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.

Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza: retrospective cohort study.

BACKGROUND: We examine differences in posthospitalisation outcomes, and health system resource use, for patients hospitalised with COVID-19 during the UK's first pandemic wave in 2020, and influenza during 2018 and 2019. METHODS: This retrospective cohort study used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity. RESULTS: The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37). CONCLUSIONS: Patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

A service evaluation of passive remote monitoring technology for patients in a high-secure forensic psychiatric hospital: a qualitative study.

BACKGROUND: Technology has the potential to remotely monitor patient safety in real-time that helps staff and without disturbing the patient. However, staff and patients' perspectives on using passive remote monitoring within an inpatient setting is lacking. The study aim was to explore stakeholders' perspectives about using Oxehealth passive monitoring technology within a high-secure forensic psychiatric hospital in the UK as part of a wider mixed-methods service evaluation. METHODS: Semi-structured interviews were conducted with staff and patients with experience of using Oxehealth technology face-to-face within a private room in Broadmoor Hospital. We applied thematic analysis to the data of each participant group separately. Themes and sub-themes were integrated, finalised, and presented in a thematic map. Design, management, and analysis was meaningfully informed by both staff and patients. RESULTS: Twenty-four participants were interviewed (n = 12 staff, n = 12 patients). There were seven main themes: detecting deterioration and improving health and safety, "big brother syndrome", privacy and dignity, knowledge and understanding, acceptance, barriers to use and practice issues and future changes needed. Oxehealth technology was considered acceptable to both staff and patients if the technology was used to detect deterioration and improve patient's safety providing patient's privacy was not invaded. However, overall acceptance was lower when knowledge and understanding of the technology and its camera was limited. Most patients could not understand why both physical checks through bedroom windows, and Oxehealth was needed to monitor patients, whilst staff felt Oxehealth should not replace physical checks of patients as reassures staff on patient safety. CONCLUSIONS: Oxehealth technology is considered viable and acceptable by most staff and patients but there is still some concern about its possible intrusive nature. However, more support and education for new patients and staff to better understand how Oxehealth works in the short- and long-term could be introduced to further improve acceptability. A feasibility study or pilot trial to compare the impact of Oxehealth with and without physical checks may be needed.

Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with COVID-19 assessed in emergency departments in England: a retrospective matched cohort study.

BACKGROUND: To identify the impact of enrolment onto a national pulse oximetry remote monitoring programme for COVID-19 (COVID-19 Oximetry @home; CO@h) on health service use and mortality in patients attending Emergency Departments (EDs). METHODS: We conducted a retrospective matched cohort study of patients enrolled onto the CO@h pathway from EDs in England. We included all patients with a positive COVID-19 test from 1 October 2020 to 3 May 2021 who attended ED from 3 days before to 10 days after the date of the test. All patients who were admitted or died on the same or following day to the first ED attendance within the time window were excluded. In the primary analysis, participants enrolled onto CO@h were matched using demographic and clinical criteria to participants who were not enrolled. Five outcome measures were examined within 28 days of first ED attendance: (1) Death from any cause; (2) Any subsequent ED attendance; (3) Any emergency hospital admission; (4) Critical care admission; and (5) Length of stay. RESULTS: 15 621 participants were included in the primary analysis, of whom 639 were enrolled onto CO@h and 14 982 were controls. Odds of death were 52% lower in those enrolled (95% CI 7% to 75%) compared with those not enrolled onto CO@h. Odds of any ED attendance or admission were 37% (95% CI 16% to 63%) and 59% (95% CI 32% to 91%) higher, respectively, in those enrolled. Of those admitted, those enrolled had 53% (95% CI 7% to 76%) lower odds of critical care admission. There was no significant impact on length of stay. CONCLUSIONS: These findings indicate that for patients assessed in ED, pulse oximetry remote monitoring may be a clinically effective and safe model for early detection of hypoxia and escalation. However, possible selection biases might limit the generalisability to other populations.

Changing Patterns of Bloodstream Infections in the Community and Acute Care Across 2 Coronavirus Disease 2019 Epidemic Waves: A Retrospective Analysis Using Data Linkage.

BACKGROUND: We examined community- and hospital-acquired bloodstream infections (BSIs) in coronavirus disease 2019 (COVID-19) and non-COVID-19 patients across 2 epidemic waves. METHODS: We analyzed blood cultures of patients presenting to a London hospital group between January 2020 and February 2021. We reported BSI incidence, changes in sampling, case mix, healthcare capacity, and COVID-19 variants. RESULTS: We identified 1047 BSIs from 34 044 blood cultures, including 653 (62.4%) community-acquired and 394 (37.6%) hospital-acquired. Important pattern changes were seen. Community-acquired Escherichia coli BSIs remained below prepandemic level during COVID-19 waves, but peaked following lockdown easing in May 2020, deviating from the historical trend of peaking in August. The hospital-acquired BSI rate was 100.4 per 100 000 patient-days across the pandemic, increasing to 132.3 during the first wave and 190.9 during the second, with significant increase in elective inpatients. Patients with a hospital-acquired BSI, including those without COVID-19, experienced 20.2 excess days of hospital stay and 26.7% higher mortality, higher than reported in prepandemic literature. In intensive care, the BSI rate was 421.0 per 100 000 intensive care unit patient-days during the second wave, compared to 101.3 pre-COVID-19. The BSI incidence in those infected with the severe acute respiratory syndrome coronavirus 2 Alpha variant was similar to that seen with earlier variants. CONCLUSIONS: The pandemic have impacted the patterns of community- and hospital-acquired BSIs, in COVID-19 and non-COVID-19 patients. Factors driving the patterns are complex. Infection surveillance needs to consider key aspects of pandemic response and changes in healthcare practice.

Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England.

OBJECTIVE: To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. SUMMARY OF BACKGROUND DATA: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. METHODS: We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. RESULTS: One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5-23.3, P < 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. CONCLUSIONS: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.

Factors associated with accessing long-term adult social care in people aged 75 and over: a retrospective cohort study.

BACKGROUND: An ageing population and limited resources have put strain on state provision of adult social care (ASC) in England. With social care needs predicted to double over the next 20 years, there is a need for new approaches to inform service planning and development, including through predictive models of demand. OBJECTIVE: Describe risk factors for long-term ASC in two inner London boroughs and develop a risk prediction model for long-term ASC. METHODS: Pseudonymised person-level data from an integrated care dataset were analysed. We used multivariable logistic regression to model associations of demographic factors, and baseline aspects of health status and health service use, with accessing long-term ASC over 12 months. RESULTS: The cohort comprised 13,394 residents, aged ≥75 years with no prior history of ASC at baseline. Of these, 1.7% became ASC clients over 12 months. Residents were more likely to access ASC if they were older or living in areas with high socioeconomic deprivation. Those with preexisting mental health or neurological conditions, or more intense prior health service use during the baseline period, were also more likely to access ASC. A prognostic model derived from risk factors had limited predictive power. CONCLUSIONS: Our findings reinforce evidence on known risk factors for residents aged 75 or over, yet even with linked routinely collected health and social care data, it was not possible to make accurate predictions of long-term ASC use for individuals. We propose that a paradigm shift towards more relational, personalised approaches, is needed.

Population-level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with COVID-19 in England: a national analysis using a stepped wedge design.

BACKGROUND: To identify the population-level impact of a national pulse oximetry remote monitoring programme for COVID-19 (COVID Oximetry @home (CO@h)) in England on mortality and health service use. METHODS: We conducted a retrospective cohort study using a stepped wedge pre-implementation and post-implementation design, including all 106 Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. All symptomatic people with a positive COVID-19 PCR test result from 1 October 2020 to 3 May 2021, and who were aged ≥65 years or identified as clinically extremely vulnerable were included. Care home residents were excluded. A pre-intervention period before implementation of the CO@h programme in each CCG was compared with a post-intervention period after implementation. Five outcome measures within 28 days of a positive COVID-19 test: (i) death from any cause; (ii) any ED attendance; (iii) any emergency hospital admission; (iv) critical care admission and (v) total length of hospital stay. RESULTS: 217 650 people were eligible and included in the analysis. Total enrolment onto the programme was low, with enrolment data received for only 5527 (2.5%) of the eligible population. The period of implementation of the programme was not associated with mortality or length of hospital stay. The period of implementation was associated with increased health service utilisation with a 12% increase in the odds of ED attendance (95% CI: 6% to 18%) and emergency hospital admission (95% CI: 5% to 20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5% to 47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure. CONCLUSION: At a population level, there was no association with mortality before and after the implementation period of the CO@h programme, and small increases in health service utilisation were observed. However, lower than expected enrolment is likely to have diluted the effects of the programme at a population level.

Clinical Characteristics and Predictors of Outcomes of Hospitalized Patients With Coronavirus Disease 2019 in a Multiethnic London National Health Service Trust: A Retrospective Cohort Study.

BACKGROUND: Emerging evidence suggests ethnic minorities are disproportionately affected by coronavirus disease 2019 (COVID-19). Detailed clinical analyses of multicultural hospitalized patient cohorts remain largely undescribed. METHODS: We performed regression, survival, and cumulative competing risk analyses to evaluate factors associated with mortality in patients admitted for COVID-19 in 3 large London hospitals between 25 February and 5 April, censored as of 1 May 2020. RESULTS: Of 614 patients (median age, 69 [interquartile range, 25] years) and 62% male), 381 (62%) were discharged alive, 178 (29%) died, and 55 (9%) remained hospitalized at censoring. Severe hypoxemia (adjusted odds ratio [aOR], 4.25 [95% confidence interval {CI}, 2.36-7.64]), leukocytosis (aOR, 2.35 [95% CI, 1.35-4.11]), thrombocytopenia (aOR [1.01, 95% CI, 1.00-1.01], increase per 109 decrease), severe renal impairment (aOR, 5.14 [95% CI, 2.65-9.97]), and low albumin (aOR, 1.06 [95% CI, 1.02-1.09], increase per gram decrease) were associated with death. Forty percent (n = 244) were from black, Asian, and other minority ethnic (BAME) groups, 38% (n = 235) were white, and ethnicity was unknown for 22% (n = 135). BAME patients were younger and had fewer comorbidities. Although the unadjusted odds of death did not differ by ethnicity, when adjusting for age, sex, and comorbidities, black patients were at higher odds of death compared to whites (aOR, 1.69 [95% CI, 1.00-2.86]). This association was stronger when further adjusting for admission severity (aOR, 1.85 [95% CI, 1.06-3.24]). CONCLUSIONS: BAME patients were overrepresented in our cohort; when accounting for demographic and clinical profile of admission, black patients were at increased odds of death. Further research is needed into biologic drivers of differences in COVID-19 outcomes by ethnicity.

The J-IDEA Pandemic Planner: A Framework for Implementing Hospital Provision Interventions During the COVID-19 Pandemic.

BACKGROUND: Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for coronavirus disease 2019 (COVID-19), while retaining capacity for other emergency conditions, is one of the most challenging tasks faced by health care providers and policymakers during the pandemic. Health systems must be well-prepared to cope with large and sudden changes in demand by implementing interventions to ensure adequate access to care. We developed the first planning tool for the COVID-19 pandemic to account for how hospital provision interventions (such as cancelling elective surgery, setting up field hospitals, or hiring retired staff) will affect the capacity of hospitals to provide life-saving care. METHODS: We conducted a review of interventions implemented or considered in 12 European countries in March to April 2020, an evaluation of their impact on capacity, and a review of key parameters in the care of COVID-19 patients. This information was used to develop a planner capable of estimating the impact of specific interventions on doctors, nurses, beds, and respiratory support equipment. We applied this to a scenario-based case study of 1 intervention, the set-up of field hospitals in England, under varying levels of COVID-19 patients. RESULTS: The Abdul Latif Jameel Institute for Disease and Emergency Analytics pandemic planner is a hospital planning tool that allows hospital administrators, policymakers, and other decision-makers to calculate the amount of capacity in terms of beds, staff, and crucial medical equipment obtained by implementing the interventions. Flexible assumptions on baseline capacity, the number of hospitalizations, staff-to-beds ratios, and staff absences due to COVID-19 make the planner adaptable to multiple settings. The results of the case study show that while field hospitals alleviate the burden on the number of beds available, this intervention is futile unless the deficit of critical care nurses is addressed first. DISCUSSION: The tool supports decision-makers in delivering a fast and effective response to the pandemic. The unique contribution of the planner is that it allows users to compare the impact of interventions that change some or all inputs.

A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery.

BACKGROUND: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. METHODS: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15. RESULTS: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. CONCLUSIONS: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

Reflections, impact and recommendations of a co-produced qualitative study with young people who have experience of mental health difficulties.

BACKGROUND: There is limited evidence of genuine equal partnership where power is shared with young people with mental health difficulties throughout all research stages, particularly in data collection and analysis. OBJECTIVE: To describe how our qualitative study, exploring young peoples' perceptions on the feasibility of using technology to detect mental health deterioration, was co-produced using principles of co-production, whilst reflecting on impact, challenges and recommendations. METHODS: Young people with experience of mental health difficulties were appointed and then worked with researchers throughout all research stages. The study was evaluated against the five principles of co-production. Reflections from researchers and young people were collected throughout. RESULTS: Seven young people formed an initial Young People's Advisory Group (YPAG); three became co-researchers. Reflection was key throughout the process. Sharing power became easier and more evident as trust, confidence and mutual respect grew over time, particularly after a safe space was established. The safe space was crucial for open discussions, and our WhatsApp group enabled continual communication, support and shared decision-making. The resulting co-produced topic guide, coding framework, thematic map, papers and presentations demonstrated significant impact. CONCLUSIONS: To our knowledge, this is the first qualitative mental health study to be co-produced using the principles of co-production. Our rigorous assessment can be utilized as an informative document to help others to produce meaningful co-produced future research. Although co-production takes time, it makes significant impact to the research, researchers and co-researchers. Flexible funding for spontaneous suggestions from co-researchers and more time for interview training is recommended.

The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: an observational study.

BACKGROUND: Hospitals in England have undergone considerable change to address the surge in demand imposed by the COVID-19 pandemic. The impact of this on emergency department (ED) attendances is unknown, especially for non-COVID-19 related emergencies. METHODS: This analysis is an observational study of ED attendances at the Imperial College Healthcare NHS Trust (ICHNT). We calibrated auto-regressive integrated moving average time-series models of ED attendances using historic (2015-2019) data. Forecasted trends were compared to present year ICHNT data for the period between March 12, 2020 (when England implemented the first COVID-19 public health measure) and May 31, 2020. We compared ICHTN trends with publicly available regional and national data. Lastly, we compared hospital admissions made via the ED and in-hospital mortality at ICHNT during the present year to the historic 5-year average. RESULTS: ED attendances at ICHNT decreased by 35% during the period after the first lockdown was imposed on March 12, 2020 and before May 31, 2020, reflecting broader trends seen for ED attendances across all England regions, which fell by approximately 50% for the same time frame. For ICHNT, the decrease in attendances was mainly amongst those aged < 65 years and those arriving by their own means (e.g. personal or public transport) and not correlated with any of the spatial dependencies analysed such as increasing distance from postcode of residence to the hospital. Emergency admissions of patients without COVID-19 after March 12, 2020 fell by 48%; we did not observe a significant change to the crude mortality risk in patients without COVID-19 (RR 1.13, 95%CI 0.94-1.37, p = 0.19). CONCLUSIONS: Our study findings reflect broader trends seen across England and give an indication how emergency healthcare seeking has drastically changed. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of patients without COVID-19 did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital remains unknown. National analyses and strategies to streamline emergency services in England going forward are urgently needed.

Quality Social Connection as an Active Ingredient in Digital Interventions for Young People With Depression and Anxiety: Systematic Scoping Review and Meta-analysis.

BACKGROUND: Disrupted social connections may negatively affect youth mental health. In contrast, sustained quality social connections (QSCs) can improve mental health outcomes. However, few studies have examined how these quality connections affect depression and anxiety outcomes within digital interventions, and conceptualization is limited. OBJECTIVE: The aim of this study is to conceptualize, appraise, and synthesize evidence on QSC within digital interventions (D-QSC) and the impact on depression and anxiety outcomes for young people aged 14-24 years. METHODS: A systematic scoping review and meta-analysis was conducted using the Joanna Briggs Institute methodological frameworks and guided by experts with lived experience. Reporting was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The MEDLINE, Embase, PsycINFO, and CINAHL databases were searched against a comprehensive combination of key concepts on June 24, 2020. The search concepts included young people, digital intervention, depression, anxiety, and social connection. Google was also searched. A reviewer independently screened abstracts and titles and full text, and 9.99% (388/3882) of these were screened by a second reviewer. A narrative synthesis was used to structure the findings on indicators of D-QSC and mechanisms that facilitate the connection. Indicators of D-QSC from the included studies were synthesized to produce a conceptual framework. RESULTS: Of the 5715 publications identified, 42 (0.73%) were included. Among the included studies, there were 23,319 participants. Indicators that D-QSC was present varied and included relatedness, having a sense of belonging, and connecting to similar people. However, despite the variation, most of the indicators were associated with improved outcomes for depression and anxiety. Negative interactions, loneliness, and feeling ignored indicated that D-QSC was not present. In 24% (10/42) of the applicable studies, a meta-analysis showed a significant decrease in depression (-25.6%, 95% CI -0.352 to -0.160; P<.001) and anxiety (-15.1%, 95% CI -0.251 to -0.051; P=.003) after a D-QSC. Digital mechanisms that helped create a quality connection included anonymity, confidentiality, and peer support. In contrast, mechanisms that hindered the connection included disconnection from the real world and inability to see body language. Data synthesis also identified a 5-component conceptual framework of D-QSC that included rapport, identity and commonality, valued interpersonal dynamic, engagement, and responded to and accepted. CONCLUSIONS: D-QSC is an important and underconsidered component for youth depression and anxiety outcomes. Researchers and developers should consider targeting improved QSC between clinicians and young people within digital interventions for depression. Future research should build on our framework to further examine relationships among individual attributes of QSC, various digital interventions, and different populations.

Timing of Readmissions After Elective Total Hip and Knee Arthroplasty: Does a 30-Day All-Cause Rate Capture Surgically Relevant Readmissions?

BACKGROUND: The 30-day all-cause readmission rate is a widely used metric of hospital performance. However, there is lack of clarity as to whether 30 days is an appropriate time frame following surgical procedures. Our aim is to determine whether a 90-day time window is superior to a 30-day time window in capturing surgically relevant readmissions after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We analyzed readmissions following all primary THAs and TKAs recorded in the English National Health Service Hospital Episode Statistics database from 2008 to 2018. We compared temporal patterns of 30- and 90-day readmission rates for the following types of readmission: all-cause, surgical, return to theater, and those related to specific surgical complications. RESULTS: A total of 1.47 million procedures were recorded. After THA and TKA, over three-quarters of 90-day surgical readmissions took place within the first 30 days (78.5% and 75.7%, respectively). All-cause and surgical readmissions both peaked at day 4 and followed a similar temporal course thereafter. The ratio of surgical to medical readmissions was greater for THA than for TKA, with THA dislocation both being one of the most common surgical complications and clustering early after discharge, with 73.5% of 90-day dislocations occurring within the first 30 days. CONCLUSION: The 30-day all-cause readmission rate is a good reflection of surgically relevant readmissions that take place in the first 90 days after THA and TKA.

Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data.

BACKGROUND: Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs. AIM: To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals. METHOD: We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups. RESULTS: One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively). CONCLUSION: One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.

Adapting hospital capacity to meet changing demands during the COVID-19 pandemic.

BACKGROUND: To calculate hospital surge capacity, achieved via hospital provision interventions implemented for the emergency treatment of coronavirus disease 2019 (COVID-19) and other patients through March to May 2020; to evaluate the conditions for admitting patients for elective surgery under varying admission levels of COVID-19 patients. METHODS: We analysed National Health Service (NHS) datasets and literature reviews to estimate hospital care capacity before the pandemic (pre-pandemic baseline) and to quantify the impact of interventions (cancellation of elective surgery, field hospitals, use of private hospitals, deployment of former medical staff and deployment of newly qualified medical staff) for treatment of adult COVID-19 patients, focusing on general and acute (G&A) and critical care (CC) beds, staff and ventilators. RESULTS: NHS England would not have had sufficient capacity to treat all COVID-19 and other patients in March and April 2020 without the hospital provision interventions, which alleviated significant shortfalls in CC nurses, CC and G&A beds and CC junior doctors. All elective surgery can be conducted at normal pre-pandemic levels provided the other interventions are sustained, but only if the daily number of COVID-19 patients occupying CC beds is not greater than 1550 in the whole of England. If the other interventions are not maintained, then elective surgery can only be conducted if the number of COVID-19 patients occupying CC beds is not greater than 320. However, there is greater national capacity to treat G&A patients: without interventions, it takes almost 10,000 G&A COVID-19 patients before any G&A elective patients would be unable to be accommodated. CONCLUSIONS: Unless COVID-19 hospitalisations drop to low levels, there is a continued need to enhance critical care capacity in England with field hospitals, use of private hospitals or deployment of former and newly qualified medical staff to allow some or all elective surgery to take place.

How an electronic health record became a real-world research resource: comparison between London's Whole Systems Integrated Care database and the Clinical Practice Research Datalink.

BACKGROUND: In the UK, several initiatives have resulted in the creation of local data warehouses of electronic patient records. Originally developed for commissioning and direct patient care, they are potentially useful for research, but little is known about them outside their home area. We describe one such local warehouse, the Whole Systems Integrated Care (WSIC) database in NW London, and its potential for research as the "Discover" platform. We compare Discover with the Clinical Practice Research Datalink (CPRD), a popular UK research database also based on linked primary care records. METHODS: We describe the key features of the Discover database, including scope, architecture and governance; descriptive analyses compare the population demographics and chronic disease prevalences with those in CPRD. RESULTS: As of June 2019, Discover held records for a total of 2.3 million currently registered patients, or 95% of the NW London population; CPRD held records for over 11 million. The Discover population matches the overall age-sex distribution of the UK and CPRD but is more ethnically diverse. Most Discover chronic disease prevalences were comparable to the national rates. Unlike CPRD, Discover has identifiable care organisations and postcodes, allowing mapping and linkage to healthcare provider variables such as staffing, and includes contacts with social, community and mental health care. Discover also includes a consent-to-contact register of over 3000 volunteers to date for prospective studies. CONCLUSIONS: Like CPRD, Discover has been a number of years in the making, is a valuable research tool, and can serve as a model for other areas developing similar data warehouses.

Frequent attendances at emergency departments in England.

BACKGROUND: A small proportion of patients referred to as 'frequent attenders' account for a large proportion of hospital activity such as ED attendances and admissions. There is a lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals. METHOD: We included all attendances at all major EDs across England in the financial year 2016-2017. Patients who attended three times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group. RESULTS: 14 829 519 attendances were made by 10 062 847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended three times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended six times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30-59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had. CONCLUSION: One in 10 patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.

The Impact of a National Antimicrobial Stewardship Program on Antibiotic Prescribing in Primary Care: An Interrupted Time Series Analysis.

BACKGROUND: The Quality Premium was introduced in 2015 to financially reward local commissioners of healthcare in England for targeted reductions in antibiotic prescribing in primary care. METHODS: We used a national antibiotic prescribing dataset from April 2013 until February 2017 to examine the number of antibiotic items prescribed, the total number of antibiotic items prescribed per STAR-PU (specific therapeutic group age/sex-related prescribing units), the number of broad-spectrum antibiotic items prescribed, and broad-spectrum antibiotic items prescribed, expressed as a percentage of the total number of antibiotic items. To evaluate the impact of the Quality Premium on antibiotic prescribing, we used a segmented regression analysis of interrupted time series data. RESULTS: During the study period, over 140 million antibiotic items were prescribed in primary care. Following the introduction of the Quality Premium, antibiotic items prescribed decreased by 8.2%, representing 5933563 fewer antibiotic items prescribed during the 23 post-intervention months, as compared with the expected numbers based on the trend in the pre-intervention period. After adjusting for the age and sex distribution in the population, the segmented regression model also showed a significant relative decrease in antibiotic items prescribed per STAR-PU. A similar effect was found for broad-spectrum antibiotics (comprising 10.1% of total antibiotic prescribing), with an 18.9% reduction in prescribing. CONCLUSIONS: This study shows that the introduction of financial incentives for local commissioners of healthcare to improve the quality of prescribing was associated with a significant reduction in both total and broad-spectrum antibiotic prescribing in primary care in England.