Investigating the impact of primary care networks on continuity of care in English general practice: Analysis of interviews with patients and clinicians from a mixed methods study.

INTRODUCTION: In England, primary care networks (PCNs) offer opportunities to improve access to and sustainability of general practice through collaboration between groups of practices to provide care with a broader range of practitioner roles. However, there are concerns that these changes may undermine continuity of care. Our study investigates what the organisational shift to PCNs means for continuity of care. METHODS: The paper uses thematic analysis of qualitative data from interviews with general practitioners and other healthcare professionals (HCPs, n = 33) in 19 practices in five PCNs, and their patients (n = 35). Three patient cohorts within each participating practice were recruited, based on anticipated higher or lower needs for continuity of care: patients over 65 years with polypharmacy, patients with anxiety or depression and 'working age' adults aged between 18 and 45 years. FINDINGS: Patients and clinicians perceived changes to continuity in PCNs in our study. Larger-scale care provision in PCNs required better care coordination and information-sharing processes, aimed at improving care for 'vulnerable' patients in target groups. However, new working arrangements and ways of delivering care in PCNs undermine HCPs' ability to maintain continuity through ongoing relationships with patients. Patients experience this in terms of reduced availability of their preferred clinician, inefficiencies in care and unfamiliarity of new staff, roles and processes. CONCLUSIONS: New practitioners need to be effectively integrated to support effective team-based care. However, for patients, especially those not deemed 'vulnerable', this may not be sufficient to counter the loss of relationship with their practice. Therefore, caution is required in relation to designating patients as in need of, or not in need of continuity. Rather, continuity for all patients could be maintained through a dynamic understanding of the need for it as fluctuating and situational and by supporting clinicians to provide follow-up care. PATIENT AND PUBLIC INVOLVEMENT (PPI): A PPI group was recruited and consulted during the study for feedback on the study design, recruitment materials and interpretation of findings.

Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching.

OBJECTIVE: To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN: A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING: At a tertiary care teaching hospital. PARTICIPANTS: A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (ß2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS: Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

Enhanced Recovery After Surgery Is Associated With Improved Outcomes and Reduced Racial and Ethnic Disparities After Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis With Propensity-Score Matching.

OBJECTIVES: To evaluate whether enhanced recovery after surgery (ERAS) protocol implementation was associated with improved outcomes and decreased racial and ethnic outcome disparities after isolated coronary artery bypass graft (CABG) surgery. DESIGN: A retrospective analysis of an institutional CABG database with propensity-score matching. SETTING: At a single tertiary care teaching hospital. PARTICIPANTS: One thousand seven hundred thirty-five patients undergoing isolated CABG: 656 patients from 2016 to 2017 (pre-ERAS) and 1,079 patients from 2018 to 2020 (post-ERAS). Each patient cohort was divided into a White subgroup and a racial and ethnic minorities (Minorities) subgroup. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS patients (n = 584) compared to pre-ERAS patients (n = 584) demonstrated reductions in total length of stay (LOS) (median [interquartile range]): (7 [5-10] v 8 [6-11.5] days, p = .006), postoperative LOS (5 [4-7] v 5 [4-7] days, p = .001), total ventilation time (6.1 [4.8-9.5] v 6.6 [5.2-10.9] hours, p = .004), postoperative morphine milligram equivalents (mean ± standard deviation: 68.6 ± 57.5 v 100.0 ± 59.4, p < .001), and increased likelihood of early extubation (48.8% v 42.3%, p = .026); the Minorities subgroup demonstrated reductions in likelihood of intensive care unit (ICU) readmission (1.3% v 8.1%, p = .012) and postoperative morphine milligram equivalents (73.6 ± 64.0 v 107.8 ± 71.9, p < .001). Logistic regression models demonstrated that disparities in ICU readmission and postoperative LOS between White and Minorities patients were eliminated post-ERAS. CONCLUSIONS: ERAS for isolated CABG surgery was associated with reduced total and postoperative LOS, reduced total ventilation time, and increased early extubation for all patients, as well as reduced ICU readmission for the Minorities subgroup. ERAS implementation was associated with reduced disparities between White and racial and ethnic minority patients for ICU readmission and postoperative LOS.

Incidental COVID-19 in a heart-kidney transplant recipient with malnutrition and recurrent infections: Implications for the SARS-CoV-2 immune response.

The clinical course and outcomes of immunocompromised patients, such as transplant recipients, with COVID-19 remain unclear. It has been postulated that a substantial portion of the disease burden seems to be mediated by the host immune activation to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Herein, we present a simultaneous heart-kidney transplant (SHKT) recipient who was hospitalized for the management of respiratory failure from volume overload complicated by failure to thrive, multiple opportunistic infections, and open non-healing wounds in the setting of worsening renal dysfunction weeks prior to the first case of SARS-CoV-2 being detected in the state of Connecticut. After his third endotracheal intubation, routine nucleic acid testing (NAT) for SARS-CoV-2, in anticipation of a planned tracheostomy, was positive. His hemodynamics, respiratory status, and ventilator requirements remained stable without any worsening for 4 weeks until he had a negative NAT test. It is possible that the immunocompromised status of our patient may have prevented significant immune activation leading up to clinically significant cytokine storm that could have resulted in acute respiratory distress syndrome and multisystem organ failure.

Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening.

OBJECTIVES: Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms. METHODS: Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25-64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome-unassisted birth rates-largely unaffected by HSCA changes. RESULTS: Interviewees identified that cervical screening commissioning and provision was more complex and 'fragmented', with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups. CONCLUSIONS: Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.

Vasopressin therapy in cardiac surgery.

BACKGROUND: Arginine vasopressin (AVP) is a naturally occurring peptide with diverse effects mediated through selective V1 and V2 receptors. About 10% of patients undergoing cardiopulmonary bypass develop postoperative vasodilatory shock requiring high-dose catecholamines. We sought to examine the role of AVP therapy in cardiac surgery. METHODS: A search of Medline was conducted through September 2018 using key words and medical subject headings (MeSH) relating to AVP, copeptin, and cardiac surgery. A systematic review was performed on articles as they pertained to AVP for use as a vasopressor after cardiovascular surgery complicated by vasodilatory shock. RESULTS: A relative or absolute deficiency of Arginine vasopressin is associated with vasodilatory shock after cardiopulmonary bypass. Physiologic replacement with exogenous Arginine vasopressin results in significant increases in systemic vascular resistance and mean arterial pressure with decreased requirements of catecholamines. At doses of <0.1 U/min Arginine vasopressin is safe with very few adverse effects. CONCLUSION: Post-cardiopulmonary bypass vasodilatory shock is largely due to a relative deficiency of Arginine vasopressin. Exogenous administration of low-dose Arginine vasopressin alone or in combination with traditional catecholamines is a safe and effective way to manage this type of vasodilatory shock.

Beyond the parish pump: what next for public health?

BACKGROUND: Public health has had a history characterised by uncertainty of purpose, locus of control, and workforce identity. In many health systems, the public health function is fragmented, isolated and under-resourced. We use the most recent major reforms to the English National Health Service and local government, the Health and Social Care Act 2012 (HSCA12), as a lens through which to explore the changing nature of public health professionalism. METHODS: This paper is based upon a 3-year longitudinal study into the impacts of the HSCA12 upon the commissioning system in England, in which we conducted 141 interviews with 118 commissioners and senior staff from a variety of health service commissioner and provider organisations, local government, and the third sector. For the present paper, we developed a subset of data relevant to public health, and analysed it using a framework derived from the literature on public health professionalism, exploring themes identified from relevant policy documents and research. RESULTS: The move of public health responsibilities into local government introduced an element of politicisation which challenged public health professional autonomy. There were mixed feelings about the status of public health as a specialist profession. The creation of a national public health organisation helped raise the profile of profession, but there were concerns about clarity of responsibilities, accountability, and upholding 'pure' public health professional values. There was confusion about the remit of other organisations in relation to public health. CONCLUSIONS: Where public health professionals sit in a health system in absolute terms is less important than their ability to develop relationships, negotiate their roles, and provide expert public health influence across that system. A conflation between 'population health' and 'public health' fosters unrealistic expectations of the profession. Public health may be best placed to provide leadership for other stakeholders and professional groups working towards improving health outcomes of their defined populations, but there remains a need to clarify the role(s) that public health as a specialist profession has to play in helping to fulfil population health goals.

Thromboelastography (TEG)-based algorithm reduces blood product utilization in patients undergoing VAD implant.

OBJECTIVES: Multiple blood products are often required during and after ventricular assist device (VAD) implants. Generally, transfusion therapy is empirically guided by conventional laboratory tests. In this study, we aimed to compare a thromboelastography (TEG)-based algorithm with a laboratory coagulation test-based algorithm with respect to blood product utilization in patients undergoing VAD implant. METHODS: From June 2010 to May 2012, a total of 39 consecutive patients underwent VAD implantation. Patients undergoing VAD implant were retrospectively divided into two groups according to transfusion strategy. In the control group (n=20), the need for blood transfusion was based on clinician's discretion according to standard coagulation test results. In the TEG group (n=19), a strict protocol based on TEG parameters was followed for the usage of all perioperative blood products. Coagulation factors, TEG parameters, and blood transfusions were documented and compared between these two groups. RESULTS: There were no differences in demographic variables with the exception of a decreased CPB time in the TEG group (p=0.019). Prothrombin time (PT) (p<0.001) and international normalized ratio (INR) (p<0.001) in the postprotamine interval were significantly higher in the TEG group than in the control group. No significant difference was detected in any coagulation variable in the postoperative (ICU) period between the two groups. Platelet counts decreased in a linear fashion from baseline to the postoperative period in the two groups (p<0.001). Patients in the TEG group received significantly less fresh-frozen plasma in both the intraoperative (p=0.005) and postoperative (p=0.014) periods. Patients in the TEG group also received significantly less platelets both in the postoperative (p=0.03) period and in total amount (p=0.033). There was no difference in consumption of packed red blood cell units between the two groups. CONCLUSIONS: Our results show that the strict use of a TEG-guided algorithm significantly reduces the consumption of blood products in patients undergoing VAD implant

The impact of pulmonary hypertension on outcomes of patients with low left ventricular ejection fraction: a propensity analysis.

BACKGROUND AND AIM OF THE STUDY: Pulmonary hypertension (PH) is commonly described as a risk factor in cardiac surgery; however, the effect of a low left ventricular ejection fraction (LVEF) on PH has not been assessed. Hence, the study aim was to determine whether PH increases operative mortality and survival outcome in patients with a low LVEF. METHODS: Between January 2001 and September 2009, a total of 845 consecutive patients with LVEF < 40% was enrolled into the study. Among these patients, 444 had a pulmonary pressure < 40 mmHg (NPH group), while in 401 patients the pulmonary pressure was > or = 40 mmHg. RESULTS: Preoperatively, the PH patients were older (p < 0.001), had a lower LVEF (p = 0.001), and had a higher logistic EuroSCORE (p < 0.001) and serum creatinine level (p < 0.026) when compared to NPH patients. The PH patients showed a greater tendency to develop postoperative complications (p < 0.001). After adjusting by propensity score, the in-hospital mortality was significantly higher among PH patients (p < 0.001), while multivariate logistic regressions revealed PH as an independent predictor for in-hospital mortality (p = 0.036). The 12-, 36-, and 60-month follow up mortality rates were significantly higher in the PH group. By using a Cox logistic regression model, PH was shown to be an independent predictor for follow up mortality (p = 0.035). CONCLUSION: Pulmonary hypertension increased the morbidity and mortality in patients with a low LVEF who were undergoing cardiac surgery. Future studies may identify subgroups that may benefit from a preoperative optimization of PH and/or intra- and postoperative therapies directed at minimizing the effects of the condition.

Preoperative statins and infectious complications following cardiac surgery.

PURPOSE: Recent observational studies have suggested that statins can decrease the incidence and severity of various infections including pneumonia and bacteremia. However, the effect of statins on post-cardiac surgery infection has not been adequately evaluated. Therefore we sought to determine whether preoperative statin use resulted in a reduction in infection following cardiac surgery. METHODS: This was a cohort evaluation of all consecutive patients who underwent coronary artery bypass graft (CABG) and/or valve surgery at our institution between January 1, 2004 and August 31, 2006. Our primary outcome measure was the occurrence of at least one of the following postoperative infectious complications (pneumonia, bacteremia, sternal wound, leg vein harvest site infection, urinary tract infection, or tracheotomy site infection). We used multivariable logistic regression to control for potential confounding and to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). RESULTS: A total of 1934 patients were included in this evaluation of which 1248 received a statin preoperatively and 686 did not. Our study population was 66.3 +/- 11.6 years of age, 71.3% male; 37.2% underwent complex surgery, 3.6% were morbidly obese, and 32.0% were diabetic (each being previously identified as an independent predictor of infection following cardiac surgery). Patients receiving a statin preoperatively and not receiving a statin preoperatively varied in respect to a number of important pre- and peri- operative characteristics. Patients receiving preoperative statin therapy were more likely to have had a history of diabetes, chronic obstructive pulmonary disease or high cholesterol and to be smokers, but less likely to be undergoing urgent/emergent surgery or surgery utilizing a cardiopulmonary bypass pump (p < 0.05 for all comparisons). In total, 151 (7.8%) patients developed an infectious complication. Upon multivariable logistic regression, preoperative statin use was associated with a significant reduction in the development of infection (AOR; 0.67 (95% CI 0.46-0.99), p = 0.04). The use of a statin was not associated with a statistically significant reduction in any individual infection on its own (p > 0.08 for all). LIMITATIONS: Patients were not randomized to receive statins or not. We did not have adequate power to evaluate individual infections. CONCLUSIONS: Preoperative statin use is associated with a reduction in patients' odds of developing a postoperative infection following cardiac surgery.

Evaluating the safety implications of aprotinin use: the Retrospective Evaluation of Aprotinin in Cardio Thoracic Surgery (REACTS).

OBJECTIVES: Aprotinin is a drug used to reduce bleeding in patients undergoing cardiothoracic surgery with cardiopulmonary bypass. A recent cohort evaluation found elevated risks of renal, cardiovascular, and cerebrovascular events when aprotinin was used. We sought to determine the impact of aprotinin on safety variables among patients receiving cardiothoracic surgery with cardiopulmonary bypass from a single US hospital that reserves aprotinin for complex surgeries and Jehovah's Witnesses and does not utilize celite-based activated clotting time determinations. METHODS: We performed a cohort evaluation with multivariate logistic regression, including propensity score adjustment comprising patients from January 1, 2000 and December 31, 2005. We evaluated 3348 patients having cardiothoracic surgery in a single tertiary care medical center. We observed aprotinin use or lack of aprotinin in cardiothoracic surgery. The main outcome measures were odds (expressed as an odds ratio with 95% confidence interval) of developing myocardial infarction, cerebrovascular events, and renal dysfunction after cardiothoracic surgery between groups. RESULTS: Patients receiving aprotinin were less likely to experience a cerebrovascular event compared with control [0.65 (0.46-0.91)] and did not have an elevated odds of myocardial infarction [1.04 (0.53-2.04)] but were more likely to experience postoperative renal dysfunction [2.03 (1.37-3.01)]. CONCLUSIONS: Aprotinin was not associated with negative myocardial or cerebrovascular risks but did increase the risk of renal dysfunction. It is not known whether the renal dysfunction reflects renal damage or a transient reduction in glomerular filtration pressure.