E Thompson

Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics

Objective To determine whether variation in gastroscopy rates in English general practice populations is associated with inequality in oesophagogastric (OG) cancer outcome. Design Retrospective observational study of the Hospital Episode Statistics (HES) dataset for England (2006–2008) linked to death registration. Methods were validated using independent local and national data. General practices with new cases of OG cancer were included. Practices were grouped into tertiles according to standardised elective gastroscopy rate per capita (low, medium or high). Outcome measures for cancer cases were: emergency admission during diagnostic pathway, major surgical resection and mortality at 1 year. Covariates were: age group, gender, comorbidity, general practice average deprivation and patient deprivation. Results 22 488 incident cases of OG cancer from 6513 general practices were identified. Patients registered with the low tertile group of practices had the lowest rate of major surgery, highest rate of emergency admission and highest mortality. The inequality was widest for the most socioeconomically deprived cases. After adjustment for covariates in logistic regression, the gastroscopy rate (low, medium or high) at the patients general practice was an independent predictor of emergency admission, major surgery and mortality. Conclusions There is wide variation in the rate of gastroscopy among general practice populations in England. On average, OG cancer patients belonging to practices with the lowest rates of gastroscopy are at greater risk of poor outcome. These findings suggest that initiatives or current guidelines aimed at limiting the use of gastroscopy may adversely affect cancer outcomes.

All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death

BACKGROUND All-cause death within 30 days of ERCP is a candidate indicator of care, but institutional-level statistics require careful interpretation. National-scale, population-based outcome studies of unselected patients undergoing ERCP are needed to define expected levels of real-world mortality risk and the case-mix factors that predict poor outcome. OBJECTIVE To develop methods for analyzing administrative data for English hospitals with linkage to death registration to study all-cause mortality after first ERCPs and explore predictors of death and institutional variation. DESIGN Hospital episode statistics for 2006 to 2007 and 2007 to 2008 were linked to the statutory death register. First ERCP episodes were extracted and analyzed for demographic characteristics, admission method, diagnoses, and comorbidities. Additional linkages identified the last-coded diagnosis before death. Factors associated with 30-day death were identified by univariate and multiple logistic analyses. Pilot data and a survey were sent to clinicians at each institution. Crude and case-mix adjusted mortality were analyzed at the institutional level. MAIN OUTCOME MEASUREMENTS Death within 30 days of the first ERCP procedure. RESULTS We analyzed 20,246 first ERCPs from 2006 to 2007 and 20,422 from 2007 to 2008. Diagnostic profile: gallstone related 57.3%; cancer 12.6%; gallstone and cancer 2%; others 28.1%. All-cause 30-day death was 5.3% (2.4% in non-cancer cases). Predictors of 30-day death (adjusted odds ratio [OR]) were as follows: age (OR 6.2, for ≥85 years vs <55 years), male sex (OR 1.2 vs female), emergency admission (OR 2.0 vs elective), cancer (OR 8.6 vs no cancer), and non-cancer comorbidity (OR 1.5 vs none). A mortality risk estimator (look-up table) based on pooled data for >40,000 first ERCPs is provided. Specific procedural complication codes were identified in 1.2% of deaths (0.06% of ERCPs). At the institutional level, analysis of mortality rates was within expected statistical funnel limits, and we found no correlation with ERCP volume (Pearson r = -0.05; P > .05). LIMITATIONS The completeness and accuracy of coding may vary between different hospitals. Routine coding does not capture information about procedural complexity or severity of illness. CONCLUSION Linkage analysis of hospital episode statistics data for England provides a powerful tool for studying mortality risk after ERCP on an unselected and truly nationwide scale. Institutional-level statistics suggest that the mortality risk for patients requiring ERCP was comparable across English hospitals.

Use of mortality within 30 days of a COPD hospitalisation as a measure of COPD care in UK hospitals

Mortality rate has been proposed as a metric of hospital chronic obstructive pulmonary disease (COPD) care in light of variation seen in national COPD audits. Using Hospital Episode Statistics (hospital ‘coding’) we examined 30-day mortality after COPD hospitalisation in 150 UK hospitals during 2006–2007 and 2007–2008. Mean and median 30-day mortalities were similar each year but the coefficient of variation was >20% and hospitals could change from a low or high quartile to the median by chance. We could not detect any reasons for hospitals being at the extremes. 30-day mortality after COPD hospitalisation is a complex variable and unlikely to be useful as a primary annual COPD metric.

Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice

BACKGROUND Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution. AIMS To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellence-based chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients. METHODS Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed. RESULTS Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation. CONCLUSIONS Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.

PTH-144 Nationwide Study Of Emergency Admissions To Acute Hospitals In England For Anorexia Nervosa: Implications For Marsipan

Introduction Patients with anorexia nervosa (AN) develop significant physical complications leading to emergency admission (EmAd) to acute hospitals. There are few data on national burden, institutional case volume, frequency, nature or outcomes of EmAds for this rare, complex condition. The need for joint management of AN between medical and psychiatric teams has been highlighted 1. We aimed to define characteristics of adult patients with AN admitted as emergencies to acute hospitals in England. Methods A 2-year download of data for English acute hospitals (Hospital Episode Statistics) was obtained, linked to death registry. We extracted all EmAds in medical or surgical specialties containing ICD-10 codes for AN. Adult patients with a first (index) admission between Oct 07 and Sept 08 were selected (1-year incident cohort). Admissions in 6 months before or after index admission were extracted and ordered chronologically. Demographics and diagnosis codes for each admission were reviewed independently by two gastroenterologists (SL, KB) and a psychiatrist (SS), selecting only cases where 2 of 3 reviewers judged the coding sequence consistent with EmAd for AN. The index EmAd was classified according to primary diagnosis. Results 549 AN patients were admitted to 132 Trusts in England during the year. Mean age [sd]: 30 [11] yrs; Female: 95.4%; ≥1 Charlson co-morbidities: 11.3%. Primary diagnosis: AN, 33.5%; Complication of AN or a GI symptom, 39.2%; Poisoning or Self Harm, 17.5%; Alcohol-related, 2.4%; Miscellaneous diagnoses, 7.5%. Case load per hospital: One, 18; Two, 20; Three, 24; Four, 21; Five, 17; Six or more cases, 32 hospitals. Length of stay for index admission, mean [sd]: 7.5 [16] days. Re-admissions (within 6 months): None, 53.7%; 1–3, 38.1%; 4+, 8.1%. Range: 36 (0–36) admissions. Total NHS bed days within 6 months of index admission: 7,138. 1 in 5 were not discharged to their usual residence (e.g. transfer to psychiatric unit). Mortality: 2.7% at 30 days; 3.3% at 1 year. Conclusion Patients with AN are admitted to acute hospitals with a diverse array of physical complications and co-morbidities with high re-admission rates and significant mortality. Annual caseload per hospital varies widely but is mostly very low. This diffuse pattern of care is unlikely to provide the best model for providing high quality care. These unique data should inform the implementation of MARSIPAN and the commissioning of services. Reference MARSIPAN Group 2010;MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa. Royal College of Psychiatrists and Royal College of Physicians, London Disclosure of Interest M. Shawihdi: None Declared, E. Thompson: None Declared, S. Sharma Employee of: The Priory Hospital Cheadle Royal, S. Lal: None Declared, M. Pearson: None Declared, K. Bodger Grant/research support from: The Priory Group.

Emergency Hospital Admission as a Route for Oesophagogastric Cancer Diagnosis: A Marker of Poor Outcome and a Candidate Quality Indicator for Local Services

Introduction The UK National Cancer Plan (2000) introduced a ‘two week’ waiting time standard for suspected malignancy and guidance to encourage early diagnosis. Improved access to elective ( ELECT ) investigation should reduce the need for emergency ( EMERG ) admission. This study examined route of diagnosis and outcomes for oesophagogastric cancer ( OGC ), both locally and nationally. Methods Local OGC cases were audited for 2-year periods before (‘ Pre’ : July 97–June 99) and after (‘ Post’ : Jan 01-Dec 02) service re-design, collecting details of demographics, tumour type, stage, dates of referral, diagnosis, treatment and survival. Within a project funded by the NHS Information Centre, we developed novel linkage algorithms to analyse Hospital Episode Statistics for England (2006–2008) and methods to track OGC care chronologically, selecting only incident cases with a valid pathway of coded diagnostic and therapeutic interventions. External linkage to death registry established date of death and 2-year survival. Results LOCAL DATA : n = 333 cases ( Pre , n = 152; Post , n = 181). No change in % of patients diagnosed via EMERG route after service re-design ( Pre : 30.9% vs Post : 31.5%; p = 0.981), nor any change in age, symptom or tumour profile of EMERG cases. Local EMERG cases were older than ELEC (75 vs 68 years; p EMERG cases with dysphagia and/or weight loss had lower 3 year survival than those with other presenting features (p = 0.035). NATIONAL DATA We identified 33,115 patients with OGC, of whom 26,097 (79%) met study criteria. Of these, 7082 (27%) were EMERG and 19,015 ELEC (73%). EMERG cases were older (74 years vs 70 years; p EMERG cases varied widely between cancer networks (22% to 40%). Conclusion Findings are consistent with a recent report by the National Cancer Intelligence Network (Nov 2010) suggesting that a quarter of major cancers are diagnosed via the EMERG route. Our national linkage study suggests 27% of new OGC cases in England are diagnosed as EMERG and this mode of presentation predicts a poor outcome, confirmed by detailed local audit. Although EMERG admission is unavoidable for some cases, the observed variation across the country suggests possible unresolved inequalities in patient access. Monitoring of this candidate indicator could assess the impact of new initiatives to promote earlier elective diagnosis.

PTU-213 Self expandable metal stents (SEMS) for obstructing colorectal cancer in England: linkage analysis of hospital episode statistics

Introduction Colorectal cancer (CRC) is the 4th commonest cancer worldwide. Hospital admission with large bowel obstruction occurs in 15% and requires urgent decompression. SEMS can provide palliative treatment in advanced disease (avoiding surgical defunctioning) or preoperative bridging to elective surgery for operable disease. We aimed to describe a national profile for incidence (activity) of SEMS, volumes per Trust, length of stay and rates of readmission, reintervention and mortality for CRC in England. Methods We developed techniques within the SPSS software package to identify a 1-year cohort of incident cases of CRC, starting with a merged file of raw HES data for all care episodes in English hospitals for 2006/7 and 2007/8. We selected only patients with first coding of CRC in the middle 12 months (October–September), then extracted all their admissions within 6 months (before and after) of first cancer coding, ordering them chronologically and then screening to identify admissions for SEMS and surgical procedures. Linkage to death registry provided date of death. Patients with SEMS and no subsequent surgical resection were flagged as palliative patients and those with a subsequent resection as bridge patients. Results Overall: 517 patients were identified nationally as having SEMS placement for obstructing CRC (mean age: 72.6 yrs [SD: 12.0]; 62.5% male), with mean LOS of 7.9 [SD 11.3] days and overall mortality at 30 d (10.3%) and 90 d (18.0%). The 30 d emergency readmission rate was 15.1%. SEMS were code by 122 (81.3%) of acute Trusts in England, with volumes ranging from 1 to 24 per institution. Palliative group: (n=421, 81.4% of cases), mean LOS for index admission 9.2 [SD: 14.6] days and mortality at 30 d (12.1%) and 90 d (21.2%). Emergency readmission within 30 d (17.8%). Subsequent surgical colostomy coded in 9.5%. Palliative procedures were recorded in 122 Trusts (Volumes: 1–13 per institution), Bridge group: (n=96, 18.6% of cases), mean LOS for index admission 9.5 [SD: 10.4] days and mortality at 30 d (2.1%) and 90 d (4.2%). Emergency 30 d readmission (8.7%). Colostomy coded as part of surgery in 33.4%. Bridge procedures were coded in 48 (32%) acute Trusts (Volumes: 1–12). Conclusion Analysis of HES data suggests SEMS insertion in English hospitals is predominantly for palliative purposes and most cases selected for this intervention survive beyond 30 days and avoid operative decompression. The use of SEMS as a bridge to surgery was relatively uncommon and one third required a stoma at surgery. Variation between Trusts in coding quality is inevitable but the data suggest 1 in 5 institutions may lack provision for SEMS. Competing interests J Geraghty: Grant/Research Support from: Cook Medical, S Sarkar: None declared, M Shawihdi: None declared, E Thompson: None declared, M Pearson: None declared, K Bodger: None declared.

OC-045 Reduced Risk Of Emergency Admission For Colorectal Cancer Associated With Introduction Of Bowel Cancer Screening Across England: Retrospective National Cohort Study

Introduction We examined whether roll out of the bowel cancer screening programme (BCSP) across England was associated with a reduced risk of emergency hospital admission for people presenting with colorectal cancer (CRC) during this period. Methods Design: Retrospective cohort study of 27,763 incident cases of CRC over a 1-year period during the roll-out of screening across parts of England. Primary outcome: Emergency (unplanned) hospital admission during diagnostic pathway. Primary exposure: Living in an area where BCSP was active at the time of diagnosis. Patients were categorised into three exposure groups: BCSP not active (reference group), active <6 months or active ≥6 months. To explore confounding we studied risk of emergency admission for cases of oesophagogastric cancer using the same design. Results Risk of emergency admission for CRC in England was associated with increasing age, female gender, co-morbidity and social deprivation. After adjusting for these factors in logistic regression, the odds ratio for emergency admission in patients diagnosed ≥6 months after start-up of local screening was 0.83 (CI: 0.76–0.90). The magnitude of risk reduction was greatest for cases of screening age (OR 0.75; CI: 0.63–0.90) but this effect was apparent also for cases outside the 60–69 year age-group (OR 0.85; CI: 0.77–0.94). Living in an area with active BCSP conferred no reduction in risk of emergency admission for people diagnosed with oesophagogastric cancer during the same period. Conclusion The start-up of bowel cancer screening in England was associated with a substantial reduction in risk of emergency admission for CRC in people of all ages. This suggests that the roll-out of the programme had early and indirect benefits beyond those related directly to participation in screening. Disclosure of Interest J. Geraghty Grant/research support from: Cook Medical, M. Shawihdi: None Declared, E. Thompson: None Declared, S. Sarkar: None Declared, M. Pearson: None Declared, K. Bodger: None Declared.

S71 Computer-Guided consultation in COPD practice

RATIONALE We previously showed a comprehensive computer guided-consultation (containing prompts developed from NICE guidelines) in COPD primary care was feasible without specialist training, while preserving the autonomy of clinical decision making. The pilot study based on COPD primary care register, 88% had a proposed management change and 29% of patients had a diagnostic revision. We have re-examined the impact in real life to determine if this is repeated. Methods We report on review of 2000 patients drawn from COPD registers across 78 practices. 459 (23%) did not have COPD based on spirometry. 1541 with COPD, had a mean (SD) age of 69.4 (9.8) yrs, 903 (58.6%)male, 1407 (91.6%) had been smokers and 597 (38.4%) were current smokers. The mean (SD) FEV1 was 1.48 (0.56) with a mean FEV1 percent predicted of 61.4 and a mean FEV1/FVC ratio of 52.4. The mean (SD) MRC score was 2.58 (0.9) and BMI was 27.0 (5.9). Results Treatment modifications were implemented across various interventions. Pharmacological recommendations included the addition of: Short-acting bronchodilator in 75/1541 (4.9%), and a long-acting bronchodilator (LAMA) in 78/1541 (5.1%). Long-acting beta agonist/inhaled corticosteroid combination (LABA/ICS) was added in 75 patients including 37 with only moderate disease. In 32 (1.8%) patients the recommendation was to discontinue various inhaled medication and in 28 (1.6%) patients these were LABA/ICS combinations. In addition, 28.8% of patients currently smoking, accepted referral for smoking cessation support. 38 patients had hypoxia, 10 already on oxygen, and 4/28 (14.3%) referred for oxygen assessment. 33.3% of eligible patients were referred to pulmonary rehabilitation. 77.5% required and were provided with a written educational pack, and a formal crisis management plan formulated for 49.3% cases. Inhaler technique was inadequate in 10.2% of patients and in part drove the prescribing changes. Conclusion Using computer guiding consultation in real life practice resulted in substantial management recommendations and diagnostic revisions. COPD care can be improved, using computer guided consultation which enables non specialists to achieve it.

PWE-068 Diagnostic Yield of Serious Disease and Variation in Elective Gastroscopy Rates in English General Practice: Analysis Of Administrative Data

Introduction The optimum role for gastroscopy (OGD) in managing dyspepsia and detecting oesophagogastric cancer (OG-Ca) is controversial. UK general practitioners (GPs) serve a gatekeeper role in selecting dyspeptic patients for OGD. We reported that variation in rates of OGD at the level of GP practise populations is associated with OG-Ca outcome, specifically that low rates are related to risk of poor outcome.[1] We wished to show that GP practises with low OGD rates are likely to be operating more selective referral practise with higher yield of serious pathology. Methods GP practises with ≥1 incident case of OG-Ca were selected, as described.[1.2] Using a two-year download of HES data we identified all elective OGD procedures and obtained practise data to calculate age-sex adjusted OGD rates. Practices were divided into OGD rate tertiles (Low, Medium or High). An algorithm was developed to analyse coded diagnoses for first OGDs, identifying most “serious” condition: (1) OG-Ca, (2) Major acid-peptic diseases, (3) Minor findings (e.g. gastritis), (4) Benign GI neoplasms, (5) Upper GI symptom codes, (6) Miscellaneous (all others). We compared age and proportions with serious disease (categories: 1–2) across the GP practise tertiles. Results 587,256 patients had elective OGD from 6,513 practises serving an adult population of c.39 million. Overall, yield of OG-Ca was 2.1%, major acid-peptic diseases 11.6% and the remaining 86.3% were mainly minor pathologies or symptom codes. Mean OGD rate for Low, Middle, High practises: 4.4 vs 8.1 vs 12.9 per 1,000 population. No difference in age distribution of populations across tertiles. Mean age of patients undergoing OGD was highest for low tertile practises (60.2 vs 59.5 vs 58.4 yrs; p < 0.001) which had highest yield of serious disease: 16,595/108,679 (15.3%) vs 28,177/203,771 (13.9%) vs 36,026/274,806 (13.1%) (p < 0.001). Conclusion Low referring practises appear to target slightly older patients and achieve higher yield of serious disease. Although higher yield may be more consistent with current guidelines, it may also indicate an increased risk of referral at a later stage in the disease process and of poorer OG-Ca outcome.[1] Disclosure of Interest None Declared. References Shawihdi, M., et al. Gastroscopy rate in English general practise populations: association with outcome for oesophagogastric cancer. Gut, 2012. 61(Suppl 2):A19. Shawihdi, M., et al. Emergency Hospital Admission as a Route for Oesophagogastric Cancer Diagnosis: A Marker of Poor Outcome and a Candidate Quality Indicator for Local Services. Gastroenterology, 2011. 140( 5, Supplement 1):S207.