Carmen Tsang

Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study

Background:To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care.Methods:Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF).Results:There were 639 064 patients with a first-time admission for cancer, with 139 351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15–44 years) to 44.9% (patients aged 85 years and older, P<0.0001), with large variation by ethnicity (highest in Asians), deprivation, rurality and cancer type. In unadjusted analyses, all included patient and practice-level variables were statistically significant predictors of the admissions being unplanned. After adjustment, patient area-level deprivation was a key factor (most deprived compared with least deprived quintile OR 1.36, 95% CI 1.32–1.40). Higher total QOF performance protected against unplanned admission (OR 0.94 per 100 points; 95% CI 0.91–0.97); having no GPs with a UK primary medical qualification (OR 1.08, 95% CI 1.04–1.11) and being less able to offer appointments within 48 h were associated with higher odds.Conclusion:We have identified some patient and practice characteristics associated with a first-time admission for cancer being unplanned. The former could be used to help identify patients at high risk, while the latter raise questions about the role of practice organisation and staff training.

The Impact of a National Clinician-led Audit Initiative on Care and Mortality after Hip Fracture in England: An External Evaluation using Time Trends in Non-audit Data

Background:Hip fracture is the most common serious injury of older people. The UK National Hip Fracture Database (NHFD) was launched in 2007 as a national collaborative, clinician-led audit initiative to improve the quality of hip fracture care, but has not yet been externally evaluated. Methods:We used routinely collected data on 471,590 older people (aged 60 years and older) admitted with a hip fracture to National Health Service (NHS) hospitals in England between 2003 and 2011. The main variables of interest were the use of early surgery (on day of admission, or day after) and mortality at 30 days from admission. We compared time trends in the periods 2003–2007 and 2007–2011 (before and after the launch of the NHFD), using Poisson regression models to adjust for demographic changes. Findings:The number of hospitals participating in the NHFD increased from 11 in 2007 to 175 in 2011. From 2007 to 2011, the rate of early surgery increased from 54.5% to 71.3%, whereas the rate had remained stable over the period 2003–2007. Thirty-day mortality fell from 10.9% to 8.5%, compared with a small reduction from 11.5% to 10.9% previously. The annual relative reduction in adjusted 30-day mortality was 1.8% per year in the period 2003–2007, compared with 7.6% per year over 2007–2011 (P<0.001 for the difference). Interpretation:The launch of a national clinician-led audit initiative was associated with substantial improvements in care and survival of older people with hip fracture in England.

Cancer diagnosed by emergency admission in England: an observational study using the general practice research database.

BackgroundPatients diagnosed with cancer by the emergency route often have more advanced diseases and poorer outcomes. Rates of cancer diagnosed through unplanned admissions vary within and between countries, suggesting potential inconsistencies in the quality of care. To reduce diagnoses by this route and improve patient outcomes, high risk patient groups must be identified. This cross-sectional observational study determined the incidence of first-ever diagnoses of cancer by emergency (unplanned) admission and identified patient-level risk factors for these diagnoses in England.MethodsData for 74,763 randomly selected patients at 457 general practices between 1999 and 2008 were obtained from the General Practice Research Database (GPRD), including integrated Hospital Episode Statistics (HES) data and Office for National Statistics (ONS) mortality data. The proportion of first-ever diagnoses by emergency admission out of all recorded first cancer diagnoses by any route was analysed by patient characteristics.ResultsDiagnosis by emergency admission was recorded in 13.9% of patients diagnosed with cancer for the first time (n = 817/5870). The incidence of first cases by the emergency route was 2.51 patients per 10,000 person years. In adjusted regression analyses, patients of older age (p < 0.0001), living in the most deprived areas (RR 1.93, 95% CI 1.51 to 2.47; p < 0.0001) or who had a total Charlson score of 1 compared to 0 (RR 1.34, 95% CI 1.06 to 1.69; p = 0.014) were most at risk of diagnosis by emergency admission. Patients with more prior (all-cause) emergency admissions were less at risk of subsequent diagnosis by the emergency route (RR 0.31 per prior emergency admission, 95% CI 0.20 to 0.46; p < 0.0001).ConclusionsA much lower incidence of first-ever cancer diagnoses by emergency admission was found compared with previous studies. Identified high risk groups may benefit from interventions to reduce delayed diagnosis. Further studies should include screening and cancer staging data to improve understanding of delayed or untimely diagnosis and patient care pathways.

Adverse events recorded in English primary care: observational study using the General Practice Research Database

BACKGROUND More accurate and recent estimates of adverse events in primary care are necessary to assign resources for improvement of patient safety, while predictors must be identified to ameliorate patient risk. AIM To determine the incidence of recorded iatrogenic harm in general practice and identify risk factors for these adverse events. DESIGN AND SETTING Cross-sectional sample of 74,763 patients at 457 English general practices between 1 January 1999 and 31 December 2008, obtained from the General Practice Research Database. METHOD Patient age at study entry, sex, ethnicity, deprivation, practice region, duration registered at practice, continuity of care, comorbidities, and health service use were extracted from the data. Adverse events were defined by Read Codes for complications of care (Chapters S, T, and U). Crude and adjusted analyses were performed by Poisson regression, using generalised estimating equations. RESULTS The incidence was 6.0 adverse events per 1000 person-years (95% confidence interval [CI] = 5.74 to 6.27), equivalent to eight adverse events per 10,000 consultations (n = 2,540,877). After adjustment, patients aged 65-84 years (risk ratio [RR] = 5.62, 95% CI = 4.58 to 6.91; P<0.001), with the most consultations (RR = 2.14, 95% CI = 1.60 to 2.86; P<0.001), five or more emergency admissions (RR = 2.08, 95% CI = 1.66 to 2.60; P<0.001), or the most diseases according to expanded diagnosis clusters (RR = 8.46, 95% CI = 5.68 to 12.6; P<0.001) were at greater risk of adverse events. Patients registered at their practice for the longest periods of time were less at risk of an adverse event (RR = 0.40, 95% CI = 0.35 to 0.47; P<0.001). CONCLUSION The low incidence of recorded adverse events is comparable with other studies. Temporal sequencing of risk factors and case ascertainment would benefit from data triangulation. Future studies may explore whether first adverse events predict future incidents.

A Review of Patient Safety Measures Based on Routinely Collected Hospital Data

The literature on patient safety measures derived from routinely collected hospital data was reviewed to inform indicator development. MEDLINE and Embase databases and Web sites were searched. Of 1738 citations, 124 studies describing the application, evaluation, or validation of hospital-based medical error or complication of care measures were reviewed. Studies were frequently conducted in the United States (n = 88) between 2005 and 2009 (n = 77) using Agency for Healthcare Research and Quality patient safety indicators (PSIs; n = 79). The most frequently cited indicators included “postoperative hemorrhage or hematoma” and “accidental puncture and laceration.” Indicator refinement is supported by international coding algorithm translations but is hampered by data issues, including coding inconsistencies. The validity of PSIs and similar adverse event screens beyond internal measurement and the effects of organizational factors on patient harm remain uncertain. Development of PSIs in ambulatory care settings, including general practice and psychiatric care, needs consideration.

Routinely recorded patient safety events in primary care: a literature review

BACKGROUND Existing patient-level data can be used to measure and monitor patient safety. Data from sources including electronic patient records are routinely collected in primary care and may be suitable for adverse event screening, such as patient safety indicators. To inform the feasibility of developing primary care measures of patient harm, information about routinely collected data is needed. OBJECTIVE A literature review was conducted to determine the types of adverse events that are routinely recorded in primary care. METHODS We searched ASSIA, Cochrane Library, Embase, HMIC, ISI Web of Science, Medline and PsycInfo databases, grey literature and websites. We included only original research studies in English where routinely collected patient data were used to identify adverse events occurring in primary or ambulatory care settings. Adverse events were defined as unexpected and undesirable patient outcomes arising from health care contact. RESULTS Of 5029 citations identified, 15 were reviewed. Twelve studies used multiple data sources. Approximately 6.5% of adult emergency admissions were due to drug-related events (n = 1225). Between 0.7% and 2.3% of deaths following adverse events were attributed to treatment in primary care. A large proportion of adverse events resulting in the most severe harm may be preventable. For example, one study estimated that 42% of serious adverse drug events were avoidable. CONCLUSIONS There is limited use of routinely collected data to measure adverse events in primary care despite large volumes of data generated. The potential for using readily available data recorded in primary care for active patient safety surveillance needs further exploration.

Effects of alcohol and alcohol expectancy on perceptions of opposite-sex facial attractiveness in university students

Previous research has indicated that alcohol consumption increases the perceived attractiveness of opposite-sex faces. This may contribute to the known effects of alcohol on risky sexual behaviours. We investigated the effects of alcohol consumption on the perception of opposite-sex faces, whilst controlling for alcohol expectancy. In a balanced placebo design, males and females were allocated to one of the four groups: (1) told they would receive alcohol and did; (2) told they would receive alcohol but did not; (3) told they would not receive alcohol but did; (4) told they would not receive alcohol and did not. They then rated opposite-sex faces and neutral stimuli for ‘attractiveness’. Roughly three-quarters of the sample were classified as hazardous or harmful drinkers by the AUDIT questionnaire. No significant differences between groups in ratings of attractiveness for either set of stimuli were found. Findings remained the same in a reduced sample for whom the experimental manipulation was successful (as assessed by post-test questioning). Thus, we did not find that alcohol ingestion enhanced ratings of opposite-sex faces. Nor did we find that, in the overall sample, the expectation of receiving an alcoholic drink influenced opposite-sex face ratings. Possible explanations for these null findings are discussed.

Predicting 30-day mortality after hip fracture surgery: Evaluation of the National Hip Fracture Database case-mix adjustment model

Objectives The National Hip Fracture Database (NHFD) publishes hospital-level risk-adjusted mortality rates following hip fracture surgery in England, Wales and Northern Ireland. The performance of the risk model used by the NHFD was compared with the widely-used Nottingham Hip Fracture Score. Methods Data from 94 hospitals on patients aged 60 to 110 who had hip fracture surgery between May 2013 and July 2013 were analysed. Data were linked to the Office for National Statistics (ONS) death register to calculate the 30-day mortality rate. Risk of death was predicted for each patient using the NHFD and Nottingham models in a development dataset using logistic regression to define the models’ coefficients. This was followed by testing the performance of these refined models in a second validation dataset. Results The 30-day mortality rate was 5.36% in the validation dataset (n = 3861), slightly lower than the 6.40% in the development dataset (n = 4044). The NHFD and Nottingham models showed a slightly lower discrimination in the validation dataset compared with the development dataset, but both still displayed moderate discriminative power (c-statistic for NHFD = 0.71, 95% confidence interval (CI) 0.67 to 0.74; Nottingham model = 0.70, 95% CI 0.68 to 0.75). Both models defined similar ranges of predicted mortality risk (1% to 18%) in assessment of calibration. Conclusions Both models have limitations in predicting mortality for individual patients after hip fracture surgery, but the NHFD risk adjustment model performed as well as the widely-used Nottingham prognostic tool and is therefore a reasonable alternative for risk adjustment in the United Kingdom hip fracture population. Cite this article: Bone Joint Res 2017;6:550–556

Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database

Hip fracture is the most common reason for older patients to need emergency anaesthesia and surgery. Up to one‐third of patients die in the year after hip fracture, but this view of outcome may encourage therapeutic nihilism in peri‐operative decisions and discussions. We used a multicentre national dataset to examine relative and absolute mortality rates for patients presenting with hip fracture, stratified by ASA physical status. We analysed ASA physical status, dates of surgery, death and hospital discharge for 59,369 out of 64,864 patients in the 2015 National Hip Fracture Database; 3914 (6.6%) of whom died in hospital. Rates of death in hospital were 1.8% in ASA 1–2 patients compared with 16.5% in ASA 4 patients. Survival rates for ASA 4 patients on each of the first three postoperative days were: 98.8%, 99.1% and 99.1% (compared with figures of > 99.9% in ASA 1–2 patients over these days). Survival on postoperative day 6 was 99.4% for ASA 4 patients. Nearly half (48.6%) of the 1427 patients who did not have surgery died in hospital. Although technically sound, a focus on cumulative and relative risk of mortality may frame discussions in an unduly negative fashion, discouraging surgeons and anaesthetists from offering an operation, and deterring patients and their loved ones from agreeing to it. A more optimistic and pragmatic explanation that over 98% of ASA 4 patients survive both the day of surgery and the day after it, may be more appropriate.

Consultations with general practitioners on patient safety measures based on routinely collected data in primary care

Objectives To gauge the opinions of doctors working, or interested, in general practice on monitoring patient safety using administrative data. The findings will inform the development of routinely collected data-based patient safety indicators in general practice and elsewhere in primary care. Design Non-systematic participant recruitment, using personal contacts and colleagues’ recommendations. Setting Face-to-face consultations at participants’ places of work, between June 2010 and February 2011. Participants Four general practitioners (GPs) and a final year medical student. The four clinicians had between eight to 34 years of clinical practice experience, and held non-clinical positions in addition to their clinical roles. Main outcome measures Views on safety issues and improvement priorities, measurement methods, uses of administrative data, role of administrative data in patient safety and experiences of quality and safety initiatives. Results Medication and communication were the most commonly identified areas of patient safety concern. Perceived safety barriers included incident-reporting reluctance, inadequate medical education and low computer competency. Data access, financial constraints, policy changes and technology handicaps posed challenges to data use. Suggested safety improvements included better communication between providers and local partnerships between GPs. Conclusions The views of GPs and other primary care staff are pivotal to decisions on the future of English primary care and the health system. Broad views of general practice safety issues were shown, with possible reasons for patient harm and quality and safety improvement obstacles. There was general consensus on areas requiring urgent attention and strategies to enhance data use for safety monitoring.