M Pearson

What does distance matter? Leprosy control in West Nepal

One of the major planks of leprosy control strategies is that distance from established treatment centres deters leprosy cases from seeking treatment. The integration of leprosy care with locally available primary health care services is therefore a common feature of leprosy control programmes. Within these guidelines, a National Leprosy Control Programme was established in Nepal in 1975, with intensive case-finding surveys and the provision of leprosy care in government basic health posts. A study of one district, Lamjung, in West Nepal suggests that far from being a deterrent, distance afforded welcome anonymity for leprosy cases anxious to disguise their diagnosis and thereby avoid the social ostracism which could result. Cases from ethnic groups in which the stigma of leprosy was high travelled farther for treatment. Gender differences in distance travelled suggest that womens mobility was restricted, but the local availability of care did not increase attendance for regular treatment. It is suggested that this was more the result of poor quality of care than fear of being known locally as a leprosy case.

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.

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.

Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study

We wanted to find out if 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.

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.

PTH-090 Monitoring unplanned care and surgical events for crohn’s disease patients treated with biologics in england: linkage of routine administrative data and uk ibd registry

Introduction The UK IBD Registry (UK-IBD-R) is developing analyses of Hospital Episode Statistics (HES) with linkage to locally-recorded registry data to generate aggregated reports and indicators to support IBD services. We have created methods to categorise relevant hospital events and track outcomes in HES. For this project, we produced metrics of unplanned care and surgical events before and after initiation of biologics, generating a national scale analysis from HES alone and a proof-of-concept study with linkage to UK-IBD-R. Method Datasets: HES for England (04/05 to 13/14); UK-IBD-R dataset (to June 2016). Patient cohorts: (1) HES cohort identified using HES only. We flagged all admissions (incl. daycases) with a diagnosis of CD and procedure code X921 (biologic infusion; assumed to be infliximab), locating 1 st infusion for each case; (2) Registry cohort was based on anonymized linkage (undertaken by NHS Digital), identifying cases with a registry-recorded diagnosis of CD, a medication entry for anti-TNF drug (infliximab, inflectra or adalimumab) and a valid start date. Hospital events in HES: All-cause episodes were extracted for 1 year before (Yr-Pre) and after (Yr-Post) start of treatment, categorising each inpatient and daycase event based on admission method, diagnoses (IBD-specific, IBD-related and Other) and procedures. Abstract PTH-090 Figure 1 Results HES cohort: n=15 399 (Age: 35 [16]; 47% male); Registry cohort: n=217 (Age: 26 [13.5]; 56% male). Unplanned care activity for Yr-Pre versus Yr-Post are shown in Abstract PTH090 Figure 1, confirming substantial reductions in all-cause and CD-specific emergency care following initiation of biologics in routine UK practice (p<0.05). Of HES cohort, 10 877 (71%) continued infusion visits beyond induction phase (’Maintenance’), and 4522 (29%) did not (’Stopped’). Surgical resections at 1 year: Total, 944 (6.2%); Maintenance versus Stopped: 395 (3.6%) v. 549 (12%), p<0.05. Emergency admissions with ‘infections’ at 1 year: Total, 222 (1.4%); Maintenance versus Stopped: 146 (1.3%) v. 76 (1.7%), p=0.11. Conclusion These national scale data provide new insights into activity, costs and outcomes associated with routine use of biologics for CD in England. Linkage between UK-IBD-R and HES provides a potentially powerful tool for monitoring of activity, process and outcome of IBD care. The use of existing datasets reduces the burden of local point-of-care data collection, allowing focus on collecting items to enhance accuracy and clinical depth of analyses. [Funding: Crohn’s and Colitis UK] Disclosure of Interest None Declared

PTH-096 Improved outcomes of emergency admission for ulcerative colitis (uc) in england over the last decade: a ten year analysis of routine nhs data

Introduction Hypothesis: Over the last decade, therapy advances and a national audit programme should have improved outcomes for UC patients admitted as emergencies (Em). Method To support IBD Registry analytics, we have developed metrics from routine NHS data to allow reporting of trends in national-level indicators of IBD care. Design: Retrospective analysis of 10 years of HES data for England. Target population: 54,533 Em. admissions with UC as primary diagnosis (April ‘05 to March ‘13; n=37 170 patients). Binary Outcome Measures: Surgery (colectomy) during index admission (Sx-Index) or within 1 year (Sx-1-Year); Em. readmission within 30 days of discharge (Readmit-30d); Inpatient death during index admission (Death-Index). Case-mix Variables: Age, Gender, Co-morbidities (0, 1 or 2+, Charlson), Deprivation Status (IMD Quintiles), Any Cancer, Em. bed bays (all-cause) in preceding year (EmBedDaysLastYr). Predictor Variable: Year of Admission (Yr-Adm). Analyses: Uni- and multivariable logistic regression (stepwise), reporting adjusted odds ratios (OR) for retained variables. Adjusted for repeat admissions in same patient (clustered standard errors). Results Multivariable Models: OR for Sx-Index was reduced with increased age (0.98 per yr), 2+ co-morbidities (0.81 vs. none), females (0.74 vs. male) and for >28 EmBedDaysLastYr. OR for Death-Index was increased with increased age (1.10 per yr), co-morbidities (1.87 for one, 3.2 for two or more, vs none) and colectomy during admission (6.99 vs. no surgery) but reduced for >28 EmBedDaysLastYr (0.88 vs. none). Models for Sx-1-Year showed a similar pattern with respect to reduced OR for age, co-morbidity and females. For Readmit-30d, the most significant factor associated with reduced OR was colectomy during admission (0.43), whereas >28 EmBedDaysLastYr was associated with increased OR (2.0 vs. none). Deprivation status was not independently associated with any outcome. After adjusting for these co-variates, Yr-Adm was associated with a significant reduction in OR for both Sx-Index and Death-Index, with OR of 0.98 (0.976–0.998) and 0.91 (0.88, 0.94) per yr relative to base year. Models for all-cause admissions did not show these trends, suggesting condition-specific findings. Conclusion Risk of colectomy and inpatient death for UC patients admitted as emergencies to English hospitals has reduced over the last 10 years. Many factors may explain these trends, but cycles of UK-wide IBD audit are likely contributors. We found no signal for social inequality, but a reduced odds of surgery for females requires further study. Funding: Crohn’s and Colitis UK Disclosure of Interest M. Shawihdi: None Declared, S Dodd: None Declared, R Grainger: None Declared, S Bloom: None Declared, F Cummings: None Declared, R Driscoll: None Declared, M Pearson: None Declared, P Williamson: None Declared, K Bodger Conflict with: AbbVie, Conflict with: Boston Scientific | Takeda

PWE-143 Development of Informatics Tools for The UK IBD Registry Using Routine Data: Profiling of National-Level Hospital Activity for IBD Patients in England

Introduction We report a project to generate profiles of NHS activity for IBD patients receiving care in English hospitals, with national and local level activity reports (Trust and Primary Care Organisation) as the basis for clinically validated metrics to support services. Methods COHORT: 352,614 patients with a specific IBD diagnosis between 2003/4 and 2013/14. DATASETS: All-cause events for the cohort for each year from HES datasets: Admitted Patient Care (APC, daycase and inpatient care), Outpatient (OP) and Accident & Emergency (A&E). Source: Health & Social Care Information Centre. ANALYSIS: In IBM-SPSS, Excel and SAS. Clinical review of ICD-10 (diagnosis) and OPCS-4 (procedure) codes for all APC events, categorising all-cause activity into logical baskets of IBD-related primary diagnoses (e.g. perianal abscess) or procedures (e.g. colonoscopies). APCcategorised as elective daycases (El-D), admissions (El-Ad) or emergencies (Em-Ad). The OP dataset lacks diagnosis, so categorised by GI-relevant specialities. A&E contacts were all-cause (non-admitted). Data reported are 2013/14. Results APC: 149,115 IBD patients (42% of cohort) had hospital admission in 13/14 (389,574 admissions; El-D, 246,064; El-Ad, 26,911; Em-Ad, 105,482; Other, 11,117). Of Em-Ad, the primary diagnosis code was IBD-specific in 17,274 (CD: 10,077; UC: 7,197), non-specific IBD in 455, IBD-related conditions in 9,709, relevant GI symptoms in 6,934, benign anorectal conditions in 2,445, anaemias in 1,158, enteric infections in 1,148, colonic or small bowel cancers in 472. Categorising Em-Ad by procedures identified 5,515 with GI surgery (Perianal: 1,233; Colonic or SB resection: 1,547). Of El-Ad, 7,030 included GI surgery. El-D included 70,354 lower endoscopies and 73,968 infusions/injections. Outpatient Activity: 244,248 IBD patients (69% of cohort) attended clinic (1,351,807 all-cause visits), of which 387,503 were gastroenterology or general surgery. A&E Activity: 98,838 all-cause attendances for 53,083 IBD patients (non-admitted). At organisation level (PCT), mean emergency bed days (primary IBD diagnosis) was 247 per 100,000. Conclusion Analysis of IBD-related hospital activity in routine data is possible but requires complex algorithms. Our candidate metrics at Trust and Primary Care Organisation level will be shared with front line teams, including links between A&E, OPD and APC events and refined iteratively. Linkage to IBD Registry dataset has been tested and will allow future enhancements. Disclosure of Interest M. Shawihdi Grant/research support from: Crohn’s & Coliitis UK, A. Osborne: None Declared, E. Devonport: None Declared, R. Driscoll Consultant for: AbbVie, F. Cummings: None Declared, S. Bloom: None Declared, P. Williamson: None Declared, M. Pearson: None Declared, K. Bodger Grant/research support from: Crohn’s & Colitis UK, Speaker bureau with: AbbVie

PTU-064 Trends in Mortality for IBD Patients Admitted as an Emergency to English Hospitals: A 10-Year Analysis of Routine Administrative Data

Introduction To support the development of metrics for the UK IBD Registry, techniques are being developed to analyse Hospital Episode Statistics (HES) for England. This report is focused on in-hospital deaths (In-HD) recorded for all-cause and cause-specific emergency admissions (Em-Ad) among a nationwide cohort of IBD patients over ten years. Consecutive rounds of UK IBD Audit have suggested declining inpatient mortality in the UK, albeit limited by incomplete case capture and ascertainment bias. Methods COHORT: Any patient with a coded diagnosis of ulcerative colitis or Crohn’s disease, identified between 04/05 to 13/14. DATA EXTRACT: All-cause hospital episodes belonging to the cohort during this period (Source: Health & Social Care Information Centre). ANALYSIS: Datasets were interrogated using algorithms in IBM-SPSS, SAS and Excel, with admission and patient-level analyses. We applied a range of definitions to extract IBD-associated Em-Ad based on coded diagnoses and procedures, ranging from a narrow focus (primary diagnosis of IBD-specific codes) to broader categories (flagging of specific GI symptoms [R-codes] or selected conditions, complications or procedures suggestive of an IBD-related Em-Ad). Coding lists were informed by steering group review. Numbers and crude population-based rates of Em-Ad and In-HD were examined for each category of Em-Ad. Risk-adjusted odds ratio of death (OR) for each year were compared (co-variates: age, gender, Charlson index, Cancer codes), relative to baseline (04/05), in logistic regression models at individual patient level (first admission). Mid-year populations for England (18+) were obtained from ONS. Results 352,614 IBD patients had 887,837 all-cause Em-Ad (aged 18+). Focusing only on admissions with a primary diagnosis of IBD, there were 141,063 Em-Ad (UC = 60,278; CD = 80,785); 1,701 in-hospital deaths; a year-on-year decline in crude admission death rate (2.0% to 0.7%) and population-based rate (0.60 to 0.28 I-HD per 100,000 population). Relative to baseline year, the risk-adjusted odds ratio (OR) for death during Em-Ad (first admission with primary diagnosis; n = 82,248 patients) declined steadily over the decade (2013/14 vs 2004/5, OR: 0.43 [0.33 to 0.56]). Further modelling and sensitivity analyses will be reported. Conclusion Over the last decade there has been a significant reduction in hospital mortality for IBD patients admitted as an emergency to English hospitals. Although many factors may contribute to these improved statistics, the time period included 4 rounds of UK wide audit focusing on raising standards for in-patient care. Disclosure of Interest M. Shawihdi Grant/research support from: Crohn’s & Coliitis UK, R. Driscoll Consultant for: AbbVie, M. Pearson: None Declared, F. Cummings: None Declared, S. Bloom: None Declared, P. Williamson: None Declared, K. Bodger Grant/research support from: Crohn’s & Colitis UK, Speaker bureau with: AbbVie

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.