Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006-2017.

BACKGROUND: Frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population level use of health services and associated costs is needed to plan for ageing populations. AIM: To describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category. DESIGN AND SETTING: Retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017. METHODS: Primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced. RESULTS: Individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12 years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for sociodemographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe. CONCLUSIONS: Increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level.

Frailty transitions and prevalence in an ageing population: longitudinal analysis of primary care data from an open cohort of adults aged 50 and over in England, 2006-2017.

INTRODUCTION: frailty is common in older adults and is associated with increased health and social care use. Longitudinal information is needed on population-level incidence, prevalence and frailty progression to plan services to meet future population needs. METHODS: retrospective open cohort study using electronic health records of adults aged ≥50 from primary care in England, 2006-2017. Frailty was calculated annually using the electronic Frailty Index (eFI). Multistate models estimated transition rates between each frailty category, adjusting for sociodemographic characteristics. Prevalence overall for each eFI category (fit, mild, moderate and severe) was calculated. RESULTS: the cohort included 2,171,497 patients and 15,514,734 person-years. Frailty prevalence increased from 26.5 (2006) to 38.9% (2017). The average age of frailty onset was 69; however, 10.8% of people aged 50-64 were already frail in 2006. Estimated transitions from fit to any level of frailty were 48/1,000 person-years aged 50-64, 130/1,000 person-years aged 65-74, 214/1,000 person-years aged 75-84 and 380/1,000 person-years aged ≥ 85. Transitions were independently associated with older age, higher deprivation, female sex, Asian ethnicity and urban dwelling. Mean time spent in each frailty category decreased with age, with the longest period spent in severe frailty at all ages. CONCLUSIONS: frailty is prevalent in adults aged ≥50 and time spent in successive frailty states is longer as frailty progresses, resulting in extended healthcare burden. Larger population numbers and fewer transitions in adults aged 50-64 present an opportunity for earlier identification and intervention. A large increase in frailty over 12 years highlights the urgency of informed service planning in ageing populations.

The dynamics of frailty development and progression in older adults in primary care in England (2006-2017): a retrospective cohort profile.

BACKGROUND: Frailty is a common condition in older adults and has a major impact on patient outcomes and service use. Information on the prevalence in middle-aged adults and the patterns of progression of frailty at an individual and population level is scarce. To address this, a cohort was defined from a large primary care database in England to describe the epidemiology of frailty and understand the dynamics of frailty within individuals and across the population. This article describes the structure of the dataset, cohort characteristics and planned analyses. METHODS: Retrospective cohort study using electronic health records. Participants were aged ≥50 years registered in practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre between 2006 to 2017. Data include GP practice details, patient sociodemographic and clinical characteristics, twice-yearly electronic Frailty Index (eFI), deaths, medication use and primary and secondary care health service use. Participants in each cohort year by age group, GP and patient characteristics at cohort entry are described. RESULTS: The cohort includes 2,177,656 patients, contributing 15,552,946 person-years, registered at 419 primary care practices in England. The mean age was 61 years, 52.1% of the cohort was female, and 77.6% lived in urban environments. Frailty increased with age, affecting 10% of adults aged 50-64 and 43.7% of adults aged ≥65. The prevalence of long-term conditions and specific frailty deficits increased with age, as did the eFI and the severity of frailty categories. CONCLUSION: A comprehensive understanding of frailty dynamics will inform predictions of current and future care needs to facilitate timely planning of appropriate interventions, service configurations and workforce requirements. Analysis of this large, nationally representative cohort including participants aged ≥50 will capture earlier transitions to frailty and enable a detailed understanding of progression and impact. These results will inform novel simulation models which predict future health and service needs of older people living with frailty. STUDY REGISTRATION: Registered on www.clinicaltrials.gov October 25th 2019, NCT04139278 .

Accuracy of nature of call screening tool in identifying patients requiring treatment for out of hospital cardiac arrest.

BACKGROUND: A new pre-triage screening tool, Nature of Call (NoC), has been introduced into the telephone triage system of UK ambulance services which employ National Health Service Pathways (NHSP). Its function is to provide rapid recognition of patients who may need immediate ambulance dispatch for out-of-hospital cardiac arrest (OHCA) and withholding dispatch for other calls while further triage is undertaken. In this study, we evaluated the accuracy of NoC and NHSP in identifying patients with potentially treatable or imminent OHCA. METHODS: This retrospective, observational study reviewed consecutive calls to a UK ambulance service between October 2016 and February 2017 in which NOC, and then NHSP were applied sequentially. Only those calls for which a corresponding electronic Patient Clinical Record was available were included. Sensitivity and specificity of NOC and NHSP for recognition of an OHCA were determined by comparing allocated priority dispositions with an OHCA Treatment Registry (OHCATR). RESULTS: Of 96 423 calls received, 71 373 were reviewed. For 590 (0.8%) of these calls, the patients received treatment for OHCA. NOC identified 458 OHCATR patients; NHSP identified 467; together they identified 496. NoC captured 29 patients not identified by NHSP; NHSP captured 38 patients not identified by NOC. For NOC sensitivity was 77.6% (95% CI 74.1 to 80.8) and specificity 86.9% (95% CI 86.6 to 87.1). NHSP sensitivity was 79.2% (95% CI 75.7 to 82.2) and specificity 93.4% (95% CI 93.2 to 93.6). NoC and NHSP combined had a sensitivity of 84.1% (95% CI 80.9 to 86.8) and specificity of 85.3% (95% CI 85.1 to 85.6). CONCLUSIONS: NoC and NHSP call categorisation each achieved similar sensitivity for the identification of OHCATR, identifying most of the same patients, but each captured unique patients. Using both methods sequentially improved accuracy. The 16% of OHCATR patients not identified by either method present a challenge to ambulance dispatch systems.

Do lipid microemboli induce acute kidney injury during cardiopulmonary bypass?

BACKGROUND: Acute kidney injury (AKI) following cardiopulmonary bypass affects 5% of patients, representing significant postoperative morbidity and mortality. Animal models have shown an increased uptake of lipid microemboli (LME) into the renal vasculature, potentially indicating ischaemic causation. This study tested a new lipid filtration system (RemoweLL) against a conventional system with no lipid-depleting capacity to determine the efficacy of the filtration system and its effects on renal function. METHODS: Thirty consecutive patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Renal function was assessed using cystatin C concentrations as a surrogate marker of glomerular injury, as well as perioperative glomerular filtration rate (GFR) and serum creatinine concentrations. Patients were defined as having acute renal injury if there was an increase in absolute serum creatinine ⩾3 mg/dL (26.4 µmol/L) or 1.5-fold increase from baseline as categorised using the AKIN criteria. RESULTS: Postoperative differences in LME count between the two groups were highly significant [p<0.001]. Analysis of peak cystatin C concentrations showed significantly lower levels in the LME filtration group on the 2nd postoperative morning [p=0.04]. Two-factor ANOVA revealed a trend towards interaction, but this failed to reach significance [p=0.06]. There were no differences throughout the study period in serum creatinine or GFR [p>0.05]. There were no differences in any of the serum or urinary electrolytes. CONCLUSIONS: This study has shown a trend towards improved cystatin C removal with LME filtration; with significantly lower peak concentrations, although no further evidence of renoprotection could be demonstrated. Further research is warranted to establish possible renal benefits of LME filtration in patients undergoing cardiac surgery.

Leukocyte filtration of the cardiotomy suction. Does it affect systemic leukocyte activation or pulmonary function?

BACKGROUND: Cardiopulmonary bypass is thought to propagate a global systemic response through contact with the non-physiological surfaces of the extracorporeal circuit, leading to the stimulation of leukocytes, their adherence to endothelial cells and the release of cytotoxic molecules. This, in turn, has been shown to accelerate pulmonary injury. This study tested a new leukocyte-filtration system (RemoweLL) against a conventional system with no leukocyte-depleting capacity to determine the efficacy of the filtration system and its effects on pulmonary function. METHODS: Thirty patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Data were collected on the total number of leukocytes, their differentiation and activation, using the leukocyte adhesion integrin CD11b as a surrogate marker. Pulmonary function was assessed using the Alveolar-arterial Oxygenation Index (AaOI) and patients were categorized using the Berlin definition of acute respiratory distress syndrome (ARDS). RESULTS: Both groups showed significant increases in leukocyte numbers during CPB (p<0.001), with no differences noted between the groups. CD11b showed a significant increase in both groups, with peak activation occurring at the end of CPB, but no difference between the groups (p=0.8). There was a trend towards lower AaOI increases in the filtration group, but this did not reach significance (p=0.075) and there was no difference in ARDS definitions (p=0.33). CONCLUSIONS: Leukocyte filtration of cardiotomy suction did not influence total leukocyte counts or activation as measured by CD11b upregulation. Furthermore, no evidence could be found to suggest improved pulmonary function.

Understanding NHS hospital admissions in England: linkage of Hospital Episode Statistics to the Hertfordshire Cohort Study.

BACKGROUND: concern over the sustainability of the National Health Service (NHS) is often focussed on rising numbers of hospital admissions, particularly among older people. Hospital admissions are enumerated routinely by the Hospital Episode Statistics (HES) Service, but published data do not allow individual-level service use to be explored. This study linked information on Hertfordshire Cohort Study (HCS) participants with HES inpatient data, with the objective of describing patterns and predictors of admissions among individuals. METHODS: 2,997 community-dwelling men and women aged 59-73 years completed a baseline HCS assessment between 1998 and 2004; HES and mortality data to 31 March 2010 were linked with the HCS database. This paper describes patterns of hospital use among the cohort at both the admission and individual person level. RESULTS: the cohort experienced 8,741 admissions; rates were 391 per 1,000 person-years among men (95% CI: 380, 402) and 327 among women (95% CI: 316, 338), P < 0.0001 for gender difference. A total of 1,187 men (75%) and 981 women (69%) were admitted to hospital at least once; among these, median numbers of admissions were 3 in men (inter-quartile range, (IQR): 1, 6) and 2 in women (IQR: 1, 5). Forty-eight percent of those ever admitted had experienced an emergency admission and 70% had been admitted overnight. DISCUSSION: It is possible to link routinely collected HES data with detailed information from a cohort study. Hospital admission is common among community-dwelling 'young-old' men and women. These linked datasets will facilitate research into lifecourse determinants of hospital admission and inform strategies to manage demand on the NHS.

Reliability and acceptability of measuring sniff nasal inspiratory pressure (SNIP) and peak inspiratory flow (PIF) to assess respiratory muscle strength in older adults: a preliminary study.

BACKGROUND: Sniff nasal inspiratory pressure (SNIP) and peak oral inspiratory flow (PIF) are portable, relatively new methods for indirect measurement of respiratory muscle strength. The reliability and acceptability of these measures were investigated in older adults. METHODS: The study included 21 self-reported healthy adults, aged 65-84 years (mean 73.5; SD 6.4 years). Participants were tested in a sitting position on two occasions, 1 week apart. The best of three attempts for PIF measured through the mouth, and five for each nostril for SNIP were recorded. Reliability was tested using intra-class correlation coefficient (ICC), standard error of measurement, minimal detectable change (MDC) and Bland and Altman analysis. Feedback on the measures in relation to ease of completion and preference was obtained using a semi-structured interview. RESULTS: Between-day reliability of SNIP and PIF were ICC3,1 0.76 (95 % CI 0.49-0.9) and 0.92 (0.81-0.97), respectively. Standard error of measurement for SNIP (11.94 cmH2O) and MDC (33.10 cmH2O) were at the least 61 % higher than for PIF. The participants reported difficulties in performing SNIP, rating it as being less easy and uncomfortable to perform than PIF, with a higher rate of missing data for SNIP due to participants' dislike of the test. CONCLUSIONS: The wide range of SNIP readings, lower ICC value and negative user feedback are suggestive of a less robust and unacceptable clinical measure. PIF showed excellent reliability and acceptability and is therefore recommended for assessing inspiratory muscle strength in older people without known obstructive lung disease.

Markers of inflammatory status are associated with hearing threshold in older people: findings from the Hertfordshire Ageing Study.

BACKGROUND: Age-related hearing loss is a common disabling condition but its causes are not well understood and the role of inflammation as an influencing factor has received little consideration in the literature. OBJECTIVE: To investigate the association between inflammatory markers and hearing in community-dwelling older men and women. DESIGN: Cross-sectional analysis within a cohort study. SETTING: The Hertfordshire Ageing Study. PARTICIPANTS: A total of 343 men and 268 women aged 63-74 years on whom data on audiometric testing, inflammatory markers and covariates were available at follow-up in 1995. MAIN OUTCOME MEASURES: Average hearing threshold level (across 500-4,000 Hz) of the worst hearing ear and audiometric slope in dB/octave from 500 to 4,000 Hz. RESULTS: Older age, smoking, history of noise exposure and male gender (all P < 0.001) were associated with higher mean hearing threshold in the worse ear in univariate analysis. After adjustment for these factors in multiple regression models, four measures of immune or inflammatory status were significantly associated with hearing threshold, namely white blood cell count (r = 0.13, P = 0.001), neutrophil count (r = 0.13, P = 0.002), IL-6 (r = 0.10, P = 0.05) and C-reactive protein (r = 0.11, P = 0.01). None of the inflammatory markers was associated with maximum audiometric slope in adjusted analyses. CONCLUSIONS: Markers of inflammatory status were significantly associated with degree of hearing loss in older people. The findings are consistent with the possibility that inflammatory changes occurring with ageing may be involved in age-related hearing loss. Longitudinal data would enable this hypothesis to be explored further.

Change in treatment burden among people with multimorbidity: a follow-up survey.

BACKGROUND: Treatment burden is the effort required of patients to look after their health and the impact this has on their functioning and wellbeing. Little is known about change in treatment burden over time for people with multimorbidity. AIM: To quantify change in treatment burden, determine factors associated with this change, and evaluate a revised single-item measure for high treatment burden in older adults with multimorbidity. DESIGN AND SETTING: A 2.5-year follow-up of a cross-sectional postal survey via six general practices in Dorset, England. METHOD: GP practices identified participants of the baseline survey. Data on treatment burden (measured using the Multimorbidity Treatment Burden Questionnaire; MTBQ), sociodemographics, clinical variables, health literacy, and financial resource were collected. Change in treatment burden was described, and associations assessed using regression models. Diagnostic test performance metrics evaluated the revised single-item measure relative to the MTBQ. RESULTS: In total, 300 participants were recruited (77.3% response rate). Overall, there was a mean increase of 2.6 (standard deviation 11.2) points in treatment burden global score. Ninety-eight (32.7%) and 53 (17.7%) participants experienced an increase and decrease, respectively, in treatment burden category. An increase in treatment burden was associated with having >5 long-term conditions (adjusted ß 8.26, 95% confidence interval [CI] = 4.20 to 12.32) and living >10 minutes (versus ≤10 minutes) from the GP (adjusted ß 3.88, 95% CI = 1.32 to 6.43), particularly for participants with limited health literacy (mean difference: adjusted ß 9.59, 95% CI = 2.17 to 17.00). The single-item measure performed moderately (sensitivity 55.7%; specificity 92.4%. CONCLUSION: Treatment burden changes over time. Improving access to primary care, particularly for those living further away from services, and enhancing health literacy may mitigate increases in burden.

Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: retrospective analysis of hospital admissions data in England.

BACKGROUND: Rising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. The aim of this study was to determine the incidence and factors predicting ill-defined (R-coded) hospital admissions of older people and their association with health outcomes. METHODS: Retrospective analysis of unplanned hospital admissions to general internal and geriatric medicine wards in one hospital over 12 months (2002) with follow-up for 36 months. The study was carried out in an acute teaching hospital in England. The participants were all people aged 65 and over with unplanned hospital admissions to general internal and geriatric medicine. Independent variables included time of admission, residence at admission, route of admission to hospital, age, gender, comorbidity measured by count of diagnoses. Main outcome measures were primary diagnosis (ill-defined versus other diagnostic code), death during the hospital stay, deaths to 36 months, readmissions within 36 months, discharge destination and length of hospital stay. RESULTS: Incidence of R-codes at discharge was 21.6%, but was higher in general internal than geriatric medicine (25.6% v 14.1% respectively). Age, gender and co-morbidity were not significant predictors of R-code diagnoses. Admission via the emergency department (ED), out of normal general practitioner (GP) hours, under the care of general medicine and from non-residential care settings increased the risk of receiving R-codes. R-coded patients had a significantly shorter length of stay (5.91 days difference, 95% CI 4.47, 7.35), were less likely to die (hazard ratio 0.71, 95%CI 0.59, 0.85) at any point, but were as likely to be readmitted as other patients (hazard ratio 0.96 (95% CI 0.88, 1.05). CONCLUSIONS: R-coded diagnoses accounted for 1/5 of emergency admission episodes, higher than anticipated from total English hospital admissions, but comparable with rates reported in similar settings in other countries. Unexpectedly, age did not predict R-coded diagnosis at discharge. Lower mortality and length of stay support the view that these are avoidable admissions, but readmission rates particularly for further R-coded admissions indicate on-going health care needs. Patient characteristics did not predict R-coding, but organisational features, particularly admission via the ED, out of normal GP hours and via general internal medicine, were important and may offer opportunity for admission reduction strategies.

Change in treatment burden among people with multimorbidity: Protocol of a follow up survey and development of efficient measurement tools for primary care.

BACKGROUND: Treatment burden is the effort required of patients to look after their health and the impact this has on their functioning and wellbeing. It is likely treatment burden changes over time as circumstances change for patients and health services. However, there are a lack of population-level studies of treatment burden change and factors associated with this change over time. Furthermore, there are currently no practical screening tools for treatment burden in time-pressured clinical settings or at population level. METHODS AND ANALYSIS: This is a three-year follow-up of a cross-sectional survey of 723 people with multimorbidity (defined as three or more long-term conditions; LTCs) registered at GP practices in in Dorset, England. The survey will repeat collection of information on treatment burden (using the 10-item Multimorbidity Treatment Burden Questionnaire (MTBQ) and a novel single-item screening tool), sociodemographics, medications, LTCs, health literacy and financial resource, as at baseline. Descriptive statistics will be used to compare change in treatment burden since the baseline survey in 2019 and associations of treatment burden change will be assessed using regression methods. Diagnostic test accuracy metrics will be used to evaluate the single-item treatment burden screening tool using the MTBQ as the gold-standard. Routine primary care data (including demographics, medications, LTCs, and healthcare usage data) will be extracted from medical records for consenting participants. A forward-stepwise, likelihood-ratio logistic regression model building approach will be employed in order to assess the utility of routine data metrics in quantifying treatment burden in comparison to self-reported treatment burden using the MTBQ. IMPACT: To the authors' knowledge, this will be the first study investigating longitudinal aspects of treatment burden. Findings will improve understanding of the extent to which treatment burden changes over time for people with multimorbidity and factors contributing to this change, as well as allowing better identification of people at risk of high treatment burden.

Feasibility of Using Strength Measures, Including Peak Inspiratory Flow, for Routine Monitoring in Case Management Patients Aged 65 and Over.

Peak inspiratory flow (PIF) is a portable, relatively new method for measuring respiratory function and indirect muscle strength; the feasibility of its routine clinical measurement is unknown. To investigate the acceptability, reliability and short-term stability of PIF, alongside the established measures of peak expiratory flow (PEF) and grip strength in community dwelling case management patients. Patients were tested in a sitting position, initially on two occasions, one week apart; seven patients having repeated measures taken on a further four occasions over a seven-week period. The best of three attempts for all measures were recorded. Reliability was tested using intra-class correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC) and Bland-Altman analysis. Eight patients aged 69-91 years (mean age 81.5 ± 7.7 years; 5 males) participated. For between-day reliability using the first two time points, one week apart the ICCs (3,1) were 0.97, 0.98 and 0.99 for PIF, PEF and grip strength respectively; using all five time points resulted in ICCs of 0.92, 0.99 and 0.99 respectively. Bland-Altman plots also illustrated a good level of agreement across days. Feedback on the acceptability of the measures was gathered from patients. PIF, PEF and grip strength showed excellent reliability and acceptability. Whilst excellent reliability was observed over the seven-week period, the occurrence of clinically significant symptoms and adverse events in the presence of unchanging PIF, PEF and grip strength, suggests that the measures may not be suitable to identify patients with multiple health conditions entering a period of acute decline.

Quantification of Lipid Filtration and the Effects on Cerebral Injury During Cardiopulmonary Bypass.

BACKGROUND: Lipid microemboli (LME) are formed in pericardial suction blood which, when returned to the cardiopulmonary bypass (CPB) circuit, can pass through filter materials and are returned to the arterial cannula. LME have been observed to enter all major organs and have been associated with small capillary arteriolar dilatations in the brains of patients who have died after CPB. However, a causal relationship showing correlation between LME and organ dysfunction has not been demonstrated, or whether removal of LME results in improved organ function. METHODS: A prospective, single center, randomized controlled trial examined 30 patients (15 per group) undergoing coronary artery bypass grafting using CPB with or without a lipid-depleting filter. The effects of LME filtration on neurocognitive injury were assessed using neuron-specific enolase (NSE). RESULTS: The study group showed a significant reduction in LME after filtration of the pericardial suction blood (p < 0.001), whereas the control group exhibited a significant rise in LME (p < 0.001). There was a significant reduction in peak NSE release (p = 0.013) and significant attenuation throughout the postoperative period (p = 0.002). Correlation and regression analyses showed a significant relationship between the number of LME post-CPB and peak NSE release (r = 0.42, p = 0.02). CONCLUSIONS: Several methods of LME filtration have been proposed, but none provided a suitable, efficacious method for use within the clinical setting. The RemoweLL CPB system removes significant numbers of LME from the cardiotomy suction. Furthermore, LME correlate to the release of a known marker of neurologic injury.

Effectiveness of primary care-based vestibular rehabilitation for chronic dizziness.

BACKGROUND: Dizziness is a very common symptom and is usually managed in primary care. Vestibular rehabilitation for dizziness is a simple treatment that may be suitable for primary care delivery, but its effectiveness has not yet been determined. OBJECTIVE: To evaluate the effectiveness of nurse-delivered vestibular rehabilitation in primary care for patients with chronic dizziness. DESIGN: Single-blind randomized, controlled trial. SETTING: 20 general practices in southern England. PATIENTS: 170 adult patients with chronic dizziness who were randomly assigned to vestibular rehabilitation (n = 83) or usual medical care (n = 87). INTERVENTION: Each patient received one 30- to 40-minute appointment with a primary care nurse. The nurse taught the patient exercises to be carried out daily at home, with the support of a treatment booklet. MEASUREMENTS: Primary outcome measures were baseline, 3-month, and 6-month assessment of self-reported spontaneous and provoked symptoms of dizziness, dizziness-related quality of life, and objective measurement of postural stability with eyes open and eyes closed. RESULTS: At 3 months, improvement on all primary outcome measures in the vestibular rehabilitation group was significantly greater than in the usual medical care group; this improvement was maintained at 6 months. Of 83 treated patients, 56 (67%) reported clinically significant improvement compared with 33 of 87 (38%) usual care patients (relative risk, 1.78 [95% CI, 1.31 to 2.42]). LIMITATIONS: Psychological elements of the therapy may have contributed to outcomes, and the treatment may be effective only for well-motivated patients. CONCLUSIONS: Vestibular rehabilitation delivered by nurses in general practice improves symptoms, postural stability, and dizziness-related handicap in patients with chronic dizziness.

Professional perspectives on systemic barriers to admission avoidance: learning from a system dynamics study of older people's admission pathways.

BACKGROUND: There is debate worldwide about the best way to manage increased healthcare demand within ageing populations, particularly rising rates of unplanned and avoidable hospital admissions. OBJECTIVES: To understand health and social care professionals' perspectives on barriers to admission avoidance throughout the admissions journey, in particular: the causes of avoidable admissions in older people; drivers of admission and barriers to use of admission avoidance strategies; and improvements to reduce unnecessary admissions. DESIGN: A qualitative framework analysis of interview data from a System dynamics (SD) modelling study. METHODS: Semi-structured interviews were conducted with twenty health and social care professionals with experience of older people's admissions. The interviews were used to build understanding of factors facilitating or hindering admission avoidance across the admissions system. Data were analysed using framework analysis. RESULTS: Three overarching themes emerged: understanding the needs of the patient group; understanding the whole system; and systemwide access to expertise in care of older people. There were diverse views on the underlying reasons for avoidable admissions and recognition of the need for whole-system approaches to service redesign. CONCLUSIONS: Participants recommended system redesign that recognises the specific needs of older people, but there was no consensus on underlying patient needs or specific service developments. Access to expertise in management of older and frailer patients was seen as a barrier to admission avoidance throughout the system. IMPLICATIONS FOR PRACTICE: Providing access to expertise and leadership in care of frail older people across the admissions system presents a challenge for service managers and nurse educators but is seen as a prerequisite for effective admission avoidance. System redesign to meet the needs of frail older people requires agreement on causes of avoidable admission and underlying patient needs.

Nurse-led intermediate care: patients' perceptions.

Intermediate care currently forms one of the UK Government's main initiatives for improving the quality of post-acute care. This paper examines patients' and carers' experiences of a nurse-led unit, which aims to provide intermediate care for people no longer acutely ill. Drawing on findings from qualitative interview data, we demonstrate that patients viewed this model of care as acceptable but that they had markedly inconsistent experiences of care and reported considerable variation in their perceptions of the Unit's purpose. Some possible reasons for this are explored. Implications for the development of good quality nurse-led intermediate care are outlined.

Nurse-led inpatient care: opening the 'black box'.

With recent evaluations contradicting early reports of improved outcomes from nurse-led inpatient care, the 'black box' of nurse-led care must be opened in order to examine the model of treatment. We present findings on the processes of care in one nurse-led unit (NLU), compared with an acute ward. Patterns and quality of nursing care were quantified using bar-code technology to measure type, frequency and duration of nursing activities and Quality Patient Care Scale to measure the quality of care. NLU quality matched, but did not exceed, quality on the acute ward. Patterns of care differed between wards, but activities associated with therapeutic nursing were no more frequent on the NLU. These findings support the hypothesis that disappointing outcomes in recent evaluations may be linked to failure to implement a therapeutic model of nursing.

Chylothorax development in infants and children in the UK.

AIM: To describe the incidence, patient profile, management strategies and outcome for infants and children who developed a chylothorax in the UK. METHODS: A prospective study of infants and children ≥24 weeks' gestation - ≤16 years, who developed a chylothorax in the UK and were reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and outcome of these children. Three further data sources were accessed to confirm these data. RESULTS: The incidence in children in the UK was 0.0014% (1.4 per 100,000) and 3.2% (3200 per 100,000) for those developing a chylothorax following a cardiac surgical procedure. The incidence was highest in infants ≤12 months at 16 per 100,000 (0.016%). A total of 219 questionnaires were returned with 172 cases meeting the eligibility criteria. Development of a chylothorax was most commonly associated with cardiac surgical procedure (65.1%) and was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥1.1 mmol/L (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a medium chain triglyceride (MCT) diet (89%) was most commonly reported. The majority of the children had a prolonged hospital stay with a reported mortality of 12.2%. CONCLUSIONS: Development of a chylothorax in infants and children in the UK was not common. The primary association was with a cardiac surgical procedure. The child's hospital stay was lengthy and therefore the impact on the child, family and hospital resources were significant. Common management strategies existed but national guidance is required to optimise practice. This study allows for better information relating to this serious complication to be given to patients and families and provides the basis for future research and practice development.