Cost burden of Clostridioides difficile infection to the health service:A retrospective cohort study in Scotland

BACKGROUND:Clostridioides difficile infection (CDI) is associated with high healthcare demands and related costs. AIM:To evaluate the healthcare and economic burden of CDI in hospitalised patients with community- (HOCA-CDI) or hospital-associated CDI (HOHA-CDI) in the National Health Service in Scotland. METHODS:A retrospective cohort study was conducted, examining data between August 2010 and July 2013 from four patient-level Scottish datasets, linked to death data. Data examined included prior antimicrobial prescriptions in the community, hospitalisations, length of stay and mortality. Each CDI case was matched to three hospital-based controls on the basis of age, gender, hospital and date of admission. Descriptive economic evaluations were based on bed-day costs for different types of wards. FINDINGS:Overall, 3304 CDI cases were included in the study. CDI was associated with additional median lengths of stay of 7.2 days for HOCA-CDI and 12.0 days for HOHA-CDI compared with their respective, matched controls. The 30-day mortality rate was 6.8% for HOCA-CDI and 12.4% for HOHA-CDI. Overall, recurrence within 90 days of the first CDI episode occurred in 373/2740 (13.6%) survivors. The median additional expenditure for each initial CDI case compared with matched controls was £1713. In the 6 months after the index hospitalisation, the cost associated with a CDI case was £5126 higher than for controls. CONCLUSION:Using routinely collected national data, we demonstrate the substantial burden of CDI on healthcare services, including lengthy hospital stays and readmissions, which increase the costs of managing patients with CDI compared with matched controls

Identifying adaptation ‘on the ground’: Development of a UK adaptation inventory

Adaptation plays a crucial role in managing the unavoidable risks from climate change. The UK is considered to be at the forefront of national adaptation planning. However, the extent to which plans and programmes translate into tangible risk reducing action on the ground, as opposed to adaptive capacity building, remains less clear. Given that there is no formal database of adaptation action for the UK, despite the various needs of government to identify, assess and report on adaptation progress, including the UK national stocktake on adaptation under the UNFCCC Paris Agreement, this study outlines the development of an up-to-date and forward-looking UK Adaptation Inventory. The Inventory documents adaptation on the ground, based on national reporting to government by public and private sector organisations and a systematic review of peer-reviewed literature. The framework is centred on identifying and documenting current and planned adaptation; how it is being implemented in terms of the types of adaptation actions; and the sectors where adaptation is occurring and where gaps may remain. For the sub-set of sectors captured there is clear evidence of a wide range of cross-sectoral and sector-specific adaptation being implemented. In total, 360 examples were identified, over 80% of which have already been implemented. This comprises 134 different types of adaptation action, largely aimed at reducing vulnerability using engineered, built environment or technological mechanisms. Compared to the situation a decade earlier, this suggests that significant progress has occurred in the UK in terms of reporting and implementing adaptation, including adaptation by the private sector in climate sensitive sectors. At the broader level, the Inventory is a first step in providing a baseline assessment for the UK stocktake on adaptation; can help inform other organisations about adaptation options that are available; and provide case studies of actions in practice to help support decision-making

The limits of process: On (re)reading Henri Bergson

This article offers a reading of the work of Henri Bergson as it pertains to organizations through the lens of ideas drawn from critical realism. It suggests an alternative to interpretations based on a stark division between process and realist perspectives. Much of the existing literature presents a rather partial view of Bergson’s work. A review suggests some interesting parallels with themes in critical realism, notably the emergence of mind. Critical realism has a focus on process at its heart, but is also concerned with how the products of such processes become stabilized and form the conditions for action. This suggests that attention might usefully be paid to the relationship between organizational action and the sedimented practices grouped under the heading of ‘routines’. More attention to Bergson’s account of the relationship between instinct, intuition and intelligence provides a link to the social character of thought, something which can be mapped on to Archer’s work on reflexivity and the ‘internal conversation’. This suggests that our analyses need to pay attention to both memory and history, to building and dwelling, rather than the one-sided focus found in some process theory accounts

The impact of flooding on road transport:A depth-disruption function

Transport networks underpin economic activity by enabling the movement of goods and people. During extreme weather events transport infrastructure can be directly or indirectly damaged, posing a threat to human safety, and causing significant disruption and associated economic and social impacts. Flooding, especially as a result of intense precipitation, is the predominant cause of weather-related disruption to the transport sector. Existing approaches to assess the disruptive impact of flooding on road transport fail to capture the interactions between floodwater and the transport system, typically assuming a road is fully operational or fully blocked, which is not supported by observations. In this paper we develop a relationship between depth of standing water and vehicle speed. The function that describes this relationship has been constructed by fitting a curve to video analysis supplemented by a range of quantitative data that has be extracted from existing studies and other safety literature. The proposed relationship is a good fit to the observed data, with an R-squared of 0.95. The significance of this work is that it is simple to incorporate our function into existing transport models to produce better estimates of flood induced delays and we demonstrate this with an example from the 28"sup"th"/sup" June 2012 flood in Newcastle upon Tyne, UK. Document type: Articl

Assessing urban strategies for reducing the impacts of extreme weather on infrastructure networks

Critical infrastructure networks, including transport, are crucial to the social and economic function of urban areas but are at increasing risk from natural hazards. Minimizing disruption to these networks should form part of a strategy to increase urban resilience. A framework for assessing the disruption from flood events to transport systems is presented that couples a high-resolution urban flood model with transport modelling and network analytics to assess the impacts of extreme rainfall events, and to quantify the resilience value of different adaptation options. A case study in Newcastle upon Tyne in the UK shows that both green roof infrastructure and traditional engineering interventions such as culverts or flood walls can reduce transport disruption from flooding. The magnitude of these benefits depends on the flood event and adaptation strategy, but for the scenarios considered here 3–22% improvements in city-wide travel times are achieved. The network metric of betweenness centrality, weighted by travel time, is shown to provide a rapid approach to identify and prioritize the most critical locations for flood risk management intervention. Protecting just the top ranked critical location from flooding provides an 11% reduction in person delays. A city-wide deployment of green roofs achieves a 26% reduction, and although key routes still flood, the benefits of this strategy are more evenly distributed across the transport network as flood depths are reduced across the model domain. Both options should form part of an urban flood risk management strategy, but this method can be used to optimize investment and target limited resources at critical locations, enabling green infrastructure strategies to be gradually implemented over the longer term to provide city-wide benefits. This framework provides a means of prioritizing limited financial resources to improve resilience. This is particularly important as flood management investments must typically exceed a far higher benefit–cost threshold than transport infrastructure investments. By capturing the value to the transport network from flood management interventions, it is possible to create new business models that provide benefits to, and enhance the resilience of, both transport and flood risk management infrastructures. Further work will develop the framework to consider other hazards and infrastructure networks

Can goal-setting for patients with multimorbidity improve outcomes in primary care? Cluster randomised feasibility trial

Introduction: Goal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice. Objective: To assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial. Design and setting: Cluster-randomised controlled feasibility trial of goal-setting compared to control in six general practices. Participants: Adults with 2 or more long term health conditions and at risk of unplanned hospital admission. Interventions: General Practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation six months later. The control group received usual care planning. Outcome measures: Health-related quality of life (EQ5D5L), capability (ICEpop CAPability measure for Older people (ICECAP-O)), patient assessment of chronic illness care (PACIC) and health care use. All consultations were video or audio-recorded, and focus groups were held with participating GPs and patients. Results: Fifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years 54% were female and the median number of prescribed medications was 13, compared to 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 minutes in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting, felt it delivered more patient-centred care and highlighted the importance of training. Conclusions: This goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness

LAYERS: a decision-support tool to illustrate and assess the supply and value chain for the energy transition

Climate change mitigation strategies are developed at international, national, and local authority levels. Technological solutions such as renewable energies (RE) and electric vehicles (EV) have geographically widespread knock-on effects on raw materials. In this paper, a decision-support and data-visualization tool named “LAYERS” is presented, which applies a material flow analysis to illustrate the complex connections along supply chains for carbon technologies. A case study focuses on cobalt for lithium-ion batteries (LIB) required for EVs. It relates real business data from mining and manufacturing to actual EV registrations in the UK to visualize the intended and unintended consequences of the demand for cobalt. LAYERS integrates a geographic information systems (GIS) architecture, database scheme, and whole series of stored procedures and functions. By means of a 3D visualization based on GIS, LAYERS conveys a clear understanding of the location of raw materials (from reserves, to mining, refining, manufacturing, and use) across the globe. This highlights to decision makers the often hidden but far-reaching geo-political implications of the growing demands for a range of raw materials that are needed to meet long-term carbon-reduction targets

Invasive versus medical management in patients with prior coronary artery bypass surgery with a non-ST segment elevation acute coronary syndrome: a pilot randomized controlled trial

Background: The benefits of routine invasive management in patients with prior coronary artery bypass grafts presenting with non-ST elevation acute coronary syndromes are uncertain because these patients were excluded from pivotal trials. Methods: In a multicenter trial, non-ST elevation acute coronary syndromes patients with prior coronary artery bypass graft were prospectively screened in 4 acute hospitals. Medically stabilized patients were randomized to invasive management (invasive group) or noninvasive management (medical group). The primary outcome was adherence with the randomized strategy by 30 days. A blinded, independent Clinical Event Committee adjudicated predefined composite outcomes for efficacy (all-cause mortality, rehospitalization for refractory ischemia/angina, myocardial infarction, hospitalization because of heart failure) and safety (major bleeding, stroke, procedure-related myocardial infarction, and worsening renal function). Results: Two hundred seventeen patients were screened and 60 (mean±SD age, 71±9 years, 72% male) were randomized (invasive group, n=31; medical group, n=29). One-third (n=10) of the participants in the invasive group initially received percutaneous coronary intervention. In the medical group, 1 participant crossed over to invasive management on day 30 but percutaneous coronary intervention was not performed. During 2-years’ follow-up (median [interquartile range], 744 [570–853] days), the composite outcome for efficacy occurred in 13 (42%) subjects in the invasive group and 13 (45%) subjects in the medical group. The composite safety outcome occurred in 8 (26%) subjects in the invasive group and 9 (31%) subjects in the medical group. An efficacy or safety outcome occurred in 17 (55%) subjects in the invasive group and 16 (55%) subjects in the medical group. Health status (EuroQol 5 Dimensions) and angina class in each group were similar at 12 months. Conclusions: More than half of the population experienced a serious adverse event. An initial noninvasive management strategy is feasible. A substantive health outcomes trial of invasive versus noninvasive management in non-ST elevation acute coronary syndromes patients with prior coronary artery bypass grafts appears warranted. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01895751

Baseline characteristics, analysis plan and report on feasibility for the Prevention Of Decline in Cognition After Stroke Trial (PODCAST).

BACKGROUND: A common complication after stroke is development of cognitive impairment and dementia. However, effective strategies for reducing the risk of developing these problems remain undefined. Potential strategies include intensive lowering of blood pressure (BP) and/or lipids. This paper summarises the baseline characteristics, statistical analysis plan and feasibility of a randomised control trial of blood pressure and lipid lowering in patients post-stroke with the primary objective of reducing cognitive impairment and dementia. METHODS: The Prevention Of Decline in Cognition After Stroke Trial (PODCAST) was a multi-centre prospective randomised open-label blinded-endpoint controlled partial-factorial internal pilot trial running in secondary and primary care. Participants without dementia were enrolled 3-7 months post ischaemic stroke or spontaneous intracerebral haemorrhage, and randomised to intensive versus guideline BP lowering (target systolic BP <125 mmHg versus <140 mmHg); patients with ischaemic stroke were also randomised to intensive or guideline lipid lowering (target LDL cholesterol <1.4 mmol/L versus <3 mmol/L). The primary outcome was the Addenbrooke's Cognitive Examination-Revised; a key secondary outcome was to assess feasibility of performing a large trial of one or both interventions. Data are number (%) or mean (standard deviation). The trial was planned to last for 8 years with follow-up between 1 and 8 years. The plan for reporting the main results is included as Additional file 2. RESULTS: 83 patients (of a planned 600) were recruited from 19 UK sites between 7 October 2010 and 31 January 2014. Delays, due to difficulties in the provision of excess treatment costs and to complexity of follow-up, led to few centres taking part and a much lower recruitment rate than planned. Patient characteristics at baseline were: age 74 (SD 7) years, male 64 (77 %), index stroke ischaemic 77 (93 %), stroke onset to randomisation 4.5 [SD 1.3] months, Addenbrooke's Cognitive Examination-Revised 86 (of 100, SD 8), Montreal Cognitive Assessment 24 (of 30, SD 3), BP 147/82 (SD 19/11) mmHg, total cholesterol 4.0 (SD 0.8) mmol/L and LDL cholesterol 2.0 (SD 0.7) mmol/L, modified Rankin Scale 1.1 (SD 0.8). CONCLUSION: Limited recruitment suggests that a large trial is not feasible using the current protocol. The effects of the interventions on BP, lipids, and cognition will be reported in the main publication. TRIAL REGISTRATION: ISRCTN85562386 registered on 23 September 2009