English Hospitals Research Articles

Use of Induction of Labor and Emergency Cesarean Section and Perinatal Outcomes in English Maternity Services: A National Hospital-level Study

(BJOG. 2022;129:1899–906) Maternity services vary widely worldwide. A recent independent review of the National Health Service (NHS) in England looked at what may have been avoidable harm during births between 2000 and 2019. The review found that cesarean delivery (CD) rates were discouraged and intentionally kept low. In response, this study aimed to determine if there was an association between induction of labor and emergency CD in English hospitals and an increased risk of stillbirth, use of neonatal mechanical ventilation in babies born at term, and admission to a neonatal intensive care unit (ICU).

Adverse drug reactions and hospital admissions: Large case-control study of patients aged 65-100 years using linked English primary care and hospital data.

Adverse drug reactions (ADRs) are common and a leading cause of injury. However, information on ADR risks of individual medicines is often limited. The aim of this hypothesis-generating study was to assess the relative importance of ADR-related and emergency hospital admission for large group of medication classes. This study was a propensity-matched case-control study in English primary care. Data sources were Clinical Practice Research Databank and Aurum with longitudinal, anonymized, patient level electronic health records (EHRs) from English general practices linked to hospital records. Cases aged 65-100 with ADR-related or emergency hospital admission were matched to up to six controls by age, sex, morbidity and propensity scores for hospital admission risk. Medication groups with systemic administration as listed in the British National Formulary (used by prescribers for medication advice). Prescribing in the 84 days before the index date was assessed. Only medication groups with 50+ cases exposed were analysed. The outcomes of interest were ADR-related and emergency hospital admissions. Conditional logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CI). The overall population included 121 546 cases with an ADR-related and 849 769 cases with emergency hospital admission. The percentage of hospitalizations with an ADR-related code for admission diagnosis was 1.83% and 6.58% with an ADR-related code at any time during hospitalization. A total of 137 medication groups was included in the main ADR analyses. Of these, 13 (9.5%) had statistically non-significant adjusted ORs, 58 (42.3%) statistically significant ORs between 1.0 and 1.5, 37 (27.0%) between 1.5-2.0, 18 (13.1%) between 2.0-3.0 and 11 (8.0%) 3.0 or higher. Several classes of antibiotics (including penicillins) were among medicines with largest ORs. Evaluating the 14 medications most often associated with ADRs, a strong association was found between the number of these medicines and the risk of ADR-related hospital admission (adjusted OR of 7.53 (95% CI 7.15-7.93) for those exposed to 6+ of these medicines). There is a need for a regular systematic assessment of the harm-benefit ratio of medicines, harvesting the information in large healthcare databases and combining it with causality assessment of individual case histories.

P17 Baseline characteristics, disease progression rates and risk factors among female patients with uncomplicated urinary tract infection in England

Abstract Background and Objectives Uncomplicated urinary tract infection (uUTI) is a common, usually community-acquired bacterial infection. Little is known about risk factors for disease progression (defined here as hospitalization for Escherichia coli sepsis, bacteraemia or acute pyelonephritis) among patients with uUTI. We report the baseline demographic and clinical characteristics among female uUTI patients with/without disease progression in England. Methods This retrospective cohort study utilized anonymized patient data from 1 January 2018 to 31 December 2019 from the Clinical Practice Research Datalink (CPRD) database linked to English Hospital Episode Statistics data. Eligible patients were female, aged ≥12 years, had received an index diagnosis for a community-acquired uUTI, had ≥12 months’ CPRD data history, and had received ≥1 oral antibiotic within ±5 days of diagnosis. Patients were excluded if they had complicated UTI or complicating comorbidities, were hospitalized/visited an accident and emergency department 28 days prior to index or had received IV antibiotics as initial therapy. uUTI episodes were defined as the 28 days post-index (Figure 1). Descriptive patient (demographic and clinical characteristics), region and practice-level characteristics in the 12 month baseline period are presented for patients with/without disease progression. Figure 1.Study design. HES, Hospital Episode Statistics. Results Among 116793 female patients with a uUTI, 207 were hospitalized for E. coli sepsis, bacteraemia or acute pyelonephritis within 28 days of index (0.2%). The mean age (SD) for patients with/without progression was 67.3 (20.2) and 52.9 (21.1), respectively; 81% and 34% of patients with/without progression were ≥50 years old. Imbalances were observed for comorbid burden, baseline medications, initial presentation (i.e. home visit requirement) and prior antimicrobial treatment (Table 1). Few regional or practice-level differences were apparent (Table 1). Table 1.Patient (demographic and clinical characteristics), region and practice-level variable distribution between uUTI patients without and with hospitalization for uUTI disease progressionVariable description/Statistic or categoryPatient subgroupsno disease progression (N=116586)disease progression (N=207)N%N%Patient-level Age at diagnosis, years, mean (SD)52.9 (21.1)–67.3 (20.2)– Age at diagnosis ≥12 to <167110.600 ≥16 to <301986117157.2 ≥30 to <401668214136.3 ≥40 to <501518413115.3 ≥50 to <6024512214220 ≥65396363412661 Age at diagnosis (pooled) <5052438453919 ≥50396363416881 Charlson comorbidity index, mean (IQR)0 (0, 0)–0 (0, 1)– Charlson comorbidity category 0959448213465 118007155828 223002125.8 ≥33350.3<5 Race/ethnicity, N (%) Asian or Asian British51614.462.9 Black or Black British32872.862.9 Chinese or other group19951.7<5- Ethnic group not recorded22781204321 White41340357335 Number of hospital admissions in prior year, mean (IQR)0 (0, 0)–0 (0, 0)– Number of A&E attendances in prior year, mean (IQR)0 (0, 1)–0 (0, 1)– Smoking status Non-smoker725466211957 Ex-smoker27084236230 Smoker16956152613 Menopausal status, yes34072296029 Obesity, yes13858123316 Mild/moderate renal impairment, yes22621.9104.8 Controlled diabetes (HgA1C <6.5/7%), yes24512.1146.8 History of recurrent uUTI, yes49374.2115.3 Prior antimicrobial treatment (any), yes702746015072 Cumulative antimicrobial prescriptions, median (IQR)1 (0, 2)–<5–Region-level Quintiles of index of multiple deprivation Q1 (least deprived)26869234220 Q223597203919 Q322273193818 Q422085194622 Q5 (most deprived)21762194220 Rural-urban area classification Rural15416133014 Urban1011708717786Practice-level Practice size Small (<8000 patients)30783265627 Medium (8000–11000 patients)25377224421 Large (>11000 patients)604265210752Percentage values do not add up to 100% for ethnicity as these data were not available for all patients and mixed ethnicity is not shown due to limited interpretability.A&E, accident and emergency; HgA1C, glycated haemoglobin; Q, quintile. Conclusions Hospitalization following uUTI is rare in this study, however, at a population level, this still affects a large number of female patients. Coding limitations meant potentially linked admissions (e.g. falls and confusion) could not be identified. Hospitalizations appear to be driven by patient factors rather than regional differences or practice patterns. The role of these putative risk factors for disease progression will be explored further via multivariable logistic regression analysis.

P19 Burden of illness and costs among female patients with uncomplicated urinary tract infection in England

Abstract Background and Objectives Uncomplicated urinary tract infection (uUTI) is usually community-acquired. Data regarding the wider burden of illness from uUTI are scarce. We evaluated the burden of uUTI in female patients in England. Methods This retrospective comparative cohort study utilized linked anonymized patient data from 1 January 2017 to 29 February 2020 from the Clinical Practice Research Datalink (CPRD) and English Hospital Episode Statistics databases. All eligible patients were female, aged ≥12 years and had ≥12 months’ CPRD data available pre- and post-index (i.e. ≥24 months total). Patients with an index UTI diagnosis who had received ≥1 oral antibiotic within ±5 days of index formed the uUTI cohort; uUTI episodes were defined as 28 days from index diagnosis. Patients who had visited a primary care setting but did not have a UTI (uUTI or complicated UTI [cUTI]) diagnosis during the study period formed the control cohort and were matched to the index date of uUTI patients. Patients who were hospitalized or visited an accident and emergency department 28 days prior to index, had cUTI and/or had received IV antibiotics as initial therapy were excluded. Burden of illness (index/12 month follow-up all-cause and UTI-related healthcare resource use [HCRU] and costs) was evaluated in a 1:1 age- and Charlson Comorbidity Index (CCI) score-matched cohort. Results Overall, 120519 female patients with uUTI and 233670 female control patients (without uUTI) were identified and matched 1:1. Before matching, more of the uUTI cohort patients versus controls were <50 years old, had a higher mean CCI score, and were more often menopausal; region- and practice-level differences were modest (Table 1). HCRU and costs were significantly higher among uUTI patients versus matched controls, notably for primary care, specialist, and accident and emergency visits, and hospital admissions (P<0.001, Table 2). After adjusting for patient characteristics, Poisson or negative binomial models showed significant HCRU differences in primary and secondary care for uUTI patients versus matched controls (Table 3). Conclusions Patients with uUTI in England had significantly higher burden of illness, consuming more resources, during index uUTI episodes and follow-up, versus matched controls.

P18 Treatment patterns and extent of inappropriate antimicrobial treatment among female patients with uncomplicated urinary tract infection in England

P18 Treatment patterns and extent of inappropriate antimicrobial treatment among female patients with uncomplicated urinary tract infection in England

Intermittent point prevalence surveys on healthcare-associated infections, 2011 and 2016, in England: what are the surveillance and intervention priorities?

Point prevalence surveys are an important surveillance method for determining the burden of healthcare-associated infections (HCAIs). To outline the key results of two point prevalence surveys in England (2011 and 2016). All National Health Service and independent sector hospitals in England were eligible to participate. Data were collected between September and November in both 2011 and 2016 based on the protocol and codebook devised by the European Centre for Disease Prevention and Control. Analysis was performed using Stata Version 13 and SAS Version 9.3. A mixed-effects model was applied, which allowed estimation of organization-specific means and accounted for the heterogeneity in the responses from different organizations. A total of 100,755 case records were included (52,433 in 2011 and 48,312 in 2016). The estimated prevalence of HCAIs was slightly higher in 2016 [6.89%, 95% confidence interval (CI) 6.21-7.57%] than in 2011 (6.41%, 95% CI 5.75-7.06%). In both surveys, the prevalence of HCAIs was highest in adult intensive care units (23.1% in 2011, 21.2% in 2016), and pneumonia/lower respiratory tract infections was the most common cause of HCAIs (22.7% in 2011 vs 29.2% in 2016). Inpatients in acute hospitals were older and had higher risk of dying in 2016 compared with 2011; however, the proportion of inpatients with HCAIs or on antibiotics did not differ significantly. The burden of HCAIs in English hospitals increased slightly between 2011 and 2016. However, the proportion of inpatients with HCAIs or on antibiotics did not differ significantly.

“To Be a Priest? Or a Physician?”: The Development of English Hospitals and the Influence of Christianity in the 16th and 17th Centuries

“To Be a Priest? Or a Physician?”: The Development of English Hospitals and the Influence of Christianity in the 16th and 17th Centuries

Voiceless and vulnerable: An existential phenomenology of the patient experience in 21st century British hospitals.

Current health policy, high-profile failuresand increased media scrutiny have led to a significant focus on patient experience in Britain's National Health Service (NHS). Patient experience data is typically gathered through surveys of satisfaction. The study aimed to support a better understanding of the patient experience and patients' expression of it through consideration of the aspects of the patient experience on NHS wards which are by their nature impossible to capture through patient satisfaction surveys. Existential phenomenology was used to develop an in-depth exploratory narrative, expressed through the voices of the participants. Data collection involved in-depth face-to-face interviews with 12 purposively sampled participants, with analysis by means of hermeneutics. Though the individuality of each experience was apparent and cannot be overemphasised, common factors emerging from the data included uncertainty and unexpectedness, suffering and finitude, the futility of feedbackand bureaucracy and absurdity. Overall, participants demonstrated how their individual personalities and expectations affected their response both to illness or injury and to their hospital admissions, highlighting feelings of vulnerability and voicelessness as a response to hospitalisation. The findings of this study provide useful insight into the patient experience on British hospital wards, and the value of an existential-phenomenological approach is demonstrated.

Comparison of outcomes for patients with and without a serious mental illness presenting to hospital for chronic obstruction pulmonary disease: retrospective observational study using administrative data.

There are few data on the profile of those with serious mental illness (SMI) admitted to hospital for physical health reasons. To compare outcomes for patients with and without an SMI admitted to hospital in England where the primary reason for admission was chronic obstructive pulmonary disease (COPD). This was a retrospective, observational analysis of the English Hospital Episodes Statistics data-set for the period from 1 April 2018 to 31 March 2019, for patients aged 18-74 years with COPD as the dominant reason for admission. Patient with an SMI (psychosis spectrum disorder, bipolar disorder) were identified. 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. The burden of comorbidity was similar between the two groups. After adjusting for covariates, SMI was associated with significantly greater risk of length of stay than the median (odds ratio 1.24, 95% CI 1.12-1.37, P ≤ 0.001) and with 30-day emergency readmission (odds ratio 1.51, 95% confidence interval 1.34-1.69, P ≤ 0.001) 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.

Bleeding related hospitalizations and mortality in England 2014-2019.

Acute bleeding is common and associated with increased morbidity and mortality. Epidemiological studies evaluating trends in bleeding-related hospitalisations and mortality are important as they have potential to guide resource allocation and service provision, however, despite this literature evaluating the national burden and annual trends are lacking. Our objective was to report the national burden and incidence of bleeding-related hospitalisation and mortality.This was a population-based review of all people in England between 2014 and 2019 either admitted to an acute care ward of a National Health Service (NHS) English hospital, or who died. Admissions and deaths were required to have a primary diagnosis of significant bleeding.There was a total of 3,238,427 hospitalisations with a mean of 539,738 ± 6033 per year and 81,264 deaths with a mean of 13,544 ± 331 per year attributable to bleeding. The mean annual incident rate for bleeding-related hospitalisations was 975 per 100,000 patient years and for mortality was 24.45. Over the study period there was a significant 8.2% reduction in bleeding related deaths (χ2 test for trend 91.4, p < 0.001). A direct relationship between increasing age and incidence of bleeding-related hospitalisation and mortality was seen.Bleeding remains a common cause of hospitalisation and death. The reduction in bleeding related mortality requires further investigation. This data may serve to guide future interventions designed to reduce bleeding-related morbidity and mortality.

The qualities of data: how nurses and their managers act on patient feedback in an English hospital

PurposeTo investigate ethnographically how patient experience data, as a named category in healthcare organisations, is actively “made” through the co-creative interactions of data, people and meanings in English hospitals.Design/methodology/approachThe authors draw on fieldnotes, interview recordings and transcripts produced from 13 months (2016–2017) of ethnographic research on patient experience data work at five acute English National Health Service (NHS) hospitals, including observation, chats, semi-structured interviews and documentary analysis. Research sites were selected based on performance in a national Adult Inpatient Survey, location, size, willingness to participate and research burden. Using an analytical approach inspired by actor–network theory (ANT), the authors examine how data acquired meanings and were made to act by clinical and administrative staff during a type of meeting called a “learning session” at one of the hospital study sites.FindingsThe authors found that the processes of systematisation in healthcare organisations to act on patient feedback to improve to the quality of care, and involving frontline healthcare staff and their senior managers, produced shifting understandings of what counts as “data” and how to make changes in response to it. Their interactions produced multiple definitions of “experience”, “data” and “improvement” which came to co-exist in the same systematised encounter.Originality/valueThe article's distinctive contribution is to analyse how patient experience data gain particular attributes. It suggests that healthcare organisations and researchers should recognise that acting on data in standardised ways will constantly create new definitions and possibilities of such data, escaping organisational and scholarly attempts at mastery.

Major trauma presentations and patient outcomes in English hospitals during the COVID-19 pandemic: An observational cohort study.

Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related "lockdown" restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England. We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded. This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.

EPrescribing-Based Antimicrobial Stewardship Practices in an English National Health Service Hospital: Qualitative Interview Study Among Medical Prescribers and Pharmacists.

Antimicrobial resistance, the ability of microorganisms to survive antimicrobial drugs, is a public health emergency. Although electronic prescribing (ePrescribing)-based interventions designed to reduce unnecessary antimicrobial usage exist, these often do not integrate effectively with existing workflows. As a result, ePrescribing-based interventions may have limited impact in addressing antimicrobial resistance. We sought to understand the existing ePrescribing-based antimicrobial stewardship (AMS) practices in an English hospital preceding the implementation of functionality designed to improve AMS. We conducted 18 semistructured interviews with medical prescribers and pharmacists with varying levels of seniority exploring current AMS practices and investigating potential areas for improvement. Participants were recruited with the help of local gatekeepers. Topic guides sought to explore both formal and informal practices surrounding AMS, and challenges and opportunities for ePrescribing-based intervention. We coded audio-recorded and transcribed data with the help of the Technology, People, Organizations, and Macroenvironmental factors framework, allowing emerging themes to be added inductively. We used NVivo 12 (QSR International) to facilitate coding. Antimicrobial prescribing and review processes were characterized by competing priorities and uncertainty of prescribers and reviewers around prescribing decisions. For example, medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and the rationale for prescribing decisions was not always clear. Prescribing involved a complex set of activities carried out by various health care practitioners who each only had a partial and temporary view of the whole process, and whose relationships were characterized by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, newly qualified doctors and pharmacists were hesitant to change a consultant's prescribing decision when reviewing prescriptions. Multidisciplinary communication, collaboration, and coordination promoted good AMS practices by reducing uncertainty. Design of ePrescribing-based interventions to improve AMS needs to take into account the multitude of actors and organizational complexities involved in the prescribing and review processes. Interventions that help reduce prescriber or reviewer uncertainty and improve multidisciplinary collaboration surrounding initial antimicrobial prescribing and subsequent prescription review are most likely to be effective. Without such attention, interventions are unlikely to fulfill their goal of improving patient outcomes and combatting antimicrobial resistance.

Neonatal mortality in NHS maternity units by timing and mode of birth: a retrospective linked cohort study

ObjectivesTo compare neonatal mortality in English hospitals by time of day and day of the week according to care pathway.DesignRetrospective cohort linking birth registration, birth notification and hospital episode data.SettingNational...

The Russo-Turkish War in Crimea and Nightingale's Role in It (1854-1855)

In October 1853, the Ottoman Empire declared war on Russia, after a series of disputes over the holy places in Jerusalem and Russian claims to protect the Orthodox subjects of the Ottoman Empire. The British and French, allies of the Ottoman Empire, sought to check Russian expansion. The majority of the Crimean War took place in Crimea, Russia. However, the British troop base and hospitals for the care of sick and wounded soldiers were established primarily at Scutari (Uskudar), across the Bosphorus from Constantinople (Istanbul). As the war broke out, reports returned to Britain about the terrible conditions for the sick and wounded British soldiers. Popular on the mistreatment of wounded British soldiers, a friend of Florence Nightingale, the Secretary of War, Sidney Herbert, wrote to Florence and asked her to lead a group of nurses to attend the headquarters of the British forces. So Florence Nightingale volunteered to go to Turkey then known as Scutari, accompanied by thirty-eight women, including eighteen Catholic, Anglican and Roman sisters, to war.

Benchmarking short-term postoperative mortality across neurosurgery units: is hospital administrative data good enough for risk-adjustment?

BackgroundSurgical mortality indicators should be risk-adjusted when evaluating the performance of organisations. This study evaluated the performance of risk-adjustment models that used English hospital administrative data for 30-day mortality after neurosurgery.MethodsThis retrospective cohort study used Hospital Episode Statistics (HES) data from 1 April 2013 to 31 March 2018. Organisational-level 30-day mortality was calculated for selected subspecialties (neuro-oncology, neurovascular and trauma neurosurgery) and the overall cohort. Risk adjustment models were developed using multivariable logistic regression and incorporated various patient variables: age, sex, admission method, social deprivation, comorbidity and frailty indices. Performance was assessed in terms of discrimination and calibration.ResultsThe cohort included 49,044 patients. Overall, 30-day mortality rate was 4.9%, with unadjusted organisational rates ranging from 3.2 to 9.3%. The variables in the best performing models varied for the subspecialties; for trauma neurosurgery, a model that included deprivation and frailty had the best calibration, while for neuro-oncology a model with these variables plus comorbidity performed best. For neurovascular surgery, a simple model of age, sex and admission method performed best. Levels of discrimination varied for the subspecialties (range: 0.583 for trauma and 0.740 for neurovascular). The models were generally well calibrated. Application of the models to the organisation figures produced an average (median) absolute change in mortality of 0.33% (interquartile range (IQR) 0.15–0.72) for the overall cohort model. Median changes for the subspecialty models were 0.29% (neuro-oncology, IQR 0.15–0.42), 0.40% (neurovascular, IQR 0.24–0.78) and 0.49% (trauma neurosurgery, IQR 0.23–1.68).ConclusionsReasonable risk-adjustment models for 30-day mortality after neurosurgery procedures were possible using variables from HES, although the models for trauma neurosurgery performed less well. Including a measure of frailty often improved model performance.

Do co-morbidities, frailty and functional status identify patients who may not benefit from ICD therapy?

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific ISR lite. Background In carefully selected patients, Implantable Cardioverter Defibrillators reduce all-cause mortality by reducing the burden of sudden cardiac death. Most patients who have an ICD implant do not receive life-prolonging therapy from it. Little research has been undertaken to determine which patients benefit the least from ICD therapy. As patients age and accumulate comorbidities, the risk of death increases and the benefit of ICDs diminishes. Purpose We sought to evaluate the impact of comorbidity, frailty, functional status on death prior to ICD therapy as this group has the least to gain from ICD therapy. Methods A prospective, multicentre, observational study involving 15 English hospitals was undertaken. Patients were eligible for inclusion for the study if they were scheduled to have a de novo, replacement or an upgrade to a high-energy device (transvenous or subcutaneous ICD or CRT-D). Baseline characteristics were collected including age, gender, device type, LV function, medication, baseline bloods if available and were asked to complete a frailty assessment, Fried score; a functional status questionnaire (EQ5D5L), Charlson Co-morbidity Score and EQ5D5L data were calculated. Results In total, 662 patients were enrolled, mean age 65.6 (IQR 65-75) years, 77.3% male, 55.9% de novo implants, 33.4% replacements and 10.5% upgrade. Overall, 32% were for a secondary prevention indication, 49.% had a single or dual chamber transvenous ICD, 45.3% had a CRT-D and 5% had an S-ICD) implanted. A total of 63 patients (9.5%) died across this period, of these, 54 died without receiving appropriate therapy. Frailty was present in 83/662 (12.5%) and severe co-morbidity was present in 69/662 (10.4%). The overall survival probability estimated to be 90.2% at 2.5 years, and was 68% in frail patients. Figure 1. Multivariate predictors of death with no appropriate therapy were identified and a risk score comprising frailty, severe co-morbidity, age &amp;gt;70 years, eGFR &amp;lt;60 ml/min/1.73 m2 EQ5D5L &amp;lt;0.6 was developed. Table 1. The model performance was: sensitivity= 80.7%; specificity = 81.6%; precision 27.3%; accuracy 81.6% and AUC 0.81. Conclusion Frailty and severe co-morbidity are powerful, independent predictors of death with no appropriate in ICD/CRT-D recipients.

The Elites‐Mutual‐Attraction Effect: How Relative Reputation Influences Employee Flows between Organizations

AbstractIn this study, we draw on signalling theory to examine the organization‐level relationship between reputation and employee movement in and out of organizations. Focusing on organizations’ media reputations relative to their peers, we map all employee flows between organizational dyads in a population of English hospitals. We find support for our main argument that an organization's relative reputation predicts employee mobility above and beyond what can be explained by its absolute level of reputation. In particular, our findings suggest that the number of employees moving between two organizations is highest when both organizations have a high reputation. We refer to this as the elites’ mutual attraction effect (EMA‐effect). We also find that the motives of voluntary leavers and geographical distance between two organizations influence the strength of this EMA‐effect. Overall, this study shows that developing and testing dyadic theory can extend research on organizational reputation and collective turnover in meaningful ways.

Spillover effects of financial incentives for providers onto non-targeted patients: daycase surgery in English hospitals.

Incentives for healthcare providers may also affect non-targeted patients. These spillover effects have important implications for the full impact and evaluation of incentive schemes. However, there are few studies on the extent of such spillovers in health care. We investigated whether incentives to perform surgical procedures as daycases affected whether other elective procedures in the same specialties were also treated as daycases. 8,505,754 patients treated for 92 non-targeted procedures in 127 hospital trusts in England between April and March 2016. Interrupted time series analysis of the probability of being treated as a daycase for non-targeted patients treated in six specialties where targeted patients were also treated and three specialties where they were not. The daycase rate initially increased (1.04 percentage points, SE: 0.30) for patients undergoing a non-targeted procedure in incentivised specialties but then reduced over time. Conversely, the daycase rate gradually decreased over time for patients treated in a non-incentivised specialty. Spillovers from financial incentives have variable effects over different activities and over time. Policymakers and researchers should consider the possibility of spillovers in the design and evaluation of incentive schemes.

Exploring the Complex Associations Between Prenatal and Early-Life Infections and Obsessive-Compulsive and Tic-Related Disorders

An association between rheumatic fever and chorea was first posited at the beginning of the 19th century, but it was not until the mid–19th century that these observations crystalized into a widely accepted understanding that rheumatism caused Sydenham chorea ( 1 Martino D. Tanner A. Defazio G. Church A.J. Bhatia K.P. Giovannoni G. Dale R.C. Tracing Sydenham’s chorea: Historical documents from a British paediatric hospital. Arch Dis Child. 2005; 90: 507-511 Crossref PubMed Scopus (13) Google Scholar ). Advances in diagnostic methods, including the use of the stethoscope to detect cardiac manifestations of rheumatic fever, partially explain this discovery. However, perhaps an even more significant factor was the gradual shift during this period in the locus of medical care from the home to specialized centers, such as children’s hospitals, which led to case-based registries ( 1 Martino D. Tanner A. Defazio G. Church A.J. Bhatia K.P. Giovannoni G. Dale R.C. Tracing Sydenham’s chorea: Historical documents from a British paediatric hospital. Arch Dis Child. 2005; 90: 507-511 Crossref PubMed Scopus (13) Google Scholar ). It was from examination of these registries that British researchers were initially able to show a temporal relationship between seasonal spikes in rheumatic fever and chorea in children. SEE CORRESPONDING ARTICLE ON PAGE 1023 SEE CORRESPONDING ARTICLE ON PAGE 1023 Prenatal and Early Childhood Infections and Subsequent Risk of Obsessive-Compulsive Disorder and Tic Disorders: A Nationwide, Sibling-Controlled StudyBiological PsychiatryVol. 93Issue 11PreviewPostinfectious autoimmune processes are hypothesized to be causally related to both obsessive-compulsive disorder (OCD) and tic disorders, but current evidence is conflicting. This study examined whether prenatal maternal (and paternal, as an internal control) infections and early childhood infections in the offspring (i.e., during the first 3 years of life) were associated with a subsequent risk of OCD and Tourette syndrome or chronic tic disorder (TS/CTD). Full-Text PDF Open Access