Hospital Episode Statistics Data Research Articles

Genetic Validation of Psoriasis Phenotyping in UK Biobank Supports the Utility of Self-Reported Data and Composite Definitions for Large Genetic and Epidemiological Studies

Genetic Validation of Psoriasis Phenotyping in UK Biobank Supports the Utility of Self-Reported Data and Composite Definitions for Large Genetic and Epidemiological Studies

European Cancer Summit 2022 submission for Special Network: Impact of the Covid-19 Pandemic on CancerImpact of the COVID-19 Pandemic on Cancer Surgery and Cancer Mortality in England

BackgroundDuring the pandemic there has been an impact on the number of patients entering the cancer pathway, because of changes in patients presenting and GP referral behaviours. The aim was to understand whether different groups in our society have been disproportionately affected by the pandemic in terms of the care they have received for their cancer. MethodsThe study looked specifically at elective admissions from the Hospital Episode Statistics data for all cancers combined and separately for breast, bowel, lung, and prostate cancers to investigate the number of patients admitted for cancer surgery over time. The ONS Mortality Dataset was used to investigate the place of death for patients who had died from cancer.Mortality rates were calculated to identify whether there was a rise in in-hospital mortality during the pandemic. Deaths were defined as an in-hospital death for a patient admitted with a primary diagnosis of cancer. Age-standardised mortality rates were created across the last five years, broken down by cancer type, sex and deprivation quintile. ResultsThe analysis shows a decrease in patients undergoing surgery at the start of the pandemic for all demographic groups. At the start of the pandemic, the largest decreases for all cancers combined by ethnicity could be seen in White (42.6%) and Asian or Asian British (44.6%). While by age, the largest decrease was seen in women aged 40-49.For lung cancer surgery, there were differences by deprivation quintile during the recovery period, showing a 42.0% increase in the least deprived compared to a 27.6% increase in the most deprived. However, changes at the beginning of the pandemic were similar across all quintiles.Age standardised mortality rates showed an increase in in-hospital deaths following the start of the pandemic. ConclusionsWhile we know that there are inequalities in access to cancer surgery, particularly by age, for the most part, the results of our analysis indicate that the recovery period of the COVID-19 pandemic has not exacerbated these inequalities. However, it is difficult to understand the extent to which any variation in access to cancer services is unwarranted.

Assessing national patterns and outcomes of pituitary surgery: is hospital administrative data good enough?

Purpose Patterns of surgical care, outcomes, and quality of care can be assessed using hospital administrative databases but this requires accurate and complete data. The aim of this study was to explore whether the quality of hospital administrative data was sufficient to assess pituitary surgery practice in England. Methods The study analysed Hospital Episode Statistics (HES) data from April 2013 to March 2018 on all adult patients undergoing pituitary surgery in England. A series of data quality indicators examined the attribution of cases to consultants, the coding of sellar and parasellar lesions, associated endocrine and visual disorders, and surgical procedures. Differences in data quality over time and between neurosurgical units were examined. Results A total of 5613 records describing pituitary procedures were identified. Overall, 97.3% had a diagnostic code for the tumour or lesion treated, with 29.7% (n = 1669) and 17.8% (n = 1000) describing endocrine and visual disorders, respectively. There was a significant reduction from the first to the fifth year in records that only contained a pituitary tumour code (63.7%–47.0%, p < .001). The use of procedure codes that attracted the highest tariff increased over time (66.4%–82.4%, p < .001). Patterns of coding varied widely between the 24 neurosurgical units. Conclusion The quality of HES data on pituitary surgery has improved over time but there is wide variation in the quality of data between neurosurgical units. Research studies and quality improvement programmes using these data need to check it is of sufficient quality to not invalidate their results.

Association between outpatient follow-up and incidence of revision after knee and hip replacements: a population-based cohort study

BackgroundFollow-up visits 5 or 7 years after surgery were recommended for people having primary hip or knee replacement. The benefits of this practice to patients and the healthcare system, however, have not yet been specifically examined. The aim of this study was to investigate the association between long-term follow-up outpatient hospital visits and revision rates for patients who undergo primary knee or hip replacement surgery.MethodsCohorts were identified for patients undergoing knee or hip replacement surgery using medical records from primary care practices within the UK Clinical Practice Research Datalink (CPRD) GOLD dataset linked to hospital records from the English Hospital Episodes Statistics (HES) data. Two groups of patients were compared in terms of revision and mortality rates: those with at least one long-term (between five and 10 years since primary surgery) follow-up visit at the orthopaedic department (‘Follow-up’ group), and those without (‘No follow-up’ group).ResultsA total of 9856 (4349 in the Follow-up group) patients with knee replacement and 10,837 (4870 in the Follow-up group) with hip replacement were included in the analysis. For knee replacement, the incidence of revision was 3.6% for those followed-up and 0.6% for those not followed-up. An adjusted regression model confirmed the difference in the hazard ratio (HR) for revision was statistically significant (HR: 5.65 [95% CI 3.62 to 8.81]). Mortality at 4 years was lower for the Follow-up (17%) compared to the No follow-up group (21%), but this difference was not statistically significant (HR: 0.95 [0.84 to 1.07]). For hip replacement, the incidence of revision rates were 3.2 and 1.4% for the follow-up and not follow-up groups, respectively, the difference being statistically significant (HR: 2.34 [1.71 to 3.20]). Mortality was lower for the Follow-up (15%) compared to the No follow-up group (21%), but the difference was not statistically significant (HR: 0.91 [0.81 to 1.02]).ConclusionPatients attending follow-up orthopaedic consultations show a higher risk of revision surgery compared to those who are not followed-up. A cause for this difference could not be identified in this study but a likely explanation is that surgeons play an effective role as ultimate arbitrators when identifying patients to be included in long-term follow-up lists.

ERCP for bile duct stones across a national service, demonstrating a high requirement for repeat procedures.

Background and study aims Bile duct stones (BDS) represent approximately 50 % of the requirement for endoscopic retrograde cholangiopancreatography (ERCP) within most services. Significant variation in outcome rates for BDS clearance at ERCP has been reported, and endoscopy societies have set standards for expected clearance rates. The aim of this study was to analyze procedure outcomes across a national service. Patients and methods Using verified hospital episode statistics (HES) data for the National Health Service (NHS) in England, we analyzed all patients having first ERCPs for BDS from 2015 to 2017, and followed these patients for at least 2 years. Results In total 37,468 patients underwent a first ERCP for BDS, with 69.8 % undergoing only one procedure. This figure of less than 70 % of BDS cleared at first ERCP is below the Key Performance Indicators as set by the British Society of Gastroenterology (> 75 %) and the European Society of Gastrointestinal Endoscopy (> 90 %). Of 55,556 ERCPs done for BDS, 52.9 % were repeat procedures, with 11,322 patients needing multiple procedures. For hospitals performing significant numbers of ERCPs (more than 600 for BDS during the study period) patients undergoing repeat ERCPs for BDS ranged from 9 % to 50 %. Conclusions In this nationwide study, the performance at clearing BDS at first ERCP was suboptimal, with high numbers of repeat procedures required. This may have a negative impact on both patient outcomes and experience, and increase pressure on endoscopy services. Apparent variation of outcome between acute hospital care providers requires further analysis.

Increasing incidence of spondylodiscitis in England: An analysis of the national health service (NHS) hospital episode statistics from 2012 to 2021

BackgroundSpondylodiscitis is a potentially life-threatening infection of the intervertebral disk and adjacent vertebral bodies, with a mortality rate of 2–20%. Given the aging population, the increase in immunosuppression, and intravenous drug use in England, the incidence of spondylodiscitis is postulated to be increasing; however, the exact epidemiological trend in England remains unknown. ObjectiveThe Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise the annual activity and longitudinal change of spondylodiscitis in England. MethodsThe HES database was interrogated for all cases of spondylodiscitis between 2012 and 2019. Data for the length of stay, waiting time, age-stratified admissions, and ‘Finished Consultant Episodes’ (FCEs), which correspond to a patient's hospital care under a lead clinician, were analysed. ResultsIn total, 43135 FCEs for spondylodiscitis were identified between 2012 and 2022, of which 97.1% were adults. Overall admissions for spondylodiscitis have risen from 3 per 100,000 population in 2012/13 to 4.4 per 100,000 population in 2020/21. Similarly, FCEs have increased from 5.8 to 10.3 per 100,000 population, in 2012–2013 and 2020/21 respectively. The highest increase in admissions from 2012 to 2021 was recorded for those aged 70–74 (117% increase) and aged 75-59 (133% increase), among those of working age for those aged 60–64 years (91% increase). ConclusionPopulation-adjusted admissions for spondylodiscitis in England have risen by 44% between 2012 and 2021. Healthcare policymakers and providers must acknowledge the increasing burden of spondylodiscitis and make spondylodiscitis a research priority.

Cardiovascular outcomes and mortality after incident ischaemic stroke in patients with a recent cancer history

Background: Up to 10% of patients with ischaemic stroke have comorbid cancer and stroke in these patients is thought to have a poor short-term prognosis. There is little known about the long-term cardiovascular morbidity and mortality outcomes after incident ischaemic stroke in patients with recent cancer history.Objective: To assess the risk of subsequent cardiovascular morbidity and mortality outcomes in patients with an incident ischaemic stroke and recent cancer history.Methods: Patients aged ≥18 years with an incident ischaemic stroke between 1998 and 2017, with any diagnosis of cancer within 12 months before the stroke event, and no prior history of serious vascular event were identified from UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics (HES) data. To minimize selection bias, these patients were propensity-score matched with patients with incident ischaemic stroke and no history of cancer. Propensity-score matching was done using covariates such as demographic data, vascular risk factors, comorbid conditions, and prescribed medication. Multivariable models (Competing risks and Cox regression) were used to determine the risk of subsequent major adverse cardiovascular event (MACE) outcomes and all-cause mortality.Results: Our cohort included 22,460 patients with a median age of 75 (IQR 64–83) years and a follow-up of 12.3 (IQR 7.2–16.7) years. Recent cancer was identified in 1,149 patients (5.1%) at the time of incident ischaemic stroke. The patients with recent cancer history had a lower risk of composite MACE (sub-distribution hazard ratio (SHR) 0.83 [95% CI: 0.75–0.92]) and recurrent stroke (SHR 0.85 95% CI:0.75–0.96]) and a higher risk of all-cause mortality (hazard ratio 1.67 [95% CI:1.47–1.91]). The risk of coronary heart disease, peripheral vascular disease, heart failure, and CVD-related death outcomes did not differ significantly between the groups.Conclusions: After incident ischaemic stroke, patients with recent cancer history have a lower risk of composite MACE and recurrent stroke outcomes but a higher risk of all-cause mortality when compared with patients without a prior history of cancer.

HPB P40 Assessing The Cholecystectomy Pathway: Are Standards Being Truly Met?

Abstract Background Research suggests better outcomes for patients having cholecystectomy &amp;lt;8 days of presenting with symptoms1. Locally collected data from the GI surgery department at Royal Surrey County Hospital (RSCH) reported that 94% of eligible cases with acute biliary pathology underwent cholecystectomy &amp;lt;8 days of presentation. However, Hospital episode statistics (HES) data suggest it's lower. RSCH participates in a national project evaluating the care of patients presenting acutely with biliary pathology (the CholoeQuic-ER study), and the latest outcomes from that study indicate that we are in the top 5 trusts nationally for acute management of gallstone disease, with a median time from admission to surgery of 3 days, resulting in significant improvements in bed occupancy and patient experience The primary aim was to ascertain what proportion of patients; 1) were eligible for an acute cholecystectomy or deemed unfit. 2) were eligible for cholecystectomy but were not referred during the inpatient admission, 3) were coded as having acute biliary pathology but had an alternative primary diagnosis. The secondary aim was to ascertain whether they met the standard of undertaking cholecystectomy &amp;lt;8 days of presentation with gallstone disease and why there was a discrepancy between the departmental data and HES data. Methods The hospital coding department provided a list of patients discharged from RSCH in September 2019 with a coding suggesting acute biliary pathology. ICD-10 codes covering cholelithiasis, cholecystitis, other diseases of the gallbladder and acute pancreatitis were used (the same methodology as the CholeQuic-ER study). Results There were 118 patients who were discharged in September 2019 with ICD-10 codes diagnostic of acute biliary pathology. Of the 118 patients, 48 (40.7%) were correctly coded with biliary pathology and 70 (59.3%) were not. Twenty-eight (58.3%) of those patients who were correctly coded had a surgical/ procedural intervention. Twenty (41.7%) of the correctly coded patients did not have surgical/procedural intervention, 9 (45%) discharged with outpatient surgical/AEC review pertaining to the biliary pathology. Nine (45%) discharged with alternative primary diagnosis, 2 (10%) discharged with a primary biliary pathology and no surgical intervention/follow-up. Of the original 118 patients, 70 (59.3%) patients did not have biliary pathology; 31 (44.2%) had no data specifically for September 2019, for the further 39 (55.7%) patients, there was incorrect coding e.g. Pneumonia Using the ICD codes employed by the CholeQuic-ER study, 66.9% of cases identified were inappropriately classified as primary biliary pathology and were not eligible for cholecystectomy. The final outcomes were 28/48 (58.3%) had underwent appropriate procedure for their primary biliary pathology at index admission. 20/48 (41.7%) did not have definitive treatment at their index admission. Conclusions The results demonstrate a high number of patients with acute biliary pathology who did not undergo definitive treatment at their index admission or within 8 days of presentation. Use of the methodology employed by the CholeQuic-ER study using HES data was inaccurate in correctly identifying patients with acute biliary pathology. Accurate coding of patients requires liaison between coding and clinical teams to help narrow discrepancies between HES data and RSCH data not only in the field of general surgery but in other departments. We plan to work with the coding department to improve the outcome coding to help reflect the excellent outcomes we are achieving for these patients.

Association between antidementia medication use and mortality in people diagnosed with dementia with Lewy bodies in the UK: A retrospective cohort study.

Dementia with Lewy bodies (DLBs) is a common cause of dementia but has higher mortality than Alzheimer's disease (AD). The reasons for this are unclear, but antidementia drugs (including acetylcholinesterase inhibitors [AChEIs] and memantine) symptomatically benefit people with DLB and might improve outcomes. We investigated whether AChEIs and/or memantine were associated with reduced hospital admissions and mortality. We performed a retrospective cohort study of those diagnosed with DLB between 1 January 2005 and 31 December 2019, using data from electronic clinical records of secondary care mental health services in Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), United Kingdom (catchment area population approximately 0.86 million), as well as linked records from national Hospital Episode Statistics (HES) data. Eligible patients were those who started AChEIs or memantine within 3 months of their diagnosis (cases) and those who never used AChEIs or memantine (controls). Outcomes included admission, length of stay, and mortality. Cox proportional hazard and linear regression models were used. Of 592 patients with DLB, 219 never took AChEIs or memantine, 100 took AChEIs only, and 273 took both AChEIs and memantine. The cohorts were followed up for an average of 896 days, 981 days, and 1,004 days, respectively. There were no significant differences in the cohorts' baseline characteristics, except for socioeconomic status that was lower in patients who never took AChEIs or memantine (χ2 = 23.34, P = 0.003). After controlling for confounding by sociodemographic factors (age, sex, marital status, ethnicity, socioeconomic status), antipsychotic use, antidepressant use, cognitive status, physical comorbidity, anticholinergic burden, and global health performance, compared with patients who never took AChEIs or memantine, patients taking AChEIs only or taking both had a significantly lower risk of death (adjusted hazard ratio (HR) = 0.67, 95% CI = 0.48 to 0.93, p = 0.02; adjusted HR = 0.64, 95% CI = 0.50 to 0.83, P = 0.001, respectively). Those taking AChEIs or both AChEIs and memantine had significantly shorter periods of unplanned hospital admission for physical disorders (adjusted coefficient -13.48, 95% CI = [-26.87, -0.09], P = 0.049; adjusted coefficient -14.21, 95% CI = [-24.58, -3.85], P = 0.007, respectively), but no difference in length of stay for planned admissions for physical disorders, or for admissions for mental health disorders. No significant additional associations of memantine on admission, length of stay, and mortality were found (all P > 0.05). The main limitation was that this was a naturalistic study and possible confounds cannot be fully controlled, and there may be selection bias resulting from nonrandom prescription behaviour in clinical practice. However, we mimicked the intention-to-treat design of clinical trials, and the majority of baseline characters were balanced between cohorts. In addition, our series of sensitivity analyses confirmed the consistency of our results. In this study, we observed that use of AChEIs with or without memantine in DLB was associated with shorter duration of hospital admissions and decreased risk of mortality. Although our study was naturalistic, it supports further the use of AChEIs in DLB.

Impact of social deprivation on clinical outcomes of adults hospitalised with community-acquired pneumonia in England: a retrospective cohort study

IntroductionSocioeconomic deprivation has been associated with an increased incidence of infection and poorer clinical outcomes during influenza pandemics and the COVID-19 pandemic. The aim of this study was to determine...

Provision of NICE-recommended varicose vein treatment in the NHS.

Standardization of access to treatment and compliance with clinical guidelines are important to ensure the delivery of high-quality care to people with varicose veins. In the National Health Service (NHS) in England, commissioning of care for people with varicose veins is performed by Clinical Commissioning Groups (CCGs) and clinical guidelines have been developed by the National Institute for Health and Care Excellence (NICE CG168). The Evidence-Based Intervention (EBI) programme was introduced in the NHS with the aim of improving care quality and supporting implementation of NICE CG168. The aim of this study was to assess access to varicose vein treatments in the NHS and the impact of EBI. CCG policies for the delivery of varicose vein treatments in the NHS in England were obtained from 2017 (before EBI introduction) and 2019 (after EBI introduction) and categorized by two independent reviewers into levels of compliance with NICE CG168. Hospital Episode Statistics data were compared with the NICE commissioning model predictions. A quality-adjusted life-year was valued at £20 000 (Euro 23 000 15 November 2022). Despite the introduction of the EBI programme, CCG compliance with NICE CG168 fell from 34.0 per cent (64 of 191) to 29.0 per cent (55 of 191). Some 33.0 per cent of CCG policies (63 of 191) became less compliant and only 7.3 per cent (14 of 191) changed to become fully compliant. Overall, 66.5 per cent of CCGs (127 of 191) provided less than the recommended intervention rate before EBI and this increased to 73.3 per cent (140 of191) after EBI. The overall proportion of patients estimated to require treatment annually who received treatment fell from 44.0 to 37.0 per cent. The associated estimated loss in net health benefit was between £164 and 174 million (Euro 188 million and 199 million 15 November 2022) over 3 years. A compliant policy was associated with a higher intervention rate; however, commissioning policy was associated with only 16.8 per cent of the variation in intervention rate (R2 = 0.168, P < 0.001). Many local varicose vein commissioning policies in the NHS are not compliant with NICE CG168. More than half of patients who should be offered varicose vein treatment are not receiving it, and there is widespread geographical variation. The EBI programme has not been associated with any improvement in commissioning or access to varicose vein treatment.

Treat-to-target urate-lowering therapy and hospitalizations for gout: results from a nationwide cohort study in England.

To investigate associations between treat-to-target urate-lowering therapy (ULT) and hospitalizations for gout. Using linked Clinical Practice Research Datalink and NHS Digital Hospital Episode Statistics data, we described the incidence and timing of hospitalizations for flares in people with index gout diagnoses in England from 2004-2020. Using Cox proportional hazards and propensity models, we investigated associations between ULT initiation, serum urate target attainment, colchicine prophylaxis, and the risk of hospitalizations for gout. Of 292 270 people with incident gout, 7719 (2.64%) had one or more hospitalizations for gout, with an incidence rate of 4.64 hospitalizations per 1000 person-years (95% CI 4.54, 4.73). There was an associated increased risk of hospitalizations within the first 6 months after ULT initiation, when compared with people who did not initiate ULT [adjusted Hazard Ratio (aHR) 4.54; 95% CI 3.70, 5.58; P < 0.001]. Hospitalizations did not differ significantly between people prescribed vs not prescribed colchicine prophylaxis in fully adjusted models. From 12 months after initiation, ULT associated with a reduced risk of hospitalizations (aHR 0.77; 95% CI 0.71, 0.83; P < 0.001). In ULT initiators, attainment of a serum urate <360 micromol/l within 12 months of initiation associated with a reduced risk of hospitalizations (aHR 0.57; 95% CI 0.49, 0.67; P < 0.001) when compared with people initiating ULT but not attaining this target. ULT associates with an increased risk of hospitalizations within the first 6 months of initiation but reduces hospitalizations in the long term, particularly when serum urate targets are achieved.

Foods, nutrients and hip fracture risk: A prospective study of middle-aged women

Hip fracture affects 1.6 million people globally each year, and increases morbidity and mortality. There is potential for risk reduction through diet modification, but prospective evidence for associations between intake of several foods and nutrients and hip fracture risk is limited. This study aimed to investigate associations between food and nutrient intakes and hip fracture risk in the UK Women's Cohort Study, and to determine the role of body mass index (BMI) as a potential effect modifier. Dietary, lifestyle, anthropometric, and socio-economic information of UK women, ages 35-69 years, were collected in a survey at recruitment (1995-1998), and included a validated 217-item food frequency questionnaire. Hip fracture cases were identified by linking participant data at recruitment with their Hospital Episode Statistics (HES) up to March 2019. Cox regression models were used to estimate associations between standard portions of food and nutrient intakes and hip fracture risk over a median follow-up time of 22.3 years. Among 26,318 women linked to HES data (556,331 person-years), 822 hip fracture cases were identified. After adjustment for confounders, every additional cup of tea or coffee per day was associated with a 4% lower risk of hip fracture (HR (95% CI): 0.96 (0.92, 1.00)). A 25g/day increment of dietary protein intake was also associated with a 14% lower risk of hip fracture (0.86 (0.73, 1.00)). In subgroup analyses, BMI modified linear associations between dietary intakes of protein, calcium, total dairy, milk, and tea and hip fracture risk (pinteraction=0.02, 0.002, 0.003, 0.001, and 0.003, respectively); these foods and nutrients were associated with a reduced risk of hip fracture in underweight but not healthy or overweight participants. In particular, risk of hip fracture in underweight participants (28 cases, 545 participants) was 45% lower for every 25g/day protein consumed (0.55 (0.38, 0.78)). This is the first prospective cohort study internationally of multiple food and nutrient intakes in relation to hip fracture risk by BMI using linkage to hospital records. Results suggest that the potential roles of some foods and nutrients in hip fracture prevention, particularly protein, tea and coffee in underweight women, merit confirmation. Clinicaltrials.gov NCT05081466.

Numbers and types of neurological emergencies in England and the influence of socioeconomic deprivation: a retrospective analysis of hospital episode statistics data

ObjectivesIn this first large-scale analysis of neurological emergency admissions in England, we determine the number and types of emergency admissions with neurological emergency diagnostic codes, how many are under the...

Using set visualisation to find and explain patterns of missing values: a case study with NHS hospital episode statistics data

ObjectivesMissing data is the most common data quality issue in electronic health records (EHRs). Missing data checks implemented in common analytical software are typically limited to counting the number of...

Incidence of cognitive impairment and dementia after hospitalisation for pneumonia: a UK population-based matched cohort study.

Survivors of common infections may develop cognitive impairment or dementia; however, the risk of these conditions in people hospitalised with pneumonia is not well established. A matched cohort study was conducted using Hospital Episode Statistics (HES) data linked to the Clinical Practice Research Database (CPRD). Adults with the first International Classification of Diseases (10th Revision) code for pneumonia recorded in the HES between 1 July 2002 and 30 June 2017 were included, and up to four controls without hospitalisation for pneumonia in the CPRD were matched by sex, age and practice. Cognitive impairment and dementia incidence rates were calculated and survival analysis was performed comparing those hospitalised with pneumonia to the general population. The incidence rates of cognitive impairment and dementia were 18 (95% CI 17.3-18.7) and 13.2 (95% CI 13-13.5) per 1000 person-years among persons previously hospitalised with pneumonia and the matched cohort respectively. People previously hospitalised with pneumonia had 53% higher incidence of cognitive impairment and dementia (adjusted hazard ratio (aHR) 1.53, 95% CI 1.46-1.61) than their matched cohort. The highest incidence was observed within 1 year of hospitalisation for pneumonia compared to the general population (aHR 1.89, 95% CI 1.75-2.05). Age modified the effect of hospitalisation for pneumonia on cognitive impairment and dementia such that the size of effect was stronger in people between 45 and 60 years old (p-value for interaction <0.0001). Cognitive impairment and dementia are more likely to be diagnosed in people who have been hospitalised for pneumonia, especially in the first year after discharge, than in the general population.

Developing and validating a prognostic model for mortality in patients with heart failure

Abstract Background Heart Failure (HF) constitutes a major public health problem which remains highly prevalent in the UK and globally. Primary care plays a role in the long-term management of patients with heart failure but there are no clinically useful prognostic models to guide primary care professionals in determining those at increased risk of mortality, who could benefit from appropriate advanced care planning or escalation of treatment. Several predictive models exist but due to several limitations, clinical utility of these in the UK are limited. Purpose This study developed and validated a prognostic algorithm, the Nottingham Heart Failure Model, to predict the one-year risk of all-cause mortality in patients with HF. Methods This was a retrospective open cohort study using electronic primary care records from the UK Clinical Practice Research Datalink (CPRD) linked with secondary care records from Hospital Episode Statistics (HES) and death registration data from the Office for National Statistics (ONS). Adults with a diagnosis of heart failure were identified and multivariable Cox regression models were used to identify the risk factors that were independently associated with mortality. A prognostic model was developed to predict the one-year risk of mortality in patients with heart failure, and this was validated by bootstrapping 200 samples of the derivation data. The cohort was then split into even quartiles based on predicted risk scores from the model. These risk groups ranged from one to four with one indicating the quartile of scores with the lowest risk. Kaplan Meier curves were then produced for each group. The Royston D-statistic was then used to assess the discrimination of these quartiles by quantifying the observed separation between these groups. Results A total of 109,577 patients with diagnoses of heart failure were followed up from 1 January 2000 to 31 December. There were 16,437 deaths during the period of follow up. We identified 29 factors which were significantly associated with mortality risk and a prognostic model which incorporated these factors, was developed. The resulting prognostic model obtained a model validation score (C-statistic) of 0.79. The agreement between the observed and predicted proportion of events showed excellent apparent calibration. The D statistic of 1.65 suggests that the model provides a reasonably high amount of prognostic separation. Conclusion(s) Several patient characteristics including comorbidities, treatments, and biomarkers are significantly associated with heart failure mortality. This new model has the potential to accurately predict heart failure mortality within one year and will enable primary care professionals to better risk stratify their patients with heart failure. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Aziz Foundation

Automated deep learning quantification of epicardial adiposity on cardiac CT predicts atrial fibrillation risk immediately following cardiac surgery and long-term

Abstract Introduction Epicardial adipose tissue (EAT) is a visceral fat deposit within the pericardial sac which surrounds the heart myocardium and coronary arteries. The automated quantification of EAT volume is possible from routine CCTA scans via a deep-learning approach. The use of automated EAT quantification for the assessment of atrial fibrillation (AF) risk in the post-operative period, and longer-term, has not been previously investigated. Purpose To apply a deep-learning approach for automated segmentation of EAT from routine CCTA scans to assess the immediate post-operative and long-term risk of AF conveyed by EAT. Methods A deep-learning automated EAT segmentation tool using a 3D Residual-U-Net neural network architecture for 3D volumetric segmentation of CCTA data was created and trained on over 2800 consecutive CCTA performed as part of clinical care in patients with stable chest pain from 2015 onwards within the European arm of the Oxford Risk Factors And Non Invasive Imaging (ORFAN) Study. External validation in 817patients demonstrated excellent correlation between machine and human expert (CCC = 0.972). The prognostic value of deep-learning derived EAT volume was assessed in the AdipoRedOx Study (n=253; UK patients undergoing cardiac surgery) against both immediate in-hospital outcomes and longer-term outcomes from UK-wide NHS data, with adjustment for AF risk factors. Results There were 97 cases of new-onset AF in the immediate post-operative period (38.3%). EAT volume was found to be an independent predictor of post-operative AF regardless of body mass index. Utilising the median EAT volume as the cut point, the adjusted hazard ratio (HR [95% CI]) for risk of new-onset post-operative AF in-hospital was 1.56 [1.09–3.85], p&amp;lt;0.01 (Figure 1A). In receiver-operator characteristic analysis EAT volume added significant incremental prognostic power for the discrimination of in-hospital post-operative AF over a traditional risk factor model ΔAUC=0.101, p&amp;lt;0.01 (Figure 1B). Over a median follow-up period of 89 months there were 48 unique cases (19%) of confirmed AF found in nation-wide NHS hospital episode statistics data for the AdipoRedOx cohort. EAT volume was found to be a significant independent predictor of long-term AF. Utilising the median EAT volume as the cut point, the adjusted HR for risk of new-onset long-term AF following cardiac surgery was 1.25 [1.08–3.17], p&amp;lt;0.01 (Figure 1C). Conclusions Automatically segmented EAT volume measured using a deep learning network predicts risk of both short-term new onset AF following cardiac surgery, and long-term risk of AF in the 7 years following the surgery independently of BMI and AF risk factors. This suggests that EAT is a potent mediator of AF risk in the post cardiac surgery setting. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation - TG/19/2/34831EU Commission - 965286

Effectiveness of primary care psychological therapy services for the treatment of depression and anxiety in people living with dementia: Evidence from national healthcare records in England.

SummaryBackgroundDepression and anxiety are common and deleterious in people living with dementia (PLWD). It is currently unknown whether routinely provided psychological therapy can help reduce these symptoms in PLWD. This study aimed to investigate improvements in depression and anxiety symptoms over the course of therapy offered in primary care psychological therapy services in PLWD and to compare outcomes to people without dementia.MethodsNational data from Improving Access to Psychological Therapies services (IAPT) across England linked with Hospital Episode Statistics data, the Mental Health Services Dataset, and HES-ONS mortality data were used to identify 1,549 PLWD who completed a course of psychological treatment in IAPT between 2012-2019 and a propensity score matched control group without identified dementia. Outcome measures included pre-post intervention changes in depression (PHQ-9) and anxiety (GAD-7) symptoms and therapy outcomes (reliable improvement, recovery, deterioration).FindingsSymptoms of depression (t(1548)=31·05, p<·001) and anxiety (t(1548)=30·31, p<·001) improved in PLWD over the course of psychological therapy with large effect sizes (depression: d=-0·83; anxiety: d=-0·80). However, PLWD were less likely to reliably improve (OR=·75, 95%CI[·63,·88], p<·001) or recover (OR=·75, 95%CI[·64,·88], p=·001), and more likely to deteriorate (OR=1·35, 95%CI[1·03,1·78], p=·029) than a matched control sample without dementia.InterpretationPsychological therapy may be beneficial for PLWD with depression or anxiety, but it is currently not as effective as for people without dementia. More research is needed to improve access to psychological therapies and to understand this discrepancy and how therapies can be adapted to further improve outcomes.FundingThis work was supported by the Alzheimer's Society.

Effect of competing mortality risks on predictive performance of the QFracture-2012 risk prediction tool for major osteoporotic fracture and hip fracture: external validation cohort study in a UK primary care population

ObjectiveTo externally evaluate the QFracture-2012 risk prediction tool for predicting the risk of major osteoporotic fracture and hip fracture.DesignExternal validation cohort study.SettingUK primary care population. Linked general practice (Clinical Practice...