Studies and Research
Acute and General Medicine and Emergency Medicine
Future Healthcare Journal
This is a review paper based on the observations of the NHS GIRFT programme Emergency Medicine and Acute and General Medicine team during deep dive visits to NHS hospital trusts across England. The review identifies that some fundamental aspects of acute medical care are not provided at all trust, resulting in preventable hospitalisation and over-use of emergency departments.
- Areas where deficiencies were found include care outside hospital, appropriately sized, staffed, located and configured acute medical units, multi-speciality same-day emergency care (SDEC) pathways, multidisciplinary care on wards and readmission prevention.
- The use of SDEC pathways should be expanded and rolled out across England.
- ‘Hospital at home’ (or virtual ward) services are developing and require local evaluation. Digital technologies make it possible to provide acute care in and across more settings.
- Addressing the fundamentals of acute medical care, evaluating new service opportunities, strong clinical and managerial partnerships, better data for analytics, and a multi-speciality, multi-professional approach will enable a better level of care to be achieved.
Emergency Medicine Journal
Delays to timely admission from emergency departments are known to harm patients. This study used data from the Hospital Episodes Statistics dataset to assess and quantify the increased risk of death resulting from delays to inpatient admission from emergency department in England.
- Between April 2016 and March 2018, 26.7 million people attended an ED, with 7.5 million patients admitted (5.2 million individual patients).
- The crude 30-day mortality rate was 8.7%.
- A linear increase in mortality was found from 5 hours after time of arrival at the emergency department up to 12 hours (when accurate data collection ceased).
Cardiology
Heart
This paper sets out the case for the GIRFT programme in cardiology and the potential benefits to the specialty of following the GIRFT methodology to drive change, improve outcomes for patients and increase service efficiency.
Clinical coding
BMJ Health and Care Informatics
To gain maximum insight from large administrative healthcare datasets it is important to understand their data quality. This study reports inconsistencies in the recording of mandatory diagnostic codes within the Hospital Episodes Statistics dataset in England.
- Three exemplar medical conditions where recording is mandatory once diagnosed were chosen: autism, type II diabetes mellitus and Parkinson’s disease dementia. We identified the first occurrence of the code for each condition for a patient during the period April 2013 to March 2021 and in subsequent hospital spells.
- For autism, diabetes and Parkinson’s disease dementia respectively, 43.7%, 8.6% and 31.2% of subsequent spells had inconsistencies.
- Coding inconsistencies were highly correlated with non-coding of an underlying condition, a change in hospital trust and greater time between the spell with the first coded diagnosis and the subsequent spell.
- For patients with diabetes or Parkinson’s disease dementia, the code recording for spells without an overnight stay were found to have a higher rate of inconsistencies.
- Where these mandatory diagnoses are not recorded in administrative datasets, and where clinical decisions are made based on such data, there is potential for this to impact patient care.
International Journal of Medical Informatics
This was a sub-study of a larger study looking at data inconsistencies across a range of conditions. This study looked at recording of autism on hospital admission in more detail.
- Data were available for 172,324 unique patients who had been recorded as having an autism diagnosis on first admission between April 2013 and March 2021.
- In total, 43.7 % of subsequent spells were found to have inconsistencies. The features most strongly associated with inconsistencies included greater age, greater deprivation, longer time since the first spell, change in provider, shorter length of stay, being female and a change in the main specialty description.
- For patients who died in hospital, inconsistencies in their final spell were significantly associated with being 80 years and over, being female, greater deprivation and use of a palliative care code in the death spell.
- Such inconsistencies have the potential to distort our understanding of service use in key demographic groups of people with autism.
COVID-19
Clinical Otolaryngology
The aim of this study was to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes.
The study’s findings included:
- Tracheostomy is safe and advantageous for critical care COVID-19 patients.
- Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.
- In patients that survived, earlier timing of tracheostomy (≤14 days post admission to critical care) was significantly associated with shorter length of stay.
EClinical Medicine
The aim of this study was to investigate the extent of variation in COVID-19 outcomes between NHS trusts and regions in England using data from March–July 2020.
Key findings were:
- After adjusting for covariates, the extent of the variation in-hospital mortality rates between hospital trusts and regions was relatively modest.
- Trusts with the largest baseline number of beds and a greater proportion of patients admitted to critical care had the lowest in-hospital mortality rates.
- There is little evidence of clustering of deaths within hospital trusts.
Lancet Regional Health - Europe
This was a follow-up of our earlier study and compared outcomes for hospital patients with COVID-19 in the early and late stages of the first wave of the pandemic in England.
Key findings were:
- Compared to patients in March-May, patients in June-September were younger, more likely to be female and of Asian ethnicity, but less likely to be of Black ethnicity.
- Adjusted in-hospital mortality rates declined from 33–34% in March to 11–12% in September.
- From March-May to June-September the relative odds of death in patients with a diagnosis of metastatic carcinoma increased, but decreased for males, patients with obesity and diabetes.
Lancet Respiratory Medicine
This was one of the first studies published anywhere in the world to describe COVID-19 outcomes for hospital patients on an entire country or large region.
The study provided evidence that:
- 91,541 adult patients with COVID-19 were discharged during March-May 2020, with 28,200 (30·8%) in-hospital deaths.
- Adjusted in-hospital mortality improved from 52·2% in the first week of March to 16·8% in the last week of May 2020.
- Mortality rates in Black and Black British ethnicity patients were no higher than for White ethnicity patients, once they were admitted to hospital.
- That in-hospital mortality rates for Asian and Asian British ethnicity patients were slightly higher than for White patients.
Thorax
We aimed to examine the profile of, and outcomes for, all people hospitalised with COVID-19 across the first and second waves of the pandemic in England
The study’s findings included:
- Over the 13 months (March 2020 to March 2021), 374 244 unique patients had a diagnosis of COVID-19 during a hospital stay.
- Adjusted mortality rates fell from 40%–50% in March 2020 to 11% in August 2020 before rising to 21% in January 2021 and declining steadily to March 2021.
- Improvements in mortality rates were less apparent in older and comorbid patients.
- Although mortality rates fell for all ethnic groups from the first to the second wave, declines were less pronounced for Asian and Black African ethnic groups.
Thrombosis Research
The aim of this study was to detail the incidence of venous thromboembolism (VTE) in patients hospitalised with COVID-19 in England
The study’s findings included:
- Over the first 13 months of the pandemic, 374,244 unique patients had a diagnosis of COVID-19 during a hospital stay, of whom 17,346 (4.6%) had a recorded diagnosis of VTE.
- VTE was more commonly recorded in patients aged 40–79 years, males and in patients of Black ethnicity.
- Recorded VTE diagnosis was associated with longer hospital stay and higher adjusted in-hospital mortality.
Interactive Journal of Medical Research
Older adults have worse outcomes following hospitalisation with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes.
- This study used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for patients aged 65 years and over hospitalised with COVID-19 in England. In total, 215,831 patients were included.
- The most important frailty items in predicting mortality were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items were cancer, heart failure, and renal disease.
- The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.
Emergency Medicine Journal
This study investigated the role of strain on hospital services on outcomes for patients admitted to hospital with COVID-19.
- All unique patients aged ≥18 years in England with a diagnosis of COVID-19 admitted to hospital between 1 July 2020 and 28 February 2021 were included. Bed-strain was calculated as the number of beds occupied by patients with COVID-19 divided by the maximum COVID-19 bed occupancy during the study period. This was calculated for every patient during their stay
- There were 253,768 unique hospitalised patients with a diagnosis of COVID-19 during a hospital stay. Patient admissions peaked in January 2021 (n=89,047). The crude mortality rate peaked slightly earlier in December 2020 (26.4%).
- After adjustment for covariates, the mortality rate in the lowest and highest quartile of bed-strain was 23.6% and 25.3%, respectively. For the lowest and the highest quartile of bed-strain, adjusted mean length of stay was 13.2 days and 11.6 days, respectively in survivors and was 16.5 days and 12.6 days, respectively in patients who died in hospital.
- High levels of bed-strain were associated with higher in-hospital mortality rates, although the effect was relatively using our measure.
- Shorter hospital stay during periods of greater strain may partly reflect changes in patient management.
International Journal of Data Science and Analytics
This study looked to model hospital acquired COVID-19 infection rates across the first year of the pandemic in England using a machine learning approach.
- From the Hospital Episodes Statistics database, we identified 374,244 adult hospital patients in England with a diagnosis of COVID-19 and discharged between March 1, 2020, and March 31, 2021.
- The model estimated a mean hospital acquired infection rate of 10.5%, with a peak close to 18% during the first wave, but much lower rates (7%) thereafter.
- Hospital acquired infections were highly correlated with longer hospital stay, high trust capacity strain, greater age and a higher degree of patient frailty.
- Hospital acquired infections were associated with higher mortality rates and more severe COVID-19 sequelae, including pneumonia, kidney disease and sepsis.
Cranial neurosurgery
British Journal of Neurosurgery
The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. There are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery.
- Data were available for 4,590 endoscopic transsphenoidal pituitary procedures conducted in England between April 2013 and March 2019.
- After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year, post-procedural haemorrhage and length of stay greater than the median.
- A higher trust volume was associated with reduced risk of post-procedural haemorrhage, but with none of the other patient outcomes studied.
- Thresholds for minimum annual surgeon volume should be set, but should be guided by practical, operational and technical consideration and take into account the views of patients and their families.
Ear, nose and throat surgery
Anaesthesia
This study looked at the safety of paediatric tonsillectomy when performed as a day-case.
The study’s findings included:
- There was a lower day-case rate in specialist paediatric ENT trusts (50%) than at non-specialist trusts (62%). This was likely due to their more complex case mix and longer travel distances for patients.
- Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories.
- We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes.
Clinical Otolaryngology
As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may help reduce waiting lists. This study aimed to provide evidence that day-case surgery is safe for endoscopic sinus surgery (ESS).
- Over a five-year period, data were available for 49,223 patients operated on across 129 NHS hospital trusts in England.
- In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/15 to 78.7% in 2018/19.
- Day-case patients had lower rates of 30-day emergency readmission.
- Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar.
Endocrinology
British Journal of Surgery
The study’s findings included:
- Only one third of surgeons (who operated on just over a half of all patients) performed at least six adrenalectomy procedures in the previous year.
- For open surgery, emergency readmission rates fell from 15.2% to 6.4% for surgeons and from 13.2% to 6.1% per cent for trusts between the lowest- and highest-volume categories.
- Significant, but less dramatic falls were also seen for minimally invasive surgery.
Gland Surgery
This article is a summary of recent research findings in relation to volume-outcome relationships for adrenal surgery.
- Observed volume-outcome relationships in adrenal surgery were placed within the context of unwarranted variation in clinical practice.
- The need for data from outside the United States was emphasised.
- Minimising unwarranted variation in service provision and patient outcomes is likely to be an important part of the recovery of elective services following the COVID-19 pandemic.
JAMA Surgery
This study investigated volume-outcome associations for parathyroid surgery in England.
The study’s findings included:
- Across the period, the number of surgeons conducting parathyroid surgery changed little.
- Repeat parathyroid surgery at 1 year was significantly associated with surgeon volume, but not trust volume, in the previous 12 months.
- Extended hospital stay, hypoparathyroidism/calcium disorder, and postprocedural complications were also associated with lower surgeon volume.
Langenbeck's Archives of Surgery
The aim of this study was to investigate outcomes in England in relationship to hospital and surgeon annual volumes for total thyroidectomy.
The study’s findings included:
- There is significant correlation between surgeon volume and clinical outcome for total thyroidectomy. Larger volume surgeons had reduced levels of post-surgical complications; length of stay > 2 and > 4 days; emergency readmission at 30 days; and hypoparathyroidism, vocal cord palsy, stridor, and tracheostomy at 1-year post-surgery.
- For hospital volume a relationship was less obvious and less consistent across outcome measures. Larger hospital volume was associated with lower levels of emergency readmission at 30 days and hypoparathyroidism at 1 year.
- The relationship between surgeon annual volume and outcomes was approximately linear, and a low-volume threshold could not be defined.
Litigation
Clinical Otolaryngology
This study looked at the incidence and characteristics of otorhinolaryngology clinical negligence claims in England.
- This was a retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otorhinolaryngology between April 2013 and April 2018.
- A total of 727 claims were identified with an estimated potential cost of £108 million. The mean cost of a claim was £148 923.
- Head and neck surgery was the subspecialty with the highest number of claims (n = 313, 43%) and highest cost (£51.5 million) followed by otology (n = 171, £24.5 million) and rhinology (n = 171, £13.6 million).
- 59% of claims were associated with an operation where mastoid surgery and endoscopic sinus surgery (both 46 procedures) were equally associated with the greatest number of claims.
- The most frequent causes for clinical negligence claims included failure or delay to diagnose (25%), failure or delay to treat (19%), intra-operative complications (18%) and failure of the consent process (15%).
- This study highlights the importance of robust pathways in out-patient diagnostics and the consenting process in order to deliver better patient care and reduce the impact of litigation.
Journal of Laryngology and Otology
This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018.
- There were 171 rhinology related claims with a total estimated potential cost of £13.6 million.
- Over three quarters of all rhinology claims were associated with surgery.
- Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172,978). Unnecessary pain (33.9%) and unnecessary operation (28.1%) were the most common patient injuries.
- Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology.
Journal of Laryngology and Otology
This study was a retrospective review of all clinical negligence claims in otology in England held by National Health Service Resolution between April 2013 and April 2018.
- There were 171 claims in otology, with a potential cost of £24.5 million. Over half of these were associated with hearing loss.
- Stapedectomy was the highest mean cost per claim operation at £769 438.
- The most common reasons for litigation were failure or delay in treatment (23%), failure or delay in diagnosis (20%), intra-operative complications (15%) and inadequate consent (13%).
International Journal of Pediatric Otorhinolaryngology
This was a retrospective review of all clinical negligence claims within paediatric otolaryngology (0–17 years inclusive) in the NHS in England between April 2013 and March 2020.
- There were 100 claims in pediatric otorhinolaryngology accounting for an estimated potential total cost of just under £49 million with an average of 14 claims per year.
- 52% of claims were related to an operation. Cause codes ‘Operator Error/Intra-Op Problem’, ‘Diathermy Injury’ and ‘Failure to Warn – Consent’ were the most common.
- The most common operation cited in a claim was tonsillectomy with an average cost per claim of £47,084.
- There were 21 claims coded as either ‘failure to diagnose’ or ‘failure to treat’ in relation to cholesteatoma, with an average cost per claim of £61,086.
- Opportunities exist to reduce patient morbidity, mortality and improve the patient experience through litigation data analysis.
BJS Open
This study was a review of litigation claims in breast surgery with the aim of identifying opportunities to improve clinical practice and patient safety
- All general and plastic surgical claims specifically for breast surgery notified to NHS Resolution between April 2012 and April 2018 were reviewed.
- Ac total of 449 relating to breast surgery were identified and reviewed. The median number of claims over the six-year period per NHS trust was two. The most frequent causes of litigation were dissatisfaction with cosmetic outcome (26.9%) and patient-reported delays in diagnosis (26.9%).
- A large proportion of claims related to breast implant surgery (17.4%)
- Issues regarding consent/communication were common (15.4%).
- The estimated annual cost of breast surgery litigation claims ranged from £5.6 million to £9.6 million.
- Patient-reported delays in diagnosis and dissatisfaction with cosmetic outcome are the most common causes of litigation related to breast surgery. These key themes should be the focus for workforce learning, with the aim of improving patient care and experience.
Journal of Laryngology and Otology
This paper describes thyroid surgery related litigation claims in the NHS from April 2015 to March 2020, to establish learning points in order to improve patient care and minimise litigation risk.
- Sixty claims were identified. Thirty-eight claims (63.3%) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349.
- Claims related to diagnostic issues were most common (n= 19).
- Of claims associated with operative causes (n= 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited.
- Utilisation of well-established protocols will likely reduce litigation in thyroid surgery.
British Dental Journal
A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to hospital dentistry between April 2015 and April 2020.
- A total of 492 claims were identified, with an estimated potential cost of £14 million.
- The most frequent causes for clinical negligence claims included failure/delay in treatment (n = 175; £3.9 million), inappropriate treatment (n = 56; £1.8 million) and failure to warn/obtain informed consent (n = 37; £1.5 million). Wrong site surgery was cited in 33 claims.
- The most frequent injury reported was dental damage (n = 197; £4.3 million), unnecessary pain (n = 125; £2.3 million) and nerve damage (n = 52; £2.4 million).
- A focus on patient safety measures and effective communication may help to improve patient outcomes and reduce the burden of litigation claims on the NHS.
Ophthalmology
This was a retrospective review of all clinical negligence claims within ophthalmology in the NHS in England between April 2013 and March 2018.
- Over the five-year period, 1254 ophthalmology claims were reported, costing an estimated £193 million. The annual cost increased from £28.1 million to £40.2 million over the five years.
- The most common subspecialty involved in litigation was cataract surgery (24%), followed by vitreoretinal surgery (10%) and medical retina (10%). Paediatric ophthalmology accounted for only 14 claims (1%) but had the highest mean cost per claim of £1.7 million.
- Failure/delay in treatment (30%) and failure/delay in diagnosis (16%) were the most common causes with costs of £70.0 million and £45.8 million respectively. Other visual problems (45%), blindness (25%), and “unnecessary pain” (10%) were the most commonly coded injuries.
- A lack of timely diagnosis or treatment accounts for a significant proportion of clinical negligence claims in ophthalmology. This reinforces the importance of improving referral pathways, risk stratification, and clinical governance to prioritise resources to those with sight-threatening disease.
Bone and Joint 360
Over ten years from 2006/07 to 2016/17 the UK National Audit Office reported that the number of clinical negligence claims across the NHS had doubled from 5,300 to 10,600 with a quadrupling of cost from £0.4 billion to £1.6 billion. This study looked at the number of cost of claims in orthopaedics following the publication of the GIRFT National Report for orthopaedics in 2015. The report made specific recommendations regarding how to reduce claims volumes in orthopaedics.
- In a four-year period immediately following the initial orthopaedic GIRFT visits, an 25.7% fall in claim numbers has been observed in orthopaedics (1,617 in 2013/14 to 1,202 in 2017/18). This was accompanied by a 14.8% fall in associated costs (175.9 in 2013/14 to 146.8 in 2017/18).
- This fall in orthopaedics is set against a large increase in the number of claims and costs in other specialties.
- The decline in the number and costs associated with claims in orthopaedics is encouraging. Efforts should be increased to reduce costs and number of claims in other clinical areas.
European Spine Journal
This study looked at the incidence and characteristics of spinal surgery clinical negligence claims in England.
- This study was a retrospective review of 978 clinical negligence claims held by NHS Resolution against spinal surgery cases identified from claims against ‘Neurosurgery’ and ‘Orthopaedic Surgery’.
- Clinical negligence claims in spinal surgery were estimated to cost £535.5 million over this five-year period.
- The most common causes for claims were related to clinical judgement and timing of diagnosis and intervention (52%), interpretation of results/clinical picture (26%), unsatisfactory outcome to surgery (19.6%), fail to warn/informed consent (8.1%) and ‘never events’ (including wrong site surgery or retained instrument post-operation) (2.7%).
- Clinicians and managers should share experience from clinical negligence claims to improve outcomes for patients and reduce the burden of these claims on the NHS.
Mental Health Rehabilitation
BJPsych Open
There is some evidence that patients with serious mental illness (SMI) who are admitted to hospital for a reason unconnected to their SMI and poorer outcomes than otherwise similar patients without a SMI. This study looked at outcomes for patients with and without a SMI admitted to hospital in England where the primary reason for admission was a physical illness (chronic obstructive pulmonary disease).
- Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI.
- Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. Despite being younger, the burden of comorbidity was similar between the SMI and non-SMI groups.
- After adjusting for age, sex, frailty, and other important variables, SMI was associated with significantly greater risk long hospital stay and 30-day emergency readmission but not with in-hospital mortality.
- Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.
Oral and maxillofacial surgery
British Journal of Oral and Maxillofacial Surgery
When patients attend the emergency department with facial fractures that require surgery and are immediately admitted, surgery can be delayed as theatre time is prioritised for other more urgent patients. One solution is to send the patient home and admit them as an elective patient at a later date. This study investigated outcomes of patients admitted directly and those seen as elective patients following fracture of the mandible or zygomatic complex.
- The study’s findings included:
For both mandibular and zygomatic complex fractures there was substantial variation between NHS trusts in the proportion of patients admitted for swift elective surgery. - Elective admission was independently associated with shorter overall stay and lower emergency readmission rates.
- We found no evidence that delays to definitive surgery through elective admission had a negative impact on emergency readmission rates.
Orthopaedic surgery
Journal of Arthroplasty
This study evaluated the impact on patient outcomes of stopping hip precautions in patients undergoing total hip replacement surgery. Outcomes of interest were dislocation rates, emergency readmissions and length of stay.
The study’s findings included:
- No increase in 180-day dislocation rates or 30-day emergency readmission rates after stopping hip precautions.
- There was a significant immediate change in median length of stay from 4 to 3 days on stopping hip precautions.
- Potential benefits include reduced costs, faster recovery for patients and more efficient bed usage.
Journal of Arthroplasty
This study looked at the evidence to support a key GIRFT recommendation from the orthopaedic surgery national report regarding use of uncemented hip fixation in people aged 70 years and older undergoing primary total hip arthroplasty.
The study’s findings included:
- Revision rates at 1-7 years follow-up for patients aged 70 years and older undergoing primary total hip replacement were significantly higher for uncemented fixation compared to cemented or hybrid fixation.
- Although mortality rates were higher for patients with cemented fixation this was most likely due to the greater age of the population rather than the fixation method used.
- Revision rates in trusts where uncemented fixation predominated were not significantly lower for uncemented fixation compared to all other fixation methods.
Bone and Joint Journal
Summary
- Revision total knee and hip revisions are complex procedures with higher rates of re-revision, complications, and mortality compared to primary procedures. It is recommended that such procedures be conducted in specialist revsion hubs. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes.
- The EMSON revision network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England.
- Between April 20111 and March 2018, 57,621 revision hip and 33,828 revision knee procedures were performed across England. Of these,1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within EMSON.
- Re-revision rates within one year for revision hips were 7.3% and 6.0%, and for revision knees were 11.6% and 7.4% pre- and post-intervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for revision hips and from 11.7% to 9.7% for knee revisions for the rest of England.
- The improvement in re-revision rates across the study period were greater for EMSON than for the rest of England.
Journal of Arthroplasty
In England, a large variety of orthopaedic prostheses and methods of fixation are currently being used in hip and knee replacement surgery. This study looked at the survival of these prostheses relative to their cost.
- The 8th Annual Report from the National Joint Registry (2011) reporting on prostheses used in 2010 was analysed.
- There has been a decline in the proportion of cemented total hip replacements over the five years to 2010. Uncemented total hip replacements were the most common form of primary hip replacement in this period. This was despite cemented total hip replacements demonstrating the lowest revision rate at seven years (3.8%).
- There was substantial variation in survivorship across prosthesis types, suggesting there is scope to reduce the variety of prosthesis used across the NHS, reduce costs of procurement and improve patient outcomes.
Pathology
British Journal of Haematology
A national Venous Thromboembolism (VTE) Prevention Programme was introduced in England in 2010, with limited subsequent study of its impact. Whilst the National Outcomes Framework reports VTE deaths related to hospitalisation annually, there are little data regarding VTE prevention practice or non-fatal VTE associated with hospitalisation. This study reports the first national thrombosis survey undertaken in collaboration with the GIRFT programme.
98 Hospital trusts participated in at least one survey, contributing data regarding VTE prevention in 9553 patients.
- Anti-coagulant thromboprophylaxis was prescribed to 88% of patients when indicated, with 8.1% of patients missing doses.
- Written patient information was provided to 31%.
- Of 4595 episodes of hospital associated VTE, 13% were considered potentially preventable.
- The survey highlights the success of the national programme and areas for improvement in delivery of thromboprophylaxis and patient information.
Renal Medicine
Nephrology Dialysis Transplantation
This study describes the development of a case mix-adjusted 30-day mortality indicator for patients with post-hospitalisation acute kidney injury. The case-mix adjusted measure will allow a better comparison of outcomes when comparing healthcare providers across England.
- A total of 250,504 post-hospitalisation acute kidney injury episodes were studied across 103 NHS hospital trusts between January 2017 and December 2018.
- The mean 30-day mortality rate was 28.6%. Adjusted mortality rates for 12 trusts were above and 11 below the expected range, suggesting some unwarranted variation in outcomes.
- Presentation at trusts with a co-located specialist nephrology service was associated with a lower mortality risk.
- The findings have allowed trusts with high mortality rates to be identified and supported in improving outcomes through the adaptation of best practice care pathways to suit the local situation.
Spinal surgery
Archives of Osteoporosis
Vertebroplasty and balloon kyphoplasty are commonly used to treat osteoporotic spinal fractures. Kyphoplasty is widely used, but it is more expensive than vertebroplasty and outcomes are thought to be similar. This study reviewed outcomes for vertebroplasty and balloon kyphoplasty for the surgical treatment of osteoporotic spinal fracture.
- We reviewed 5,792 vertebroplasty and 3,136 balloon kyphoplasty procedures conducted in England over a 7-year period.
- In the 63 NHS hospital trusts that conducted more than 20 procedures during the study period, the proportion of procedures conducted as balloon kyphoplasty varied from 0 to 100%.
- There was no difference in outcomes between vertebroplasty and balloon kyphoplasty patients or between trusts performing ≥ 70% and ≤ 30% of procedures as balloon kyphoplasty.
Global Spine Journal
This study analysed data from the Hospital Episodes Statistics dataset for England to evaluate whether posterior lumbar decompression/discectomy (PLDD) was safe when performed as a same-day discharge procedure in low-complexity, low risk patients.
- Data were available for 45,814 PLDD performed across 103 hospital trusts of which 7,914 (17.3%) were performed as same-day discharge.
- Same-day discharge rates varied from 87.7% to 0% across the 90 hospital trusts that operated on more than 50 patients during the study period.
- Fourteen (15.6%) trusts had same-day discharge rates above 30% and 57 (63.3%) trusts had same-day discharge rates below 10%.
- The odds of emergency hospital readmission within 90 days were lower for same-day discharge patients.
- There was no difference in outcomes for patients seen at trusts with a same-day discharge rate of ≥30% compared to trusts with a same-day discharge rate of ≤10%.
European Spine Journal
This was a systematic review that examined the strength of evidence that multiple facet joint injections (FJIs) and medial branch blocks (MBBs) are effective in treating low back pain.
- Three studies were identified that investigated the efficacy of multiple FJIs or MBBs.
- None of these studies reported sustained positive outcomes at long-term follow-up.
- There is a paucity of good evidence supporting the efficacy of multiple FJIs and MBBs in treating low back pain.
Surgical Site Infection
Annals of the Royal College of Surgeons of England
This study analysed data from the Hospital Episodes Statistics dataset for England to evaluate whether posterior lumbar decompression/discectomy (PLDD) was safe when performed as a same-day discharge procedure in low-complexity, low risk patients.
- Data were available for 45,814 PLDD performed across 103 hospital trusts of which 7,914 (17.3%) were performed as same-day discharge.
- Same-day discharge rates varied from 87.7% to 0% across the 90 hospital trusts that operated on more than 50 patients during the study period.
- Fourteen (15.6%) trusts had same-day discharge rates above 30% and 57 (63.3%) trusts had same-day discharge rates below 10%.
- The odds of emergency hospital readmission within 90 days were lower for same-day discharge patients.
- There was no difference in outcomes for patients seen at trusts with a same-day discharge rate of ≥30% compared to trusts with a same-day discharge rate of ≤10%.
Annals of the Royal College of Surgeons of England
This paper reports the findings of the second Getting it Right First Time (GIRFT) national surgical site infections survey for orthopaedic and spinal surgery.
- Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019.
- A total of 309 infections were reported from orthopaedics, and 58 infections were reported from spinal surgery.
- Surgical site infection rates have remained low compared with the earlier 2017 GIRFT survey.
- Primary shoulder replacement reported the lowest infection rate (0.4%) and revision shoulder replacement the highest (2.5%) rates.
- The elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full surgical site infection prevention bundle to minimise the risk of infection and improve patient outcomes.
Urology
British Journal of Urology International
The aim of this study was to investigate outcomes for robot-assisted radical prostate surgery (RARP) in England relative to annual surgeon and hospital trust volume.
The study’s findings included:
- The proportion of procedures conducted as RARPs increased from 53.2% in 2013 to 92.6% in 2018.
- There was a significant relationship between 90-day emergency hospital readmission and trust and surgeon annual volume
- From lowest to highest volume category there was a decline in the adjusted proportion of patients readmitted as an emergency at 90 days from 10.6% to 7.0% for trusts and from 9.4% to 8.3% for surgeons.
British Journal of Urology International
This study looked at evidence for the GIRFT recommended minimum annual volume for nephrectomy and cystectomy surgery in England.
Key findings of the study were:
- There was little evidence of trust or surgeon volume influencing readmission rates or mortality.
- There was some evidence of shorter length of hospital stay for high-volume surgeons for both procedures.
- The current level of centralisation of nephrectomy and cystectomy surgery is appears to be sufficient to maintain good outcomes.
Journal of Clinical Urology
This study, published in 2019 looked at the safety of day-case transurethral resection of bladder tumour (TURBT) surgery in England.
Key findings were:
- In 2017-18 only 17.9% of TURBT procedures were conducted as day-case surgery with substantial variation in rates of day-case surgery across NHS trusts in England.
- Comparing trusts with the highest and lowest rates of day-case surgery there were no differences in the profiles of the patients seen or in outcomes.
- Patients undergoing TURBT as day-case surgery have at least as good outcomes as those having an overnight stay.
Journal of Clinical Urology
A Journal of Clinical Urology study, published in 2021, which investigated the impact of the GIRFT programme on three specific recommendations from the Urology national report.
The study’s findings included:
- The proportion of transurethral resection of bladder tumour (TURBT) surgery carried out as day cases more than doubled following a GIRFT visit.
- GIRFT had a significant impact on reducing the use of hospital beds for overnight stays.
- A significant change in trend was observed in stent use to manage to ureteric stones, following a GIRFT visit
- The usage of ureteroscopy or Extracorporeal Shock Wave Lithotripsy (ESWL) increased significantly after GIRFT visits, suggesting a more efficient use of resources through reduced return admissions, offering definitive treatment at an earlier stage, and improvements to patient quality of life.
Journal of Evaluation in Clinical Practice
The study’s findings included:
- Only one third of surgeons (who operated on just over a half of all patients) performed at least six adrenalectomy procedures in the previous year.
- For open surgery, emergency readmission rates fell from 15.2% to 6.4% for surgeons and from 13.2% to 6.1% per cent for trusts between the lowest- and highest-volume categories.
- Significant, but less dramatic falls were also seen for minimally invasive surgery.
European Urology Open Science
The National Health Service (NHS) in England has set a net-zero target for carbon emissions it controls directly by 2040 and for all carbon emissions by 2045. Increasing use of day-case surgery pathways may help in meeting this target. This study investigated the potential carbon saving associated with moving from in-patient stay to day-case bladder tumour surgery.
- Of 209,269 TURBT procedures conducted in England between April 2013 and March 2022, 41 583 (20%) were classified as day-case surgery.
- The day-case rate increased from 13% in 2013/14 to 31% in 2021/22.
- This increase in day-case rates over the nine year study period was estimated to have save 2.9 million kg CO2 equivalents (equivalent to powering 2716 homes for 1 year).
- We calculated that potential carbon savings for the financial year 2021/22 if all hospitals in England achieved the upper-quartile day-case rate would be enough to power 198 homes for 1 year.
Vascular surgery
European Journal of Vascular and Endovascular Surgery
This study investigated whether a volume–outcome relationship exists for elective abdominal aortic aneurysm (AAA) surgery in England.
Key findings of the study were:
- For open AAA surgery, lower trust annual volume was associated with higher 30-day emergency re-admission rates and higher 30-day mortality, and lower surgeon annual volume was associated with higher 30-day mortality and length of hospital stay greater than the median.
- For endovascular AAA surgery, lower surgeon annual volume was associated with not having an overnight stay in critical care.
- Overall, there was strong evidence of a volume–outcome relationship for open surgery but not for endovascular surgery.
European Journal of Vascular and Endovascular Surgery
The GIRFT national report for vascular surgery recommended that, for carefully selected patients, angioplasty may have better patient outcomes and be amore efficient than bypass surgery in lower limb revascularisation for limb salvage. This study used observational data to compare outcomes for the two procedures.
- Data for 98,109 procedures were extracted from the Hospital Episodes Statistics database for England for a seven-year period: 1 April 2011 – 31 March 2018.
- For non-diabetic patients, one year amputation free survival was higher for angioplasty than for bypass. For diabetic patients, there was no difference in outcomes.
- One year amputation rates, 30-day emergency re-admission rates, and length of stay were all lower for angioplasty, and 30-day revascularisation rates were lower for bypass for both diabetic and non-diabetic patients.
- Although far from definitive due to differences in demographics and presentation between the two groups, in carefully selected patients, angioplasty may be a preferable alternative to bypass surgery. Future clinical trials may provide more definitive data.