The Getting It right First Time (GIRFT) programme in urology; rationale and methodology

The Getting It Right First Time (GIRFT) programme is a quality improvement initiative covering the National Health Service in England. The programme aims to standardise clinical practices and improve patient and system level outcomes by utilising data-driven insights and clinically-led recommendations. There are GIRFT workstreams for every medical and surgical specialty, including urology. Defining features of the GIRFT methodology are that it is clinically led by experienced clinicians, data-driven, and specialty specific. Each specialty workstream conducts deep-dive visits to every hospital, analysing performance data and engaging with clinicians and management to identify and share improvement priorities. For urology, GIRFT has completed deep-dive visits and published reports outlining priority areas for development. Reports include recommendations pertaining to streamlining care pathways, reducing the acuity of care environments, enhancing emergency services, optimising utilisation of outpatient services, and workforce training and utilisation. The GIRFT academy provides guides for implementing best practices specific to priority areas of care. These include important disease pathways, and GIRFT-advocated innovations such as urology investigation units and urology area networks. GIRFT offers clinical transformation, cost reduction, equity in access to care, and leaner models of care that are often more environmentally sustainable. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices.

Safety of Same-Day Discharge Posterior Lumbar Decompression and/or Discectomy: An Observational Study Using Administrative Data From England

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Same-day discharge is widely used in many surgical specialities. If carefully planned, it can improve patient outcomes whilst using resources efficiently. We aimed to investigate the safety of same-day discharge following a posterior lumbar decompression and/or discectomy (PLDD).

METHODS

This was a retrospective analysis of administrative data. We extracted data from the Hospital Episodes Statistics database for the 5 years from 1st April 2014 to 31st March 2019. Patients undergoing an elective one or two level PLDD aged 19-54 years during the index stay were included. The primary exposure variable was same-day discharge or post-surgery overnight stay and the primary outcome was emergency hospital readmission within 90 days post-discharge.

RESULTS

Data were available for 45,814 PLDD performed across 103 hospital trusts of which 7914 (17.3%) were performed as same-day discharge. Same-day discharge rates varied from 87.7% to 0% across the 90 hospital trusts that operated on more than 50 patients during the study period. Fourteen (15.6%) trusts had same-day discharge rates above 30% and 57 (63.3%) trusts had same-day discharge rates below 10%. The odds of emergency hospital readmission within 90 days were lower for same-day discharge patients (odds ratio .72 (95% confidence interval .61 to .85). There was no difference in outcomes for patients seen at trusts with a same-day discharge rate of ≥30% compared to trusts with a same-day discharge rate of ≤10%.

CONCLUSIONS

Same-day discharge low-complexity elective PLDD is safe in adult patients below the age of 55 years. There is potential for many providers to substantially increase their rates of same-day discharge.

Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data

PURPOSE

Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery have to stay in hospital for at least one night. The aim of this study was to identify the factors associated with conversion from day-case to in-patient management for elective inguinal hernia repair surgery.

METHODS

This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified. The exposure of interest was discharged on the day of admission (day-case) or requiring overnight stay. The primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level.

RESULTS

A total of 351,528 planned day-case elective primary inguinal hernia repairs were identified over the eight-year study period. Of these, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and be operated on by a low-annual volume surgeon. Post-procedural complications were strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 3.3% to 21.3%.

CONCLUSIONS

There was considerable variation in conversion to in-patient stay rates for inguinal hernia repair across ICBs in England. Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates.

Factors associated with poorer outcomes for posterior lumbar decompression and or/or discectomy: an exploratory analysis of administrative data

PURPOSE

This study aimed to identify factors associated with poorer patient outcomes for lumbar decompression and/or discectomy (PLDD).

METHODS

We extracted data from the Hospital Episodes Statistics database for the 5 years from 1st April 2014 to 31st March 2019. Patients undergoing an elective one- or two-level PLDD aged ≥ 17 years and without evidence of revision surgery during the index stay were included. The primary patient outcome measure was readmission within 90 days post-discharge.

RESULTS

Data for 93,813 PLDDs across 111 hospital trusts were analysed. For the primary outcome, greater age [< 40 years vs 70-79 years odds ratio (OR) 1.28 (95% confidence interval (CI) 1.14 to 1.42), < 40 years vs ≥ 80 years OR 2.01 (95% CI 1.76-2.30)], female sex [OR 1.09 (95% CI 1.02-1.16)], surgery over two spinal levels [OR 1.16 (95% CI 1.06-1.26)] and the comorbidities chronic pulmonary disease, connective tissue disease, liver disease, diabetes, hemi/paraplegia, renal disease and cancer were all associated with emergency readmission within 90 days. Other outcomes studied had a similar pattern of associations.

CONCLUSIONS

A high-throughput PLDD pathway will not be suitable for all patients. Extra care should be taken for patients aged ≥ 70 years, females, patients undergoing surgery over two spinal levels and those with specific comorbidities or generalised frailty.

Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

Trends in day-case bladder outflow obstruction surgery: a study using Hospital Episode Statistics

OBJECTIVES

To describe the contemporary evolution of day-case bladder outflow obstruction (BOO) surgery in England and to profile day-case BOO surgery practices across England in terms of the types of operation performed and their safety profiles.

MATERIALS AND METHODS

This was a retrospective observational analysis of Hospital Episode Statistics and UK Office for National Statistics data. All 111 043 recorded operations across 117 hospital trusts over 66 months, from 1 January 2017 to 30 June 2022, were obtained. Operations were identified as one of: transurethral resection of prostate (TURP); laser ablation or enucleation; vapour therapy; prostatic urethral lift (PUL); or bladder neck incision. Monthly day-case rate trends were plotted across the study period. Descriptive data, day-case rates and 30-day hospital readmissions were analysed for each operation type. Multilevel regression modelling with mixed effects was performed to determine whether day-case surgery was associated with higher 30-day hospital readmissions.

RESULTS

Day-case patients were younger, with fewer comorbidities. Time series analysis showed a linear day-case rate increase from 8.3% (January 2017) to 21.0% (June 2022). Day-case rates improved for 92/117 trusts in 2021/2022 compared with 2017. Three of the six trusts with the highest day-case rates performed predominantly day-case TURP, and the other three laser surgery. Nationally, PUL and vapour surgery had the highest day-case rates (80.9% and 38.1%). Most inpatient operations were TURP. Multilevel regression modelling found reduced odds of 30-day readmission after day-case BOO surgery (all operations pooled), no difference for day-case vs inpatient TURP, and reduced odds following day-case LASER operations.

CONCLUSIONS

The day-case rates for BOO surgery have linearly increased. Minimally invasive surgical technologies are commonly performed as day cases, whereas high day-case rates for TURP and for laser ablation operations are seen in a minority of hospitals. Day-case pathways to treat BOO can be safely developed irrespective of operative modality.

Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes

PURPOSE

Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, in England there is evidence of wide variation in day-case rates across hospitals. Reducing the extent of this variation has the potential to support more efficient use of resources (e.g., clinician time, hospital beds) and help the recovery of elective surgical activity following the COVID-19 pandemic. The aims of this study were to explore the extent of variation in day-case rates across healthcare providers in England and to evaluate the safety of day-case elective primary inguinal hernia repair surgery.

METHODS

This was an exploratory, retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 were identified. The exposure of interest was day-case or in-patient stay, and the primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level.

RESULTS

A total of 413,059 elective primary inguinal hernia repairs were identified over the 8-year study period. Of these, 326,833 (79.1%) were day-case procedures. During the most recent financial year (2021-22), the highest day-case rate for an ICB was 93.8% and the lowest 66.1%. After adjusting for covariates, day-case surgery was associated with significantly lower rates of 30-day emergency readmission (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.58-0.64, p < 0.001) and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge. Rates of 30-day emergency readmission were significantly lower in ICBs with high rates of day-case surgery (OR 0.84, 95% CI 0.74-0.96, p < 0.001) than in ICBs with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates (OR 1.20, 95% CI 1.04-1.40, p = 0.015).

CONCLUSIONS

For the outcomes studied, we found no consistent evidence that day-case elective inguinal hernia repair was unsafe for selected patients. Currently, there is substantial variation between ICBs in terms of delivering day-case surgery. Reducing this variability may help address the current pressures on the NHS in elective surgery.

Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data

OBJECTIVE

Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk.

METHODS

Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed.

RESULTS

Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited.

CONCLUSION

Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.

Trends Over Time in the Use, Carbon Footprint and Costs of Facet Joint Injections and Medial Branch Blocks to Manage Lumbar Pain in England: Retrospective Analysis of an Administrative Dataset

STUDY DESIGN

Retrospective analysis of an administrative dataset.

OBJECTIVE

This study aims to investigate changing practice over a six-year period in the use of repeated lumbar facet joint injections/medial branch blocks in England.

METHODS

Patient data were extracted from the Hospital Episodes Statistics database for the period 1st April 2015 to 31st March 2021 for the index lumbar injection and for repeat lumbar injections performed within one year of the first. The exposure of interest was two injections within 180 days or three within one year. Patients aged <17 years and where the body site was listed as cervical, thoracic or sacral were excluded.

RESULTS

Data were available for 134,249 patients of which, 8,922 (6.6%) had either two injections within 180 days or three injections within one year. First injections fell from 42,511 in 2015/16 to 13,368 in 2019/20 as did the number of repeat injections: 4,018 to 424 for the same period. If all years had the same carbon footprint as 2019/20, 2.8 kilotons of CO2e would have been saved over the five years, enough to power 2,575 average UK homes for 1 year. The financial cost of injections decreased from £27.6 million in 2015/16 to £7.9 million in 2019/20.

CONCLUSIONS

The number of patients having repeated lumbar injections has decreased over time but has not been eliminated. More work is needed to educate patients and clinicians regarding alternative and more effective treatments.

Comparison of outcomes for patients with and without a serious mental illness presenting to hospital for chronic obstruction pulmonary disease: retrospective observational study using administrative data

BACKGROUND

There are few data on the profile of those with serious mental illness (SMI) admitted to hospital for physical health reasons.

AIMS

To compare outcomes for patients with and without an SMI admitted to hospital in England where the primary reason for admission was chronic obstructive pulmonary disease (COPD).

METHOD

This was a retrospective, observational analysis of the English Hospital Episodes Statistics data-set for the period from 1 April 2018 to 31 March 2019, for patients aged 18-74 years with COPD as the dominant reason for admission. Patient with an SMI (psychosis spectrum disorder, bipolar disorder) were identified.

RESULTS

Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI. Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. The burden of comorbidity was similar between the two groups. After adjusting for covariates, SMI was associated with significantly greater risk of length of stay than the median (odds ratio 1.24, 95% CI 1.12-1.37, P ≤ 0.001) and with 30-day emergency readmission (odds ratio 1.51, 95% confidence interval 1.34-1.69, P ≤ 0.001) but not with in-hospital mortality.

CONCLUSION

Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.

Role of hospital strain in determining outcomes for people hospitalised with COVID-19 in England

BACKGROUND

In England, reported COVID-19 mortality rates increased during winter 2020/21 relative to earlier summer and autumn months. This study aimed to examine the association between COVID-19-related hospital bed-strain during this time and patient outcomes.

METHODS

This was a retrospective observational study using Hospital Episode Statistics data for England. All unique patients aged ≥18 years in England with a diagnosis of COVID-19 who had a completed (discharged alive or died in hospital) hospital stay with an admission date between 1 July 2020 and 28 February 2021 were included. Bed-strain was calculated as the number of beds occupied by patients with COVID-19 divided by the maximum COVID-19 bed occupancy during the study period. Bed-strain was categorised into quartiles for modelling. In-hospital mortality was the primary outcome of interest and length of stay a secondary outcome.

RESULTS

There were 253 768 unique hospitalised patients with a diagnosis of COVID-19 during a hospital stay. Patient admissions peaked in January 2021 (n=89 047), although the crude mortality rate peaked slightly earlier in December 2020 (26.4%). After adjustment for covariates, the mortality rate in the lowest and highest quartile of bed-strain was 23.6% and 25.3%, respectively (OR 1.13, 95% CI 1.09 to 1.17). For the lowest and the highest quartile of bed-strain, adjusted mean length of stay was 13.2 days and 11.6 days, respectively in survivors and was 16.5 days and 12.6 days, respectively in patients who died in hospital.

CONCLUSIONS

High levels of bed-strain were associated with higher in-hospital mortality rates, although the effect was relatively modest and may not fully explain increased mortality rates during winter 2020/21 compared with earlier months. Shorter hospital stay during periods of greater strain may partly reflect changes in patient management over time.

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset

INTRODUCTION

As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for endoscopic sinus surgery (ESS). The aim of this study was to investigate the safety of day-case ESS in England.

DESIGN

Secondary analysis of administrative data.

METHODS

We extracted data from the Hospital Episodes Statistics database for the 5 years from 1 April 2014 to 31 March 2019. Patients undergoing elective ESS procedures aged ≥17 years were included. Exclusion criteria included malignant neoplasm, complex systemic disease and trans-sphenoidal pituitary surgery. The primary outcome was readmission within 30 days post-discharge. Multilevel, multivariable logistic regression modelling was used to compare outcomes for those operated on as day-cases and those with an overnight stay after adjusting for demographic, frailty, comorbidity and procedural covariates.

RESULTS

Data were available for 49 223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/2015 to 78.7% in 2018/2019. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar.

CONCLUSIONS

Our data support the view that ESS can safely be performed as day-case surgery in most cases, although it will not be suitable for all patients. There appears to be scope to increase rates of day-case ESS in some hospital trusts in England.

The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England

BACKGROUND

Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England.

METHODS

Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure.

RESULTS

Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied.

CONCLUSIONS

A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

Data quality and autism: Issues and potential impacts

INTRODUCTION

Large healthcare datasets can provide insight that has the potential to improve outcomes for patients. However, it is important to understand the strengths and limitations of such datasets so that the insights they provide are accurate and useful. The aim of this study was to identify data inconsistencies within the Hospital Episodes Statistics (HES) dataset for autistic patients and assess potential biases introduced through these inconsistencies and their impact on patient outcomes. The study can only identify inconsistencies in recording of autism diagnosis and not whether the inclusion or exclusion of the autism diagnosis is the error.

METHODS

Data were extracted from the HES database for the period 1st April 2013 to 31st March 2021 for patients with a diagnosis of autism. First spells in hospital during the study period were identified for each patient and these were linked to any subsequent spell in hospital for the same patient. Data inconsistencies were recorded where autism was not recorded as a diagnosis in a subsequent spell. Features associated with data inconsistencies were identified using a random forest classifiers and regression modelling.

RESULTS

Data were available for 172,324 unique patients who had been recorded as having an autism diagnosis on first admission. In total, 43.7 % of subsequent spells were found to have inconsistencies. The features most strongly associated with inconsistencies included greater age, greater deprivation, longer time since the first spell, change in provider, shorter length of stay, being female and a change in the main specialty description. The random forest algorithm had an area under the receiver operating characteristic curve of 0.864 (95 % CI [0.862 - 0.866]) in predicting a data inconsistency. For patients who died in hospital, inconsistencies in their final spell were significantly associated with being 80 years and over, being female, greater deprivation and use of a palliative care code in the death spell.

CONCLUSIONS

Data inconsistencies in the HES database were relatively common in autistic patients and were associated a number of patient and hospital admission characteristics. Such inconsistencies have the potential to distort our understanding of service use in key demographic groups.

Frailty, Comorbidity, and Associations With In-Hospital Mortality in Older COVID-19 Patients: Exploratory Study of Administrative Data

BACKGROUND

Older adults have worse outcomes following hospitalization with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes.

OBJECTIVE

We aimed to identify the key comorbidities and domains of frailty that were associated with in-hospital mortality in older patients with COVID-19 using models developed for machine learning algorithms.

METHODS

This was a retrospective study that used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for hospitalized patients in England aged 65 years or older. The data set was split into separate training (70%), test (15%), and validation (15%) data sets during model development. Global frailty was assessed using the Hospital Frailty Risk Score (HFRS) and specific domains of frailty were identified using the Global Frailty Scale (GFS). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Additional features employed in the random forest algorithms included age, sex, deprivation, ethnicity, discharge month and year, geographical region, hospital trust, disease severity, and International Statistical Classification of Disease, 10th Edition codes recorded during the admission. Features were selected, preprocessed, and input into a series of random forest classification algorithms developed to identify factors strongly associated with in-hospital mortality. Two models were developed; the first model included the demographic, hospital-related, and disease-related items described above, as well as individual GFS domains and CCI items. The second model was similar to the first but replaced the GFS domains and CCI items with the HFRS as a global measure of frailty. Model performance was assessed using the area under the receiver operating characteristic (AUROC) curve and measures of model accuracy.

RESULTS

In total, 215,831 patients were included. The model using the individual GFS domains and CCI items had an AUROC curve for in-hospital mortality of 90% and a predictive accuracy of 83%. The model using the HFRS had similar performance (AUROC curve 90%, predictive accuracy 82%). The most important frailty items in the GFS were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items in the CCI were cancer, heart failure, and renal disease.

CONCLUSIONS

The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.

COVID-19 hospital activity and in-hospital mortality during the first and second waves of the pandemic in England: an observational study

INTRODUCTION

We aimed to examine the profile of, and outcomes for, all people hospitalised with COVID-19 across the first and second waves of the pandemic in England.

METHODS

This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged ≥18 years in England with a diagnosis of COVID-19 who had a hospital stay that was completed between 1 March 2020 and 31 March 2021 were included. In-hospital mortality was the primary outcome of interest. The second wave was identified as starting on 1 September 2020. Multilevel logistic regression modelling was used to investigate the relationship between mortality and demographic, comorbidity and temporal covariates.

RESULTS

Over the 13 months, 374 244 unique patients had a diagnosis of COVID-19 during a hospital stay, of whom 93 701 (25%) died in hospital. Adjusted mortality rates fell from 40%-50% in March 2020 to 11% in August 2020 before rising to 21% in January 2021 and declining steadily to March 2021. Improvements in mortality rates were less apparent in older and comorbid patients. Although mortality rates fell for all ethnic groups from the first to the second wave, declines were less pronounced for Bangladeshi, Indian, Pakistani, other Asian and black African ethnic groups.

CONCLUSIONS

There was a substantial decline in adjusted mortality rates during the early part of the first wave which was largely maintained during the second wave. The underlying reasons for consistently higher mortality risk in some ethnic groups merits further study.

Litigation in pediatric otorhinolaryngology: Lessons in improving patient care

OBJECTIVE(S)

Medico-legal claims involving children place a substantial financial burden on health services and have a profound emotional and psychological impact on clinicians. Our objective was to analyze both the common causes and cost of litigation in pediatric otorhinolaryngology.

METHODS

A retrospective review of all clinical negligence claims within pediatric otolaryngology (0-17 years inclusive) in NHS (National Health Service) England held by the clinical negligence service 'NHS Resolution between' 4/2013 and 4/2020.

RESULTS

There were 100 claims in pediatric otorhinolaryngology accounting for an estimated potential total cost of just under £49 million with an average of 14 claims per year. Over half (52%) of claims were related to an operation with cause codes "Operator Error/Intra-Op Problem", "Diathermy Injury" and "Failure to Warn - Consent" most cited. The most common operation cited in a claim was tonsillectomy with an average cost per claim of £47,084. There were 21 claims coded as either "failure to diagnose" or "failure to treat" in relation to cholesteatoma, with an average cost per claim of £61,086.

CONCLUSION

This is the largest study to date analyzing the reasons and potential cost of clinical negligence claims within pediatric otolaryngology. Many learning opportunities exist to reduce patient morbidity, mortality and improve the patient experience through litigation data analysis.

Data consistency in the English Hospital Episodes Statistics database

BACKGROUND

To gain maximum insight from large administrative healthcare datasets it is important to understand their data quality. Although a gold standard against which to assess criterion validity rarely exists for such datasets, internal consistency can be evaluated. We aimed to identify inconsistencies in the recording of mandatory International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) codes within the Hospital Episodes Statistics dataset in England.

METHODS

Three exemplar medical conditions where recording is mandatory once diagnosed were chosen: autism, type II diabetes mellitus and Parkinson's disease dementia. We identified the first occurrence of the condition ICD-10 code for a patient during the period April 2013 to March 2021 and in subsequent hospital spells. We designed and trained random forest classifiers to identify variables strongly associated with recording inconsistencies.

RESULTS

For autism, diabetes and Parkinson's disease dementia respectively, 43.7%, 8.6% and 31.2% of subsequent spells had inconsistencies. Coding inconsistencies were highly correlated with non-coding of an underlying condition, a change in hospital trust and greater time between the spell with the first coded diagnosis and the subsequent spell. For patients with diabetes or Parkinson's disease dementia, the code recording for spells without an overnight stay were found to have a higher rate of inconsistencies.

CONCLUSIONS

Data inconsistencies are relatively common for the three conditions considered. Where these mandatory diagnoses are not recorded in administrative datasets, and where clinical decisions are made based on such data, there is potential for this to impact patient care.

Getting it right first time: national survey of surgical site infection 2019

Introduction

Surgical site infections (SSIs) are associated with increased morbidity and mortality. Deep SSI, or prosthetic joint infection (PJI), is associated with revision surgery involving longer operative times with higher infection rates, longer length of stay (LoS) and high costs in addition to the catastrophic effect on the patient. The surveillance of SSI is important for patient decision making, identification of outliers for support and maximising focussed improvement. This paper reports the findings of the second Getting it Right First Time (GIRFT) national SSI survey for orthopaedic and spinal surgery.

Methods

Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019. For a patient to be included, they had to present with SSI within the study period and within 1 year of the index procedure.

Results

A total of 309 SSIs were reported from primary and revision, total hip, knee, shoulder, elbow and ankle replacements, and 58 SSIs were reported from lumbar spine single level discectomy or decompression, lumbar spine single-level instrumented posterior fusion, posterior cervical spine decompression and instrumented fusion and posterior correction of adolescent idiopathic scoliosis. SSIs rates have remained low compared with the 2017 survey. There were variations in SSI rates by procedure, with primary shoulder replacement reporting the lowest (0.4%) and revision shoulder replacement the highest (2.5%) rates.

Conclusions

The authors recommend that the elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full SSI prevention bundle to minimise the risk of infection and improve patient outcomes.

Hospital dentistry litigation in England: clinical negligence claims against the NHS 2015-2020

Introduction Litigation against the NHS in England is rising. The aim of this study was to determine the incidence and characteristics of hospital dentistry clinical negligence claims in England.Methods A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to hospital dentistry between April 2015 and April 2020. Analysis was performed using the information for cause, patient injury and claim cost.Results A total of 492 claims were identified, with an estimated potential cost of £14 million. The most frequent causes for clinical negligence claims included failure/delay in treatment (n = 175; £3.9 million), inappropriate treatment (n = 56; £1.8 million) and failure to warn/obtain informed consent (n = 37; £1.5 million). Wrong site surgery was cited in 33 claims. The most frequent injury reported was dental damage (n = 197; £4.3 million), unnecessary pain (n = 125; £2.3 million) and nerve damage (n = 52; £2.4 million).Conclusion Clinical negligence claims in hospital dentistry are related to several different aspects of patient management and are not limited to treatment complications alone. Human ergonomics and patient perception of dentistry cannot be controlled but a focus on patient safety measures and effective communication can serve as tools to combat these factors.

An observational study of vertebroplasty and kyphoplasty for osteoporotic spinal fractures: utilisation and outcomes in England using an administrative dataset

We reviewed outcomes for vertebroplasty and balloon kyphoplasty for the surgical treatment of osteoporotic spinal fracture. Our study of 5792 vertebroplasty and 3136 balloon kyphoplasty procedures conducted in England over a 7-year period found no evidence that the patient outcomes studied were poorer for vertebroplasty than for balloon kyphoplasty.

PURPOSE

To investigate use, safety and functional outcomes of vertebroplasty (VP) and balloon kyphoplasty (BKP) techniques for osteoporotic spinal fracture for patients operated on within the National Health Service in England.

METHODS

This was an observational analysis of administrative data. Data were extracted from the Hospital Episodes Statistics database for the period 1^st April 2011 to 31^st March 2018 for all VP and BKP procedures. Patients aged < 19 years, with metastatic carcinoma and undergoing other decompression procedures, were excluded. The primary outcome was repeat spinal surgery within 1 year. Secondary outcomes were 30-day emergency readmission, death within 1 year, extended hospital stay, post-procedural pain within 30 days and post-procedural haemorrhage or infection within 30 days. Multilevel, multivariable logistic regression was used to adjust for covariates.

RESULTS

Data were available for 5792 VP and 3136 BKP patients operated on at 96 hospital trusts. In the 63 trusts that conducted more than 20 procedures during the study period, the proportion of procedures conducted as BKP varied from 0 to 100%. There was no difference in any of the outcomes between VP and BKP patients or between trusts performing ≥ 70% and ≤ 30% of procedures as BKP.

CONCLUSIONS

With regard to the outcomes studied, there is no evidence that VP is associated with poorer outcomes than BKP.

Volume-Outcome Associations for Parathyroid Surgery in England: Analysis of an Administrative Data Set for the Getting It Right First Time Program

Importance

Previous studies have suggested an association between surgical volume and patient outcomes for parathyroid surgery. However, most previous studies are relatively small and the literature is dominated by studies form the US, which might not be readily generalizable to other settings.

Objective

To investigate volume-outcome associations for parathyroid surgery in England.

Design, Setting, and Participants

Cohort study that included all National Health Service hospital trusts in England with secondary analysis of administrative data using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Participants included all adult, elective hospital admissions for parathyroid surgery without a diagnosis of multiple endocrine neoplasia, parathyroid cancer, or kidney disease over a 5-year period (April 2014-March 2019 inclusive).

Exposures

The number of procedures conducted in the year prior to the index procedure by each surgeon and each hospital trust.

Main Outcomes and Measures

Repeat parathyroid surgery within 1 year of the index procedure.

Results

This study included data for 17 494 participants who underwent parathyroidectomies conducted across 125 hospital trusts. The median (IQR) age of patients was 62 (53-71) years, and 13 826 were female (79.0%). Across the period, the number of surgeons conducting parathyroid surgery changed little (280 in 2014-2015 and 2018-2019), although the number of procedures conducted rose from 3331 to 3848 per annum. Repeat parathyroid surgery at 1 year was significantly associated with surgeon volume (odds ratio [OR], 0.99; 95% CI, 0.98-0.99), but not trust volume, in the previous 12 months. Extended length of stay (OR, 0.98; 95% CI, 0.98-0.99), hypoparathyroidism/calcium disorder (OR, 1.0; 95% CI, 0.99-1.0), and postprocedural complications (OR, 0.99; 95% CI, 0.99-1.0) were also associated with lower surgeon volume.

Conclusions and Relevance

In this cohort study, higher surgeon annual volume was associated with decreased rates of repeat parathyroid surgery. A minimum volume threshold of 20 procedures per annum should improve patient outcomes, although possible negative effects on access to services should be monitored.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme

RATIONALE, AIMS, AND OBJECTIVES

The Getting It Right First Time programme aims to reduce variation in clinical practice that unduly impacts on outcomes for patients in the National Health Service (NHS) in England; often termed "unwarranted variation." However, there is no "gold standard" method for detecting unwarranted variation. The aim of this study was to describe a method to allow such variation in recorded practice or patient outcomes between NHS trusts to be detected using data over multiple time periods. By looking at variation over time, it was hoped that patterns that could be missed by looking at data at a single time point, or averaged over a longer time period, could be identified.

METHODS

This was a retrospective time-series analysis of observational administrative data. Data were extracted from the Hospital Episodes Statistics database for two exemplar aspects of clinical practice within the field of urology: (a) use of ureteric stents on first emergency admission to treat urinary tract stones and (b) waiting times for definitive surgery for urinary retention. Data were categorized into 3-month time periods and three rules were used to detect unwarranted variation in the outcome metric relative to the national average: (a) two of any three consecutive values greater than two standard deviations above the mean, (b) four of any five consecutive values greater than one standard deviation above the mean, and (c) eight consecutive values above the mean.

RESULTS

For the urinary tract stones dataset, 24 trusts were identified as having unwarranted variation in the outcomes using funnel plots and 23 trusts using the time-series method. For the urinary retention data, 18 trusted were identified as having unwarranted variation in the outcomes using funnel plots and 22 trusts using the time-series method.

CONCLUSIONS

The time-series method may complement other methods to help identify unwarranted variation.

An observational study of volume-outcome effects for robot-assisted radical prostatectomy in England

OBJECTIVES

To investigate volume-outcome relationships in robot-assisted radical prostatectomy (RARP) for cancer using data from the Hospital Episodes Statistics (HES) database for England.

MATERIALS AND METHODS

Data for all adult, elective RPs for cancer during the period January 2013-December 2018 (inclusive) were extracted from the HES database. The HES database records data on all National Health Service (NHS) hospital admissions in England. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (laparoscopic, open or robot-assisted), hospital length of stay (LOS), emergency readmissions, and deaths. Multilevel modelling was used to adjust for hierarchy and covariates.

RESULTS

Data were available for 35 629 RPs (27 945 RARPs). The proportion of procedures conducted as RARPs increased from 53.2% in 2013 to 92.6% in 2018. For RARP, there was a significant relationship between 90-day emergency hospital readmission (primary outcome) and trust volume (odds ratio [OR] for volume decrease of 10 procedures: 0.99, 95% confidence interval [CI] 0.99-1.00; P = 0.037) and surgeon volume (OR for volume decrease of 10 procedures: 0.99, 95% CI 0.99-1.00; P = 0.013) in the previous year. From lowest to highest volume category there was a decline in the adjusted proportion of patients readmitted as an emergency at 90 days from 10.6% (0-49 procedures) to 7.0% (≥300 procedures) for trusts and from 9.4% (0-9 procedures) to 8.3% (≥100 procedures) for surgeons. LOS was also significantly associated with surgeon and trust volume, although 1-year mortality was associated with neither.

CONCLUSIONS

There is evidence of a volume-outcome relationship for RARP in England and minimising low-volume RARP will improve patient outcomes. Nevertheless, the observed effect size was relatively modest, and stakeholders should be realistic when evaluating the likely impact of further centralisation at a population level.

Volume-outcome relationship for adrenalectomy: analysis of an administrative dataset for the Getting It Right First Time Programme

BACKGROUND

A minimum volume threshold of at least six procedures per annum per surgeon has been set in UK and European guidelines for adrenal surgery. The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume.

METHODS

Data were extracted from the Hospital Episodes Statistics database for England. A 6-year period (January 2013 to December 2018 inclusive) for all adult admissions for unilateral adrenal surgery was used. The primary outcome measure was an emergency readmission within 30 days of discharge following surgery. Procedures were categorized as open or minimally invasive surgery for analysis. Multilevel modelling was used to adjust for hierarchy and potential confounders.

RESULTS

Data for 4189 adrenalectomies were identified. Only one third of surgeons (who operated on just over a half of all patients) performed at least six procedures in the year prior to the index procedure. For open surgery, emergency readmission rates fell significantly from 15.2 to 6.4 per cent for surgeons and from 13.2 to 6.1 per cent for trusts between the lowest- and highest-volume categories. Significant, but less dramatic falls were also seen for minimally invasive surgery.

CONCLUSION

A volume-outcome effect was identified for adrenal surgery in England. Minimum volume thresholds should be set, although these may need to be more ambitious than the current threshold if outcomes are to be optimized.

Litigation in breast surgery: unique insights from the English National Health Service experience

Background

The increase in medical negligence claims against the National Health Service (NHS) over the past decade has had a detrimental impact on limited financial and human resources that could otherwise be available for direct clinical care. The aim of this study was to review litigation claims in breast surgery as part of the national Getting It Right First Time quality improvement initiative, with the aim of identifying opportunities to improve clinical practice and patient safety.

Methods

All general and plastic surgical claims notified to NHS Resolution between April 2012 and April 2018 were reviewed. Claims related specifically to breast surgery were retrieved manually, and case summaries were analysed independently by two breast surgeons.

Results

From 6915 claims, 449 relating to breast surgery were identified and reviewed. The mean(s.d.) claimant age was 46(13) years. The median number of claims over the 6-year period per NHS trust was 2 (range 0–22). The most frequent causes of litigation were dissatisfaction with cosmetic outcome (121 claims, 26.9 per cent) and patient-reported delays in diagnosis (121, 26.9 per cent). A large proportion of claims related to breast implant surgery (78, 17.4 per cent), and issues regarding consent/communication were common (69, 15.4 per cent). The estimated annual cost of breast surgery litigation claims ranged from £5.57 to £9.59 million (€6.35–11.02 million).

Conclusion

Patient-reported delays in diagnosis and dissatisfaction with cosmetic outcome are the most common causes of litigation related to breast surgery. These key themes should be the focus for workforce learning, with the aim of improving patient care and experience.

Changes in COVID-19 in-hospital mortality in hospitalised adults in England over the first seven months of the pandemic: An observational study using administrative data

Background

Previous research by our team identified factors associated with in-hospital mortality in patients with a diagnosis of COVID-19 in England between March and May 2020. The aim of the current paper was to investigate the changing role of demographics and co-morbidity, with a particular focus on ethnicity, as risk factors for in-hospital mortality over an extended period.

Methods

This was a retrospective observational study using the Hospital Episode Statistics administrative dataset. All patients aged ≥ 18 years in England with a diagnosis of COVID-19 who had a hospital stay that was completed (discharged alive or died) between 1st March and 30th September 2020 were included. In-hospital mortality was the primary outcome of interest. Multilevel logistic regression was used to model the relationship between in-hospital mortality with adjustment for the covariates: age, sex, deprivation, ethnicity, date of discharge and a number of comorbidities.

Findings

Compared to patients in March-May (n = 93,379), patients in June-September (n = 24,059) were younger, more likely to be female and of Asian ethnicity, but less likely to be of Black ethnicity. In-hospital mortality rates, adjusted for covariates, declined from 33–34% in March to 11–12% in September. Compared to the March-May period, Bangladeshi, Indian and Other Asian ethnicity patients had a lower relative odds of death (compared to White ethnicity patients) during June-September. For Pakistani patients, the decline in-hospital mortality rates was more modest across the same time periods with the relative odds of death increasing slightly (odds ratio (95% confidence interval)) 1.24 (1.10 to 1.40) and 1.35 (1.08 to 1.69) respectively. From March-May to June-September the relative odds of death in patients with a diagnosis of metastatic carcinoma increased (1.90 (1.73 to 2.08) vs 3.01 (2.55 to 3.54)) but decreased for male patients (1.44 (1.39 to 1.49) vs 1.27 (1.17 to 1.38)) and patients with obesity (1.42 (1.34 to 1.52) vs 0.97 (0.83 to 1.14)) and diabetes without complications (1.14 (1.10 to 1.19) vs 0.95 (0.87 to 1.05)).

Interpretation

In-hospital mortality rates for patients with a diagnosis of COVID-19 have fallen substantially and there is evidence that the relative importance of some covariates has changed since the start of the pandemic. These patterns should continue to be tracked as new variants of the virus emerge, vaccination programmes are rolled out and hospital pressures fluctuate.

Funding

None.

Patient factors and temporal trends associated with COVID-19 in-hospital mortality in England: an observational study using administrative data

Background

Analysis of the effect of COVID-19 on the complete hospital population in England has been lacking. Our aim was to provide a comprehensive account of all hospitalised patients with COVID-19 in England during the early phase of the pandemic and to identify the factors that influenced mortality as the pandemic evolved.

Methods

This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative dataset. All patients aged 18 years or older in England who completed a hospital stay (were discharged alive or died) between March 1 and May 31, 2020, and had a diagnosis of COVID-19 on admission or during their stay were included. In-hospital death was the primary outcome of interest. Multilevel logistic regression was used to model the relationship between death and several covariates: age, sex, deprivation (Index of Multiple Deprivation), ethnicity, frailty (Hospital Frailty Risk Score), presence of comorbidities (Charlson Comorbidity Index items), and date of discharge (whether alive or deceased).

Findings

91 541 adult patients with COVID-19 were discharged during the study period, among which 28 200 (30·8%) in-hospital deaths occurred. The final multilevel logistic regression model accounted for age, deprivation score, and date of discharge as continuous variables, and sex, ethnicity, and Charlson Comorbidity Index items as categorical variables. In this model, significant predictors of in-hospital death included older age (modelled using restricted cubic splines), male sex (1·457 [1·408–1·509]), greater deprivation (1·002 [1·001–1·003]), Asian (1·211 [1·128–1·299]) or mixed ethnicity (1·317 [1·080–1·605]; vs White ethnicity), and most of the assessed comorbidities, including moderate or severe liver disease (5·433 [4·618–6·392]). Later date of discharge was associated with a lower odds of death (0·977 [0·976–0·978]); adjusted in-hospital mortality improved significantly in a broadly linear fashion, from 52·2% in the first week of March to 16·8% in the last week of May.

Interpretation

Reductions in the adjusted probability of in-hospital mortality for COVID-19 patients over time might reflect the impact of changes in hospital strategy and clinical processes. The reasons for the observed improvements in mortality should be thoroughly investigated to inform the response to future outbreaks. The higher mortality rate reported for certain ethnic minority groups in community-based studies compared with our hospital-based analysis might partly reflect differential infection rates in those at greatest risk, propensity to become severely ill once infected, and health-seeking behaviours.

Funding

None.

Fixation Method and Subsequent Revision Rates for Elective Primary Hip Arthroplasty in People Aged 70 Years and Older: Analysis of National Administrative Data Sets by the UK Getting It Right First Time Program

BACKGROUND

We aimed to understand the role of fixation method in predicting subsequent revision rates in people aged 70 years and older undergoing elective primary total hip arthroplasty (THA) within the UK National Health Service (NHS).

METHODS

Data on elective primary THAs conducted in people aged 70 years and older between April 1, 2012, and March 31, 2018, and subsequent revisions conducted up to March 31, 2019, were extracted from the Hospital Episodes Statistics database for all NHS procedures in England. A flexible parametric competing risks model was used to identify the role of fixation method in predicting revision and adjust for age, sex, frailty, year of surgery, and all-cause mortality.

RESULTS

Data were available for 190,656 procedures. Crude revision rates at 1-7 years follow-up in those who had cemented, hybrid/reverse hybrid, and uncemented fixation were 1.8%, 1.8%, and 2.3%, respectively. There was a high level of variation between NHS trusts in the proportionate use of fixation method. The differences in the hazard of revision between uncemented and cemented fixation (hazard ratio, 1.238 [95% confidence interval, 1.148-1.336]) and hybrid/reverse hybrid fixation (hazard ratio, 1.184 [95% confidence interval, 1.082-1.297]) were both significant. In secondary analysis, there was evidence that revision rates in trusts where uncemented fixation predominated were not significantly lower for uncemented fixation compared to all other fixation methods.

CONCLUSIONS

Revision rates were significantly higher for elective primary THA in people aged 70 years and older who have uncemented fixation, compared to those who had cemented and hybrid/reverse hybrid fixation.

Understanding volume-outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

OBJECTIVES

To investigate volume-outcome relationships in nephrectomy and cystectomy for cancer.

MATERIALS AND METHODS

Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in the England. Data were included for a 5-year period (April 2013-March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot-assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors.

RESULTS

Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high-volume surgeons, although the volume measure and threshold used were important.

CONCLUSIONS

We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower-volume centres, rather than further centralization.

A novel ceramic coating for reduced metal ion release in metal-on-metal hip surgery

An ovine total hip arthroplasty model was developed to evaluate metal ion release, wear, the biological response and adverse tissue reaction to metal-on-metal (MoM) bearing materials. The performance of an advanced superlattice ceramic coating (SLC) was evaluated as a bearing surface and experimental groups divided into; (1) MoM articulating surfaces coated with a SLC coating (SLC-MoM), (2) uncoated MoM surfaces (MoM), and (3) metal on polyethylene (MoP) surfaces. Implants remained in vivo for 13 months and blood chromium (Cr) and cobalt (Co) metal ion levels were measured pre and postoperatively. Synovial tissue was graded using an ALVAL scoring system. When compared with the MoM group, sheep with SLC-MoM implants showed significantly lower levels of chromium and cobalt metal ions within blood over the 13-month period. Evidence of gray tissue staining was observed in the synovium of implants in the MOM group. A significantly lower ALVAL score was measured in the SLC-MoM group (3.88) when compared with MoM components (6.67) (p = 0.010). ALVAL results showed no significant difference when SLC-MOM components were compared to MoP (5.25). This model was able to distinguish wear and the effect of released debris between different bearing combinations and demonstrated the effect of a SLC coating when applied onto the bearing surface. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1760-1771, 2019.

Isolated tuberculosis of the calcaneum in a constitutionally well patient

A 66-year-old Caucasian man presented with a 9-month history of a painful left heel with associated soft tissue swelling. Pitting oedema was present to the upper shin. Plain radiograph showed a sclerotic calcaneum with lucent patches and the CT scan revealed bony destruction at the posterosuperior aspect of the calcaneus with a moth-eaten appearance. To obtain a more definitive diagnosis, the patient underwent a CT-guided biopsy, which showed caseating granulomatous inflammation strongly suggestive of Mycobacterium infection. A Ziehl-Neilson stain did not show any microorganisms. Microbiology confirmed the presence of Staphylococcus aureas. A diagnosis of tuberculosis with concomitant Staphylococcus superinfection was made based on the histology and clinical context. The patient was treated with curettage and cementing of the lesion in order to debride the infected tissue and provide structural support to the bone. A 9-month course of quadruple antituberculous therapy was also initiated.

The outcome of resection of the distal ulna for tumour without soft-tissue or prosthetic reconstruction

In patients with a tumour affecting the distal ulna it is difficult to preserve the function of the wrist following extensive local resection. We report the outcome of 12 patients (nine female, three male) who underwent excision of the distal ulna without local soft-tissue reconstruction. In six patients, an aggressive benign tumour was present and six had a malignant tumour. At a mean follow-up of 64 months (15 to 132) the mean Musculoskeletal Tumour score was 64% (40% to 93%) and the mean DASH score was 35 (10 to 80). The radiological appearances were satisfactory in most patients. Local recurrence occurred in one patient with benign disease and two with malignant disease. The functional outcome was thus satisfactory at a mean follow-up in excess of five years, with a relatively low rate of complications. The authors conclude that complex reconstructive soft-tissue procedures may not be needed in these patients.

How safe is curettage of low-grade cartilaginous neoplasms diagnosed by imaging with or without pre-operative needle biopsy?

The pre-operative differentiation between enchondroma, low-grade chondrosarcoma and high-grade chondrosarcoma remains a diagnostic challenge. We reviewed the accuracy and safety of the radiological grading of cartilaginous tumours through the assessment of, first, pre-operative radiological and post-operative histological agreement, and second the rate of recurrence in lesions confirmed as high-grade on histology. We performed a retrospective review of major long bone cartilaginous tumours managed by curettage as low grade between 2001 and 2012. A total of 53 patients with a mean age of 47.6 years (8 to 71) were included. There were 23 men and 30 women. The tumours involved the femur (n = 20), humerus (n = 18), tibia (n = 9), fibula (n = 3), radius (n = 2) and ulna (n = 1). Pre-operative diagnoses resulted from multidisciplinary consensus following radiological review alone for 35 tumours, or with the addition of pre-operative image guided needle biopsy for 18. The histologically confirmed diagnosis was enchondroma for two (3.7%), low-grade chondrosarcoma for 49 (92.6%) and high-grade chondrosarcoma for two (3.7%). Three patients with a low-grade tumour developed a local recurrence at a mean of 15 months (12 to 17) post-operatively. A single high-grade recurrence (grade II) was treated with tibial diaphyseal replacement. The overall recurrence rate was 7.5% at a mean follow-up of 4.7 years (1.2 to 12.3). Cartilaginous tumours identified as low-grade on pre-operative imaging with or without additional image-guided needle biopsy can safely be managed as low-grade without pre-operative histological diagnosis. A few tumours may demonstrate high-grade features histologically, but the rates of recurrence are not affected.

A review of the surgical management of sacral chordoma

BACKGROUND

Sacral chordomas are rare low-to-intermediate grade malignant tumours, which arise from remnants of the embryonic notochord. This review explores prognostic factors in the management of sacral chordomas and provides guidance on the optimal treatment regimens based on the current literature.

PATIENTS AND METHODS

Electronic searches were performed using MEDLINE, Embase and the Cochrane library to identify studies on prognostic factors in the management of sacral chordomas published between January 1970 and December 2013. The literature search and review process identified 100 articles that were included in the review article. This included both surgical and non-surgical studies on the management of sacral chordomas.

RESULTS

Sacrectomy with wide resection margins forms the mainstay of treatment but is associated with high risk of disease recurrence and reduced long-term survival. Adequate resection margins may require sacrifice of adjacent nerve roots, musculature and ligaments leading to functional compromise and mechanical instability. Large tumour size (greater than 5-10 cm in diameter), dedifferentiation and greater cephalad tumour extension are associated with increased risk of disease recurrence and reduced survival. Chordomas are poorly responsive to conventional radiotherapy and chemotherapy.

CONCLUSION

Operative resection with wide resection margins offers the best long-term prognosis. Inadequate resection margins, large tumour size, dedifferentiation, and greater cephalad chordoma extension are associated with poor oncological outcomes. Routine long-term follow-up is essential to enable early detection and treatment of recurrent disease.

Revision cartilage cell transplantation for failed autologous chondrocyte transplantation in chronic osteochondral defects of the knee

The management of failed autologous chondrocyte implantation (ACI) and matrix-assisted autologous chondrocyte implantation (MACI) for the treatment of symptomatic osteochondral defects in the knee represents a major challenge. Patients are young, active and usually unsuitable for prosthetic replacement. This study reports the results in patients who underwent revision cartilage transplantation of their original ACI/MACI graft for clinical or graft-related failure. We assessed 22 patients (12 men and 10 women) with a mean age of 37.4 years (18 to 48) at a mean of 5.4 years (1.3 to 10.9). The mean period between primary and revision grafting was 46.1 months (7 to 89). The mean defect size was 446.6 mm(2) (150 to 875) and they were located on 11 medial and two lateral femoral condyles, eight patellae and one trochlea. The mean modified Cincinnati knee score improved from 40.5 (16 to 77) pre-operatively to 64.9 (8 to 94) at their most recent review (p < 0.001). The visual analogue pain score improved from 6.1 (3 to 9) to 4.7 (0 to 10) (p = 0.042). A total of 14 patients (63%) reported an 'excellent' (n = 6) or 'good' (n = 8) clinical outcome, 5 'fair' and one 'poor' outcome. Two patients underwent patellofemoral joint replacement. This study demonstrates that revision cartilage transplantation after primary ACI and MACI can yield acceptable functional results and continue to preserve the joint.

In vivo roughening of retrieved total knee arthroplasty femoral components

BACKGROUND

Joint registry data highlights the higher rates of cumulative revision for younger patients undergoing TKR. One of the reasons associated with this higher revision rate may be due to the wear of the UHMWPE leading to loosening. Alternate bearing surfaces have been developed to address this problem; however, roughening of the metal bearing surface has not been demonstrated in vivo.

METHOD

We recorded roughness measurements of retrieved femoral components.

RESULTS

Average lateral condyle roughness was 0.032 μm, compared to control values of 0.020 μm, p=0.002; average medial condyle roughness was 0.028 μm, compared to a control value of 0.019, p<0.001.

CONCLUSION

There was a small but statistically significant roughening of femoral components in vivo compared to controls. This may have important implications for aseptic loosening of knee arthroplasty components and the decision to use scratch resistant components.

Identification of the biopsy track in musculoskeletal tumour surgery: a novel technique using India ink

Local recurrence along the biopsy track is a known complication of percutaneous needle biopsy of malignant musculoskeletal tumours. In order to completely excise the track with the tumour its identification is essential, but this becomes increasingly difficult over time. In an initial prospective study, 22 of 45 patients (48.8%) identified over a three-month period, treated by resection of a musculoskeletal tumour, had an unidentifiable biopsy site at operation, with identification statistically more difficult after 50 days. We therefore introduced the practice of marking the biopsy site with India ink. In all 55 patients undergoing this procedure, the biopsy track was identified pre-operatively (100%); this difference was statistically significant. We recommend this technique as a safe, easy and accurate means of ensuring adequate excision of the biopsy track.

Custom-made rotating hinge total knee replacement in a patient with congenital tibial deficiency avoids the need for amputation

We report a unique case of a patient with type 2 congenital tibial deficiency and disabling knee osteoarthritis in whom a custom-made rotating hinge knee replacement was successfully performed, allowing continued mobilisation with a below-knee prosthesis, thereby avoiding the need for an above-knee amputation. Level of evidence Therapeutic study, Level IV.

Custom rotating-hinge total knee replacement in patients with spina bifida and severe neuromuscular dysfunction

Spina bifida (SB) is a congenital disorder which may result in a number of musculoskeletal problems. Total knee replacement (TKR) in this patient group is technically demanding due to bone deformity, soft tissue contracture, muscle tone abnormality and ligament insufficiency. This is a retrospective review of three patients with SB and disabling knee arthritis who were managed with a custom rotating-hinge (RHK) total knee system. All patients reported an improvement in knee pain and stability at mean follow-up 47 months (43-53). Mean Oxford Knee score improved from 21 preoperatively to 32 at final follow-up. One patient required revision of tibial and patella components at 37 months for lateral patella instability and excessive wear. Custom RHK for patients with SB, severe neuromuscular dysfunction and bone deformity relieves pain, restores stability and improves early knee function; however there is a significant risk of extensor mechanism complications and functional outcome is worse than primary TKR in the general population.

Autologous chondrocyte implantation for osteochondral lesions in the knee using a bilayer collagen membrane and bone graft: a two- to eight-year follow-up study

Matrix-induced autologous chondrocyte implantation (MACI) is an established technique used to treat osteochondral lesions in the knee. For larger osteochondral lesions (> 5 cm(2)) deeper than approximately 8 mm we have combined the use of two MACI membranes with impaction grafting of the subchondral bone. We report our results of 14 patients who underwent the 'bilayer collagen membrane' technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There were 12 men and two women with a mean age of 23.6 years (16 to 40). The mean size of the defect was 7.2 cm(2) (5.2 to 12 cm(2)) and were located on the medial (ten) or lateral (four) femoral condyles. The mean modified Cincinnati knee score improved from 45.1 (22 to 70) pre-operatively to 82.8 (34 to 98) at the most recent review (p < 0.05). The visual analogue pain score improved from 7.3 (4 to 10) to 1.7 (0 to 6) (p < 0.05). Twelve patients were considered to have a good or excellent clinical outcome. One graft failed at six years. The BCMT resulted in excellent functional results and durable repair of large and deep osteochondral lesions without a high incidence of graft-related complications.

The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae

PURPOSE

Chondromalacia patella is a distinct clinical entity of abnormal softening of the articular cartilage of the patella, which results in chronic retropatellar pain. Its aetiology is still unclear but the process is thought to be a due to trauma to superficial chondrocytes resulting in a proteolytic enzymic breakdown of the matrix. Our aim was to assess the effectiveness of autologous chondrocyte implantation on patients with a proven symptomatic retropatellar lesion who had at least one failed conventional marrow-stimulating therapy.

METHODS

We performed chondrocyte implantation on 48 patients: 25 received autologous chondrocyte implantation with a type I/III membrane (ACI-C) method (Geistlich Biomaterials, Wolhusen, Switzerland), and 23 received the Matrix-assisted Chondrocyte Implantation (MACI) technique (Genzyme, Kastrup, Denmark).

RESULTS

Over a mean follow-up period of 40.3 months, there was a statistically significant improvement in subjective pain scoring using the visual analogue scale (VAS) and objective functional scores using the Modified Cincinnati Rating System (MCS) in both groups.

CONCLUSIONS

Chondromalacia patellae lesions responded well to chondrocyte implantation. Better results occurred with MACI than with ACI-C. Excellent and good results were achieved in 40% of ACI-C patients and 57% of MACI patients, but success of chondrocyte implantation was greater with medial/odd-facet lesions. Given that the MACI procedure is technically easier and less time consuming, we consider it to be useful for treating patients with symptomatic chondral defects secondary to chondromalacia patellae.

FREE FIBULAR GRAFT RECONSTRUCTION FOLLOWING RESECTION OF CHONDROSARCOMA IN THE FIRST METACARPAL

Chondrosarcoma is most frequently present in the pelvis and long bones and rarely seen in the bones of the hand. Traditionally the treatment of choice for involvment of the hand is ray amputation, however this causes significant functional deficit if there is thumb involvement. There are limited cases in literature of resection of thumb chondrosarcoma with restoration of function. We present a case of high grade chondrosarcoma of the first metacarpal treated with resection and free fibular graft reconstruction. We report excellent functional outcome with this procedure.

Deep soft tissue leiomyoma mimicking fibromatosis in a 5-year-old male

Leiomyomas of the deep soft tissue in the extremities of children are very rare. These benign soft tissue tumors occur more frequently in adults between the fourth and sixth decades of age. Women are more commonly affected than men, with the uterus the most common location. We present a rare case of deep soft tissue leiomyoma in the foot of a 5-year-old male. The tumor was misdiagnosed as a desmoid-type fibromatosis from the findings of both magnetic resonance imaging and needle biopsy. The unusual age of presentation, atypical location, and failure of magnetic resonance imaging and ultrasound-guided needle biopsy in diagnosing the lesion make the case interesting. The case also highlights the importance of treating such patients at specialist tertiary centers with a multidisciplinary setting.

Bizarre parosteal osteochondromatous proliferation of bone: clinical management of a series of 22 cases

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora's lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.

Autologous chondrocyte implantation in the adolescent knee

BACKGROUND

Autologous chondrocyte implantation (ACI) has been shown to have favorable results in the treatment of symptomatic chondral and osteochondral lesions. However, there are few reports on the outcomes of this technique in adolescents.

PURPOSE

The aim of this study was to assess pain relief and functional outcome in adolescents undergoing ACI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-five adolescent patients undergoing ACI or matrix-assisted chondrocyte implantation (MACI) were identified from a larger cohort. Four patients were lost to follow-up, leaving 31 patients (24 ACI, 7 MACI). The mean age was 16.3 years (range, 14-18 years) with a mean follow-up of 66.3 months (range, 12-126 months). There were 22 male and 9 female patients. All patients were symptomatic; 30 had isolated lesions and 1 had multiple lesions. Patients were assessed preoperatively and postoperatively using the visual analog scale (VAS) score for pain, the Bentley Functional Rating Score, and the Modified Cincinnati Rating System. At 1 year postoperatively, patients were recalled for a diagnostic biopsy, which was successfully attained in 21 patients.

RESULTS

The mean pain scores improved from 5 preoperatively to 1 postoperatively. The Bentley Functional Rating Score improved from 3 to 0, while the Modified Cincinnati Rating System improved from 48 preoperatively to 92 postoperatively with 84% of patients achieving excellent or good results. All postoperative scores exhibited significant improvement from preoperative scores. One patient underwent graft hypertrophy and 1 patient's graft failed and was revised. Biopsy results revealed hyaline cartilage in 24% of cases, mixed fibro/hyaline cartilage in 19%, and fibrocartilage in 57%.

CONCLUSION

Results show that, in this particular group who received ACI, patients experienced a reduction in pain and significant improvement in postoperative function after ACI or MACI. The authors believe that ACI is appropriate in the management of carefully selected adolescents with symptomatic chondral and osteochondral defects.

The use of massive endoprostheses for the treatment of bone metastases

Purpose. We report a series of 58 patients with metastatic bone disease treated with resection and endoprosthetic reconstruction over a five-year period at our institution. Introduction. The recent advances in adjuvant and neoadjuvant therapy in cancer treatment have resulted in improved prognosis of patients with bone metastases. Most patients who have either an actual or impending pathological fracture should have operative stabilisation or reconstruction. Endoprosthetic reconstructions are indicated in patients with extensive bone loss, failed conventional reconstructions, and selected isolated metastases. Methods and Results. We identified all patients who were diagnosed with metastatic disease to bone between 1999 and 2003. One hundred and seventy-one patients were diagnosed with bone metastases. Metastatic breast and renal cancer accounted for 84 lesions (49%). Fifty-eight patients with isolated bone metastasis to the appendicular skeleton had an endoprosthetic reconstruction. There were 28 males and 30 females. Twelve patients had an endoprosthesis in the upper extremity and 46 patients had an endoprosthesis in the lower extremity. The mean age at presentation was 62 years (24 to 88). At the time of writing, 19 patients are still alive, 34 patients have died, and 5 have been lost to follow up. Patients were followed up and evaluated using the musculoskeletal society tumour score (MSTS) and the Toronto extremity salvage score (TESS). The mean MSTS was 73% (57% to 90%) and TESS was 71% (46% to 95%). Mean follow-up was 48.2 months (range 27 to 82 months) and patients died of disease at a mean of 22 months (2 to 51 months) from surgery. Complications included 5 superficial wound infections, 1 aseptic loosening, 4 dislocations, 1 subluxation, and 1 case, where the tibial component of a prosthesis rotated requiring open repositioning. Conclusions. We conclude that endoprosthetic replacement for the treatment of isolated bone metastases is a reliable method of limb reconstruction in selected cases. It is associated with low complication and failure rates in our series, and achieves the aims of restoring function, allowing early weight bearing and alleviating pain.