SCD. RESULTS Overall, 471 patients (66.2%) had myocardial fibrosis (median 5.9% of left ventricular mass, IQR: 2.2-13.3). Twenty-two (3.1%) reached the primary end point. The extent but not the presence of fibrosis was a significant univariable predictor of the primary end point (HR per 5% LGE: 1.24, 95% CI 1.06 to 1.45; p=0.007 and HR for LGE: 2.69, 95% CI 0.91 to 7.97; p=0.073, respectively). However, on multivariable analysis, only LV-EF remained statistically significant (HR: 0.92, 95% CI 0.89 to 0.95; p<0.001). For the secondary outcome of cardiovascular mortality/aborted SCD, the presence and the amount of fibrosis were significant predictors on univariable but not multivariable analysis after adjusting for LV-EF and non-sustained ventricular tachycardia. CONCLUSIONS The amount of myocardial fibrosis was a strong univariable predictor of SCD risk. However, this effect was not maintained after adjusting for LV-EF. Further work is required to elucidate the interrelationship between fibrosis and traditional predictors of outcome in HCM.
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Affiliation(s)
- Tevfik F Ismail
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Andrew Jabbour
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Ankur Gulati
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Amy Mallorie
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Sadaf Raza
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Thomas E Cowling
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Bibek Das
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Jahanzaib Khwaja
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | | | - Ricardo Wage
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | | | - William J McKenna
- Institute of Cardiovascular Science, University College London, London, UK
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, UK
| | - Amanda Varnava
- West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK
| | - Carl Shakespeare
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Department of Cardiology, South London Healthcare NHS Trust, London, UK
| | - Martin R Cowie
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Stuart A Cook
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Perry Elliott
- Institute of Cardiovascular Science, University College London, London, UK
| | - Rory O'Hanlon
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
| | - Dudley J Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
| | - Sanjay K Prasad
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK Imperial College London, London, UK
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Calderón-Larrañaga A, Soljak M, Cowling TE, Gaitatzis A, Majeed A. Association of primary care factors with hospital admissions for epilepsy in England, 2004-2010: National observational study. Seizure 2014; 23:657-61. [PMID: 24997845 DOI: 10.1016/j.seizure.2014.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 03/10/2014] [Revised: 05/13/2014] [Accepted: 05/16/2014] [Indexed: 12/11/2022] Open
Abstract
PURPOSE There has been little research on the accessibility and quality of primary care services for epilepsy and emergency hospital admissions for epilepsy. METHODS We examined time trends in admissions for epilepsy in England between 2004-2005 and 2010, and the association of admission rates with population and primary care factors. The units of analysis were the registered populations of 8622 general practices. We used negative binomial regression to model indicators from the Quality and Outcomes Framework, the UK's primary care pay for performance scheme, to measure the accessibility and quality of care for epilepsy, and supply of general practitioners, after adjustment for population factors. RESULTS The mean indirectly standardised admission rate decreased from 122.9 to 102.6 (-16.5%; P<0.001) over the study period, while the mean percentage of patients seizure free increased from 65.3% to 74.9% (P<0.001). In the multivariable analysis, a one unit increase in the percentage of seizure free adult patients on epilepsy drugs predicted a 0.20% decrease (IRR=0.9980; 95% CI: 0.9974-0.9986) in admission rate. The percentage of patients who were able to book a GP appointment over two days ahead predicted a 0.12% decrease (IRR=0.9988; 95% CI: 0.9982-0.9994). The deprivation score of practice populations (IRR=1.0179; P<0.001) and general practitioner supply (IRR=1.0022; P<0.001) were both positively associated with admission rates. CONCLUSION Patient access to primary care appointments and percentage of patients who have been recorded as seizure free for 12 months were associated with lower admission rates. However the effect sizes are small relative to that of population deprivation.
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Affiliation(s)
- Amaia Calderón-Larrañaga
- Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Zaragoza, Spain
| | - Michael Soljak
- Department of Primary Care and Public Health, Imperial College London, London, UK.
| | - Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Athanasios Gaitatzis
- Department, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Telford TF1 6TF, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Cowling TE, Harris MJ, Majeed A. What is our plan for acute unscheduled care? Ann Intern Med 2013; 159:575-6. [PMID: 24126656 DOI: 10.7326/0003-4819-159-8-201310150-00019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A, Wachter RM, Harris MJ. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PLoS One 2013; 8:e66699. [PMID: 23776694 PMCID: PMC3680424 DOI: 10.1371/journal.pone.0066699] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 05/09/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England. METHODS A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. MAIN RESULT AND CONCLUSION: General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
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Ismail TF, Jabbour A, Gulati A, Mallorie A, Raza S, Cowling TE, Das B, Khwaja J, Wage R, Moon J, Varnava A, Shakespeare C, Elliott P, OHanlon R, Pennell DJ, Prasad SK. Late gadolinium enhancement cardiovascular magnetic resonance for sudden cardiac death risk stratification in hypertrophic cardiomyopathy. J Cardiovasc Magn Reson 2013. [PMCID: PMC3559668 DOI: 10.1186/1532-429x-15-s1-o67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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