A comparison of synthetic control approaches for the evaluation of policy interventions using observational data: Evaluating the impact of redesigning urgent and emergency care in Northumberland.

OBJECTIVE: To compare the original synthetic control (OSC) method with alternative approaches (Generalized [GSC], Micro [MSC], and Bayesian [BSC] synthetic control methods) and re-evaluate the impact of a significant restructuring of urgent and emergency care in Northeast England, which included the opening of the UK's first purpose-built specialist emergency care hospital. DATA SOURCES: Simulations and data from Secondary Uses Service data, a single comprehensive repository for patient-level health care data in England. STUDY DESIGN: Hospital use of individuals exposed and unexposed to the restructuring is compared. We estimate the impact using OSC, MSC, BSC, and GSC applied at the general practice level. We contrast the estimation methods' performance in a Monte Carlo simulation study. DATA COLLECTION/EXTRACTION METHODS: Hospital activity data from Secondary Uses Service for patients aged over 18 years registered at a general practice in England from April 2011 to March 2019. PRINCIPAL FINDINGS: None of the methods dominated all simulation scenarios. GSC was generally preferred. In contrast to an earlier evaluation that used OSC, GSC reported a smaller impact of the opening of the hospital on Accident and Emergency (A&E) department (also known as emergency department or casualty) visits and no evidence for any impact on the proportion of A&E patients seen within 4 h. CONCLUSIONS: The simulation study highlights cases where the considered methods may lead to biased estimates in health policy evaluations. GSC was found to be the most reliable method of those considered. Considering more disaggregated data over a longer time span and applying GSC indicates that the specialist emergency care hospitals in Northumbria had less impact on A&E visits and waiting times than suggested by the original evaluation which applied OSC to more aggregated data.

The impact of the COVID-19 pandemic on antimicrobial prescribing at a specialist paediatric hospital: an observational study.

BACKGROUND: The COVID-19 pandemic has severely impacted healthcare delivery and there are growing concerns that the pandemic will accelerate antimicrobial resistance. OBJECTIVES: To evaluate the impact of the COVID-19 pandemic on antibiotic prescribing in a tertiary paediatric hospital in London, UK. METHODS: Data on patient characteristics and antimicrobial administration for inpatients treated between 29 April 2019 and Sunday 28 March 2021 were extracted from the electronic health record (EHR). Interrupted time series analysis was used to evaluate antibiotic days of therapy (DOT) and the proportion of prescribed antibiotics from the WHO 'Access' class. RESULTS: A total of 23 292 inpatient admissions were included. Prior to the pandemic there were an average 262 admissions per week compared with 212 during the pandemic period. Patient demographics were similar in the two periods but there was a shift in the specialities that patients had been admitted to. During the pandemic, there was a crude increase in antibiotic DOTs, from 801 weekly DOT before the pandemic to 846. The proportion of Access antibiotics decreased from 44% to 42%. However, after controlling for changes in patient characteristics, there was no evidence for the pandemic having an impact on antibiotic prescribing. CONCLUSIONS: The patient population in a specialist children's hospital was affected by the COVID-19 pandemic, but after adjusting for these changes there was no evidence that antibiotic prescribing was significantly affected by the pandemic. This highlights both the value of routine, high-quality EHR data and importance of appropriate statistical methods that can adjust for underlying changes to populations when evaluating impacts of the pandemic on healthcare.

Ethical funding for trustworthy AI: proposals to address the responsibilities of funders to ensure that projects adhere to trustworthy AI practice.

AI systems that demonstrate significant bias or lower than claimed accuracy, and resulting in individual and societal harms, continue to be reported. Such reports beg the question as to why such systems continue to be funded, developed and deployed despite the many published ethical AI principles. This paper focusses on the funding processes for AI research grants which we have identified as a gap in the current range of ethical AI solutions such as AI procurement guidelines, AI impact assessments and AI audit frameworks. We highlight the responsibilities of funding bodies to ensure investment is channelled towards trustworthy and safe AI systems and provides case studies as to how other ethical funding principles are managed. We offer a first sight of two proposals for funding bodies to consider regarding procedures they can employ. The first proposal is for the inclusion of a Trustworthy AI Statement' section in the grant application form and offers an example of the associated guidance. The second proposal outlines the wider management requirements of a funding body for the ethical review and monitoring of funded projects to ensure adherence to the proposed ethical strategies in the applicants Trustworthy AI Statement. The anticipated outcome for such proposals being employed would be to create a 'stop and think' section during the project planning and application procedure requiring applicants to implement the methods for the ethically aligned design of AI. In essence it asks funders to send the message "if you want the money, then build trustworthy AI!".

Healthcare utilization among migrants to the UK: cross-sectional analysis of two national surveys.

OBJECTIVE: To contribute objective evidence on health care utilization among migrants to the UK to inform policy and service planning. METHODS: We analysed data from Understanding Society, a household survey with fieldwork from 2015 to 2017, and the European Health Interview Survey with data collected between 2013 and 2014. We explored health service utilization among migrants to the UK across primary care, inpatient admissions and maternity care, outpatient care, mental health, dental care and physiotherapy. We adjusted for age, sex, long-term health conditions and time since moving to the UK. RESULTS: Health care utilization among migrants to the UK was lower than utilization among the UK-born population for all health care dimensions except inpatient admissions for childbirth; odds ratio (95%CI) range 0.58 (0.50-0.68) for dental care to 0.88 (0.78-0.98) for primary care). After adjusting for differences in age and self-reported health, these differences were no longer observed, except for dental care (odds ratio 0.57, 95%CI 0.49-0.66, P < 0.001). Across primary care, outpatient and inpatient care, utilization was lower among those who had recently migrated, increasing to the levels of the nonmigrant population after 10 years or more since migrating to the UK. CONCLUSIONS: This study finds that newly arrived migrants tend to utilize less health care than the UK population and that this pattern was at least partly explained by better health, and younger age. Our findings contribute nationally representative evidence to inform public debate and decision-making on migration and health.

The implications of high bed occupancy rates on readmission rates in England: A longitudinal study.

Hospital bed occupancy rates in the English National Health Service have risen to levels considered clinically unsafe. This study assesses the association of increased bed occupancy with changes in the percentage of overnight patients discharged from hospital on a given day, and their subsequent 30-day readmission rate. Longitudinal panel data methods are used to analyse secondary care records (n = 4,193,590) for 136 non-specialist Trusts between April 2014 and February 2016. The average bed occupancy rate across the study period was 90.4%. A 1% increase in bed occupancy was associated with a 0.49% rise in the discharge rate, and a 0.011% increase in the 30-day readmission rate for discharged patients. These associations became more pronounced once bed occupancy exceeded 95%. When bed occupancy rates were high, hospitals discharged a greater proportion of their patients. Those were mostly younger and less clinically complex, suggesting that hospitals are successfully prioritising early discharge amongst least vulnerable patients. However, while increased bed occupancy was not associated with a substantial increase in overall 30-day readmission rates, the relationship was more pronounced in older and sicker patients, indicating possible links with short-fallings in discharge processes.

Effect of an integrated care pathway on use of primary and secondary healthcare by patients at high risk of emergency inpatient admission: a matched control cohort study in Tower Hamlets.

OBJECTIVES: To assess the effects of an integrated care pathway on the use of primary and secondary healthcare by patients at high risk of emergency inpatient admission. DESIGN: Observational study of a real-life deployment of integrated care, using patient-level administrative data. Regression analysis was used to compare integrated care patients with matched controls. SETTING: A deprived, inner city London borough (Tower Hamlets). PARTICIPANTS: 1720 patients aged 50+ years registered with a general practitioner in Tower Hamlets and at high risk of emergency inpatient admission enrolled onto integrated care during 2014. These patients were matched to control patients, also selected from Tower Hamlets, with respect to demographics, diagnoses of health conditions, previous hospital use and risk score. INTERVENTIONS: Enrolled patients were eligible for a range of interventions, such as case management, support with self-care and enhanced care coordination. Control patients received usual care. PRIMARY AND SECONDARY ENDPOINTS: Number of emergency inpatient admissions in the year after enrolment onto integrated care. Secondary endpoints included numbers of elective inpatient admissions, inpatient bed days, accident and emergency attendances, outpatient attendances and general practitioner contacts in the year after enrolment. RESULTS: There was no evidence that the integrated care pathway reduced patients' healthcare utilisation in the first year post-enrolment. Matched controls and integrated care patients were similar at baseline. Following enrolment, integrated care patients were more likely than matched controls to experience elective inpatient admissions (adjusted incidence rate ratio (IRR)=1.27, 95% CI 1.08 to 1.49, p=0.004). They were also more likely to experience general practitioner contacts (adjusted IRR=1.11, 95% CI 1.06 to 1.16, p<0.001), but other endpoints were not significantly different between the groups. CONCLUSIONS: The integrated care pathway was not associated with a reduction in healthcare utilisation in the first year, but appeared to have increased elective inpatient admissions and general practitioner workload.

Effect on secondary care of providing enhanced support to residential and nursing home residents: a subgroup analysis of a retrospective matched cohort study.

BACKGROUND: Thirteen residential care homes and 10 nursing homes specialising in older people in Rushcliffe, England, participated in an improvement programme. The enhanced support provided included regular visits from named general practitioners and additional training for care home staff. We assessed and compared the effect on hospital use for residents in residential and nursing homes, respectively. METHODS: Using linked care home and administrative hospital data, we examined people aged 65 years or over who moved to a participating care home between 2014 and 2016 (n=568). We selected matched control residents who had similar characteristics to the residents receiving enhanced support and moved to similar care homes not participating in the enhanced support (n=568). Differences in hospital use were assessed for residents of each type of care home using multivariable regression. RESULTS: Residents of participating residential care homes showed lower rates of potentially avoidable emergency admissions (rate ratio 0.50, 95% CI 0.30 to 0.82), emergency admissions (rate ratio 0.60, 95% CI 0.42 to 0.86) and Accident & Emergency attendances (0.57, 95% CI 0.40 to 0.81) than matched controls. Hospital bed days, outpatient attendances and the proportion of deaths that occurred out of hospital were not statistically different. For nursing home residents, there were no significant differences for any outcome. CONCLUSIONS: The enhanced support was associated with lower emergency hospital use for older people living in residential care homes but not for people living in nursing homes. This might be because there was more potential to reduce emergency care for people in residential care homes. In nursing homes, improvement programmes may need to be more tailored to residents' needs or the context of providing care in that setting.

The association between living alone and health care utilisation in older adults: a retrospective cohort study of electronic health records from a London general practice.

BACKGROUND: In 2016, one in three older people in the UK were living alone. These patients often have complex health needs and require additional clinical and non-clinical support. This study aimed to analyse the association between living alone and health care utilisation in older patients. METHODS: We conducted a retrospective cohort study of 1447 patients over the age of 64, living in 1275 households who were registered at a large general practice in South East London. The utilisation of four different types of health care provision were examined in order to explore the impact of older patients living alone on health care utilisation. RESULTS: After adjusting for patient demographics and clinical characteristics, living alone was significantly associated with a higher probability of utilising emergency department and general practitioner services, with odds ratios of 1.50 (95% confidence interval [CI] 1.16 to 1.93) and 1.40 (95% CI 1.04 to 1.88) respectively. CONCLUSIONS: Living alone has an impact on health care service utilisation for older patients. We show that general practice data can be used to identify older patients who are living alone, and general practitioners are in a unique position to identify those who could benefit from additional clinical and non-clinical support. Further research is needed to understand the mechanism driving higher utilisation for those patients who live alone.

Weekend admissions may be associated with poorer recording of long-term comorbidities: a prospective study of emergency admissions using administrative data.

BACKGROUND: Many studies have investigated the presence of a 'weekend effect' in mortality following hospital admission, and these frequently use diagnostic codes from administrative data for information on comorbidities for risk adjustment. However, it is possible that coding practice differs between week and weekend. We assess patients with a confirmed history of certain long-term health conditions and investigate how well these are recorded in subsequent week and weekend admissions. METHODS: We selected six long-term conditions that are commonly assessed when risk-adjusting mortality rates, via the Charlson and Elixhauser indices. Using Hospital Episode Statistics data from England for the period April 2009 to March 2011, we identified patients with the condition recorded at least twice, on separate emergency admissions. Then we assessed how often each condition was recorded on subsequent emergency admissions between April 2011 and March 2013. We then compared coding between week and weekend admissions using the Cochran-Mantel-Haenszel test, stratifying by hospital. RESULTS: We studied 111,457 patients with chronic pulmonary disease, 106,432 with diabetes, 36,447 with congestive heart failure, 30,996 with dementia, 7808 with hemiplegia or paraplegia and 5877 with metastatic cancer. Across the entire week, between April 2011 and March 2013, coding completeness ranged from 89% for diabetes to 43% for hemiplegia/paraplegia. Compared with weekday admissions, congestive heart failure was less likely to be recorded as a secondary diagnosis at the weekend (odds ratio 0.92, 95% CI, 0.88 to 0.97), with smaller but statistically significant differences also detected for chronic pulmonary disease (odds ratio 0.96, 95% CI, 0.93 to 0.99) and diabetes (odds ratio 0.95, 95% CI 0.91 to 0.99). There was no statistically significant difference in recording between week and weekend admissions for dementia (odds ratio 1.04, 95% CI 0.97 to 1.11), hemiplegia/paraplegia (odds ratio 0.99, 95% CI 0.89 to 1.10) or metastatic cancer (odds ratio 1.04, 95% CI 0.90 to 1.20). CONCLUSIONS: Long-term conditions are often not recorded on administrative data and the lack of recording may be worse for weekend admissions. Studies of the weekend effect that rely on administrative data might have underestimated the health burden of patients, particularly if admitted at the weekend.

Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records.

OBJECTIVE: To quantify the association between patient self-management capability measured using the Patient Activation Measure (PAM) and healthcare utilisation across a whole health economy. RESULTS: 12 270 PAM questionnaires were returned from 9348 patients. In the adjusted analyses, compared with the least activated group, highly activated patients (level 4) had the lowest rate of contact with a general practitioner (rate ratio: 0.82, 95% CI 0.79 to 0.86), emergency department attendances (rate ratio: 0.68, 95% CI 0.60 to 0.78), emergency hospital admissions (rate ratio: 0.62, 95% CI 0.51 to 0.75) and outpatient attendances (rate ratio: 0.81, 95% CI 0.74 to 0.88). These patients also had the lowest relative rate (compared with the least activated) of 'did not attends' at the general practitioner (rate ratio: 0.77, 95% CI 0.68 to 0.87), 'did not attends' at hospital outpatient appointments (rate ratio: 0.72, 95% CI 0.61 to 0.86) and self-referred attendance at emergency departments for conditions classified as minor severity (rate ratio: 0.67, 95% CI 0.55 to 0.82), a significantly shorter average length of stay for overnight elective admissions (rate ratio 0.59, 95% CI 0.37 to 0.94),and a lower likelihood of 30- day emergency readmission (rate ratio: 0.68 , 95% CI 0.39 to 1.17), though this did not reach significance. CONCLUSIONS: Self-management capability is associated with lower healthcare utilisation and less wasteful use across primary and secondary care.

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016.

OBJECTIVE: To assess trends in 30-day emergency readmission rates across England over one decade. DESIGN: Retrospective study design. SETTING: 150 non-specialist hospital trusts in England. PARTICIPANTS: 23 069 134 patients above 18 years of age who were readmitted following an initial admission (n=62 584 297) between April 2006 and February 2016. PRIMARY AND SECONDARY OUTCOMES: We examined emergency admissions that occurred within 30 days of discharge from hospital ('emergency readmissions') as a measure of healthcare quality. Presented are overall readmission rates, and disaggregated by the nature of the indexed admission, including whether it was elective or emergency, and by clinical health condition recorded. All rates were risk-adjusted for patient age, gender, ethnicity, socioeconomic status, comorbidities and length of stay. RESULTS: The average risk-adjusted, 30-day readmission rate increased from 6.56% in 2006/2007 to 6.76% (P<0.01) in 2012/2013, followed by a small decrease to 6.64% (P<0.01) in 2015/2016. Emergency readmissions for patients discharged following elective procedures decreased by 0.13% (P<0.05), whereas those following emergency admission increased by 1.27% (P<0.001). Readmission rates for hip or knee replacements decreased (-1.29%; P<0.001); for acute myocardial infarction (-0.04%; P<0.49), stroke (+0.62%; P<0.05), chronic obstructive pulmonary disease (+0.41%; P<0.05) and heart failure (+0.15%; P<0.05) remained stable; and for pneumonia (+2.72%; P<0.001), diabetes (+7.09%; P<0.001), cholecystectomy (+1.86%; P<0.001) and hysterectomy (+2.54%; P<0.001) increased. CONCLUSIONS: Overall, emergency readmission rates in England remained relatively stable across the observation period, with trends of slight increases contained post 2012/2013. However, there were large variations in trends across clinical areas, with some experiencing marked increases in readmission rates. This highlights the need to better understand variations in outcomes across clinical subgroups to allow for targeted interventions that will ensure highest standards of care provided for all patients.

Are self-reported telemonitored blood pressure readings affected by end-digit preference: a prospective cohort study in Scotland.

OBJECTIVE: Simple forms of blood pressure (BP) telemonitoring require patients to text readings to central servers creating an opportunity for both entry error and manipulation. We wished to determine if there was an apparent preference for particular end digits and entries which were just below target BPs which might suggest evidence of data manipulation. DESIGN: Prospective cohort study SETTING: 37 socioeconomically diverse primary care practices from South East Scotland. PARTICIPANTS: Patients were recruited with hypertension to a telemonitoring service in which patients submitted home BP readings by manually transcribing the measurements into text messages for transmission ('patient-texted system'). These readings were compared with those from primary care patients with uncontrolled hypertension using a system in which readings were automatically transmitted, eliminating the possibility of manipulation of values ('automatic-transmission system'). METHODS: A generalised estimating equations method was used to compare BP readings between the patient-texted and automatic-transmission systems, while taking into account clustering of readings within patients. RESULTS: A total of 44 150 BP readings were analysed on 1068 patients using the patient-texted system compared with 20 705 readings on 199 patients using the automatic-transmission system. Compared with the automatic-transmission data, the patient-texted data showed a significantly higher proportion of occurrences of both systolic and diastolic BP having a zero end digit (OR 2.1, 95% CI 1.7 to 2.6) although incidence was <2% of readings. Similarly, there was a preference for systolic 134 and diastolic 84 (the threshold for alerts was 135/85) (134 systolic BP OR 1.5, 95% CI 1.3 to 1.8; 84 diastolic BP OR 1.5, 95% CI 1.3 to 1.9). CONCLUSION: End-digit preference for zero numbers and specific-value preference for readings just below the alert threshold exist among patients in self-reporting their BP using telemonitoring. However, the proportion of readings affected is small and unlikely to be clinically important. TRIAL REGISTRATION NUMBER: ISRCTN72614272; Post-results.

Reductions in Readmission Rates Are Associated With Modest Improvements in Patient-reported Health Gains Following Hip and Knee Replacement in England.

BACKGROUND: Although many hospital readmission reduction initiatives have been introduced globally, health care systems ultimately aim to improve patients' health and well-being. We examined whether the hospitals that report greater success in reducing readmissions also see greater improvements in patient-reported outcomes. RESEARCH DESIGN: We examined hospital groups (Trusts) that provided hip replacement or knee replacement surgery in England between April 2010 and February 2013. For each Trust, we calculated risk-adjusted 30-day readmission rates from administrative datasets. We also obtained changes in patient-reported health between presurgical assessment and 6-month follow-up, using general health EuroQuol five dimensions questionaire (EQ-5D) and EuroQuol visual analogue scales (EQ-VAS) and procedure-specific (Oxford Hip and Knee Scores) measures. Panel models were used to assess whether changes over time in risk-adjusted readmission rates were associated with changes over time in risk-adjusted health gains. RESULTS: Each percentage point reduction in the risk-adjusted readmission rate for hip replacement was associated with an additional health gain of 0.004 for EQ-5D [95% confidence interval (CI), 0.002-0.006], 0.39 for EQ-VAS (95% CI, 0.26-0.52), and 0.32 for Oxford Hip Score (95% CI, 0.15-0.27). Corresponding figures for knee replacement were 0.003 for EQ-5D (95% CI, 0.001-0.004), 0.21 for EQ-VAS (95% CI, 0.12-0.30), and 0.14 in the Oxford Knee Score (95% CI, 0.09-0.20). CONCLUSIONS: Reductions in readmission rates were associated with modest improvements in patients' sense of their health and well-being at the hospital group level. In particular, fears that efforts to reduce readmission rates have had unintended consequences for patients appear to be unfounded.