Improving access to psychological therapies : a review of the progress made by sites in the first rollout year

Improving Access to Psychological Therapies (IAPT) is a programme designed to make psychological therapies for common mental health problems widely available. Following pilot work in Doncaster and Newham, the first wave of roll‐out sites started operation in 2008. We report a study of their work in the year from October 2008 to September 2009. Allowing for varying start times, this was roughly their first full year of operation

Acute kidney injury and post-reperfusion syndrome in liver transplantation

In the past decades liver transplantation (LT) has become the treatment of choice for patients with end stage liver disease (ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death (DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease (CKD). Acute kidney injury (AKI) post-LT has been recently recognized as an important risk factor for the occurrence of de novo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome (PRS) that can influence recipient’s morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since pre-LT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A PubMed search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on PubMed search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRS-induced AKI, avoiding confounding factors, we have limited our study to “acute kidney injury AND DCD AND liver transplantation”. Accordingly, three out of five studies were selected for our purpose

Variability and performance of NHS England's 'reason to reside' criteria in predicting hospital discharge in acute hospitals in England:a retrospective, observational cohort study

OBJECTIVES: NHS England (NHSE) advocates ‘reason to reside’ (R2R) criteria to support discharge planning. The proportion of patients without R2R and their rate of discharge are reported daily by acute hospitals in England. R2R has no interoperable standardised data model (SDM), and its performance has not been validated. We aimed to understand the degree of intercentre and intracentre variation in R2R-related metrics reported to NHSE, define an SDM implemented within a single centre Electronic Health Record to generate an electronic R2R (eR2R) and evaluate its performance in predicting subsequent discharge. DESIGN: Retrospective observational cohort study using routinely collected health data. SETTING: 122 NHS Trusts in England for national reporting and an acute hospital in England for local reporting. PARTICIPANTS: 6 602 706 patient-days were analysed using 3-month national data and 1 039 592 patient-days, using 3-year single centre data. MAIN OUTCOME MEASURES: Variability in R2R-related metrics reported to NHSE. Performance of eR2R in predicting discharge within 24 hours. RESULTS: There were high levels of intracentre and intercentre variability in R2R-related metrics (p<0.0001) but not in eR2R. Informedness of eR2R for discharge within 24 hours was low (J-statistic 0.09–0.12 across three consecutive years). In those remaining in hospital without eR2R, 61.2% met eR2R criteria on subsequent days (76% within 24 hours), most commonly due to increased NEWS2 (21.9%) or intravenous therapy administration (32.8%). CONCLUSIONS: Reported R2R metrics are highly variable between and within acute Trusts in England. Although case-mix or community care provision may account for some variability, the absence of a SDM prevents standardised reporting. Following the development of a SDM in one acute Trust, the variability reduced. However, the performance of eR2R was poor, prone to change even when negative and unable to meaningfully contribute to discharge planning

Major adverse cardiovascular events and all-cause mortality after emergency general surgery among kidney failure patients

BACKGROUND: Emergency general surgery (EGS) is associated with increased mortality, with kidney failure a contributing risk, but comparative outcomes between patients with kidney failure and the general population are lacking.METHODS: In this retrospective population-cohort study, data were analysed for all EGS procedures performed in England between 1 April 2004 and 31 March 2019. EGS was defined as partial colectomy, small bowel resection, cholecystectomy, appendicectomy, lysis of peritoneal adhesions, surgery for peptic ulcer, or laparotomy. The main outcome measure was major adverse cardiovascular events (MACEs) and all-cause mortality after surgery.RESULTS: From 691 064 procedures, 0.16 per cent (n = 1097) and 0.23 per cent (n = 1567) were performed on kidney transplant and dialysis recipients respectively. Laparotomy was the most frequent EGS procedure for kidney transplant (46 per cent of procedures, n = 507) and dialysis (45 per cent of procedures, n = 704) recipients, with the highest 30-day and 1-year mortality. In logistic regression analysis, both kidney failure cohorts had higher risk for experiencing MACEs in the postoperative interval after emergency laparotomy; within 3 months (dialysis; OR 2.44 (95 per cent c.i. 2.08 to 2.87), P &amp;lt; 0.001 and transplant; OR 2.05 (95 per cent c.i. 1.57 to 2.68), P &amp;lt; 0.001) and within 1 year (dialysis; OR 2.39 (95 per cent c.i. 2.06 to 2.77), P &amp;lt; 0.001 and transplant; OR 2.21 (95 per cent c.i. 1.76 to 2.77), P &amp;lt; 0.001); however, in a propensity-score-matched cohort, increased risk for MACEs was observed among dialysis patients after emergency laparotomy (HR 2.10 (95 per cent c.i. 1.82 to 2.43), P &amp;lt; 0.001) but not kidney transplant recipients (HR 1.17 (95 per cent c.i. 0.97 to 1.41), P = 0.096).CONCLUSION: Mortality after emergency surgery is higher for patients with kidney failure and dialysis is worse than kidney transplantation, with cardiovascular deaths more common than the general population.</p

Major adverse cardiovascular events and all-cause mortality after emergency general surgery among kidney failure patients

BACKGROUND: Emergency general surgery (EGS) is associated with increased mortality, with kidney failure a contributing risk, but comparative outcomes between patients with kidney failure and the general population are lacking.METHODS: In this retrospective population-cohort study, data were analysed for all EGS procedures performed in England between 1 April 2004 and 31 March 2019. EGS was defined as partial colectomy, small bowel resection, cholecystectomy, appendicectomy, lysis of peritoneal adhesions, surgery for peptic ulcer, or laparotomy. The main outcome measure was major adverse cardiovascular events (MACEs) and all-cause mortality after surgery.RESULTS: From 691 064 procedures, 0.16 per cent (n = 1097) and 0.23 per cent (n = 1567) were performed on kidney transplant and dialysis recipients respectively. Laparotomy was the most frequent EGS procedure for kidney transplant (46 per cent of procedures, n = 507) and dialysis (45 per cent of procedures, n = 704) recipients, with the highest 30-day and 1-year mortality. In logistic regression analysis, both kidney failure cohorts had higher risk for experiencing MACEs in the postoperative interval after emergency laparotomy; within 3 months (dialysis; OR 2.44 (95 per cent c.i. 2.08 to 2.87), P &amp;lt; 0.001 and transplant; OR 2.05 (95 per cent c.i. 1.57 to 2.68), P &amp;lt; 0.001) and within 1 year (dialysis; OR 2.39 (95 per cent c.i. 2.06 to 2.77), P &amp;lt; 0.001 and transplant; OR 2.21 (95 per cent c.i. 1.76 to 2.77), P &amp;lt; 0.001); however, in a propensity-score-matched cohort, increased risk for MACEs was observed among dialysis patients after emergency laparotomy (HR 2.10 (95 per cent c.i. 1.82 to 2.43), P &amp;lt; 0.001) but not kidney transplant recipients (HR 1.17 (95 per cent c.i. 0.97 to 1.41), P = 0.096).CONCLUSION: Mortality after emergency surgery is higher for patients with kidney failure and dialysis is worse than kidney transplantation, with cardiovascular deaths more common than the general population.</p

Clinical outcomes and costs of cardiac revascularisation in England and New York State

Objectives: Healthcare expenditure per-capita in the USA is higher than in England. We hypothesised that clinical outcomes after cardiac revascularisation are better in the USA. We compared costs and outcomes of patients undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in England and New York State (NYS). Methods: Costs and total mortality were assessed using the Hospital Episode Statistics for England and the Statewide Planning and Research Cooperative System for NYS. Outcomes after a first CABG or PCI were assessed in patients undergoing a first CABG (n=142 969) or PCI (n=431 416). Results: After CABG, crude total mortality in England was 0.72% lower at 30 days and 3.68% lower at 1 year (both P<0.001). After PCI, crude total mortality was 0.35% lower at 30 days and 3.55% lower at 1 year (both P<0.001). No differences emerged in total mortality at 30 days after either CABG (England: HR 1.02,95% CI 0.94 to 1.10) or PCI (HR 1.04, 95% CI 0.99 to 1.09) after covariate adjustment. At 1 year, adjusted total mortality was lower in England after both CABG (HR 0.74, 95% CI 0.71 to 0.78) and PCI (HR 0.66, 95% CI 0.65 to 0.68). After adjustment for cost-to-charge ratios and purchasing power parities, costs in NYS amounted to uplifts of 3.8-fold for CABG and 3.6-fold for PCI. Conclusions: Total mortality after CABG and PCI was similar at 30 days and lower in England at 1 year. Costs were approximately fourfold higher in NYS

Fractures in kidney transplant recipients : a comparative study between England and New York State

Objectives: Fractures are associated with high morbidity and are a major concern to kidney transplant recipients. There has not been any comparative analysis conducted between countries in the contemporary era to inform future international prevention trials. Materials and Methods: Data were obtained from the Hospital Episode Statistics and the Statewide Planning and Research Cooperative databases on all adult kidney transplants performed in England and New York State respectively (2003-2013) and on post-transplant fracture-related hospitalization (2003-2014). Results: In total, 18,493 English and 11,602 New York State kidney transplant recipients were included. Overall, 637 (3.4%) English and 398 (3.4%) New York State recipients sustained a fracture giving an unadjusted event rate of 7.0 and 5.9 per 1000 years respectively (P=0.948). A total of 147 (0.8%) English and 101 (0.9%) New York State recipients sustained a hip fracture, giving an unadjusted event rate of 1.6 and 1.5 per 1000 years respectively (P=0.480). There were no differences in the cumulative incidence of all fractures or hip fractures. One-year mortality after any fracture (9% and 11%) or after a hip fracture (15% and 17%) was not different between cohorts. Conclusions: Contemporaneous English and New York State kidney transplant recipients have very similar fracture rates and mortality post-fracture

Sex‐Specific Differences in Survival and Heart Failure Hospitalization After Cardiac Resynchronization Therapy With or Without Defibrillation

Background Women are underrepresented in cardiac resynchronization therapy (CRT) trials. Some studies suggest that women fare better than men after CRT. We sought to explore clinical outcomes in women and men undergoing CRT-defibrillation or CRT-pacing in real-world clinical practice. Methods and Results A national database (Hospital Episode Statistics for England) was used to quantify clinical outcomes in 43 730 patients (women: 10 890 [24.9%]; men: 32 840 [75.1%]) undergoing CRT over 7.6 years, (median follow-up 2.2 years, interquartile range, 1-4 years). In analysis of the total population, the primary end point of total mortality (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.69-0.76) and the secondary end point of total mortality or heart failure hospitalization (aHR, 0.79, 95% CI 0.75-0.82) were lower in women, independent of known confounders. Total mortality (aHR, 0.73; 95% CI, 0.70-0.76) and total mortality or heart failure hospitalization (aHR, 0.79; 95% CI, 0.75-0.82) were lower for CRT-defibrillation than for CRT-pacing. In analyses of patients with (aHR, 0.89; 95% CI, 0.80-0.98) or without (aHR, 0.70; 95% CI, 0.66-0.73) a myocardial infarction, women had a lower total mortality. In sex-specific analyses, total mortality was lower after CRT-defibrillation in women (aHR, 0.83; P=0.013) and men (aHR, 0.69; P<0.001). Conclusions Compared with men, women lived longer and were less likely to be hospitalized for heart failure after CRT. In both sexes, CRT-defibrillation was superior to CRT-pacing with respect to survival and heart failure hospitalization. The longest survival after CRT was observed in women without a history of myocardial infarction

Predictors and Significance of Readmission after Esophagogastric Surgery:A Nationwide Analysis

Objective: The aim of this study is to identify risk factors for readmission after elective esophagogastric cancer surgery and characterize the impact of readmission on long-term survival. The study will also identify whether the location of readmission to either the hospital that performed the primary surgery (index hospital) or another institution (nonindex hospital) has an impact on postoperative mortality.Background: Over the past decade, the center-volume relationship has driven the centralization of major cancer surgery, which has led to improvements in perioperative mortality. However, the impact of readmission, especially to nonindex centers, on long-term mortality remains unclear.Methods: This was a national population-based cohort study using Hospital Episode Statistics of adult patients undergoing esophagectomy and gastrectomy in England between January 2008 and December 2019.Results: This study included 27,592 patients, of which overall readmission rates were 25.1% (index 15.3% and nonindex 9.8%). The primary cause of readmission to an index hospital was surgical in 45.2% and 23.7% in nonindex readmissions. Patients with no readmissions had significantly longer survival than those with readmissions (median: 4.5 vs 3.8 years; P &lt; 0.001). Patients readmitted to their index hospital had significantly improved survival as compared to nonindex readmissions (median: 3.3 vs 4.7 years; P &lt; 0.001). Minimally invasive surgery and surgery performed in high-volume centers had improved 90-day mortality (odds ratio, 0.75; P &lt; 0.001; odds ratio, 0.60; P &lt; 0.001).Conclusion: Patients requiring readmission to the hospital after surgery have an increased risk of mortality, which is worsened by readmission to a nonindex institution. Patients requiring readmission to the hospital should be assessed and admitted, if required, to their index institution.<br/