Michael Pearson

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 1u2005year. Covariates were: age group, gender, comorbidity, general practice average deprivation and patient deprivation. Results 22u2005488 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.

National Audit of Seizure management in Hospitals (NASH): results of the national audit of adult epilepsy in the UK

Objectives About 100u2005000 people present to hospitals each year in England with an epileptic seizure. How they are managed is unknown; thus, the National Audit of Seizure management in Hospitals (NASH) set out to assess prior care, management of the acute event and follow-up of these patients. This paper describes the data from the second audit conducted in 2013. Setting 154 emergency departments (EDs) across the UK. Participants Data from 4544 attendances (median age of 45u2005years, 57% men) showed that 61% had a prior diagnosis of epilepsy, 12% other neurological problems and 22% were first seizure cases. Each ED identified 30 consecutive adult cases presenting due to a seizure. Primary and secondary outcome measures Details were recorded of the patients prior care, management at hospital and onward referral to neurological specialists onto an online database. Descriptive results are reported at national level. Results Of those with epilepsy, 498 (18%) were on no antiepileptic drug therapy and 1330 (48%) were on monotherapy. Assessments were often incomplete and witness histories were sought in only 759 (75%) of first seizure patients, 58% were seen by a senior doctor and 57% were admitted. For first seizure patients, advice on further seizure management was given to 264 (27%) and only 55% were referred to a neurologist or epilepsy specialist. For each variable, there was wide variability among sites that was not explicable. For the sites who partook in both audits, there was a trend towards better care in 2013, but this was small and dwarfed by the intersite variability. Conclusions These results have parallels with the Sentinel Audit of Stroke performed a decade earlier. There is wide intersite variability in care covering the entire care pathway, and a need for better organised and accessible care for these patients.

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

BACKGROUNDnAll-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.nnnOBJECTIVEnTo 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.nnnDESIGNnHospital 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.nnnMAIN OUTCOME MEASUREMENTSnDeath within 30 days of the first ERCP procedure.nnnRESULTSnWe 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).nnnLIMITATIONSnThe completeness and accuracy of coding may vary between different hospitals. Routine coding does not capture information about procedural complexity or severity of illness.nnnCONCLUSIONnLinkage 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.

Comparison of case note review methods for evaluating quality and safety in health care

OBJECTIVESnTo determine which of two methods of case note review--holistic (implicit) and criterion-based (explicit)--provides the most useful and reliable information for quality and safety of care, and the level of agreement within and between groups of health-care professionals when they use the two methods to review the same record. To explore the process-outcome relationship between holistic and criterion-based quality-of-care measures and hospital-level outcome indicators.nnnDATA SOURCESnCase notes of patients at randomly selected hospitals in England.nnnREVIEW METHODSnIn the first part of the study, retrospective multiple reviews of 684 case notes were undertaken at nine acute hospitals using both holistic and criterion-based review methods. Quality-of-care measures included evidence-based review criteria and a quality-of-care rating scale. Textual commentary on the quality of care was provided as a component of holistic review. Review teams comprised combinations of: doctors (n = 16), specialist nurses (n = 10) and clinically trained audit staff (n = 3) and non-clinical audit staff (n = 9). In the second part of the study, process (quality and safety) of care data were collected from the case notes of 1565 people with either chronic obstructive pulmonary disease (COPD) or heart failure in 20 hospitals. Doctors collected criterion-based data from case notes and used implicit review methods to derive textual comments on the quality of care provided and score the care overall. Data were analysed for intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs) and completeness of criterion data capture, and comparisons were made within and between staff groups and between review methods. To explore the process-outcome relationship, a range of publicly available health-care indicator data were used as proxy outcomes in a multilevel analysis.nnnRESULTSnOverall, 1473 holistic and 1389 criterion-based reviews were undertaken in the first part of the study. When same staff-type reviewer pairs/groups reviewed the same record, holistic scale score inter-rater reliability was moderate within each of the three staff groups [intraclass correlation coefficient (ICC) 0.46-0.52], and inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61-0.88). When different staff-type pairs/groups reviewed the same record, agreement between the reviewer pairs/groups was weak to moderate for overall care (ICC 0.24-0.43). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement (p-values for difference 0.406 and 0.223, respectively), although results from all three staff types showed no overall level of agreement (p-value for difference 0.057). Detailed qualitative analysis of the textual data indicated that the three staff types tended to provide different forms of commentary on quality of care, although there was some overlap between some groups. In the process-outcome study there generally were high criterion-based scores for all hospitals, whereas there was more interhospital variation between the holistic review overall scale scores. Textual commentary on the quality of care verified the holistic scale scores. Differences among hospitals with regard to the relationship between mortality and quality of care were not statistically significant.nnnCONCLUSIONSnUsing the holistic approach, the three groups of staff appeared to interpret the recorded care differently when they each reviewed the same record. When the same clinical record was reviewed by doctors and non-clinical audit staff, there was no significant difference between the assessments of quality of care generated by the two groups. All three staff groups performed reasonably well when using criterion-based review, although the quality and type of information provided by doctors was of greater value. Therefore, when measuring quality of care from case notes, consideration needs to be given to the method of review, the type of staff undertaking the review, and the methods of analysis available to the review team. Review can be enhanced using a combination of both criterion-based and structured holistic methods with textual commentary, and variation in quality of care can best be identified from a combination of holistic scale scores and textual data review.

Qualitative study of paramedics' experiences of managing seizures: a national perspective from England

Objectives The UK ambulance service is expected to now manage more patients in the community and avoid unnecessary transportations to hospital emergency departments (ED). Most people it attends who have experienced seizures have established epilepsy, have experienced uncomplicated seizures and so do not require the full facilities of an ED. Despite this, most are transported there. To understand why, we explored paramedics’ experiences of managing seizures. Design and setting Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed. Participants A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics. Results Participants’ confirmed how most seizure patients attended to do not clinically require an ED. They explained, however, that a number of factors influence their care decisions and create a momentum for these patients to still be taken. Of particular importance was the lack of access paramedics have to background medical information on patients. This, and the limited seizure training paramedics receive, meant paramedics often cannot interpret with confidence the normality of a seizure presentation and so transport patients out of precaution. The restricted time paramedics are expected to spend ‘on scene’ due to the way the ambulance services’ performance is measured and that are few alternative care pathways which can be used for seizure patients also made conveyance likely. Conclusions Paramedics are working within a system that does not currently facilitate non-conveyance of seizure patients. Organisational, structural, professional and educational factors impact care decisions and means transportation to ED remains the default option. Improving paramedics access to medical histories, their seizure management training and developing performance measures for the service that incentivise care that is cost-effective for all of the health service might reduce unnecessary conveyances to ED.

A structured judgement method to enhance mortality case note review: development and evaluation

Background Case note review remains a prime means of retrospectively assessing quality of care. This study examines a new implicit judgement method, combining structured reviewer comments with quality of care scores, to assess care of people who die in hospital. Methods Using 1566 case notes from 20 English hospitals, 40 physicians each reviewed 30–40 case notes, writing structured judgement-based comments on care provided within three phases of care, and on care overall, and scoring quality of care from 1 (unsatisfactory) to 6 (very best care). Quality of care comments on 119 people who died (7.6% of the cohort) were analysed independently by two researchers to investigate how well reviewers provided structured short judgement notes on quality of care, together with appropriate care scores. Consistency between explanatory textual data and related scores was explored, using overall care score to group cases. Results Physician reviewers made informative, clinical judgement-based comments across all phases of care and usually provided a coherent quality of care score relating to each phase. The majority of comments (83%) were explicit judgements. About a fifth of patients were considered to have received less than satisfactory care, often experiencing a series of adverse events. Conclusions A combination of implicit judgement, explicit explanatory comment and related quality of care scores can be used effectively to review the spectrum of care provided for people who die in hospital. The method can be used to quickly evaluate deaths so that lessons can be learned about both poor and high quality care.

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

BACKGROUNDnApplying 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.nnnAIMSnTo 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.nnnMETHODSnPractice 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.nnnRESULTSnOf 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.nnnCONCLUSIONSnComputer-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.

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.

Referral patterns after a seizure admission in an English region: an opportunity for effective intervention? An observational study of routine hospital data

Objectives To identify emergency seizure admissions to hospital and their subsequent access to specialist outpatient services. Design Algorithmic analysis of anonymised routine hospital data over 7u2005years using specialist follow-up by 3u2005months as the target outcome. Population All adults resident in Merseyside and Cheshire, England. Main Outcomes Whether, and when, access to the specialist advice that might prevent further admissions was offered. Results 1.4% of all emergency medical admissions are as a result of seizure. In the following 12u2005months 35% were readmitted and experienced a mean of 2.3 emergency department visits. Only 27% (48% of those already known to specialists and 13% of those not known) were offered appointments. Subsequent attendance at a specialist clinic is more likely if already known to a clinic, if aged <35u2005years, if female, or required a longer spell in hospital. Extrapolation from other work suggests 100u2005000 bed days per annum could be saved. Conclusions Most seizure admissions are not being referred for the help that could prevent future admissions. The majority of those that are referred are not seen within an appropriate time frame. Our service structures are not providing an optimum service for people with epilepsy.

Paramedics' views on their seizure management learning needs: a qualitative study in England

Introduction The UK ambulance service often attends to suspected seizures. Most persons attended to will not require the facilities of a hospital emergency department (ED) and so should be managed at scene or by using alternative care pathways. Most though are transported to ED. One factor that helps explain this is paramedics can have low confidence in managing seizures. Objectives With a view to ultimately developing additional seizure management training for practicing paramedics, we explored their learning needs, delivery preferences and potential drivers and barriers to uptake and effectiveness. Design and setting Semistructured interviews were conducted with a purposive sample of paramedics from the English ambulance service. Interviews were transcribed and thematically analysed. Participants A diverse sample of 19 professionals was recruited from 5 different ambulance NHS trusts and the College of Paramedics. Results Participants said seizure management was neglected within basic and postregistration paramedic training. Most welcomed additional learning opportunities and identified gaps in knowledge. This included how to differentiate between seizure types and patients that do and do not need ED. Practical, interactive e-learning was deemed the most preferable delivery format. To allow paramedics to fully implement any increase in skill resulting from training, organisational and structural changes were said to be needed. This includes not penalising paramedics for likely spending longer on scene. Conclusions This study provides the first evidence on the learning needs and preferences of paramedics regarding seizures. It can be used to inform the development of a bespoke training programme for paramedics. Future research should develop and then assess the benefit such training has on paramedic confidence and on the quality of care they offer to seizure patients.