Care After Presenting with Seizures (CAPS): An analysis of the impact of a seizure referral pathway and nurse support on neurology referral rates for patients admitted with a seizure.

INTRODUCTION: The National Audit of Seizure Management in Hospitals (NASH) identified low referral rates to neurology and epilepsy services after an emergency department attendance or admission with a seizure. METHODS: National Health Service Secondary Users Service (SUS) data were used to assess the impact of a seizure pathway at seven hospitals in Cheshire & Merseyside, which was implemented in 2014. Three of these hospitals also had a nurse employed part-time to support the pathway. Patients admitted with a seizure between 2011 and 2018 inclusive were identified using an algorithm based on ICD-10 codes, and the primary outcome was a neurology referral within 3 months of admission. Regression models were used to assess the impact of age, deprivation and comorbidity on post admission clinic referral rates. RESULTS: 13,285 admissions with seizure were included in the analysis. 5,677 had not attended a neurology clinic appointment in the 12 months before the admission. The percentage of whom that were offered an appointment following the admission was: 16.0% before the pathway and 35.9% with the nurse-supported pathway, which was significant in the regression model. 4,700 admissions had attended a neurology clinic appointment in the 12 months before the admission. Of this group, the percentage of whom that were offered an appointment following the admission was: 55.2% before the pathway and 62.4% with the nurse-supported pathway, an increase that was not significant in the regression model. The regression models identified significant health inequalities whereby older patients, those with comorbidities and those living in deprived areas were significantly less likely to be referred. CONCLUSION: Neurology out-patient appointment rates following an admission with seizures are low, worryingly so for those with no neurology appointment in the previous 12 months. A nurse-supported pathway can improve appointment rates, but the effect is modest. Further service redesign is required; the impact of which should be rigorously evaluated.

Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics.

OBJECTIVE: To determine whether variation in gastroscopy rates in English general practice populations is associated with inequality in oesophagogastric (OG) cancer outcome. DESIGN: Retrospective observational study of the Hospital Episode Statistics (HES) dataset for England (2006-2008) linked to death registration. METHODS: were validated using independent local and national data. General practices with new cases of OG cancer were included. Practices were grouped into tertiles according to standardised elective gastroscopy rate per capita (low, medium or high). Outcome measures for cancer cases were: emergency admission during diagnostic pathway, major surgical resection and mortality at 1 year. Covariates were: age group, gender, comorbidity, general practice average deprivation and patient deprivation. RESULTS: 22 488 incident cases of OG cancer from 6513 general practices were identified. Patients registered with the low tertile group of practices had the lowest rate of major surgery, highest rate of emergency admission and highest mortality. The inequality was widest for the most socioeconomically deprived cases. After adjustment for covariates in logistic regression, the gastroscopy rate (low, medium or high) at the patient's general practice was an independent predictor of emergency admission, major surgery and mortality. CONCLUSIONS: There is wide variation in the rate of gastroscopy among general practice populations in England. On average, OG cancer patients belonging to practices with the lowest rates of gastroscopy are at greater risk of poor outcome. These findings suggest that initiatives or current guidelines aimed at limiting the use of gastroscopy may adversely affect cancer outcomes.

All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death.

BACKGROUND: All-cause death within 30 days of ERCP is a candidate indicator of care, but institutional-level statistics require careful interpretation. National-scale, population-based outcome studies of unselected patients undergoing ERCP are needed to define expected levels of real-world mortality risk and the case-mix factors that predict poor outcome. OBJECTIVE: To develop methods for analyzing administrative data for English hospitals with linkage to death registration to study all-cause mortality after first ERCPs and explore predictors of death and institutional variation. DESIGN: Hospital episode statistics for 2006 to 2007 and 2007 to 2008 were linked to the statutory death register. First ERCP episodes were extracted and analyzed for demographic characteristics, admission method, diagnoses, and comorbidities. Additional linkages identified the last-coded diagnosis before death. Factors associated with 30-day death were identified by univariate and multiple logistic analyses. Pilot data and a survey were sent to clinicians at each institution. Crude and case-mix adjusted mortality were analyzed at the institutional level. MAIN OUTCOME MEASUREMENTS: Death within 30 days of the first ERCP procedure. RESULTS: We analyzed 20,246 first ERCPs from 2006 to 2007 and 20,422 from 2007 to 2008. Diagnostic profile: gallstone related 57.3%; cancer 12.6%; gallstone and cancer 2%; others 28.1%. All-cause 30-day death was 5.3% (2.4% in non-cancer cases). Predictors of 30-day death (adjusted odds ratio [OR]) were as follows: age (OR 6.2, for ≥85 years vs <55 years), male sex (OR 1.2 vs female), emergency admission (OR 2.0 vs elective), cancer (OR 8.6 vs no cancer), and non-cancer comorbidity (OR 1.5 vs none). A mortality risk estimator (look-up table) based on pooled data for >40,000 first ERCPs is provided. Specific procedural complication codes were identified in 1.2% of deaths (0.06% of ERCPs). At the institutional level, analysis of mortality rates was within expected statistical funnel limits, and we found no correlation with ERCP volume (Pearson r = -0.05; P > .05). LIMITATIONS: The completeness and accuracy of coding may vary between different hospitals. Routine coding does not capture information about procedural complexity or severity of illness. CONCLUSION: Linkage analysis of hospital episode statistics data for England provides a powerful tool for studying mortality risk after ERCP on an unselected and truly nationwide scale. Institutional-level statistics suggest that the mortality risk for patients requiring ERCP was comparable across English hospitals.

The UK National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project--a feasibility study of large-scale clinical service peer review.

RATIONALE, AIMS AND OBJECTIVES: Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale. METHODS: All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals. RESULTS: A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4-week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions. CONCLUSIONS: It is possible to deliver successful large-scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation.

Asthma management in primary care: does increasing patient medication improve symptoms?

AIMS: We set out to observe the General Practitioner (GP) management of a cohort of asthma patients over a 2-year period by comparing asthma health status, spirometry, British Thoracic Society treatment step, inhaled medication uptake and psychological status. Changes in these parameters were assessed over the 2-year period. METHODS: One hundred fourteen subjects were recruited from four GP practices, two in the inner city and two in suburbia. Subjects were assessed at baseline and at 2 years using the Juniper asthma quality of life questionnaire, the locally devised Q score (a simple patient-focused morbidity index) and the hospital anxiety and depression (HAD) scale. Spirometry (forced expiratory volume in 1 s, forced vital capacity and peak expiratory flow) was recorded using a Micro Medical portable spirometer (Micro Medical Ltd, Chatham, UK); the best values from three acceptable attempts were recorded. RESULTS: Data for 90 subjects reviewed at baseline and at 24 months were compared to the original cohort of 114 subjects. Patients who had the treatment increased showed no apparent benefit over 2 years. They had similar physiology and symptom scores at baseline but had higher HAD scores (particularly depression element P < 0.05) initially. The picture remained constant over the 2 years. CONCLUSION: Asthma guidelines define the aim of treatment to minimise or abolish symptoms. We suggest that if the symptoms are not measured, they remain unrecognised. This is something that could and should be incorporated routinely into clinical practice because this is morbidity that is largely treatable.

Ventilatory responses to inhaled carbon dioxide, hypoxia, and exercise in idiopathic hyperventilation.

Idiopathic hyperventilation (IH) is a poorly understood condition of sustained hypocapnia and controversial etiology. Although behavioral/emotional factors may contribute, it is uncertain whether chemosensitivity is altered, hyperventilation is maintained during exercise, and the associated breathlessness reflects the hyperventilation. In 39 patients with IH and 23 control subjects, we described ventilatory responses to isocapnic-hypoxia, hyperoxic-hypercapnia, and exercise; breath-hold tolerance; breathlessness; and psychologic status. Patients demonstrated hyperventilation at rest, with hypocapnia (28 +/- 3.8 mm Hg), a normal (slightly alkaline) arterial pH and [H(+)]a, and a significant base excess (-4.5 +/- 2.7 mEq/L), consistent with compensated respiratory alkalosis. Hyperventilation was sustained during exercise, despite hyperoxic-hypercapnic ventilatory responsiveness being normal and isocapnic-hypoxic ventilatory responsiveness being low relative to control (but exceeding control [2.4 +/- 1.0 vs. 1.6 +/- 0.5 L/min/%, p < 0.05] with acute restoration to normocapnia). Hyperventilation was maintained during exercise, at the resting CO(2) "setpoint." Relative to control, the breath-hold tolerance was attenuated, and dyspnea during exercise was significantly greater and not simply ascribable to the high ventilation. These observations suggest that patients with IH have a sustained hyperventilatory and dyspneic drive that, although not attributable to central chemosensitivity, may possibly have peripheral chemoreflex contributions. The nature and etiology of this chronic hyperventilatory drive remain unclear.

Using prescribing indicators to measure the quality of prescribing to elderly medical in-patients.

OBJECTIVES: to evaluate the performance of hospitals using eight indicators designed to assess prescribing practice in medical in-patients aged > or =65 years. DESIGN: local coalition teams were invited to collect cross-sectional prescribing and clinical data on 100 consecutive medical in-patients aged > or =65 years during a specific week in April 1999. SETTING: 102 hospitals across England. PARTICIPANTS: all NHS Trust hospitals in Wales and England were invited to participate in the study. MAIN OUTCOME MEASURES: the performance and inter-hospital variation of hospitals in eight indicators of prescribing. Also, the age-related appropriate use of anti-thrombotic stroke prophylaxis in atrial fibrillation, of aspirin in angina and of benzodiazepines. RESULTS: data were collected on 9,979 patients prescribed 70,458 medications. The number of hospitals achieving the prescribing goal for the indicators varied between 0 and 70. Frequency of administration instructions with 'as required' prescriptions were documented on 60% (10,403/17,258) of occasions. Generic (or acceptable proprietary) names were used for 84% (58,953/70,458) medications, 50% (4,870/9,778) of patients had documentation of allergy status on the drug chart and 23% (1,380/6,060) of patients had the potential risk of exceeding the maximum recommended dosage (4 g/24 h) of paracetamol. Long-acting hypoglycaemic drugs were prescribed to 50 patients. Anti-thrombotic stroke prophylaxis in atrial fibrillation were used appropriately for 53% (805/1,518) of patients, aspirin was used appropriately in angina for 90% (952/1,052) of patients and benzodiazepines were used appropriately for 49% (824/1,689) of patients. For the latter three indicators, the appropriate use of medications declined from 60% to 44%, 95% to 85% and 53% to 44% in patients aged >/=85 years compared with those aged 65-74 years. CONCLUSIONS: prescribing indicators were effective in evaluating the performance of 102 hospitals on prescribing practice to medical in-patients aged >/=65 years. Prescribing to elderly medical in-patients is sub-optimal but targets were achieved by some hospitals. This should inspire those hospitals not achieving high standards to improve their performance. The higher level of inappropriate prescribing with increasing age is unacceptable.

Ageism in the management of lung cancer.

BACKGROUND: age-related differences in the treatment of lung cancer patients have been reported in the past, but most previous studies have not recorded case-mix factors, nor have they studied the impact of such ageism on survival. METHODS: a questionnaire-based study of diagnostic and case-mix factors was carried out across 48 hospital Trusts in the UK between 1997 and 1998. We identified 1,652 patients and followed through with regard to their treatment and survival for 6 months after diagnosis. RESULTS: the median age of the population was 69 years, and for this analysis, was divided into three age groups: under 65 years, 65-74 and 75 years and over. There were significant inverse correlations between age and histological diagnosis, any active treatment and survival, even when corrected for case-mix factors and non-cancer causes of death. For example, the surgical resection rate in patients with confirmed non-small cell lung cancer with good performance status, no chronic obstructive pulmonary disease and limited disease was 37% in the younger patients compared with 15% in those 75 and over. The overall mortality rates at 6 months ranged from 42% in patients under 65 to 58% in the over 75s. CONCLUSIONS: this national study of lung cancer care in the UK has shown large age-related differences in management and survival in patients with lung cancer, largely independent of case-mix factors. The reasons for this are complex but such under-treatment in the elderly may be one factor underlying the poor outcomes in lung cancer patients in the UK.