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Hausenloy D.J.,University College London | Hausenloy D.J.,National Health Research Institute | Hausenloy D.J.,National Heart Research Institute Singapore | Hausenloy D.J.,National University of Singapore | And 15 more authors.
New England Journal of Medicine | Year: 2015

BACKGROUND Whether remote ischemic preconditioning (transient ischemia and reperfusion of the arm) can improve clinical outcomes in patients undergoing coronary-artery bypass graft (CABG) surgery is not known. We investigated this question in a randomized trial. METHODS We conducted a multicenter, sham-controlled trial involving adults at increased surgical risk who were undergoing on-pump CABG (with or without valve surgery) with blood cardioplegia. After anesthesia induction and before surgical incision, patients were randomly assigned to remote ischemic preconditioning (four 5-minute inflations and deflations of a standard blood-pressure cuff on the upper arm) or sham conditioning (control group). Anesthetic management and perioperative care were not standardized. The combined primary end point was death from cardiovascular causes, nonfatal myocardial infarction, coronary revascularization, or stroke, assessed 12 months after randomization. RESULTS We enrolled a total of 1612 patients (811 in the control group and 801 in the ischemic- preconditioning group) at 30 cardiac surgery centers in the United Kingdom. There was no significant difference in the cumulative incidence of the primary end point at 12 months between the patients in the remote ischemic preconditioning group and those in the control group (212 patients [26.5%] and 225 patients [27.7%], respectively; hazard ratio with ischemic preconditioning, 0.95; 95% confidence interval, 0.79 to 1.15; P = 0.58). Furthermore, there were no significant between- group differences in either adverse events or the secondary end points of perioperative myocardial injury (assessed on the basis of the area under the curve for the high-sensitivity assay of serum troponin T at 72 hours), inotrope score (calculated from the maximum dose of the individual inotropic agents administered in the first 3 days after surgery), acute kidney injury, duration of stay in the intensive care unit and hospital, distance on the 6-minute walk test, and quality of life. CONCLUSIONS Remote ischemic preconditioning did not improve clinical outcomes in patients undergoing elective on-pump CABG with or without valve surgery. Copyright © 2015 Massachusetts Medical Society. All rights reserved.


Bardsley M.,Nuffield Trust | Blunt I.,Nuffield Trust | Davies S.,Southwark Business Support Unit | Dixon J.,Nuffield Trust
BMJ Open | Year: 2013

Objective: To identify trends in emergency admissions for patients with clinical conditions classed as 'ambulatory care sensitive' (ACS) and assess if reductions might be due to improvements in preventive care. Design: Observational study of routinely collected hospital admission data from March 2001 to April 2011. Admission rates were calculated at the population level using national population estimates for area of residence. Participants: All emergency admissions to National Health Service (NHS) hospitals in England from April 2001 to March 2011 for people residents in England. Main outcome measures: Age-standardised emergency admissions rates for each of 27 specific ACS conditions (ICD-10 codes recorded as primary or secondary diagnoses). Results: Between April 2001 and March 2011 the number of admissions for ACS conditions increased by 40%. When ACS conditions were defined solely on primary diagnosis, the increase was less at 35% and similar to the increase in emergency admissions for non-ACS conditions. Age-standardised rates of emergency admission for ACS conditions had increased by 25%, and there were notable variations by age group and by individual condition. Overall, the greatest increases were for urinary tract infection, pyelonephritis, pneumonia, gastroenteritis and chronic obstructive pulmonary disease. There were significant reductions in emergency admission rates for angina, perforated ulcers and pelvic inflammatory diseases but the scale of these successes was relatively small. Conclusions: Increases in rates of emergency admissions suggest that efforts to improve the preventive management of certain clinical conditions have failed to reduce the demand for emergency care. Tackling the demand for hospital care needs more radical approaches than those adopted hitherto if reductions in emergency admission rates for ACS conditions overall are to be seen as a positive outcome of for NHS.


Shaw S.E.,Blizard Institute | Rosen R.,Nuffield Trust
Journal of Health Services Research and Policy | Year: 2013

Integrated care is central to current health care reforms as policy makers and practitioners struggle to address fragmentation of care planning and delivery. However, those pursuing integration have failed to appreciate the complex nature of fragmentation. We seek to bring some much-needed clarity to current debate by considering fragmentation as a 'wicked problem' requiring a locally driven and multifaceted approach to integration. © SAGE Publications Ltd 2013.


Bardsley M.,Nuffield Trust | Steventon A.,Nuffield Trust | Doll H.,University of East Anglia
BMC Health Services Research | Year: 2013

Background: Telehealth is increasingly used in the care of people with long term conditions. Whilst many studies look at the impacts of the technology on hospital use, few look at how it changes contacts with primary care professionals. The aim of this paper was to assess the impacts of home-based telehealth interventions on general practice contacts. Method. Secondary analysis of data from a Department of Health funded cluster-randomised trial with 179 general practices in three areas of England randomly assigned to offer telehealth or usual care to eligible patients. Telehealth included remote exchange of vitals signs and symptoms data between patients and healthcare professionals as part of the continuing management of patients. Usual care reflected the range of services otherwise available in the sites, excluding telehealth. Anonymised data from GP systems were used to construct person level histories for control and intervention patients. We tested for differences in numbers of general practitioner and practice nurse contacts over twelve months and in the number of clinical readings recorded on general practice systems over twelve months. Results: 3,230 people with diabetes, chronic obstructive pulmonary disease or heart failure were recruited in 2008 and 2009. 1219 intervention and 1098 control cases were available for analysis. No statistically significant differences were detected in the numbers of general practitioner or practice nurse contacts between intervention and control groups during the trial, or in the numbers of clinical readings recorded on the general practice systems. Conclusions: Telehealth did not appear associated with different levels of contact with general practitioners and practice nurses. We note that the way that telehealth impacts on primary care roles may be influenced by a number of other features in the health system. The challenge is to ensure that these systems lead to better integration of care than fragmentation. Trial registration number. International Standard Randomised Controlled Trial Number Register ISRCTN43002091. © 2013 Bardsley et al.; licensee BioMed Central Ltd.


Context: Predictive models can be used to identify people at high risk of unplanned hospitalization, although some of the high-risk patients they identify may not be amenable to preventive care. This study describes the development of "impactibility models," which aim to identify the subset of at-risk patients for whom preventive care is expected to be successful. Methods: This research used semistructured interviews with representatives of thirty American organizations that build, use, or appraise predictive models for health care. Findings: Impactibility models may refine the output of predictive models by (1) giving priority to patients with diseases that are particularly amenable to preventive care; (2) excluding patients who are least likely to respond to preventive care; or (3) identifying the form of preventive care best matched to each patient's characteristics. Conclusions: Impactibility models could improve the efficiency of hospital-avoidance programs, but they have important implications for equity and access. © 2010 Milbank Memorial Fund. Published by Wiley Periodicals Inc.


Billings J.,New York University | Georghiou T.,Nuffield Trust | Blunt I.,Nuffield Trust | Bardsley M.,Nuffield Trust
BMJ Open | Year: 2013

Objectives: To test the performance of new variants of models to identify people at risk of an emergency hospital admission. We compared (1) the impact of using alternative data sources (hospital inpatient, A&E, outpatient and general practitioner (GP) electronic medical records) (2) the effects of local calibration on the performance of the models and (3) the choice of population denominators. Design: Multivariate logistic regressions using person-level data adding each data set sequentially to test value of additional variables and denominators. Setting: 5 Primary Care Trusts within England. Participants: 1 836 099 people aged 18-95 registered with GPs on 31 July 2009. Main outcome measures: Models to predict hospital admission and readmission were compared in terms of the positive predictive value and sensitivity for various risk strata and with the receiver operating curve C statistic. Results: The addition of each data set showed moderate improvement in the number of patients identified with little or no loss of positive predictive value. However, even with inclusion of GP electronic medical record information, the algorithms identified only a small number of patients with no emergency hospital admissions in the previous 2 years. The model pooled across all sites performed almost as well as the models calibrated to local data from just one site. Using population denominators from GP registers led to better case finding. Conclusions: These models provide a basis for wider application in the National Health Service. Each of the models examined produces reasonably robust performance and offers some predictive value. The addition of more complex data adds some value, but we were unable to conclude that pooled models performed less well than those in individual sites. Choices about model should be linked to the intervention design. Characteristics of patients identified by the algorithms provide useful information in the design/costing of intervention strategies to improve care coordination/outcomes for these patients.


Steventon A.,Nuffield Trust | Roberts A.,Nuffield Trust
BMC Health Services Research | Year: 2012

Background: Information about how long people stay in care homes is needed to plan services, as length of stay is a determinant of future demand for care. As length of stay is proportional to cost, estimates are also needed to inform analysis of the long-term cost effectiveness of interventions aimed at preventing admissions to care homes. But estimates are rarely available due to the cost of repeatedly surveying individuals. Methods. We used administrative data from three local authorities in England to estimate the length of publicly-funded care homes stays beginning in 2005 and 2006. Stays were classified into nursing home, permanent residential and temporary residential. We aggregated successive placements in different care home providers and, by linking to health data, across periods in hospital. Results: The largest group of stays (38.9%) were those intended to be temporary, such as for rehabilitation, and typically lasted 4 weeks. For people admitted to permanent residential care, median length of stay was 17.9 months. Women stayed longer than men, while stays were shorter if preceded by other forms of social care. There was significant variation in length of stay between the three local authorities. The typical person admitted to a permanent residential care home will cost a local authority over £38,000, less payments due from individuals under the means test. Conclusions: These figures are not apparent from existing data sets. The large cost of care home placements suggests significant scope for preventive approaches. The administrative data revealed complexity in patterns of service use, which should be further explored as it may challenge the assumptions that are often made. © 2012 Steventon and Roberts.; licensee BioMed Central Ltd.


Steventon A.,Nuffield Trust | Bardsley M.,Nuffield Trust
Journal of Health Services Research and Policy | Year: 2011

Objective: Although over half a million migrants arrive in England each year, information about their use of health services is limited. Our aim was to describe the use of secondary care by international immigrants and compare it to people moving within England. Methods: Routine anonymized data were used to identify people who appear as registering with a general practitioner (GP) for the first time in England, yet are aged 15 or over. We assumed that most long-term residents will have registered before the age of 15, and therefore the majority of those registering for the first time later in life will be international immigrants. The study compared hospital admissions among first registrants to the general population of England and to within-England migrants, selected using propensity scoring. Results: The first registrants aged 15 or over had around half the rate of hospital admission as that of the general population of England. They were also less likely to have a hospital admission than a matched group of within-England migrants. The lower admission rates persisted over several years and were consistent in three consecutive cohorts of first registrants (each consisting of over half a million people). Conclusions: The assumption that international immigrants use more secondary care than the members of the indigenous population appears to be unfounded. © The Royal Society of Medicine Press Ltd 2011.


Blumenthal D.,Harvard University | Blumenthal D.,Partners Health System | Dixon J.,Nuffield Trust
The Lancet | Year: 2012

Two landmark and controversial bills reforming health care in the USA and England were recently passed. Despite the different history and context to health care in both countries, there is much room for mutual learning. This paper identifies three areas relating to financing, organisation, and information technology. For example, new payment mechanisms to encourage higher quality and efficiency are being developed and tested, particularly bundled payments, pay for performance, and value-based purchasing. In the USA, new national bodies to scrutinise payments in health care and to test promising new interventions to improve quality and efficiency will have lessons for the NHS. The faster adoption of electronic health records and their use in England to assess quality is a useful lesson for the USA. The new accountable care organisations and clinical commissioning groups have much to learn from each other as they develop.


Steventon A.,Nuffield Trust | Tunkel S.,Ernst And Young | Blunt I.,Nuffield Trust | Bardsley M.,Nuffield Trust
BMJ (Online) | Year: 2013

Objectives To test the effect of a telephone health coaching service (Birmingham OwnHealth) on hospital use and associated costs. Design Analysis of person level administrative data. Difference-in-difference analysis was done relative to matched controls. Setting Community based intervention operating in a large English city with industry. Participants 2698 patients recruited from local general practices before 2009 with heart failure, coronary heart disease, diabetes, or chronic obstructive pulmonary disease; and a history of inpatient or outpatient hospital use. These individuals were matched on a 1:1 basis to control patients from similar areas of England with respect to demographics, diagnoses of health conditions, previous hospital use, and a predictive risk score. Intervention Telephone health coaching involved a personalised care plan and a series of outbound calls usually scheduled monthly. Median length of time enrolled on the service was 25.5 months. Control participants received usual healthcare in their areas, which did not include telephone health coaching. Main outcome measures Number of emergency hospital admissions per head over 12 months after enrolment. Secondary metrics calculated over 12 months were: hospital bed days, elective hospital admissions, outpatient attendances, and secondary care costs. Results In relation to diagnoses of health conditions and other baseline variables, matched controls and intervention patients were similar before the date of enrolment. After this point, emergency admissions increased more quickly among intervention participants than matched controls (difference 0.05 admissions per head, 95% confidence interval 0.00 to 0.09, P=0.046). Outpatient attendances also increased more quickly in the intervention group (difference 0.37 attendances per head, 0.16 to 0.58, P<0.001), as did secondary care costs (difference £175 per head, £22 to £328, P=0.025). Checks showed that we were unlikely to have missed reductions in emergency admissions because of unobserved differences between intervention and matched control groups. Conclusions The Birmingham OwnHealth telephone health coaching intervention did not lead to the expected reductions in hospital admissions or secondary care costs over 12 months, and could have led to increases.

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