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As death rates decrease, people affected by cardiovascular disease (CVD) continue to live with these diseases and the associated challenges, long-term. We aimed to identify the biggest challenges for people affected by CVD in the UK and explore the sources of support and information used to help manage conditions, to inform future service provision. An online questionnaire was sent and advertised to people over 16 years old in the UK self-identifying as affected by CVD (living with CVD, had risk factors, or a carer). There were 13,885 responses. The top five challenges were: feeling down, sad, or depressed; making changes to the way or amount of exercise; anxiety, fear, and uncertainty about the future; having one member of staff to speak to about all aspects of care; and being given information on the side effects of medications. Key challenges were not restricted to a particular condition, indicated by minimal variation between types of CVD. One-quarter of respondents indicated they do not use online resources or digital technologies to help manage their health. The volume and inconsistency of online sources were reported as barriers to using these. The results highlight the psychological and physical consequences of living with CVD. Fragmented care and variable access to information and support further compound these issues. Providing holistic care needs attention; the acknowledgement of psychological needs and access to support, alongside physical challenges is necessary. Stakeholders in healthcare and information technology should work together to ensure online information and support is clear, consistent, and reliable. Experience Framework This article is associated with the Innovation & Technology lens of The Beryl Institute Experience Framework. (http://bit.ly/ExperienceFramework) Access other PXJ articles related to this lens. Access other resources related to this lens

Research into the practice of medication review is developing across the world in response to the ever-increasing burden of inappropriate polypharmacy. Education, training and support of undergraduates and novice practitioners to equip them to participate in the medication review process could lead to long-term shifts in practice. The purpose of this study was to explore the awareness of pharmacy and medical undergraduates about medication review, deprescribing and polypharmacy, in order to inform improvement strategies. In November 2016, all final-year medical and pharmacy students at a London (UK) university were invited to complete a short questionnaire survey. Qualitative analysis inductively themed free-text comments and quantitative analysis used descriptive statistics to summarize responses, with chi-square tests used to indicate differences between the groups. The overall response rate was 34% (171/500). The terms ‘medication review’ and ‘polypharmacy’ were known to the students, whilst the term ‘deprescribing’ was unfamiliar with no difference between the groups. The term ‘medication review’ meant different things to the groups: pharmacy students suggested a focus on adherence and patient understanding, whilst medical students focused on interactions and whether medicines were still indicated. The groups differed in their perceptions of who they thought undertook reviews, who identifies potentially inappropriate medicines, who makes the final decision to deprescribe and the frequency of medication reviews. Both groups reported that on qualification they would not be comfortable stopping a medicine without discussion with a senior colleague, but would be comfortable prompting a senior colleague to review. Both groups had some awareness of medication review tools. The meaning of the term ‘medication review’ differed between the student groups. While medical students focused on clinical aspects, pharmacy students emphasized patient experience. Both groups anticipated a lack of confidence in deprescribing without senior support, highlighting the need for alignment between education and professional development syllabi in a way that combines the variety of professional perspectives. Prompts by juniors could lead to more medication reviews within existing practice, and may give them invaluable experience in reviewing medicines in their future careers as seniors.

Background and Aims At the end of life, a person’s needs and goals change. It is, therefore, important to review medications to ensure optimum symptom control and to deprescribe unnecessary treatment. The aim of the study was to assess the impact of Specialist Palliative Care (SPC) review on reducing polypharmacy and prescribing anticipatory symptom control medication in inpatients at the end of life. Methodology Adult inpatient deaths between July 2018 and February 2019 in an acute London Hospital were identified. Deaths in Intensive Care Unit and within 24 hours of admission were excluded. Demographic data, medication name and number on admission, at death and which were discontinued, were collected. Evidence of a SPC review and prescription for anticipatory medication were recorded. Using SPSS software, Chi Squared and Mann Whitney U tests were performed to identify statistical differences in prescribing for patients who had been reviewed by SPC. Results 201 patients were identified. 159 patients (79%) were reviewed by SPC, a median of 5 days prior to death (interquartile range 2–11 days). Significantly more medications were discontinued in those who were reviewed by SPC (6.4 medications per patient) than those who were not reviewed (4.2 medications per patient, Conclusion SPC review reduced polypharmacy at the end of life and also increased the likelihood of anticipatory medication prescription. However, this mostly occurred only a few days prior to death. There needs to be continued focus on early identification of patients nearing end of life and medication review to enable appropriate deprescribing. Further research needs to determine whether deprescribing improves quality of life.

Background Cumulative impact zones (CIZs) are a discretionary policy lever available to local government, used to restrict the availability of alcohol in areas deemed already saturated. Despite little evidence of their effect, over 200 such zones have been introduced. This study explores the impact of three CIZs on the licensing of venues in the London Borough of Southwark. Methods Using 10 years of licensing data, we examined changes in the issuing of licences on the introduction of three CIZs within Southwark, relative to control areas. The number of licence applications made (N = 1110), the number issued, and the proportion objected to, were analysed using negative binomial regression. Results In one area tested, CIZ implementation was associated with 119% more licence applications than control areas (incidence rate ratios (IRR) = 2.19, 95% confidence intervals (CI): 1.29–3.73, P = 0.004) and 133% more licences granted (IRR = 2.33, 95% CI: 1.31–4.16, P = 0.004). No significant effect was found for the other two areas. CIZs were found to have no discernible effect on the relative proportion of licence applications receiving objections. Conclusions CIZs are proposed as a key lever to limit alcohol availability in areas of high outlet density. We found no evidence that CIZ establishment reduced the number of successful applications in Southwark.

BackgroundUnscheduled visits to emergency departments (ED) have increased in the UK in recent years. Children who are repeat attenders are relatively understudied.AimsTo describe the sociodemographic and clinical characteristics of preschoolers who attend ED a large District General Hospital.Method/study designObservational study analysing routinely collected ED operational data. Children attending four or more visits per year were considered as ‘frequent attenders’. Poisson regression was used with demographic details (age, sex, ethnicity, sociodemographic status) to predict number of attendances seen in the year. We further analysed detailed diagnostic characteristics of a random sample of 10% of attendees.Main findings10 169 patients visited in the 12-month period with 16 603 attendances. 655 individuals attended on 3335 occasions. 6.4% of this population accounted for 20.1% of total visits. In the 10% sample, there were 304 attendances, and 69 (23%) had an underlying chronic long-standing illness (CLSI). This group were 2.4 times more likely to be admitted as inpatients compared with those without such conditions, median length of stay of 6.2 hours versus 2.5 hours (p=NS).ConclusionsFrequent ED attenders fall broadly into two distinct clinical groups: those who habitually return with self-limiting conditions and those with or without exacerbation of underlying CLSI. Both groups may be amenable to both additional nursing and other forms of community support to enhance self-care and continuity of care. Further research is required to increase our understanding of specific individual family and health system factors that predict repeat attendance in this age group.

The number of trainees moving directly into training posts following their foundation training is decreasing1 and the same pattern is emerging after CMT. Previous studies identified factors behind CMTs leaving the formal training route, but didn’t explore the motivations behind this.2,3 Understanding the reasons why trainees take a break from traditional training trajectories is crucial in order to ensure structures are embedded to support them. This study investigates trainees’ motivations in taking a break after CMT and develops recommendations to support trainees. 60-minute semi-structured, recorded, anonymised and transcribed telephone interviews with nine CMTs (five women and four men working …

ObjectivesCumulative impact zones (CIZs) are a widely implemented local policy intended to restrict alcohol availability in areas proliferated with licensed outlets. Limited previous research has questioned their effectiveness and suggested they may play a more nuanced role in shaping local alcohol environments. This study evaluates the association between CIZ implementation and the number of licence applications made, and the number issued, relative to a control region.DesignA quantitative observational study.SettingThe inner London Borough of Southwark, which currently enforces three CIZs.PopulationLicence applications received by Southwark Council’s Licensing Authority between 1 April 2006 and 31 March 2017 (n=1254).InterventionsCIZ implementation.Primary outcome measuresFive outlet types were categorised and evaluated: drinking establishments, eateries, takeaways, off sales and other outlets. Primary outcome measures were the number of applications received and the number of licences issued. These were analysed using Poisson regression of counts over time.ResultsAcross all CIZs, implementation was associated with greater increases in the number of eateries in CIZ regions (incidence rate ratio (IRR)=1.58, 95% CI: 1.02–2.45, p=0.04) and number of takeaway venues (IRR=3.89, 95% CI: 1.32–11.49, p=0.01), relative to the control area. No discernible association was found for the remaining outlet types. Disaggregating by area indicated a 10-fold relative increase in the number of new eateries in Peckham CIZ (IRR=10.38, 95% CI: 1.39–77.66, p=0.02) and a fourfold relative increase in the number of newly licensed takeaways in Bankside CIZ (IRR=4.38, 95% CI: 1.20–15.91, p=0.03).ConclusionsCIZs may be useful as policy levers to shape local alcohol environments to support the licensing goals of specific geographical areas and diversify the night-time economy.

In the editorial of this deprescribing themed issue, we began by recognising that deprescribing is not easy. For many clinicians, the decision to deprescribe is hampered by the lack of evidence for safe methods of deprescribing. We identified the need for education to support clinicians in their deprescribing endeavours. Here, we describe our strategy to educate around deprescribing, which emerged from the medicines optimisation work stream at the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Northwest London (CLAHRC NWL). CLAHRC NWL is a research and implementation programme1 ,2 that uses the model for improvement3 as a central component of quality improvement (QI) initiatives. We contend that education about deprescribing should adopt both a ‘top down’ to include senior clinicians, and ‘bottom up’ to include junior staff and students. This is supported by a patient safety initiative that was found to be best facilitated by such a combination approach to change.4 We will focus on the latter (hereafter bottom-up approach): educating junior and undergraduate clinicians, so that they enter the workplace with the confidence and skill to at least consider the need for deprescribing both at the point of initial prescribing and when undertaking medication review. We are conscious that the term bottom-up approach can have a number of meanings, here we use it to refer to the capacity to lead to grass-roots changes that will grow and pervade practice, rather than ‘command and control’ regulations on actions. The theory and practice of education are, at this level, andragogy (the education of adults), thus the principles of adult learning should be used;5 yet the evaluation techniques used for child education may prove useful for long-term assessments of change, for instance, those studies seeking to address differentials in earnings. …

Background:Falls are a common cause of morbidity and hospitalisation in older people. Inappropriate prescribing and polypharmacy contribute to falls risk in elderly patients. This study’s aim was to quantify the problem and find out if medication review in the hospital setting led to deprescribing of medicines associated with falls risk.Methods:Admissions records for elderly patients were examined to identify those whose presenting complaint included a fall. Inpatient medication charts, pharmaceutical care notes, medical notes and discharge summaries were examined to identify any falls-risk medicines from admission histories and to determine if any medication review took place, and whether or not changes were made as a result. In particular deprescribing and dose reduction details were analysed. Results:100 patients over 70 years old were admitted following a fall during the two months study period. The mean number of medicines on admission was 6.8 per patient with polypharmacy found in 62/100 (62%). One or more falls-risk medicine was found in 65/100 (65%) patients. Medicines review was carried out in 86/100 (86%) of patients, and 59/697 (8.5%) medicines were deprescribed. Pharmacist involvement in medication review led to a significant reduction in the number of falls-risk medicines per patient (p=0.002).Conclusion:Inappropriate prescribing and polypharmacy are found frequently in elderly patients at admission following a fall. Comprehensive medicines reviews should be carried out in all such patients with the objective of deprescribing or reducing doses to minimise risk of harm. Involvement of a pharmacist improves the rate of reduction of falls-risk medicines.

ObjectivesThe relationship between patient feedback in the General Practice Patient Survey (GPPS) and Care Quality Commission (CQC) inspections of practices was investigated to understand whether there is an association between patient views and regulator ratings of quality. The specific aims were to understand whether patients’ self-reported experiences of primary care can predict CQC inspection ratings of GP practices by: (i) Measuring the association between GPPS results and CQC inspection ratings of GP practices; (ii) Building a predictive model of GP practice quality ratings that use GPPS results; and (iii) Evaluating the predictive model for risk stratification.DesignRetrospective analysis of routinely collected data using decision tree modelling.SettingPrimary care: GP practices in England.Primary and secondary outcome measuresGPPS scores and GP practice CQC inspection ratings during 2018.ResultsMost GP practices (72%, 974/1350) were rated as ‘Good’ overall by CQC. Simply assuming that all practices will be rated as ‘Good’ results in a correct prediction 72% of the time, and it was not possible to improve on this overall level of predictive accuracy using decision tree modelling (correct in 73% of cases). However, a set of GPPS questions were found to have value in identifying practices at elevated risk of a poor inspection rating.ConclusionsAlthough there were some associations between GPPS data and CQC inspection ratings, there were limitations to the use of GPPS data for predictive analysis. This is a likely result of the majority of CQC inspections of GPs resulting in a ‘Good’ or ‘Outstanding’ rating. However, some GPPS questions were found to have value in identifying practices at higher risk of an ‘Inadequate’ or ‘Requires Improvement’ rating, and this may be valuable for surveillance purposes. For example, the CQC could use key questions from the survey to target inspection planning.

BackgroundAn ecological correlation has been observed between licensed premises and alcohol-related violence (ARV). In the UK to date, no evidence directly connects alcohol-related harm to a single premises type. Recent policies have called for a diversified alcohol offer, yet quantitative evidence in support remains sparse. This study aims to inform policy by determining whether diversification of the alcohol economy is desirable and to inform the licensing process and submission of public health evidence.MethodsUsing 11 years of local licensing data from the London Borough of Southwark, alcohol availability over time was approximated by the number of extant alcohol licences, categorised by outlet type: drinking establishments, eateries, takeaways, off-sales and ‘other’. Harm was quantified drawing on law enforcement intelligence that recorded ARV. A linked data set was analysed using negative binomial regression, contrasting cumulative impact zones (CIZ)—a common alcohol control policy—with non-CIZ geographies.ResultsEach licensed drinking establishment was associated with a 1.6% (95% CI 0.7% to 2.6%; p=0.001) increase in ARV, respectively. ‘Other’ outlets had a protective effect and were associated with a 1.8% (95% CI 1.0% to 2.5%; pConclusionThis study provides direct evidence for an association between alcohol-related harm and licensed premises. The varying associations between outlet type and ARV provide local public health stakeholders with an evidence base upon which to advocate for licensing policies that diversify alcohol availability.

To investigate the feasibility of using freeware to model and forecast disease on a local scale, we report the results of modeling measles using a spatial patch model centered around 73 clinics in the North West London Borough of Ealing. MMR1 and MM2 immunization data was extracted for three cohorts, age 1-3, 4-6 and 7-19 and patient population was estimated using general practice profile records. We designed the measles model using the open source Spatiotemporal Epidemio-logical Modeler (STEM), extending a compartmental disease model to include both maternal immunity and delays in antibody response after immunization. Individuals above age 19 are not included in the modeling. Next, we generate an approximate 20-year model of vaccination coverage for Ea-ling. In England, children are immunized between age 1 and 2, then again at around age 5; hence immunization events are modeled for the age 1-3 and age 4-6 cohorts. Parameter values were based on measles research literature; transmission coeffi-cients were estimated using the Polymod contact data and also fitted to 2011-2012 case reporting data for Ealing. To examine possible effects of policy change, we create two scenarios A and B. In A, we increase vaccination coverage by 10% for all clinics; in B, we focus only on the bottom 10% of the poorest performing clinics (8 clinics total) and equivalently improve their coverage. Scenario A reduces measles from an initial level of 60 cases per year (2011) to 26 cases per year in 2017 (a 58% reduction), compared to the status quo which declines to 45 cases per year. Scenario B reduces measles by 44%, or to 34 cases per year in 2017. We conclude that local scale modeling is possible, and that the transparency of anal-ysis provided by an open source application lends credence to the output of the models.

© The Author 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. Background: checklists are increasingly proposed as a means to enhance safety and quality of care. However, their use has been met with variable levels of success. The Frailsafe project focused on introducing a checklist with the aim to increase completion of key clinical assessments and to facilitate communication for the care of older patients in acute admissions. Objectives: to examine the use of the Frailsafe checklist, including potential to contribute to improved safety, quality and reliability of care. Methods: 110 qualitative interviews and group discussions with healthcare professionals and other specialties, 172 h of ethnographic observation in 12 UK hospitals and reporting of high-level process data (completion of checklist and relevant frailty assessments). Qualitative analysis followed a thematic and theory-driven approach. Results: through use of the checklist, hospital teams identified limitations in their existing assessments (e.g. absence of delirium protocols) and practices (e.g. unnecessary catheter use). This contributed to hospitals reporting just 24.0% of sampled patients as having received all clinical assessments across key domains for this population for the duration of the project (1,687/7,021 checklists as fully completed). Staffperceptions and experiences of using the checklist varied significantly, primarily driven by the extent to which the aims of this quality improvement project aligned with local service priorities and pre-existing team communications styles. Conclusions: the Frailsafe checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices. Further work is needed to understand whether and how checklists can be embedded in complex, multidisciplinary care.

© 2015, BMJ Publishing Group. All rights reserved.Objectives Our aim was to explore junior doctors attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. Method An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. Results Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacists duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. Conclusions Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a bottom-up educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.

Obstructive sleep apnoea (OSA) is a condition characterised by repetitive upper airway collapse during sleep. The condition carries a range of health sequelae that can prove fatal in cases with co-existing risk factors for the condition, such as obesity and hypertension. Utilisation of a high-performance screening tool for OSA is thus important. A retrospective audit using the ESS and Stop-Bang scores, alongside Apnoea-Hypopnea Index values, for patients who underwent polysomnography over 1 year. Multinomial logistic regression was used to compare the predictive abilities of ESS, SBM, and body mass index (BMI) for the patient outcome groups, "None" (No OSA), "Notreat" (OSA not requiring treatment) and "treat" (OSA requiring treatment). The influences of age, gender and BMI on outcome group were also assessed. 126 bariatric and 66 non-bariatric patients were included. Multinomial logistic regression failed to demonstrate predictive ability of ESS. A higher Stop-Bang score significantly increases the risk being in the "treat" group. In addition, male gender, greater age and a higher BMI each individually increase the risk of OSA requiring treatment. Stop-Bang failed to demonstrate predictive significance when age and gender were controlled for. ESS is not an appropriate screening tool for OSA. Stop-Bang, however, remains a useful screening tool, with the ability to detect patient with OSA in need of treatment. Further study may benefit the development and implementation of a concise and more specific screening tool that considers high evidence-based risk factors for OSA, including male gender, greater age and raised BMI.

Quality improvement and implementation (QI&I) initiatives face critical challenges in an era of evidence-based, value-driven patient care. Whether front-line staff, large organisations or government bodies design and run QI&I, there is increasing need to demonstrate impact to justify investment of time and resources in implementing and scaling up an intervention. Decisions about sustaining, scaling up and spreading an initiative can be informed by evidence of causation and the estimated attributable effect of an intervention on observed outcomes. Achieving this in healthcare can be challenging, where interventions often are multimodal and applied in complex systems.1 Where there is weak evidence of causation, credibility in the effectiveness of the intervention is reduced with a resultant reduced desire to replicate. The greater confidence of a causal relationship between QI&I interventions and observed results, the greater our confidence that improvement will result when the intervention occurs in different settings. Guidance exists for design, conduct, evaluation and reporting of QII2–4; the Standards for QUality Improvement Reporting Excellence (SQUIRE) and the Standards for Reporting Implementation Studies (STARI) guidelines were developed specifically for reporting QI&I initiatives.5 6 However, much of this guidance is targeted at larger formal evaluations, and may require levels of resource or expertise not available to all QI&I initiatives. This paper proposes QI&I initiatives, regardless of scope and resources, can be enhanced by applying epidemiological principles, adapted from those promulgated by Austin Bradford Hill.7 Hill proposed nine ‘aspects of association’ that could be considered before ‘… deciding that the most likely interpretation is causation ’.7 His objective was to improve the ability to form scientific judgements about causality. The nine aspects, subsequently referred to as the ‘Bradford Hill Criteria’ (BHC), are considered in the following sections. With roots in causes of disease, the BHC have natural alignment with healthcare. …

ObjectivesPatients diagnosed with pancreatic cancer have the poorest survival prognosis of any cancer. This survey aimed to describe their experiences of care and supportive care needs to inform future service provision.DesignCross-sectional questionnaire survey of patients with pancreatic cancer in the UK.SettingIndividuals at any stage along the care pathway were recruited via five National Health Service sites in the UK, and online, from January to June 2018.Participants274 individuals completed the questionnaire (78% (215) were completed online). Approximately half of participants were diagnosed within the last year (133/274). Of 212 providing gender details, 82 were male and 130 were female. Ninety per cent (192/213) described themselves as White British.Primary outcome measuresExperiences of communication and information; involvement in treatment decisions; supportive care needs.ResultsCommunication with, and care received from, clinical staff were generally reported positively. However, 29% (75/260) of respondents did not receive enough information at diagnosis, and 10% (25/253) felt they were not involved in decisions about their treatment, but would have liked to be. Supportive care needs were greatest in psychological and physical/daily living domains. 49% (108/221) of respondents reported one or more moderate/high unmet needs within the last month, of which the most commonly reported were: dealing with uncertainty about the future; fears about the cancer spreading; not being able to do things they used to; concerns about those close to them; lack of energy; anxiety; feelings of sadness and feeling down/depressed. Experiences were poorer, and unmet supportive care needs greater, in patients with unresectable disease.ConclusionsPatients with pancreatic cancer have unmet information and support needs across the cancer trajectory. Psychological and physical support appears to be the biggest gap in care. Needs should be assessed and supportive care interventions implemented from the point of diagnosis, and monitored regularly to help patients live as good a quality of life as possible.

Objectives Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge. Setting An acute 400-bedded teaching hospital in London, UK. Participants The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months. Interventions Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives. Results Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems. Conclusions New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Objectives: Hospital board members are asked to consider large amounts of quality and safety data with a duty to act on signals of poor performance. However, in order to do so it is necessary to distinguish signals from noise (chance). This article investigates whether data in English National Health Service (NHS) acute care hospital board papers are presented in a way that helps board members consider the role of chance in their decisions. Methods: Thirty English NHS trusts were selected at random and their board papers retrieved. Charts depicting quality and safety were identified. Categorical discriminations were then performed to document the methods used to present quality and safety data in board papers, with particular attention given to whether and how the charts depicted the role of chance, that is, by including control lines or error bars. Results: Thirty board papers, containing a total of 1488 charts, were sampled. Only 88 (6%) of these charts depicted the role of chance, and only 17 of the 30 board papers included any charts depicting the role of chance. Of the 88 charts that attempted to represent the role of chance, 16 included error bars and 72 included control lines. Only 6 (8%) of the 72 control charts indicated where the control lines had been set (eg, 2 vs 3 SDs). Conclusions: Hospital board members are expected to consider large amounts of information. Control charts can help board members distinguish signals from noise, but often boards are not using them. We discuss demand-side and supply-side barriers that could be overcome to increase use of control charts in Q1 healthcare.

Background: Chelsea and Westminster Hospital introduced the Chelsea Early Warning Score (CEWS) in 2007 to aid the recognition of acutely unwell patients. The Royal College of Physicians subsequently recommended a National Early Warning Score (NEWS) for implementation across the NHS. The aim of this study was to evaluate local adherence to CEWS to identify potential obstacles to the consistent implementation of NEWS. Method: Emergency Department (ED) and Acute Assessment Unit (AAU) notes were retrospectively reviewed for a convenience sample of 102 patients admitted to the AAU. Outcome measures were completeness of documentation of CEWS parameters, documentation and accuracy of aggregate CEWS scores. Aggregate NEWS scores were calculated from the documented observations and the calculated CEWS and NEWS scores were compared. Results: Physiological observations were documented for all patients attending the ED and AAU. Heart rate, blood pressure, respiratory rate, oxygen saturation and conscious level were documented in over 95% of ED and AAU patients. Urine output was recorded for only 48% of ED and 69% of AAU patients. Aggregate CEWS scores were documented for 66% of ED and 84% of AAU patients. These were calculated accurately in 73% of ED and 79% of AAU patients. Calculation errors were eleven times more likely to result in under-scoring than over-scoring. NEWS scores were significantly higher than CEWS for the same observations and would have resulted in a 71% increase in patients requiring escalation of care in the ED and a 116% increase in AAU. Conclusion: Concerns highlighted with CEWS were the incomplete and inaccurate recording of aggregate scores, with underscoring resulting in the potential failure to recognise deteriorating patients. It is anticipated that NEWS will be accompanied by standardised documentation and training across the NHS which will support more complete and accurate recording of physiological data. Furthermore, NEWS appears from this study to be more sensitive than CEWS, thereby minimising the chance of missed deterioration.

Introduction Cumulative impact zones (CIZs) are a widely used local policy to control alcohol availability in areas deemed saturated. However, there is no academic evidence of their effectiveness, and the harm associated with outlet types remains understudied. Recent alcohol policy has called for a shift towards diversified alcohol availabilitybut quantitative evidence in support of this policy is sparse. We aimed to assess whether a change in licensing policy in a London borough was associated with diversification of alcohol availability and accompanying alcohol-related violence (ARV). Method Using 11 years of local licensing data (2005/06–16/17) from the London Borough of Southwark, we measured the availability of alcohol over time by the number of extant alcohol licences (539 in 2016/17) and outlet type (drinking establishments, eateries, takeaways, off-sales, and other). We quantified harm by drawing on law enforcement intelligence that identified the incidence of alcohol-related violence against the person (deemed ARV). We analysed a linked dataset using negative binomial regression to mitigate overdispersion of data, controlling for CIZ and non-CIZ locations. Findings Across all three CIZs, implementation of the policy (in 2008 and 2009) was not associated with a change in number of licences issued. Upon disaggregation by outlet type, CIZ implementation was associated with an increase in the number of licences for eateries (incidence rate ratio [IRR] 1·58, 95% CI 1·02–2·52; p=0·04) and takeaways (3·89, 1·32–11·49; p=0·01). There was no effect on the other outlet types. Each licensed takeaway and off-sales was associated with an increase in ARV (1·7%, IRR 1·02, 95% CI 1·004–1·031; p=0·012, and 1·3%, 1·01, 1·003–1·023; p=0·008, respectively), but there was no association with drinking establishments or eateries. The other outlet type was associated with a 2·4% decrease in ARV (IRR 0·98, 95% CI 0·966–0·986; p Interpretation Although CIZ policies in Southwark have not reduced the number of licences issued, implementation has led to changes in the types of licensed outlets. We propose that takeaways and off-sales are associated with after-hours drinking and congregation. Our findings provide local stakeholders with an evidence-base for continuing to advocate licensing policy that diversifies availability. The use of law enforcement data may be biased towards areas commonly patrolled and might not capture groups who avoid police involvement (eg, gangs). Linking complementary datasets (eg, emergency department, ambulance services) would enrich the picture of alcohol-related harm. Funding None.

Objectives Population ageing may result in increased comorbidity, functional dependence and poor quality of life. Mechanisms and pathophysiology underlying frailty have not been fully elucidated, thus absolute consensus on an operational definition for frailty is lacking. Frailty scores in the acute medical care setting have poor predictive power for clinically relevant outcomes. We explore the utility of frailty syndromes (as recommended by national guidelines) as a risk prediction model for the elderly in the acute care setting. Setting English Secondary Care emergency admissions to National Health Service (NHS) acute providers. Participants There were N=2 099 252 patients over 65 years with emergency admission to NHS acute providers from 01/01/2012 to 31/12/2012 included in the analysis. Primary and secondary outcome measures Outcomes investigated include inpatient mortality, 30-day emergency readmission and institutionalisation. We used pseudorandom numbers to split patients into train (60%) and test (40%). Receiver operator characteristic (ROC) curves and ordering the patients by deciles of predicted risk was used to assess model performance. Using English Hospital Episode Statistics (HES) data, we built multivariable logistic regression models with independent variables based on frailty syndromes (10th revision International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10) coding), demographics and previous hospital utilisation. Patients included were those >65 years with emergency admission to acute provider in England (2012). Results Frailty syndrome models exhibited ROC scores of 0.624–0.659 for inpatient mortality, 0.63–0.654 for institutionalisation and 0.57–0.63 for 30-day emergency readmission. Conclusions Frailty syndromes are a valid predictor of outcomes relevant to acute care. The models predictive power is in keeping with other scores in the literature, but is a simple, clinically relevant and potentially more acceptable measurement for use in the acute care setting. Predictive powers of the score are not sufficient for clinical use.

Objectives This study aims to identify patient and treatment factors that affect clinical outcomes of community psychological therapy through the development of a predictive model using historic data from 2 services in London. In addition, the study aims to assess the completeness of data collection, explore how treatment outcomes are discriminated using current criteria for classifying recovery, and assess the feasibility and need for undertaking a future larger population analysis. Design Observational, retrospective discriminant analysis. Setting 2 London community mental health services that provide psychological therapies for common mental disorders including anxiety and depression. Participants A total of 7388 patients attended the services between February 2009 and May 2012, of which 4393 (59%) completed therapy, or there was an agreement to end therapy, and were included in the study. Primary and secondary outcome measures Different combinations of the clinical outcome scores for anxiety Generalised Anxiety Disorder-7 and depression Patient Health Questionnaire-9 were used to construct different treatment outcomes. Results The predictive models were able to assign a positive or negative clinical outcome to each patient based on 5 independent pre-treatment variables, with an accuracy of 69.4% and 79.3%, respectively: initial severity of anxiety and depression, ethnicity, deprivation and gender. The number of sessions attended/missed were also important factors identified in recovery. Conclusions Predicting whether patients are likely to have a positive outcome following treatment at entry might allow suitable modification of scheduled treatment, possibly resulting in improvements in outcomes. The model also highlights factors not only associated with poorer outcomes but inextricably linked to prevalence of common mental disorders, emphasising the importance of social determinants not only in poor health but also poor recovery.

Important side effects and potential clinical hazards have emerged from long-term follow up in some drug classes used in type 2 diabetes treatment. Systematic phase 4 post-marketing data in early use of newer diabetes drugs may have a role in informing drug choice in practice and assist in pharmacoeconomic assessments of these drug choices. We carried out a comparison of the prevalence of drug withdrawals derived from both liraglutide registration trial data, and a systematic, prospective case-note review of all new liraglutide prescriptions (n=176) from a specialist diabetes clinic over the first 12 months of drug introduction. Trial data used for the marketing authorisation application for liraglutide reported 7.0% withdrawal due to adverse events. Equal numbers of patients experienced mild, moderate and severe side effects. By contrast, data derived from a 'real world' clinical group describe 14.8% withdrawal due to adverse events, with withdrawal typically occurring early, by three months. Adverse events were more frequently responsible for treatment withdrawal at lower, compared to higher, doses of liraglutide therapy. Systematic observations of withdrawals in early use of new drugs in current clinical practice are higher than reported in registration trial data. These data highlight that postmarketing surveillance should inform guideline recommendations and pharmacoeconomic evaluations. Copyright © 2012 John Wiley & Sons.

Disease prevalence can be spatially analysed to provide support for service implementation and health care planning, these analyses often display geographic variation. A key challenge is to communicate these results to decision makers, with variable levels of Geographic Information Systems (GIS) knowledge, in a way that represents the data and allows for comprehension. The present research describes the combination of established GIS methods and software tools to produce a novel technique of visualising disease admissions and to help prevent misinterpretation of data and less optimal decision making. The aim of this paper is to provide a tool that supports the ability of decision makers and service teams within health care settings to develop services more efficiently and better cater to the population; this tool has the advantage of information on the position of populations, the size of populations and the severity of disease.A standard choropleth of the study region, London, is used to visualise total emergency admission values for Chronic Obstructive Pulmonary Disease and bronchiectasis using ESRI's ArcGIS software. Population estimates of the Lower Super Output Areas (LSOAs) are then used with the ScapeToad cartogram software tool, with the aim of visualising geography at uniform population density. An interpolation surface, in this case ArcGIS' spline tool, allows the creation of a smooth surface over the LSOA centroids for admission values on both standard and cartogram geographies. The final product of this research is the novel Cartogram Interpolation Surface (CartIS).The method provides a series of outputs culminating in the CartIS, applying an interpolation surface to a uniform population density. The cartogram effectively equalises the population density to remove visual bias from areas with a smaller population, while maintaining contiguous borders. CartIS decreases the number of extreme positive values not present in the underlying data as can be found in interpolation surfaces.This methodology provides a technique for combining simple GIS tools to create a novel output, CartIS, in a health service context with the key aim of improving visualisation communication techniques which highlight variation in small scale geographies across large regions. CartIS more faithfully represents the data than interpolation, and visually highlights areas of extreme value more than cartograms, when either is used in isolation.

SummaryStudies in North America and Europe indicate that the prevalence of blood-borne viruses (BBVs) is elevated in individuals with severe mental illness; there are no comparable data for the UK. We offered routine testing for HIV, and hepatitis B and C in an inner-London in-patient psychiatric unit as a service improvement. Of the patients approached 83% had mental capacity to provide informed consent for testing and 66% of patients offered testing accepted. Although it was not our objective to establish the prevalence of BBVs, 18% of patients had serological evidence of a current or previous BBV infection, we found that offering routine testing in an in-patient psychiatric setting is both practical and acceptable to patients.

Aims To establish trends in diagnoses in pre-school children admitted to a large urban hospital over a 10 year period with respiratory symptoms. To explore the feasibility of developing a baseline for time trend analysis with the objective of assessing the effects of service innovations designed to improve quality of care for children with asthma and allergy. Methods We analysed routine data in-patient attendances to the hospital between 2004 and 2013. We included all children under 5 years old where there was coding of diagnosis on discharge. Descriptive analysis of the top 5 diagnoses over 10 years. Results There were 12,601 admissions of children under 5 years old in the study period which accounted for 60.5% of the total admissions of children under 15 years old. Acute upper respiratory infection, acute bronchiolitis, and asthma were consistently the top 3 diagnoses in 9 out of the 10 years in this age group; over half of the diagnoses (mean 51.2%, sd 7.9, [40.3–63.3%]). Acute upper respiratory infection was the leading diagnosis in 8 out of the 10 years and ranged from 41.6% (2004) to 13.1% (2013). There was a relative reduction in the proportion of children diagnosed with URTis over this time with an increase in other categories (Figure 1). The majority of admissions were less than 1.6 days. Conclusion Acute respiratory infection has been consistently the main primary diagnosis of pre-school children admitted on to our wards. The increase in “asthma” might suggest possible systematic diagnostic coding differences during this time period or a true increase in prevalence in this age group as has been described 1 . Accurate baseline data is essential especially for this age group where a diagnosis of asthma may vary considerably between practitioners and over time. Adherence to recent guidelines on accurate diagnosis in preschoolers 2 and appropriate staff training of clinicians and clinical coders may help to refine this further. References Radhakrishnan D, Dell S, Guttmann A, Shariff S, Liu K, To T. Trends in the age of diagnosis of childhood asthma. J Allergy Clin Immunol 2014; 134(5):1057–62.e5 Saglani S, Bush A. Asthma in preschool children: the next challenge. Curr Opin Allergy Clin Immunol 2009; 9:141–5

Background Unscheduled attendances are increasing annually in preschool children under 5 years of age in England. Despite research in adult settings on recurrent attenders, there is limited UK data in pre-schoolers. Nationally, this is one of the largest population groups attending emergency and urgent care facilities. Further characterisation of socio-demographic, GP and clinical characteristics may identify a potential group suitable for intervention. We hypothesised that small and very; arge practices might have increased risk of PRA. Aims To describe the socio-demographic and general practice factors of under-5 patients who attend an A&E and/or UCC in a large metropolitan DGH. Which socio-demographic factors are predictive of being a paediatric recurrent attender ( PRA ) presenting with ≥4 ED visits? Does GP practice size have an influence on ED use? Methods Retrospective study using a dataset of emergency attendances from 01 October 2013 to 30 September 2014. PRA is defined as a child younger than 5, with ≥4 unscheduled ED visits during the year. Descriptive statistics, univariate analyses and logistic regression techniques were used to analyse the characteristics of the study population. Deprivation measures included IMD and IDACI. Stata software was used to analyse the data. Results During the study period, there were 16,220 attendances by 9770 individual patients. 7.8% of patients accounted for 20.7% of visits. The distribution is shown in Table 1. The following factors were found to be significantly predictive (p Limitations include suboptimal clinical coding and lack of data on GP: child patient ratios. Conclusion This is the first study to combine both A and E and UCC data in a single locality. Children under five who attend 4 or more times in a year are more likely to be Asian infants from medium deprivation households, with a respiratory illness and attending out of hours. Clinical characterisation from more detailed notes review aims to identify those who might benefit from specialist community nursing support and educational intervention. We are currently interviewing parents in these groups to better understand motivations for attendance.

This paper outlines a structured argument for the use of routine health and demographic data to support the delivery of equitable services that are better aligned to the needs of the populations they serve. The paper describes case studies from a nationally funded research and quality improvement programme in London, UK as examples of targeting existing services, without top-down reconfiguration, using quality improvement methodology.Three case studies are presented each demonstrating a differing use of geocoded routine data. The first demonstrates the use of a novel composite metric for the prospective targeting of service improvement; the second shows how routine geo-coded health data can be used to support the geographical location of services; the third demonstrates how routine data can be used to evaluate the impact of improvement initiatives on disparities in healthcare. All methods provide a novel way of analyzing current service provision to ensure targeting of services where needed and contributing to the quality and cost challenges faced by healthcare providers and commissioners.

Background Improving access to psychological therapies (IAPTs) services deliver evidence-based care to people with depression and anxiety. A quality improvement (QI) initiative was undertaken by an IAPT service to improve referrals providing an opportunity to evaluate equitable access. Methods QI methodologies were used by the clinical team to improve referrals to the service. The collection of geo-coded data allowed referrals to be mapped to small geographical areas according to deprivation. Results A total of 6078 patients were referred to the IAPT service during the period of analysis and mapped to120 unique lower super output areas (LSOAs). The average weekly referral rate rose from 17 during the baseline phase to 43 during the QI implementation phase. Spatial analysis demonstrated all 15 of the high deprivation/low referral LSOAs were converted to high deprivation/high or medium referral LSOAs following the QI initiative. Conclusion This work highlights the importance of QI in developing clinical services aligned to the needs of the population through the analysis of routine data matched to health needs. Mapping can be utilized to communicate complex information to inform the planning and organization of clinical service delivery and evaluate the progress and sustainability of QI initiatives.

To determine whether the process of emergency care waiting in England has changed following the modification of the operational standard for the 4 h waiting time target from 98% to 95% in June 2010.Retrospective analysis of publicly available 'total time spent in accident and emergency' data from Department of Health.Patients attending emergency departments (EDs) in England between October 2002 and September 2011. In 2005, the government set an operational standard that 98% of patients should wait4 h in ED. In June 2010, the government announced that the operating standard would change to 95% immediately.Percentage of patients waiting4 h (weekly and quarterly), and total number of patients waiting4 h.The average percentage of patients waiting4 h fell from 98% to 95% almost immediately following the operational standard change. Consequently, between October 2010 and September 2011, approximately 383 000 additional patients in England EDs waited in excess of 4 h than had the 98% standard been attained. The emergency care system appears to have been stabilised at this new level.The policy change for waiting times in EDs in England has resulted in the process of emergency care in England adjusting to the new operational standard of 95% of patients waiting4 h. As a result, more patients are waiting4 h to receive the care they need; consequently, outcomes are likely to suffer.

Background The XmR chart is a powerful analytical tool in statistical process control (SPC) for detecting special causes of variation in a measure of quality. In this analysis a statistic called the average moving range is used as a measure of dispersion of the data. This approach is correct for data with natural underlying order, such as time series data. There is however conflict in the literature over the appropriateness of the XmR chart to analyse data without an inherent ordering. Methods We derive the maxima and minima for the average moving range in data without inherent ordering, and show how to calculate this for any data set. We permute a real world data set and calculate control limits based on these extrema. Results In the real world data set, permuting the order of the data affected an absolute difference of 109 percent in the width of the control limits. Discussion We prove quantitatively that XmR chart analysis is problematic for data without an inherent ordering, and using real-world data, demonstrate the problem this causes for calculating control limits. The resulting ambiguity in the analysis renders it unacceptable as an approach to making decisions based on data without inherent order. Conclusion The XmR chart should only be used for data endowed with an inherent ordering, such as a time series. To detect special causes of variation in data without an inherent ordering we suggest that one of the many well-established approaches to outlier analysis should be adopted. Furthermore we recommend that in all SPC analyses authors should consistently report the type of control chart used, including the measure of variation used in calculating control limits.

diabetes (T2DM) in the young is a growing concern in many countries worldwide. In previous studies, positive associations with obesity, female gender, and family history have been noted. Newham, East London, has one of the highest prevalence of T2DM in the UK as well as one of the youngest populations. Our aim was to establish the prevalence and characteristics of T2DM in young people in Newham, and compare findings with existing data. Forty-four young people (≤25 years) with T2DM and an equal number of young people with type 1 diabetes were examined. A retrospective analysis of existing patient records utilising diabetes and pathology databases was conducted. The age-specific prevalence of T2DM in children and young adults within Newham was noted to be the highest in the UK at 0.57/1000 (58 out of 100300). There was a strong association with obesity and 77% of those with T2DM were found to have a body mass index ≥25kg/m 2 . Many had features of the metabolic syndrome. This analysis confirms the high prevalence of T2DM with obesity in young people, particularly among minority ethnic groups, and adds to concern among health care providers and commissioners about the need for preventative strategies to tackle this problem. Copyright © 2012 John Wiley & Sons. Practical Diabetes2012; 29(5): 193-198