Do expanded seven-day NHS services improve clinical outcomes? Analysis of comparative institutional performance from the “NHS Services, Seven Days a Week” project 2013–2016

Background: The cause of adverse weekend clinical outcomes remains unknown. In 2013, the “NHS Services, Seven Days a Week” project was initiated to improve access to services across the seven-day week. Three years on, we sought to analyse the impact of such changes across the English NHS. Methods: Aggregated trust-level data on crude mortality rates, Summary Hospital-Level Mortality Indicator (SHMI), mean length of stay (LOS), A&E admission and four-hour breach rates were obtained from national Hospital Episode Statistics and A&E datasets across the English NHS, excluding mental and community health trusts. Trust annual reports were analysed to determine the presence of any seven-day service reorganisation in 2013–2014. Funnel plots were generated to compare institutional performance and a difference in differences analysis was performed to determine the impact of seven-day changes on clinical outcomes between 2013 and 2014, 2014–2015 and 2015–2016. Data was summarised as mean (SD). Results: Of 159 NHS trusts, 79 (49.7%) instituted seven-day changes in 2013–2014. Crude mortality rates, A&E admission rates and mean LOS remained relatively stable between 2013 and 2016, whilst A&E four-hour breach rates nearly doubled from 5.3 to 9.7%. From 2013 to 2014 to 2014–2015 and 2015–2016, there were no significant differences in the change in crude mortality (2014–2015 p = 0.8, 2015–2016 p = 0.9), SHMI (2014–2015 p = 0.5, 2015–2016 p = 0.5), mean LOS (2014–2015 p = 0.5, 2015–2016 p = 0.4), A&E admission (2014–2015 p = 0.6, 2015–2016 p = 1.0) or four-hour breach rates (2014–2015 p = 0.06, 2015–2016 p = 0.6) between trusts that had implemented seven-day changes compared to those which had not. Conclusions: Adverse weekend clinical outcomes may not be ameliorated by large scale reorganisations aimed at improving access to health services across the week. Such changes may negatively impact care quality without additional financial investment, as demonstrated by worsening of some outcomes. Detailed prospective research is required to determine whether such reallocation of finite resources is clinically effective

Commentary: Role of VEGF, nitric oxide, and sympathetic neurotransmitters in the pathogenesis of tendinopathy: A review of the current evidences

I read the recent systematic review which asked some interesting questions regarding the pathogenesis of tendinopathy (Vasta et al., 2016). The statement “histologic studies have demonstrated the absence of inflammatory infiltrates” is not supported by the current evidence base

Commentary: Role of VEGF, nitric oxide, and sympathetic neurotransmitters in the pathogenesis of tendinopathy: A review of the current evidences

I read the recent systematic review which asked some interesting questions regarding the pathogenesis of tendinopathy (Vasta et al., 2016). The statement “histologic studies have demonstrated the absence of inflammatory infiltrates” is not supported by the current evidence base

Approaches to assessing shoulder pain.

Gray and colleagues recommend a three step approach in assessing shoulder pain for non-specialists. I would point readers to the methodologically robust review by Hermans et al summarising the evidence for the various special tests in diagnosing rotator cuff tendinopathy

The management of suspected scaphoid fractures in the UK: a national cross-sectional study

Aims Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance. Methods This national cross-sectional study was carried out at 87 NHS centres in the UK involving 122 EDs and 184 minor injuries units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for suspected scaphoid fractures in EDs, MIUs, and orthopaedic services. Overall, 62 of 87 centres (71%) had a guideline for the management of suspected scaphoid fractures. Results A total of 11 of 87 centres (13%) had MRI directly available from the ED. Overall, 14 centres (17%) used cross-sectional imaging direct from the ED: MRI in 11 (13%), CT in three (3%), and a mixture of MRI/CT in one (1%). Four centres (6%) used cross-sectional imaging direct from the MIU: MRI in three (4%) and CT in two (2%). Of 87 centres’ orthopaedic specialist services, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in three (3%), and radiographs in 11 (13%). Conclusion Only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance.</p

Approaches to assessing shoulder pain.

Gray and colleagues recommend a three step approach in assessing shoulder pain for non-specialists. I would point readers to the methodologically robust review by Hermans et al summarising the evidence for the various special tests in diagnosing rotator cuff tendinopathy

Review: Emerging concepts in the pathogenesis of tendinopathy.

Tendinopathy is a common clinical problem and has a significant disease burden attached, not only in terms of health care costs, but also for patients directly in terms of time off work and impact upon quality of life. Controversy surrounds the pathogenesis of tendinopathy, however the recent systematic analysis of the evidence has demonstrated that many of the claims of an absence of inflammation in tendinopathy were more based around belief than robust scientific data. This review is a summary of the emerging research in this topical area, with a particular focus on the role of neuronal regulation and inflammation in tendinopathy

Development of a surgical trainer assessment questionnaire.

Background The assessment of surgical trainees has become well-established in practice; however, this is not yet the case for surgical trainers. The aim of this study was to develop a trainer assessment questionnaire (OxTrAQ) based on the 12 key trainer attributes identified by a previous systematic review, to then explore this questionnaire’s potential domains and test its reliability. Methods The OxTrAQ was piloted at two surgical training centres in two surgical subspecialities. At each centre, every trainee assessed every trainer while under their clinical supervision. Results Internal consistency (Cronbach’s alpha) was calculated for this 12-item questionnaire as 0.958. Factor analysis revealed two domains which accounted for 77.997% of the variance; these were the general domain (nine items) and the independence domain (three items). Inter-observer reliability was shown by the intraclass correlation coefficients (ICCs) (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.951, 0.945 and 0.955 for centre 1 and 0.857, 0.819 and 0.883 for centre 2, respectively. Intra-observer reliability was shown by the ICCs (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.925, 0.913 and 0.940, respectively. Construct validity was demonstrated by a high correlation (Spearman rho = 0.886, P = 0.019) between trainer scores and the scores predicted by the trainers themselves. Conclusions The OxTrAQ is a simple trainer assessment questionnaire which has demonstrated both high inter- and intra-observer reliability.</p