Prognosis following upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal (GI) bleeding is one of the most common, high risk emergency disorders in the western world. Almost nothing has been reported on longer term prognosis following upper GI bleeding. The aim of this study was to establish mortality up to three years following hospital admission with upper GI bleeding and its relationship with aetiology, co-morbidities and socio-demographic factors. METHODS: Systematic record linkage of hospital inpatient and mortality data for 14 212 people in Wales, UK, hospitalised with upper GI bleeding between 1999 and 2004 with three year follow-up to 2007. The main outcome measures were mortality rates, standardised mortality ratios (SMRs) and relative survival. RESULTS: Mortality at three years was 36.7% overall, based on 5215 fatalities. It was highest for upper GI malignancy (95% died within three years) and varices (52%). Compared with the general population, mortality was increased 27-fold during the first month after admission. It fell to 4.3 by month four, but remained significantly elevated during every month throughout the three years following admission. The most important independent prognostic predictors of mortality at three years were older age (mortality increased 53 fold for people aged 85 years and over compared with those under 40 years); oesophageal and gastric/duodenal malignancy (48 and 32 respectively) and gastric varices aetiologies (2.8) when compared with other bleeds; non-upper GI malignancy, liver disease and renal failure co-morbidities (15, 7.9 and 3.9); social deprivation (29% increase for quintile V vs I); incident bleeds as an inpatient (31% vs admitted with bleeding) and male patients (25% vs female). CONCLUSION: Our study shows a high late as well as early mortality for upper GI bleeding, with very poor longer term prognosis following bleeding due to malignancies and varices. Aetiologies with the worst prognosis were often associated with high levels of social deprivation.

What happens to work if you're unwell? Beliefs and attitudes of managers and employees with musculoskeletal pain in a public sector setting.

INTRODUCTION: Musculoskeletal complaints can impact on work in terms of productivity, sickness absence and long term incapacity for work. While employee attitudes and knowledge can drive absenteeism and presenteeism behaviour, managers also play an important role in influencing this via the quality of their relationships with employees and their role in implementing organisational policies and procedures. The aims of this study were to investigate the beliefs and attitudes of managers and employees with musculoskeletal pain about sickness absence, presenteeism, and return to work and to identify areas of consensus and conflict. METHODS: 18 employees with musculoskeletal pain and 20 managers from two large public sector organisations in South Wales, UK, took part in individual face-to-face interviews. Data were analysed thematically using NVivo. RESULTS: Employees' and managers' reports indicated that there was a strong culture of presenteeism in these organisations. Establishing the legitimacy of complaints was a salient theme for both managers and employees, although their views were in conflict. Employees reported feeling that contact with employers was intrusive when sickness absence was legitimate. Managers were supportive of those who they felt were 'genuinely' unwell, but also cited examples of people 'working the system' and not reporting absences appropriately. CONCLUSIONS: These issues require careful consideration of the rights and responsibilities of both employees and employers, where strategies for improving communication, trust, and creating an environment conducive to successful return to work need to be investigated.

Feasibility of using routinely collected inpatient data to monitor quality and inform choice: a case study using the UK inflammatory bowel disease audit.

OBJECTIVE: To assess the utility and cost of using routinely collected inpatient data for large-scale audit. DESIGN: Comparison of audit data items collected nationally in a designed audit of inflammatory bowel disease (UK IBD audit) with routinely collected inpatient data; surveys of audit sites to compare costs. SETTING: National Health Service hospitals across England, Wales and Northern Ireland that participated in the UK IBD audit. PATIENTS: Patients in the UK IBD audit. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Percentage agreement between designed audit data items collected for the UK IBD audit and routine inpatient data items; costs of conducting the designed UK IBD audit and the routine data audit. RESULTS: There were very high matching rates between the designed audit data and routine data for a small subset of basic important information collected in the UK IBD audit, including mortality; major surgery; dates of admission, surgery, discharge and death; principal diagnoses; and sociodemographic patient characteristics. There were lower matching rates for other items, including source of admission, primary reason for admission, most comorbidities, colonoscopy and sigmoidoscopy. Routine data did not cover most detailed information collected in the UK IBD audit. Using routine data was much less costly than collecting designed audit data. CONCLUSION: Although valuable for large population-based studies, and less costly than designed data, routine inpatient data are not suitable for the evaluation of individual patient care within a designed audit.

Delays in response and triage times reduce patient satisfaction and enablement after using out-of-hours services.

BACKGROUND: several different models of out-of-hours primary care now exist in the UK. Important outcomes of care include users' satisfaction and enablement to manage their illness or condition, but the determinants of these outcomes in the unscheduled care domain are poorly understood. Aim. To identify predictors of user satisfaction and enablement across unscheduled care or GP out-of-hours service providers in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP out-of-hours services, three Accident and Emergency units and an all Wales telephone advice service in Wales. METHODS: postal survey using the Out-of-hours Patient Questionnaire. Logistic regression was used to fit both satisfaction and enablement models, based on demographic variables, service provider and treatment received and perceptions or ratings of the care process. RESULTS: eight hundred and fifty-five of 3250 users responded (26% response rate, range across providers 14-41%, no evidence of non-response bias for age or gender). Treatment centre consultations were significantly associated with decreased patient satisfaction and decreased enablement compared with telephone advice. Delays in call answering or callback for triage and shorter consultations were significantly associated with lower satisfaction. Waiting more than a minute for initial call answering was associated with lower enablement. CONCLUSIONS: giving users more time to discuss their illness in consultations may enhance satisfaction and enablement but this may be resource intensive. More simple interventions to improve access by quicker response and triage, and keeping users informed of waiting times, could also serve to increase satisfaction and ultimately impact on their enablement.

The need to improve the interface between in-hours and out-of-hours GP care, and between out-of-hours care and self-care.

BACKGROUND: considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users' experiences of their care are an important part of 'quality of care' and are valuable for identifying areas for improvement. AIM: to identify strengths and weaknesses of out-of hours service provision in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP services, three Accident and Emergency units and NHS Direct in Wales. METHOD: survey using the validated Out-of-Hours questionnaire. We identified the four most and least favourably rated items regarding users' experience of care. These were analysed by type of care provided, telephone advice, treatment centre and home visit groups. RESULTS: eight hundred and fifty-five of 3250 users responded (26% response rate). Across providers and types of care, consistent strengths were the 'manner of treatment by call operator' and the 'explanation of the next step by call operator'. Consistent weaknesses were the 'speed of call back by the clinician', the 'information provided by the GP', 'getting medication after the consultation' and 'when to contact the (in-hours) GP'. CONCLUSIONS: users of out-of-hours care identify clear and consistent strengths and weaknesses of service provision across Wales. Specific areas for improvement concern the interface between in-hours care and out-of-hours care and between out-of-hours care and self-care. GP surgeries need to give better information on how to access the out-of-hours services. Out-of-hours providers should improve their advice on how and when to access in-hours surgeries and also improve the availability of medicines after out-of-hours consultations.

Streamline triage and manage user expectations: lessons from a qualitative study of GP out-of-hours services.

BACKGROUND: Several models of GP out-of-hours provision exist in the UK but there is little detail about their effectiveness to meet users' needs and expectations. AIM: To explore users' needs, expectations, and experiences of out-of-hours care, and to identify proposals for service redesign. SETTING: Service providers in urban (GP cooperative), mixed (hospital based), rural (private) locations in Wales. PARTICIPANTS: Sixty recent service users or carers (20 in each location). METHOD: Semi-structured telephone interviews; thematic analysis. RESULTS: Users' concerns were generally consistent across the three different services. Efficiency was a major concern, with repetitive triage procedures and long time delays at various stages in the process being problematic. Access to a doctor when required was also important to users, who perceived an obstructive gatekeeping function of preliminary contacts. Expectations moderated the relationship between user concerns and satisfaction. Where expectations of outcome were unfulfilled, participants reported greater likelihood of reconsulting with the same or alternative services for the same illness episode. Accurate expectations concerning contacts with the next administrative, nursing, or medical staff professional were managed by appropriate information provision. CONCLUSION: Users require more streamlined and flexible triage systems. Their expectations need to be understood and incorporated into how services advise and provide services for users, and actively managed to meet the aims of both enhancing satisfaction and enabling users to cope with their condition. Better information and education about services are needed if users are to derive the greatest benefit and satisfaction. This may influence choices about using the most appropriate forms of care.

Hospitalized prevalence and 5-year mortality for IBD: record linkage study.

AIM: To establish the hospitalized prevalence of severe Crohn's disease (CD) and ulcerative colitis (UC) in Wales from 1999 to 2007; and to investigate long-term mortality after hospitalization and associations with social deprivation and other socio-demographic factors. METHODS: Record linkage of administrative inpatient and mortality data for 1467 and 1482 people hospitalised as emergencies for > or = 3 d for CD and UC, respectively. The main outcome measures were hospitalized prevalence, mortality rates and standardized mortality ratios for up to 5 years follow-up after hospitalization. RESULTS: Hospitalized prevalence was 50.1 per 100 000 population for CD and 50.6 for UC. The hospitalized prevalence of CD was significantly higher (P < 0.05) in females (57.4) than in males (42.2), and was highest in people aged 16-29 years, but the prevalence of UC was similar in males (51.0) and females (50.1), and increased continuously with age. The hospitalized prevalence of CD was slightly higher in the most deprived areas, but there was no association between social deprivation and hospitalized prevalence of UC. Mortality was 6.8% and 14.6% after 1 and 5 years follow-up for CD, and 9.2% and 20.8% after 1 and 5 years for UC. For both CD and UC, there was little discernible association between mortality and social deprivation, distance from hospital, urban/rural residence and geography. CONCLUSION: CD and UC have distinct demographic profiles. The higher prevalence of hospitalized CD in more deprived areas may reflect higher prevalence and higher hospital dependency.