Kymberley Thorne

The effects of the Two-Week Rule on NHS colorectal cancer diagnostic services: A systematic literature review

BackgroundThe Two-Week Rule (TWR) was introduced to ensure that all patients with a suspected colorectal cancer (CRC) saw a hospital specialist within 14 days of an urgent GP referral. Guidelines were available to GPs to facilitate the appropriate TWR referral of patients exhibiting high-risk CRC symptoms.MethodsWe aimed to evaluate the TWR and its CRC detection rate on NHS CRC diagnostic services by performing a literature search and critically appraising the peer-reviewed studies. Only 12 studies were eligible for inclusion. Data was collected and overall results were given as weighted averages.ResultsThe studies identified indicated that only 10.3% of patients referred by the TWR were eventually diagnosed with CRC. When examining the referral origin of all CRC patients diagnosed during the time of the studies, 24% had been referred using the TWR, 24.1% were referred as emergency cases, and 52.4% were referred using alternative routes. No evidence was found to indicate that the TWR had resulted in identifying CRC patients at an earlier, more treatable stage of their disease.ConclusionThe TWR referral system needs to be improved to increase the number of CRC patients referred using this fast track method as they present to their GP. The TWR and new NICE Guidelines for the referral of patients with suspected cancer should be independently evaluated.

The incidence of acute pancreatitis: impact of social deprivation, alcohol consumption, seasonal and demographic factors

The incidence of acute pancreatitis has increased sharply in many European countries and the USA in recent years.

Review article: the prevalence of Helicobacter pylori and the incidence of gastric cancer across Europe.

There is little up‐to‐date review evidence on the prevalence of Helicobacter pylori across Europe.

Randomised controlled trial. Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: Trial design and protocol (CONSTRUCT)

Introduction Many patients with ulcerative colitis (UC) present with acute exacerbations needing hospital admission. Treatment includes intravenous steroids but up to 40% of patients do not respond and require emergency colectomy. Mortality following emergency colectomy has fallen, but 10% of patients still die within 3 months of surgery. Infliximab and ciclosporin, both immunosuppressive drugs, offer hope for treating steroid-resistant UC as there is evidence of their short-term effectiveness. As there is little long-term evidence, this pragmatic randomised trial, known as Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: a Trial (CONSTRUCT), aims to compare the clinical and cost-effectiveness of infliximab and ciclosporin for steroid-resistant UC. Methods and analysis Between May 2010 and February 2013, 52 UK centres recruited 270 patients admitted with acute severe UC who failed to respond to intravenous steroids but did not need surgery. We allocated them at random in equal proportions between infliximab and ciclosporin.The primary clinical outcome measure is quality-adjusted survival, that is survival weighted by Crohns and Colitis Questionnaire (CCQ) participants’ scores, analysed by Cox regression. Secondary outcome measures include: the CCQ—an extension of the validated but community-focused UK Inflammatory Bowel Disease Questionnaire (IBDQ) to include patients with acute severe colitis and stoma; two general quality of life measures—EQ-5D and SF-12; mortality; survival weighted by EQ-5D; emergency and planned colectomies; readmissions; incidence of adverse events including malignancies, serious infections and renal disorders; disease activity; National Health Service (NHS) costs and patient-borne costs. Interviews investigate participants’ views on therapies for acute severe UC and healthcare professionals’ views on the two drugs and their administration. Ethics and dissemination The Research Ethics Committee for Wales has given ethical approval (Ref. 08/MRE09/42); each participating Trust or Health Board has given NHS Reseach & Development approval. We plan to present trial findings at international and national conferences and publish in high-impact peer-reviewed journals. Trial registration number ISRCTN: 22663589; EudraCT number: 2008-001968-36

Survey of digestive health across Europe: Final report. Part 1: The burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe

United European Gastroenterology (UEG) which represents gastroenterology and hepatology and its sub-disciplines across Europe relies on accurate and up to date information on the burden of gastrointestinal diseases in Europe, the availability and quality of diagnostic and therapeutic services and the economic impact of these diseases across the member countries of the European Union to inform its strategy in advising relevant agencies on future clinical services and research priorities. Determining the trajectory of the morbidity and mortality of digestive diseases is vital in planning health services for the future and in making the case for investment in research where there are clear gaps in knowledge. In addition there are marked economic differences across the member nations in Europe and this is reflected in the funding available to support health services, making it highly likely that there are important disparities in the accessibility to high-quality healthcare. In September 2012 the UEG Council accepted a proposal from the UEG Future Trends Committee to commission a detailed survey of digestive health across Europe. The Future Trends Committee developed an outline framework for the study, following which there was an open, competitive process across Europe to identify a competent research group to undertake the project. The contract was awarded to an experienced group within the College of Medicine, Swansea University, United Kingdom, and the project was formally initiated in April 2013. The research group at Swansea has worked closely with the Committee, including an interim update meeting with the Committee in October 2013. The Committee also had the opportunity to make specific comments on a draft final report submitted in May 2014; a final report, Survey of Digestive Health Across Europe was received in August 2014. The final report is organised into two parts: Part 1, The burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe and Part 2, The economic impact and burden of digestive disorders. We present here the executive summaries of the two parts of the survey, but the full report can be found on the UEG journal website. It is anticipated that several shorter publications will follow, focusing on some specific topics of particular importance and interest. Michael Farthing President United European Gastroenterology

Mortality following Stroke, the Weekend Effect and Related Factors: Record Linkage Study.

Background Increased mortality following hospitalisation for stroke has been reported from many but not all studies that have investigated a ‘weekend effect’ for stroke. However, it is not known whether the weekend effect is affected by factors including hospital size, season and patient distance from hospital. Objective To assess changes over time in mortality following hospitalisation for stroke and how any increased mortality for admissions on weekends is related to factors including the size of the hospital, seasonal factors and distance from hospital. Methods A population study using person linked inpatient, mortality and primary care data for stroke from 2004 to 2012. The outcome measures were, firstly, mortality at seven days and secondly, mortality at 30 days and one year. Results Overall mortality for 37 888 people hospitalised following stroke was 11.6% at seven days, 21.4% at 30 days and 37.7% at one year. Mortality at seven and 30 days fell significantly by 1.7% and 3.1% per annum respectively from 2004 to 2012. When compared with week days, mortality at seven days was increased significantly by 19% for admissions on weekends, although the admission rate was 21% lower on weekends. Although not significant, there were indications of increased mortality at seven days for weekend admissions during winter months (31%), in community (81%) rather than large hospitals (8%) and for patients resident furthest from hospital (32% for distances of >20 kilometres). The weekend effect was significantly increased (by 39%) for strokes of ‘unspecified’ subtype. Conclusions Mortality following stroke has fallen over time. Mortality was increased for admissions at weekends, when compared with normal week days, but may be influenced by a higher stroke severity threshold for admission on weekends. Other than for unspecified strokes, we found no significant variation in the weekend effect for hospital size, season and distance from hospital.

Weekend emergency admissions and mortality in England and Wales.

Increased mortality for hospital admissions at weekends has been reported for emergency admissions overall and for specific disorders, although the size of this effect varies across reports. No evidence exists that compares a wide range of emergency disorders or, for confirmatory purposes, is based on two independent information sources. Further evidence is needed to defi ne which disorders are susceptible to the weekend effect. A Wellcome Trust project of mortality after emergency admissions across England and Wales was used to investigate disorder susceptibility to the weekend effect across two different health-care systems and two independent information sources. Systematic record linkage of national administrative inpatient and mortality data was used for emergency admissions to all public hospitals across England and Wales. Mortality at 30 days was established for admissions on weekends, and compared with admissions on weekdays, for emergency disorders overall and for 15 major circulatory, gastrointestinal, respiratory, and trauma disorders from Jan 1, 2004, to Dec 31, 2012. Logistic regression modelling was used to adjust mortality for patient age, sex, and comorbidities (table, appendix). Overall mortality at 30 days after emergency admissions in England was slightly lower than in Wales (5·59% vs 5·64%). The increased mortality for weekend admissions compared with weekdays was similar in England and Wales. Mortality was higher in England than in Wales in 2004–06, similar in 2007–08, and lower in England than in Wales in 2009–10 and 2011–12. The sizes of the weekend eff ects on mortality in England and Wales were consistent for all 15 disorders and the Pearson’s correlation for each disorder across the two countries was 0·57. The weekend eff ect was strongest for abdominal aortic aneurysm followed by other disorders with very high mortality during the acute phase; pulmonary embolism, stroke, and subarachnoid haemorrhage. Little or no weekend eff ect was observed for acute myocardial infarction and less acute disorders; chronic obstructive pulmonary disease, pneumonia, hip fracture, acute pancreatitis, and inflammatory bowel disease. No signifi cant variation was observed in the weekend effect over time or across patient age groups. These data provide new evidence as to the emergency disorders that are most strongly affected by the weekend effect and show that findings are quite consistent across two health-care systems. The weekend eff ect is most apparent for disorders with very high mortality that often require access to specialist investigation and care during critical acute phases. We declare no competing interests. We acknowledge support from the Wellcome Trust (093564/Z/10/Z). We thank Judy Williams for clerical assistance, Alan Watkins for statistical advice, and the Health Information Research Unit (Swansea, UK) for access to the Secure Anonymised Information Linkage databank.

MATRICS: A Method for Aggregating The Reporting of Interventions in Complex Studies

Background There are few rigorous methods for combining qualitative and quantitative findings from studies with complex interventions using multiple research methods and giving appropriate weight to each without introducing bias to the overall conclusions. We developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) for the ENIGMA study (Evaluating Innovations in Gastroenterology by the NHS Modernisation Agency) – a multicentre, mixed-methods study to evaluate the impact of the Modernising Endoscopy Services programme [1], funded by the UK National Institute for Health Research (NIHR SDO ref 08/1304/46).

Colectomy rates in patients with ulcerative colitis following treatment with infliximab or ciclosporin: a systematic literature review.

This review aimed to compile all available published data on colectomy rates following treatment using infliximab or ciclosporin in adult ulcerative colitis patients and to analyse colectomy rates, timing to colectomy and postcolectomy mortality for each treatment. We systematically reviewed the literature after 1990 reporting colectomy rates in ulcerative colitis patients treated with infliximab or ciclosporin, excluding articles on paediatric patients, patients with indeterminate colitis or Crohn’s disease and bowel surgery not related to ulcerative colitis. We presented weighted mean colectomy rates and mortality rates. Cox’s regression was used to assess time to colectomy adjusting for colitis severity, patient age and sex. We tabulated 78 studies reporting on ciclosporin and/or infliximab and colectomy rates or postcolectomy mortality rates. Not all studies reported data in a standardized manner. Infliximab had a significantly lower colectomy rate than ciclosporin at 36 months when analysing all studies, studies directly comparing infliximab and ciclosporin and studies using severe colitis patients, but not at 3, 12 or 24 months. Severity and age were key indicators in the likelihood of undergoing colectomy after treatment. Postcolectomy mortality rates were less than 1.5% for both drugs. This review indicates that long-term colectomy rates following infliximab are significantly lower than ciclosporin in the longer term, and that postcolectomy mortality following infliximab and ciclosporin is very low. However, many key data items were missing from research articles, reducing our ability to establish with more confidence the actual impact of these two drugs on colectomy rates and postcolectomy mortality rates.

Successful development and testing of a Method for Aggregating the Reporting of Interventions in Complex Studies (MATRICS)

OBJECTIVES To develop a tool for the accurate reporting and aggregation of findings from each of the multiple methods used in a complex evaluation in an unbiased way. STUDY DESIGN AND SETTING We developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) within a gastroenterology study [Evaluating New Innovations in (the delivery and organisation of) Gastrointestinal (GI) endoscopy services by the NHS Modernisation Agency (ENIGMA)]. We subsequently tested it on a different gastroenterology trial [Multi-Institutional Nurse Endoscopy Trial (MINuET)]. We created three layers to define the effects, methods, and findings from ENIGMA. We assigned numbers to each effect in layer 1 and letters to each method in layer 2. We used an alphanumeric code based on layers 1 and 2 to every finding in layer 3 to link the aims, methods, and findings. We illustrated analogous findings by assigning more than one alphanumeric code to a finding. We also showed that more than one effect or method could report the same finding. We presented contradictory findings by listing them in adjacent rows of the MATRICS. RESULTS MATRICS was useful for the effective synthesis and presentation of findings of the multiple methods from ENIGMA. We subsequently successfully tested it by applying it to the MINuET trial. CONCLUSION MATRICS is effective for synthesizing the findings of complex, multiple-method studies.