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Aims COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms. Methods A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory. Results A total of 888 patients responded. Better health, pain, and mood scores were reported by upper limb patients. The longest waiters reported better health but poorer mood and anxiety scores. Overall, 82% had tried self-help measures to ease symptoms; 94% wished to proceed with their intervention; and 21% were prepared to tolerate deferral. Qualitative analysis highlighted the overall patient mood to be represented by the terms ‘understandable’, ‘frustrated’, ‘pain’, ‘disappointed’, and ‘not happy/depressed’. COVID-19-mandated health and safety measures and technology solutions were felt to be implemented well. However, patients struggled with access to doctors and pain management, quality of life (physical and psychosocial) deterioration, and delay updates. Conclusion This is the largest study to hear the views of this ‘hidden’ cohort. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within the constraints of current resources. In response, we developed a reproducible local action plan to address highlighted issues. Cite this article: Bone Jt Open 2021;2(8):583–593.

COVID-19 has highlighted the need for a standardised approach for prioritising patients requiring elective care. The Royal College of Surgeons of England (RCS) developed guidance at the start of the pandemic for prioritising surgical patients based on the urgency of different procedures. Imperial College Healthcare NHS Trust (ICHT) has extended this to all aspects of elective care to enable standardised decision-making based on clinical priority, clinical harm and patient vulnerability. This was a clinically led project that involved close collaboration with lay partners, who were concerned that the RCS guidance lacked the sensitivity to reflect individual patients’ needs. Our novel elective care recovery matrix is designed to be applicable across all elective care services and at Trust or system level. Implementation at ICHT progressed rapidly: as of 28 August 2020 >200 consultants have received training on the process and 58% of all surgical orders have been prioritised using the new framework (5,134/8,800). While COVID-19 was the driver, the applicability can be wider and could inform new ways of working. The framework enables rapid quantification of individual patient care requirements, thus enabling clinicians to target more accurately those patients with the greatest need and those who would see the greatest benefit.

This is an independent report on NHS waiting lists for elective procedures in England. It isthe first analysis to focus specifically on procedures rather than the overall waiting list which includes outpatients and medical treatments. We report that in addition to the 1 million people waiting for elective procedures on the NHS waiting list in England, there are also 3.3 million people on the 'hidden' waiting list. We have presented specialty-level breakdowns and have identified 20 key procedures that represent 70% of the waiting list. We project waiting lists through to 2030.

Purpose The primary aim of our study was to investigate elective orthopaedic care during the first wave government-imposed COVID-19 lockdown and at four weeks and 21 weeks after resuming elective care. The secondary aim of our study was to evaluate the implementation of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) COVID-19 Guidelines and Recommendations for Resuming Elective Surgery in the clinical practice of Belgian knee surgeons. Methods We sent three anonymous online surveys to 102 Belgian Knee Society members (BKS) at times mentioned above. Addressed topics were: (1) participant demographics, (2) elective surgeries, (3) outpatient visits, (4) ESSKA Guidelines, (5) patient and surgeon safety. Results During the COVID-19 lockdown, there was a decrease of 97% in elective knee surgeries and 91% in outpatient visits. At four and 21 weeks after resuming elective care, volumes were respectively 67% and 89% for elective surgeries and 81% and 91% for outpatient visits. Regarding ESSKA guidelines, 91% of surgeons had no COVID-19 testing prior to resuming elective care. Ninety-two per cent reported preoperative ( Conclusion Our study shows that elective surgeries and outpatient visits were almost completely interrupted during the COVID-19 lockdown and were still below normal at four and 21 weeks after resuming elective care. Regarding ESSKA COVID-19 guidelines, our study observes good compliance in preoperative patient COVID-19 testing, but lower compliance for preoperative health care personnel testing, patient selection, use of PPE, and locoregional anaesthesia. Level of Evidence V

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NHS England and NHS Improvement. 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf. Accessed August 2020. Royal College of Ophthalmologists. Preparing eye care services for a potential Covid-19 second wave. Royal College of Ophthalmologists. 2020. https://www.rcophth.ac.uk/wp-content/uploads/2020/08/RCOphth-Second-Wave-Guidance-v3.pdf. Accessed August 2020. LOCSU. Services Map. LOCSU. 2020. http://www.locsu.co.uk/wp-content/uploads/2020/08/LOCSU-CCG-Services-Map-A4-Aug-2020.pdf. Harper R, Dhawahir-Scala F, Wilson H, Gunn PJG, Jinkinson M, Pretty IA et al. Development and implementation of a Greater Manchester COVID19 Urgent Eyecare Service. Eye. 2020:1–4. https://doi.org/10.1038/s41433-020-1042-6. Clinical Council for Eye Health Commissioning (CCEHC). System and Assurance Framework for Eye-health (SAFE)—Emergency and Urgent Care. Clinical Council for Eye Health Commissioning (CCEHC). 2018. https://www.college-optometrists.org/uploads/assets/e827d379-9165-4656-9458c83b0e33da79/SAFE-Emergency-and-Urgent-Care.pdf. Accessed August 2020. Clinical Council for Eye Health Commissioning (CCEHC). Priorities for delivering the NHS Long Term Plan for Eye Health. Clinical Council for Eye Health Commissioning (CCEHC). 2019. https://www.college-optometrists.org/uploads/assets/d2837ae1-45b7-43e2-b0c019e4536b7611/CCEHC-priorities-for-delivering-the-NHS-LTP-for-Eye-Health-October-2019.pdf. Accessed August 2020. Clinical Council for Eye Health Commissioning (CCEHC). System and Assurance Framework for Eye-health (SAFE)—Overview and Resources. Clinical Council for Eye Health Commissioning (CCEHC). 2018. https://www.college-optometrists.org/the-college/ccehc/safe-systems-assurance-framework-for-eye-health.html. Accessed August 2020. Download references Public Health and Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK Parul Desai Kings College Hospital NHS Foundation Trust, Frognal Avenue, Sidcup, Kent, DA14 6LT, UK David Parkins Local Optical Committee Support Unit, LOCSU, 2 Woodbridge Street, London, EC1R ODG, UK Zoe Richmond You...

Highlights • The innovative surgical techniques for reconstruction the abdominal wall defect without using the mesh. • Technique to repair abdominal wall defect in the infected area. • Nylon darn repair for reconstruction of the abdominal wall defect., Introduction Reconstruction of the abdominal wall supplemented by surgery of the abdominal wall infection or the excision of the abdominal wall tumor is one of the most difficult procedures due to the need to avoid incisional hernia and to minimize the spread of infection. The primary purpose of the repair of the abdominal wall is to safeguard the visceral organs and avoid postoperative incisional hernia. Many of the abdominal wall restoration procedures include simple sutures of rectus abdominis aponeurosis, component separation procedure, and open mesh repair. Mesh restoration is currently the gold standard in elective care for most instances of abdominal wall reconstruction. Presentation of case A male patient aged 69 years had cutaneous mucormycosis. We agreed to perform a wide excision of the lesion. There was a large abdominal wall defect after the excision. Due to concerns about mesh repair due to contaminated surgical area and loss of skin shielding, we opted to use Nylon Darn for abdominal closure. Discussion We documented our technique for abdominal wall reconstruction using adapted Nylon darn. Conclusion For closing abdominal wall defects in surgical areas with elevated infection rates, the newly-designed technique proposed in this paper could be an alternative approach.

Due to the COVID-19 pandemic, elective medical services have had to be reduced to a minimum, which has also affected care in pain medicine. Following these drastic cutbacks, a cautious resumption of elective care is planned. This also applies to the delivery of inpatient and day-care interdisciplinary multimodal pain therapy (IMPT). Since the majority of pain medicine centers have been closed to date, the question has arisen as to whether a resumption of regular care can be easily provided under the required protective measures. To answer this question, the authors conducted a survey among patients that were in a position to make a direct comparison between IMPT under normal conditions as well as under the currently required protective measures. The survey recorded the level of disruption caused by the different protective measures in the various treatment modules. An evaluation of the questionnaires, which were completed by two patient groups and all therapists involved, revealed that interdisciplinary multimodal pain therapy is possible without significant impairments even under the required protective measures. In particular, wearing protective masks proved to be the protective measure with the greatest negative impact. However, options like the use of protective visors or relocating treatment modules to the outdoors offer practicable alternative solutions for protection. Both patient and therapist satisfaction was high despite these constraints, and personal concern regarding possible infection low.

The COVID-19 pandemic has resulted in significant clinical and economic consequences for medical practices of all specialties across the nation. Although the clinical implications are of the utmost importance, the economic consequences have also been serious and resulted in substantial damage to the US healthcare system, including pain practices. Outpatient pain practices have had to significantly change their clinical care pathways, including the incorporation of telemedicine. Elective medical and interventional care has been postponed. For the most part, ambulatory surgical centers have had to cease operations. As patient volumes have decreased for non-emergent elective care, the financial indicators have deteriorated. This review article will provide insight into solutions to mitigate the clinical and economic challenges induced by COVID-19. Undoubtedly, the COVID-19 pandemic will have short-term and long-term implications for all medical practices and facilities. In order to survive, medical practices will need dynamic, operational, and creative strategic plans to mitigate the disruption in medical care and pathways for successful reintegration of clinical and surgical practice.

In an early stage of the COVID-19 outbreak, hospitals in England were asked to postpone elective treatments in order to accommodate the expected demand for COVID-19 related admissions. This study a...

The waiting list for elective care in England could reach 12 million by early 2025 without additional staff and bed capacity, the government’s spending watchdog has forecast. In a report published on 1 December,1 the National Audit Office (NAO) cautioned that tackling the existing backlog and restoring elective and cancer care to the required standards would be a daunting challenge for the NHS. By September 2021 some 5.83 million patients were on the waiting list for elective care, 1.95 million of whom had waited for more than 18 weeks for treatment and 301 000 for more than a year, it said. Although cancer activity in the NHS had recovered to pre-pandemic levels by June 2021, the watchdog estimated that 240 000 to 740 000 urgent referrals …

NHS hospitals across the UK are creating extra bed capacity to relieve ongoing operational pressures from covid-19 and to tackle the growing backlog in elective care. Reports are increasing of trusts being forced to cancel elective operations in the face of major pressure on services (box 1), and ongoing bed shortages are prompting some trusts to add more capacity. Box 1 ### Elective operations cancelled Last week it was reported that most elective surgery had been cancelled at the Princess Alexandra Eye Pavilion in Edinburgh until March 2022 to allow staff to be redeployed to the nearby Edinburgh Royal Infirmary.1 Meanwhile, five hospitals in Leeds were reported to have cancelled most “priority 2” elective operations on Tuesday 2 November after a surge in numbers of patients with covid-19 and in the emergency department.2 In a statement Mark Liddington, medical director of operations for planned care at Leeds Teaching Hospitals NHS Trust, confirmed that said some procedures “that are not assessed as clinically urgent” had been postponed but said “the situation has … RETURN TO TEXT

Introduction Elective care in the UK came to a standstill with the advent of the COVID-19 pandemic. A restart could only be enabled with ‘green site’ separation and a ‘covid protected’ zone. A ‘hospital within the hospital’ concept was developed including 9 elective theatres, 28 ring fenced elective beds, a surgical enhanced care unit, a canteen, and a separated entrance. This model was underpinned with PPE, enhanced infection control and guidance for staff. The study documented the ability to recover elective activity and therefore provide a training environment for surgical trainees. Method Data was collected weekly (7/20 to 1/21) through the business informatics system with regard to theatres cases completed compared to the activity achieved in the 11-theatre elective estate pre COVID-19. Results Pre COVID-19, an average of 263 cases were completed per week. In the first week of operation, 31% of theatre capacity was achieved. By week 7, 106% of pre COVID was recorded and 130% by week 11. This was maintained until the impact of the second wave where activity has reduced to 50% but is not anticipated to reduce further as local anaesthetic and blocks maybe utilised. Conclusions This ‘hospital within the hospital’ has enabled elective care to return to above normal levels, with increased efficiencies. This has enabled a rapid return to a training environment for trainees disheartened with deployment to critical care in the first wave.

INTRODUCTION AND OBJECTIVE: Guidelines for endourological procedures during COVID-19 have suggested to defer nonobstructed stones, while obstructed/ infected stones should be considered emergencies.1,2 In our centre, screening protocols (as per Ministry of Health's guidelines)3 were implemented with prioritization strategies so that elective care could safely continue, albeit at deescalated rates. COVID or septic patients underwent decompression with stent or nephrostomy insertion, while non-COVID and non-septic patients underwent primary ureteroscopy (URS) or retrograde intrarenal surgery (RIRS). All interventions were done only by consultants, and surgical precautions such as donning of personal protective equipment were undertaken.4 We aim to report the outcomes of endourological surgery for stone disease in our centre during COVID. METHODS: We conducted a prospective review of all endourological surgeries for stones in our centre between 23 Jan and 31 Aug 2020, when all non-necessary surgeries were deferred. RESULTS: 201 surgeries were performed on 159 patients (93 emergencies, 108 electives)- 36 (17.9%) stent insertions, 116 (57.7%) URS and 49 (24.4%) RIRS. 34 patients were females and 125 males. Median age of patients was 50, with 37% ≥ 60. 31 patients were ASA ≥ 3. None were COVID positive. Mean single stone size was 8.17 mm (1-38) and cumulative stone size was 10.63 mm(1-84). 44 patients had multiple stones. The index stone location was proximal ureter in 111 (55.2%), mid ureter 19 (9.45%), distal ureter 67 (33.3%), renal 4 (1.99%). 55 (27.4%) procedures were carried out due to previously stented stones, 10 (4.98%) bilateral obstruction/ single kidney, 77 (38.3%) failed MET/ persistently symptomatic stone, 16 (7.96%) intractable colic, 14 (6.96%) AKI, and 20 (9.95%) sepsis. 166 (66.6%) patients had stent inserted post operatively- 15 with threads that precluded the need for scope guided removal. 27 (10.8%) had a ureteric catheter that was removed prior to discharge. The overall stone free rate was 97.4%;95 (59.7%) were stone free with 1 procedure. 60 (37.7%) required staged procedures. An average of 1.41 procedures/ patient was needed to be stone free. 2 (0.99%) patients had Clavien Dindo Grade III complications. 9 (4.48%) were readmitted- 7 for UTI and 1 for stent symptoms. Median length of stay was 2 days (0- 43). CONCLUSIONS: Our centre demonstrated favourable outcomes in patients undergoing endourological surgery for stone diseases during COVID by following strict screening protocols and surgical precautions. The results support the continuation of endourological surgery with the proposed framework in regions with similar COVID trends.

The COVID-19 pandemic has led to severe disruption of healthcare systems and elective planned care.1 While pandemics are infrequent, the disruption of elective care by acute respiratory viral infections is an annual occurrence, including administration of oral food challenges (OFCs) to children with suspected allergy. A major barrier to performing OFCs outside tertiary centres is the risk of adverse events including anaphylaxis.2 3 We recently reported a large series of food challenges in a COVID-19 stepdown facility,4 and here we describe our process of managing anaphylaxis in this setting. Five regional paediatric allergy clinics across Ireland jointly used a vacant COVID-19 field hospital over 6 weeks. OFCs were performed within a pod system, with each pod containing up to six patients (figure 1). Resuscitation protocols and equipment trolleys were identical to those in hospital. For anticipated anaphylaxis events, patient journey was mapped …

The article is devoted to semantic content of integral anamnesis - basic part of national integrated electronic health record. Integral anamnesis is a formalized set of the most important clinical data of a patient aimed at safety and continuous medical care both emergency and elective care. A short review of international projects of implementation and trans border exchange of key information about a patient is presented. Information content of integral anamnesis is presented which is developed in our country and includes 15 main sections: disability, benefits, social factors, addiction and occupational hazards, significant vital parameters, blood types and rhesus factor, pathological reactions, vaccination and immunization, epidemiological anamnesis, significant (dispensary) diseases, surgical interventions, medical devices and implants, pregnancies and deliveries, current medications and non-drug treatment. Administration, structure, problems, readiness of reference materials for coding of information presented in integral anamnesis are described. At the moment most of the necessary reference materials are finished and available on the portal of normative-reference information of the Ministry of Health of the Russian Federation (http://nsi.rosminzdrav.ru/): 20 basic and 7 additional ones. At the current stage it provides interoperability of medical information systems in integral anamnesis. Such time-consuming reference books as surgical interventions, instrumental diagnostic studies, federal reference book of medications are being actively developed. The section «Epidemiological anamnesis of a patient» stays practically unformalized. The first step in this direction is development of a reference book of immunobiological medications for specific prophylaxis, diagnosis and treatment. The aim of the study of semantic interoperability for integral anamnesis was reached by development of 27 reference books posted on the federal portal of normative-reference information of the Ministry of Health of Russia; the next stage should be development of technologies of formation and upgrade of the information of integral anamnesis.

NHS England is to invest £160m (€186m; $225m) to test new initiatives to reduce the hospital waiting lists that have soared to 4.7 million people during the covid-19 pandemic. Selected areas of England will test quicker access to diagnostic testing at one stop facilities, pop-up clinics to treat and discharge patients closer to home, Saturday specialist clinics staffed by multidisciplinary teams, and “virtual wards” to assess people at home. A high volume service for removing cataracts in a day, 3D eye scanners, antibiotic kits to use at home, “pre-hab” for patients before surgery, artificial intelligence in GP surgeries, and greater access to specialist advice for GPs will also be trialled across a dozen areas and five specialist children’s hospitals. Amanda Pritchard, the …

Primary care is under “immense pressure” and needs investment, clear national priorities, and new mechanisms to measure workload in order to restore services and support staff in the aftermath of the covid-19 pandemic, leaders have said. In a paper1 published on 10 May, the NHS Confederation highlighted the increasing and unsustainable workload facing primary care services as they provide routine care while also seeing patients with long covid, those with multiple comorbidities and long term conditions, people waiting for elective care, and the growing number requiring mental health support. It comes after recent figures from NHS Digital showed that general practices in England delivered nearly three …

BackgroundThis paper aims to describe the profile of oral cancer (OC) patients, their risk classification and identify the time between screening and treatment initiation in Rio de Janeiro Municipality.MethodData were obtained from the healthcare Regulation System (SISREG) regarding the period January 2013 to September 2015. Descriptive, bivariate and multivariate analysis were performed identifying the factors associates with a diagnosis of OC as well as the time to treatment initiation (TTI) differences between groups.ResultsFrom 3,862 individuals with a potential OC lesion, 6.9 % had OC diagnosis. OC patients were 62.3 y.o. (mean), 64.7 % male, 36.1 % were white and 62.5 % of the records received a red/yellow estimated risk classification. Being older, male, white and receiving a high-risk classification was associated with having an OC diagnosis. OC TTI was in average 59.1 days and median of 50 days significantly higher than non-OC individuals (p = 0.007). TTI was higher for individuals older than 60 years old, male, and white individuals and for risk classification red and yellow, nevertheless while in average none of these differences were statistically significant, the median of individuals classified as low risk was significantly (p = 0.044) lower than those with high risk.ConclusionsTime to treatment initiation (TTI) was higher for OC patients related to non OC. Despite OC confirmed was associated with risk at screening classified as urgent or emergent, a high percentage of OC patients had their risk classified for elective care when specialized care was requested.

This article explores the potential for maximum waiting times targets to improve access to healthcare in a country with limited financial resources. The study combines policy analysis, off-the-record communications, face-to-face interviews, public opinion surveys and open access patient complaints to create a rich picture of how waiting time targets are monitored and implemented in theory and practice. The study found that most waiting time targets in the Russian Federation are unrealistically low, while institutional and operational arrangements for their implementation have not been built in most regions. Estimates of actual waiting times are fragmented and unreliable. The lack of meaningful regulation and monitoring encourages opportunistic behavior among health providers to meet the targets while there is growing uncertainty among patients. Maximum waiting times targets alone are insufficient to reduce excessive waiting times. Successful implementation relies on robust data systems and standardized measurements for waiting times as well as meaningful regulation and monitoring.

The aim of this article was to discuss biosafety measures described in the main protocols for minimizing the risk of COVID-19 transmission during dental care. COVID-19 appeared in China in late 2019 and quickly spread to other countries. Factors inherent to dental practice, such as proximity to the patient, transmission through saliva and breath, and the generation of aerosols during procedures, place the dental team at the top of the list among the most vulnerable healthcare providers. Health authorities initially recommended only maintaining urgent and emergency care and suspending elective dental procedures. Currently, elective care is gradually being resumed and requires numerous adjustments to the environment and professional routine in terms of biosafety. Several methods had been recommended to prevent the spread of other infectious diseases prior to the outbreak of COVID-19. However, further modifications are needed for the waiting room, patient screening and flow, procedures, garments, and even in dental office itself. Thus, dental professionals need to be prepared to adopt the new recommendations in order to reduce the chance of disease transmission.

Liverpool and neighbouring local authorities will become the first area of England to have new restrictions imposed under the new three tiered risk system designed to stem rising covid-19 infections across England, the government has announced. Liverpool itself had 609 cases per 100 000 population on 13 October, a 14.3% rise over the previous week. Neighbouring Knowsley, included in the measures that apply to the Liverpool City Region, which also includes Halton, Sefton, St Helens, and Wirral, had 669.5 cases per 100 000. Liverpool has the steepest increase in covid-19 admissions to hospital in England, and the highest number, with more than 250 patients in beds at Liverpool University Hospitals NHS Foundation Trust, around 15% of bed capacity. In a memo seen by the Health Service Journal , Steve Warburton, chief executive of the trust, said that it was scaling back non-urgent operations to help cope with the surge.1 “We recognise that this will be distressing for patients whose elective care needs to be …

Patients should be admitted to hospital for planned or elective care only if they have self-isolated for 14 days beforehand and tested negative for covid-19, says new guidance for trusts in England designed to increase the number of routine operations and treatments.1 People who require urgent and emergency care should be tested on arrival and streamed accordingly, with services split to make the risk of picking up the virus in hospital as low as possible, said NHS England. In emergency departments and other walk-in services trusts should ensure that measures are in place to maintain social distancing. The guidance says that outpatient appointments should be conducted …

Healthcare leaders have called for more funding for the NHS as data show that 5.45 million patients in England are now waiting for routine care. Data published by NHS England and NHS Improvement on 12 August show that the number of patients waiting for consultant led elective care in June had risen to 5 454 314. Of those, 304 803 patients had been waiting more than 52 weeks.1 Deborah Ward, senior analyst at the health think tank the King’s Fund, warned that waiting lists had the potential to grow further, as …

The population in the UK is changing, increasing overall as well as seeing arise in people over 65 years. This is predictable and most likely due to improvements in lifestyle and healthcare. This change will place our social and healthcare systems in the UK under increasing duress. Orthopaedics will, in all likelihood, see an impact on both elective care as well as in the trauma side of the services we provide. Caring for this elderly group of patients will mean that our current therapeutic pathways will have to be modified. This article aims to give a better understanding of the changes that are likely as well as some strategies that can be developed to meet these challenges.

Background To quantify how baseline differences in patients undergoing hip arthroplasty for fracture vs elective care potentially lead to significant differences in immediate health care outcomes and whether these differences affect feasibility of current bundled payment models. Methods New York Statewide Planning and Research Cooperative System database for the years 2000-2014. Results A total of 76,654 patients underwent total hip arthroplasty or hemiarthroplasty between 2010 and 2014; 82.8% of the sample was for elective care and 17.2% for fracture-related etiology. Fracture patients were significantly older, more likely to be female, Caucasian, reimbursed by Medicare, and receive general anesthesia. Comorbidity burden and postoperative complications were significantly higher in the fracture group, and hospital charges were significantly greater for fracture patients as compared with those of the elective cohort. Conclusion Patients undergoing hip arthroplasty for fracture care are significantly older and have more medical comorbidities than patients treated on an elective basis, leading to more in-hospital complications, greater length of stay, increased hospital costs, and significantly more hospital readmissions. The present bundled payment system, even with the recent modification, still unfairly penalizes hospitals that manage fracture patients and has the potential to incentivize hospitals to defer providing definitive surgical management for these patients. Future amendments to the bundled payment system should consider further separating hip arthroplasty patients based on etiology and comorbidities, allowing for a more accurate reflection of these distinct patient groups.

As otolaryngologists, we identify as subspecialists and fellowship-trained surgeons and may even identify as "super-subspecialists." The likelihood of being redeployed and drawing from knowledge learned during our postgraduate year 1 training seemed exceedingly unlikely until physician resources became scarce in some health care systems during the COVID-19 pandemic. More now than ever, it is evident that our broad training is valuable in helping patients and allowing the otolaryngologist to meaningfully contribute to the larger health care community, especially while the majority (70%-95%) of elective care is delayed. With our skill set, otolaryngologists are poised to support various aspects of hospital wards, intensive care units, emergency departments, and beyond.

Background While multiple studies have examined the cost of health care for one aspect of sickle cell disease care, few have focussed on the overall cost of comprehensive care for sickle cell disease. Methods We conducted a retrospective cohort study of children with sickle cell disease treated in a comprehensive care centre from 1 January 2015 to 31 December 2016. Health care utilisation of included patients was based upon data from two main sources. The clinical practice guideline was used to determine the expected resource use of routine comprehensive care (planned elective care), and the financial claims database was used to estimate real-world resource use associated with acute and inpatient care (additional care). Results A total of 125 children with sickle cell disease were analysed. Expenditures for these patients averaged euro5049 [standard deviation (SD) euro1634] per child per year. Total yearly costs per patient varied considerably, ranging from euro669 to euro84 010, and less than 15% of patients were responsible for 50% of the health care costs. The majority (37%) of costs was associated with inpatient hospital care, which increased by age group, 27% with diagnostics, 19% with treatment, 11% with outpatients' visits and 6% with emergency care. Conclusion We have described real-world resource use and expenditures for children with sickle cell disease in a European comprehensive care centre. It seems that costs of a comprehensive approach with effective management in the outpatient setting is favourable when compared to episodic health care.

Introduction Increasing prevalence of chronic liver disease has caused demand for elective paracentesis in refractory ascites to exceed capacity in NHS Tayside, with patients diverting to acute care areas. Assessing the current elective care pathway has allowed us to develop the service in order to increase capacity, reduce pressures on unplanned care and reduce costs. Method 12 weeks of prospective data were collected on patients receiving elective paracentesis. Recommendations made on analysis of this data (Excel) led to changes in the standard operating procedure and a further 6 weeks of prospective data collection closed the PDSA cycle. Results In the initial data collection, 31 elective paracentesis’ were completed on 15 individual patients. Drains were in situ for a median of 24 hours, necessitating an overnight stay. On average 10,966ml of fluid were drained (range 4324ml – 19692ml). The rate of ascitic drainage plateaued at 8 hours, with an average, 74% (range 53%-100%) of total ascitic fluid drained at this point. From this we hypothesized that adequate drainage could be achieved with a day case procedure. During the second data collection, 27 elective paracentesis’ were completed on 12 individual patients with drains in situ for 8 hours. On average 8,123ml of fluid were drained (range 3903ml – 20996ml). If we extrapolate this data over 12weeks we could accommodate a 74% increase in capacity between study groups. 20% albumin replaced 4.5% to reduce volume infused, therefore reducing further time constraints on admission. On average 3 bottles of 4.5% albumin were used in the initial study group and only 2 bottles of 20% in the second study group. This lead to a cost saving, on average of £57.06 per paracentesis, this becomes substantial when added to the cost savings of day case versus overnight stay. There were no clinically significant changes in renal function or haemodynamic parameters in either data set. 86% of patients initially studied had a UKELD score greater than 49 with a median value of 54.5 (range 4–0). There were 7 repeat attenders in the initial group and 4 in the second, attending 3 and 4 weekly, respectively. Only one patient was studied in both data sets with increased drain frequency from monthly to fortnightly. Conclusions Both data sets have shown variability of ascitic fluid volume and drainage rates. We must continue an individualised approach to refractory ascites, but changes to our standard operating procedure have increased elective paracentesis capacity by 74%, reduced pressure on unplanned care and reduced costs by £793.06 per paracentesis. The changes are safe with no clinically significant renal function or haemodynamic deterioration. It is difficult to attribute cause to changes in paracentesis frequency given the multiple confounding factors related to ascites production.

Introducing competition into the NHS in England to try to drive up quality had the perverse effect of lowering it for some elective procedures, a team of economists from Surrey and York universities has found. In a paper presented this week at the Royal Economic Society’s conference in Warwick, the authors said that emergency readmissions after hip and knee replacements rose after patient choice was introduced between 2006 and 2008.1 Greater numbers of emergency readmissions imply a lower quality of care. Emergency readmissions after hip replacements rose by 8.5% and after knee replacements by 7.7%, …