The impact of the COVID-19 pandemic on 397 631 elective dental admissions among the under-25s in England: a retrospective study.

BACKGROUND: COVID-19 caused widespread disruptions to health services worldwide, including reductions in elective surgery. Tooth extractions are among the most common reasons for elective surgery among children and young people (CYP). It is unclear how COVID-19 affected elective dental surgeries in hospitals over multiple pandemic waves at a national level. METHODS: Elective dental tooth extraction admissions were selected using Hospital Episode Statistics. Admission trends for the first 14 pandemic months were compared with the previous five years and results were stratified by age (under-11s, 11-16s, 17-24s). RESULTS: The most socioeconomically deprived CYP comprised the largest proportion of elective dental tooth extraction admissions. In April 2020, admissions dropped by >95%. In absolute terms, the biggest reduction was in April (11-16s: -1339 admissions, 95% CI -1411 to -1267; 17-24s: -1600, -1678 to -1521) and May 2020 (under-11s: -2857, -2962 to -2752). Admissions differed by socioeconomic deprivation for the under-11s (P < 0.0001), driven by fewer admissions than expected by the most deprived and more by the most affluent during the pandemic. CONCLUSION: Elective tooth extractions dropped most in April 2020, remaining below pre-pandemic levels throughout the study. Despite being the most likely to be admitted, the most deprived under-11s had the largest reductions in admissions relative to other groups.

Does early return to theatre add value to rates of revision at 3 years in assessing surgeon performance for elective hip and knee arthroplasty? National observational study.

BACKGROUND: Joint replacement revision is the most widely used long-term outcome measure in elective hip and knee surgery. Return to theatre (RTT) has been proposed as an additional outcome measure, but how it compares with revision in its statistical performance is unknown. METHODS: National hospital administrative data for England were used to compare RTT at 90 days (RTT90) with revision rates within 3 years by surgeon. Standard power calculations were run for different scenarios. Funnel plots were used to count the number of surgeons with unusually high or low rates. RESULTS: From 2006 to 2011, there were 297 650 hip replacements (HRs) among 2952 surgeons and 341 226 knee replacements (KRs) among 2343 surgeons. RTT90 rates were 2.1% for HR and 1.5% for KR; 3-year revision rates were 2.1% for HR and 2.2% for KR. Statistical power to detect surgeons with poor performance on either metric was particularly low for surgeons performing 50 cases per year for the 5 years. The correlation between the risk-adjusted surgeon-level rates for the two outcomes was +0.51 for HR and +0.20 for KR, both p<0.001. There was little agreement between the measures regarding which surgeons had significantly high or low rates. CONCLUSION: RTT90 appears to provide useful and complementary information on surgeon performance and should be considered alongside revision rates, but low case loads considerably reduce the power to detect unusual performance on either metric.

Exploring the impact of consultants' experience on hospital mortality by day of the week: a retrospective analysis of hospital episode statistics.

OBJECTIVE: To examine the association of consultants' experience with mortality by day of the week when elective surgery was performed. DESIGN: Retrospective observational study using English hospital administrative data. SETTING: All acute and specialist English National Health Service (NHS) hospitals carrying out elective surgery between financial years 2008-2009 and 2010-2011. PARTICIPANTS: Patients undergoing elective surgical procedures. MAIN OUTCOME MEASURES: Death in or out of hospital within 30 days of the surgical procedure taking place. RESULTS: We examined 3 922 091 (26 409 deaths) elective procedures with valid consultant information between 2008-2009 and 2010-2011 in English hospitals; there were 21 196 consultants in charge of these procedures, which took place in 163 NHS hospitals. Consultant seniority had no significant impact in predicting mortality (p=0.345). Patients undergoing elective surgery under junior consultants had slightly lower odds of 30-day death when compared with patients under more experienced consultants (OR 0.95, 95% CI 0.91 to 0.99). We found significant mortality variation among consultants in charge of elective procedures within hospitals, with only moderate variation between hospitals. The adjusted odds of death remained higher for Friday (OR 1.48, 95% CI 1.42 to 1.54), Saturday (OR 1.97, 95% CI 1.83 to 2.12) and Sunday (OR 1.67, 95% CI 1.50 to 1.85) after adjusting for consultant seniority and patient characteristics. Consultant experience is significantly lower (p<0.0001) on a Friday (median (SD) was 7.9 years (4.4)) than the Monday to Thursday average (median (SD) was 8.5 years (4.3)). CONCLUSIONS: Our cohort of patients shows that consultant seniority is not a significant factor in predicting 30-day mortality following elective surgery by day of the week. The end-of-the-week effect remains significant after adjusting for patient, consultant and hospital effects, suggesting that other unobserved factors may be driving the higher mortality towards the end of the week. Consultant's years of experience are lowest on a Friday; however, we do not believe that this small variation has any impact on patient outcomes.

The Global Comparators project: international comparison of 30-day in-hospital mortality by day of the week.

OBJECTIVE: To examine the association of mortality by day of the week for emergency and elective patients. DESIGN: Retrospective observational study using the international dataset from the Global Comparators (GC) project consisting of hospital administrative data. SETTING: 28 hospitals from England, Australia, USA and the Netherlands during 2009-2012. PARTICIPANTS: Emergency and surgical-elective patients. MAIN OUTCOME MEASURES: In-hospital deaths within 30 days of emergency admission or of elective surgery. RESULTS: We examined 2 982 570 hospital records; adjusted odds of 30-day death were higher for weekend emergency admissions to 11 hospitals in England (OR 1.08, 95% CI 1.04 to 1.13 on Sunday), 5 hospitals in USA (OR 1.13, 95% CI 1.04 to 1.24 on Sunday) and 6 hospitals in the Netherlands (OR 1.20, 95% CI 1.09 to 1.33 on Saturday). Emergency admissions to the six Australian hospitals showed no daily variation in adjusted 30-day mortality, but showed a weekend effect at 7 days post emergency admission (OR 1.12, 95% CI 1.04 to 1.22 on Saturday). All weekend elective patients showed higher adjusted odds of 30-day postoperative death; we observed a 'Friday effect' for elective patients in the six Dutch hospitals. CONCLUSIONS: We show that mortality outcomes for our sample vary within each country and per day of the week in agreement with previous studies of the 'weekend effect'. Due to limitations of administrative datasets, we cannot determine the reasons for these findings; however, the international nature of our database suggests that this is a systematic phenomenon affecting healthcare providers across borders. Further investigation is needed to understand the factors that give rise to the weekend effect. The participating hospitals represent varied models of service delivery, and there is a potential to learn from best practice in different healthcare systems.

Staff perceptions of quality of care: an observational study of the NHS Staff Survey in hospitals in England.

BACKGROUND: There is some evidence to suggest that higher job satisfaction among healthcare staff in specific settings may be linked to improved patient outcomes. This study aimed to assess the potential of staff satisfaction to be used as an indicator of institutional performance across all acute National Health Service (NHS) hospitals in England. METHODS: Using staff responses from the NHS Staff Survey 2009, and correlating these with hospital standardised mortality ratios (HSMR), correlation analyses were conducted at institutional level with further analyses of staff subgroups. RESULTS: Over 60 000 respondents from 147 NHS trusts were included in the analysis. There was a weak negative correlation with HSMR where staff agreed that patient care was their trust's top priority (Kendall τ = -0.22, p<0.001), and where they would be happy with the care for a friend or relative (Kendall τ = -0.30, p<0.001). These correlations were identified across clinical and non-clinical groups, with nursing staff demonstrating the most robust correlation. There was no correlation between satisfaction with the quality of care delivered by oneself and institutional HSMR. CONCLUSIONS: In the context of the continued debate about the relationship of HSMR to hospital performance, these findings of a weak correlation between staff satisfaction and HSMR are intriguing and warrant further investigation. Such measures in the future have the advantage of being intuitive for lay and specialist audiences alike, and may be useful in facilitating patient choice. Whether higher staff satisfaction drives quality or merely reflects it remains unclear.

Using routine data to monitor inequalities in an acute trust: a retrospective study.

BACKGROUND: Reducing inequalities is one of the priorities of the National Health Service. However, there is no standard system for monitoring inequalities in the care provided by acute trusts. We explore the feasibility of monitoring inequalities within an acute trust using routine data. METHODS: A retrospective study of hospital episode statistics from one acute trust in London over three years (2007 to 2010). Waiting times, length of stay and readmission rates were described for seven common surgical procedures. Inequalities by age, sex, ethnicity and social deprivation were examined using multiple logistic regression, adjusting for the other socio-demographic variables and comorbidities. Sample size calculations were computed to estimate how many years of data would be ideal for this analysis. RESULTS: This study found that even in a large acute trust, there was not enough power to detect differences between subgroups. There was little evidence of inequalities for the outcome and process measures examined, statistically significant differences by age, sex, ethnicity or deprivation were only found in 11 out of 80 analyses. Bariatric surgery patients who were black African or Caribbean were more likely than white patients to experience a prolonged wait (longer than 64 days, aOR = 2.47, 95% CI: 1.36-4.49). Following a coronary angioplasty, patients from more deprived areas were more likely to have had a prolonged length of stay (aOR = 1.66, 95% CI: 1.25-2.20). CONCLUSIONS: This study found difficulties in using routine data to identify inequalities on a trust level. Little evidence of inequalities in waiting time, length of stay or readmission rates by sex, ethnicity or social deprivation were identified although some differences were identified which warrant further investigation. Even with three years of data from a large trust there was little power to detect inequalities by procedure. Data will therefore need to be pooled from multiple trusts to detect inequalities.