Appraisal of National Institute for Health and Care Research activity in primary care in England: cross-sectional study.

BACKGROUND: The National Institute for Health and Care Research (NIHR) was set up to enhance clinical and health research activity in a variety of National Health Service (NHS) healthcare settings, including primary care. OBJECTIVE: To appraise how overall General Practitioner (GP) practice performance, location, and staffing levels may interact with NIHR Portfolio activity in primary care in England. METHODS: Cross-sectional summary of GP practice research activity and practice descriptors; complete data from 6,171 GP practices was collated from NIHR (using data for 2013-2023 for Portfolio studies), Public Health England, Care Quality Commission, and NHS Digital sources, respectively. RESULTS: In primary care, 1 million patients have been recruited into NIHR Portfolio studies in the last decade. The top 10% of practices-measured by different studies recruited to-contributed over 50% of that accrual. When the top decile of GP practices is compared to the 20% least active GP practices, research activity is significantly and individually linked with larger GP practices. Furthermore, it is significantly yet modestly associated with GP practice performance (positive patient feedback, Care Quality Commission rating), lower locality deprivation levels, and lower patient to GP ratios. CONCLUSIONS: Research activity in GP practices is-as seen previously with hospitals-significantly linked with better GP practice performance and patient feedback. Practice list size and staffing levels in particular interact with the aforementioned. This should be taken into account when determining strategies to increase patient and GP practice participation in NIHR Portfolio research studies.

Priorities for successful use of artificial intelligence by public health organizations: a literature review.

Artificial intelligence (AI) has the potential to improve public health's ability to promote the health of all people in all communities. To successfully realize this potential and use AI for public health functions it is important for public health organizations to thoughtfully develop strategies for AI implementation. Six key priorities for successful use of AI technologies by public health organizations are discussed: 1) Contemporary data governance; 2) Investment in modernized data and analytic infrastructure and procedures; 3) Addressing the skills gap in the workforce; 4) Development of strategic collaborative partnerships; 5) Use of good AI practices for transparency and reproducibility, and; 6) Explicit consideration of equity and bias.

Comparison of mortality hazard ratios associated with health behaviours in Canada and the United States: a population-based linked health survey study.

BACKGROUND: Modern health surveillance and planning requires an understanding of how preventable risk factors impact population health, and how these effects vary between populations. In this study, we compare how smoking, alcohol consumption, diet and physical activity are associated with all-cause mortality in Canada and the United States using comparable individual-level, linked population health survey data and identical model specifications. METHODS: The Canadian Community Health Survey (CCHS) (2003-2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Consistent variable definitions were used to estimate country-specific mortality hazard ratios with sex-specific Cox proportional hazard models, including smoking, alcohol, diet and physical activity, sociodemographic indicators and proximal factors including disease history. RESULTS: A total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 58,232 respondents and 497,909 person-years from the NHIS were included. Absolute mortality risk among those with a 'healthy profile' was higher in the United States compared to Canada, especially among women. Adjusted mortality hazard ratios associated with health behaviours were generally of similar magnitude and direction but often stronger in Canada. CONCLUSION: Even when methodological and population differences are minimal, the association of health behaviours and mortality can vary across populations. It is therefore important to be cautious of between-study variation when aggregating relative effect estimates from differing populations, and when using external effect estimates for population health research and policy development.

Five-year risk of admission to long-term care home and death for older adults given a new diagnosis of dementia: a population-based retrospective cohort study.

BACKGROUND: After diagnosis of a health condition, information about survival and potential transition from community into institutional care can be helpful for patients and care providers. We sought to describe the association between a new diagnosis of dementia and risk of admission to a long-term care home and death at 5 years. METHODS: We conducted a population-based retrospective cohort study using linked health administrative databases. We identified individuals aged 65 years or older, living in the community, with a first documented diagnosis of dementia between Jan. 1, 2010, and Dec. 31, 2012, in Ontario, Canada. Dementia diagnosis was captured using diagnostic codes from hospital discharges, physician billings, assessments conducted for home care and long-term care, and dispensed prescriptions for cholinesterase inhibitors. Our primary outcome measures were 5-year risk of death and placement in a long-term care home, adjusted for sociodemographic and clinical factors. RESULTS: We identified 108 757 individuals in our study cohort. By the end of 5 years, 24.4% remained alive in the community and 20.5% were living in a long-term care home. Of the 55.1% who died, about half (27.9%) were admitted to a long-term care home before death. Three risk factors were associated with increased odds of death: older age (age ≥ 90 yr; odds ratio [OR] 9.5, 95% confidence interval [CI] 8.8-10.2 [reference: age 65-69 yr]), male sex (OR 1.7, 95% CI 1.6-1.7), and the presence of organ failure, including chronic obstructive pulmonary disease (OR 1.7, 95% CI 1.7-1.8), congestive heart failure (OR 2.0, 95% CI 1.9-2.0) and renal failure (OR 1.7, 95% CI 1.6-1.8). Groups formed by combinations of these 3 factors had an observed 5-year risk of death varying between 22% and 91%. INTERPRETATION: Among community-dwelling older adults with newly identified dementia in Ontario, the majority died or were admitted to a long-term care home within 5 years. This information may be helpful for discussions on prognosis and need for admission to long-term care.

Patient referral from primary care to psychological therapy services: a cohort study.

BACKGROUND: Improving Access to Psychological Therapy (IAPT) services in England offer psychological therapy for patients with mental health issues such as depression and anxiety disorders. OBJECTIVE: How are primary care patients referred to IAPT, to what degree does this correlate with subsequent attendance, and how is the referral process perceived by patients? METHODS: Retrospective analysis of medical records covering June 2018-June 2019 in seven general practices servicing 96 000 patients, to identify and survey patients with anxiety and/or depression. RESULTS: Records of 6545 patients were appraised; 2612 patients were deemed suitable for IAPT intervention by the GP. Of those, 1424 (55%) attended at least one IAPT appointment whereas 1188 (45%) did not. These 'attender' and 'non-attender' cohorts did not differ in age, gender or level of deprivation; neither did GP advice to self-refer rather than making a direct GP referral influence the attendance rate. The most common reasons for IAPT non-attendance include symptom improvement (22%), lack of belief in psychotherapy effectiveness (16%) or a patient feeling too unwell to either refer themselves or attend (12%). CONCLUSIONS: Neither certain age or gender, nor the mode of patient referral to IAPT is associated with eventual attendance. Future research is indicated to identify in more detail if any specific mental health conditions are more likely to lead to non-attendance. Furthermore, there may be scope for a targeted approach for subgroups of patients, e.g. those who indicate they are feeling mentally too unwell, to enable them to attend IAPT screening and therapy appointments.

Development and cohort study of an audit approach to evaluate patient management in family practice in the UK: the 7S tool.

BACKGROUND: In the UK, there is increased pressure on general practitioners' time due to an increase in (elderly) population and a shortage of general practitioners. This means that time has to be used efficiently, whilst optimizing adherence to consistent, appropriate and timely provision of care. OBJECTIVE(S): Create an audit tool that assists general practitioners and family practice staff to evaluate if patients are managed as effectively as possible, and to test the usefulness of this tool in a family practice. METHODS: The '7S' audit tool has seven outcome elements; these broadly stand for what the actual and desired patient contact outcome was, or should have been. Terms include 'surgery', 'speak' and 'specific other' for an appointment at the practice, by telephone or with a dedicated specialist such as a practice nurse or phlebotomist, respectively. RESULTS: A very small, rural, general practice in the UK was audited using the 7S tool. Five hundred patient contacts were reviewed by an independent general practitioner and the decision made if the mode of contact was appropriate or not for each case; in one of the three cases, the choice of care provision was inappropriate and chronic disease cases contributed most to this. General practitioners instigated the majority of poor patient management choices, and chronic disease patients were frequently seen in suboptimal settings. CONCLUSIONS: Inefficiencies in the management of patients in family practice can be identified with the 7S audit tool, thereby producing evidence for staff education and service reconfiguration.

International population-based health surveys linked to outcome data: A new resource for public health and epidemiology.

BACKGROUND: National health surveys linked to vital statistics and health care information provide a growing source of individual-level population health data. Pooling linked surveys across jurisdictions would create comprehensive datasets that are larger than most existing cohort studies, and that have a unique international and population perspective. This paper's objectives are to examine the feasibility of pooling linked population health surveys from three countries, facilitate the examination of health behaviours, and present useful information to assist in the planning of international population health surveillance and research studies. DATA AND METHODS: The design, methodologies and content of the Canadian Community Health Survey (2003 to 2008), the United States National Health Interview Survey (2000, 2005) and the Scottish Health Survey (SHeS) (2003, 2008 to 2010) were examined for comparability and consistency. The feasibility of creating common variables for measuring smoking, alcohol consumption, physical activity and diet was assessed. Sample size and estimated mortality events were collected. RESULTS: The surveys have comparable purposes, designs, sampling and administration methodologies, target populations, exclusions, and content. Similar health behaviour questions allow for comparable variables to be created across the surveys. However, the SHeS uses a more detailed risk factor evaluation for alcohol consumption and diet data. Therefore, comparisons of alcohol consumption and diet data between the SHeS and the other two surveys should be performed with caution. Pooling these linked surveys would create a dataset with over 350,000 participants, 28,424 deaths and over 2.4 million person-years of follow-up. DISCUSSION: Pooling linked national population health surveys could improve population health research and surveillance. Innovative methodologies must be used to account for survey dissimilarities, and further discussion is needed on how to best access and analyze data across jurisdictions.

Open-label, randomised, multicentre crossover trial assessing two-layer compression bandaging for chronic venous insufficiency: results of the APRICOT trial.

Compression bandaging is the mainstay therapy for chronic venous insufficiency and venous leg ulcers, but patient compliance can be challenging due to associated discomfort. The study discussed here aimed to compare AndoFlex TLC Calamine and Coban2 compression bandaging in relation to patient comfort and pruritus symptomology, with severity of pruritus as the primary outcome. This was a multi-centre, prospective, non-blinded, randomised controlled crossover trial involving 39 randomised patients with chronic venous insufficiency patients. In two periods, the patients wore AndoFlex TLC Calamine or Coban2 for 3 weeks each. No significant differences in validated pruritus outcome measures were observed, including a non-significant treatment effect for the severity of pruritus scale (n=35 trial completers; p-value=0.24, Wilcoxon test). However, after trying both bandages, 21 of the 35 patients (60%) definitely preferred AndoFlex TLC Calamine, whereas 4 patients (11%) definitely preferred Coban2. Thus, AndoFlex TLC Calamine compression bandage therapy was preferred by most patients, although this observation could not be confirmed using validated patient-reported outcome measures for pruritus. Further research is indicated to establish if patient preference translates into favourable clinical outcomes. ISRCTN number: ISRCTN95282887.

Development and validation of a cardiovascular disease risk-prediction model using population health surveys: the Cardiovascular Disease Population Risk Tool (CVDPoRT).

BACKGROUND: Routinely collected data from large population health surveys linked to chronic disease outcomes create an opportunity to develop more complex risk-prediction algorithms. We developed a predictive algorithm to estimate 5-year risk of incident cardiovascular disease in the community setting. METHODS: We derived the Cardiovascular Disease Population Risk Tool (CVDPoRT) using prospectively collected data from Ontario respondents of the Canadian Community Health Surveys, representing 98% of the Ontario population (survey years 2001 to 2007; follow-up from 2001 to 2012) linked to hospital admission and vital statistics databases. Predictors included body mass index, hypertension, diabetes, and multiple behavioural, demographic and general health risk factors. The primary outcome was the first major cardiovascular event resulting in hospital admission or death. Death from a noncardiovascular cause was considered a competing risk. RESULTS: We included 104 219 respondents aged 20 to 105 years. There were 3709 cardiovascular events and 818 478 person-years follow-up in the combined derivation and validation cohorts (5-year cumulative incidence function, men: 0.026, 95% confidence interval [CI] 0.025-0.028; women: 0.018, 95% 0.017-0.019). The final CVDPoRT algorithm contained 12 variables, was discriminating (men: C statistic 0.82, 95% CI 0.81-0.83; women: 0.86, 95% CI 0.85-0.87) and was well-calibrated in the overall population (5-year observed cumulative incidence function v. predicted risk, men: 0.28%; women: 0.38%) and in nearly all predefined policy-relevant subgroups (206 of 208 groups). INTERPRETATION: The CVDPoRT algorithm can accurately discriminate cardiovascular disease risk for a wide range of health profiles without the aid of clinical measures. Such algorithms hold potential to support precision medicine for individual or population uses. Study registration: ClinicalTrials.gov, no. NCT02267447.

Comparison of clinical outcomes between variceal and non-variceal gastrointestinal bleeding in patients with cirrhosis.

BACKGROUND AND AIM: Acute upper gastrointestinal bleeding (UGIB) in cirrhosis is associated with significant morbidity and mortality and can be classified as acute variceal bleeding (AVB) or non-variceal bleeding (NVB). Differences in mortality, hospital length of stay (LOS), and 30-day readmission have yet to be determined. As such, the study aimed to evaluate differences in these clinical outcomes in cirrhotic patients admitted with UGIB. METHODS: This retrospective study included all cirrhotic patients hospitalized for UGIB who underwent upper endoscopy from July 2014 to July 2016. AVB was defined as the presence of varices on endoscopy with high-risk stigmata such as cherry-red spots. Mortality, intensive care unit admission, hospital LOS, and 30-day hospital readmission were recorded and compared among patients with AVB and NVB. RESULTS: A total of 116 patients with cirrhosis were included, 73 with AVB and 43 with NVB. Patients with NVB were older than those with AVB (60.4 ± 11.1 vs 55.0 ± 9.5, P = 0.006) whereas patients with AVB were more likely to have known esophageal varices (64.4% vs 37.2%, P = 0.007). Patients with AVB and NVB had similar mortality (15.1% vs 9.3%, P = 0.57), hospital LOS (4.9, interquartile range: 3.6-6.9 days vs 5.0, interquartile range: 2.7-8.3 days), and 30-day readmission rates (19.2% vs 30.2%, P = 0.18). Severity of clinical presentation was associated with increased LOS and overall mortality, including the need for intensive care unit admission, but these were not associated with 30-day readmission rates. CONCLUSION: There were no differences in clinical outcomes, including mortality, in cirrhotic patients admitted with AVB and NVB.

Re-excision and survival following breast conserving surgery in early stage breast cancer patients: a population-based study.

BACKGROUND: Increasing population-based evidence suggests that patients who receive breast conserving surgery (BCS) plus radiotherapy have superior survival than those who receive mastectomy. It is unclear, however, how BCS followed by re-excision is associated with all-cause and breast cancer-specific mortality, and whether the BCS survival advantage is maintained if re-excision is needed. The aim of this study was to investigate the clinical, patient, provider and geographic variation associated with receipt of re-excision surgery, and to examine the relationship between re-excision and all-cause and breast cancer-specific mortality. METHODS: All women diagnosed with stage I-III breast cancer in Alberta, Canada from 2002 to 2009 were identified from the Alberta Cancer Registry, of which 11,626 were eligible for study inclusion. Type of first breast cancer surgery after diagnosis, subsequent re-excisions within 1 year, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate the adjusted odds ratios of re-excision by the factors of interest. Poisson regression models were fitted to compare all-cause and breast cancer-specific mortality by surgical pattern. RESULTS: Re-excision surgery was received by 19% (N = 5659) of patients who initially received BCS. The adjusted odds of re-excision varied significantly by geography of surgery, and by individual surgeon among stage I and II patients beyond the variation explained by the factors investigated (Stage I OR standard deviation (SD) = 0.43; stage II OR SD = 0.39). Patients who were treated with BCS plus re-excision surgery with either mastectomy or further BCS had similar all-cause and breast cancer-specific mortality as those treated with BCS without re-excision. CONCLUSION: These results suggest that breast cancer patients who are treated with BCS plus re-excision surgery by either mastectomy or further BCS have similar survival as those treated with BCS without re-excision. The significant variation in the likelihood of re-excision by geography and by individual surgeon is concerning, especially given the costs to the patient associated with additional surgery and the financial costs to the health system.

Measuring Burden of Unhealthy Behaviours Using a Multivariable Predictive Approach: Life Expectancy Lost in Canada Attributable to Smoking, Alcohol, Physical Inactivity, and Diet.

BACKGROUND: Behaviours such as smoking, poor diet, physical inactivity, and unhealthy alcohol consumption are leading risk factors for death. We assessed the Canadian burden attributable to these behaviours by developing, validating, and applying a multivariable predictive model for risk of all-cause death. METHODS: A predictive algorithm for 5 y risk of death-the Mortality Population Risk Tool (MPoRT)-was developed and validated using the 2001 to 2008 Canadian Community Health Surveys. There were approximately 1 million person-years of follow-up and 9,900 deaths in the development and validation datasets. After validation, MPoRT was used to predict future mortality and estimate the burden of smoking, alcohol, physical inactivity, and poor diet in the presence of sociodemographic and other risk factors using the 2010 national survey (approximately 90,000 respondents). Canadian period life tables were generated using predicted risk of death from MPoRT. The burden of behavioural risk factors attributable to life expectancy was estimated using hazard ratios from the MPoRT risk model. FINDINGS: The MPoRT 5 y mortality risk algorithms were discriminating (C-statistic: males 0.874 [95% CI: 0.867-0.881]; females 0.875 [0.868-0.882]) and well calibrated in all 58 predefined subgroups. Discrimination was maintained or improved in the validation cohorts. For the 2010 Canadian population, unhealthy behaviour attributable life expectancy lost was 6.0 years for both men and women (for men 95% CI: 5.8 to 6.3 for women 5.8 to 6.2). The Canadian life expectancy associated with health behaviour recommendations was 17.9 years (95% CI: 17.7 to 18.1) greater for people with the most favourable risk profile compared to those with the least favourable risk profile (88.2 years versus 70.3 years). Smoking, by itself, was associated with 32% to 39% of the difference in life expectancy across social groups (by education achieved or neighbourhood deprivation). CONCLUSIONS: Multivariable predictive algorithms such as MPoRT can be used to assess health burdens for sociodemographic groups or for small changes in population exposure to risks, thereby addressing some limitations of more commonly used measurement approaches. Unhealthy behaviours have a substantial collective burden on the life expectancy of the Canadian population.

Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer.

PURPOSE: To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada. METHODS: All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals. RESULTS: Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated. CONCLUSIONS: Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.

Synthesis and optimization of N-heterocyclic pyridinones as catechol-O-methyltransferase (COMT) inhibitors.

A series of N-heterocyclic pyridinone catechol-O-methyltransferase (COMT) inhibitors were synthesized. Physicochemical properties, including ligand lipophilic efficiency (LLE) and clogP, were used to guide compound design and attempt to improve inhibitor pharmacokinetics. Incorporation of heterocyclic central rings provided improvements in physicochemical parameters but did not significantly reduce in vitro or in vivo clearance. Nevertheless, compound 11 was identified as a potent inhibitor with sufficient in vivo exposure to significantly affect the dopamine metabolites homovanillic acid (HVA) and dihydroxyphenylacetic acid (DOPAC), and indicate central COMT inhibition.

Factors related to breast cancer detection mode and time to diagnosis in Alberta, Canada: a population-based retrospective cohort study.

BACKGROUND: Understanding the factors affecting the mode and timeliness of breast cancer diagnosis is important to optimizing patient experiences and outcomes. The purposes of the study were to identify factors related to the length of the diagnostic interval and assess how they vary by mode of diagnosis: screen or symptom detection. METHODS: All female residents of Alberta diagnosed with first primary breast cancer in years 2004-2010 were identified from the Alberta Cancer Registry. Data were linked to Physician Claims and screening program databases. Screen-detected patients were identified as having a screening mammogram within 6-months prior to diagnosis; remaining patients were considered symptom-detected. Separate quantile regression was conducted for each detection mode to assess the relationship between demographic/clinical and healthcare factors. RESULTS: Overall, 38 % of the 12,373 breast cancer cases were screen-detected compared to 47 % of the screen-eligible population. Health region of residence was strongly associated with cancer detection mode. The median diagnostic interval for screen and symptom-detected cancers was 19 and 21 days, respectively. The variation by health region, however, was large ranging from an estimated median of 4 to 37 days for screen-detected patients and from 17 to 33 days for symptom-detected patients. Cancer stage was inversely associated with the diagnostic interval for symptom-detected cancers, but not for screen-detected cancers. CONCLUSION: Significant variation by health region in both the percentage of women with screen-detected cancer and the length of the diagnostic interval for screen and symptom-detected breast cancers suggests there could be important differences in local breast cancer diagnostic care coordination.

Treatment variation in patients diagnosed with early stage breast cancer in Alberta from 2002 to 2010: a population-based study.

BACKGROUND: Breast-conserving surgery (BCS) followed by radiotherapy is generally the preferred treatment for women diagnosed with early stage breast cancer. This study aimed to investigate the proportion of patients who receive BCS versus mastectomy and post-BCS radiotherapy, and explore factors associated with receipt of these treatments in Alberta, Canada. METHODS: A retrospective population-based study was conducted that including all patients surgically treated with stage I-III breast cancer diagnosed in Alberta from 2002-2010. Clinical characteristics, treatment information and patient age at diagnosis were collected from the Alberta Cancer Registry. Log binomial multiple regression was used to calculate stage-specific relative risk estimates of receiving BCS and post-BCS radiotherapy. RESULTS: Of the 14 646 patients included in the study, 44% received BCS, and of those, 88% received post-BCS radiotherapy. The adjusted relative risk of BCS was highest in Calgary and lowest in Central Alberta for all disease stages. Relative to surgeries performed in Calgary, those performed in Central Alberta were significantly less likely to be BCS for stage I (RR = 0.65; 95% 0.57, 0.72), II (RR = 0.58; 95% 0.49, 0.68), and III (RR = 0.62; 95% CI: 0.37, 0.95) disease, respectively, adjusting for patient age at diagnosis, clinical and treatment characteristics. No significant variation of post-BCS radiotherapy was found. CONCLUSIONS: Factors such as region of surgical treatment should not be related to the receipt of standard care within a publicly-funded health care system. Further investigation is needed to understand the significant geographic variation present within the province in order to identify appropriate interventions.

Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia.

BACKGROUND: Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. METHODS: The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort. DISCUSSION: We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes. TRIAL REGISTRATION: NCT05371782.

A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT).

INTRODUCTION: Avoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data. METHODS AND ANALYSIS: The derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18-74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Abstract Database (1999/2000-2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000-2006 compared to 2007-2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell's concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement. ETHICS AND DISSEMINATION: This study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.

Development and validation of a practical clinical risk prediction model for post-endoscopic retrograde cholangiopancreatography pancreatitis.

Background: Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables. Methods: Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation. Results: Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003. Conclusions: We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available.

Management of urinary tract infections in the community: a clinical audit and patient survey.

BACKGROUND: Urinary tract infection (UTI) is a common ailment but can develop into sepsis. The outcomes related to UTI may potentially be affected by both patient and clinician management of UTI. AIM: To explore the circumstances around a single UTI episode to determine whether there are patient and clinician-related variables that may contribute to differences in management. DESIGN & SETTING: Survey and clinical audit in 12 general practices in England. METHOD: Patients (n = 504) completed a bespoke survey and their corresponding index UTI consultation was audited. The TARGET (Treat Antibiotics Responsibly, Guidance, Education and Tools) UTI audit toolkit was utilised. RESULTS: A significantly higher proportion of females compared with males used self-management measures. Increase in fluid intake was 78% for females aged <65 years and 71% for females aged >65 years compared with 53% for males (P<0.001, Χ2 test). Analgesic use was 50% for females aged <65 years and 41% for females aged >65 years compared with 36% for males (P = 0.036, Χ2 test). Males also indicated they lacked UTI knowledge when compared with females (P = 0.002, Kruskal-Wallis test). Males also claimed to have waited significantly longer for a consultation appointment (P = 0.027, Χ2 test). Antibiotics were prescribed in 98% of all cases, with adherence to clinical diagnostic guidelines lowest in females aged <65 years. Only 40% (89/221 of cases in this guideline sub-cohort [females aged >65 years]) would have been a UTI, according to TARGET criteria, following a medical record audit. CONCLUSION: UTI symptom management by clinicians is suboptimal; the presence or absence of symptoms is often insufficiently recorded in medical records. Additionally, suboptimal adherence to guidelines concerning urinalysis and microbiological investigation is common. Known increased clinical risks for males may be compounded by their more limited knowledge of (self)-managing UTI and their comparatively late presentation.