Modifiable risk factors that may be addressed in routine care to prevent progression to and extension of multimorbidity in people with COPD: a systematic literature review.

Chronic obstructive pulmonary disease (COPD) is a multisystem disease, and many patients have multiple conditions. We explored multimorbidity patterns that might inform intervention planning to reduce health-care costs while preserving quality of life for patients. Literature searches up to February 2022 revealed 4419 clinical observational and comparative studies of risk factors for multimorbidity in people with COPD, pulmonary emphysema, or chronic bronchitis at baseline. Of these, 29 met the inclusion criteria for this review. Eight studies were cluster and network analyses, five were regression analyses, and 17 (in 16 papers) were other studies of specific conditions, physical activity and treatment. People with COPD more frequently had multimorbidity and had up to ten times the number of disorders of those without COPD. Disease combinations prominently featured cardiovascular and metabolic diseases, asthma, musculoskeletal and psychiatric disorders. An important risk factor for multimorbidity was low socioeconomic status. One study showed that many patients were receiving multiple drugs and had increased risk of adverse events, and that 10% of medications prescribed were inappropriate. Many patients with COPD have mainly preventable or modifiable multimorbidity. A proactive multidisciplinary approach to prevention and management could reduce the burden of care.

Clinical, humanistic and economic outcomes, including experiencing of patient safety events, associated with admitting patients to single rooms compared with shared accommodation for acute hospital admissions: a systematic review and narrative synthesis.

OBJECTIVES: Assess the impact of single rooms versus multioccupancy accommodation on inpatient healthcare outcomes and processes. DESIGN: Systematic review and narrative synthesis. DATA SOURCES: Medline, Embase, Google Scholar and the National Institute for Health and Care Excellence website up to 17 February 2022. ELIGIBILITY CRITERIA: Eligible papers assessed the effect on inpatients staying in hospital of being assigned to a either a single room or shared accommodation, except where that assignment was for a direct clinical reason like preventing infection spread. DATA EXTRACTION AND SYNTHESIS: Data were extracted and synthesised narratively, according to the methods of Campbell et al. RESULTS: Of 4861 citations initially identified, 145 were judged to be relevant to this review. Five main method types were reported. All studies had methodological issues that potentially biased the results by not adjusting for confounding factors that are likely to have contributed to the outcomes. Ninety-two papers compared clinical outcomes for patients in single rooms versus shared accommodation. No clearly consistent conclusions could be drawn about overall benefits of single rooms. Single rooms were most likely to be associated with a small overall clinical benefit for the most severely ill patients, especially neonates in intensive care. Patients who preferred single rooms tended to do so for privacy and for reduced disturbances. By contrast, some groups were more likely to prefer shared accommodation to avoid loneliness. Greater costs associated with building single rooms were small and likely to be recouped over time by other efficiencies. CONCLUSIONS: The lack of difference between inpatient accommodation types in a large number of studies suggests that there would be little effect on clinical outcomes, particularly in routine care. Patients in intensive care areas are most likely to benefit from single rooms. Most patients preferred single rooms for privacy and some preferred shared accommodation for avoiding loneliness. PROSPERO REGISTRATION NUMBER: CRD42022311689.

Bridging the impactibility gap in population health management: a systematic review.

OBJECTIVES: Assess whether impactibility modelling is being used to refine risk stratification for preventive health interventions. DESIGN: Systematic review. SETTING: Primary and secondary healthcare populations. PAPERS: Articles published from 2010 to 2020 on the use or implementation of impactibility modelling in population health management, reported with the terms 'intervenability', 'amenability', and 'propensity to succeed' (PTS) and associated with the themes 'care sensitivity', 'characteristic responders', 'needs gap', 'case finding', 'patient selection' and 'risk stratification'. INTERVENTIONS: Qualitative synthesis to identify themes for approaches to impactibility modelling. RESULTS: Of 1244 records identified, 20 were eligible for inclusion. Identified themes were 'health conditions amenable to care' (n=6), 'PTS modelling' (n=8) and 'comparison or combination with clinical judgement' (n=6). For the theme 'health conditions amenable to care', changes in practice did not reduce admissions, particularly for ambulatory care sensitive conditions, and sometimes increased them, with implementation noted as a possible issue. For 'PTS modelling', high costs and needs did not necessarily equate to high impactibility and targeting a larger number of individuals with disorders associated with lower costs had more potential. PTS modelling seemed to improve accuracy in care planning, estimation of cost savings, engagement and/or care quality. The 'comparison or combination with clinical judgement' theme suggested that models can reach reasonable to good discriminatory power to detect impactable patients. For instance, a model used to identify patients appropriate for proactive multimorbid care management showed good concordance with physicians (c-statistic 0.75). Another model employing electronic health record scores reached 65% concordance with nurse and physician decisions when referring elderly hospitalised patients to a readmission prevention programme. However, healthcare professionals consider much wider information that might improve or impede the likelihood of treatment impact, suggesting that complementary use of models might be optimum. CONCLUSIONS: The efficiency and equity of targeted preventive care guided by risk stratification could be augmented and personalised by impactibility modelling.

Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative.

OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia. Undiagnosed and poorly managed AF increases risk of stroke. The Hounslow AF quality improvement (QI) initiative was associated with improved quality of care for patients with AF through increased detection of AF and appropriate anticoagulation. This study aimed to evaluate whether there has been a change in stroke and bleeding rates in the Hounslow population following the QI initiative. METHODS: Using hospital admissions data from January 2011 to August 2018, interrupted time series analysis was performed to investigate the changes in standardised rates of admission with stroke and bleeding, following the start of the QI initiative in October 2014. RESULTS: There was a 17% decrease in the rate of admission with stroke as primary diagnosis (incidence rate ratio (IRR) 0.83; 95% CI 0.712 to 0.963; p<0.014). There was an even larger yet not statistically significant decrease in admission with stroke as primary diagnosis and AF as secondary diagnosis (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071). No significant changes were observed in bleeding admissions. For each outcome, an additional regression model including both the level change and an interaction term for slope change was created. In all cases, the slope change was small and not statistically significant. CONCLUSION: Reduction in stroke admissions may be associated with the AF QI initiative. However, the immediate level change and non-significant slope change suggests a lack of effect of the intervention over time and that the decrease observed may be attributable to other events.

Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation.

OBJECTIVE: To assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England. METHODS: Data on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011-June 2014 and July 2014-December 2017. RESULTS: Between 2011-2014 and 2014-2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI -11.5% to -11.1%) from 86 467 in 2011-2014 to 76 730 in 2014-2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289. CONCLUSIONS: Despite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.

"Bow-tie" optimal pathway discovery analysis of sepsis hospital admissions using the Hospital Episode Statistics database in England.

OBJECTIVE: The "Bow-tie" optimal pathway discovery analysis uses large clinical event datasets to map clinical pathways and to visualize risks (improvement opportunities) before, and outcomes after, a specific clinical event. This proof-of-concept study assesses the use of NHS Hospital Episode Statistics (HES) in England as a potential clinical event dataset for this pathway discovery analysis approach. MATERIALS AND METHODS: A metaheuristic optimization algorithm was used to perform the "bow-tie" analysis on HES event log data for sepsis (ICD-10 A40/A41) in 2016. Analysis of hospital episodes across inpatient and outpatient departments was performed for the period 730 days before and 365 days after the index sepsis hospitalization event. RESULTS: HES data captured a sepsis event for 76 523 individuals (>13 years), relating to 580 000 coded events (across 220 sepsis and non-sepsis event classes). The "bow-tie" analysis identified several diagnoses that most frequently preceded hospitalization for sepsis, in line with the expectation that sepsis most frequently occurs in vulnerable populations. A diagnosis of pneumonia (5 290 patients) and urinary tract infections (UTIs; 2 057 patients) most often preceded the sepsis event, with recurrent UTIs acting as a potential indicative risk factor for sepsis. DISCUSSION: This proof-of-concept study demonstrates that a "bow-tie" pathway discovery analysis of the HES database can be undertaken and provides clinical insights that, with further study, could help improve the identification and management of sepsis. The algorithm can now be more widely applied to HES data to undertake targeted clinical pathway analysis across multiple healthcare conditions.

A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation.

Aims: To determine whether changing patterns of anticoagulant use in atrial fibrillation (AF) have impacted on stroke rates in England. Methods and results: English national databases, 2006-2016, were interrogated to assess stroke admissions and oral anticoagulant use. The number of patients with known AF increased linearly from 692 054 to 983 254 (prevalence 1.29% vs. 1.71%). Hospital episodes of AF-related stroke/100 000 AF patients increased from 80/week in 2006 to 98/week in 2011 and declined to 86/week in 2016 (2006-2011 difference 18.0, 95% confidence interval (CI) 17.9-18.1, 2011-2016 difference -12.0, 95% CI -12.1 to -11.9). Anticoagulant use amongst patients with CHA2DS2-VASc ≥2 increased from 48.0% to 78.6% and anti-platelet use declined from 42.9% to 16.1%; the greatest rate of change occurred in the second 5 year period (for anticoagulants 2006-2011 difference 4.8%, 95% CI 4.5-5.1%, 2011-2016 difference 25.8%, 95% CI 25.5-26.1%). After adjustment for AF prevalence, a 1% increase in anticoagulant use was associated with a 0.8% decrease in the weekly rate of AF-related stroke (incidence rate ratio 0.992, 95% CI 0.989-0.994). Had the use of anticoagulants remained at 2009 levels, 4068 (95% CI 4046-4089) more strokes would have been predicted in 2015/2016. Conclusion: Between 2006 and 2016, AF prevalence and anticoagulant use in England increased. From 2011, hospitalized AF-related stroke rates declined and were significantly associated with increased anticoagulant uptake.