David Cromwell

Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study.

Objective To determine whether the variation in unadjusted rates of caesarean section derived from routine data in NHS trusts in England can be explained by maternal characteristics and clinical risk factors. Design A cross sectional analysis using routinely collected hospital episode statistics was performed. A multiple logistic regression model was used to estimate the likelihood of women having a caesarean section given their maternal characteristics (age, ethnicity, parity, and socioeconomic deprivation) and clinical risk factors (previous caesarean section, breech presentation, and fetal distress). Adjusted rates of caesarean section for each NHS trust were produced from this model. Setting 146 English NHS trusts. Population Women aged between 15 and 44 years with a singleton birth between 1 January and 31 December 2008. Main outcome measure Rate of caesarean sections per 100 births (live or stillborn). Results Among 620 604 singleton births, 147 726 (23.8%) were delivered by caesarean section. Women were more likely to have a caesarean section if they had had one previously (70.8%) or had a baby with breech presentation (89.8%). Unadjusted rates of caesarean section among the NHS trusts ranged from 13.6% to 31.9%. Trusts differed in their patient populations, but adjusted rates still ranged from 14.9% to 32.1%. Rates of emergency caesarean section varied between trusts more than rates of elective caesarean section. Conclusion Characteristics of women delivering at NHS trusts differ, and comparing unadjusted rates of caesarean section should be avoided. Adjusted rates of caesarean section still vary considerably and attempts to reduce this variation should examine issues linked to emergency caesarean section.

Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics

Objectives To examine whether rate of reoperation after breast conserving surgery is associated with patients’ characteristics and investigate whether reoperation rates vary among English NHS trusts. Design Cohort study using patient level data from hospital episode statistics. Setting English NHS trusts. Participants Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008. Main outcome measure Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery. Results 55 297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11 032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10 212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45 793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%). Conclusion: One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

Key messages from the National Prospective Tonsillectomy Audit.

Objectives: Investigation of the occurrence of postoperative hemorrhage after tonsillectomy and risk factors for these complications.

Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.

To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends.

Self management for men with lower urinary tract symptoms: randomised controlled trial

Objective To evaluate the effectiveness of self management as a first line intervention for men with lower urinary tract symptoms. Design Randomised controlled trial. Setting A teaching hospital and a district general hospital in London. Participants 140 men (mean age 63 (SD 10.7) years), recruited between January 2003 and April 2004, referred by general practitioners to urological outpatient departments with uncomplicated lower urinary tract symptoms. Interventions Self management and standard care (n=73) or standard care alone (n=67). The self management group took part in three small group sessions comprising education, lifestyle advice, and training in problem solving and goal setting skills. Main outcome measures The primary outcome measure was treatment failure measured at 3, 6, and 12 months. Symptom severity (international prostate symptom score; higher scores represent a poorer outcome) was used as a secondary outcome. Results At three months, treatment failure had occurred in 7 (10%) of the self management group and in 27 (42%) of the standard care group (difference=32%, 95% confidence interval 18% to 46%). Corresponding differences in the frequency of treatment failure were 42% (27% to 57%) at six months and 48% (32% to 64%) at 12 months. At three months, the mean international prostate symptom score was 10.7 in the self management group and 16.4 in the standard care group (difference=5.7, 3.7 to 7.7). Corresponding differences in score were 6.5 (4.3 to 8.7) at six months and 5.1 (2.7 to 7.6) at 12 months. Conclusions Self management significantly reduced the frequency of treatment failure and reduced urinary symptoms. Because of the large observed benefit of self management, the results of this study support the case for a large multicentre trial to confirm whether self management could be considered as first line treatment for men with lower urinary tract symptoms. Trial registration National Research Register N0263115137; Clinical trials NCT00270309.

Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis

BackgroundObjective: To compare the risk of placenta previa at second birth among women who had a cesarean section (CS) at first birth with women who delivered vaginally.MethodsRetrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England. Multiple logistic regression was used to adjust the estimates for maternal age, ethnicity, deprivation, placenta previa at first birth, inter-birth interval and pregnancy complications. In addition, we conducted a meta-analysis of the reported results in peer-reviewed articles since 1980.ResultsThe rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76). In the meta-analysis of 37 previously published studies from 21 countries, the overall pooled random effects odds ratio was 2.20 (95% CI 1.96-2.46). Our results from the current study is consistent with those of the meta-analysis as the pooled odds ratio for the six population-based cohort studies that analyzed second births only was 1.51 (95% CI 1.39-1.65).ConclusionsThere is an increased risk of placenta previa in the subsequent pregnancy after CS delivery at first birth, but the risk is lower than previously estimated. Given the placenta previa rate in England and the adjusted effect of previous CS, 359 deliveries by CS at first birth would result in one additional case of placenta previa in the next pregnancy.

Primary care patients in the emergency department: Who are they? A review of the definition of the ‘primary care patient’ in the emergency department

Objective:  To review the definition of ‘primary care’ and ‘inappropriate’ patients in ED and develop a generally acceptable working definition of a ‘primary care’ presentation in ED.

The performance of instrumental activities of daily living scale in screening for cognitive impairment in elderly community residents

A retrospective analysis of Short Orientation-Memory-Concentration (OMC) and Lawtons IADL data was performed to assess the association between instrumental activities of daily living (IADL) and a rating of cognitive impairment, and to test whether IADL measures can be used to screen for dementia. The study analyzed data from 1,095 elderly community residents who were regarded as potentially benefiting from care coordination. Three IADL items (telephone use, self-medication, and handling finances) were statistically associated with cognitive impairment (OMC cutoff 10/11), independent of age and sex. An IADL indicator based on these items had only modest power in predicting cognitive impairment, its highest sensitivity being 0.71. Specificity was 0.75 at this point, but increased to 0.97 if higher indicator scores were used to define a positive result. In conclusion, the usefulness of an IADL indicator seems limited to ruling out further cognitive assessment rather than positively identify those with dementia.

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.

Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success

To investigate the demographic and obstetric factors associated with the uptake and success rate of vaginal birth after caesarean section (VBAC).