How should we measure ambulance service quality and performance?

The problem Ambulance services in England treat 6.5 million people per year but get no information about what happens to patients after discharge. This has led to a reliance on measuring response times rather than outcomes to assess how well services perform, and little opportunity for identifying problems and good practice or evaluating service developments. Research aim There is a lack of consensus on which outcome measures are important for pre-hospital care so we set out to address this within the Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) research programme. Methods We conducted a two round Delphi study to prioritise outcome measures identified from a systematic review and a multi-stakeholder consensus event. 20 participants scored 57 measures over two rounds. Participants included policy makers and commissioners, clinical ambulance service and ambulance service operational groups. Outcomes were scored in three categories: patient outcomes; whole service measures and clinical management. Results Highly ranked patient outcome measures related to pain, survival, recontacts and patient experience. High ranking outcomes in the Clinical Management group related to compliance with protocols and guidelines and appropriateness and accuracy of triage. In the Whole Service measures group highly ranked measures related to completeness of clinical records, staff training and time to definitive care. Conclusions The next steps are to identify which measures are suitable for measuring with routine data; use a linked dataset to build predictive models and determine what aspects of care can predict good or poor outcomes (mortality and non-mortality); measure the effectiveness and quality of ambulance service care, and; assess the practical use of the measures and the linked data as a way to support quality improvement in the NHS

Managing alcohol-related attendances in emergency care: can diversion to bespoke services lessen the burden?

Acute alcohol intoxication (AAI) has a long history of burdening emergency care services. Healthcare systems around the world have explored a variety of different services that divert AAI away from EDs to better manage their condition. Little formal evaluation has been undertaken, particularly in the UK where alcohol misuse is one of the highest in the world. In this article, we outline a brief history of diversionary services, introduce the concept of Alcohol Intoxication Management Services (AIMS) and describe examples of AIMS in the UK. We then describe Evaluating the Diversion of Alcohol-Related Attendances, a natural experiment including six cities with AIMS compared with six cities without, that involves an ethnographic study, records patient experiences in both AIMS and EDs, assesses impact on key performance indicators in healthcare and evaluates the cost-effectiveness of AIMS

How should we measure ambulance service quality and performance? Results from a Delphi study

Background and objectives The Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE) research programme aims to develop better ways of measuring the quality of ambulance service care. Ambulance service care is often measured by the speed of the ambulance response rather than the quality of care provided or patient outcomes. Whilst response times are relevant to a small proportion of seriously ill patients, they are not clinically relevant for most people who contact the ambulance service. We identified existing and aspirational ambulance service quality and performance measures from reviews of the literature and interviews with service users and prioritised these as part of a Delphi study. Methods We conducted a Delphi study to prioritise ambulance service quality and performance measures. 42 people were invited to take part and 29 agreed. Of the 29 participants, 20 provided data for 2 Delphi rounds. For each round, 67 measures were scored on a 1 – 9 scale. Participants included policy makers and commissioners, clinical ambulance service and ambulance service operational groups. Outcomes were included from three categories: patient outcomes; whole service measures and clinical management. Measures with a median group score of 7 or above were classified as high scoring measures. Results There was little score change between the two Delphi rounds and over half of the measures scored 7 or above (13/25 patient outcomes, 9/10 clinical management measures and 18/32 whole system measures scored 7 and above). High scoring patient outcome measures related to pain, survival, patient experience and re-contacts with emergency medical services. The highest scoring patient outcomes were: proportion of ambulance service calls referred for telephone advice who re-contact the ambulance service within 24 hours and proportion of patients given analgesia who report having pain. Low scoring measures related to re-contacts with non-EMS services, intubation and wound infection. Nearly all of the clinical management measures scored highly. These measures related to correct categorisation of urgency, patient safety and compliance with protocols and guidelines. The highest ranking measure was: proportion of life-threatening category A calls correctly identified as category A. The only high scoring time measures were time to definitive care and ambulance response time within 30 minutes. Other high scoring whole system measures were compliance with training and completion of patient records, whereas over triage and other time measures, for example, average time spent on scene or other response times scored <7. Conclusion Participants thought time to definitive care was more important than speed of response. Other important measures related to pain management, patient safety, re-contacts with EMS services and correct identification of call urgency. The public acceptability of the Delphi results will be discussed during a patient and public involvement (PPI) event, where PPI participants will have an opportunity to vote on and discuss the measures. Following this, a final shortlist of measures will be used to inform a predictive model to identify what aspects of care can predict good or poor outcomes (mortality and non-mortality) and we will use this to measure the effectiveness and quality of ambulance service car

Moving on from response rates: linking patient level ambulance data to ED, hospital and survival data to assess quality and performance

The problem The ambulance service has no information about what happens beyond the prehospital phase of care. This leads to process measures, e.g. response rates, being used as a proxy for quality of care. Research aim To develop better ways of measuring the quality and performance of ambulance service care. Methods Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) is a five year National Institute for Health Research (NIHR) programme to develop better ways of measuring the performance, quality and impact of ambulance service care by: identifying and prioritising ambulance related outcome measures; creating a new information source by linking together routinely collected data; using the linked dataset to build predictive models to assess what aspects of care can predict good or poor outcomes (mortality and non-mortality) and measure the effectiveness and quality of ambulance service care; assessing the practical use of the measures and the linked data as a way to support quality improvement in the NHS; in order to provide better information about effectiveness and quality of care. We developed a data linking methodology that was acceptable to patients and complied with information legislation. Data from two participating ambulance services were processed and linked to other routinely collected data through the NHS Health and Social Care Information Centre’s Trusted Data Linkage Service, which is a designated safe haven for health information. Conclusions It is possible to link ambulance service data to subsequent care information. The new database can be used to support audit and research and to measure the impact of any new changes and innovations in how ambulance services provide care, to ensure continued improvements for patients. Allied to this we used consensus methods to develop a set of outcome measures for measuring the quality and performance of ambulance service care, which will be tested within the linked dataset using predictive models

HLA-DQA1*05 carriage associated with development of anti-drug antibodies to infliximab and adalimumab in patients with Crohn's Disease

Anti-tumor necrosis factor (anti-TNF) therapies are the most widely used biologic drugs for treating immune-mediated diseases, but repeated administration can induce the formation of anti-drug antibodies. The ability to identify patients at increased risk for development of anti-drug antibodies would facilitate selection of therapy and use of preventative strategies.This article is freely available via Open Access. Click on Publisher URL to access the full-text

Thiopurine monotherapy is effective in ulcerative colitis but significantly less so in Crohn’s disease: long-term outcomes for 11 928 patients in the UK inflammatory bowel disease bioresource

Objective: Thiopurines are widely used as maintenance therapy in inflammatory bowel disease (IBD) but the evidence base for their use is sparse and their role increasingly questioned. Using the largest series reported to date, we assessed the long-term effectiveness of thiopurines in ulcerative colitis (UC) and Crohn’s disease (CD), including their impact on need for surgery. Design: Outcomes were assessed in 11 928 patients (4968 UC, 6960 CD) in the UK IBD BioResource initiated on thiopurine monotherapy with the intention of maintaining medically induced remission. Effectiveness was assessed retrospectively using patient-level data and a definition that required avoidance of escalation to biological therapy or surgery while on thiopurines. Analyses included overall effectiveness, time-to-event analysis for treatment escalation and comparison of surgery rates in patients tolerant or intolerant of thiopurines. Results: Using 68 132 patient-years of exposure, thiopurine monotherapy appeared effective for the duration of treatment in 2617/4968 (52.7%) patients with UC compared with 2378/6960 (34.2%) patients with CD (p<0.0001). This difference was corroborated in a multivariable analysis: after adjusting for variables including treatment era, thiopurine monotherapy was less effective in CD than UC (OR 0.47, 95% CI 0.43 to 0.51, p<0.0001). Thiopurine intolerance was associated with increased risk of surgery in UC (HR 2.44, p<0.0001); with a more modest impact on need for surgery in CD (HR=1.23, p=0.0015). Conclusion: Thiopurine monotherapy is an effective long-term treatment for UC but significantly less effective in CD

Mortality rates among patients successfully treated for hepatitis C in the era of interferon-free antivirals: population based cohort study

Objectives To quantify mortality rates for patients successfully treated for hepatitis C in the era of interferon-free, direct acting antivirals and compare these rates with those of the general population.Design Population based cohort study.Setting British Columbia, Scotland, and England (England cohort consists of patients with cirrhosis only).Participants 21 790 people who were successfully treated for hepatitis C in the era of interferon-free antivirals (2014-19). Participants were divided into three liver disease severity groups: people without cirrhosis (pre-cirrhosis), those with compensated cirrhosis, and those with end stage liver disease. Follow-up started 12 weeks after antiviral treatment completion and ended on date of death or 31 December 2019.Main outcome measures Crude and age-sex standardised mortality rates, and standardised mortality ratio comparing the number of deaths with that of the general population, adjusting for age, sex, and year. Poisson regression was used to identify factors associated with all cause mortality rates.Results 1572 (7%) participants died during follow-up. The leading causes of death were drug related mortality (n=383, 24%), liver failure (n=286, 18%), and liver cancer (n=250, 16%). Crude all cause mortality rates (deaths per 1000 person years) were 31.4 (95% confidence interval 29.3 to 33.7), 22.7 (20.7 to 25.0), and 39.6 (35.4 to 44.3) for cohorts from British Columbia, Scotland, and England, respectively. All cause mortality was considerably higher than the rate for the general population across all disease severity groups and settings; for example, all cause mortality was three times higher among people without cirrhosis in British Columbia (standardised mortality ratio 2.96, 95% confidence interval 2.71 to 3.23; P<0.001) and more than 10 times higher for patients with end stage liver disease in British Columbia (13.61, 11.94 to 15.49; P<0.001). In regression analyses, older age, recent substance misuse, alcohol misuse, and comorbidities were associated with higher mortality rates.Conclusion Mortality rates among people successfully treated for hepatitis C in the era of interferon-free, direct acting antivirals are high compared with the general population. Drug and liver related causes of death were the main drivers of excess mortality. These findings highlight the need for continued support and follow-up after successful treatment for hepatitis C to maximise the impact of direct acting antivirals

Mitochondrial physiology

As the knowledge base and importance of mitochondrial physiology to evolution, health and disease expands, the necessity for harmonizing the terminology concerning mitochondrial respiratory states and rates has become increasingly apparent. The chemiosmotic theory establishes the mechanism of energy transformation and coupling in oxidative phosphorylation. The unifying concept of the protonmotive force provides the framework for developing a consistent theoretical foundation of mitochondrial physiology and bioenergetics. We follow the latest SI guidelines and those of the International Union of Pure and Applied Chemistry (IUPAC) on terminology in physical chemistry, extended by considerations of open systems and thermodynamics of irreversible processes. The concept-driven constructive terminology incorporates the meaning of each quantity and aligns concepts and symbols with the nomenclature of classical bioenergetics. We endeavour to provide a balanced view of mitochondrial respiratory control and a critical discussion on reporting data of mitochondrial respiration in terms of metabolic flows and fluxes. Uniform standards for evaluation of respiratory states and rates will ultimately contribute to reproducibility between laboratories and thus support the development of data repositories of mitochondrial respiratory function in species, tissues, and cells. Clarity of concept and consistency of nomenclature facilitate effective transdisciplinary communication, education, and ultimately further discovery