Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study.

BACKGROUND: Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions. METHODS AND FINDINGS: We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26-5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34-8.47, p < 0.001) and sustained trend increase (3.14, 3.08-3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of -22.8 (-24.5 to -21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; -15.0, -15.5 to -14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of -2.28 (-2.98 to -1.57, p = 0.002) and sustained decrease in trend of -0.88 (-1.12 to -0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change -5.04, -7.56 to -2.51, p = 0.011), women aged 20 to 24 years (step change -4.52, -7.48 to -1.57, p = 0.030), and women from the most deprived group (step change -4.40, -6.89 to -1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of -5.31 abortions per 1,000 women, or -38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings. CONCLUSIONS: In this study, we found that LARC uptake increased and abortions fell in the period after the P4P scheme in British primary care, with additional impact for young women aged 20-24 years and those from deprived backgrounds.

Smoking Status at Diagnosis and Subsequent Smoking Cessation: Associations With Corticosteroid Use and Intestinal Resection in Crohn's Disease.

BACKGROUND: The impact of smoking at diagnosis and subsequent smoking cessation on clinical outcomes in Crohn's disease (CD) has not been evaluated in a population-based cohort. METHODS: Using a nationally representative clinical research database, we identified incident cases of CD between 2005 and 2014. We compared the following outcomes: overall corticosteroid (CS) use; flares requiring CS; CS dependency and intestinal surgery between smokers and non-smokers at time of CD diagnosis. Differences in these outcomes were also compared between persistent smokers and smokers who quit within 2 years of diagnosis. RESULTS: We identified 3553 patients with a new CD diagnosis over the study period of whom 1121 (32%) were smokers. Smokers at CD diagnosis had significantly higher CS-use (56 versus 47%, p < 0.0001), proportionally more CS flares (>1 CS flare/year: 9 versus 6%, p < 0.0001), and higher CS dependency (27 versus 21%, p < 0.0001) than non-smokers. Regression analysis identified smoking at diagnosis to be associated with a higher risk of intestinal surgery (HR 1.64, 95% CI 1.16-2.52). There was a significantly higher proportion of 'quitters' who remained steroid-free through follow-up in comparison to 'persistent smokers' (45.4 versus 37.5%, respectively, p = 0.02). 'Quitters' also had lower rates of CS dependency compared to 'persistent smokers' (24 versus 33%, p = 0.008). CONCLUSIONS: Smokers at CD diagnosis have higher CS-use, CS dependency and higher risk of intestinal surgery. Quitting smoking appears to have beneficial effects on disease related outcomes, including reducing CS dependency highlighting the importance of offering early smoking cessation support.

Impact of preventive primary care on children's unplanned hospital admissions: a population-based birth cohort study of UK children 2000-2013.

BACKGROUND: Universal health coverage (UHC) aims to improve child health through preventive primary care and vaccine coverage. Yet, in many developed countries with UHC, unplanned and ambulatory care sensitive (ACS) hospital admissions in childhood continue to rise. We investigated the relation between preventive primary care and risk of unplanned and ACS admission in children in a high-income country with UHC. METHODS: We followed 319,780 children registered from birth with 363 English practices in Clinical Practice Research Datalink linked to Hospital Episodes Statistics, born between January 2000 and March 2013. We used Cox regression estimating adjusted hazard ratios (HR) to examine subsequent risk of unplanned and ACS hospital admissions in children who received preventive primary care (development checks and vaccinations), compared with those who did not. RESULTS: Overall, 98% of children had complete vaccinations and 87% had development checks. Unplanned admission rates were 259, 105 and 42 per 1000 child-years in infants (aged < 1 year), preschool (1-4 years) and primary school (5-9 years) children, respectively. Lack of preventive care was associated with more unplanned admissions. Infants with incomplete vaccination had increased risk for all unplanned admissions (HR 1.89, 1.79-2.00) and vaccine-preventable admissions (HR 4.41, 2.59-7.49). Infants lacking development checks had higher risk for unplanned admission (HR 4.63, 4.55-4.71). These associations persisted across childhood. Children who had higher consulting rates with primary care providers also had higher risk of unplanned admission (preschool children: HR 1.17, 1.17-1.17). One third of all unplanned admissions (62,154/183,530) were for ACS infectious illness. Children with chronic ACS conditions, asthma, diabetes or epilepsy had increased risk of unplanned admission (HR 1.90, 1.77-2.04, HR 11.43, 8.48-15.39, and HR 4.82, 3.93-5.91, respectively). These associations were modified in children who consulted more in primary care. CONCLUSIONS: A high uptake of preventive primary care from birth is associated with fewer unplanned and ACS admissions in children. However, the clustering of poor health, a lack of preventive care uptake, and social deprivation puts some children with comorbid conditions at very high risk of admission. Strengthening immunisation coverage and preventive primary care in countries with poor UHC could potentially significantly reduce the health burden from hospital admission in children.

The weekend effect: does hospital mortality differ by day of the week? A systematic review and meta-analysis.

BACKGROUND: The concept of a weekend effect, poorer outcomes for patients admitted to hospitals at the weekend is not new, but is the focus of debate in England. Many studies have been published which consider outcomes for patients on admitted at the weekend. This systematic review and meta-analysis aims to estimate the effect of weekend admission on mortality in UK hospitals. METHODS: This is a systematic review and meta-analysis of published studies on the weekend effect in UK hospitals. We used EMBASE, MEDLINE, HMIC, Cochrane, Web of Science and Scopus to search for relevant papers. We included systematic reviews, randomised controlled trials and observational studies) on patients admitted to hospital in the UK and published after 2001. Our outcome was death; studies reporting mortality were included. Reviewers identified studies, extracted data and assessed the quality of the evidence, independently and in duplicate. Discrepancy in assessment was considered by a third reviewer. All meta-analyses were performed using a random-effects meta-regression to incorporate the heterogeneity into the weighting. RESULTS: Forty five articles were included in the qualitative synthesis. 53% of the articles concluded that outcomes for patients either undergoing surgery or admitted at the weekend were worse. We included 39 in the meta-analysis which contributed 50 separate analyses. We found an overall effect of 1.07 [odds ratio (OR)] (95%CI:1.03-1.12), suggesting that patients admitted at the weekend had higher odds of mortality than those admitted during the week. Sub-group analyses suggest that the weekend effect remained when measures of case mix severity were included in the models (OR:1.06 95%CI:1.02-1.10), but that the weekend effect was not significant when clinical registry data was used (OR:1.03 95%CI: 0.98-1.09). Heterogeneity was high, which may affect generalisability. CONCLUSIONS: Despite high levels of heterogeneity, we found evidence of a weekend effect in the UK, even after accounting for severity of disease. Further work is required to examine other potential explanations for the "weekend effect" such as staffing levels and other organisational factors. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews -registration number: CRD42016041225 .

Training community healthcare workers on the use of information and communication technologies: a randomised controlled trial of traditional versus blended learning in Malawi, Africa.

BACKGROUND: Despite the increasing uptake of information and communication technologies (ICT) within healthcare services across developing countries, community healthcare workers (CHWs) have limited knowledge to fully utilise computerised clinical systems and mobile apps. The 'Introduction to Information and Communication Technology and eHealth' course was developed with the aim to provide CHWs in Malawi, Africa, with basic knowledge and computer skills to use digital solutions in healthcare delivery. The course was delivered using a traditional and a blended learning approach. METHODS: Two questionnaires were developed and tested for face validity and reliability in a pilot course with 20 CHWs. Those were designed to measure CHWs' knowledge of and attitudes towards the use of ICT, before and after each course, as well as their satisfaction with each learning approach. Following validation, a randomised controlled trial was conducted to assess the effectiveness of the two learning approaches. A total of 40 CHWs were recruited, stratified by position, gender and computer experience, and allocated to the traditional or blended learning group using block randomisation. Participants completed the baseline and follow-up questionnaires before and after each course to assess the impact of each learning approach on their knowledge, attitudes, and satisfaction. Per-item, pre-post and between-group, mean differences for each approach were calculated using paired and unpaired t-tests, respectively. Per-item, between-group, satisfaction scores were compared using unpaired t-tests. RESULTS: Scores across all scales improved after attending the traditional and blended learning courses. Self-rated ICT knowledge was significantly improved in both groups with significant differences between groups in seven domains. However, actual ICT knowledge scores were similar across groups. There were no significant differences between groups in attitudinal gains. Satisfaction with the course was generally high in both groups. However, participants in the blended learning group found it more difficult to follow the content of the course. CONCLUSIONS: This study shows that there is no difference between blended and traditional learning in the acquisition of actual ICT knowledge among community healthcare workers in developing countries. Given the human resource constraints in remote resource-poor areas, the blended learning approach may present an advantageous alternative to traditional learning.

Evaluation of community provision of a preventive cardiovascular programme - the National Health Service Health Check in reaching the under-served groups by primary care in England: cross sectional observational study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England's National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups. METHODS: Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs). We assessed variation between local authorities in terms of age, sex, deprivation and ethnicity structures using two sample t-tests and within local authority variation in terms of ethnicity and deprivation using Chi squared tests and two sample t-tests respectively. RESULTS: Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs - namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40-49 and 50-59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs. CONCLUSIONS: Community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities therein.

Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012: Retrospective Cohort Study.

OBJECTIVE: To compare trends in pediatric emergency appendectomy and adverse surgical outcomes between district general hospitals (DGHs) and specialist pediatric centers (SPCs). BACKGROUND: In the past decades in England, a significant reduction in the number of children operated by adult general surgeons has raised concerns about their surgical outcomes compared with specialist pediatric surgeons. METHODS: Using Hospital Episode Statistics, we analyzed patient-level data between April 2001 and March 2012. Main inclusion criteria were children younger than 16 years admitted to NHS-England hospitals for an emergency appendectomy. Main outcomes were annual age-sex adjusted appendectomy rates and postoperative risk of readmission, complication, and reintervention. RESULTS: A total of 83,679 emergency pediatric appendectomies were performed in 21 SPCs and 183 DGHs in England. SPCs performed only 18% of these operations (15,002). Annual age-sex standardized appendectomy rates fell from 87 to 68 per 100,000 population at an estimated 2% (rate ratio, 0.98) fall per annum. This was accompanied by a national annual increased risk of negative appendectomy, complication, reintervention, and readmission (adjusted odds ratio: 1.02, 1.03, 1.04, and 1.06, respectively). Children who had appendectomies in DGHs had 28% more negative appendectomies, 11% more complications, and 11% more readmissions than those in SPCs. Postoperative length of stay was double in SPCs compared with DGHs (median, 4 vs 2 days). CONCLUSIONS: Major reductions in the number of pediatric emergency appendectomies in England over the past decade were associated with an overall increase in adverse surgical outcomes. Children operated in DGHs have more reinterventions, complications, and negative appendectomy rates than those operated in SPCs.

Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions.

PURPOSE: We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions. METHODS: We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions. RESULTS: There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004. CONCLUSIONS: The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.

Cost-effectiveness of the children and young People's health partnership (CYPHP) model of integrated care versus enhanced usual care: analysis of a pragmatic cluster randomised controlled trial in South London.

Background: Integration of paediatric health services across primary and secondary care holds great promise for the management of chronic conditions, yet limited evidence exists on its cost-effectiveness. This paper reports the results of the economic evaluation of the Children and Young People's Health Partnership (CYPHP) aimed at integrating care for children with common chronic conditions (asthma, eczema, and constipation). Methods: Cost-effectiveness, cost-utility and cost-benefit analyses were conducted alongside a pragmatic cluster randomised controlled trial involving 97,970 children in 70 general practices in South London, including 1,731 participants with asthma, eczema and or constipation with self-reported health-related quality of life measures. Analyses considered the National Health Service (NHS)/Personal Social Service (PSS) and societal perspectives, and time horizons of 6 and 12-months. Costs included intervention delivery, health service use (primary and secondary care), referrals to social services, and time lost from work and school. Health outcomes were measured through the Paediatric Quality of Life Inventory, the Child Health Utility 9-Dimensions, and monetarised benefit combining Quality-Adjusted Life Years (QALYs) for children and parental mental well-being. Results present incremental cost-effectiveness ratios (ICERs), compared to a willingness to pay threshold (WTP) of £20,000-30,000/QALY, and net monetary benefit (NMB), with deterministic sensitivity analyses. Findings: At 6 months, from the NHS/PSS perspective, CYPHP is not cost-effective (ICER = £721,000/QALY), and this result holds at 12 months (ICER = £45,586/QALY). However, under the societal perspective CYPHP falls within WTP thresholds (ICER = £22,966/QALY), with a probability of being cost-effective between 0.4 and 0.6 at £20,000/QALY and £30,000/QALY, respectively. The cost-benefit analysis yields a positive NMB of CYPHP at 12 months £109 under the societal perspective, with similar probabilistic results. Interpretation: CYPHP was not cost-effective at 6 months or under the NHS/PSS perspective. Trends towards cost-effectiveness are observed once a longer time horizon and a more inclusive perspective on effects is considered. Further research beyond 12 months is needed as the model becomes firmly embedded into the paediatric healthcare delivery system. Funding: This research was funded by Guy's and St Thomas' Charity, Lambeth and Southwark Clinical Commissioning Groups. The funders had no role in the writing of the manuscript, decision to submit it for publication, or any other process involved in the research.

Changing contexts of child health: an assessment of unmet physical, psychological and social needs of children with common chronic childhood illness.

BACKGROUND: We assessed the biopsychosocial needs and key health drivers among children living with a common chronic illness, as baseline for a cluster randomised controlled trial of a child health system strengthening intervention. METHODS: Cross-sectional data were analysed from a large population sample of children from South London with asthma, eczema or constipation, as exemplar tracer conditions of a new integrated care service. Descriptive and regression analyses, accounting for sociodemographic factors, investigated social needs, psychosocial outcomes and quality of life associated with poor symptom control. RESULTS: Among 7779 children, 4371 children (56%) had at least one uncontrolled physical health condition. Across the three domains of physical health, mental health and social needs, 77.5% of children (n=4304 of 5554) aged 4-15 years had at least one unmet need, while 16.3% of children had three unmet needs. Children from the most socioeconomically disadvantaged quintile had a 20% increased risk of at least one poorly controlled physical condition (risk ratio (RR)=1.20, 95% CI: 1.11 to 1.31, p<0.001) compared with those from the least disadvantaged quintile. There was an 85% increased risk of clinically important mental health needs among children with uncontrolled asthma (RR=1.85, 95% CI: 1.65 to 2.07, p<0.001), 57% for active constipation (RR=1.57, 95% CI: 1.12 to 2.20, p<0.01) and 39% for uncontrolled eczema (RR=1.39, 95% CI: 1.24 to 1.56, p<0.001). Health-related quality of life was associated with poor symptom control. CONCLUSIONS: There is a large burden of unmet biopsychosocial needs among children with chronic illness, signalling an urgent need for prevention, early intervention and integrated biopsychosocial care.

Effect of the Children and Young People's Health Partnership model of paediatric integrated care on health service use and child health outcomes: a pragmatic two-arm cluster randomised controlled trial.

BACKGROUND: Paediatric health systems across high-income countries are facing avoidable adverse outcomes and increasing demands and costs. The aim of this study was to compare the effect of an enhanced usual care model with that of an integrated health-care model that offers local health clinics for general paediatric problems and early intervention and care for children and young people with tracer conditions. METHODS: In this pragmatic two-arm cluster randomised controlled trial, we compared the Children and Young People's Health Partnership (CYPHP) model of care versus enhanced usual care (EUC) among children registered at general practices in south London, UK. The CYPHP trial intervention was delivered between April 1, 2018, and June 30, 2021, and children younger than 16 years during the intervention period and registered at study practices on June 30, 2021, were included in the analysis. A restricted randomisation (1:1) following a computer-generated sequence was done by a masked independent statistician at the level of general practice cluster, stratified by borough (Lambeth or Southwark). Cluster allocation and data collection were masked, with unmasking of trial statisticians before analysis. The CYPHP model comprised all elements of EUC (electronic decision support, a primary care hotline, health checks, self-management support and health promotion, and resilience building and mental health first aid) plus local child health clinics delivered by paediatricians and general practitioners, and a nurse-led early intervention service for children with tracer conditions (asthma, eczema, and constipation). Primary outcomes were non-elective admissions (NELA; admissions coded as an emergency) among the whole trial population up to June 30, 2021, and paediatric quality of life (Pediatric Quality of Life Inventory [PedsQL]) among participants with tracer conditions at 6 months after recruitment. Secondary outcomes were primary and secondary care use, child mental health, parental wellbeing, standardised symptom scores for asthma, eczema, and constipation, health-care quality, and child absences from school and parent absences from work. The trial was registered on ClinicalTrials.gov, NCT03461848, and is complete. FINDINGS: The trial was conducted between April 1, 2018, and Dec 31, 2021. In total, 23 general practice clusters, consisting of 70 practices with 97 970 registered children, were randomised to CYPHP (n=11) or EUC (n=12). We found no effect, at the population level, of CYPHP versus EUC on non-elective admissions during the intervention period (adjusted mean incidence rate ratio [IRR] 1·00 [95% CI 0·91 to 1·10], p=0·99). Among children with tracer conditions, we found no difference in paediatric quality of life (PedsQL score) at 6 months (adjusted mean difference -0·033 [95% CI -0·122 to 0·055], p=0·46). As a secondary outcome, among children with tracer conditions and requiring care, NELA rates at 12 months did not differ between the CYPHP and EUC groups (66·1 per 1000 person-years vs 75·3 per 1000 person-years; adjusted mean IRR 0·87 [0·61-1·22], p=0·42). In children requiring care, a statistically significant improvement was observed in eczema symptoms at 6 months from baseline in the CYPHP group versus the EUC group (adjusted mean difference -1·370 [-2·630 to -0·122], p=0·032). Quality of asthma care significantly improved among children in the CYPHP group compared with children in the EUC group. No significant improvement was seen for all other secondary outcomes. INTERPRETATION: Although the CYPHP trial found a null effect for the primary outcomes, we found clinically important improvements in some secondary outcomes including care quality. Previous research has shown that large-scale system change requires time to observe a potential positive effect. FUNDING: Guy's and St Thomas Charity, the Lambeth and Southwark Clinical Commissioning Groups, and Evelina London Children's Hospital.

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices.

BACKGROUND: In the UK, while most primary care contacts are uncomplicated, safety incidents do occur and result in patient harm, for example, failure to recognise a patient's deterioration in health. AIM: To determine the patient and healthcare factors associated with potentially missed acute deterioration in health. DESIGN AND SETTING: Cohort of patients registered with English Clinical Practice Research Datalink general practices between 1 April 2014 and 31 December 2017 with linked hospital data. METHOD: A potentially missed acute deterioration was defined as a patient having a self-referred admission to hospital having been seen in primary care by a GP in the 3 days beforehand. All diagnoses and subsets of commonly-reported missed conditions were analysed.. RESULTS: A total of 116 097 patients contacted a GP 3 days before an emergency admission. Patients with sepsis (adjusted odds ratio [aOR] 1.09, 95% confidence interval [CI] = 1.01 to 1.18) or urinary tract infections (aOR 1.09, 95% CI = 1.04 to 1.14) were more likely to self-refer. The duration of GP appointments was associated with self-referral. On average, a 5-minute increase in appointment time resulted in a 10% decrease in the odds of self-referred admissions (aOR 0.90, 95% CI = 0.89 to 0.91). Patients having a telephone consultation (compared with face-to-face consultation) (aOR 1.14, 95% CI = 1.11 to 1.18) previous health service use, and presence of comorbidities were also associated with self-referred admission. CONCLUSION: Differentiating acute deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The findings of this study support the call for longer GP consultations and caution against reliance on telephone consultations in primary care; however, more research is needed to understand the underlying mechanisms.

General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: a qualitative analysis.

OBJECTIVES: Reminders in primary care administrative systems aim to help clinicians provide evidence-based care, prescribe safely and save money. However, increased use of reminders can lead to alert fatigue. Our study aimed to assess general practitioners' (GPs) and nurse practitioners' (NPs) views on electronic reminders in primary care. DESIGN: A qualitative analysis using semistructured interviews. SETTING AND PARTICIPANTS: Fifteen GPs and NP based in general practices located in North-West London and Yorkshire, England. METHODS: We collected data on participants' views on: (1) perceptions of the value of information provided; (2) reminder-related behaviours and (3) how to improve reminders. We carried out a thematic analysis. RESULTS: Participants were familiar with reminders in their clinical systems and felt many were important to support their clinical work. However, participants reported, on average, 70% of reminders were ignored. Four major themes emerged: (1) reaction to a reminder, which was mixed and varied by situation. (2) Factors influencing the decision to act on reminders, often related to experience, consultation styles and interests of participants. Time constraints, alert design, inappropriate presentation and litigation were also factors. (3) Negative consequences of using reminders were increased workload or costs and compromising GP and NPs behaviour. (4) Factors relating to improving users' engagement with reminders were prevention of unnecessary reminders through data linkage across healthcare administrative systems or the development of more intelligent algorithms. Participants felt training was vital to effectively manage reminders. CONCLUSIONS: GPs and NPs believe reminders are useful in supporting the provision of good quality patient care. Improving GPs and NPs' engagement with reminders centres on further developing their relevance to their clinical practice, which is personalised, considers cognitive workflow and suppresses inappropriate presentation.

Trends in healthcare use in children aged less than 15 years: a population-based cohort study in England from 2007 to 2017.

OBJECTIVE: To describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017 DESIGN: Population-based retrospective cohort study. METHODS: We used linked data from the Clinical Practice Research Datalink to study children's primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists. RESULTS: Between 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (-1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017. CONCLUSIONS: Over the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children's use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.

Preschool respiratory hospital admissions following infant bronchiolitis: a birth cohort study.

BACKGROUND: Bronchiolitis causes significant infant morbidity worldwide from hospital admissions. However, studies quantifying the subsequent respiratory burden in children under 5 years are lacking. OBJECTIVE: To estimate the risk of subsequent respiratory hospital admissions in children under 5 years in England following bronchiolitis admission in infancy. DESIGN: Retrospective population-based birth cohort study. SETTING: Public hospitals in England. PATIENTS: We constructed a birth cohort of 613 377 infants born between 1 April 2007 and 31 March 2008, followed up until aged 5 years by linking Hospital Episode Statistics admissions data. METHODS: We compared the risk of respiratory hospital admission due to asthma, wheezing and lower and upper respiratory tract infections (LRTI and URTI) in infants who had been admitted for bronchiolitis with those who had not, using Cox proportional hazard regression. We adjusted hazard ratios (HR) for known respiratory illness risk factors including living in deprived households, being born preterm or with a comorbid condition. RESULTS: We identified 16 288/613 377 infants (2.7%) with at least one admission for bronchiolitis. Of these, 21.7% had a further respiratory hospital admission by age 5 years compared with 8% without a previous bronchiolitis admission (HR (adjusted) 2.82, 95% CI 2.72 to 2.92). The association was greatest for asthma (HR (adjusted) 4.35, 95% CI 4.00 to 4.73) and wheezing admissions (HR (adjusted) 5.02, 95% CI 4.64 to 5.44), but were also significant for URTI and LRTI admissions. CONCLUSIONS: Hospital admission for bronchiolitis in infancy is associated with a threefold to fivefold risk of subsequent respiratory hospital admissions from asthma, wheezing and respiratory infections. One in five infants with bronchiolitis hospital admissions will have a subsequent respiratory hospital admission by age 5 years.

The impact of smoking and smoking cessation on disease outcomes in ulcerative colitis: a nationwide population-based study.

BACKGROUND: Smokers are less likely to develop ulcerative colitis (UC) but the impact of smoking and subsequent cessation on clinical outcomes in UC is unclear. AIM: To evaluate the effect of smoking status and smoking cessation on disease outcomes. METHODS: Using a nationally representative clinical research database, we identified incident cases of UC during 2005-2016. Patients were grouped as never-smokers, ex-smokers and smokers based on smoking status recorded in the 2 years preceding UC diagnosis. We defined subgroups of persistent smokers and smokers who quit within 2 years after diagnosis. We compared the rates of overall corticosteroid use, corticosteroid-requiring flares, corticosteroid dependency, thiopurine use, hospitalisation and colectomy between these groups. RESULTS: We identified 6754 patients with a new diagnosis of UC over the study period with data on smoking status, of whom 878 were smokers at diagnosis. Smokers had a similar risk of corticosteroid-requiring flares (OR 1.16, 95% CI 0.92-1.25), thiopurine use (HR 0.84, 95% CI 0.62-1.14), corticosteroid dependency (HR 0.85, 95% CI 0.60-1.11), hospitalisation (HR 0.92, 95% CI 0.72-1.18) and colectomy (HR 0.78, 95% CI 0.50-1.21) in comparison with never-smokers. Rates of flares, thiopurine use, corticosteroid dependency, hospitalisation and colectomy were not significantly different between persistent smokers and those who quit smoking after a diagnosis of UC. CONCLUSIONS: Smokers and never-smokers with UC have similar outcomes with respect to flares, thiopurine use, corticosteroid dependency, hospitalisation and colectomy. Smoking cessation was not associated with worse disease course. The risks associated with smoking outweigh any benefits. UC patients should be counselled against smoking.

Indicators of deterioration in young adults with serious mental illness: a systematic review protocol.

BACKGROUND: The first signs of serious mental illnesses (SMIs) including schizophrenia, bipolar disorder and major depression are likely to occur before the age of 25. The combination of high prevalence of severe mental health symptoms, inability to recognise mental health deterioration and increased likelihood of comorbidity in a complex transitional young group makes detecting deterioration paramount. Whilst studies have examined physical and mental health deterioration in adults, no systematic review has examined the indicators of mental and physical deterioration in young adults with SMI. The study aim is to systematically review the existing evidence from observational studies that examine the indicators of mental and physical deterioration in young adults with SMI and highlight gaps in knowledge to inform future research. METHODS: Seven databases including CINHAL, MEDLINE, Embase, PsycINFO, Health Management Information Consortium, Cochrane databases and Web of Science will be searched against five main facets (age, serious mental illness, sign, deterioration and patient) and a subsequent comprehensive list of search terms. Searches will be run individually in each database to reflect each unique set of relevant subject headings and appropriate MeSH terms. Inclusion and exclusion criteria were developed and refined by the research team. Two reviewers will participate in each search stage including abstract/title and full text screening, data extraction and appraisal, to ensure reliability. A narrative synthesis of the data will also be conducted. DISCUSSION: This systematic review will likely make a significant contribution to the field of mental health and help inform future research pertaining to interventions that help highlight deteriorating patients. This may vary depending on the patient group, mental illness or deterioration type. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017075755.

National hospital mortality surveillance system: a descriptive analysis.

OBJECTIVE: To provide a description of the Imperial College Mortality Surveillance System and subsequent investigations by the Care Quality Commission (CQC) in National Health Service (NHS) hospitals receiving mortality alerts. BACKGROUND: The mortality surveillance system has generated monthly mortality alerts since 2007, on 122 individual diagnosis and surgical procedure groups, using routinely collected hospital administrative data for all English acute NHS hospital trusts. The CQC, the English national regulator, is notified of each alert. This study describes the findings of CQC investigations of alerting trusts. METHODS: We carried out (1) a descriptive analysis of alerts (2007-2016) and (2) an audit of CQC investigations in a subset of alerts (2011-2013). RESULTS: Between April 2007 and October 2016, 860 alerts were generated and 76% (654 alerts) were sent to trusts. Alert volumes varied over time (range: 40-101). Septicaemia (except in labour) was the most commonly alerting group (11.5% alerts sent). We reviewed CQC communications in a subset of 204 alerts from 96 trusts. The CQC investigated 75% (154/204) of alerts. In 90% of these pursued alerts, trusts returned evidence of local case note reviews (140/154). These reviews found areas of care that could be improved in 69% (106/154) of alerts. In 25% (38/154) trusts considered that identified failings in care could have impacted on patient outcomes. The CQC investigations resulted in full trust action plans in 77% (118/154) of all pursued alerts. CONCLUSION: The mortality surveillance system has generated a large number of alerts since 2007. Quality of care problems were found in 69% of alerts with CQC investigations, and one in four trusts reported that failings in care may have an impact on patient outcomes. Identifying whether mortality alerts are the most efficient means to highlight areas of substandard care will require further investigation.

Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis.

OBJECTIVE: To investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality. BACKGROUND: There is increasing interest in performance monitoring in the NHS. Since 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied. METHODS: We investigated alerts sent to Acute National Health Service hospital trusts in England in 2011-2013. We examined risk-adjusted mortality (relative risk) for all monitored diagnosis and procedure groups at a hospital trust level for 12 months prior to an alert and 23 months post alert. We used an interrupted time series design with a 9-month lag to estimate a trend prior to a mortality alert and the change in trend after, using generalised estimating equations. RESULTS: On average there was a 5% monthly increase in relative risk of mortality during the 12 months prior to an alert (95% CI 4% to 5%). Mortality risk fell, on average by 61% (95% CI 56% to 65%), during the 9-month period immediately following an alert, then levelled to a slow decline, reaching on average the level of expected mortality within 18 months of the alert. CONCLUSIONS: Our results suggest an association between an alert notification and a reduction in the risk of mortality, although with less lag time than expected. It is difficult to determine any causal association. A proportion of alerts may be triggered by random variation alone and subsequent falls could simply reflect regression to the mean. Findings could also indicate that some hospitals are monitoring their own mortality statistics or other performance information, taking action prior to alert notification.