Experiences of commissioning services for child and adolescent mental health in England (UK): a qualitative framework analysis.

OBJECTIVES: To explore commissioners' experiences of commissioning services for child and adolescent mental health, their perspectives on the needs of their populations, the challenges they face and their needs for support and data. DESIGN: Qualitative study involving semi-structured interviews. All interviews were audio-recorded and transcribed verbatim. Data were analysed using framework analysis. SETTING: England, UK. PARTICIPANTS: 12 integrated care board commissioners, responsible for commissioning NHS England Child and Adolescent Mental Health Services (CAMHS). RESULTS: We identified five themes: 'reflections on role'; 'priorities and tensions: working in a complex and evolving integrated care system'; 'insights and evidence: the role and use of data and informants'; 'children's mental health in the limelight: influences and expectations'; and 'responding to need "CAMHS as the answer to everything"'. Combined, these themes highlight the integral role commissioners play in providing oversight over the local system and challenges to this role including disproportionate funding for services for child and adolescent mental health, different use and value ascribed to 'qualitative' and 'quantitative' data, rises in demand and the limited focus on early intervention and prevention. CONCLUSIONS: CAMHS commissioners are currently negotiating a complex and changing political, social and economic environment with competing priorities and pressures. Our research indicates that commissioners require greater support as their roles continue to evolve.

Global mortality and readmission rates following COPD exacerbation-related hospitalisation: a meta-analysis of 65 945 individual patients.

Background: Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design. Methods: A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement. Results: Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event. Conclusions: This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD.

The Faculty of Public Health: past, present and future.

This year we celebrate 50 years of the UK Faculty of Public Health (FPH). This commentary serves as a reflection on the history of the FPH, considering the origins of public health in the UK and the role of the FPH in shaping public health practice and policy. The genesis and evolution of the FPH are discussed, drawing upon reflections from past presidents and the wider literature. Historical shifts in the identity and roles of public health practitioners are also explored in the context of an increasingly complex and dynamic health and social care system. Key changes in public health practice are described, including the development of a multidisciplinary public health workforce and an increased focus on health inequalities over recent decades. Building upon this is a discussion of the current purpose of the FPH and perspectives on the future of the FPH amidst a changing public health landscape.

Bilevel positive airway pressure ventilation for non-COPD acute hypercapnic respiratory failure patients: A systematic review and meta-analysis.

The effectiveness of bi-level positive airway pressure (BiPAP) in patients with acute hypercapnic respiratory failure (AHRF) due to etiologies other than chronic obstructive pulmonary disease (COPD) is unclear. To systematically review the evidence regarding the effectiveness of BiPAP in non-COPD patients with AHRF. The Cochrane Library, MEDLINE, EMBASE, and CINAHL Plus were searched according to prespecified criteria (PROSPERO-CRD42018089875). Randomized controlled trials (RCTs) assessing the effectiveness of BiPAP versus continuous positive airway pressure (CPAP), invasive mechanical ventilation, or O2 therapy in adults with non-COPD AHRF were included. The primary outcomes of interest were the rate of endotracheal intubation (ETI) and mortality. Risk-of-bias assessment was performed, and data were synthesized and meta-analyzed where appropriate. Two thousand four hundred and eighty-five records were identified after removing duplicates. Eighty-eight articles were identified for full-text assessment, of which 82 articles were excluded. Six studies, of generally low or uncertain risk-of-bias, were included involving 320 participants with acute cardiogenic pulmonary edema (ACPO) and solid tumors. No significant differences were seen between BiPAP ventilation and CPAP with regard to the rate of progression to ETI (risk ratio [RR] = 1.49, 95% confidence interval [CI], 0.63-3.62, P = 0.37) and in-hospital mortality rate (RR = 0.71, 95% CI, 0.25-1.99, P = 0.51) in patients with AHRF due to ACPO. The efficacy of BiPAP appears similar to CPAP in reducing the rates of ETI and mortality in patients with AHRF due to ACPO. Further research on other non-COPD conditions which commonly cause AHRF such as obesity hypoventilation syndrome is needed.

Ward-Based Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure Unrelated to Chronic Obstructive Pulmonary Disease.

Background: The use of ward-based noninvasive ventilation (NIV) for acute hypercapnic respiratory failure (AHRF) unrelated to chronic obstructive pulmonary disease (COPD) remains controversial. This study evaluated the outcomes and failure rates associated with NIV application in the ward-based setting for patients with AHRF unrelated to COPD. Methods: A multicentre, retrospective cohort study of patients with AHRF unrelated to COPD was conducted. COPD was not the main reason for hospital admission, treated with ward-based NIV between February 2004 and December 2018. All AHRF patients were eligible; exclusion criteria comprised COPD patients, age < 18 years, pre-NIV pH < 7.35, or a lack of pre-NIV blood gas. In-hospital mortality was the primary outcome; univariable and multivariable models were constructed. The obesity-related AHRF group included patients with AHRF due to obesity hypoventilation syndrome (OHS), and the non-obesity-related AHRF group included patients with AHRF due to pneumonia, bronchiectasis, neuromuscular disease, or fluid overload. Results: In total, 479 patients were included in the analysis; 80.2% of patients survived to hospital discharge. Obesity-related AHRF was the indication for NIV in 39.2% of all episodes and was the aetiology with the highest rate of survival to hospital discharge (93.1%). In the multivariable analysis, factors associated with a higher risk of in-hospital mortality were increased age (odds ratio, 95% CI: 1.034, 1.017-1.051, P < 0.001) and pneumonia on admission (5.313, 2.326-12.131, P < 0.001). In the obesity-related AHRF group, pre-NIV pH < 7.15 was associated with significantly increased in-hospital mortality (7.800, 1.843-33.013, P=0.005); however, a pre-NIV pH 7.15-7.25 was not associated with increased in-hospital mortality (2.035, 0.523-7.915, P=0.305). Conclusion: Pre-NIV pH and age have been identified as important predictors of surviving ward-based NIV treatment. Moreover, these data support the use of NIV in ward-based settings for obesity-related AHRF patients with pre-NIV pH thresholds down to 7.15. However, future controlled trials are required to confirm the effectiveness of NIV use outside critical care settings for obesity-related AHRF.

Pneumonia in exacerbations of COPD: what is the clinical significance?

It is vital that clinicians identify radiological consolidation in hospitalised COPD patients, as this confers an increased mortality risk, has important implications for risk stratification and influences management http://bit.ly/2q2vH2J.

Prevalence and predictors of adherence to controller therapy in adult patients with severe/difficult-to-treat asthma: a systematic review and meta-analysis.

Objective: Nonadherence to prescribed treatment is an important cause for poor asthma control. This systematic review aimed to determine the prevalence and determinants of nonadherence in adult patients with severe asthma.Data sources: Embase and Pubmed were searched for publications in English studying adult patients and containing the keywords "severe asthma", "adherence", and "compliance".Study selection: Only studies utilizing objective methods for monitoring adherence and clear definition of the level of asthma severity were included. Predominantly pediatric studies or studies of less severe asthma were excluded.Results: The search returned 488 reports, of which 14 reports (of 2297 patients) were included. The weighted mean age of patients was 44 years and 64% were females. In studies using a cutoff of acquiring 50% or less of the medication, an overall rate of nonadherence was 42.9%. For studies reporting nonadherence of a continuous scale, the weighted mean nonadherence was 42.9% (95% CI 28.2-49.5). Meta-analysis of adherence predictors showed that male sex was associated with adherence with an odds ratio of 2.25 and higher asthma quality of life questionnaire (AQLQ) scores with a mean difference 0.47 points in adherent patients. Other predictors were reported to have significant association with adherence (e.g. older age, more knowledge about asthma, simpler medication schedules) but these were from single studies.Conclusion: Nonadherence to therapy is a common problem in the management of patients with severe asthma. More robust and objective methods are needed to homogenize and improve the accuracy of assessment methods. More studies are needed from developing countries. Systematic review registration number: CRD42018114669.