Characterising non-urgent users of the emergency department (ED): A retrospective analysis of routine ED data

Background The pressures of patient demand on emergency departments (EDs) continue to be reported worldwide, with an associated negative impact on ED crowding and waiting times. It has also been reported that a proportion of attendances to EDs in different international systems could be managed in settings such as primary care. This study used routine ED data to define, measure and profile non-urgent ED attendances that were suitable for management in alternative, non-emergency settings. Methods We undertook a retrospective analysis of three years of Hospital Episode and Statistics Accident Emergency (HES A&E) data for one large region in England, United Kingdom (April 1st 2011 to March 31st 2014). Data was collected on all adult (>16 years) ED attendances from each of the 19 EDs in the region. A validated process based definition of nonurgent attendance was refined for this study and applied to the data. Using summary statistics non-urgent attenders were examined by variables hypothesised to influence them as follows: age at arrival, time of day and day of week and mode of arrival. Odds ratios were calculated to compare non-urgent attenders between groups. Results There were 3,667,601 first time attendances to EDs, of which 554,564 were defined as nonurgent (15.1%). Non-urgent attendances were significantly more likely to present out of hours than in hours (OR = 1.19, 95% CI: 1.18 to 1.20, P<0.001). The odds of a non-urgent attendance were significantly higher for younger patients (aged 16–44) compared to those aged 45–64 (odds ratio: 1.42, 95% CI: 1.41 to 1.43, P<0.001) and the over 65’s (odds ratio: 3.81, 95% CI: 3.78 to 3.85, P<0.001). Younger patients were significantly more likely to attend non-urgently out of hours compared to the 45–64’s (OR = 1.24, 95% CI: 1.22 to 1.25, P<0.001) and the 65+’s (OR = 1.38, 95% CI: 1.35 to 1.40, P<0.001). 110,605/554,564 (19.9%) of the non-urgent attendances arrived by ambulance, increasing significantly out of hours versus in hours (OR = 2.12, 95% CI: 2.09 to 2.15, P<0.001). Conclusions Younger adults are significantly more likely as older counterparts to use the ED to obtain healthcare that could be provided in a less urgent setting and also more likely to do this out of hours. Alternative services are required to manage non-urgent demand, currently being borne by the ED and the ambulance service, particularly in out of hours

Inconsistent evidence: Analysis of six national guidelines for vaginal birth after cesarean section

Background: Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice. Methods: English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made. Results: Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent. Conclusions: VBAC guidelines are characterized by quasi-experimental evidence and consensus-based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice. © 2010, Copyright the Authors. © 2010, Wiley Periodicals, Inc

A re-examination of the anatomy and systematics of the tomistomine crocodylians from the Miocene of Italy and Malta

Once a much more globally widespread crocodylian clade, Tomistominae is today represented by just one species, Tomistoma schlegelii (the false gharial), restricted to south-east Asia. Although tomistomine fossil occurrences are recognized from the early Eocene (∼55 Ma) onwards, their remains are often incomplete, making appropriate taxonomic classification within the group problematic. This is especially pertinent to several taxa from the Miocene of Europe, which were historically erected from fragmentary remains. Here we re-examine and describe four approximately contemporaneous taxa from Malta and Italy to determine their taxonomy and phylogenetic affinities: Melitosaurus champsoides, Tomistoma calaritanum, Tomistoma gaudense and Tomistoma lyceense. We place them into a phylogenetic analysis for the first time, comprising 70 taxa scored for 244 characters, several of which are revised or novel, and apply a number of character weighting strategies. Whereas ‘Tomistoma lyceense’ is deemed to be an indeterminate tomistomine, a unique combination of features confirms Melitosaurus champsoides, Tomistoma calaritanum and Tomistoma gaudense as three distinct species. These three taxa are recovered as derived tomistomines, with characters such as a posterior maxillary process between the lacrimal and nasal, large supratemporal fenestrae that are wider than long, and the posteromedial alignment of the last three premaxillary teeth, suggesting a close relationship with the approximately contemporaneous European taxa, Tomistoma lusitanica and Gavialosuchus eggenburgensis. It is unlikely that any of these species belong to Tomistoma, with the possibility that they can all be classified under Melitosaurus and Gavialosuchus. However, we retain them in open nomenclature pending reassessment of the remaining European Miocene tomistomines. Our taxonomic and phylogenetic revision helps to elucidate past tomistomine diversity in the Miocene of the Mediterranean region, prior to the group’s extirpation, and is an important first step in resolving the complicated history of European tomistomine systematics

The identification of a novel, high frequency variant in the Cytochrome b gene in an isolated population of a rare fish, Spined Loach Cobitis taenia, in England: A population worth protecting?

The spined loach Cobitis taenia, is listed as a protected species under Appendix 3 of the Bern Convention and Annex II of the European Council Directive (92/43/EEC) on the conservation of natural habitats and of wild fauna and flora. It is desirable therefore to understand the genetic diversity within European populations. In a molecular genetic analysis of the cytochrome b gene in Cobitis taenia from three sites in the upper reaches of the River Trent catchment, a novel high frequency variant was identified which has not been previously reported in any European or Non-European population

Effectiveness and safety of chest pain assessment to prevent emergency admissions: ESCAPE cluster randomised trial

Abstract Objective To determine whether introducing chest pain unit care reduces emergency admissions without increasing reattendances and admissions over the next 30 days. Design Cluster randomised before and after intervention trial. Setting 14 diverse acute hospitals in the United Kingdom. Participants Patients attending the emergency department with acute chest pain during the year before and the year after the intervention started. Intervention Establishment of chest pain unit care compared with continuation of routine care. Main outcome measures Proportion of chest pain attendances resulting in admission; reattendances and admissions over the next 30 days; daily emergency medical admissions (all causes); and proportion of emergency department attendances with chest pain. Results The introduction of chest pain unit care was associated with weak evidence of an increase in emergency department attendances with chest pain (16% v 3.5%; P=0.08); no change in the proportion of chest pain attendances resulting in admission (odds ratio 0.998, 95% confidence interval 0.940 to 1.059; P=0.945); small increases in the proportion reattending (odds ratio 1.10, 1.00 to 1.21; P=0.036) or being admitted (1.30, 0.97 to 1.74; P=0.083) over the next 30 days; and evidence of increased daily medical admissions (1.7 per day, 95% confidence interval 0.8 to 2.5; P<0.001). However, this last finding was highly sensitive to changes in the method used to handle missing data. Conclusion The introduction of chest pain unit care did not reduce the proportion of patients with chest pain admitted and may have been associated with increased emergency department attendances with chest pain. Trial registration Current Controlled Trials ISRCTN5531841

Outcomes of breech birth by mode of delivery: a population linkage study

Background: Trial evidence supports a policy of caesarean section for singleton breech presentations at term but vaginal breech birth is considered a safe option for selected women. Aims: To provide recent Australian data on outcomes associated with intended mode of delivery for term breech singletons in women who meet conservative eligibility criteria for vaginal breech birth. Materials and Methods: Birth and hospital records from 2009 to 2012 in New South Wales were used to identify women with non-anomalous pregnancies who would be considered eligible for vaginal breech birth. Intended mode of delivery was inferred from labour onset and management. Results: Of 10,133 women with term breech singleton pregnancies, 5,197 (51.3%) were classified as eligible for vaginal breech delivery. Of these, 6.8% intended vaginal breech birth, 76.4% planned caesarean section, and intention could not be determined for 16.8%. Women intending vaginal delivery had higher rates of neonatal morbidity (6.0% vs. 2.1%), neonatal birth trauma (7.4% vs. 0.9%), Apgar <4 at 1 minute (10.5% vs. 1.1%), Apgar<7 at 5 minutes (4.3% vs. 0.5%), and NICU/SCN admissions (16.2% vs. 6.6%) than those planning caesarean section. Increased perinatal risks remained after adjustment for maternal characteristics. Severe maternal morbidity (1.4% vs. 0.7%) and postpartum readmission (4.6% vs. 4.0%) were higher in the intended vaginal compared to planned caesarean births but these differences were not statistically significant. Conclusions: In a population of women classified as being eligible for vaginal breech birth, intended vaginal delivery was associated with higher rates of neonatal morbidity than planned caesarean section.NHMRC, AR

Reporting issues in group sequential randomised controlled trials: a systematic review protocol of published journal reports

Background: Adaptive designs are somewhat underused, despite prominence given to methodology in the statistical literature. Some concerns relates to robustness of adaptive designs in decision making, acceptability of trial findings to change practice, anxiety about early stopping of trials and worry about wrong decision making. These issues could be linked to inadequate reporting of the conduct of such clinical trials. We assess the reporting of group sequential randomised controlled trials (RCTs), which are one of the most well-understood adaptive designs in the confirmatory setting. Methods: We undertake a systematic review searching Ovid MEDLINE from 1st January 2001 to 23rd September 2014 and including parallel group confirmatory group sequential RCTs that were prospectively designed using the Frequentist approach. Eligible trials are screened for completeness in reporting against the CONSORT 2010 checklist with some proposed modifications to capture issues such as statistical bias correction following early stopping. Descriptive statistics aided with forest plots on CONSORT compliance are presented. Discussion: Reporting of the conduct of adaptive designs is an area which has not been fully explored. Hence, the findings from this study can enlighten us on the adequacy in reporting of well-understood group sequential RCTs as a class of adaptive designs and on ways to address some of the cited concerns. Most importantly, the study can inform policy makers on the adequacy of the current CONSORT statements in enhancing reporting of such adaptive designs

Contribution of Changing Risk Factors to the Trend in Breech Presentation at Term

Background: Recent population-wide changes in perinatal risk factors may affect rates of breech presentation at birth, and have implications for the provision of breech services and clinical training in breech management. Aims: To determine the trend in breech presentation at term and investigate whether changes in maternal and pregnancy characteristics explain the observed trend. Materials and Methods: All singleton term (≥37 week) births in New South Wales during 2002 – 2012 were identified through birth and associated hospital records. Annual rates of breech presentation were determined. Logistic regression modelling was used to predict expected rates of breech presentation over time and these were compared with observed rates. A priori predictors included maternal age, country of birth, parity, smoking during pregnancy, diabetes, pregnancy hypertension, placenta praevia, previous singleton term breech, previous caesarean section, infant sex, gestational age, birthweight, and congenital anomalies. Hospital and Medicare data were used to assess trends in external cephalic version. Results: Among 914,147 singleton term births, 3.1% were breech at delivery. Rates declined from 3.6% in 2002 to 2.7% in 2012 (test for trend p<0.001). Breech presentation was predicted to increase from 3.6% in 2002 to 4.3% in 2012 because of increased maternal age, nulliparity, maternal diabetes, history of breech presentation and previous caesarean section. Use of external cephalic version appears to have increased over time. Conclusions: Breech presentation at delivery has decreased in New South Wales. Increased use of external cephalic version likely accounts for this decline, as changes in risk factors do not.NHMRC, AR