M Shawihdi

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.

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.

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.

OTU-028 Benchmarking of activity, process and outcome of emergency admission for ulcerative colitis across english hospitals

Introduction The UK IBD Registry aims to make information work better for patients, clinical teams and the NHS. As part of the benchmarking reports provided to participating Trusts, we have developed organisational level metrics from routinely collected hospital episode statistics (HES) data – working with front-line teams to iteratively develop reports with feedback on content and local face-validity. We report national-level findings and institutional variation in activity, process and outcome of emergency care for UC. Methods Admitted patient care data for English hospitals were analysed, identifying all-cause admissions for patients with UC and constructing algorithms to identify emergency activity, track process and outcome for UC-specific emergency admissions (UC-Em-Ad), including in-hospital death (I-H-D) and emergency surgery (Em-Surg), all-cause 30 day readmission (30D-RA) and twelve month outcome. Reports containing 5 year national and local trends and cumulative 5 year performance were distributed to sites in Dec 2017. This analysis summarises selected data for 133 Trusts present in all fiscal years (11/12 to 15/16). Results Nationally, there were 31,371 UC-Em-Ad (2 65 799 bed days; median LoS 6 days; 22 809 patients; mean age 40 years; male 50%; additional coded co-morbidities in 23%) with 1451 Em-Surg (4.62%=crude surgery rate; mean age 44 years; male 56.1%), 324 I-H-D (1.03%=crude mortality rate; mean age 76 years; 67% had additional coded co-morbidities; only 16% of deaths were post-surgery), 4916 30D-RA (15.7%=crude readmission rate). At Trust level, mean (95% limits) for indirectly standardised rates were: I-H-D 1.03% (0.90%–1.15%), Em-Surg 4.79% (4.31%–5.27%), 30D-RA 15.55% (15.0%–16.1%). Few outliers were identified and none consistently over time, with no significant trends identified for volume-outcome relationships. Funnel plots and regression analyses will be presented. Conclusions These data provide real-world insights into processes and outcomes of emergency care for UC across England in the last five years, with a series of metrics to support both national and local quality improvement efforts. Linkages between HES and local Registry data offers potential to validate, refine and extend these benchmarking metrics. Funding Crohn’s and Colitis UK.

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