Use of hospital services by age and comorbidity after an index heart failure admission in England: an observational study

© Published by the BMJ Publishing Group Limited.Objectives To describe hospital inpatient, emergency department (ED) and outpatient department (OPD) activity for patients in the year following their first emergency admission for heart failure (HF). To assess the proportion receiving specialist assessment within 2â €...weeks of hospital discharge, as now recommended by guidelines. Design Observational study of national administrative data. Setting All acute NHS hospitals in England. Participants 82â €...241 patients with an index emergency admission between April 2009 and March 2011 with a primary diagnosis of HF. Main outcome measures Cardiology OPD appointment within 2â €...weeks and within a year of discharge from the index admission; emergency department (ED) and inpatient use within a year. Results 15.1% died during the admission. Of the 69â €...848 survivors, 19.7% were readmitted within 30â €...days and half within a year, the majority for non-HF diagnoses. 6.7% returned to the ED within a week of discharge, of whom the majority (77.6%) were admitted. The two most common OPD specialties during the year were cardiology (24.7% of the total appointments) and anticoagulant services (12.5%). Although half of all patients had a cardiology appointment within a year, the proportion within the recommended 2â €...weeks of discharge was just 6.8% overall and varied by age, from 2.4% in those aged 90+ to 19.6% in those aged 18-45 (p<0.0001); appointments in other specialties made up only some of the shortfall. More comorbidity at any age was associated with higher rates of cardiology OPD follow-up. Conclusions Patients with HF are high users of hospital services. Postdischarge cardiology OPD follow-up rates fell well below current National Institute for Health and Care Excellence guidelines, particularly for the elderly and those with less comorbidity

Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study

Background: Previous research suggests that non-obstetric surgery is carried out in 1 – 2% of all pregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of the evidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelines regarding non-obstetric surgery in pregnant women. Objectives: To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgery was or was not carried out. To further analyse common procedure groups. Data Source: Hospital Episode Statistics (HES) maternity data collected between 2002 – 3 and 2011 – 12. Main outcomes: Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, long inpatient stay, stillbirth and low birthweight. Methods: We utilised HES, an administrative database that includes records of all patient admissions and day cases in all English NHS hospitals. We analysed HES maternity data collected between 2002 – 3 and 2011 – 12, and identified pregnancies in which non-obstetric surgery was carried out. We used logistic regression models to determine the adjusted relative risk and attributable risk of non-obstetric surgical procedures for adverse birth outcomes and the number needed to harm. Results: We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out. In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgery was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that for every 287 pregnancies in which a surgical operation was carried out there was one additional stillbirth; for every 31 operations there was one additional preterm delivery; for every 25 operations there was one additional caesarean section; for every 50 operations there was one additional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby. Limitations: We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Many spontaneous abortions will not be associated with a hospital admission and, therefore, will not be included in our analysis. A spontaneous abortion may be more likely to be reported if it occurs during the same hospital admission as the procedure, and this could account for the associated increased risk with surgery during pregnancy. There are missing values of key data items to determine parity, gestational age, birthweight and stillbirth. Conclusions: This is the first study to report the risk of adverse birth outcomes following non-obstetric surgery during pregnancy across NHS hospitals in England. We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Our observational study can never attribute a causal relationship between surgery and adverse birth outcomes, and we were unable to determine the risk of not undergoing surgery where surgery was clinically indicated. We have some reservations over associations of risk factors with spontaneous abortion because of potential ascertainment bias. However, we believe that our findings and, in particular, the numbers needed to harm improve on previous research, utilise a more recent and larger data set based on UK practices, and are useful reference points for any discussion of risk with prospective patients. The risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery is relatively low, confirming that surgical procedures during pregnancy are generally safe. Future work: Further evaluation of the association of non-obstetric surgery and spontaneous abortion. Evaluation of the impact of non-obstetric surgery on the newborn (e.g. neonatal intensive care unit admission, prolonged length of neonatal stay, neonatal death). Funding: The National Institute for Health Research Health Services and Delivery Research programme

Changes in heart failure management and long-term mortality over ten years: observational study

Objectives: To estimate the long-term survival of two cohorts of people diagnosed with heart failure 10 years apart and to assess differences in patient characteristics, clinical guideline compliance and survival by diagnosis setting. Methods Data: for patients aged 18 and over with a new diagnosis of heart failure in the Clinical Practice Research Datalink in 2001–2002 (5966 patients in 156 practices) and 2011–2012 (12 827 patients in 331 practices). Survival rates since diagnosis were described using Kaplan-Meier plots. Compliance with national guidelines was summarised. Results: 2011/2012 patients were older than those diagnosed a decade before, with lower blood pressure and cholesterol but more comorbidity and healthcare contacts. For those diagnosed in 2001/2002, the 5-year survival was 40.0% (40.2% in the 2011/2012 cohort), 10-year survival was 20.8%, and 15-year survival 11.1%. Improvement in survival between the two time periods was seen only in those diagnosed in primary care (5-year survival 46.0% vs 57.4%, compared with 33.9% and 32.6% for hospital-diagnosed patients). Beta-blocker use rose from 24.3% to 39.1%; renin–angiotensin system blockers rose from 31.8% to 54.3% (both p<0.001). There was little change for loop diuretics and none for thiazide diuretics. For the 9963 patients with symptoms recorded by their general practitioner before diagnosis, brain natriuretic peptide (BNP) testing was low, but echocardiogram use rose from 8.3% to 19.3%, and specialist referral rose from 7.2% to 24.6% (all p<0.001)

Common sequences of emergency readmissions among high-impact users following AAA repair

Introduction The aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate. Methods The patient cohort (2006-2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data. Results From a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among rAAA repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastro-intestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%) and ischaemic heart disease (3.3%). Conclusion A significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community

Trends in immediate postmastectomy breast reconstruction in the United Kingdom

The study aimed to evaluate local and national trends in immediate breast reconstruction (IBR) using the national English administrative records, Hospital Episode Statistics. Our prediction was an increase in implant-only and free flap procedures and a decline in latissimus flap reconstructions.Data from an oncoplastic center were interrogated to derive numbers of implant-only, autologous latissimus dorsi (LD), LD-assisted, and autologous pedicled or free flap IBR procedures performed between 2004 and 2013. Similarly, Hospital Episode Statistics data were used to quantify national trends in these procedures from 1996 to 2012 using a curve fitting analysis.National data suggest an increase in LD procedures between 1996 (n = 250) and 2002 (n = 958), a gradual rise until 2008 (n = 1398) followed by a decline until 2012 (n = 1090). As a percentage of total IBR, trends in LD flap reconstruction better fit a quadratic (R(2) = 0.97) than a linear function (R(2) = 0.63), confirming a proportional recent decline in LD flap procedures. Conversely, autologous (non-LD) flap reconstructions have increased (1996 = 0.44%; 2012 = 2.76%), whereas implant-only reconstructions have declined (1996 = 95.42%; 2012 = 84.92%). Locally, 70 implant-assisted LD procedures were performed in 2003 -2004, but only 2 were performed in 2012 to 2013.Implants are the most common IBR technique; autologous free flap procedures have increased, and pedicled LD flap procedures are in decline

Regional variation in trajectories of long-term readmission rates among patients in England with heart failure

Background We aimed to compare the characteristics and types of heart failure (HF) patients termed “high-impact users”, with high long-term readmission rates, in different regions in England. This will allow clinical factors to be identified in areas with potentially poor quality of care. Methods Patients with a primary diagnosis of heart failure (HF) in the period 2008–2009 were identified using nationally representative primary care data linked to national hospital data and followed up for 5 years. Group-based trajectory models and sequence analysis were applied to their readmissions. Results In each of the 8 NHS England regions, multiple discrete groups were identified. All the regions had high-impact users. The group with an initially high readmission rate followed by a rapid decline in the rate ranged from 2.5 to 11.3% across the regions. The group with constantly high readmission rate compared with other groups ranged from 1.9 to 12.1%. Covariates that were commonly found to have an association with high-impact users among most of the regions were chronic respiratory disease, chronic renal disease, stroke, anaemia, mood disorder, and cardiac arrhythmia. Respiratory tract infection, urinary infection, cardiopulmonary signs and symptoms and exacerbation of heart failure were common causes in the sequences of readmissions among high-impact users in all regions. Conclusion There is regional variation in England in readmission and mortality rates and in the proportions of HF patients who are high-impact users

Venous thromboembolism rates after hip and knee arthroplasty and hip fractures

Background The ideal thromboprophylaxis regime following lower limb arthroplasty and proximal femur fractures remains controversial. Guidelines disagree on the type of chemical prophylaxis, its dose or duration. This article describes a method of monitoring venous thromboembolism (VTE) rates following Total Hip (THA), Total Knee Arthroplasty (TKA) and surgery for hip fractures (NOF#). Methods Over 3 years, all patients investigated for VTE were analysed using Picture Archiving Communications System (PACS). All positive scans were then cross-referenced using PACS and local registry data to see if they had undergone THA, TKA or NOF# in the preceding 90 days. Mortality data were obtained from the national administrative database, Hospital Episode Statistics. Results Five thousand seven hundred eighty-eight patients underwent investigation for VTE and there were 29 diagnoses of PE and 24 of DVT. There was a 0.77% rate of symptomatic DVT after THA, 0.05% after TKA and 0.55% after NOF #. The rate of confirmed symptomatic PE for THA was 0.46, 0.27% for TKA and 0.96% for NOF #. Mortality at one-year post-THA was 0.6, 0.6% for TKA and 25.9% after NOF#. All patients contacted either remained within the catchment area for the minimum 90 postoperative days or died within the catchment area. Conclusions The 90 day post-operative prevalence of symptomatic VTE of 1.2, 0.3 and 1.5% in THA, TKA and NOF # respectively are similar to other studies using symptomatic and imaging positive VTE as their endpoint. The study uses a method of collecting data which can be utilised in centres where PACS is available