School absence and achievement in children with isolated orofacial clefts.

OBJECTIVES: To examine school absence and academic achievement among 7-year-old children with isolated orofacial clefts in England. DESIGN: Analysis of educational data linked to national cleft registry and administrative hospital data. SETTING: English state schools. PATIENTS: 3523 children with isolated clefts aged 7 years between 2006 and 2014. MAIN OUTCOME MEASURES: Annual school absence and reaching the national 'expected level' according to teacher-assessed academic achievement. RESULTS: Children with isolated clefts had higher mean annual school absence (10.5 days) than their peers in the national population (8.9 days). Total absence was higher in children with a cleft lip and palate (CLP; 11.3 days) or with a cleft palate only (CPO; 10.5 days) than in children with a cleft lip only (CLO; 9.5 days). The percentage reaching the expected academic level decreased with increasing school absence (from 77.4% (923/1192) with annual school absence ≤5 days to 43.4% (193/445) with annual school absence >20 days). However, differences in school absence did not explain that children with CPO (65.9% reaching expected level) or CLP (66.1% reaching expected level) had poorer levels of academic achievement than children with CLO (73.5% reaching expected level). Children with a cleft were twice as often recognised as having special education needs (40.5%) than their peers (21.6%). CONCLUSIONS: School absence and cleft type are both independently associated with school attainment at 7 years. Children with an isolated cleft, especially when the palate is involved, and those with high levels of school absence may benefit from increased support addressing their educational needs.

Early academic achievement in children with isolated clefts: a population-based study in England.

OBJECTIVES: We used national data to study differences in academic achievement between 5-year-old children with an isolated oral cleft and the general population. We also assessed differences by cleft type. METHODS: Children born in England with an oral cleft were identified in a national cleft registry. Their records were linked to databases of hospital admissions (to identify additional anomalies) and educational outcomes. Z-scores (signed number of SD actual score is above national average) were calculated to make outcome scores comparable across school years and across six assessed areas (personal development, communication and language, maths, knowledge of world, physical development andcreative development). RESULTS: 2802 children without additional anomalies, 5 years old between 2006 and 2012, were included. Academic achievement was significantly below national average for all six assessed areas with z-scores ranging from -0.24 (95% CI -0.32 to -0.16) for knowledge of world to -0.31 (-0.38 to -0.23) for personal development. Differences were small with only a cleft lip but considerably larger with clefts involving the palate. 29.4% of children were documented as having special education needs (national rate 9.7%), which varied according to cleft type from 13.2% with cleft lip to 47.6% with bilateral cleft lip and palate. CONCLUSIONS: Compared with national average, 5-year-old children with an isolated oral cleft, especially those involving the palate, have significantly poorer academic achievement across all areas of learning. These outcomes reflect results of modern surgical techniques and multidisciplinary approach. Children with a cleft may benefit from extra academic support when starting school.

Grommet Surgery in Children With Orofacial Clefts in England.

OBJECTIVE: To assess grommet insertion practice in the first 5 years of life among children with an orofacial cleft in England. DESIGN: Analysis of national administrative data of hospital admissions. SETTING: National Health Service hospitals, England. PATIENTS: Patients born between 1997 and 2005 who underwent surgical cleft repair. INTERVENTION: Children receiving grommets before the age of 5 years. OUTCOME MEASURES: The proportion of children receiving grommets before the age of 5 years, the timing of the first grommet insertion, and the proportion of children having repeat grommet insertions were examined according to cleft type, the absence or presence of additional anomalies, socioeconomic deprivation, and region of residence. RESULTS: The study included 8,269 children. Before the age of 5 years, 3,015 (36.5%) children received grommets. Of these, 33.2% received their first grommets at primary cleft repair and 33.3% underwent multiple grommet insertion procedures. The most common age for the first procedure was between 6 and 12 months. Children with a cleft affecting the palate were more likely to receive grommets than children with a cleft lip alone (45.5% versus 4.5%). Grommet insertion practice also varied according to year of birth, absence or presence of additional anomalies, socioeconomic deprivation, and region of residence. CONCLUSION: Grommets practice in children with a cleft appears to vary according to their clinical characteristics. The differences in practice observed according to deprivation and region of residence need to be further explored.

Linkage of a national clinical liver transplant database with administrative hospital data: methods and validation.

INTRODUCTION: The UK Liver Transplant Audit (UKLTA) database contains clinical information on all liver transplants carried out in the UK. To expand its potential for research and service evaluation, we linked it to the Hospital Episode Statistics (HES), an administrative database of all admissions to English National Health Service (NHS) hospitals. MATERIALS AND METHODS: In the UKLTA database, we identified the linkable records of first liver transplantation between April 1997 and March 2010. We linked UKLTA records to HES records on the basis of NHS number, gender, date of birth, and postcode, as well as procedure codes for liver transplantation and dates of transplant. In linked records, agreement of primary liver disease diagnoses according to both databases was expressed as a proportion of the linked records and using kappa statistic. RESULTS: There were 5,815 linkable records in the UKLTA database, of which 4,959 records were successfully linked with HES (85.3%). Among these, 4,922 records (99.3%) had at least one diagnosis coded in HES relevant to an indication for liver transplantation. The overall agreement of primary liver disease diagnoses between UKLTA data and HES was 77.8% (95% CI 76.6%-79.0%) with a kappa of 0.75 (0.74-0.76). Diagnostic agreement can be further improved by using broader groupings of clinically related diagnoses. CONCLUSION: Linkage of clinical data and administrative hospital data provides a rich resource for the study of liver transplantation.

Hospital admissions for dental treatment among children with cleft lip and/or palate born between 1997 and 2003: an analysis of Hospital Episode Statistics in England.

BACKGROUND: Children with clefts have an increased tendency for dental anomalies and caries. AIM: To determine the pattern of hospital admissions for dental treatment during primary dentition among children with clefts. DESIGN: Cohort study based on Hospital Episode Statistics, an administrative database of all admissions to National Health Service hospitals in England. Patients born alive between 1997 and 2003 who had both a cleft diagnosis and cleft repair were included. The number of hospital admissions for surgical removal of teeth, simple extraction of teeth, and restoration of teeth before the age of seven was examined. RESULTS: Eight hundred and fifty-eight hospital admissions for dental treatment among 6551 children (<7 year) with a cleft were identified. 66.4% of admissions were primarily for caries and 95.6% involved extractions. 11.4% of children had at least one admission for dental treatment. The presence of additional anomalies, having a more severe cleft type, and living in relatively deprived areas increased the risk of hospital admission. CONCLUSIONS: Factors increasing the risk of hospital admission among cleft children should be taken into account when planning services. Efforts to reduce the number of hospital admissions should be focused on disease prevention, particularly among those most at risk of caries.

Hospital care of children with a cleft in England.

OBJECTIVE: To analyse hospital admissions in the first 2 years of life among children with cleft lip and/or palate in England. DESIGN: Analysis of national administrative data of hospital admissions. SETTING: National Health Service hospitals. PATIENTS: Patients born alive between 1997 and 2008 who underwent surgical cleft repair. OUTCOME MEASURES: Number of admissions, including the birth episode, and days spent in hospital were examined. Children were analysed according to cleft type and whether or not they had additional congenital anomalies. RESULTS: 10 892 children were included. In their first 2 years, children without additional anomalies (n=8482) had on average 3.2 admissions and 13.2 days in hospital, which varied from 2.6 admissions and 9.2 days with cleft lip to 4.7 admissions and 19.7 days with bilateral cleft lip and palate (BCLP). Children with additional anomalies (n=2410) had on average 6.7 admissions and 51.4 days in hospital, which varied from 6.4 admissions and 48.5 days with cleft palate to 8.8 admissions and 67.5 days with BCLP. The mean number and duration of cleft-related admissions was similar in children without (1.6 admissions and 6.4 days) and in those with additional anomalies (1.5 admissions and 8.5 days). 35.2% of children without additional anomalies had at least one emergency admission, whereas the corresponding figure was 67.3% with additional anomalies. CONCLUSIONS: The burden of hospital care in the first 2 years of life varied according to cleft type and presence of additional anomalies. However, cleft-specific hospital care did not differ between children with and without additional anomalies.

Centralisation of services for children with cleft lip or palate in England: a study of hospital episode statistics.

BACKGROUND: In 1998, a process of centralisation was initiated for services for children born with a cleft lip or palate in the UK. We studied the timing of this process in England according to its impact on the number of hospitals and surgeons involved in primary surgical repairs. METHODS: All live born patients with a cleft lip and/or palate born between April 1997 and December 2008 were identified in Hospital Episode Statistics, the database of admissions to English National Health Service hospitals. Children were included if they had diagnostic codes for a cleft as well as procedure codes for a primary surgical cleft repair. Children with codes indicating additional congenital anomalies or syndromes were excluded as their additional problems could have determined when and where they were treated. RESULTS: We identified 10,892 children with a cleft. 21.0% were excluded because of additional anomalies or syndromes. Of the remaining 8,606 patients, 30.4% had a surgical lip repair only, 41.7% a palate repair only, and 28.0% both a lip and palate repair. The number of hospitals that carried out these primary repairs reduced from 49 in 1997 to 13, with 11 of these performing repairs on at least 40 children born in 2008. The number of surgeons responsible for repairs reduced from 98 to 26, with 22 performing repairs on at least 20 children born in 2008. In the same period, average length of hospital stay reduced from 3.8 to 3.0 days for primary lip repairs, from 3.8 to 3.3 days for primary palate repairs, and from 4.6 to 2.6 days for combined repairs with no evidence for a change in emergency readmission rates. The speed of centralisation varied with the earliest of the nine regions completing it in 2001 and the last in 2007. CONCLUSIONS: Between 1998 and 2007, cleft services in England were centralised. According to a survey among patients' parents, the quality of cleft care improved in the same period. Surgical care became more consistent with current recommendations. However, key outcomes, including facial appearance and speech, can only be assessed many years after the initial surgical treatment.

Diathermy power settings as a risk factor for hemorrhage after tonsillectomy.

OBJECTIVE: To investigate bipolar diathermy power settings as a risk factor for postoperative hemorrhage following tonsillectomy. STUDY DESIGN AND SETTING: A prospective cohort study was undertaken between July 2003 and September 2004 in National Health Service (NHS) and independent hospitals in England and Northern Ireland. Data were collected on patient characteristics, tonsillectomy technique, and postoperative hemorrhage within 28 days of surgery. RESULTS: Among the 9572 patients who had a tonsillectomy performed with bipolar diathermy dissection and hemostasis, the overall rate of hemorrhage was 4.6 percent and the risk of hemorrhage was not associated with the diathermy power setting. Among the 8465 patients who had tonsillectomy with cold steel dissection and bipolar diathermy hemostasis, the rate of hemorrhage increased from 1.8% in patients with the lowest power settings (6 to 8 watts) to 3.7% in those with settings above 18 watts (P value for trend = 0.005). CONCLUSION: In tonsillectomies using cold steel dissection and bipolar diathermy for hemostasis, the risk of postoperative hemorrhage becomes greater as diathermy power increases.

Revision rates after primary hip and knee replacement in England between 2003 and 2006.

BACKGROUND: Hip and knee replacement are some of the most frequently performed surgical procedures in the world. Resurfacing of the hip and unicondylar knee replacement are increasingly being used. There is relatively little evidence on their performance. To study performance of joint replacement in England, we investigated revision rates in the first 3 y after hip or knee replacement according to prosthesis type. METHODS AND FINDINGS: We linked records of the National Joint Registry for England and Wales and the Hospital Episode Statistics for patients with a primary hip or knee replacement in the National Health Service in England between April 2003 and September 2006. Hospital Episode Statistics records of succeeding admissions were used to identify revisions for any reason. 76,576 patients with a primary hip replacement and 80,697 with a primary knee replacement were included (51% of all primary hip and knee replacements done in the English National Health Service). In hip patients, 3-y revision rates were 0.9% (95% confidence interval [CI] 0.8%-1.1%) with cemented, 2.0% (1.7%-2.3%) with cementless, 1.5% (1.1%-2.0% CI) with "hybrid" prostheses, and 2.6% (2.1%-3.1%) with hip resurfacing (p < 0.0001). Revision rates after hip resurfacing were increased especially in women. In knee patients, 3-y revision rates were 1.4% (1.2%-1.5% CI) with cemented, 1.5% (1.1%-2.1% CI) with cementless, and 2.8% (1.8%-4.5% CI) with unicondylar prostheses (p < 0.0001). Revision rates after knee replacement strongly decreased with age. INTERPRETATION: Overall, about one in 75 patients needed a revision of their prosthesis within 3 y. On the basis of our data, consideration should be given to using hip resurfacing only in male patients and unicondylar knee replacement only in elderly patients.

Adult orthotopic liver transplantation in the United Kingdom and Ireland between 1994 and 2005.

BACKGROUND: The UK and Ireland Liver Transplant Audit collects information on all liver transplantations that are carried out in both countries. In this paper, we describe these transplantations and their outcomes in adult patients according to primary liver disease diagnosis, type of transplantation and period. METHODS: A prospective cohort study of 7906 orthotopic liver transplantations carried out between April 1994 and June 2005 in the United Kingdom and Ireland. Multivariable logistic regression was used to investigate improvements in mortality according to period of transplantation adjusted for recipient and donor characteristics. RESULTS: A total of 6,850 transplantations were done in adults (patients 16 years or older). Of these, 836 (12.2%) were first super-urgent procedures (33.7% men; median age 36 years), and 5,072 (74.0%) first elective procedures (60.0% men; median age 52 years). The percentage of patients who received a donor organ with abnormal appearance gradually increased, especially in patients receiving an elective transplant. Mortality at 90 days after first super-urgent transplant decreased from 29.6% (95% confidence interval: 23.5% to 36.9%) before October 1, 1996 to 16.0% (11.7% to 21.7%) after October 1, 2002. Considering the same time periods, mortality at 90 days after first elective transplant decreased from 10.6% (8.9% to 12.7%) to 7.7% (6.3% to 9.3%). Multivariable analysis demonstrated that these improvements cannot be explained by changes in the risk profile of recipients and donors. CONCLUSIONS: Patients undergoing a liver transplantation in the most recent years had a better survival than patients with similar characteristics transplanted 10 years earlier. Posttransplant survival has improved despite a deteriorating quality of donor organs.

Developing a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors.

BACKGROUND: Current statistical prognostic models for mortality after liver transplantation do not have good discriminatory ability. Furthermore, the methodology used to develop these models is often flawed. The objective of this paper is to develop a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors, employing a rigorous model development method. METHODS: We used data on 4,829 patient that were prospectively collected for the UK & Ireland Liver Transplant Audit. Switching regression was employed to impute missing values combined with a bootstrapping approach for variable selection. RESULTS: In all, 452 patients (9.4%) died within 90 days of their transplantation. The final prognostic model was well calibrated and discriminated moderately well between patients who did and who did not die (c-statistic 0.65, 95% CI [0.63, 0.68]). Although discrimination was not excellent overall, the results showed that those patients with a "low" chance of dying within 90 days of their transplant and those with a "high" chance of dying could be differentiated from patients with a "intermediate" chance. CONCLUSIONS: Our model can provide transplant candidates with predictions of their early posttransplantation prospects before any donor information is known, which is essential information for patients with end-stage liver disease for whom liver transplantation is a treatment option.

Complications of surgery for nasal polyposis and chronic rhinosinusitis: the results of a national audit in England and Wales.

OBJECTIVE: The objective of this study was to determine the rate of complications of surgery for nasal polyposis and chronic rhinosinusitis as well as their risk factors. STUDY DESIGN, SETTING, PARTICIPANTS, AND OUTCOME MEASURES: The authors conducted a prospective study of 3,128 patients who underwent sinonasal surgery during 2000 and 2001 in 87 National Health Service hospitals in England and Wales. Patients completed a preoperative questionnaire that included the Sino-Nasal Outcome Test, a measure of sinonasal symptoms severity and health-related quality of life. Surgeons provided information about polyp extent, opacity of the sinuses on computed tomography (Lund-Mackay score), comorbidity (American Society of Anesthesiologists score), and the occurrence of perioperative complications. RESULTS: Major complications (orbital or intracranial complications, bleeding requiring ligation or orbital decompression, or return to the operating room) occurred in 11 patients (0.4%). Minor complications (all other untoward events) occurred in 207 patients (6.6%). Most frequently reported minor complications were excessive perioperative hemorrhage bleeding (5.0%) as well as postoperative hemorrhage requiring treatment (0.8%). Multivariate analysis indicated that the complication rate was linked to the extent of disease measured in terms of symptom severity and health-related quality of life, the extent of polyposis, level of opacity of the sinuses on computed tomography, and the presence of comorbidity, but not surgical characteristics (extent of surgery, use of endoscope or microdebrider, grade of surgeon, and adjunctive turbinate surgery). CONCLUSIONS: The risk of complications depended on patient characteristics rather than on the surgical technique used. Measures of the extent of disease and comorbidity may help in identifying patients at high risk of complications.

Functional status of patients before liver transplantation as a predictor of posttransplant mortality.

BACKGROUND: Risk models for mortality after liver transplantation have poor predictive ability. We examined whether the performance of these risk models can be improved by including information about patients' functional status (i.e., their ability to carry out activities of daily living) in addition to conventional clinical risk factors. METHODS: The UK and Ireland Liver Transplant Audit has data on all liver transplantations carried out in both countries since 1994. We examined the association of functional status measures taken immediately before transplantation on a 5-point scale (modified version of the Eastern Cooperative Oncology Group performance status) and mortality 90 days after transplantation. Logistic regression was used to adjust for other risk factors. RESULTS: Posttransplant mortality increased from 5.3% in patients able to carry out normal activity without restriction (functional status 1) to 24.8% in patients completely reliant on nursing and medical care (functional status 5; P for trend 0.003). This association remained after adjustment for conventional risk factors (adjusted P for trend 0.003). Adjusted odds ratios with functional status 3 (the most frequent functional status) as baseline category were 0.60 (95% confidence interval 0.29-1.25) for functional status 1, 0.70 (0.50-0.97) for functional status 2, 1.00 (0.71-1.41) for functional status 4, and 1.85 (1.07-3.19) for functional status 5. CONCLUSIONS: Considering a patient's functional status or more general measures of a patient's health status before transplantation in addition to conventional clinical factors may help to improve our ability to predict posttransplant survival.

Pretransplant MELD score and post liver transplantation survival in the UK and Ireland.

It has been shown that the model for end-stage liver disease (MELD) score is an accurate predictor of survival in patients with liver disease without transplantation. Four recent studies carried out in the United States have demonstrated that the MELD score obtained immediately prior to transplantation is also associated with post-transplant patient survival. Our aim was to evaluate how accurately the MELD score predicts 90-day post-transplant survival in adult patients with chronic liver disease in the UK and Ireland. The UK and Ireland Liver Transplant Audit has data on all liver transplants since 1994. We studied survival of 3838 adult patients after first elective liver transplantation according to United Network for Organ Sharing categories of their MELD scores (< or = 10, 11-18, 19-24, 25-35, > or =36). The overall survival at 90-days was 90.2%. The 90-day survival varied according to the United Network for Organ Sharing MELD categories (92.6%, 91.9%, 89.7%, 89.7%, and 70.8%, respectively; P < 0.01). Therefore, only those patients with a MELD score of 36 or higher (3% of the patients) had a survival that was markedly lower than the rest. As a consequence, the ability of the MELD score to discriminate between patients who were dead or alive was poor (c-statistic 0.58). Re-estimating the coefficients in the MELD regression model, even allowing for nonlinear relationships, did not improve its discriminatory ability. In conclusion, in the UK and Ireland the MELD score is significantly associated with post-transplant survival, but its predictive ability is poor. These results are in agreement with results found in the United States. Therefore, the most appropriate system to support patient selection for transplantation will be one that combines a pretransplant survival model (e.g., MELD score) with a properly developed post-transplant survival model.