Health Episode Statistics Research Articles

Uterine-preserving treatments or hysterectomy reintervention after myomectomy or uterine artery embolisation: A retrospective cohort study of long-term outcomes.

To assess comparative rates of further uterine-preserving procedures (UPP) or hysterectomy reintervention, after myomectomy or uterine artery embolisation (UAE). Population-based, retrospective cohort study. England. Women who underwent myomectomy or UAE between 2010 and 2015 under the NHS. Data was abstracted from NHS Health Episode Statistics datasets. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox proportional-hazards regression. 30-day readmission, UPP and hysterectomy reintervention rates. 9443 and 6224 women underwent elective myomectomy or UAE, respectively. After 118 136 total person-years of follow-up, the rate of hysterectomy was 8.34 and 20.98 per 1000 patient years for myomectomy or UAE, respectively. There was a 2.4-fold increased risk of undergoing hysterectomy after UAE when compared with myomectomy in adjusted models (HR 2.38 [95% CI 2.10-2.66]) [adjusted for age, ethnicity, multiple deprivation index, geographical region and comorbidities]. The HR for undergoing a UPP reintervention was 1.44 (95% CI 1.29-1.60) in favour of myomectomy. The rate of hysterectomy was increased 22% following UAE compared with laparoscopic myomectomy (0.97-1.52). Age may influence reintervention rates, and there was variation in hysterectomy risk when stratified by geographical region. After a median of 7 years of follow-up, there is a 2.4-fold increased rate of hysterectomy and 44% increased risk of UPPs as reintervention after UAE, relative to myomectomy. These findings will aid pre-procedure counselling for women with fibroids. Future work should investigate the effect of other outcome modifiers, such as fertility intentions and fibroid anatomical characteristics.

Cardiovascular risk in patients with small abdominal aortic aneurysms

BackgroundAbdominal aortic aneurysm (AAA) is a cardiovascular health problem. Ultrasound screening has been shown to reduce the risk of AAA-related, but not all-cause, mortality. The recent introduction of screening in several countries has meant that thousands of patients with a small AAA (<5·5cm) that does not require immediate treatment are diagnosed annually. We sought to investigate the cardiovascular profiles of patients with ectatic aortas and assess whether participation in screening reduces cardiovascular risk. MethodsWe used three sets of data: from the National Health Service AAA Screening Programme (NAAASP) during the 2013–14 round that were linked with Health Episode Statistics (HES) (235 409 individuals); a subset of the Framingham Study population who had an abdominal CT scan in 2004–05 and were followed up for 10 years (1383 individuals); and data for patients with a small AAA who had been in surveillance for at least 1 year in the UK Aneurysm Growth Study (UKAGS) (384 individuals) or from a national UK audit (1538 individuals), to assess cardiovascular risk and events. FindingsIn the linked NAAASP–HES cohort, cardiovascular mortality was 0·30% (95% CI 0·28–0·32) for individuals with an abdominal aortic diameter of less than 2·5 cm; 0·81% (0·51–1·11) for those between 2·5 and 2·9 cm; and 1·30% (0·90–1·71) for those less than 3·0 cm. Death from a cardiovascular event was more likely for individuals with a small AAA than for those without AAA (risk ratio 4·33, 95% CI 3·15–5·97). In the Framingham cohort, abdominal aortic diameter was independently associated with cardiovascular events (hazard ratio [HR] 1·1, 95% CI 1·02–1·18; p<0·0001). An abdominal aortic diameter of more than 2·5 cm was also associated with cardiovascular events (HR 7·6, 95% CI 5·1–11·3; p<0·0001). In the UKAGS and audit populations, patients were not more likely to take antiplatelet agents or statins after entering screening surveillance; cholesterol concentrations and blood pressure also increased. InterpretationIn these contemporary large cohorts of patients with small AAA, cardiovascular events and death were common and were the leading cause of death. The implication is that patients are not more likely to receive cardiovascular protection if they enter screening or surveillance with existing protocols. Cardiovascular risk reduction interventions should be implemented in screening programmes in the future. FundingAcademy of Medical Sciences, National Institute for Health Research (NIHR) Leicester Cardiovascular Biomedical Research Unit, NIHR.

The ageing population is neglected in research studies of traumatic brain injury

Introduction The UK population is ageing with increasing number of elderly patients suffering traumatic brain injury (TBI). The purpose of this study was to identify national TBI admission demographics, analyse the temporal evolution of TBI mortality in a single centre and conduct a systematic review of the literature to identify whether there is an age bias amongst researchers studying TBI. Methods National demographics for TBI were obtained from Health Episode Statistics. TBI patients admitted from 2000 to 2011 to Cambridge University Hospitals Neurocritical Care Unit (NCCU) were divided into age groups (<60, 60–74, ≥75 years). Temporal evolution of mortality was analysed using a logistic regression method. A systematic literature review was conducted to identify primary TBI research studies. Patient’s ages were extracted and an average mean age was calculated and compared over time. Results From 1998, national TBI admissions have increased with the greatest rise in >60-year age group (p < 0.0001). In a tertiary referral critical care unit (n = 1145), the 60–74 year age group (compared to <60) had a significantly lower improvement in mortality over time (OR: 1.15, 95% CI: 1.02–1.31). A literature review revealed a mean age of 32.73 years (SD ± 12.85) for patients recruited to primary TBI studies. Conclusion Despite increased admissions of elderly patients following TBI and static mortality (single centre, 60–74 year age group) there is little or no evidence of a corresponding increase in the age of patients recruited for TBI studies. In addition to the difficulties this presents in forming evidence-based decisions for the patient with TBI, it may also represent a wider problem for ICU research in an ever-ageing critical care population. More research needs to be conducted to establish the treatment end points for an ageing population.

025 * NATIONAL ADMINISTRATIVE DATA PRODUCES A VERY ACCURATE RISK PREDICTION MODEL FOR SHORT- AND LONG-TERM MORTALITY FOLLOWING CARDIAC SURGERY

Objectives: Various models exist to predict short-term risk-adjusted outcomes after cardiac surgery. Many models are calibrated using administrative data and are subject to controversy. This study compares predictive performance for short- and long-term mortality of a procedure-specific risk prediction model based on administrative NHS Health Episode Statistics (HES) data for England against the re-calibrated logistic EuroSCORE. Methods: Procedure-specific models were built on administrative data and tested using an independent dataset sampled at a later period. Models are applicable to patients having isolated CABG, isolated valve or combined CABG and valve surgery. Outcomes at hospital discharge and 1 year are linked with national death registrations (ONS). Comparisons between the models are conducted on a local cohort of patients between 2010 and 2013 using C-statistic for performance and Hosmer-Lemeshow for calibration across different risk strata. Results: A total of 84,791 patients in England and 1174 locally were identified. HES models have higher or comparable predictive performance compared to the re-calibrated logistic EuroSCORE (Table 1). Model calibration assessed via Hosmer-Lemeshow procedure also demonstrates good performance. C-statistics test for risk prediction models C-statistics test for risk prediction models Conclusion: The national administrative dataset has produced very accurate short- and long-term mortality prediction after cardiac surgery. Future iterations should explore further statistical methods and focus on developing procedure-specific algorithms.

PTU-127 Resource Use Associated With Hepatic Encephalopathy In Patients With Severe Liver Disease

IntroductionOvert hepatic encephalopathy (HE) is associated with frequent hospitalisations which are expensive to manage and result in poor quality of life. The aim was to estimate the resource use associated...

Injuries, envenomations and stings from exotic pets

A variety of exotic vertebrate and invertebrate species are kept as 'pets' including fishes, amphibians (for example, frogs and toads), reptiles (turtles, crocodiles, lizards and snakes), birds, mammals (for example, primates, civets, and lions), and invertebrates (for example spiders, scorpions, and centipedes), and ownership of some of these animals is rising. Data for 2009-2011 suggest that the number of homes with reptiles rose by approximately 12.5%. Recent surveys, including only some of these animals, indicated that they might be present in around 18.6% of homes (equal to approximately 42 million animals of which around 40 million are indoor or outdoor fish). Many exotic 'pets' are capable of causing injury or poisoning to their keepers and some contacts prove fatal. We examined NHS Health Episode Statistics for England using selected formal categories for hospital admissions and bed days for 2004-2010 using the following categories of injury, envenomation or sting; bitten or struck by crocodile or alligator; bitten or crushed by other reptiles: contact with venomous snakes and lizards; contact with scorpions. Between 2004 and 2010 these data conservatively show a total of 760 full consultation episodes, 709 admissions and 2,121 hospital bed days were associated with injuries probably from exotic pets. Injuries, envenomations and stings from exotic pets constitute a small but important component of emerging medical problems. Greater awareness of relevant injuries and medical sequelae from exotic pet keeping may help medics formulate their clinical assessment and advice to patients.

Trends in the surgical options for the treatment of menorrhagia in Scotland: examination of health episode statistics, 2000–2008

Menorrhagia is a common and important problem that has a significant impact on women's health. Menorrhagia is treated by surgical methods if primary medical methods fail. Surgical methods have changed over time and the traditional method of hysterectomy has been replaced by minimally invasive techniques. An examination of practice in Scotland suggests that minimally invasive techniques are now the most common surgical method of treating menorrhagia. Abdominal hysterectomies are still performed commonly, but the trend is towards a reduction in procedures performed annually. The changing technique of managing menorrhagia has an impact on the training of future gynaecologists.

Have two UK national guidelines had any effect on grommets day-case utilisation and rate over the last 10 years?

Grommets insertion is a common otolaryngological procedure for the treatment of persistent otitis media with effusion. In 2002, the Department of Health (DoH) Day Surgery guidelines stipulated that at least 75% of grommets insertions should be undertaken as day-cases. In 2008, after governmental perception of a higher than necessary grommet insertion rate, the National Institute for Health and Clinical Excellence (NICE) guidelines aimed at reducing inappropriate grommet insertions. This study analyses the effect these national interventions have had on grommets insertion in England and Wales. A retrospective study was undertaken. Data were extracted from the patient episode databases of England (Health Episode Statistics) and Wales (Patient Episode Database of Wales) from 2000 until 2010 using OPCS-4 code D151. Statistical change in practice following the introduction of the interventions was assessed using linear regression. 341,526 and 16,400 grommets insertions were performed in England and Wales, respectively. Linear regression analysis demonstrated that implementation of the Day Surgery guidelines significantly improved day-case rates in both national cohorts (England P < 0.0001, Wales P < 0.0001) and reduced mean waiting times for grommets insertion in both cohorts (England P < 0.05, Wales P < 0.01). Regression analysis also showed that implementation of the NICE guidelines had no effect on the number of grommet insertions in England (P > 0.5) and Wales (P > 0.5). In conclusion, the DoH guidelines have increased grommets day-case provision and reduced waiting times in both England and Wales, whereas the NICE guidelines have not affected overall levels of grommet insertion in either national cohort.

A retrospective audit of weight loss in bariatric surgery patients

Background: Bariatric surgery results in significant weight loss and a reduction in co-morbidities in morbidly obese patients (Colquitt et al., 2009). The number of patients undergoing bariatric surgery nationally has increased significantly since 2002 (Ells et al., 2007). The aim of this audit was to evaluate an emerging bariatric service by comparing the weight loss achieved by local bariatric patients with published literature. Methods: Case notes of 28 patients who underwent bariatric surgery in a University Hospital Trust were reviewed. Patients had undergone either Laparoscopic adjustable gastric banding (LAGB) (n = 7) or a laparoscopic Roux en Y gastric bypass (LRYGB) (n = 21). The initial weight (kg) on admission for surgery, and weight loss (kg) of patients at 6 months (n = 28) and at 1 year (n = 24) post-surgery were recorded. The mean weight loss and total percentage weight loss at 6 months and 1 year post-surgery were calculated and analysis of variance used to compare the groups at 6 and 12 months. Results: Patients undergoing LTYGB lost significantly more weight at 6 (P < 0.005) and 12 months P < (0.005) than the LAGB. The differential between the two groups increased over the next 6 months as shown in Table 1. Discussion: This audit showed a trend towards higher weight loss in patients who underwent LRYGB versus LAGB; a trend that has also been reported by larger published studies (Maggard et al., 2005; Strostrom et al., 2004). Maximum weight loss post-bariatric surgery occurs at 1–2 years (Colquitt et al., 2009; Strostrom et al., 2004). Because this was an audit of an emerging bariatric service, weight loss data at 1 year post-surgery were available for only 24 patients. The average weight loss and percentage weight loss of patients post-LRYGB was higher than the weight loss of 37 kg reported in a meta-analysis of controlled studies on weight loss in bariatric surgery (Maggard et al., 2005). However, in this audit of patients post-LAGB, the average total and percentage weight loss and average percentage weight loss was below the 24.2 kg reported by Maggard et al. (2005) and 21% by Strostrom et al. (2004). Before changes are made to clinical practice, this audit should be repeated to reflect increasing patient numbers over time. Future audits could address further outcome measures to facilitate a wider evaluation of the bariatric service. Conclusions: In this audit, weight loss post-LRYGB is greater, and weight loss post-LAGB is less than published data. Larger numbers are required before altering clinical practice.

Obesity Surgery in England: An Examination of the Health Episode Statistics 1996–2005

The authors examined the uptake of obesity surgery across England. Data were analyzed from the Hospital Episode Statistics covering all 9 goverment office regions with a total population of 49.1 million. The data analyzed covered 9 years 1996/97 - 2004/05. 1,465 records were identified with a primary diagnostic code for obesity and an operation code for obesity surgery. The surgery was performed mostly in women (male to female ratio of 1:5), who were predominantly mid-aged (average 40.4 years +/- SD 9.00), the majority of whom reside in local authority districts ranked within the lowest two deprivation quintiles. The availability of obesity surgery varied considerably across the 9 different regions of England, although the number of operations increased nationally over time. Access to this intervention is highly variable and does not appear to reflect estimated regional differences in morbid obesity. This specialist service may benefit from more effective national organization, to ensure appropriate capacity and eliminate inequalities in service delivery.

Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3

Twenty years ago 60% of patients with menorrhagia who were referred to a gynaecologist had a hysterectomy as treatment.1 Endometrial ablation was firstdescribed in the United Kingdom in 1989 and...

If the NHS introduced a '50 procedures a year' policy, what proportion of consultant firms would be affected?

Governments, insurers, quality assurance agencies and others have used the higher volume = better quality relationship as a basis for health policy. This relationship is probably real enough to justify these policies. However, even if it were not real, there are other reasons why these and other organizations such as the National Health Service (NHS) may favour high-volume providers. This paper attempts to answer the question: 'If, for common elective procedures, the NHS instituted a high-volume purchasing policy that requires consultant firms to perform a minimum of "50 procedures a year", what proportion of consultant firms would be affected?' The aims of this study were to estimate the proportion of NHS consultant firms that perform common elective procedures less than 50 times a year and to estimate the proportion of firms that would have to stop providing these procedures if a '50 procedures a year' purchasing policy were introduced. A descriptive analysis was carried out and modelling was performed on data stored in an NHS health episode statistics database of patients treated in West Midlands NHS facilities. For each of 12 common elective procedures we assumed that a volume threshold of at least 50 a year were set, and calculated the proportion of NHS consultant firms undertaking each procedure who performed less than 50 of those procedures each year and the proportion of firms who would have had to stop providing each procedure. All firms performing some procedures, e.g. cataract extraction, did so at least 50 times a year. By contrast, no firm repaired more than 50 recurrent inguinal hernias a year. If a volume threshold of at least 50 procedures a year were set for a basket of 12 common elective procedures, then about 40 per cent of firms would no longer be eligible to provide a procedure. Even if a lower 'one a month' threshold were set, about 20 per cent of firms would still not be eligible to provide that procedure. Introduction of a high-volume policy would affect a considerable number of firms, as many NHS consultant firms perform some common elective procedures infrequently. Some consultants would see the introduction of a high-volume policy as an opportunity to further specialize and super-specialize. Others would see it as a policy that restricts them to providing a narrower range of procedures, makes their professional practice less interesting, and reduces their professional autonomy. Postgraduate training institutions need to consider the possibility and implications of high-volume policies, as many junior doctors would probably need to learn to provide a narrower range of skills than at present.

Has Calman-Hine succeeded? Analysis of breast cancer procedure loads per consultant firm before and after the Calman-Hine report

The Calman-Hine report was published in the UK in April 1995. It recommended the reorganization of cancer services into high-volume specialist units. This study analyzes Health Episode Statistics from the West Midlands Region of the UK NHS in order to establish whether – for breast cancer – specialization is occurring. We believe it is. Each year since the start of our analysis (1992) the proportion of procedures performed by ‘high-volume’ firms increased. The number of firms undertaking breast cancer procedures fell.