How do time trends in inhospital mortality compare? A retrospective study of England and Scotland over 17 years using administrative data

Objectives To examine the trends in inhospital mortality for England and Scotland over a 17-year period to determine whether and if so to what extent the time trends differ after controlling for differences in the patients treated. Design Analysis of retrospective administrative hospital data using descriptive aggregate statistics of trends in inhospital mortality and estimates of a logistic regression model of individual patient-level inhospital mortality accounting for patient characteristics, case-mix, and country-specific and year-specific intercepts. Setting Secondary care across all hospitals in England and Scotland from 1997 to 2013. Population Over 190 million inpatient admissions, either electively or emergency, in England or Scotland from 1997 to 2013. Data Hospital Episode Statistics for England and the Scottish Morbidity Record 01 for Scotland. Main outcome measures Separately for two admission pathways (elective and emergency), we examine aggregate time trends of the proportion of patients who die in hospital and a binary variable indicating whether an individual patient died in hospital or survived, and how that indicator is influenced by the patient’s characteristics, the year and the country (England or Scotland) in which they were admitted. Results Inhospital mortality has declined in both countries over the period studied, for both elective and emergency admissions, but has declined more in England than Scotland. The difference in trend reduction is greater for elective admissions. These differences persist after controlling for patient characteristics and case-mix. Conclusions Comparing data at country level suggests questions about the roles performed by or functioning of their healthcare systems. We found substantial differences between Scotland and England in regard to the trend reductions in inhospital mortality. Hospital resources are therefore being deployed increasingly differently over time in these two countries for reasons that have yet to be explained

Reading under the Common Core: Latinx Students’ Agency and Meaning-Making Practices in Peer Discussions about Text

The widespread adoption of the Common Core State Standards (CCSS), since 2010, has led to a growing concern among education scholars and practitioners about how the new standards will impact the educational trajectories of students from minoritized linguistic, ethnic, and racial backgrounds (Bunch, Walqui, & Pearson, 2014; Hakuta, Santos, & Fang, 2013; Lee, Quinn, & Valdés, 2013). In the area of English Language Arts (ELA), the close reading of texts, particularly informational texts, is identified as one of the primary reading skills students are expected to acquire, and is presented as central to students’ academic success in school and beyond. The CCSS narrowly define close reading as the practice of extracting knowledge and evidence from texts, paying limited attention to students’ broader learning contexts and existing funds of knowledge (Moll et al., 1992). The CCSS’s conceptualization of close reading contrasts with a sociocultural orientation to literacy (Castanheira, Crawford, Dixon, & Green, 2001; Hull & Moje, 2012) in which students’ language and literacy practices are viewed as socially situated and constructed. Drawing on the latter perspective, as well as on Neo-Vygotskian sociocultural theory (Rogoff, 1990) and a sociocultural linguistic framework (Bucholtz & Hall, 2005), the present study examines student interactions within and across instructional activities designed to support the acquisition of literacy skills required for close reading and analysis of complex texts. This dissertation presents a discourse analysis of classroom interaction in a 6th grade public school classroom in Southern California that was documented over the course of five months using video and audio recordings, participant observation, field notes, and samples of students’ work. The observations and analysis focus on peer discussions involving emergent bilinguals (García, 2009) from Latinx immigrant backgrounds, several of whom had been recently transitioned out of the school’s English Language Development (ELD) program. Findings suggest that students fluidly employed a range of linguistic and cultural resources, such as the use of their funds of knowledge and various linguistic registers, to make meaning and co-construct their understanding of texts with others. Students often used academic language as part of these interactions and demonstrated strong awareness of their language choices—particularly how they were connected to discourses about “standard” and “academic” language. Lastly, students’ engagement in different literacy tasks was locally constructed and influenced by factors such as the characteristics of specific texts and students’ affective responses to those texts. These finding have implications for how teaching practices associated with reading can be designed to leverage students’ knowledge and interests and expand learning opportunities for linguistically and racially marginalized students. Based on the findings, I propose an integrative and dynamic sociocultural approach to conceptualizing, teaching, and assessing students’ literacy practices in the classroom

Publicly funded hospital care : expenditure growth and its determinants

Understanding the drivers of growth in health care expenditure is crucial for forecasting future health care requirements and for the efficient use of resources. We consider total hospital admitted care expenditure in England between 2009/10 and 2016/17. Decomposition techniques are used to separate changes in expenditure into elements due to changes in the distribution of characteristics, of both individuals and the services they receive, and due to changes in the impact of characteristics on expenditures. Growth in aggregate expenditure was due to increases in total patient admissions together with a substantial shift towards episodes of non-elective care, particularly the use of long-stay care. Decomposition of patient level expenditure suggests efficiency gains in treatment across the full distribution of expenditures, but that these were outweighed by structural changes towards a greater proportion of patients presenting with high-dimensional comorbidities. This is particularly relevant at the top end of the expenditure distribution and accounts for a large proportion of the total expenditure growth

The determinants of health care expenditure growth

Understanding the drivers of growth in health care expenditure is crucial for forecasting future health care requirements and to ameliorate inefficient expenditure. This paper considers the detailed breakdown of hospital inpatient expenditures across the period 2007/08 to 2014/15. Decomposition techniques are used to unpick the observed rise in expenditure into a component due to a change in the distribution of characteristics, for example, greater prevalence of morbidity, and a component due to structural changes in the impact of such characteristics on expenditures (coefficient effects, for example, due to technological change). This is undertaken at the mean using standard decomposition techniques, but also across the full distribution of expenditures to gain an understanding of where in the distribution growth and its determinants are most relevant. Decomposition at the mean indicates a larger role for a structural change in characteristics rather than a change in coefficients. A key driver is an increased prevalence of comorbidities. When considering the full distribution we observe a decrease in expenditure at the bottom of the distribution (bottom two quintiles) but increasing expenditure thereafter. The largest increases are observed at the top of the expenditure distribution. Where changes in structural characteristics dominate changes in coefficients in explaining the rise in expenditure. Increases in comorbidities (and the average number of first diagnoses) across the two periods, together with increases in non-elective long stay episodes and non-elective bed days are important drivers of expenditure increases

Trends in and drivers of Healthcare Expenditure in the English NHS : a retrospective analysis

Background: In England, rises in healthcare expenditure consistently outpace growth in both GDP and total public expenditure. To ensure the National Health Service (NHS) remains financially sustainable, relevant data on healthcare expenditure are needed to inform decisions about which services should be delivered, by whom and in which settings. Methods: We analyse routine data on NHS expenditure in England over 9 years (2008/09 to 2016/17). To quantify the relative contribution of the different care settings to overall healthcare expenditure, we analyse trends in 14 healthcare settings under three broad categories: Hospital Based Care (HBC), Diagnostics and Therapeutics (D&T) and Community Care (CC). We exclude primary care and community mental health services settings due to a lack of consistent data. We employ a set of indices to aggregate diverse outputs and to disentangle growth in healthcare expenditure that is driven by activity from that due to cost pressures. We identify potential drivers of the observed trends from published studies. Results: Over the 9-year study period, combined NHS expenditure on HBC, D&T and CC rose by 50.2%. Expenditure on HBC rose by 54.1%, corresponding to increases in both activity (29.2%) and cost (15.7%). Rises in expenditure in inpatient (38.5%), outpatient (57.2%), and A&E (59.5%) settings were driven predominately by higher activity. Emergency admissions rose for both short-stay (45.6%) and long-stay cases (26.2%). There was a switch away from inpatient elective care (which fell by 5.1%) and towards day case care (34.8% rise), likely reflecting financial incentives for same-day discharges. Growth in expenditure on D&T (155.2%) was driven by rises in the volume of high cost drugs (270.5%) and chemotherapy (110.2%). Community prescribing grew by 45.2%, with costs falling by 24.4%. Evidence on the relationship between new technologies and healthcare expenditure is mixed, but the fall in drug costs could reflect low generic prices, and the use of health technology assessment or commercial arrangements to inform pricing of new medicines

Understanding the differences in in-hospital mortality between Scotland and England

Aims: We describe differences in in-hospital mortality between Scotland and England and test whether these differences are robust to controlling for the case-mix of patients. In spite of Scotland and England having much in common in regard to their hospital systems and populations we observe trends in-hospital mortality – the percentage of elective and emergency Continuous Inpatient Spells (CIS) that ended in death – that are different: England’s in-hospital mortality rates have decreased faster than Scotland’s for both types of admissions. Data: Individual patient data from England (HES) and Scotland (SMR01) for the period 2003/04 – 2011/12. Episode data is linked into CIS. Sample: Elective and emergency admissions, including day cases and excluding maternity. Methods: Logit regression of in-hospital death on country and financial year dummies, and their interaction, controlling for age group, gender, deprivation decile, and HRG of the first episode; separately for elective and emergency admissions. Results: For elective admissions, England has a lower initial in-hospital mortality rate than Scotland, and this rate decreases in both countries but the decrease has been faster in England. For emergency admissions, England starts with a slightly higher in-hospital mortality rate and both countries in-hospital mortality rates reduce throughout the period but England’s does so faster. Conclusions: There are differences in in-hospital mortality between Scotland and England; these differences increase over time and persist when we account for patient characteristics. It is important to understand the causes and consequences of these differences and we make a number of suggestions for future research on this issue

Defining and measuring unmet need to guide healthcare funding: : identifying and filling the gaps.

Budget allocations to Clinical Commissioning Groups include adjustments for unmet need for healthcare, but there is a lack of robust evidence to support this. This article describes a literature review with an objective to understand the available evidence regarding unmet need. We developed a conceptual framework for what constitutes ideal evidence that; defines unmet need for a given population, indicates how that need can be met by health care, establishes the barriers to meeting need and provides relevant proxies based on observable measures. Our search focused on recent and empirical UK data and conceptual papers. We found no one article which satisfied all requirements of ideal evidence; the literature was strongest in defining need but weakest in regard to establishing observable proxies of need capable of being used in budget allocations. Our review was limited by its timescale and a vast body of literature, which translated into a limited number of key words for the search. We conclude that further research to inform budget allocation is required and should focus on conditions or services where adverse health outcomes from unmet need are amenable to healthcare interventions and which affect a sizeable proportion of the population

Hospital trusts productivity in the English NHS: : uncovering possible drivers of productivity variations

In 2009, the NHS Chief Executive warned that a potential funding gap of £20 billion should be met by extensive efficiency savings by March 2015. Our study investigates possible drivers of differential Trust performance (productivity) for the years 2010/11-2012/13. Productivity is measured as Outputs/Inputs. We extend previous productivity work at Trust level by including a fuller range of care settings, including Inpatient, A&E and Community Care, in our output measure. Inputs include staff, equipment, and capital resources. We analyse variation in Total Factor and Labour Productivity with ordinary least squares regressions. Explanatory variables include efficiency in resource use measures, Trust and patient characteristics. We find productivity varies substantially across Trusts but is consistent across time. Larger Trusts are associated with lower productivity. Patient age groups treated is also found to be important. Foundation Trust status is associated with lower Total Factor Productivity, while treating more patients in their last year of life is surprisingly associated with higher Labour Productivity. Variation in productivity is persistent across years, and not fully explained by case-mix adjustment. A lack of convergence in productivity may indicate outstanding scope to improve Trust productivity based on mimicking the practises of the most productive providers

Medical spending and hospital inpatient care in England : An analysis over time

Health care in England is predominantly provided free at the point of service through the publicly funded National Health Service (NHS). Total NHS expenditure, which has risen in real terms by an average of 3.7% per annum since the inception of the NHS in 1948, constituted 7.9% of GDP in 2012. This paper presents a summary of the trends in medical expenditure in England and then using detailed administrative data presents analysis of the growth over 15 years of expenditure and activity in hospital inpatient health care, which represents around 20-25% of all NHS expenditure. We document the coincidence of observed trends in expenditure with reported activity, morbidity and the proximity of individuals to death. We find that; (i) expenditure for both elective and emergency inpatient care broadly follows activity so expenditure is mostly driven by activity rather than unit costs; (ii) expenditure is concentrated in individuals with multiple diseases so that the prevalence and identification of complex medical conditions are important drivers of expenditure and (iii) health care activity rises substantially for individuals in the period before death so that expenditure is driven substantially by mortality in the population. Taken together these findings indicate that this element of health care expenditure in England has been substantially driven by the underlying morbidity and age of the population in conjunction with improving health care technolog

Measuring the activity of mental health services in England : variation in categorising activity for payment purposes

In the context of international interest in reforming mental health payment systems, national policy in England has sought to move towards an episodic funding approach. Patients are categorised into care clusters, and providers will be paid for episodes of care for patients within each cluster. For the payment system to work, clusters need to be appropriately homogenous in terms of financial resource use. We examine variation in costs and activity within clusters and across health care providers. We find that the large variation between providers with respect to costs within clusters mean that a cluster-based episodic payment system would have substantially different financial impacts across providers