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BACKGROUND: COVID-19 outbreaks still occur in English care homes despite the interventions in place. METHODS: We developed a stochastic compartmental model to simulate the spread of SARS-CoV-2 within an English care home. We quantified the outbreak risk with baseline non-pharmaceutical interventions (NPIs) already in place, the role of community prevalence in driving outbreaks, and the relative contribution of all importation routes into a fully susceptible care home. We also considered the potential impact of additional control measures in care homes with and without immunity, namely: increasing staff and resident testing frequency, using lateral flow antigen testing (LFD) tests instead of polymerase chain reaction (PCR), enhancing infection prevention and control (IPC), increasing the proportion of residents isolated, shortening the delay to isolation, improving the effectiveness of isolation, restricting visitors and limiting staff to working in one care home. We additionally present a Shiny application for users to apply this model to their facility of interest, specifying care home, outbreak and intervention characteristics. RESULTS: The model suggests that importation of SARS-CoV-2 by staff, from the community, is the main driver of outbreaks, that importation by visitors or from hospitals is rare, and that the past testing strategy (monthly testing of residents and daily testing of staff by PCR) likely provides negligible benefit in preventing outbreaks. Daily staff testing by LFD was 39% (95% 18-55%) effective in preventing outbreaks at 30 days compared to no testing. CONCLUSIONS: Increasing the frequency of testing in staff and enhancing IPC are important to preventing importations to the care home. Further work is needed to understand the impact of vaccination in this population, which is likely to be very effective in preventing outbreaks.
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COVID-19 , SARS-CoV-2 , COVID-19/epidemiología , COVID-19/prevención & control , Brotes de Enfermedades/prevención & control , Humanos , Control de Infecciones , VacunaciónRESUMEN
Background: Norovirus places a substantial burden on healthcare systems, arising from infected patients, disease outbreaks, beds kept unoccupied for infection control, and staff absences due to infection. In settings with high rates of bed occupancy, opportunity costs arise from patients who cannot be admitted due to beds being unavailable. With several treatments and vaccines against norovirus in development, quantifying the expected economic burden is timely. Methods: The number of inpatients with norovirus-associated gastroenteritis in England was modeled using infectious and noninfectious gastrointestinal Hospital Episode Statistics codes and laboratory reports of gastrointestinal pathogens collected at Public Health England. The excess length of stay from norovirus was estimated with a multistate model and local outbreak data. Unoccupied bed-days and staff absences were estimated from national outbreak surveillance. The burden was valued conventionally using accounting expenditures and wages, which we contrasted to the opportunity costs from forgone patients using a novel methodology. Results: Between July 2013 and June 2016, 17.7% (95% confidence interval [CI], 15.6%â21.6%) of primary and 23.8% (95% CI, 20.6%â29.9%) of secondary gastrointestinal diagnoses were norovirus attributable. Annually, the estimated median 290000 (interquartile range, 282000â297000) occupied and unoccupied bed-days used for norovirus displaced 57800 patients. Conventional costs for the National Health Service reached £107.6 million; the economic burden approximated to £297.7 million and a loss of 6300 quality-adjusted life-years annually. Conclusions: In England, norovirus is now the second-largest contributor of the gastrointestinal hospital burden. With the projected impact being greater than previously estimated, improved capture of relevant opportunity costs seems imperative for diseases such as norovirus.
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Infecciones por Caliciviridae/economía , Brotes de Enfermedades/economía , Gastroenteritis/economía , Hospitalización/economía , Control de Infecciones/economía , Absentismo , Adulto , Anciano , Anciano de 80 o más Años , Infecciones por Caliciviridae/epidemiología , Costo de Enfermedad , Infección Hospitalaria/economía , Infección Hospitalaria/epidemiología , Infección Hospitalaria/virología , Brotes de Enfermedades/prevención & control , Inglaterra/epidemiología , Femenino , Gastroenteritis/epidemiología , Gastroenteritis/virología , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Norovirus/aislamiento & purificaciónRESUMEN
BACKGROUND: Antibiotic-resistant bacteria (ARB) are selected by the use of antibiotics. The rational design of interventions to reduce levels of antibiotic resistance requires a greater understanding of how and where ARB are acquired. Our aim was to determine whether acquisition of ARB occurs more often in the community or hospital setting. METHODS: We used a mathematical model of the natural history of ARB to estimate how many ARB were acquired in each of these two environments, as well as to determine key parameters for further investigation. To do this, we explored a range of realistic parameter combinations and considered a case study of parameters for an important subset of resistant strains in England. RESULTS: If we consider all people with ARB in the total population (community and hospital), the majority, under most clinically derived parameter combinations, acquired their resistance in the community, despite higher levels of antibiotic use and transmission of ARB in the hospital. However, if we focus on just the hospital population, under most parameter combinations a greater proportion of this population acquired ARB in the hospital. CONCLUSIONS: It is likely that the majority of ARB are being acquired in the community, suggesting that efforts to reduce overall ARB carriage should focus on reducing antibiotic usage and transmission in the community setting. However, our framework highlights the need for better pathogen-specific data on antibiotic exposure, ARB clearance and transmission parameters, as well as the link between carriage of ARB and health impact. This is important to determine whether interventions should target total ARB carriage or hospital-acquired ARB carriage, as the latter often dominated in hospital populations.
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Antibacterianos/uso terapéutico , Infecciones Comunitarias Adquiridas , Infección Hospitalaria , Farmacorresistencia Microbiana/fisiología , Modelos Teóricos , Antibacterianos/farmacología , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Infecciones Comunitarias Adquiridas/transmisión , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Infección Hospitalaria/transmisión , Inglaterra/epidemiología , Escherichia coli/efectos de los fármacos , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/epidemiología , Infecciones por Escherichia coli/transmisión , Humanos , Resistencia betalactámica/efectos de los fármacosRESUMEN
Opportunity costs of bed-days are fundamental to understanding the value of healthcare systems. They greatly influence burden of disease estimations and economic evaluations involving stays in healthcare facilities. However, different estimation techniques employ assumptions that differ crucially in whether to consider the value of the second-best alternative use forgone, of any available alternative use, or the value of the actually chosen alternative. Informed by economic theory, this paper provides a taxonomic framework of methodologies for estimating the opportunity costs of resources. This taxonomy is then applied to bed-days by classifying existing approaches accordingly. We highlight differences in valuation between approaches and the perspective adopted, and we use our framework to appraise the assumptions and biases underlying the standard approaches that have been widely adopted mostly unquestioned in the past, such as the conventional use of reference costs and administrative accounting data. Drawing on these findings, we present a novel approach for estimating the opportunity costs of bed-days in terms of health forgone for the second-best patient, but expressed monetarily. This alternative approach effectively re-connects to the concept of choice and explicitly considers net benefits. It is broadly applicable across settings and for other resources besides bed-days.
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Ocupación de Camas/economía , Asignación de Recursos para la Atención de Salud/economía , Modelos Económicos , Costos y Análisis de Costo , Humanos , Tiempo de Internación/economíaRESUMEN
BACKGROUND: In 2016, one in three older people in the UK were living alone. These patients often have complex health needs and require additional clinical and non-clinical support. This study aimed to analyse the association between living alone and health care utilisation in older patients. METHODS: We conducted a retrospective cohort study of 1447 patients over the age of 64, living in 1275 households who were registered at a large general practice in South East London. The utilisation of four different types of health care provision were examined in order to explore the impact of older patients living alone on health care utilisation. RESULTS: After adjusting for patient demographics and clinical characteristics, living alone was significantly associated with a higher probability of utilising emergency department and general practitioner services, with odds ratios of 1.50 (95% confidence interval [CI] 1.16 to 1.93) and 1.40 (95% CI 1.04 to 1.88) respectively. CONCLUSIONS: Living alone has an impact on health care service utilisation for older patients. We show that general practice data can be used to identify older patients who are living alone, and general practitioners are in a unique position to identify those who could benefit from additional clinical and non-clinical support. Further research is needed to understand the mechanism driving higher utilisation for those patients who live alone.
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Medicina General , Aceptación de la Atención de Salud/estadística & datos numéricos , Características de la Residencia/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Registros Electrónicos de Salud , Femenino , Medicina General/organización & administración , Encuestas de Atención de la Salud , Humanos , Londres/epidemiología , Masculino , Calidad de Vida , Estudios RetrospectivosRESUMEN
BACKGROUND: Many studies have investigated the presence of a 'weekend effect' in mortality following hospital admission, and these frequently use diagnostic codes from administrative data for information on comorbidities for risk adjustment. However, it is possible that coding practice differs between week and weekend. We assess patients with a confirmed history of certain long-term health conditions and investigate how well these are recorded in subsequent week and weekend admissions. METHODS: We selected six long-term conditions that are commonly assessed when risk-adjusting mortality rates, via the Charlson and Elixhauser indices. Using Hospital Episode Statistics data from England for the period April 2009 to March 2011, we identified patients with the condition recorded at least twice, on separate emergency admissions. Then we assessed how often each condition was recorded on subsequent emergency admissions between April 2011 and March 2013. We then compared coding between week and weekend admissions using the Cochran-Mantel-Haenszel test, stratifying by hospital. RESULTS: We studied 111,457 patients with chronic pulmonary disease, 106,432 with diabetes, 36,447 with congestive heart failure, 30,996 with dementia, 7808 with hemiplegia or paraplegia and 5877 with metastatic cancer. Across the entire week, between April 2011 and March 2013, coding completeness ranged from 89% for diabetes to 43% for hemiplegia/paraplegia. Compared with weekday admissions, congestive heart failure was less likely to be recorded as a secondary diagnosis at the weekend (odds ratio 0.92, 95% CI, 0.88 to 0.97), with smaller but statistically significant differences also detected for chronic pulmonary disease (odds ratio 0.96, 95% CI, 0.93 to 0.99) and diabetes (odds ratio 0.95, 95% CI 0.91 to 0.99). There was no statistically significant difference in recording between week and weekend admissions for dementia (odds ratio 1.04, 95% CI 0.97 to 1.11), hemiplegia/paraplegia (odds ratio 0.99, 95% CI 0.89 to 1.10) or metastatic cancer (odds ratio 1.04, 95% CI 0.90 to 1.20). CONCLUSIONS: Long-term conditions are often not recorded on administrative data and the lack of recording may be worse for weekend admissions. Studies of the weekend effect that rely on administrative data might have underestimated the health burden of patients, particularly if admitted at the weekend.
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Enfermedad Crónica/terapia , Tratamiento de Urgencia/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Comorbilidad , Inglaterra , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Prospectivos , Ajuste de Riesgo , Factores de TiempoRESUMEN
Background: Long-term care facilities (LTCFs) are thought to be important reservoirs of antimicrobial-resistant (AMR) bacteria; however, there is no routine surveillance of resistance in LTCF residents, or large population-based studies comparing AMR in LTCFs with the community, so the relative burden of AMR in LTCFs remains unknown. Objectives: To compare the frequency of antibiotic resistance of urinary tract bacteria from residents of LTCFs for the elderly and adults aged 70 years or older living in the community. Methods: Positive urine specimens reported to any diagnostic microbiology laboratory in the West Midlands region (England) from 1 April 2010 to 31 March 2014 collected from individuals aged 70 years or older were analysed. The resistance of Escherichia coli and Klebsiella to trimethoprim, nitrofurantoin, third-generation cephalosporins and ciprofloxacin and the rate of laboratory-confirmed E. coli and Klebsiella urinary tract infection (UTI) were assessed in LTCF residents and in the community. Results: LTCF residents had a laboratory-confirmed E. coli and Klebsiella UTI rate of 21 per 100 person years compared with 8 per 100 person years in the elderly living in the community [rate ratio (RR)=2.66, 95% CI = 2.58-2.73] and a higher rate of developing E. coli and Klebsiella UTIs caused by bacteria resistant to trimethoprim (RR = 4.41, 95% CI = 4.25-4.57), nitrofurantoin (RR = 4.38, 95% CI = 3.98-4.83), ciprofloxacin (RR = 5.18, 95% CI = 4.82-5.57) and third-generation cephalosporins (RR = 4.49, 95% CI = 4.08-4.94). Conclusions: Residents of LTCFs for the elderly had more than double the rate of E. coli and Klebsiella UTI and more than four times the rate of E. coli and Klebsiella UTI caused by antibiotic-resistant bacteria compared with those living in the community.
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Farmacorresistencia Bacteriana , Infecciones por Escherichia coli/microbiología , Escherichia coli/efectos de los fármacos , Infecciones por Klebsiella/microbiología , Klebsiella/efectos de los fármacos , Instituciones Residenciales , Infecciones Urinarias/microbiología , Anciano , Anciano de 80 o más Años , Reservorios de Enfermedades/microbiología , Inglaterra/epidemiología , Escherichia coli/aislamiento & purificación , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/epidemiología , Femenino , Humanos , Klebsiella/aislamiento & purificación , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/efectos de los fármacos , Cuidados a Largo Plazo , Masculino , Infecciones Urinarias/tratamiento farmacológico , Infecciones Urinarias/epidemiología , Orina/microbiologíaRESUMEN
OBJECTIVES: The objectives of this study were to estimate the relative transmissibility of mupirocin-resistant (MupR) and mupirocin-susceptible (MupS) MRSA strains and evaluate the long-term impact of MupR on MRSA control policies. METHODS: Parameters describing MupR and MupS strains were estimated using Markov chain Monte Carlo methods applied to data from two London teaching hospitals. These estimates parameterized a model used to evaluate the long-term impact of MupR on three mupirocin usage policies: 'clinical cases', 'screen and treat' and 'universal'. Strategies were assessed in terms of colonized and infected patient days and scenario and sensitivity analyses were performed. RESULTS: The transmission probability of a MupS strain was 2.16 (95% CI 1.38-2.94) times that of a MupR strain in the absence of mupirocin usage. The total prevalence of MupR in colonized and infected MRSA patients after 5 years of simulation was 9.1% (95% CI 8.7%-9.6%) with the 'screen and treat' mupirocin policy, increasing to 21.3% (95% CI 20.9%-21.7%) with 'universal' mupirocin use. The prevalence of MupR increased in 50%-75% of simulations with 'universal' usage and >10% of simulations with 'screen and treat' usage in scenarios where MupS had a higher transmission probability than MupR. CONCLUSIONS: Our results provide evidence from a clinical setting of a fitness cost associated with MupR in MRSA strains. This provides a plausible explanation for the low levels of mupirocin resistance seen following 'screen and treat' mupirocin usage. From our simulations, even under conservative estimates of relative transmissibility, we see long-term increases in the prevalence of MupR given 'universal' use.
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Antiinfecciosos Locales/uso terapéutico , Portador Sano/tratamiento farmacológico , Transmisión de Enfermedad Infecciosa/prevención & control , Farmacorresistencia Bacteriana , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Mupirocina/uso terapéutico , Infecciones Estafilocócicas/prevención & control , Antiinfecciosos Locales/farmacología , Portador Sano/prevención & control , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Infección Hospitalaria/transmisión , Hospitales de Enseñanza , Humanos , Control de Infecciones/métodos , Londres/epidemiología , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Modelos Estadísticos , Mupirocina/farmacología , Política Organizacional , Prevalencia , Infecciones Estafilocócicas/tratamiento farmacológico , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/transmisiónRESUMEN
BACKGROUND: Dynamic transmission models are increasingly being used to improve our understanding of the epidemiology of healthcare-associated infections (HCAI). However, there has been no recent comprehensive review of this emerging field. This paper summarises how mathematical models have informed the field of HCAI and how methods have developed over time. METHODS: MEDLINE, EMBASE, Scopus, CINAHL plus and Global Health databases were systematically searched for dynamic mathematical models of HCAI transmission and/or the dynamics of antimicrobial resistance in healthcare settings. RESULTS: In total, 96 papers met the eligibility criteria. The main research themes considered were evaluation of infection control effectiveness (64%), variability in transmission routes (7%), the impact of movement patterns between healthcare institutes (5%), the development of antimicrobial resistance (3%), and strain competitiveness or co-colonisation with different strains (3%). Methicillin-resistant Staphylococcus aureus was the most commonly modelled HCAI (34%), followed by vancomycin resistant enterococci (16%). Other common HCAIs, e.g. Clostridum difficile, were rarely investigated (3%). Very few models have been published on HCAI from low or middle-income countries.The first HCAI model has looked at antimicrobial resistance in hospital settings using compartmental deterministic approaches. Stochastic models (which include the role of chance in the transmission process) are becoming increasingly common. Model calibration (inference of unknown parameters by fitting models to data) and sensitivity analysis are comparatively uncommon, occurring in 35% and 36% of studies respectively, but their application is increasing. Only 5% of models compared their predictions to external data. CONCLUSIONS: Transmission models have been used to understand complex systems and to predict the impact of control policies. Methods have generally improved, with an increased use of stochastic models, and more advanced methods for formal model fitting and sensitivity analyses. Insights gained from these models could be broadened to a wider range of pathogens and settings. Improvements in the availability of data and statistical methods could enhance the predictive ability of models.
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Infección Hospitalaria/transmisión , Modelos Biológicos , Bases de Datos Factuales , Farmacorresistencia Bacteriana , HumanosRESUMEN
BACKGROUND: Hip fracture is a leading cause of disability and mortality among older people. During the COVID-19 pandemic, orthopaedic care pathways in the National Health Service in England were restructured to manage pressures on hospital capacity. We examined the indirect consequences of the pandemic for hospital mortality among older patients with hip fracture, admitted from care homes or the community. METHODS: Retrospective analysis of linked care home and hospital inpatient data for patients with hip fracture aged 65 years and over admitted to hospitals in England during the first year of the pandemic (1 March 2020 to 28 February 2021) or during the previous year. We performed survival analysis, adjusting for case mix and COVID-19 infection, and considered live discharge as a competing risk. We present cause-specific hazard ratios (HRCS) for the effect of admission year on hospital mortality risk. RESULTS: During the first year of the pandemic, there were 55 648 hip fracture admissions: a 5.2% decrease on the previous year. 9.5% of patients had confirmed or suspected COVID-19. Hospital stays were substantially shorter (p<0.05), and there was a higher daily chance of discharge (HRCS 1.40, 95% CI 1.38 to 1.41). Overall hip fracture inpatient mortality increased (7.2% in 2020/2021 vs 6.4% in 2019/2020), but patients without concomitant COVID-19 infection had lower mortality rates compared with the year before (5.3%). Admission during the pandemic was associated with a 11% increase in the daily risk of hospital death for patients with hip fracture (HRCS 1.11, 95% CI 1.05 to 1.16). CONCLUSIONS: Although COVID-19 infections led to increases in hospital mortality, overall hospital mortality risk for older patients with hip fracture remained largely stable during the first year of the pandemic.
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COVID-19 , Fracturas de Cadera , Humanos , Anciano , COVID-19/complicaciones , Mortalidad Hospitalaria , Pandemias , Estudios Retrospectivos , Medicina Estatal , Fracturas de Cadera/epidemiología , Fracturas de Cadera/complicaciones , Análisis de SupervivenciaRESUMEN
BACKGROUND: Seasonal influenza places a substantial burden annually on healthcare services. Policies during the COVID-19 pandemic limited the transmission of seasonal influenza, making the timing and magnitude of a potential resurgence difficult to ascertain and its impact important to forecast. METHODS: We have developed a hierarchical generalised additive model (GAM) for the short-term forecasting of hospital admissions with a positive test for the influenza virus sub-regionally across England. The model incorporates a multi-level structure of spatio-temporal splines, weekly cycles in admissions, and spatial correlation. Using multiple performance metrics including interval score, coverage, bias, and median absolute error, the predictive performance is evaluated for the 2022-2023 seasonal wave. Performance is measured against autoregressive integrated moving average (ARIMA) and Prophet time series models. RESULTS: Across the epidemic phases the hierarchical GAM shows improved performance, at all geographic scales relative to the ARIMA and Prophet models. Temporally, the hierarchical GAM has overall an improved performance at 7 and 14 day time horizons. The performance of the GAM is most sensitive to the flexibility of the smoothing function that measures the national epidemic trend. CONCLUSIONS: This study introduces an approach to short-term forecasting of hospital admissions for the influenza virus using hierarchical, spatial, and temporal components. The methodology was designed for the real time forecasting of epidemics. This modelling framework was used across the 2022-2023 winter for healthcare operational planning by the UK Health Security Agency and the National Health Service in England.
Seasonal influenza causes a burden for hospitals and therefore it is useful to be able to accurately predict how many patients might be admitted with the disease. We attempted to predict influenza admissions up to 14 days in the future by creating a computational model that incorporates how the disease is reported and how it spreads. We evaluated our optimised model on data acquired during the winter of 2022-2023 data in England and compared it with previously developed models. Our model was better at modelling how influenza spreads and predicting future hospital admissions than the models we compared it to. Improving how influenza admissions are forecast can enable hospitals to prepare better for increased admissions, enabling improved treatment and reduced death for all patients in hospital over winter.
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OBJECTIVES: To describe the characteristics of high-cost high-need children and young people (CYP) (0-24 years) in England. METHODS: Retrospective observational study using data from the Clinical Practice Research Database linked to Hospital Episode Statistics in 2014/2015 and 2015/2016. Healthcare utilisation of primary and secondary care services were calculated, and costs were estimated using Healthcare Resource Group for secondary care and Personal Social Services Research Unit for primary care. High-cost high-need CYP were defined as the top 5% of users by cost. RESULTS: 3891 of 73 392 CYP made up the top 5% that were classified as high-cost high-need, and this group accounted for 54% of total annual costs. In this population, 7.3% were males <5 years and 11.0% were females 20-24 years. Inpatient care (acute) accounted for 63% of known spending in high-cost high-need patients. Total mean monthly cost per patient was 22.7 times greater in the high-cost high-need group compared with all other patients (£4417 vs £195). 29% of CYP in the high-cost high-need group in 2014/2015 were also classified as high-cost high-need in the following year. CONCLUSIONS: These findings indicate the importance of further understanding and anticipating trends in CYP health spending to optimise care, reduce costs and inform new models of care. This includes integrated services, a further look into societal factors in reducing health inequalities and a particular focus of mental health services, the demand of which increases with age.
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Costos de la Atención en Salud , Servicios de Salud Mental , Adolescente , Niño , Atención a la Salud , Femenino , Hospitalización , Humanos , Masculino , Aceptación de la Atención de Salud , Estudios RetrospectivosRESUMEN
BACKGROUND: Multiple conditions are more prevalent in some minoritised ethnic groups and are associated with higher mortality rate but studies examining differential mortality once conditions are established is US-based. Our study tested whether the association between multiple conditions and mortality varies across ethnic groups in England. METHODS AND FINDINGS: A random sample of primary care patients from Clinical Practice Research Datalink (CPRD) was followed from 1st January 2015 until 31st December 2019. Ethnicity, usually self-ascribed, was obtained from primary care records if present or from hospital records. Long-term conditions were counted from a list of 32 that have previously been associated with greater primary care, hospital admissions, or mortality risk. Cox regression models were used to estimate mortality by count of conditions, ethnicity and their interaction, with adjustment for age and sex for 532,059 patients with complete data. During five years of follow-up, 5.9% of patients died. Each additional condition at baseline was associated with increased mortality. The direction of the interaction of number of conditions with ethnicity showed a statistically higher mortality rate associated with long-term conditions in Pakistani, Black African, Black Caribbean and Other Black ethnic groups. In ethnicity-stratified models, the mortality rate per additional condition at age 50 was 1.33 (95% CI 1.31,1.35) for White ethnicity, 1.43 (95% CI 1.26,1.61) for Black Caribbean ethnicity and 1.78 (95% CI 1.41,2.24) for Other Black ethnicity. CONCLUSIONS: The higher mortality rate associated with having multiple conditions is greater in minoritised compared with White ethnic groups. Research is now needed to identify factors that contribute to these inequalities. Within the health care setting, there may be opportunities to target clinical and self-management support for people with multiple conditions from minoritised ethnic groups.
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Población Negra , Etnicidad , Pueblo Asiatico , Inglaterra/epidemiología , Hospitalización , Humanos , Persona de Mediana EdadRESUMEN
BACKGROUND: Longer GP consultations are recommended as one way of improving care for people with multimorbidity. In Scotland, patients who are multimorbid and living in deprived areas do not have longer consultations, although their counterparts in the least deprived areas do. This example of the inverse care law has not been examined in England. AIM: To assess GP consultation length by socioeconomic deprivation and multimorbidity. DESIGN AND SETTING: Random sample of 1.2 million consultations from 1 April 2014 to 31 March 2016 for 190 036 adults in England drawn from the Clinical Practice Research Datalink. METHOD: Consultation duration was derived from time of opening and closing the patient's electronic record. Mean duration was estimated by multimorbidity level and type, adjusted for number of consultations and other patient and staff characteristics and patient and practice random effects. RESULTS: Consultations lasted 10.9 minutes on average and mean duration increased with number of conditions. Patients with ≥6 conditions had 0.9 (95% confidence interval [CI] = 0.8 to 1.0) minutes longer than those with none. Patients who are multimorbid and with a mental health condition had 0.5 (CI = 0.4 to 0.5) minutes longer than patients who were not multimorbid. However, consultations were 0.5 (CI = 0.4 to 0.5) minutes shorter in the most compared with the least deprived fifth of areas at all levels of multimorbidity. CONCLUSION: GPs in England spend longer with patients who have more conditions, but, at all multimorbidity levels, those in deprived areas have less time per GP consultation. Further research is needed to assess the impact of consultation length on patient and system outcomes for those with multimorbidity.
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Registros Electrónicos de Salud , Multimorbilidad , Adulto , Inglaterra/epidemiología , Humanos , Atención Primaria de Salud , Derivación y Consulta , Escocia , Factores SocioeconómicosRESUMEN
BACKGROUND: The daily management of long-term conditions falls primarily on individuals and informal carers, but the impact of household context on health and social care activity among people with multiple long-term conditions (MLTCs) is understudied. AIM: To test whether co-residence with a person with MLTCs (compared with a co-resident without MLTCs) is associated with utilisation and cost of primary, community, secondary health care, and formal social care. DESIGN & SETTING: Linked data from health providers and local government in Barking and Dagenham for a retrospective cohort of people aged ≥50 years in two-person households in 2016-2018. METHOD: Two-part regression models were applied to estimate annualised use and cost of hospital, primary, community, mental health, and social care by MLTC status of individuals and co-residents, adjusted for age, sex, and deprivation. Applicability at the national level was tested using the Clinical Practice Research Datalink (CPRD). RESULTS: Forty-eight per cent of people with MLTCs in two-person households were co-resident with another person with MLTCs. They were 1.14 (95% confidence interval [CI] = 1.00 to 1.30) times as likely to have community care activity and 1.24 (95% CI = 0.99 to 1.54) times as likely to have mental health care activity compared with those co-resident with a healthy person. They had more primary care visits (8.5 [95% CI = 8.2 to 8.8] versus 7.9 [95% CI = 7.7 to 8.2]) and higher primary care costs. Outpatient care and elective admissions did not differ. Findings in national data were similar. CONCLUSION: Care utilisation for people with MLTCs varies by household context. There may be potential for connecting health and community service input across household members.
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OBJECTIVE: To contribute objective evidence on health care utilization among migrants to the UK to inform policy and service planning. METHODS: We analysed data from Understanding Society, a household survey with fieldwork from 2015 to 2017, and the European Health Interview Survey with data collected between 2013 and 2014. We explored health service utilization among migrants to the UK across primary care, inpatient admissions and maternity care, outpatient care, mental health, dental care and physiotherapy. We adjusted for age, sex, long-term health conditions and time since moving to the UK. RESULTS: Health care utilization among migrants to the UK was lower than utilization among the UK-born population for all health care dimensions except inpatient admissions for childbirth; odds ratio (95%CI) range 0.58 (0.50-0.68) for dental care to 0.88 (0.78-0.98) for primary care). After adjusting for differences in age and self-reported health, these differences were no longer observed, except for dental care (odds ratio 0.57, 95%CI 0.49-0.66, P < 0.001). Across primary care, outpatient and inpatient care, utilization was lower among those who had recently migrated, increasing to the levels of the nonmigrant population after 10 years or more since migrating to the UK. CONCLUSIONS: This study finds that newly arrived migrants tend to utilize less health care than the UK population and that this pattern was at least partly explained by better health, and younger age. Our findings contribute nationally representative evidence to inform public debate and decision-making on migration and health.
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Servicios de Salud Materna , Migrantes , Estudios Transversales , Femenino , Humanos , Aceptación de la Atención de Salud , Embarazo , Reino UnidoRESUMEN
In response to unprecedented surges in the demand for hospital care during the SARS-CoV-2 pandemic, health systems have prioritized patients with COVID-19 to life-saving hospital care to the detriment of other patients. In contrast to these ad hoc policies, we develop a linear programming framework to optimally schedule elective procedures and allocate hospital beds among all planned and emergency patients to minimize years of life lost. Leveraging a large dataset of administrative patient medical records, we apply our framework to the National Health Service in England and show that an extra 50,750-5,891,608 years of life can be gained compared with prioritization policies that reflect those implemented during the pandemic. Notable health gains are observed for neoplasms, diseases of the digestive system, and injuries and poisoning. Our open-source framework provides a computationally efficient approximation of a large-scale discrete optimization problem that can be applied globally to support national-level care prioritization policies.
RESUMEN
OBJECTIVE: This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes. DATA SOURCES: We used individual-level patient data from 11 health systems. STUDY DESIGN: We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex. DATA COLLECTION/EXTRACTION METHODS: Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. PRINCIPAL FINDINGS: The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona. CONCLUSION: Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.
Asunto(s)
Países Desarrollados/estadística & datos numéricos , Insuficiencia Cardíaca , Fracturas de Cadera , Mortalidad Hospitalaria/tendencias , Evaluación de Resultado en la Atención de Salud , Readmisión del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Australia , Diabetes Mellitus/economía , Diabetes Mellitus/terapia , Europa (Continente) , Femenino , Anciano Frágil/estadística & datos numéricos , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Fracturas de Cadera/economía , Fracturas de Cadera/rehabilitación , Fracturas de Cadera/cirugía , Humanos , Masculino , América del Norte , Evaluación de Resultado en la Atención de Salud/economía , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricosRESUMEN
OBJECTIVE: This study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture. DATA SOURCES: We used individual-level patient data from five care settings. STUDY DESIGN: We compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized.. DATA COLLECTION/EXTRACTION METHODS: The data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. PRINCIPAL FINDINGS: The sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting. CONCLUSION: Across 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care.