ABSTRACT
This Arts and Medicine feature reviews the 2019 movie Collective, which documents corruption underlying poor patient outcomes in the Romanian national health system and provides an update on the people and reform efforts featured in the film.
Subject(s)
Delivery of Health Care , Health Facilities , National Health Programs , Delivery of Health Care/standards , Health Care Reform , Health Facilities/standards , National Health Programs/standards , State Medicine/standards , Motion PicturesABSTRACT
Genetic testing for cancer predisposition has been curtailed by the cost of sequencing, and testing has been restricted by eligibility criteria. As the cost of sequencing decreases, the question of expanding multi-gene cancer panels to a broader population arises. We evaluated how many additional actionable genetic variants are returned by unrestricted panel testing in the private sector compared to those which would be returned by adhering to current NHS eligibility criteria. We reviewed 152 patients referred for multi-gene cancer panels in the private sector between 2014 and 2016. Genetic counselling and disclosure of all results was standard of care provided by the Consultant. Every panel conducted was compared to current eligibility criteria. A germline pathogenic / likely pathogenic variant (P/LP), in a gene relevant to the personal or family history of cancer, was detected in 15 patients (detection rate of 10%). 46.7% of those found to have the P/LP variants (7 of 15), or 4.6% of the entire set (7 of 152), did not fulfil NHS eligibility criteria. 46.7% of P/LP variants in this study would have been missed by national testing guidelines, all of which were actionable. However, patients who do not fulfil eligibility criteria have a higher Variant of Uncertain Significance (VUS) burden. We demonstrated that the current England NHS threshold for genetic testing is missing pathogenic variants which would alter management in 4.6%, nearly 1 in 20 individuals. However, the clinical service burden that would ensue is a detection of VUS of 34%.
Subject(s)
Biomarkers, Tumor/genetics , Genetic Counseling/standards , Genetic Testing/standards , Neoplasms/epidemiology , State Medicine/standards , Adolescent , Adult , Aged , Aged, 80 and over , England/epidemiology , Female , Genetic Counseling/statistics & numerical data , Genetic Predisposition to Disease , Genetic Testing/statistics & numerical data , Germ-Line Mutation , Humans , Incidence , Male , Middle Aged , Neoplasms/diagnosis , Neoplasms/genetics , Retrospective Studies , Risk Assessment/standards , Risk Assessment/statistics & numerical data , Young AdultSubject(s)
COVID-19 Vaccines/administration & dosage , COVID-19/prevention & control , Mandatory Programs/legislation & jurisprudence , State Medicine/legislation & jurisprudence , Vaccination/legislation & jurisprudence , COVID-19/economics , COVID-19/epidemiology , COVID-19 Vaccines/economics , England/epidemiology , Government Employees/legislation & jurisprudence , Health Policy/economics , Health Policy/legislation & jurisprudence , Humans , Mandatory Programs/economics , Mandatory Programs/standards , State Medicine/standards , Vaccination/economics , Vaccination/standardsSubject(s)
Elective Surgical Procedures , Health Plan Implementation/organization & administration , State Medicine/organization & administration , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/transmission , Communicable Disease Control/standards , England/epidemiology , Health Services Accessibility/organization & administration , Health Services Accessibility/standards , Humans , State Medicine/standardsSubject(s)
Delivery of Health Care, Integrated/organization & administration , Organizational Innovation , Quality of Health Care/organization & administration , Risk Management/organization & administration , Delivery of Health Care, Integrated/standards , Humans , State Medicine/organization & administration , State Medicine/standards , United KingdomSubject(s)
COVID-19/prevention & control , Health Personnel/legislation & jurisprudence , Mandatory Programs/legislation & jurisprudence , State Medicine/legislation & jurisprudence , Vaccination/legislation & jurisprudence , Attitude of Health Personnel , COVID-19/epidemiology , COVID-19/virology , England/epidemiology , Health Personnel/standards , Humans , Immunization, Secondary/standards , Infectious Disease Transmission, Professional-to-Patient/prevention & control , Mandatory Programs/standards , Pandemics/prevention & control , SARS-CoV-2/pathogenicity , State Medicine/standards , Vaccination/standardsSubject(s)
Emergency Medical Services/organization & administration , State Medicine/organization & administration , Emergency Medical Services/standards , Humans , Quality Improvement/organization & administration , Quality of Health Care/organization & administration , State Medicine/standards , United KingdomABSTRACT
We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). 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. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.
Subject(s)
Ambulatory Surgical Procedures/trends , Patient Discharge/trends , Patient Safety , State Medicine/trends , Tonsillectomy/trends , Adolescent , Ambulatory Surgical Procedures/standards , Child , Child, Preschool , England/epidemiology , Female , Humans , Male , Patient Discharge/standards , Patient Safety/standards , Postoperative Complications/diagnosis , Postoperative Complications/epidemiology , State Medicine/standards , Tonsillectomy/standards , Treatment OutcomeSubject(s)
COVID-19/prevention & control , Elective Surgical Procedures/statistics & numerical data , Health Services Accessibility/statistics & numerical data , COVID-19/epidemiology , COVID-19/transmission , Communicable Disease Control/standards , Elective Surgical Procedures/standards , Elective Surgical Procedures/trends , England/epidemiology , Forecasting , Health Services Accessibility/organization & administration , Health Services Accessibility/standards , Health Services Accessibility/trends , Hospitalization/statistics & numerical data , Hospitalization/trends , Humans , State Medicine/organization & administration , State Medicine/standards , State Medicine/statistics & numerical data , State Medicine/trendsSubject(s)
Confidentiality , Drug Costs , Drug Industry , Evidence-Based Medicine/standards , State Medicine/standards , Cardiovascular Agents/economics , Cardiovascular Agents/therapeutic use , Cost-Benefit Analysis , Humans , RNA, Small Interfering/economics , RNA, Small Interfering/therapeutic use , United KingdomABSTRACT
BACKGROUND: Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring. OBJECTIVE: To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic. METHODS: With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England. RESULTS: 20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420). CONCLUSIONS: Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.
Subject(s)
Anticoagulants/administration & dosage , Blood Coagulation/drug effects , COVID-19 , Drug Substitution/standards , Factor Xa Inhibitors/administration & dosage , Practice Guidelines as Topic/standards , Practice Patterns, Physicians'/standards , State Medicine/standards , Warfarin/administration & dosage , Aged , Anticoagulants/adverse effects , Blood Coagulation Tests , Drug Monitoring , Drug Prescriptions , Drug Substitution/adverse effects , Drug Utilization/standards , England , Factor Xa Inhibitors/adverse effects , Female , Humans , Male , Middle Aged , Patient Safety , Primary Health Care/standards , Retrospective Studies , Risk Assessment , Risk Factors , Warfarin/adverse effectsSubject(s)
Hyperventilation , Obesity Hypoventilation Syndrome , Obesity/complications , Sleep Apnea, Obstructive , State Medicine/standards , Adolescent , Adult , Female , Humans , Hyperventilation/etiology , Male , Middle Aged , Obesity Hypoventilation Syndrome/etiology , Practice Guidelines as Topic , Syndrome , Young AdultSubject(s)
Early Medical Intervention , Early Warning Score , Emergency Medical Services , Risk Assessment/methods , Sepsis , Critical Pathways/standards , Diagnostic Errors/prevention & control , Early Diagnosis , Early Medical Intervention/methods , Early Medical Intervention/standards , Emergency Medical Services/methods , Emergency Medical Services/organization & administration , Humans , Practice Guidelines as Topic , Sepsis/diagnosis , Sepsis/therapy , State Medicine/standards , Time-to-Treatment , United KingdomABSTRACT
Emeritus Professor Alan Glasper, from the University of Southampton, discusses recent changes to the way in which the Care Quality Commission (CQC) conducts its health and social care inspections.