National Health Service Patients Research Articles

Creating a learning health system to include environmental determinants of health: The GroundsWell experience.

Policies aiming to prevent ill health and reduce health inequalities need to consider the full complexity of health systems, including environmental determinants. A learning health system that incorporates environmental factors needs healthcare, social care and non-health data linkage at individual and small-area levels. Our objective was to establish privacy-preserving household record linkage for England to ensure person-level data remain secure and private when linked with data from households or the wider environment. A stakeholder workshop with participants from our regional health board, together with the regional data processor, and the national data provider. The workshop discussed the risks and benefits of household linkages. This group then co-designed actionable dataflows between national and local data controllers and processors. A process was defined whereby the Personal Demographics Service, which includes the addresses of all patients of the National Health Service (NHS) in England, was used to match patients to a home identifier, for the time they are recorded as living at that address. Discussions with NHS England resulted in secure and quality-assured data linkages and a plan to flow these pseudonymised data onwards into regional health boards. Methods were established, including the generation of matching algorithms, transfer processes and information governance approvals. Our collaboration accelerated the development of a new data governance application, facilitating future public health intervention evaluations. These activities have established a secure method for protecting the privacy of NHS patients in England, while allowing linkage of wider environmental data. This enables local health systems to learn from their data and improve health by optimizing non-health factors. Proportionate governance of health and linked non-health data is practical in England for incorporating key environmental factors into a learning health system.

Self-referral to musculoskeletal physiotherapy in the National Health Service (NHS): a mixed methods, four-domain analysis of 1,000 adult new patients initially assessed via telephone versus face-to-face

Introduction In some regions, NHS patients are able to self-refer to physiotherapy. Initial assessment and triage of these referrals is via telephone (PhysioDirect) or face-to-face (Physio Access Clinic). There is currently a scarcity of literature comparing both methods in physiotherapy triage. A multi-domain mixed-methods comparison was conducted to evaluate cost, outcomes & satisfaction of both methods. Method Data was collected for telephone and face-to-face self-referrals from October 2021 to February 2022 and analysed to compare patient outcome, patient satisfaction, physiotherapist perception and cost between both delivery methods. Results Outcomes were analysed across 2402 total patient contacts, with face-to-face assessment showing improved outcomes in all areas compared to telephone assessment. Patient satisfaction was greater following face-to-face assessment than telephone. Physiotherapists showed greater satisfaction, greater diagnostic confidence, greater feeling of support and improved learning with a face-to-face approach. Scaled to 150 patients per week face-to-face only was associated with an annual saving of over £40,000 compared to telephone only initial assessment. This is equivalent to 1503 physiotherapist hours and 550 administrative hours. Conclusion Patients self-referring to musculoskeletal physiotherapy via a face-to-face clinic have improved outcomes with greater reported satisfaction. Physiotherapists preferred face-to-face appointments in all facets examined within this study. A significant annual cost saving was evident through face-to-face contact which is especially relevant in the current economic climate of the NHS. Given these notable advantages of face-to-face triage over telephone triage, these findings could inform the planning of future physiotherapy provision.

Cognitive Functional Therapy compared with usual physiotherapy care in people with persistent low back pain: a mixed methods feasibility randomised controlled trial in the United Kingdom National Health Service

ObjectivesTo determine the feasibility of completing a definitive randomised controlled trial (RCT), evaluating the clinical and cost-effectiveness of Cognitive Functional Therapy (CFT) in comparison to usual physiotherapy care (UPC), for people with persistent low back pain (LBP). Design and settingA two-arm parallel feasibility RCT completed in a United Kingdom (UK) Secondary Care National Health Service (NHS) physiotherapy service. ParticipantsSixty adult participants who reported LBP lasting for more than three months, that was not attributable to a serious (e.g. cancer) or specific (e.g. radiculopathy) underlying cause, were invited to participate. Participants were allocated at random to receive CFT or UPC. InterventionsCognitive Functional Therapy and Usual Physiotherapy Care for persistent LBP. Main outcome measuresThe primary outcome was the feasibility of completing a definitive RCT, defined by recruitment of at least 5 participants per month, delivery of CFT per protocol and securing relevant and acceptable outcome measures. Data concerning study processes, resources, management and participant reported outcome measures were collected at baseline, 3, 6 and 12-month follow-up. ResultsSixty participants (n = 30 CFT and n = 30 UPC) were recruited with 80% (n = 48), 72% (n = 43) and 53% (n = 32) retained at 3, 6 and 12-month follow-up respectively. NHS physiotherapists were trained to competence and delivered CFT with fidelity. CFT was tolerated by participants with no adverse events. Relevant and clinically important outcome data were collected at all time points (0.4%, 3%, 1% and 0.8% of data was missing from the returned outcome measure booklets at baseline and 3, 6 and 12-month follow-up respectively). The Roland-Morris disability questionnaire was considered the most suitable primary outcome measure with a proposed sample size of 540 participants for a definitive cluster RCT. ConclusionIt is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future study should incorporate an internal pilot to address aspects of feasibility further, including participant retention strategies. Clinical trial registration numberISRCTN12965286 Contribution of the paper•Cognitive Functional Therapy (CFT) has shown encouraging results for reducing pain and disability in people with persistent LBP in previous clinical trials. The clinical and cost-effectiveness of CFT has not previously been evaluated in a definitive trial in the United Kingdom National Health Service. This is the first study to evaluate the feasibility of completing such a trial.•The findings of this study confirmed that;•NHS patients can be recruited on time and to target, with no safety concerns regarding a randomised controlled trial.•NHS physiotherapists can be trained to competence to deliver CFT with fidelity.•Clinically relevant and important data can be collected using standardised outcome measures.•New knowledge about the feasibility of completing a definitive trial of CFT in the UK NHS has been gained.

The Impact of Continuous Lenalidomide Maintenance Treatment on People Living with Multiple Myeloma - a Single-Centre Qualitative Service Evaluation

Background: Randomised trials examining continuous lenalidomide maintenance after autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM) have demonstrated progression free survival (PFS) and overall survival benefit compared to placebo. In 2021 the UK National Institute of Clinical Excellence (NICE) approved lenalidomide maintenance for all newly diagnosed National Health Service (NHS) patients receiving ASCT after induction chemotherapy. Patient-reported outcomes from observational studies suggest lenalidomide causes tolerable adverse effects. However, clinical trial data demonstrate that neutropenia, fatigue, neuropathy, and gastrointestinal issues are common, particularly in the first six months of treatment, and that lenalidomide increases the risk of secondary malignancies. Before lenalidomide maintenance was used in this setting, individuals would typically enter a treatment-free phase after ASCT, where they might experience a reasonable quality of life (QoL) without treatment burden. Studies suggest that medication breaks allow patients to detach from the ‘illness’ experience, but with continuous lenalidomide that opportunity is lost. Whilst the PFS benefit of lenalidomide maintenance is proven, both short- and longer-term toxicities reported in clinical trials suggest the trade-off between efficacy and harm should be considered. In-depth information about how continuous lenalidomide impacts individuals' QoL is scant. The overall objective of this qualitative service evaluation was to examine patients' experience of lenalidomide maintenance, including perceived impact on QoL and experience of side-effects. It was anticipated that findings would result in clinical service improvement through the delivery of communication better suited to patients' needs and priorities when facing treatment choices. Methods: We conducted 20 one-to-one semi-structured interviews with purposively selected patients (10 female and 10 male) from a specialist MM center in London. All participants had undergone induction chemotherapy followed by ASCT and were receiving continuous lenalidomide. Ages ranged from 45 to 71 years (median 58). The sample comprised 12 White British, 2 Black Caribbean, 1 Black African, 1 Asian Indian, 2 from other ethnic groups and 2 with undisclosed ethnicity. Lenalidomide treatment duration varied; seven patients had received lenalidomide for 1-6 months, five for 7-12 months, five for 13-18 months, one for 19-24 months, and two for over 24 months. Reflexive thematic analysis was used for data analysis. Results: Four themes were developed from the data: 1) Lenalidomide: understanding its role and rationale, 2) Reframing the loss of a treatment-free period to a return to normal life, 3) The reality of being on continuous lenalidomide maintenance: balancing hopes with hurdles, 4) Gratitude and Grievances: Exploring patients' mixed perceptions of care and communication. Most patients believed lenalidomide maintenance would double remission time and were compelled by the relative certainty it offered, which contrasted with the unpredictability of MM. Many participants reported that lenalidomide helped to diminish fears about relapse, and thus most did not feel they were missing out on a treatment break. The impact of lenalidomide maintenance on patients' QoL varied; younger patients reported no/negligible side-effects, while several older patients with comorbidities described significant symptom burden, such as skin rashes, debilitating fatigue, unpredictable gastric disturbances and bone pain, occasionally leading to treatment discontinuation which caused distress at the perceived loss of prolonged remission. The transition from frontline to maintenance treatment required a return to greater patient autonomy as medical support was reduced. Some patients described anxiety and depression in this period, suggesting the need for greater support. The study also highlighted specific challenges that younger patients experience, such as concerns about sexual transmission and fertility, which merits further research. Conclusions: Understanding the real-world symptom burden in MM is key as continuous treatment becomes routine. Qualitative research on the impact of treatment could lead to a more comprehensive understanding, helping patients cope with the increasingly chronic nature of this disease.

A qualitative study exploring healthcare workers' lived experiences of the impacts of COVID-19 policies and guidelines on maternal and reproductive healthcare services in the United Kingdom.

During the COVID-19 pandemic, pregnant women were regarded as vulnerable to poor health outcomes if infected with the SARS-CoV-2 (COVID-19) virus. To protect the United Kingdom's (UK) National Health Service (NHS) and pregnant patients, strict infection control policies and regulations were implemented. This study aimed to understand the impact of the COVID-19 policies and guidelines on maternal and reproductive health services during the pandemic from the experiences of healthcare workers (HCWs) caring for these patients. This qualitative study involved HCWs from the United Kingdom Research study into Ethnicity and COVID-19 outcomes in Healthcare workers (UK-REACH) project. Semi-structured interviews and focus groups were conducted online or by telephone with 44 diverse HCWs. Transcripts were thematically analyzed following Braun and Clarke's principles of qualitative analysis. Three key themes were identified during analysis. First, infection control policies impacted appointment availability, resulting in many cancellations and delays to treatment. Telemedicine was also used extensively to reduce risks from face-to-face consultations, disadvantaging patients from minoritized ethnicities. Secondly, staff shortages and redeployments reduced availability of consultations, appointments, and sonography scans. Finally, staff and patients reported challenges accessing timely, reliable and accurate information and guidance. COVID-19 demonstrated how a global health crisis can impact maternal and reproductive health services, leading to reduced service quality and surgical delays due to staff redeployment policies. Our findings underscore the implications of policy and future health crises preparedness. This includes tailored infection control policies, addressing elective surgery backlogs early and improved dissemination of relevant vaccine information.

Design and Implementation of a National Program to Monitor the Prevalence of SARS-CoV-2 IgG Antibodies in England Using Self-Testing: The REACT-2 Study.

Data System. The UK Department of Health and Social Care funded the REal-time Assessment of Community Transmission-2 (REACT-2) study to estimate community prevalence of SARS-CoV-2 IgG (immunoglobulin G) antibodies in England. Data Collection/Processing. We obtained random cross-sectional samples of adults from the National Health Service (NHS) patient list (near-universal coverage). We sent participants a lateral flow immunoassay (LFIA) self-test, and they reported the result online. Overall, 905 991 tests were performed (28.9% response) over 6 rounds of data collection (June 2020-May 2021). Data Analysis/Dissemination. We produced weighted estimates of LFIA test positivity (validated against neutralizing antibodies), adjusted for test performance, at local, regional, and national levels and by age, sex, and ethnic group and area-level deprivation score. In each round, fieldwork occurred over 2 weeks, with results reported to policymakers the following week. We disseminated results as preprints and peer-reviewed journal publications. Public Health Implications. REACT-2 estimated the scale and variation in antibody prevalence over time. Community self-testing and -reporting produced rapid insights into the changing course of the pandemic and the impact of vaccine rollout, with implications for future surveillance. (Am J Public Health. 2023;113(11):1201-1209. https://doi.org/10.2105/AJPH.2023.307381).

A real-world study of the first use of palbociclib for the treatment of advanced breast cancer within the UK National Health Service as part of the novel Ibrance® Patient Program.

The Ibrance® Patient Program was established to provide access to palbociclib for UK National Health Service (NHS) patients with metastatic breast cancer (MBC), pending a funding decision. Non-interventional cohort study involving a retrospective medical record review of patients commenced on palbociclib between April and December 2017 at eight UK centres. Primary outcomes included clinicopathological characteristics, treatment patterns, clinical outcomes and selected adverse events. Overall, 191 patients were identified, median age of 57.0 years (range 24.3-90.9); 30% were diagnosed with de novo MBC; 72% received first-line and 10% as ≥ second-line treatment. Median progression-free survival (95% CI) was 22.8 months (16.5-not reached [NR]) in first-line; NR in patients with de novo MBC; 7.8 months (6.8-NR) in ≥ second-line (median follow-up: 24 months). Median overall survival (OS) was NR in the overall cohort; OS rate (95% CI) at 24 months was 74.2% (67.1-81.9%) in first-line; 82.1% (72.6-92.8%) in patients with de novo MBC; 55.0% (37.0-81.8%) in ≥ second-line. Forty-seven per cent of patients developed grade 3-4 neutropenia; 3% febrile neutropenia. This study supports the effectiveness of palbociclib and demonstrates the benefit to patients of early access schemes that bridge the gap between regulatory approval and NHS funding for new medicines. Clinical trial: ClinicalTrial.gov:NCT03921866.

Did the Acute Frailty Network improve outcomes for older people living with frailty? A staggered difference-in-difference panel event study

ObjectivesTo evaluate whether the Acute Frailty Network (AFN) was more effective than usual practice in supporting older people living with frailty to return home from hospital sooner and healthier.DesignStaggered difference-in-difference...

P42 Are chest X-rays still necessary for prebiologic tuberculosis screening? A retrospective audit

Abstract Biologics are commonly used in autoimmune dermatological conditions as an option if other treatments are unsuccessful or contraindicated. However, one major side-effect of biologics is immunosuppression, which may lead to the reactivation of latent tuberculosis (TB) in patients. The British Association of Dermatology has implemented guidelines that require doctors to screen for TB before prescribing biologics to patients. The 2020 guidelines advise screening questions, performance of a chest X-ray (CXR) and an interferon-γ release assay (IGRA). Current studies show that CXR has a sensitivity of 15% when diagnosing latent TB. While there is no gold standard for diagnosing latent TB, the IGRA is a commonly used test and is shown to be four times more effective than the tuberculin skin test. This study questions the diagnostic value of CXR in the screening of TB in asymptomatic patients, and whether it should be removed from the guidelines for such patients. A retrospective audit of dermatological patients in our trust was done over a 24-month period (January 2020–January 2022). Patients selected for the audit were those diagnosed with psoriasis or hidradenitis suppurativa and started on biologics during this 24-month period. Patients were assessed on the following: patient history, CXR results, IGRA results and screening outcomes. The data were quantitatively analysed to uncover the necessity of performing a CXR on patients starting biologics. Between January 2020 and January 2022, 77 patients were scheduled for prebiologic TB screening; CXRs were performed in 74 patients (96%), while 72 (94%) of patients had IGRA tests. During this period, three patients (4%) were diagnosed with latent TB based on positive IGRA results and normal CXR findings. They were subsequently treated for latent TB infection prior to biologic therapy. None of the patients with negative IGRA results had positive CXR findings for TB. This finding suggests that CXR is unnecessary at the initial stage of prebiologic TB screening for asymptomatic patients. IGRA can detect both latent and active TB, while CXR is recommended for the diagnosis of active TB. Mandating CXR comes at a cost to the National Health Service and subjects patients to unnecessary radiation exposure. We propose that CXR be done only for patients who are either symptomatic for TB or have a positive IGRA result.

BT13 MySkinDoctor: lessons learnt from assessing 120 000 teledermatology patients

Abstract MySkinDoctor is a novel teledermatology platform that enables dermatologists to review images submitted directly by the patient via their smartphone, in addition to any metadata and the standard general practitioner referral. The three sets of data are used to triage or provide advice and guidance to National Health Service patients throughout the south east of England. Since its inception in 2019, the service has completed the assessment of > 120 000 cases. Analysis of the data shows that an unnecessary first appointment has been avoided in 48% of cases. This has led to a sharp reduction in waiting times in the areas in which it is being used (an average of 6 weeks) vs. neighbouring areas where waiting times remain between 27 and 50 weeks. Another benefit of the service is that, on average, each patient using it submits three digital images that are subsequently tagged inter alia with their age, sex, body location and the consultant’s diagnosis. This has resulted in a large, and growing, digital image library with associated dataset of patients that has been used to develop an artificial intelligence platform called ‘dermXai’. Using convolutional neural networks for image identification has produced an accuracy of determination of > 90% for the top 20 conditions seen. We will discuss the implementation schedule and regulatory challenges that need to be met in order for dermXai to support clinical decision-making. There are also environmental and economic benefits associated with using MySkinDoctor. Since its inception, it has saved > 40 000 road miles—over twice Earth’s circumference. This is a CO2 saving of 16 488 kg. The benefit to patients and their carers in terms of saving travel and regaining otherwise lost productivity time is difficult to quantify but could be studied prospectively. Patient-led digital dermatology is the obvious evolution of traditional teledermatology and our successful experience with MySkinDoctor and dermXai in southern England provides a template for a national service that will eliminate backlogs and significantly reduce patient waiting times. Conflicts of interest: Dr Bav Shergill is the Chief Medical Officer of MySkinDoctor Ltd and a Director of dermXai.

Mixed-methods evaluation of point-of-care hepatitis C virus RNA testing in a Scottish prison

ObjectivesHepatitis C virus (HCV) poses a global public health threat. Prisons are a focus of prevention efforts due to high infection burdens. Expedition of treatment for incarcerated people is critical,...

UK physiotherapists delivering physical activity advice: what are the challenges and possible solutions? A qualitative study

ObjectivesDespite the known health benefits of physical activity (PA), PA levels are in decline. Healthcare professionals, including physiotherapists, have been identified as ideal conduits to promote PA, yet their knowledge...

Clinical characteristics of patients undergoing primary bariatric surgery in the United Kingdom based on the National Bariatric Surgery Registry.

Baseline demographic characteristics and operations undertaken for patients having bariatric surgery in the United Kingdom are largely unknown. This study aimed to describe the profile of patients having primary bariatric surgery in the National Health Service (NHS) or by self-pay, and associated operations performed for both pathways. The National Bariatric Surgery Registry dataset for 5 years between January 2015 and December 2019 was used. 34 580 patients underwent primary bariatric surgery, of which 75.9% were NHS patients. Mean patient age and initial body mass index were significantly higher for NHS compared to self-pay patients (mean age 45.8 ± 11.3 [SD] vs. 43.0 ± 12.0 years and initial body mass index 48.0 ± 7.9 vs. 42.9 ± 7.3kg/m2 , p < .001). NHS patients were more likely to have obesity-related complicationscomparedtoself-paypatients: prevalence of Type 2 diabetes mellitus 27.7% versus 8.3%, hypertension 37.1% versus 20.1%, obstructive sleep apnoea 27.4% versus 8.9%, severely impaired functional status 19.3% versus 13.9%, musculoskeletal pain 32.5% versus 20.1% and being on medication for depression 31.0% versus 25.9%,respectively(all p < .001). Gastric bypass was the most commonly performed primary NHS bariatric operation 57.2%, but sleeve gastrectomy predominated in self-pay patients 48.7% (both p < .001). In contrast to self-pay patients, NHS patients are receiving bariatric surgery only once they are older and at a much more advanced stage of obesity-related disease complications.

The incidence and management of peripheral nerve injury in England (2005–2020)

Anonymized hospital episode statistical (HES) data on admitted patient care was obtained from NHS Digital for all National Health Service (NHS) patients sustaining PNI of all body regions between 2005 and 2020. Total numbers of finished consultant episodes (FCEs) or FCEs/100,000 population were used to demonstrate changes in demographic variables, anatomical locations of injury, mechanisms of injury, speciality, and main operation. There was a mean national incidence of 11.2 (95% CI 10.9, 11.6) events per 100,000 population per year. Males were at least twice as likely (p<0.0001) to sustain a PNI. Upper limb nerves at or distal to the wrist were most commonly injured. Knife injuries increased (p<0.0001), whereas glass injuries decreased (p<0.0001). Plastic surgeons increasingly managed PNI (p=0.002) as opposed to orthopaedic surgeons (p=0.006) or neurosurgeons (p=0.001). There was an increase in neurosynthesis (p=0.022) and graft procedures (p<0.0001) during the study period. PNI is a significant national healthcare problem predominantly affecting distal, upper limb nerves of men of working age. Injury prevention strategies, improved targeted funding and rehabilitation pathways are needed to reduce the injury burden and improve patient care.

Bariatric-metabolic surgery for NHS patients with type 2 diabetes in the United Kingdom National Bariatric Surgery Registry.

Bariatric-metabolic surgery is approved by the National Institute of Health and Care Excellence (NICE) for people with severe obesity and type 2 diabetes (T2DM) (including class 1 obesity after 2014). This study analysed baseline characteristics, disease severity and operations undertaken in people with obesity and T2DM undergoing bariatric-metabolic surgery in the UK National Health Service (NHS) compared to those without T2DM. Baseline characteristics, trends over time and operations undertaken were analysed for people undergoing primary bariatric-metabolic surgery in the NHS using the National Bariatric Surgical Registry (NBSR) for 11 years from 2009 to 2019. Clinical practice before and after the publication of the NICE guidance (2014) was examined. Multivariate logistic regression was used to determine associations with T2DM status and the procedure undertaken. 14,948/51,715 (28.9%) participants had T2DM, with 10,626 (71.1%) on oral hypoglycaemics, 4322 (28.9%) on insulin/other injectables, and with T2DMdiagnosed 10+ years before surgery in 3876 (25.9%). Participants with T2DM, compared to those without T2DM, were associated with older age (p < 0.001), male sex (p < 0.001), poorer functional status (p < 0.001), dyslipidaemia (OR: 3.58 (CI: 3.39-3.79); p < 0.001), hypertension (OR: 2.32 (2.19-2.45); p < 0.001) and liver disease (OR: 1.73 (1.58-1.90); p < 0.001), but no difference in body mass index was noted. Fewer people receiving bariatric-metabolic surgery after 2015 had T2DM (p < 0.001), although a very small percentage increase of those with class I obesity and T2DM was noted. Gastric bypass was the commonest operation overall. T2DM status was associated with selection for gastric bypass compared to sleeve gastrectomy (p < 0.001). NHS bariatric-metabolic surgery is used for people with T2DM much later in the disease process when it is less effective. National guidance on bariatric-metabolic surgery and data from multiple RCTs have had little impact on clinical practice.

Integrating drones into NHS patient diagnostic logistics systems: Flight or fantasy?

Healthcare accounts for approximately 5% of emissions in developed nations, and the public healthcare provider in the United Kingdom (UK), the National Health Service (NHS), has set a target to reach net-zero emissions by 2040 without detriment to its quality of patient care. With Uncrewed Aerial Vehicles (UAVs; a.k.a. drones, UAS, or RPAS) starting to be used in healthcare systems outside the UK, there is interest in how they could be integrated into NHS operations to transport diagnostic specimens. Reflecting on a business-as-usual analysis of current NHS diagnostic specimen logistics across the Solent region (southern UK), this paper critically evaluates the practical reality of integrating UAV deliveries of this commodity, identifying the benefits and challenges that must be addressed to realise commercial services, including dangerous goods legislation, cargo stability, routing, and weather. In the analysis, 14 out of 79 surgeries could be realistically served by a 5m wingspan vertical take-off/landing (VTOL) UAV: seven directly, and seven via ground-based transfers. The results suggested that an average of 1,628 samples could be served by UAV each week, resulting in 42 flights/week with 10 taxi services to cover periods where weather limited flying. This equated to an approximate total service cost of £2,964/week if regulations develop to relax UAV personnel constraints. The introduction of UAVs reduced the marginal external costs (greenhouse gas emissions, congestion, and air pollution) by £196 per week and cut travel times to UAV served sites by 72% (weather permitting). Tailpipe emissions (excl. taxis), vehicle-kilometres travelled, and van costs were reduced by 20%, 20%, and 23% (respectively), but the overall system cost increased by 56%. Whilst this increase is likely to make the introduction of UAV services financially challenging, the benefits in terms of emissions and journey time savings may offset some of the additional cost and warrant further investigation.

Ant colony optimisation of a community pharmacy dispensing process using Coloured Petri-Net simulation and UK pharmacy in-field data

There are 11,619 community pharmacies in England which dispense over 1 billion prescriptions each year, providing essential primary care to NHS (National Health Service) patients. These pharmacies are facing pressure from a number of sources including funding cuts and high demands on services, while trying to deliver the highest standards of care. This paper presents an optimisation of a Coloured Petri Net (CPN) community pharmacy simulation model using an Ant Colony Optimisation (ACO) method. The CPN method was proposed by Naybour et al . Quantitative data from UK community pharmacies was collected by the authors and incorporated into the CPN simulation model. The optimisation is made up of a choice of how many staff to employ, which prescription checking strategy to use, and which staff work pattern to implement. This method aims to provide decision makers with a set of optimal pharmacy configurations at different cost levels. This can help to support pharmacy safety, efficiency, and improve decision making processes. It has been demonstrated how reliability modelling techniques traditionally used in safety-critical industries, can be used to carry out safety and efficiency analyses of healthcare systems, such as dispensing processes in community pharmacies, illustrated in this contribution.

Patient-rated satisfaction and improvement following hip and knee replacements: Development of prediction models.

Effective preoperative assessments of determinants of health status and function may improve postoperative outcomes. We developed risk scores of preoperative patient factors and patient-reported outcome measures (PROMs) as predictors of patient-rated satisfaction and improvement following hip and knee replacements. Prospectively collected National Health Service and independent sector patient data (n = 30,457), including patients' self-reported demographics, comorbidities, PROMs (Oxford Hip/Knee score (OHS/OKS)and European Quality of Life (EQ5D index and health-scale), were analysed. Outcomes were defined as patient-reported satisfaction and improvement following surgery at 7-month follow-up. Univariable and multivariable-adjusted logistic regressions were undertaken to build prediction models; model discrimination was evaluated with the concordance index (c-index) and nomograms were developed to allow the estimation of probabilities. Of the 14,651 subjects with responses for satisfaction following hip replacements 564 (3.8%) reported dissatisfaction, and 1433 (9.2%) of the 15,560 following knee replacement reported dissatisfaction. A total of 14,662 had responses for perceived improvement following hip replacement (lack of improvement in 391; 2.7%) and 15,588 following knee replacement (lack of improvements in 1092; 7.0%). Patients reporting poor outcomes had worse preoperative PROMs. Several factors, including age, gender, patient comorbiditiesand EQ5D, were included in the final prediction models: C-indices of these models were 0.613 and 0.618 for dissatisfaction and lack of improvement, respectively, for hip replacementand 0.614 and 0.598, respectively, for knee replacement. Using easily accessible preoperative patient factors, including PROMs, we developed models which may help predict dissatisfaction and lack of improvement following hip and knee replacements and facilitate risk stratification and decision-making processes.

Concussion in Non-athletes: Assessment of Cognition and Symptomatology (CONTACTS) study protocol – an exploratory cohort study investigating the utility of sports concussion assessment tools and salivary microRNAs to diagnose concussion in NHS patients

IntroductionConcussion is a complex pathophysiological process with a wide range of non-specific signs and symptoms. There are currently no objective diagnostic tests to identify concussion, and diagnosis relies solely on...

Recording of 'COVID-19 vaccine declined': a cohort study on 57.9 million National Health Service patients' records in situ using OpenSAFELY, England, 8 December 2020 to 25 May 2021.

BackgroundPriority patients in England were offered COVID-19 vaccination by mid-April 2021. Codes in clinical record systems can denote the vaccine being declined.AimWe describe records of COVID-19 vaccines being declined, according to clinical and demographic factors.MethodsWith the approval of NHS England, we conducted a retrospective cohort study between 8 December 2020 and 25 May 2021 with primary care records for 57.9 million patients using OpenSAFELY, a secure health analytics platform. COVID-19 vaccination priority patients were those aged ≥ 50 years or ≥ 16 years clinically extremely vulnerable (CEV) or ’at risk’. We describe the proportion recorded as declining vaccination for each group and stratified by clinical and demographic subgroups, subsequent vaccination and distribution of clinical code usage across general practices.ResultsOf 24.5 million priority patients, 663,033 (2.7%) had a decline recorded, while 2,155,076 (8.8%) had neither a vaccine nor decline recorded. Those recorded as declining, who were subsequently vaccinated (n = 125,587; 18.9%) were overrepresented in the South Asian population (32.3% vs 22.8% for other ethnicities aged ≥ 65 years). The proportion of declining unvaccinated patients was highest in CEV (3.3%), varied strongly with ethnicity (black 15.3%, South Asian 5.6%, white 1.5% for ≥ 80 years) and correlated positively with increasing deprivation.ConclusionsClinical codes indicative of COVID-19 vaccinations being declined are commonly used in England, but substantially more common among black and South Asian people, and in more deprived areas. Qualitative research is needed to determine typical reasons for recorded declines, including to what extent they reflect patients actively declining.