Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study.

BACKGROUND: Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics. OBJECTIVE: We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened. METHODS: Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis. RESULTS: Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance. CONCLUSIONS: Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

Estimating the cost-effectiveness of maternal vaccination and monoclonal antibodies for respiratory syncytial virus in Kenya and South Africa.

BACKGROUND: Respiratory syncytial virus (RSV) causes a substantial burden of acute lower respiratory infection in children under 5 years, particularly in low- and middle-income countries (LMICs). Maternal vaccine (MV) and next-generation monoclonal antibody (mAb) candidates have been shown to reduce RSV disease in infants in phase 3 clinical trials. The cost-effectiveness of these biologics has been estimated using disease burden data from global meta-analyses, but these are sensitive to the detailed age breakdown of paediatric RSV disease, for which there have previously been limited data. METHODS: We use original hospital-based incidence data from South Africa (ZAF) and Kenya (KEN) collected between 2010 and 2018 of RSV-associated acute respiratory infection (ARI), influenza-like illness (ILI), and severe acute respiratory infection (SARI) as well as deaths with monthly age-stratification, supplemented with data on healthcare-seeking behaviour and costs to the healthcare system and households. We estimated the incremental cost per DALY averted (incremental cost-effectiveness ratio or ICER) of public health interventions by MV or mAb for a plausible range of prices (5-50 USD for MV, 10-125 USD for mAb), using an adjusted version of a previously published health economic model of RSV immunisation. RESULTS: Our data show higher disease incidence for infants younger than 6 months of age in the case of Kenya and South Africa than suggested by earlier projections from community incidence-based meta-analyses of LMIC data. Since MV and mAb provide protection for these youngest age groups, this leads to a substantially larger reduction of disease burden and, therefore, more favourable cost-effectiveness of both interventions in both countries. Using the latest efficacy data and inferred coverage levels based on antenatal care (ANC-3) coverage (KEN: 61.7%, ZAF: 75.2%), our median estimate of the reduction in RSV-associated deaths in children under 5 years in Kenya is 10.5% (95% CI: 7.9, 13.3) for MV and 13.5% (10.7, 16.4) for mAb, while in South Africa, it is 27.4% (21.6, 32.3) and 37.9% (32.3, 43.0), respectively. Starting from a dose price of 5 USD, in Kenya, net cost (for the healthcare system) per (undiscounted) DALY averted for MV is 179 (126, 267) USD, rising to 1512 (1166, 2070) USD at 30 USD per dose; for mAb, it is 684 (543, 895) USD at 20 USD per dose and 1496 (1203, 1934) USD at 40 USD per dose. In South Africa, a MV at 5 USD per dose would be net cost-saving for the healthcare system and net cost per DALY averted is still below the ZAF's GDP per capita at 40 USD dose price (median: 2350, 95% CI: 1720, 3346). For mAb in ZAF, net cost per DALY averted is 247 (46, 510) USD at 20 USD per dose, rising to 2028 (1565, 2638) USD at 50 USD per dose and to 6481 (5364, 7959) USD at 125 USD per dose. CONCLUSIONS: Incorporation of new data indicating the disease burden is highly concentrated in the first 6 months of life in two African settings suggests that interventions against RSV disease may be more cost-effective than previously estimated.

Real-world evidence of multiple myeloma treated from 2013 to 2019 in the Hospital District of Helsinki and Uusimaa, Finland.

Background: The rapid development of multiple myeloma (MM) management underscores the value of real-world data. In our study we examined 509 adult MM patients treated with immunochemotherapy (ICT) with/without stem cell transplantation (SCT) from 2013 to 2019 in the Hospital District of Helsinki and Uusimaa, Finland. Materials & methods: Our study was based on computational analyses of data integrated into the hospital data lake. Results: After 2017, treatment pattern diversity increased with improved access to novel treatments. 5-year survivals were 74.4% (95% CI: 65.5-84.5) in SCT-eligible and 44.0% (95% CI: 37.6-51.4) in non-SCT subgroups. In the SCT-eligible subgroup, high first-year hospitalization costs were followed by stable resource requirements. Conclusion: Hospital data lakes can be adapted to carry out complex analysis of large MM cohorts.

To better understand how multiple myeloma (a type of blood cancer) is clinically managed, we examined 509 adult patients using advanced computer analysis and data stored in the Hospital District of Helsinki and Uusimaa information system. Our study found that after 2017, there was more variety in treatments due to better access to new therapies. Compared with a nontransplant group (44.0%), patients eligible for stem cell transplantation had a better 5-year survival rate (74.4%) and used higher levels of healthcare resources. Our study highlights the potential of hospital data systems to study large groups of multiple myeloma patients and inform strategies to tackle the burden associated with the treatment costs of multiple myeloma.

Violence in the Great Recession.

Substantial evidence suggests that economic hardship causes violence. However, a large majority of this research relies on observational studies that use traditional violence surveillance systems that suffer from selection bias and over-represent vulnerable populations, such as people of color. To overcome limitations of prior work, we employed a quasi-experimental design to assess the impact of the Great Recession on explicit violence diagnoses (injuries identified to be caused by a violent event) and proxy violence diagnoses (injuries highly correlated with violence) for child maltreatment, intimate partner violence, elder abuse, and their combination. We used Minnesota hospital data (2004-2014), conducting a difference-in-differences analysis at the county level (n = 86) using linear regression to compare changes in violence rates from before the recession (2004-2007) to after the recession (2008-2014) in counties most affected by the recession, versus changes over the same time period in counties less affected by the recession. The findings suggested that the Great Recession had little or no impact on explicitly identified violence; however, it affected proxy-identified violence. Counties that were more highly affected by the Great Recession saw a greater increase in the average rate of proxy-identified child abuse, elder abuse, intimate partner violence, and combined violence when compared with less-affected counties.

Real-world data on diffuse large B-cell lymphoma in 2010-2019: usability of large data sets of Finnish hospital data lakes.

Background: Real-world data on diffuse large B-cell lymphoma (DLBCL) has remained incomplete. In Finland, health record data originally recorded in different hospital data record systems are collectively available via data lake technology, enabling efficient extraction and analysis of large data sets. The usability of Finnish data lake data in the assessment of DLBCL was evaluated. Methods: Adult DLBCL patients diagnosed between 2010 and 2019, home municipality in the Hospital District of Southwest Finland and data available in respective data lake were included. Results: The algorithmic determination of treatment lines and respective survival was successful. Patient characterization was feasible, albeit partly incomplete because of limited data content/availability and coverage. Stage, International Prognostic Index and cell of origin were available for 63.0, 68.3 and 28.4% of patients, respectively. Genetic aberrations were not structurally available or feasible to extract without a manual chart review. Conclusion: Finnish data lakes represent an efficient way to analyze large DLBCL data sets. The current study provides a tool for developing recording practices in routine care.

Homelessness among psychiatric inpatients in North Rhine-Westphalia: a retrospective routine data analysis.

BACKGROUND: Within the last five years the number of homeless persons in Germany has more than doubled, with many suffering from mental illnesses that require treatment. Whether the mental illness itself led to losing shelter or whether the state of being homeless increased the likelihood of developing symptoms of a mental disorder remains unclear. The current study assessed the interaction of homelessness and mental illness from a care provider perspective. METHODS: We conducted a retrospective analysis of inpatient routine data from 20 psychiatric hospitals in North Rhine-Westphalia (NRW), Germany, over a period of four years (N = 366,767 inpatient treatment cases). Patients were considered "homeless" if they had no fixed unique address. RESULTS: About 2.4% of the analyzed cohort was classified as homeless, with increasing tendency over the study period (+14% from 2016 to 2019). The percentage of homeless patients varied broadly between the hospitals (0.2-6.3%). Homeless patients were more often male and on average eight years younger than patients with a fixed address. Homeless patients experienced more involuntary measures (admission and restraint), had a shorter course of treatment and were more often discharged within one day. Every second homeless case was diagnosed with a substance use disorder and every third homeless case with a psychotic disorder, whereas affective disorders were diagnosed less frequently in this group. Psychiatric comorbidity occurred more often in homeless patients whereas somatic diseases did not. CONCLUSIONS: Multiple patient-related sociodemographic and local factors are associated with homelessness of psychiatric inpatients. In addition, clinical factors differ between homeless and non-homeless patients, pointing to more severe mental illness and treatment complications (e.g., coercive measures) in homeless persons. Thus, homelessness of psychiatric inpatients can imply special challenges that need to be considered by healthcare providers and politicians, with the goal of optimizing mental and social care and the mental health outcomes of homeless persons.

Impact of the COVID-19 Epidemic on hospitalization for diabetic foot ulcers during lockdown: A French nationwide population-based study.

AIMS/HYPOTHESIS: The aim of this study was to examine the impact of the COVID-19 epidemic on the hospitalization rates for diabetic foot ulcer (DFU), osteomyelitis and lower limb revascularization procedure in people with DFU. METHODS: This nationwide retrospective cohort study included hospital data on all people hospitalized in France for diabetes in weeks 2-43 in 2020, including the COVID-19 lockdown period, compared to same period in 2019. RESULTS: The number of hospitalizations for DFU decreased significantly in weeks 12-19 (during the lockdown) (p < 10-4 ). Hospitalization for foot osteomyelitis also decreased significantly in weeks 12-19 (p < 10-4 ). The trend was the same for lower limb amputations and revascularizations associated with DFU or amputation. CONCLUSIONS/INTERPRETATION: The marked drop in hospitalization rates for DFU, osteomyelitis and lower limb revascularization procedures in people with DFU observed in France during the lockdown period suggests that COVID-19 was a barrier to DFU care, and may illustrate the combined deleterious effects of hospital overload and changes in health-related behaviour.

Prediction of hospital bed capacity during the COVID- 19 pandemic.

BACKGROUND: Prediction of the necessary capacity of beds by ward type (e.g. ICU) is essential for planning purposes during epidemics, such as the COVID- 19 pandemic. The COVID- 19 taskforce within the Ghent University hospital made use of ten-day forecasts on the required number of beds for COVID- 19 patients across different wards. METHODS: The planning tool combined a Poisson model for the number of newly admitted patients on each day with a multistate model for the transitions of admitted patients to the different wards, discharge or death. These models were used to simulate the required capacity of beds by ward type over the next 10 days, along with worst-case and best-case bounds. RESULTS: Overall, the models resulted in good predictions of the required number of beds across different hospital wards. Short-term predictions were especially accurate as these are less sensitive to sudden changes in number of beds on a given ward (e.g. due to referrals). Code snippets and details on the set-up are provided to guide the reader to apply the planning tool on one's own hospital data. CONCLUSIONS: We were able to achieve a fast setup of a planning tool useful within the COVID- 19 pandemic, with a fair prediction on the needed capacity by ward type. This methodology can also be applied for other epidemics.

Hospital Productivity After Data Breaches: Difference-in-Differences Analysis.

BACKGROUND: Data breaches are an inevitable risk to hospitals operating with information technology. The financial costs associated with data breaches are also growing. The costs associated with a data breach may divert resources away from patient care, thus negatively affecting hospital productivity. OBJECTIVE: After a data breach, the resulting regulatory enforcement and remediation are a shock to a hospital's patient care delivery. Exploiting this shock, this study aimed to investigate the association between hospital data breaches and productivity by using a generalized difference-in-differences model with multiple prebreach and postbreach periods. METHODS: The study analyzed the hospital financial data of the California Office of Statewide Health Planning and Development from 2012 to 2016. The study sample was an unbalanced panel of hospitals with 2610 unique hospital-year observations, including general acute care hospitals. California hospital data were merged with breach data published by the US Department of Health and Human Services. The dependent variable was hospital productivity measured as value added. The difference-in-differences model was estimated using fixed effects regression. RESULTS: Hospital productivity did not significantly differ from the baseline for 3 years after a breach. Data breaches were not significantly associated with a reduction in hospital productivity. Before a breach, the productivity of hospitals that experienced a data breach maintained a parallel trend with control hospitals. CONCLUSIONS: Hospital productivity was resilient against the shocks from a data breach. Nonetheless, data breaches continue to threaten hospitals; therefore, health care workers should be trained in cybersecurity to mitigate disruptions.

Estimating Transmission Parameters for Respiratory Syncytial Virus and Predicting the Impact of Maternal and Pediatric Vaccination.

BACKGROUND: Respiratory syncytial virus (RSV) is a leading cause of respiratory tract illness in young children and a major cause of hospital admissions globally. METHODS: Here we fit age-structured transmission models with immunity propagation to data from the Netherlands (2012-2017). Data included nationwide hospitalizations with confirmed RSV, general practitioner (GP) data on attendance for care from acute respiratory infection, and virological testing of acute respiratory infections at the GP. The transmission models, equipped with key parameter estimates, were used to predict the impact of maternal and pediatric vaccination. RESULTS: Estimates of the basic reproduction number were generally high (R0 > 10 in scenarios with high statistical support), while susceptibility was estimated to be low in nonelderly adults (<10% in persons 20-64 years) and was higher in older adults (≥65 years). Scenario analyses predicted that maternal vaccination reduces the incidence of infection in vulnerable infants (<1 year) and shifts the age of first infection from infants to young children. CONCLUSIONS: Pediatric vaccination is expected to reduce the incidence of infection in infants and young children (0-5 years), slightly increase incidence in 5 to 9-year-old children, and have minor indirect benefits.

Association between hospital admission for ketoacidosis and subsequent suicide attempt in young adults with type 1 diabetes.

AIMS/HYPOTHESIS: The aim of this study was to examine the associations between hospitalisation for diabetic ketoacidosis and subsequent hospitalisation for suicide attempt in young adults with type 1 diabetes. METHODS: This nationwide historical cohort study included hospital data on all young people hospitalised in France for type 1 diabetes in 2008. Epidemiological follow-up focused on hospitalisations (medical and psychiatric hospital data) from the index hospitalisation to 2017. Survival analyses were done using a Cox proportional hazards regression model to explore the association between hospitalisation for ketoacidosis and subsequent hospitalisation for a suicide attempt. RESULTS: In 2008, 16,431 people aged 18-35 years had a hospitalisation mentioning type 1 diabetes. Among them, 1539 (9.4%) had at least one hospitalisation for ketoacidosis between 2008 and 2010. At 9 years, 7.2% of the group hospitalised for ketoacidosis had been hospitalised for a suicide attempt vs only 2.5% in the group not hospitalised for ketoacidosis. The association between hospitalisation for ketoacidosis and suicide attempt decreased over time and was no longer significant after 5 years. CONCLUSIONS/INTERPRETATION: We found that young adults admitted to hospital for diabetic ketoacidosis have an increased risk of being admitted to hospital for a subsequent suicide attempt. The risk of a suicide attempt was the highest in the 12 months following the ketoacidosis episode. Our findings support the recommendation that screening for depression and suicide risk should be part of the routine clinical assessment of individuals with type 1 diabetes and ketoacidosis.

Getting a grippe on severity: a retrospective comparison of influenza-related hospitalizations and deaths captured in reportable disease and administrative data sources in Ontario, Canada.

BACKGROUND: Since 2009, in Ontario, reportable disease surveillance data has been used for timely in-season estimates of influenza severity (i.e., hospitalizations and deaths). Due to changes in reporting requirements influenza reporting no longer captures these indicators of severity, necessitating exploration of other potential sources of data. The purpose of this study was to complete a retrospective analysis to assess the comparability of influenza-related hospitalizations and deaths captured in the Ontario reportable disease information system to those captured in Ontario's hospital-based discharge database. METHODS: Hospitalizations and deaths of laboratory-confirmed influenza cases reported during the 2010-11 to 2013-14 influenza seasons were analyzed. Information on hospitalizations and deaths for laboratory-confirmed influenza cases were obtained from two databases; the integrated Public Health Information System, which is the provincial reportable disease database, and the Discharge Abstract Database, which contains information on all in-patient hospital visits using the International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) coding standards. Analyses were completed using the ICD-10 J09 and J10 diagnosis codes as an indicator for laboratory-confirmed influenza, and a secondary analysis included the physician-diagnosed influenza J11 diagnosis code. RESULTS: For each season, reported hospitalizations for laboratory-confirmed influenza cases in the reportable disease data were higher compared to hospitalizations with J09 and J10 diagnoses codes, but lower when J11 codes were included. The number of deaths was higher in the reportable disease data, whether or not J11 codes were included. For all four seasons, the weekly trends in the number of hospitalizations and deaths were similar for the reportable disease and hospital data (with and without J11), with seasonal peaks occurring during the same week or within 1 week of each other. CONCLUSION: In our retrospective analyses we found that hospital data provided a reliable estimate of the trends of influenza-related hospitalizations and deaths compared to the reportable disease data for the 2010-11 to 2013-14 influenza seasons in Ontario, but may under-estimate the total seasonal number of deaths. Hospital data could be used for retrospective end-of-season assessments of severity, but due to delays in data availability are unlikely to be timely estimates of severity during in-season surveillance.

Validation of verbal autopsy methods using hospital medical records: a case study in Vietnam.

BACKGROUND: Information on causes of death (COD) is crucial for measuring the health outcomes of populations and progress towards the Sustainable Development Goals. In many countries such as Vietnam where the civil registration and vital statistics (CRVS) system is dysfunctional, information on vital events will continue to rely on verbal autopsy (VA) methods. This study assesses the validity of VA methods used in Vietnam, and provides recommendations on methods for implementing VA validation studies in Vietnam. METHODS: This validation study was conducted on a sample of 670 deaths from a recent VA study in Quang Ninh province. The study covered 116 cases from this sample, which met three inclusion criteria: a) the death occurred within 30 days of discharge after last hospitalisation, and b) medical records (MRs) for the deceased were available from respective hospitals, and c) the medical record mentioned that the patient was terminally ill at discharge. For each death, the underlying cause of death (UCOD) identified from MRs was compared to the UCOD from VA. The validity of VA diagnoses for major causes of death was measured using sensitivity, specificity and positive predictive value (PPV). RESULTS: The sensitivity of VA was at least 75% in identifying some leading CODs such as stroke, road traffic accidents and several site-specific cancers. However, sensitivity was less than 50% for other important causes including ischemic heart disease, chronic obstructive pulmonary diseases, and diabetes. Overall, there was 57% agreement between UCOD from VA and MR, which increased to 76% when multiple causes from VA were compared to UCOD from MR. CONCLUSIONS: Our findings suggest that VA is a valid method to ascertain UCOD in contexts such as Vietnam. Furthermore, within cultural contexts in which patients prefer to die at home instead of a healthcare facility, using the available MRs as the gold standard may be meaningful to the extent that recall bias from the interval between last hospital discharge and death can be minimized. Therefore, future studies should evaluate validity of MRs as a gold standard for VA studies in contexts similar to the Vietnamese context.

Do hospital doctors test for thrombophilia in patients with venous thromboembolism?

The predictive value of factor V Leiden and the G20210A prothrombin mutation regarding recurrent venous thromboembolism (VTE) is limited and does not influence subsequent patient management. Systematic testing for such genetic thrombophilia should be avoided, but to which extent such testing is practiced in a Swiss Hospital is unknown. To examine the current practice of factor V Leiden and/or G20210A prothrombin mutation testing in a University Hospital, and to assess the clinical consequences of testing on patients. 1388 adult patients (48.7% women) with a main diagnosis of VTE hospitalized at the Lausanne university hospital between January 2013 and December 2015. FV Leiden and/or prothrombin G20210A mutation testing was performed in 61 (4.4%) patients with VTE, an average of 20 patients/year. On multivariable analysis, age < 65 years [odds ratio and (95% confidence interval) 5.91 (3.12-11.19)], being admitted in a medical ward [5.71 (2.02-16.16)] and staying in the intensive care unit [0.34 (0.12-0.97)] were associated with thrombophilia testing. No differences were found between patients with and without testing regarding in-hospital mortality [OR and 95% CI for tested vs. non-tested: 0.23 (0.03-1.73), p = 0.153] and length of stay (multivariable adjusted average ± standard error: 16.9 ± 3.3 vs. 20.0 ± 0.7 days for tested and non-tested patients, respectively, p = 0.875). Thrombophilia testing in hospitalized patients with a main diagnosis of VTE is seldom performed. FV Leiden and/or prothrombin G20210A mutation should not be routinely assessed in patients with acute VTE.

Baseline incidence of intussusception in early childhood before rotavirus vaccine introduction, the Netherlands, January 2008 to December 2012.

Intussusception is a rare, potentially life-threatening condition in early childhood. It gained attention due to an unexpected association with the first rotavirus vaccine, RotaShield, which was subsequently withdrawn from the market. Across Europe, broad variations in intussusception incidence rates have been reported. This study provides a first estimate of intussusception incidence in young children in the Netherlands from 1 January 2008 to 31 December 2012, which could be used for future rotavirus safety monitoring. Our estimates are based on two different sources: electronic medical records from the primary healthcare database (IPCI), as well as administrative data from the Dutch hospital register (LBZ). The results from our study indicate a low rate of intussusception. Overall incidence rate in children < 36 months of age was 21.2 per 100,000 person-years (95% confidence interval (CI): 12.5-34.3) based on primary healthcare data and 22.6 per 100,000 person-years (95% CI: 20.9-24.4) based on hospital administrative data. The estimates suggest the upper and lower bound of the expected number of cases.

Management patterns and predictors of mortality among US patients with cancer hospitalized for malignant bowel obstruction.

BACKGROUND: Malignant bowel obstruction affects an estimated 3% to 15% of patients with cancer, with a mean survival of <4 weeks reported in patients with inoperable malignant bowel obstruction. In the current study, the authors assessed predictors of survival and the influence of treatment modality in US patients with cancer who were hospitalized for malignant bowel obstruction. METHODS: All the US cancer patients hospitalized with malignant bowel obstruction in 2006 and 2010 were included. Data were obtained from the Nationwide Inpatient Sample provided by the Agency for Healthcare Research and Quality. Malignant bowel obstruction diagnoses and treatment variables were identified using Clinical Classifications Software codes based on International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Univariate and multivariate analyses were performed with a logistic model, weighted chi-square test, and a generalized linear model. RESULTS: The authors identified 942,014 and 1,103,528 hospitalizations for malignant bowel obstruction in 2006 and 2010, respectively. Medical management, upper gastrointestinal obstruction, health insurance coverage, and obesity were found to be significantly associated with better hospital survival. Multivariate analysis also demonstrated significantly increased odds of death with male sex, advanced age, AJCC stage IV disease, multiple comorbid conditions (except acquired immunodeficiency syndrome), and weight loss. There were no significant differences with stratification based on the location and etiology of the obstruction (primary tumor vs metastatic). CONCLUSIONS: Malignant bowel obstruction is a common cause of death in hospitalized patients with advanced cancer in the United States. The odds of death are especially high in older patients and those with concurrent medical illnesses. Lack of insurance coverage, significant weight loss, and surgical management also appear to be associated with higher mortality in this population.

A cross-sector approach to explore socio-ecological associations with treatment engagement behaviours in Northern Ghana.

BACKGROUND: Cancer presents a growing global burden, not least in African countries such as Ghana where high cancer treatment dropouts has been identified due to numerous social, cultural and financial reasons. There is little understanding regarding patterns of treatment access behaviour, especially in Northern Ghana, which this study was designed to explore. METHODS: Through cross-sector collaboration, we extracted and clinically validated cancer patient records available in the Tamale Teaching Hospital. These were analysed descriptively and through multi-variate logistic regression. A treatment mapping process was also applied to highlight challenges in data collection. Multiple imputation with chained equations was conducted for high levels of missing data. Sensitivity analysis was applied to assess the impact of missing data. RESULTS: Treatment drop-out was high even when uncertainty due to missing data was accounted for, and only 27 % of patients completely engaged with treatment. High drop-out was found for all cancers including those covered by the Ghana National Health Insurance scheme. Multi-variate logistic regression revealed that social, health condition and systemic factors influence treatment engagement until completion. High missing data was observed for liver, ovarian, colorectal, gastric, bladder, oesophageal and head and neck and skin cancers, and soft tissue sarcomas, which limited model fitting. CONCLUSION: Treatment drop-out is a critical issue in Northern Ghana. There was high missing data due to the dynamic, complex and decentralised treatment pathway. Future studies are needed to understand the complex challenges in data recording. POLICY SUMMARY: Treatment drop out is a pertinent issue that policy makers should look to address. Further discussion with stakeholders involved in cancer treatment and data collection is required to better understand challenges to routine data collection in the local setting. This will allow policy to be designed to cater for the impact of multiple intersecting health and social factors on treatment completion.

Cyclist safety around trams: A market survey.

Tram systems present safety risks to cyclists, however only limited research has explored this topic, of which most has focused on crash and hospital data, and severe crash events. This paper presents the first known cyclist market survey focused specifically on the experience of cyclists related to safety around trams, including unreported incidents and those that did not result in hospital attendance. Findings suggest that track-skid incidents are more common than track-wedge incidents, in contrast to previous research that emphasizes track-wedging as a larger issue than skidding. This is may be explained by the differing outcomes, with track-wedging more likely to result in injury. This research is thus significant in identifying track skidding as a major risk concern, causing a majority of crashes, while also confirming that track wedging is the major severity concern. In the last five years, 21% of respondents were involved in at least one tram-track-related crash. This was less than the share of respondents involved in falls (50%), crashes relating to road defects (36%) or collisions with motor vehicles (29%). However, half of survey respondents (52%) reported cycling on roads with tram tracks for 0-20% of their cycling, which might suggest that tram track-related crash rates are high given that most inner-city cycling occurs on roads without tracks. Track-skidding was found to be associated with wet conditions. Those involved in at least one track-skid in the last five years where more likely to have been cycling more than 3 years, but involvement in track-wedging was more likely amongst those cycling > 10 years and aged < 45 years. Implications for research and practice are suggested.

Greek Hospital Data Mining and Analysis.

Monitoring the performance of hospitals is a crucial issue related both with the quality of healthcare services and with country's economy. An easy and trustful way of evaluating health systems is through key performance indicators (KPIs). Such indicators are widely used for the identification of gaps in the quality or efficiency of the services provided. The main aim of this study is the analysis of the financial and operational indicators at hospitals in the 3rd and 5th Healthcare Regions of Greece. In addition, through cluster analysis and data visualization we attempt to uncover hidden patterns that may lie within our data. The results of the study support the need for re-evaluation of the assessment methodology of Greek hospitals to identify the weaknesses in the system, while evidently unsupervised learning exposes the potential of group-based decision making.

Quantifying patient- and hospital-level antimicrobial resistance dynamics in Staphylococcus aureus from routinely collected data.

Introduction. Antimicrobial resistance (AMR) to all antibiotic classes has been found in the pathogen Staphylococcus aureus. The reported prevalence of these resistances varies, driven by within-host AMR evolution at the patient level, and between-host transmission at the hospital level. Without dense longitudinal sampling, pragmatic analysis of AMR dynamics at multiple levels using routine surveillance data is essential to inform control measures.Gap Statement. The value and limitations of routinely collected hospital data to gain insight into AMR dynamics at the hospital and individual levels simultaneously are unclear.Methodology. We explored S. aureus AMR diversity in 70 000 isolates from a UK paediatric hospital between 2000-2021, using electronic datasets containing multiple routinely collected isolates per patient with phenotypic antibiograms and information on hospitalization and antibiotic consumption.Results. At the hospital level, the proportion of isolates that were meticillin-resistant (MRSA) increased between 2014-2020 from 25-50 %, before sharply decreasing to 30%, likely due to a change in inpatient demographics. Temporal trends in the proportion of isolates resistant to different antibiotics were often correlated in MRSA, but independent in meticillin-susceptible S. aureus. Ciprofloxacin resistance in MRSA decreased from 70-40 % of tested isolates between 2007-2020, likely linked to a national policy to reduce fluoroquinolone usage in 2007. At the patient level, we identified frequent AMR diversity, with 4 % of patients ever positive for S. aureus simultaneously carrying, at some point, multiple isolates with different resistances. We detected changes over time in AMR diversity in 3 % of patients ever positive for S. aureus. These changes equally represented gain and loss of resistance.Conclusion. Within this routinely collected dataset, we found that 65 % of changes in resistance within a patient's S. aureus population could not be explained by antibiotic exposure or between-patient transmission of bacteria, suggesting that within-host evolution via frequent gain and loss of AMR genes may be responsible for these changing AMR profiles. Our study highlights the value of exploring existing routine surveillance data to determine underlying mechanisms of AMR. These insights may substantially improve our understanding of the importance of antibiotic exposure variation, and the success of single S. aureus clones.