Tonsillectomy among children with low baseline acute throat infection consultation rates in UK general practices: a cohort study.

OBJECTIVE: To investigate the effectiveness of tonsillectomy in reducing acute throat infection (ATI) consultation rates over 6 years' follow-up among children with low baseline ATI consultation rates. DESIGN: Retrospective cohort study. SETTING: UK general practices from the Clinical Practice Research Datalink. PARTICIPANTS: Children aged 4-15 years with ≤3 ATI consultations during the 3 years prior to 2001 (baseline). 450 children who underwent tonsillectomy (tonsillectomy group) and 13 442 other children with an ATI consultation (comparison group) in 2001. MAIN OUTCOME MEASURES: Mean differences in ATI consultation rates over the first 3 years' and subsequent 3 years' follow-up compared with 3 years prior to 2001 (baseline); odds of ≥3 ATI consultations at the same time points. RESULTS: Among children in the tonsillectomy group, the 3-year mean ATI consultation rate decreased from 1.31 to 0.66 over the first 3 years' follow-up and further declined to 0.60 over the subsequent 3 years' follow-up period. Compared with children who had no operation, those who underwent tonsillectomy experienced a reduction in 3-year mean ATI consultations per child of 2.5 (95% CI 2.3 to 2.6, p<0.001) over the first 3 years' follow-up, but only 1.2 (95% CI 1.0 to 1.4, p<0.001) over the subsequent 3 years' follow-up compared with baseline, respectively. This equates to a mean reduction of 3.7 ATI consultations over a 6-year period and approximates to a mean annual reduction of 0.6 ATI consultations per child, per year, over 6 years' follow-up. Children who underwent tonsillectomy were also much less likely to experience ≥3 ATI consultations during the first 3 years' follow-up (adjusted OR=0.12, 95% CI 0.08 to 0.17) and the subsequent 3 years' follow-up (adjusted OR=0.24, 95% CI 0.14 to 0.41). CONCLUSIONS: Among children with low baseline ATI rates, there was a statistically significant reduction in ATI consultation rates over 6 years' follow-up. However, the relatively modest clinical benefit needs to be weighed against the potential risks and complications associated with surgery

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data

BACKGROUND: The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. OBJECTIVE: To determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department. METHODS: Retrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. RESULTS: The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. CONCLUSIONS: Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear

Multi-morbidity in hospitalised older patients: who are the complex elderly?

BACKGROUND:No formal definition for the "complex elderly" exists; moreover, these older patients with high levels of multi-morbidity are not readily identified as such at point of hospitalisation, thus missing a valuable opportunity to manage the older patient appropriately within the hospital setting. OBJECTIVES:To empirically identify the complex elderly patient based on degree of multi-morbidity. DESIGN:Retrospective observational study using administrative data. SETTING:English hospitals during the financial year 2012-13. SUBJECTS:All admitted patients aged 65 years and over. METHODS:By using exploratory analysis (correspondence analysis) we identify multi-morbidity groups based on 20 target conditions whose hospital prevalence was ≥ 1%. RESULTS:We examined a total of 2788900 hospital admissions. Multi-morbidity was highly prevalent, 62.8% had 2 or more of the targeted conditions while 4.7% had six or more. Multi-morbidity increased with age from 56% (65-69yr age-groups) up to 67% (80-84yr age-group). The average multi-morbidity was 3.2±1.2 (SD). Correspondence analysis revealed 3 distinct groups of older patients. Group 1 (multi-morbidity ≤2), associated with cancer and/or metastasis; Group 2 (multi-morbidity of 3, 4 or 5), associated with chronic pulmonary disease, lung disease, rheumatism and osteoporosis; finally Group 3 with the highest level of multi-morbidity (≥6) and associated with heart failure, cerebrovascular accident, diabetes, hypertension and myocardial infarction. CONCLUSIONS:By using widely available hospital administrative data, we propose patients in Groups 2 and 3 to be identified as the complex elderly. Identification of multi-morbidity patterns can help to predict the needs of the older patient and improve resource provision

A novel profluorescent dinitroxide for imaging polypropylene degradation

Free-radical processes underpin the thermo-oxidative degradation of polyolefins. Thus, to extend the lifetime of these polymers, stabilizers are generally added during processing to scavenge the free radicals formed as the polymer degrades. Nitroxide radical precursors, such as hindered amine stabilizers (HAS),1,2 are common polypropylene additives as the nitroxide moiety is a potent scavenger of polymer alkyl radicals (R¥). Oxidation of HAS by radicals formed during polypropylene degradation yields nitroxide radicals (RRNO¥), which rapidly trap the polymer degradation species to produce alkoxyamines, thus retarding oxidative polymer degradation. This increase in polymer stability is demonstrated by a lengthening of the “induction period” of the polymer (the time prior to a sharp rise in the oxidation of the polymer). Instrumental techniques such as chemiluminescence or infrared spectroscopy are somewhat limited in detecting changes in the polymer during the initial stages of degradation. Therefore, other methods for observing polymer degradation have been sought as the useful life of a polymer does not extend far beyond its “induction period

Predictors of 30-day readmission after total knee arthroplasty: analysis of 566,323 procedures in the United Kingdom

BACKGROUND: All-cause 30-day readmission after total knee arthroplasty (TKA) is currently used as a measure of hospital performance in the United States and elsewhere. Readmissions from surgical causes may more accurately reflect preventability and costs. However, little is known about whether predictors of each type of readmission differ. METHODS: All primary TKAs recorded in England's National Health Service administrative database from 2006 to 2015 were included. Multilevel logistic regression analysis was used to describe the effects of patient-related factors on 30-day readmission risk using 3 different readmission metrics: all-cause, surgical (defined using International Classification of Disease-10 primary admission diagnoses), and those resulting in return to theater (RTT). RESULTS: In total, 566,323 procedures were recorded. The comorbidity with the highest odds ratio (OR) for all types of readmission was psychoses (RTT OR 2.52, P 2 emergency admissions, all-cause OR 2.38, P < .001). Length of stay either more than or less than 2 days was associated with an increased risk of all-cause and surgical readmission but not RTT readmission. CONCLUSION: Patient-related predictors of surgical and RTT readmission following TKA differ from those for all-cause readmission, but only the latter metric is in widespread use

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

Long-term trends of use of health service among heart failure patients

Aims: We aimed to identify subgroups in the patient population with different trajectories of long-term readmission rates. The study also aimed to assess common causes and their sequences of readmissions for each subgroup. 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, which contain information on 10.5 million patients. HF patients were followed up for 5 years. Group-based trajectory models and sequence analysis were applied. Results: The model categorised the HF population (n = 9466) into 5 subgroups: low-impact (66.9%); two intermediate ones (27.4%); chronic high-impact (2.3%) with steady high annual readmission rates; and short-term high-impact (3.4%) with rapid decline in readmission rates. The groups were defined by their trends of yearly number of readmissions. The all-cause 5-year mortality was highest in the short-term high-impact group (n = 185, 72.8%), followed by group 2 (intermediate users) (n = 744, 58.8%), low-impact (n = 4244, 56.9%), chronic high-impact (n = 88, 37.6%) and group 1 (intermediate users) (n = 401, 30.3%) (p < 0.01). Compared with low-impact users, high-impact users were associated with higher mortality, bereavement episodes, and more out-of-hours GP visits. The chronic high-impact users had distinct sequences of causes of emergency admissions most often consisting of chest infection, ischaemic heart disease, and cardio-pulmonary signs and/or symptoms. Conclusion: Chronic high-impact users constitute a small proportion of total patients, but they have increasingly high use of healthcare services. Short-term high-impact users represent largely end of life patients. They require prompt involvement of the palliative care team to reduce unnecessary readmissions to hospital

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