Less Time In Hospital Research Articles

Description of Feelings, Perception, and Experience Before and After Switching from IV Daratumumab to the SC Form: A Mixed-Method, Cross-Sectional Survey in Multiple Myeloma Patients in Europe.

To provide real-world data on patient perceptions and experiences with subcutaneous (SC) versus intravenous (IV) daratumumab. This was a cross-sectional, mixed-method (qualitative/quantitative) survey conducted in France, Germany, Spain and the United Kingdom involving multiple myeloma (MM) patients who switched from IV to SC daratumumab in the last 12 months (qualitative phase) or 24 months (quantitative phase [26 months in the UK]) prior to enrollment in the study. Nine patients (mean age 65 years) participated in the qualitative phase and 113 patients (mean age 65.1 years) in the quantitative phase. Qualitative study results provided insights for the quantitative study and highlighted the benefits of switching from daratumumab IV to daratumumab SC as an improvement and a satisfactory change in patients' treatment journey. Quantitative survey showed that patients were significantly less anxious, stressed and nervous before SC injections than IV infusions (mean score: 1.3, 1.1, 1.4 versus 2.1, 2.0, 2.0 respectively, p<0.001), and significantly more reassured, ready/well-prepared, usual self and relieved (mean score: 3.8, 4.3, 3.7, 3.6 versus 3.0, 3.6, 3.1, 3.0 respectively, p<0.001). Immediately after SC first injection, 96.5% patients were feeling well or very well versus 77.9% immediately after IV first infusion (p<0.001). 97.3% patients were satisfied with their SC treatment versus 89.4% for the IV injection (p<0.001). Patients spent significantly less time in hospital for an SC injection of daratumumab than for an IV infusion, 1.5 hours and 5.0 hours respectively (p<0.001). In the UK, the differences between the two administration forms were less visible, likely because of confounding factors including a longer time passed since the switch from the IV to the SC form and administration of the survey. In line with results from other studies, the SC form of daratumumab had less impact on patients' emotional burden than the IV form.

A Review of Robotic Surgery in Colorectal Surgery.

Colorectal surgery is a treatment for colorectal lesions. Technological advancements have given the rise to robotic colorectal surgery, a procedure that limits excessive blood loss via 3D pin-point precision capabilities during surgeries. The aim of this study is to review robotic surgery in colorectal treatment procedures in order to dictate its ultimate merits. This is a literature review utilising PubMed and Google Scholar; it only includes case studies and case reviews related to robotic colorectal surgeries. Literature reviews are excluded. We incorporated abstracts from all articles and full publications were examined to compare the benefits of robotic surgery in colorectal treatments. The number of articles reviewed was 41 literature spanning from 2003 to 2022. We found that robotic surgeries yielded finer marginal resections, greater amounts of lymph node resections and earlier recovery of bowel functions. The patients also spent less time in hospital after surgery. The obstacles on the other hand are it costs longer operative hours and further training, which is expensive. Studies show robotic approach is a choice for treating rectal cancer. However further studies would be needed to conclude the best approach. This is especially true with patients treated for anterior colorectal resections. Based on the evidence it's safe to say that the upsides outweigh the downsides, but advancements and further research in robotic colorectal surgeries are still necessary to reduce operative hours and cost. Surgical societies should also take the initiative and set up effective training programmes for colorectal robotic surgeries, as trained physicians result in better treatment outcomes.

A community-based crisis intervention for people with borderline personality disorder

Structured clinical management is an evidence-based intervention for people with borderline personality disorder (BPD). There is a lack of evidence on crisis interventions for people with BPD, who are often admitted to hospital or supported in emergency care settings when they present with acute mental health needs. The home-based treatment team (HBTT) at an English NHS mental health trust undertook a pilot service improvement project in which they designed a ‘managing distress pathway’ – a crisis intervention for people with BPD adapted from the structured clinical management model. A small-scale evaluation of the project found that, after the intervention, patients spent less time in hospital and staff’s skills and confidence in supporting patients had improved. Patients reported high levels of satisfaction with their care. By using the principles of structured clinical management within an HBTT, non-specialist mental health practitioners can deliver effective community-based crisis interventions for people with BPD.

The role of diagnostic tests in antifungal stewardship for treating invasive fungal infections: a plain language summary.

This is a summary of an article originally published in the journal Open Forum Infectious Diseases. Invasive fungal infections are caused by fungi. They can spread to deeper parts of the body. Some diagnostic tests are slow and may delay treatment. Better tests help to identify infection early in patients. An antifungal stewardship (shortened to AFS) program is a stepwise process to improve how patients are treated. AFS programs using diagnostic tests may help to manage infections. In this study, researchers wanted to know the impact of such AFS programs. To do so, they looked at the information from 17 previously published studies, which is summarized here. Infections were identified and treated faster in studies with improved diagnostic tests. Treatment cost decreased when infections were identified and treated early. Patients were treated for shorter periods of time. They also spent less time in hospital. Number of deaths were less. AFS programs based on diagnostic tests helped patients.

Factors associated with shorter length of admission among people with dementia in England and Wales: retrospective cohort study

ObjectivesTo identify aspects of the organisation and delivery of acute inpatient services for people with dementia that are associated with shorter length of hospital stay.Design and settingRetrospective cohort study of...

Early postnatal discharge from hospital for healthy mothers and term infants.

Early postnatal discharge from hospital for healthy mothers and term infants.

Comparing Outcomes of Transcatheter Aortic Valve Implantation (TAVI) and Surgical Aortic Valve Implantation (SAVI) for Severe Aortic Stenosis Within the Southern District Health Board

Transcatheter aortic valve implantation (TAVI) provides a promising advancement in the management of aortic stenosis. Previous studies have identified the benefit of this technology, particularly in those at high risk for surgical intervention. Because of this well-documented success, TAVI was introduced to Dunedin Hospital in 2015. This study provides a retrospective observational audit of TAVI cases between 2015 and 2019 (n=71). TAVI cases were also compared against patients that had surgical aortic valve implantation (SAVI) between 2011 and 2016 (n=134) at Dunedin Hospital. Data were collected using the Heath Connect South (HCS) database, and the Society of Thoracic Surgeons (STS) and EuroSCORE surgical risk predictors calculated. It was found that TAVI patients were older, with higher surgical risk scores and greater comorbidities. Even so, rates of cardiovascular events and hospital readmissions were similar between the two groups over two years, and stroke more common in SAVI. These trends were most evident in the 80–89-year-olds. Thirty-day mortality was 4.2% for TAVI and 2.2% for SAVI. TAVI patients also spent significantly less time in hospital (2.4 days vs 9.3 days). These Results suggest the effective implementation of TAVI within Dunedin Hospital, with thirty-day mortality comparable to previous international studies. The 80-89-year-old cohort also received the greatest benefit from TAVI, which is precisely the group that has the most to gain from this procedure.

Comparison of costs related to infant hospitalisations for spontaneous, induced and Caesarean births: population-based cohort study.

Objective This study examined hospitalisations and associated in-patient costs for babies during the first year of life following spontaneous labour, compared with labour induction or prelabour Caesarean section, at each gestational age. Methods Birth data for singleton liveborn babies from 33 weeks gestation in New South Wales from 2005 to 2014 were linked to hospital and death data. Generalised linear models were used to examine the association between the type of labour and the length of hospitalisations and hospital costs. Results From 2005 to 2014, 598640 women gave birth to 1187451 liveborn singleton babies. The mean total length of hospitalisations and costs of hospitalisations for babies in the first year of life decreased significantly as week of gestational age increased to 39 weeks, then plateaued. Overall, the total length of hospitalisations and hospital costs were significantly (P<0.001) lower for babies born after spontaneous labour (5.6 days and A$8405 respectively) than for babies born following labour induction (6.1 days and A$9452 respectively) or prelabour Caesarean section (8.2 days and A$12320 respectively). Conclusions Babies born following spontaneous labour spend less time in hospital and have lower hospital costs than those born following labour induction or prelabour Caesarean section. Hospitalisations and costs decrease with each week of gestational age until 39 weeks. What is known about the topic? It is known that induction of labour and prelabour Caesarean sections are increasing, and this increase has changed the distribution of gestational age towards birth at earlier ages. It is also known that babies born before 39 weeks of gestation are at increased risk of mortality and morbidity. What does this paper add? This study shows that babies born following spontaneous labour spend the least amount of time in hospital and subsequently have the lowest hospital costs at each week of gestation compared with babies born following labour induction or prelabour Caesarean section. This study also shows a small but significant economic advantage of labour induction compared with prelabour Caesarean delivery. This study quantifies the mean time babies spend in hospital in their first year of life, by week of gestational age and mode of birth. What are the implications for practitioners? The findings from this study can assist clinicians in judicious decision making when balancing the risks and benefits of early planned births. Clinicians can use the results of this study to inform women who are intending to have a planned birth of risks they may not have anticipated, such as the increased risk of rehospitalisation. The finding that hospitalisations and costs continue to decline until 39 weeks gestation can be used to reinforce the importance of continuing the pregnancy beyond 37 weeks if safe to do so, even though 37 weeks is considered term.

The Jones Dressing Cast for Safe Aftercare of Foot and Ankle Surgery: A Modification of the Jones Dressing Bandage

Category:Ankle; Basic Sciences/Biologics; Hindfoot; Midfoot/Forefoot; Trauma; OtherIntroduction/Purpose:The management of postoperative soft tissue healing is fundamental for the success of elective foot and ankle surgery. As postoperative edema is more relevant in such surgery due to its localization, soft tissue healing can take longer and pain can restrict function. There is no universal approach to surgery aftercare among foot and ankle surgeons. Although infections following foot and ankle surgery are rare, soft tissue healing can be jeopardized after extensive and multiple approaches. Postoperative edema, however, is common and contributes to unfavorable conditions for wound healing. Our study addresses the results of avoiding postoperative edema with the use of the Jones dressing cast.Methods:We defined a precise fixation technique of the foot and ankle in the immediate post-operative phase using what we call ‘the Jones dressing cast’. This technique is a modification of the Jones dressing bandage. In a previous study we compared two groups of patients (N = 20/23) who underwent similar reconstructive surgery with the application of the described cast for one week and without. At the twomonth follow-up we observed that the group treated with the cast required less pain relief, spent less time in hospital and achieved faster autonomy using crutches (Gottlieb and Klaue, 2013). In this study we considered a group of 45 patients who underwent similar reconstructive procedures to those in the first study and who were treated with the cast for two weeks post-operatively. There was no visual check of the soft tissues before removal of the cast.Results:Although patients in Group 2 had more complex surgery, mobility was achieved earlier and hospitalization time was shorter. The incidence of infection was lower in the group wearing the cast for 2 weeks. The patients treated with the cast for 2 weeks regained autonomous mobility significantly earlier than those in Group 1 (cast 1 week or less).Conclusion:The Jones dressing cast is a useful tool that can help minimize postoperative complication rates. Wearing the cast for two weeks is preferable. Our study suggests its effectiveness in reducing soft tissue complications and facilitating independent mobility.

Understanding the toolbox: A mixed methods study of attitudes, barriers and facilitators in parental intervention of children's cancer pain at home.

Children with cancer experience pain throughout their cancer trajectory. Pain has short- and long-term negative consequences for children physically and psychologically. Children with cancer spend more time at home with their families and less time in hospital. While this has benefits for quality of life, it shifts responsibility for pain management from healthcare professionals to parents. Little is known about parents' pain management abilities in this setting. This study aimed to understand how parents of children with cancer manage their child's pain at home. A convergent, parallel, mixed methods design including pain diaries, surveys and interviews was used. Participants were parents of children with cancer on active treatment recruited from one tertiary cancer centre. Each data collection method was analysed separately and then integrated. Parents frequently under-medicate their child's pain at home. Practical barriers including the analgesic context and children finding medications unpalatable led parents to prefer non-pharmacological interventions. Attitudinal and practical barriers result in parents having an "empty toolbox" of pharmacological interventions. Consequently non-pharmacological interventions are essential to parents managing their child's cancer pain at home.

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study

BackgroundConcerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.AimsTo identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.DesignMixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.SettingQuantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.ParticipantsQuantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.Main outcome measuresLength of stay, quality of assessment and carer-rated experience.ResultsPeople with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.LimitationsThe quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.ConclusionsIf effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.Future workFuture research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.

Fewer hospitalizations and prolonged technique survival with home hemodialysis\u2013 a matched cohort study from the Swedish Renal Registry

BackgroundPatients on home hemodialysis (HHD) exhibit superior survival compared with patients on institutional hemodialysis (IHD) and peritoneal dialysis (PD). There is a sparsity of reports comparing morbidity between HHD and IHD or PD and none in a European population. The aim of this study is to compare morbidity between modalities in a Swedish population.MethodsThe Swedish Renal Registry was used to retrieve patients starting on HHD, IHD or PD. Patients were matched according to sex, age, comorbidity and start date. The Swedish Inpatient Registry was used to determine comorbidity before starting renal replacement therapy (RRT) and hospital admissions during RRT. Dialysis technique survival was compared between HHD and PD.ResultsRRT was initiated with HHD for 152 patients; these were matched with 608 patients with IHD and 456 with PD. Patients with HHD had significantly lower annual admission rate and number of days in hospital. (median 1.7 admissions; 12 days) compared with IHD (2.2; 14) and PD (2.8; 20).The annual admission rate was significantly lower for patients with HHD compared with IHD for cardiovascular diagnoses and compared with PD for infectious disease diagnoses. Dialysis technique survival was significantly longer with HHD compared with PD.ConclusionsPatients choosing HHD as initial RRT spend less time in hospital compared with patients on IHD and PD and they were more likely than PD patients, to remain on their initial modality. These advantages, in combination with better survival and higher likelihood of renal transplantation, are important incentives for promoting the use of HHD.

Post-Acute Care for Older People Following Injury: A Randomized Controlled Trial

ObjectivesThe study sought to determine whether older people, on discharge from hospital and on referral to a supported discharge team (SDT), will have: (1) reduced length of stay in hospital; (2) reduced risk of hospital readmission; and (3) reduced healthcare costs. Design/InterventionRandomized controlled trial with follow-up at 4 and 12 months of post-acute home-based rehabilitation team (SDT). Programs were delivered by trained healthcare assistants, up to 4 times a day, 7 days a week, under the guidance of registered nurses, allied health, and geriatricians for up to 6 weeks. Participants/SettingA total of 303 older women and 100 older men (mean age 81) in hospital because of injury, were randomized to either SDT (n = 201) or usual care (n = 202). The intervention was operated from Waikato hospital, a regional hospital in New Zealand. MethodsDays spent in hospital in the year following randomization and healthcare costs were collected from hospital datasets, and functional status assessed using the interRAI Contact Assessment was gathered by health professional research associates. ResultsParticipants randomized to the SDT spent less time in hospital in the period immediately prior to discharge (mean 20.9 days) in comparison to usual care (mean 26.6 days) and spent less time in hospital in the 12 months following discharge home. Healthcare costs were lower in the SDT group in the 12 months following randomization. Conclusions/ImplicationsSDT can provide an important role in reducing hospital length of stay and readmissions of older people following an injury. Almost a million older people (65+ years of age) a year in the US are hospitalized as a consequence of falls-related injuries, most often fractured hip. Hospitals are not always the best location to provide care for older people. SDTs can help with the transition from hospital to home, while reducing hospital length-of-stay.

Neurobehavioral effects of neonatal opioid exposure in mice: Influence of the OPRM1 SNP.

Opioid use among pregnant women is a growing public health concern in the United States. Infants exposed to opioids in utero are at risk of exhibiting neonatal opioid withdrawal syndrome (NOWS). The biological mechanisms underlying short and long-term consequences of in utero opioid exposure and NOWS are unknown. A potential genetic factor is a single-nucleotide polymorphism (SNP) in the mu-opioid receptor gene (OPRM1 A118G). Opioid exposed infants with the G-allele spend less time in hospitals after birth. To determine whether this SNP modulates the neurobehavioral effects of neonatal opioid exposure and withdrawal, we used mice possessing the equivalent Oprm1 SNP (A112G). Pups were treated chronically with saline or morphine from postnatal days (PNDs) 1 to 14, a developmental period equivalent to the third trimester of a human pregnancy and a sensitive period for opioid exposure in rodents. Morphine treatment produced significant developmental delays regardless of genotype and increased total ultrasonic vocalizations in males during spontaneous withdrawal. Animals were aged and tested for anxiety and drug response during adolescence and adulthood, respectively. AA morphine-treated animals showed reduced activity in the marble burying task compared with saline controls; however, this effect was absent in AG and GG animals. As adults, AA males exposed to morphine from PNDs 1 to 14 exhibited enhanced development of locomotor sensitization to morphine, whereas females showed reduced locomotor sensitization. These data suggest the involvement of the Oprm1 SNP for certain outcomes of neonatal opioid exposure and highlight the importance of considering sex and genetic variability for the prognosis of NOWS.

PF173 RESULTS FROM UKALL60+, A UK PHASE 2 STUDY IN ELDERLY PATIENTS WITH UNTREATED ACUTE LYMPHOBLASTIC LEUKAEMIA

Background:The outcome for older adults with acute lymphoblastic leukaemia (ALL) is unsatisfactory. Few studies have focussed entirely on older patients with ALL, despite an increasing incidence with age.Aims:To establish baseline expectations for CR, event free survival (EFS), OS and quality of life (QOL) measures for older patients of all ages and pre‐morbid states.Methods:UKALL60+ offered five ‘Pathways’ to be decided by investigator and patient choice (Table 1). Any patient with newly diagnosed ALL &gt;60 years (or &gt;55 and unfit for more intensive therapy) was eligible, with no exclusions for co‐morbidities, including concurrent malignancies. Baseline characteristics of each group including Charlson Comorbidity Index, ECOG, Karnofsky, IADL and CRASH scores were collected. The primary endpoint was CR rate after 2 phases of induction. Secondary objectives included EFS and OS, treatment related mortality and QOL.Results:From January 2013 to December 2018, 121 patients were recruited (5 excluded due to misdiagnosis) with a median age of 69 years (Range 55–83). Median follow up was 29.9 months (Range 1 day to 55 months). Table 1 shows treatment allocation by Pathway. Patients allocated the non‐intensive pathway D were significantly older (Median age of 73 cf. 67 years, p &lt; 0.001) and more dependant (IADL score p = 0.04) but had non‐significant differences in co‐morbidities as assessed by CRASH score and Charlson index when compared with the Intensive Pathway B. Cytogenetics or FISH was attempted at diagnosis on 98 patients. The main abnormalities detected were as follows: t(9;22) = 26, t(4;11) = 2, other MLL = 2, low hypodiploidy/near‐triploidy = 14, complex karyotype = 2.The Primary Endpoint of CR rate after 2 phases of induction by Pathway were A (Ph+ve) = 22/24 (92%), B Intensive) 33/48 (69%), C (Intensive+) 5/9 (56%), D (Non‐intensive) 8/18 (44%) and Pathway E 9/15 (60%). At a median follow up of 29 months EFS &amp; OS by Pathway were; A 59% &amp; 61%, B 57% &amp; 71% C 40% &amp; 53% and D 9% &amp; 19%.Grade 3/4 AEs were seen in the majority of patients. The most common toxicities were haematological and infections. The haematological and non‐haematological AE rate was similar in Pathway D to Pathways A‐C both for all AE's and grade 3/4 AE's.Across all Pathways 48 patients have relapsed at a median of 11.4 months. To date 68 deaths have been reported; 52 patients died of ALL and 11 from infection. Non intensive Pathway D enabled patients to spend less time in hospital, particularly in Induction I, with an average of 15 inpatient days compared with 28.5 days for Pathway B (p = 0.002).Summary/Conclusion:Our study reflects the reality that treating ALL in older patients is a difficult balance between efficacy and toxicity. AE rates were high, as expected, but despite this the majority of patients who died did so from ALL. Age but not co‐morbidities as measured by Charlson and CRASH appears to be associated with choice of therapy. Patients treated on the non‐intensive pathway D, although spending less time in hospital had similar AE rates. They had a low CR rate and less than 20% 1 year EFS rate. Patients with Ph+ve disease had a higher CR rate but this did not translate into improved EFS or OS. We noted small numbers of longer‐term survivors and anticipate that forthcoming MRD and correlative science data will shed light on the correlates of good outcome in these persons. The UKALL60+ data will be invaluable as a baseline from which to develop more effective regimens including novel agents.image

SAT-076-Long term palliative abdominal drains versus large volume paracentesis in refractory ascites due to cirrhosis: a multi-centre feasibility randomised controlled trial (the REDUCe Study)

Background and aims: Ascites develops in about 90% with advanced cirrhosis; when refractory to medical therapy, standard of care is repeated large volume paracentesis (LVP) with albumin support. Refractory ascites (RA) confers a median life expectancy of six months without liver transplantation (LT). LVP is not an optimal palliative strategy. One alternative is long-term abdominal drains (LTAD), used in advanced malignant ascites, also enabling community management. Our ultimate aim is to improve end of life care (EoLC) in advanced cirrhosis and RA. This feasibility randomised controlled trial (RCT) aimed to resolve uncertainties in designing a definitive RCT. Method: Multicentre feasibility RCT with 1:1 randomisation between standard of care (LVP) vs. LTAD (Rocket Medical) in adults with RA, ineligible for LT. Both arms received prophylactic antibiotics. LTAD were inserted under ultrasound guidance. Community nurses undertook home visits to drain ascites dependent on symptoms; (maximum 6L/week), without albumin support. Follow-up was 12 weeks with home visits every two weeks for the following assessments: clinical, questionnaire based to include quality of life, palliative care needs, carer burden and health economics (HE). Here we report clinical and HE outcomes. Results: Thirty six patients were randomised; 19 LVP (two withdrew, wanting LTAD) and 17 LTAD (one withdrew-insufficient ascites). Mean age (years) LTAD vs. LVP 66 + 10.4 vs. 68 ± 12; predominately male (76% vs. 74%). Participants were well matched at baseline in liver tests and prognostic scores: LTAD vs. LVP (serum bilirubin (μmol/L) 26 ± 15.8 vs. 16 ±10, serum albumin (g/L) 33 ± 4.2 vs. 31 ± 3.3, serum creatinine (mmol/L) 113 ± 46.7 vs.118 ± 53.1; MELD 14 ± 4.6 vs. 16 ± 7.2). One LTAD participant required hospitalisation for repeated LVP. Serum albumin (g/L) in the LTAD arm declined to 29 ± 3.3 at week two, subsequently remaining stable LTAD vs. LVP (29 ± 5.6 vs. 31 ± 5.5). Serum creatinine remained stable in both arms. There were no LTAD related serious adverse reactions. LTAD related adverse reactions included mild cellulitis (n = 4) and small volume leakage around LTAD insertion site (n = 3), all resolving rapidly. Peritonitis was rare, LTAD (possible) n = 1 and LVP n = 2. Overall mortality was 36% (12/33). Mortality and median survival (days in those who died) were 7/16 (44%) vs. 5/17 (29%), 53 days (IQR 43) vs. 61 days (IQR 35) in LTAD vs. LVP respectively. All but one death was liver related. Those in LTAD arm spent ≈20% less time in hospital. All nine alive in the LTAD arm at end of study elected to keep LTAD in. Detailed clinical and HE analysis is underway. Conclusion: Preliminary data from the REDUCe study supports the safety and efficacy of palliative LTAD in RA due to advanced cirrhosis. LTAD allows successful management in the community with reduction in health resource utilisation. Proceeding to a definitive RCT is justified.

Integrating Health and Social Care: State or Market?

Medical and nursing care have been separated from social care by deliberate design since the creation of the NHS. This divide is now entirely artificial. People spend less time in hospital than used to be the case and 4 million people over the age of 65 have a life-limiting illness. In such circumstances, medical, nursing, and personal care should be combined in a range of institutional settings. Technology is also contributing to the breakdown in the divide between medical, nursing and personal care, and the institutional settings in which they take place. There have been growing calls for the greater integration of health and social care, ranging from the current government’s policy of bringing the functions under one ministry to Labour Party proposals for a National Care Service. The National Health Service is already the fifth largest employer in the world with 1.4 million people. The social care sector employs 1.6 million people. An integrated national health and care service would be the largest employer in the world. Bringing social care within the orbit of government planning and finance would lead to the creation of a centrally planned service without precedent in the Western world. However, it is difficult to achieve integration of health and social care due to their organisational structure. Competition and markets are the best way to discover how to integrate health and social care. To achieve meaningful integration, we should make the health sector more like the social care sector and move health provision closer to the models that exist in continental Europe.

PCV153 - ELICITING PUBLIC PREFERENCES FOR REORGANIZATION OF VASCULAR SERVICES IN THE UK

The organisation of vascular services in the NHS is currently in a state of flux, with various options for reorganisation being considered. The aim of the proposed research is to elicit preferences from members of the public for: (1) treatment processes, as they have the option to undergo either keyhole surgery or open surgery for the repair of abdominal aortic aneurysms and (2) travelling distances for treatment. Telephone interviews were conducted with members of the public without a significant vascular condition. These participants were recruited from 15 different NHS Trusts in the UK. The interview involved participants being asked to trade-off the chance of a vascular treatment being successful against how far they would be willing to travel for treatment. The study included 202 participants (median age 55y; 68% female). Of these, 165 (81.7%) preferred the keyhole surgery, 36 (17.8%) preferred the open surgery and one person had no preference. When participants were told that they would have to travel to a specialist hospital that is up to 60 miles further away, 41 people refused to travel even if the chance of success for treatment was higher at the specialist hospital. In contrast, 163 people were willing to travel to the specialist hospital, even when they were told that the chance of success was no different to their local hospital. The remaining participants were willing to travel to the specialist hospital contingent upon a 3% increase in chance of treatment success. This study shows that participants preferred the keyhole surgery because of the less invasive nature of the procedure (i.e. less time in hospital, less pain and quicker recovery). Moreover, we found that the vast majority of people are willing to travel to access specialist services.

Intensive care support and clinical outcomes of patients with Ebola virus disease (EVD) in West Africa

PurposeWe investigate the impact on outcome of different levels of supportive treatment in Ebola virus disease (EVD). The NGO EMERGENCY delivered care sequentially at two Ebola Treatment Centres (ETC) in Sierra Leone: first at Lakka (fluids, symptomatic, antibiotic, antimalaria treatment, and hospital level medical care), and thereafter in Goderich, adding organ support in the only African ETC with an equipped and staffed intensive care unit (ETC-ICU).MethodsThe primary outcome in this retrospective cohort study was in-ETC mortality. Secondarily, we used multivariable logistic regression to investigate the independent impact of the IC on mortality by comparing patients in two ETCs, adjusting for potential confounders, including the viral load (base-10 logarithm in copies/ml) (LVL), modelled as a piecewise linear function. Mortality was plotted versus LVL. Confidence bands were constructed by a bootstrap technique. The number of hospital-free days within 28 was computed to assess the burden of EVD.ResultsData from 229 EVD patients were analysed (123 in Lakka, 106 in Goderich). Crude analysis showed a non-statistically significant difference in mortality (57.7% in Lakka vs 50.0% in Goderich; p = 0.19). Age and LVL were associated with mortality. Adjusted mortality was lower at the Goderich ICU-ETC (p = 0.055). This difference was observed with 80% confidence for patients with LVL between 7.5 and 8.5 copies/ml. Hospital-free days (of 28 days) were greater (7.7 vs 5.5; p = 0.03) for patients treated in the ICU-ETC.ConclusionsProvision of critical care to patients with EVD is feasible in resource-limited settings and was associated with improved survival and less time in hospital.

Cost Analysis of Initial Treatment With Endovascular Revascularization, Open Surgery, or Primary Major Amputation in Patients With Peripheral Artery Disease

Purpose: To compare the total initial treatment costs for open surgery, endovascular revascularization, and primary major amputation within a single-payer healthcare system. Methods: A multicenter, retrospective analysis was undertaken to evaluate 1138 patients with symptomatic peripheral artery disease (PAD) who underwent 1017 endovascular procedures, 86 open surgeries, and 35 major amputations between 2013 and 2016. A cost-mix analysis was performed on individual patient data generated for selected diagnosis-related groups. Mean costs are presented with the 95% confidence interval (CI). Results: There was no intergroup difference in demographics or private health insurance status. However, the amputation group had a higher proportion of emergency procedures (68.6% vs 13.3% vs 27.9%, p<0.001) and critical limb ischemia (88.6% vs 35.9% vs 37.2%, p<0.001) compared with the endovascular therapy and open surgery groups, respectively. The endovascular revascularization group spent less time in hospital and used fewer intensive care unit (ICU) resources compared with the open surgery and major amputation groups (hospital length of stay: 3.4 vs 10.0 vs 20.2 days, p<0.01; ICU: 2.4 vs 22.6 vs 54.6 hours, p<0.01), respectively. While mean prosthetic and device costs were higher in the endovascular group [AUD$2770 vs AUD$1658 (open) and AUD$1219 (amputation), p<0.01], substantial disparities were observed in costs associated with longer operating theater times, length of stay, and ICU utilization, which resulted in significantly higher costs in the open and amputation groups. After adjusting for confounders, the AUD$18,396 (95% CI AUD$16,436 to AUD$20,356) mean cost per admission for the endovascular revascularization group was significantly less (p<0.001) than the open surgery (AUD$31,908, 95% CI AUD$28,285 to AUD$35,530) and major amputation groups (AUD$43,033, 95% CI AUD$37,706 to AUD$48,361). Conclusion: Endovascular revascularization procedures for PAD cost the health payer less compared with open surgery and primary amputation. While devices used to deliver contemporary endovascular therapy are more expensive, the reduction in bed days, ICU utilization, and related hospital resources results in a significantly lower mean total cost per admission for the initial treatment.