Hospitals NHS Research Articles

How do hospital characteristics and ties relate to the uptake of second-generation biosimilars? A longitudinal analysis of Portuguese NHS hospitals, 2015–2021

ABSTRACT Background There is limited evidence on within-country discrepancies in biosimilar uptake. This study analyzes differences in timing and diffusion of biosimilar uptake across Portuguese NHS hospitals and explores possible determinants. Research design and methods We analyzed publicly accessible consumption data of originator biologic and biosimilar drugs for adalimumab, etanercept, infliximab, rituximab, and trastuzumab, by hospital and month for the years 2015–2021 (N = 9,467). We modeled the time to biosimilar adoption using survival regression models and the share of biosimilar consumption using generalized estimated equations with random hospital effects. Results Academic hospitals were characterized by a quicker uptake of adalimumab and infliximab biosimilars but lower shares for other drugs. A higher total consumption of biologics was related to a lower share of biosimilar uptake. A stronger participation in randomized controlled trials was linked to higher biosimilar shares and quicker uptake, except for rituximab. If all NHS hospitals had biosimilar shares equal to the highest ones, potential annual savings could reach 13.9 million euros. Conclusion The findings suggest a need for capacity-building on biosimilar prescribing, including for doctors of academic hospitals and those working in settings where high biosimilar use would be expected.

Extended Intensified Post-ASCT Consolidation with Daratumumab, Bortezomib, Lenalidomide and Dexamethasone (Dara-VRd) for Ultra-High Risk (UHiR) Newly Diagnosed Myeloma (NDMM) and Primary Plasma Cell Leukemia (pPCL): The UK Optimum/Muknine Trial

Background: Outcome for patients with ultra-high risk (UHiR) newly diagnosed multiple myeloma (NDMM) or primary plasma cell leukemia (pPCL) remains unsatisfactory. Recent results from MASTER (NCT03224507) and other trials unfortunately confirmed the sustained risk of post-ASCT relapse for UHiR MM patients in context of contemporary combination induction therapy, including relapse from undetectable minimal residual disease (MRD). The OPTIMUM/MUKnine (NCT03188172) trial was designed to reduce (pre- and) post-ASCT relapse risk in UHiR patients by continued Dara-VR(d) consolidation for 18 cycles, followed by Dara-R maintenance. We report here outcomes for OPTIMUM patients until end of consolidation therapy and contextualise results with outcomes of UHiR MM patients treated in the Myeloma XI (ISRCTN49407852) trial. Methods: In OPTIMUM, patients identified to have UHiR NDMM (≥2 high risk lesions: t(4;14), t(14;16), t(14;20), gain(1q), del(1p), del(17p) or SKY92 risk signature) or with pPCL (circulating plasmablasts >20%) through central molecular screening of an all-comer population received up to 6 cycles of Dara-CVRd induction and V-ASCT. All patients then received 18 cycles of post-ASCT consolidation, of which 6 cycles Dara-VRd (Cons1) and 12 cycles Dara-VR (Cons2), before moving to monthly Dara-R maintenance until progression. OPTIMUM recruited 107 UHiR patients, including 9 pPCL, from 472 screened patients with suspected NDMM from 39 UK NHS hospitals between Sep 2017 and Jul 2019. We previously reported the OPTIMUM primary endpoint analysis, which demonstrated improved PFS at 18 months post start of induction for OPTIMUM in a pre-specified comparison against UHiR patients treated in the Myeloma XI (MyXI) trial. We report here a planned analysis of OPTIMUM patient PFS and safety data after all patients completed consolidation. Results are contextualised with outcome for UHiR patients treated in MyXI with carfilzomib/cyclophosphamide-Rd (KCRd) or CRd induction, ASCT and lenalidomide maintenance or observation. Further analyses including overall survival are underway and will be presented at the meeting. Results: With median follow-up of 40.0 months (95% CI: 37.3-42.7), median PFS was not reached for OPTIMUM patients. The PFS estimate at the end of consolidation, 30 months from start of induction therapy, was 77.0% (95% CI: 68.8-85.1). For context, PFS at 30 months for UHiR patients in Myeloma XI was 39.8% (95% CI: 30.7-48.9) for the overall group, and specifically 49.7% (95% CI: 33.2-66.2) for MyXI patients randomised to KCRd and 34.1% (95% CI: 23.4-44.8) for those randomised to CRd treatment arms (Figure 1). We observed a progressive separation of PFS curves over time between OPTIMUM and MyXI, suggesting a sustained beneficial effect of ongoing post-ASCT consolidation for UHiR patients (Figure 1). Of the 85 OPTIMUM patients who received at least one cycle of consolidation post-ASCT, 80 patients completed Cons1 and 74 patients Cons2. Progressive disease was the commonest reason for trial discontinuation. Most frequent CTCAE grade 3/4 adverse events (AEs) during Cons2 included neutropenia (43.8%), thrombocytopenia (27.5%) and infection (15%). Grade 4 events were rare (≤5%) for all categories; there were no treatment-related deaths. Peripheral neuropathy rate grade ≥2 was 13.8% (Grade ≥3: 2.5%) for Cons2; no cumulative increase from Cons1 was noted. Of the initial 107 patients who started therapy in OPTIMUM, 47 had an MRD test result available at end of Cons2 at time of abstract submission. Of these, 44 (93.6%; 41.1% of overall trial population) had undetectable MRD at 10-5 sensitivity by flow cytometry. In the majority of patients undetectable MRD was sustained since ASCT. Conclusions: Prevention of relapse remains a key challenge in the treatment of UHiR MM/PCL patients, including for patients achieving undetectable MRD. OPTIMUM outcomes for extended Dara-VR consolidation in UHiR/PCL patients demonstrate 30 months PFS of 77% and compare favourably with MyXI, but also results from the MASTER trial, which recently reported 24-month PFS of 58% for UHiR patients defined by same criteria (JCO 2021). Safety data demonstrate manageable side effects with extended Dara-VR consolidation. Our results support extended, risk stratified post-ASCT therapy for UHiR MM/PCL patients. Figure Legend: PFS Kaplan-Meier plot for UHiR/PCL patients treated in OPTIMUM and Myeloma XI. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 10390: Using a Trial Modelling Framework to Emulate a Target Trial Evaluating Revascularisation Strategies in Patients With Heart Failure

Introduction: We developed a novel trial modelling framework which utilises real world data to emulate a target trial and estimate key parameters to support trial planning. We applied this framework using the UK Hospital Episode Statistics (HES), which captures all admissions at NHS hospitals in England, and reported the findings of an emulated target trial evaluating revascularisation strategies in heart failure (HF) patients with coronary artery disease. Methods: Phenotyping algorithms derived from the target trial protocol were applied to HES, to identify HF patients who had coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). Trial participants are often different from the target trial population due to voluntary basis of participation. The HES-derived cohort was matched on baseline features (age, gender, comorbidities) to an existing trial (STICH) which targeted the same high-risk population, so that the matched cohort mimics a likely trial population. Treatment effects were estimated using instrumental variable analysis (IVA) and meta-learning models to adjust for confounding. Results: A total of 13,519 HF patients undergoing revascularisation during April 2009 and March 2015 met the eligibility criteria. This HF patient cohort was matched with the STICH cohort, resulting in 2046 patients in the study cohort. The 5-year composite outcome of all-cause mortality or cardiovascular hospitalisation was observed in 51.1% of HF patients who had CABG and 70.0% in those who had PTCA. IVA showed that CABG was associated with a lower risk of the composite outcome (risk difference -16.2%, 95%CI: -20.6% to -11.8%). This was consistent with the treatment effects derived from other machine learning models. Our analyses also identified a trend in greater treatment effects being observed in the matched cohort than unmatched cohort. This suggests that a clinical trial may over-estimate treatment effects when compared to the actual treatment benefit observed in clinical practice. Conclusions: The framework provides a structured process to emulate a trial and anticipate findings of the trial. Our analyses showed that CABG is associated with a greater long-term benefit in HF patients requiring revascularisation.

Challenges and lessons learned from Scotland and England using linked administrative data to evaluate the Family Nurse Partnership: two administrative data cohort studies

BackgroundThe Family Nurse Partnership (FNP) is an early intervention aiming to support adolescent mothers and their children. The FNP has been evaluated in England and Scotland in two separate studies using linked administrative data from health, education, and social care. We aimed to make recommendations for studies using linked administrative data to evaluate public health interventions. MethodsWe constructed two cohorts of all mothers aged 13–19 years giving birth in NHS hospitals between 2010 and 2016–17 using data from Hospital Episode Statistics (England) and Maternity Inpatient and Day Case (Scotland). FNP participation was identified through linkage to FNP programme data. We also linked to health, educational, and social care data for mothers and their babies (data from the National Pupil Database and electronic Data Research and Innovation Service). Ethical approval was obtained but no consent was required because we used secondary data. We used these data to evaluate the effect of the FNP on maternal and child outcomes. FindingsKey challenges included characterising the intervention and usual care, understanding quality of multi-sector data linkage, data access delays, constructing appropriate comparator groups, and interpreting outcomes captured in administrative data. Lessons learned included that evaluations required detailed data on intervention activity (dates and geography) and assessment of usual care, which are rarely readily available and are time-consuming to gather; data linkage quality information was variable or not available, making defining denominators challenging; data access delays impeded on data analysis time; and unmeasured confounders not captured in administrative data possibly prevented the generation of an appropriate comparator group. We recommend that characteristics informing targeting should be explicitly documented, and could be enhanced by using linked primary care data and information on household members (eg, fathers). Process evaluation and qualitative research could help to provide a better understanding of mechanisms of effect. InterpretationLinkage of administrative data presents opportunities for efficient evaluation of large-scale, complex public health interventions. However, sufficient information is needed on programme metadata, targeting, and important confounders to generate meaningful results. Our findings should help to stimulate exploration by practitioners about how such programmes can be improved. FundingNational Institute for Health and Care Research.

NHS funding for dental undergraduate human disease teaching in the UK: a 20-year review

Introduction This study identifies funding of NHS services supporting dental students' teaching over the last 20 years, focusing on human disease (HD) teaching.Aims To identify NHS funding for education in UK dental schools following publication of the 1997 General Dental Council curriculum introducing specific funding for HD teaching and the years 2015/16 to 2019/20.Material and methods Searches of the medical literature, grey literature (government and regulatory authority reports, legislative articles) and freedom of information requests to hospitals helping to deliver teaching.Results There are few publications describing current funding of dental undergraduate teaching. Freedom of information requests gave data for NHS hospital allocations for teaching both clinical dentistry and HD. HD funding has dropped by £2 million in five years.Conclusions NHS Trusts linked to dental schools receive monies to deliver teaching and offset costs of accommodating students. Tracking these funds over 20 years has seen some schools lose up to £1 million of HD funding and some lose it all. Greater transparency regarding funding for HD delivery would help improve teaching. Increasing numbers of older patients, with a greater chronic disease burden who are retaining teeth into later life, need graduating dentists with good medical knowledge to deliver safe care.

Adolescent and Parent Preferences for Hypodontia: Discrete Choice Experiment

Choosing hypodontia treatment requires young people and parents to consider a large amount of information, identify what is important to them, and make trade-offs between options. This study aimed to examine young people and parents’ preferences for hypodontia treatment using discrete choice experiment (DCE). This was a cross-sectional survey of young people (12–16 y) with hypodontia of any severity, at any stage of treatment, and their parents. Participants were recruited from NHS Hospitals in England and Wales. A bespoke DCE questionnaire was developed to measure preferences for 6 attributes of hypodontia treatment (waiting time, treatment time, problems during treatment, discomfort during treatment, bite, appearance). The questionnaire was completed 1) online by young people and parents, individually or together, and 2) by child–parent dyads under observation. Preferences were analyzed using regression models. In total, 204 participants (122 young people, 56 parents, 26 dyads) completed the online questionnaire and 15 child–parent dyads completed the questionnaire under observation. The most important attribute in hypodontia treatment was improvement in appearance, but significant heterogeneity was found in preferences. Four distinct groups of participants were found: group 1 (39%): severe discomfort and problems were most important; group 2 (31%): most concerned about improvement in appearance of teeth and improvement in bite; group 3 (22%): appearance 3 times more important than any other attribute; and group 4 (9%): preferences difficult to interpret. There was variation in how child–parent dyads approached decision-making, with some negotiating joint preferences, while for others, one individual dominated. Making trade-offs in DCE tasks helped some people think about treatment and identify their preferences. Appearance is an important outcome from hypodontia treatment, but preferences vary and potential risks and functional outcome are also important to some people. There is a notable level of uncertainty in decision-making, which suggests further shared decision support would be valuable.

OC-045 AMBULATORY HERNIA SURGERY IN PRIMARY CARE

Abstract Background Approximately 100,000 hernia repairs are performed in the UK annually, the vast majority in hospital usually under general anaesthetic. Due to increased pressure on hospital facilities especially after the COVID-19 pandemic the waiting times for non-emergency surgery for benign conditions has increased. This study outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved between November 2018 and November 2021. Methods We prospectively analysed of records of 212 patients who underwent hernia repair in a primary care centre during the above period. Inclusion criteria were a) BMI<35 b) uncomplicated inguinal or umbilical hernia c) non recurrent hernia. The techniques used were Lichtenstein mesh repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were telephoned by a healthcare professional a day after their operation. The primary outcomes of the study were length of stay, immediate complications and the secondary outcome was cost effectiveness. Results The median length of post-operative stay was 26 minutes. Complications were low and seen only in 5 patients and managed conservatively. The cost of hernia repair in primary care in UK is only £1012 when compared to £1800 in an NHS hospital. Conclusion Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely, with good clinical outcomes and clear economic benefits. However, this depends on the availability of surgeons and adequate funds to establish the service.

DD-06 SPIN (SURGICAL PRACTICES IN INCISIONAL HERNIA REPAIR). A NATIONAL TRAINEE-LED COLLABORATIVE MULTICENTRE PROSPECTIVE OBSERVATIONAL STUDY

Abstract Aim There is currently no established UK database establishing reliable outcome data for surgical repair of incisional herniae (IH). Their heterogeneity (variability in size, patient comorbidity, and multiple repair techniques) has resulted in no surgical management or outcome reporting consensus. This study aims to utilise national trainee led research collaboratives to perform a multi-centre, observational, prospective study to assess variation in IH defects (by utilising pre-defined criteria from The European Hernia Society (EHS) classification for IH and a Modified Ventral Hernia Working Group) and their subsequent operative management. This study will yield valuable, standardised data on variation in practice and outcomes (complications and 3 and 12-months follow-up) to provide a platform for expanding IH research. Materials and Methods All NHS hospitals in England undertaking elective IH repair will be eligible for inclusion. Dissemination of and recruitment to the study will be driven by regional research collaborative networks. This study will include all elective adult IH repairs with. Data will be collected and managed using REDCap electronic data capture tool. There will be three distinct phases comprising; The study is currently unfunded. Funds are sought to obtain NHS Trust sponsorship and proceed to phase 3 of the study.

Machine learning can accurately detect abnormal aortic valves in CMR

Abstract Background Improving the efficiency of CMR by acquiring fewer, and more targeted sequences, would improve the diagnostic yield and reduce patient recalls. An AI-assisted clinical decision support system (CDSS) could deliver this efficiency using adaptive scanning protocols which replicate the expertise of highly trained clinicians. Normal aortic valve anatomy on the three-chamber (3CH) cine CMR is a guide to rationalising subsequent sequences, and therefore is a suitable base case for developing an AI-CDSS for CMR. Purpose We propose a machine learning approach to differentiate between normal and abnormal aortic valves from the 3CH cine. Methods We curated a unique expert-annotated dataset of 1221 frames from eighty CMR studies. For each frame, AV landmarks (two hinge points and two leaflets), and stenotic and regurgitant jets were labelled by three cardiologists. We then tested two AI models (Figure 1) to detect these AV abnormalities: A) a convolutional neural network (CNN), and B) a random forest approach. A) Using heat map regression, the AV was localised, and the jets (if present) were identified as pathological curves. We then tracked and quantified the curves in the estimated heatmaps based on their proximity, the length, orientation and angle with respect to the hinge points. B) We used a random forest approach to classify cases as normal or abnormal by using the characteristics of estimated pathological curves obtained from the heat map regression output. We trained and evaluated our models on an unseen dataset of 1017 CMR studies obtained from different scanner types across three NHS hospitals. Each CMR study report was manually assigned a binary ground truth label for a normal or abnormal AV. In total 496/1017 patients had an abnormal AV. Of those abnormal cases, 184 patients had aortic stenosis, 222 aortic regurgitation and 90 cases had mixed valve disease. We assessed the classification performance of our method with accuracy and an F1 score – a composite of precision and recall, where 1 is perfect; and heatmap regression performance for curves with mean absolute error. Results This machine learning approach classified abnormal aortic valves with good agreement to the ground truth labels with mean accuracy of 0.93 (representing approximately 451/496 patients) and mean F1 score of 0.91. The AV hinge points were localised with a mean distance error of 3.5 pixels. This was despite the small size of expert labelled data. Conclusion This machine learning solution successfully differentiated between normal and abnormal aortic valves from routine 3CH cine CMR views. More labelled datasets will enable further classification of pathology and severity, and greater accuracy. Our results represent an important stepping stone towards an AI-assisted CDSS for CMR. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): This work was supported by the UKRI CDT in AI for Healthcare http://ai4health.io

Iatrogenic and spontaneous preterm birth in England: A population-based cohort study.

To describe the rates of and risk factors associated with iatrogenic and spontaneous preterm birth and the variation in rates between hospitals. Cohort study using electronic health records. English National Health Service. Singleton births between 1 April 2015 and 31 March 2017. Multivariable Poisson regression models were used to estimate adjusted risk ratios (adjRR) to measure association with maternal demographic and clinical risk factors. Preterm births (<37 weeks of gestation) were defined as iatrogenic or spontaneous according to mode of onset of labour. Of the births, 6.1% were preterm and of these, 52.8% were iatrogenic. The proportion of preterm births that were iatrogenic increased after 32 weeks. Both sub-groups were associated with previous preterm birth, extremes of maternal age, socio-economic deprivation and smoking. Iatrogenic preterm birth was associated with higher body mass index (BMI) (BMI >40 kg/m2 adjRR 1.59, 95% CI 1.50-1.69) and previous caesarean (adjRR 1.88, 95% CI 1.83-1.95). Spontaneous preterm birth was less common in women with a higher BMI (BMI >40 kg/m2 adjRR 0.77, 95% CI 0.70-0.84) and in women with a previous caesarean (adjRR 0.87, 95% CI 0.83-0.90). More variation between NHS hospital trusts was observed in rates of iatrogenic, compared with spontaneous, preterm births. Just over half of all preterm births resulted from iatrogenic intervention. Iatrogenic births have overlapping but different patterns of maternal demographic and clinical risk factors to spontaneous preterm births. Iatrogenic and spontaneous sub-groups should therefore be measured and monitored separately, as well as in aggregate, to facilitate different prevention strategies. This is feasible using routinely acquired hospital data.

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

The forgotten dimension of integrated care: barriers to implementing integrated clinical care in English NHS hospitals.

Multimorbid patients who enter English NHS hospitals are frequently subject to care pathways designed to assess, diagnose and treat single medical conditions. Opportunities are thereby lost to offer patients more holistic, person-centred care. Hospital organisations elsewhere are known to use in-hospital, multi-specialty, integrated clinical care (ICC) to overcome this problem. This perspective piece aims to critically discuss barriers to implementing this form of ICC in the English NHS focusing on six key areas: information technologies, the primary-secondary care interface, internal hospital processes, finance, workload, professional roles and behaviours. Integrated care programmes currently underway are largely focused on macro (system) and meso (organisational) levels. A micro (clinical) level ICC, offering highly coordinated multispecialty expertise to multimorbid hospital patients could fill an important gap in the current care pathways.

Learning from hospital deaths.

Current guidelines and regulations require trusts to take full responsibility for deaths within their premises. Higher than expected deaths indicate poor standards of care or negligence. NHS Trusts need to put systems in place to ensure that they learn and extrapolate risk factors through in-depth review of care provided to patients prior to their deaths, curb and ultimately diminish relative mortality through improved practices, and improve care and safety for the whole organisation. Mortality reviews can provide insight into the standard of care that dying patients receive; this matters as NHS Hospitals are the main providers of terminal care, nationally.

First Line Treatment of Adult Glioblastoma Patients in England 2103-2018 from the GlioCova Project

Abstract AIMS The Gliocova dataset uses linked English national cancer data on all 51,775 adult primary brain tumour patients diagnosed between 2013-2018. Here we present detailed analysis of first-line treatments of adult glioblastoma (GBM) patients. METHOD We identified all adults patients diagnosed with a GBM. We focused on the first line of treatment and we defined ‘maximal’ first-line treatment as surgical resection followed by chemo-radiotherapy with 59-60 Gy and with at least one cycle of adjuvant chemotherapy Temozolomide. RESULTS 15,294 patients were diagnosed with a glioblastoma (60% male) with a median age of 66. 79% of patients received some treatment, with younger patients more likely to be treated (&amp;gt;90%, 18 - 59; &amp;lt; 30%, &amp;gt; 80). 54% underwent debulking surgery; 23%, biopsy. 14% received ‘maximal’ treatment and 21%, none. Patients who had no treatment had a median survival of 2 months whereas patients who received ‘maximal’ treatment had a median survival of 16 months. CONCLUSION Most adult patients with a GBM in England have a histological diagnosis, and some oncological treatment. However, only 14% receive ‘maximal’ treatment. Of the 3222 patients who received none, some of these may have had purely private treatment; however, our dataset includes any private sector work undertaken in NHS hospitals. Survival remains poor, but outcomes in those receiving maximal treatment match those from clinical trials. However, most patients do not receive maximal treatment, and so the easiest route to improving outcomes may be optimise delivery of treatment in the 65% of patients who receive sub-maximal treatment. More information on https://blogs.imperial.ac.uk/gliocova

Machine learning methods applied to risk adjustment of cumulative sum chart methodology to audit free flap outcomes after head and neck surgery

We describe a risk adjustment algorithm to benchmark and report free flap failure rates after immediate reconstruction of head and neck defects. A dataset of surgical care episodes for curative surgery for head and neck cancer and immediate reconstruction (n = 1593) was compiled from multiple NHS hospitals (n = 8). The outcome variable was complete flap failure. Classification models using preoperative patient demographic data, operation data, functional status data and tumour stage data, were built. Machine learning processes are described to model free flap failure. Overall complete flap failure was uncommon (4.7%) with a non-statistical difference seen between hospitals. The champion predictive model had acceptable discrimination (AUROC 0.66). This model was used to risk-adjust cumulative sum (CuSUM) charts. The use of CuSUM charts is a viable way to monitor in a ‘Live Dashboard’ this quality metric as part of the quality outcomes in oral and maxillofacial surgery audit.

Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model.

Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of &lt; 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.

Impact of introducing procalcitonin testing on antibiotic usage in acute NHS hospitals during the first wave of COVID-19 in the UK: a controlled interrupted time series analysis of organization-level data-authors' response.

Impact of introducing procalcitonin testing on antibiotic usage in acute NHS hospitals during the first wave of COVID-19 in the UK: a controlled interrupted time series analysis of organization-level data-authors' response.

Editor's Choice – Eligibility of Common Femoral Artery Atherosclerotic Disease for Endovascular Treatment – the CONFESS Study

Advances in endovascular technologies have allowed the treatment of common femoral artery (CFA) steno-occlusive disease by minimally invasive means; however, the proportion of lesions treated with common femoral artery endarterectomy (CFAE) which would be amenable to endovascular treatment is unknown. This observational study aimed to describe the morphology and composition of CFA lesions treated with CFAE and report the proportion that would be amenable to endovascular treatment with modern technologies. Patients presenting with symptomatic peripheral artery disease who underwent CFAE from January 2014 to December 2018 in two tertiary NHS hospitals were included. Extensive data relating to patient demographics, risk factors, clinical outcomes, as well as anatomical and morphological characteristics of the CFA atherosclerotic lesions, were collected which included detailed plaque analysis using 3D reconstruction of pre-operative computed tomography angiograms. CFA lesions were considered suitable for endovascular treatment if presented with patent iliac inflow, at least one patent outflow vessel (superficial femoral artery [SFA] or profunda femoral artery [PFA]), and stenotic rather than occluded CFA. A total of 829 CFAs in 737 consecutive patients who underwent CFAE were included (mean age 71 ± 10 years; 526 males, 71%); 451 (62%) presented with chronic limb threatening ischaemia. Overall, 35% of CFAs had a localised lesion (no bifurcation disease) that could possibly be treated endovascularly. In total, 376 (45%) target vessels did not feature severe calcium load, with a patent CFA, PFA, and proximal SFA and therefore would have been amenable to endovascular treatment; while 271 CFAs (33%) featured a significant calcium load which would have potentially required stenting. A significant proportion of patients with atherosclerotic CFA lesions who undergo surgery could potentially be candidates for endovascular treatment. A randomised trial comparing CFAE and new endovascular techniques in this clinical context is required.

Perioperative blood transfusion in major abdominal cancer surgery: a multi-centre service evaluation and national survey.

Anaemia is associated with complications and death after surgery. Perioperative red-cell transfusion triggers are not well defined in patients having oncological surgery, or with cardiovascular disease. We carried out a prospective multicentre cohort study and a clinician survey of UK transfusion practice in adult patients undergoing surgery for abdominal malignancy. The primary outcome was red cell transfusion. Secondary outcomes were transfusion trigger haemoglobin, incidence of complications, length of hospital stay, and acute hospital mortality. In this prospective cohort study, data were collected on 412 patients undergoing surgery for intrabdominal malignancy in 14 NHS hospitals. Twenty-two (5.2%) patients received preoperative, 42 (10.2%) intraoperative, and 52 (12.2%) postoperative red blood cell transfusion. The mean postoperative transfusion trigger was 75.3 g L-1, and the mean number of units of red blood cells transfused was 1.5 (standard deviation, 1.1). Seventeen (4.0%) patients had a documented postoperative troponin elevation. Five (1.2%) patients died within 30 days of surgery. In the survey, 117 clinicians submitted complete responses, of whom 62 (53%) indicated that a transfusion threshold of 70 g L-1 was appropriate: however, this decreased to six (5.1%) if there was evidence of recent cardiac ischaemia. There were 100 (86%) respondents who indicated equipoise for a trial of restrictive vs liberal transfusion, decreasing to 56% if there was coexisting cardiovascular disease. Many patients having oncological surgery receive red cell transfusion, the majority being given postoperatively. Restrictive transfusion practice is generally followed; however, variability exists especially in cardiovascular disease. Equipoise exists for a study of transfusion thresholds in this group.

Exploring factors influencing uptake and adherence to a home-based prehabilitation physical activity and exercise intervention for patients undergoing chemotherapy before major surgery (ChemoFit): a qualitative study

ObjectivesPreoperative exercise training can improve cardiorespiratory fitness before major surgery. However, little is known about what influences participation and adherence in high-risk patient groups. We identified barriers and facilitators to...