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Aim: We wanted to find out if roll-out of the bowel cancer screening programme (BCSP) across England was associated with a reduced risk of emergency hospital admission for people presenting with colorectal cancer (CRC) during this period., Method: This is a retrospective cohort study of 27 763 incident cases of CRC over a 1-year period during the roll-out of screening across parts of England. The primary outcome was the number of emergency (unplanned) hospital admissions during the diagnostic pathway. The primary exposure was to those living in an area where the BCSP was active at the time of diagnosis. Patients were categorized into three exposure groups: BCSP not active (reference group), BCSP active < 6 months or BCSP active ≥ 6 months., Results: The risk of emergency admission for CRC in England was associated with increasing age, female gender, comorbidity and social deprivation. After adjusting for these factors in logistic regression, the odds ratio (OR) for emergency admission in patients diagnosed ≥ 6 months after the start-up of local screening was 0.83 (CI 0.76-0.90). The magnitude of risk reduction was greatest for cases of screening age (OR 0.75; CI 0.63-0.90) but this effect was apparent also for cases outside the 60-69-year age group (OR 0.85; CI 0.77-0.94). Living in an area with active BCSP conferred no reduction in risk of emergency admission for people diagnosed with oesophagogastric cancer during the same period., Conclusion: The start-up of bowel cancer screening in England was associated with a substantial reduction in the risk of emergency admission for CRC in people of all ages. This suggests that the roll-out of the programme had indirect benefits beyond those related directly to participation in screening., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: Healthcare metrics have been used to drive improvement in outcome and delivery in UK hospital stroke and cardiac care. This model is attractive for chronic obstructive pulmonary disease (COPD) care because of disease frequency and the burden it places on primary, secondary and integrated care services., Methods: Using 'hospital episode statistics' (UK 'coding'), we examined hospital 'bed days/1000 population' in 150 UK Primary Care Trusts (PCTs) during 2006-07 and 2007-08. Data were adjusted for COPD prevalence. We looked at year-on-year consistency and factors which influenced variation., Results: There were 248 996 COPD admissions during 2006-08. 'Bed days/1000 PCT population' was consistent between years (r = 0.87; P < 0.001). There was a >2-fold difference in bed days between the best and worst performing PCTs which was primarily a consequence of variation in emergency admission rate (P < 0.001) and proportion of emergency admissions due to COPD (P < 0.001) and to only a lesser extent length of hospital stay (P < 0.001)., Conclusions: Bed days/1000 population appears a useful annual metric of COPD care quality. Good COPD care keeps patients active and out of hospital and requires co-ordinated action from both hospital and community services, with an important role for integrated care. This metric demonstrates that current care is highly variable and offers a measurable target to commission against., (© The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Mortality rate has been proposed as a metric of hospital chronic obstructive pulmonary disease (COPD) care in light of variation seen in national COPD audits. Using Hospital Episode Statistics (hospital 'coding') we examined 30-day mortality after COPD hospitalisation in 150 UK hospitals during 2006-2007 and 2007-2008. Mean and median 30-day mortalities were similar each year but the coefficient of variation was >20% and hospitals could change from a low or high quartile to the median by chance. We could not detect any reasons for hospitals being at the extremes. 30-day mortality after COPD hospitalisation is a complex variable and unlikely to be useful as a primary annual COPD metric.

Background: Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes., Methods: 234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma., Results: Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines., Conclusions: Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients.

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) have a high rate of mortality which gets worse with advancing age. It is unknown whether this is due to age related deficiencies in process of care. A study was undertaken in patients with COPD exacerbations admitted to UK hospitals to assess whether there were age related differences in the process of care that might affect outcome, and whether different models of care affected process and outcome., Methods: 247 hospital units audited activity and outcomes (inpatient death, death within 90 days, length of stay (LOS), readmission within 90 days) for 40 consecutive COPD exacerbation admissions in autumn 2003. Logistic regression methods were used to assess relationships between process and outcome at p < 0.001., Results: 7514 patients (36% aged > or = 75 years) were included. Patients aged > or = 75 years were less likely to have blood gases documented, to have FEV1 recorded, or to be given systemic corticosteroids. Those admitted under care of the elderly (CoE) physicians were less likely to enter early discharge schemes or to receive non-invasive ventilation when acidotic. Overall inpatient and 90 day mortality was 7.4% and 15.3%, respectively. Inpatient and 90 day adjusted odds mortality rates for those aged > or = 85 years (versus < or = 65 years) were 3.25 and 2.54, respectively. Mortality was unaffected by admitting physician (CoE v general v respiratory). Age predicted LOS but not readmission. Age related deficiencies in process of care did not predict inpatient or 90 day mortality, readmission, or LOS., Conclusions: Management of COPD exacerbations varies with age in UK hospitals. Inpatient and 90 day mortality is approximately three times higher in very elderly patients with a COPD exacerbation than in younger patients. Age related deficiencies in the process of care were not associated with mortality, but it is likely that they represent poorer quality of care and patient experience. Recommended standards of care should be applied equally to elderly patients with an exacerbation of COPD.

Background: The 1997 BTS/RCP national audit of acute chronic obstructive pulmonary disease (COPD) in terms of process of care has previously been reported. This paper describes from the same cases the outcomes of death, readmission rates within 3 months of initial admission, and length of stay. Identification of the main pre-admission predictors of outcome may be used to control for confounding factors in population characteristics when comparing performance between units., Methods: Data on 74 variables were collected retrospectively using an audit proforma from patients admitted to UK hospitals with acute COPD. Important prognostic variables for the three outcome measures were identified by relative risk and logistic regression was used to place these in order of predictive value., Results: 1400 admissions from 38 acute hospitals were collated. 14% of cases died within 3 months of admission with variation between hospitals of 0-50%. Poor performance status, acidosis, and the presence of leg oedema were the best significant independent predictors of death. Age above 65, poor performance status, and lowest forced expiratory volume in 1 second (FEV(1)) tertile were the best predictors of length of stay (median 8 days). 34% of patients were readmitted (range 5-65%); lowest FEV(1) tertile, previous admission, and readmission with five or more medications were the best predictors for readmission., Conclusions: Important predictors of outcome have been identified and formal recording of these may assist in accounting for confounding patient characteristics when making comparisons between hospitals. There is still wide variation in outcome between hospitals that remains unexplained by these factors. While some of this variance may be explained by incomplete recording of data or patient factors as yet unidentified, it seems likely that deficiencies in the process of care previously identified are responsible for poor outcomes in some units.

The National Health Service has employed physicians since its inception, yet 46 years later there are few data on the day-to-day work done by physicians. This paper describes the case mix of general medicine in one region using data for general medical admissions to one specialty (respiratory medicine) as a working example. The pattern of general medical inpatient admissions is consistent across the 10 districts in the Mersey region: 26% have a respiratory diagnosis, 22% cardiac, and 15% gastrointestinal. For medical day cases, 60% are gastrointestinal. The average length of stay for particular conditions varies little between hospitals, and the average consultant 'cares' for 949 consultant inpatient episodes per year. In only half the Mersey districts is the respiratory consultant provision appropriate for the case mix admitted to the hospital. A simple algorithm applied to data collected routinely by regional health authorities can yield much information upon which to plan medical manpower. Applied to a specialty, it has identified mismatches between workload and consultant type. For respiratory medicine, at least six more respiratory physicians (a 30% increase) are needed to correct the underprovision in Mersey region.