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Aims: Open lower limb fracture is a life-changing injury affecting 11.5 per 100,000 adults each year, and causes significant morbidity and resource demand on trauma infrastructures. This study aims to identify what, and how, outcomes have been reported for people following open lower limb fracture over ten years. Methods: Systematic literature searches identified all clinical studies reporting outcomes for adults following open lower limb fracture between January 2009 and July 2019. All outcomes and outcome measurement instruments were extracted verbatim. An iterative process was used to group outcome terms under standardized outcome headings categorized using an outcome taxonomy. Results: A total of 532 eligible studies were identified, reporting 1,803 outcomes with 786 unique outcome terms, which collapsed to 82 standardized outcome headings. Overall 479 individual outcome measurement instruments were identified, including 298 outcome definitions, 27 patient- and 18 clinician-reported outcome measures, and six physical performance measures. The most-reported outcome was ‘bone union/healing’ reported in over 50% of included studies, while health-related quality of life was only measured in 6% of included studies. Conclusion: Outcomes reported for people recovering from open lower limb fracture are heterogeneous, liable to outcome reporting bias, and vary widely in the definitions and the measurement tools used to collect them. Outcomes likely to be important to patients, such as quality of life and measures of physical functioning, have been neglected. This systematic review identifies the need to unify outcome measures reported on patients recovering from open lower limb fracture; this may be addressed by creating a core outcome set. Cite this article: Bone Joint Res 2023;12(2):138–146.

Introduction: Vitamin K anticoagulants were the mainstay prophylaxis of stroke in patients with atrial fibrillation and thromboembolic diseases. Non-vitamin K oral anticoagulants were approved for use in UK. To evaluate the impact of the introduction and change in guidelines on the utilisation of newer agents on the prescribing oral anticoagulants in UK. Methods: A segmented regression of interrupted time series analysis of the primary care data of oral anticoagulants from England, Scotland, Northern Ireland, and Wales between 2001 and 2021. Results: The overall utilisation of oral anticoagulants increased from 85.8, 9, 2.8, and 7.3 million defined daily doses in 2001 to 430, 36, 14.1, and 26.5 million defined daily doses in 2021 in England, Scotland, Northern Ireland, and Wales respectively. In 2021, the market domination changed from warfarin to apixaban. Segmented regression analysis showed that with the change in the National Institute for Health and Care Excellence clinical guidance in 2014, the utilisation of vitamin K anticoagulants decreased significantly by 2.39e+07, 1675341, 604863 and 2065009 defined daily doses annually in England, Scotland, Northern Ireland, and Wales, respectively. The overall expenditure on oral anticoagulants increased from £16, £1.6, £0.5, and £1.3 million in 2001 to £751, £60, £25, and £44.5 million in 2021 in England, Scotland, Northern Ireland, and Wales respectively. Conclusion: Prescribing oral anticoagulants changed in response to the change in clinical guidance. This suggests that the UK physicians followed evidence-based practice and changed to nonvitamin K oral anticoagulants primarily when recommended by the National Institute for Health and Care Excellence.

Abstract Background Perinatal depression is a significant contributor to maternal morbidity and mortality globally. Migrant women, particularly those living in low- and middle-income settings, represent a particularly vulnerable group due to stressors experienced before, during and after migration. The vast majority of global migration flows occurring within and between low- and middle-income regions, yet existing evidence focuses predominantly on migrants in high-income destinations. This study aimed to redress this significant gap in the evidence by determining the prevalence and determinants of perinatal depression among migrant women on the Thai-Myanmar border. Methods A cohort of labour migrant and refugee women was followed-up from the first trimester of pregnancy to one month post-partum. Depression status was assessed in the first, second and third trimesters of pregnancy and at one month post-partum using the Structured Clinical Interview for the Diagnosis of DSM-IV Disorders. Women diagnosed with depression had immediate access to care. Data on potential demographic, social and clinical associated factors was collected using a questionnaire. Prevalence and incidence of any depressive disorder and moderate-severe depressive disorder was calculated. Univariable and multivariable logistic regression using complete case analysis was used to estimate odds ratios (OR) of association between exposure variables and depression status. Results Five hundred sixty-eight women participated. Period prevalence (from first trimester of pregnancy to one month post-partum) of moderate-severe perinatal depression was 18.5% (95% CI 15.4–21.9%). Overall, 15.4% (95% CI 11.8–19.6%) of women developed new-onset moderate-severe depression during the study period. Forty-two participants received treatment for depression. Risk factors were interpersonal violence (OR 4.5; 95% CI 1.9–11.1); history of trauma (OR 2.4; 95% CI 1.4–4.3); self-reported history of depression (OR 2.3; 95% CI 1.2–4.2); labour migrant status (OR 2.1; 95% CI 1.1–4.0); low social support (OR 2.1; 95% CI 1.1–3.7); and maternal age (OR 1.1 per year; 95% CI 1.0–1.1). Limitations of the study include that culturally specific manifestations of depression may have been missed. Conclusions Perinatal depression represents a significant burden among migrant women on the Thai-Myanmar border. Programmes to address the determinants along with early case identification and effective treatment and referral systems are key to addressing perinatal depression in this low-resource setting.

Introduction The COVID-19 pandemic has impacted specialty chronic obstructive pulmonary disease (COPD) care. We examined the degree to which care has moved to remote approaches, eliciting clinician and patient perspectives on what is appropriate for ongoing remote delivery.Methods Using an online research platform, we conducted a survey and consensus-building process involving clinicians and patients with COPD.Results Fifty-five clinicians and 19 patients responded. The majority of clinicians felt able to assess symptom severity (n=52, 95%), reinforce smoking cessation (n=46, 84%) and signpost to other healthcare resources (n=44, 80%). Patients reported that assessing COPD severity and starting new medications were being addressed through remote care. Forty-three and 31 respondents participated in the first and second consensus-building rounds, respectively. When asked to rate the appropriateness of using remote delivery for specific care activities, respondents reached consensus on 5 of 14 items: collecting information about COPD and overall health status (77%), providing COPD education and developing a self-management plan (74%), reinforcing smoking cessation (81%), deciding whether patients should seek in-person care (72%) and initiating a rescue pack (76%).Conclusion Adoption of remote care delivery appears high, with many care activities partially or completely delivered remotely. Our work identifies strengths and limitations of remote care delivery.

AbstractBackgroundOutcome measurement in forensic mental health services can support service improvement, research, and patient progress evaluation. This systematic review aims to identify instruments available for use as outcome measures in this field and assess the evidence for the most common instruments, specific to the forensic context, which cover multiple outcome domains.MethodsStudies were identified by searching seven online databases. Additional searches were then performed for 10 selected instruments to identify additional information on their psychometric properties. Instrument manuals and gray literature was reviewed for information about instrument development and content validity. The quality of evidence for psychometric properties was summarized for each instrument based on the COnsensus-based Standards for health Measurement INstruments (COSMIN) approach.ResultsA total of 435 different instruments or variants were identified. Psychometric information on the 10 selected instruments was extracted from 103 studies. All 10 instruments had a clinician reported component with only two having patient reported scales. Half of the instruments were primarily focused on risk. No instrument demonstrated adequate psychometric properties in all eight COSMIN categories assessed. Only one instrument, the Camberwell Assessment of Need: Forensic Version, had adequate evidence for its development and content validity. The most evidence was for construct validity, while none was identified for construct stability between groups.ConclusionsDespite the large number of instruments potentially available, evidence for their use as outcome measures in forensic mental health services is limited. Future research and instrument development should involve patients and carers to ensure adequate content validity.

Background: There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system. Objectives: To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement. Design: (1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness. Setting: Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England. Participants: Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement. Interventions: Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation). Main outcome measures: Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years. Results: Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole. Limitations: Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors. Conclusion: No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts. Future work: There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals. Study registration: This study is registered as PROSPERO CRD42017059473. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

Abstract Background Perinatal depression is an important contributor to maternal morbidity and mortality worldwide. Migrant women, particularly those resettling within low- and middle-income settings, are at increased risk of perinatal depression due to multiple stressors experienced before, during and after migration. Evidence on migrant perinatal mental health to date has focused largely on women in high-income destination countries, leaving the voices of displaced women in low-income settings unheard. This study addresses the current evidence gap by exploring the experiences of migrant women living on the Thai-Myanmar border. Methods In-depth interviews were conducted with pregnant and post-partum labour migrant and refugee women on the Thai-Myanmar border who had been diagnosed with severe depression. An interview guide covering women’s current and past life experiences, social support and the impact of depression on social and occupational functioning was used as a prompt. Thematic analysis was used to identify themes emerging from women’s narratives. Results Eleven pregnant and post-partum women with severe perinatal depression took part. Participating women provided extensive insight into the many difficult aspects of their lives that they perceived as contributing to their depression status. Predominant themes emerging from women’s narratives included difficult relationships with partners, challenging life situations, mechanisms for coping with depression and impressions of mental health care. Conclusions Labour migrant and refugee women with severe perinatal depression face a wide range of chronic stressors at the individual, household and community levels that are likely to have both short- and long-term negative effects on their mental well-being and day-to-day functioning. Participating women responded positively to the mental health support they received, and findings provide important insights into how services might further support their needs.

Background: There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS. Objectives/research questions: Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery? Methods: A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process. Results: From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient’s preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of

Perinatal depression is common, and left untreated can have significant and long-lasting consequences for women, their children and their families. Migrant women are at particular risk of perinatal depression as a result of a multitude of stressors experienced before, during and after migration. Identification of perinatal depression among migrant women-particularly those living in low- and middle-income regions-remains challenging, partly due to the lack of locally-validated and culturally appropriate screens tools. This study formally validates Burmese and Sgaw Karen versions of the Refugee Health Screener-15 (RHS-15) as a screening tool for perinatal depression among migrant women living on the Thai-Myanmar border. The Structured Clinical Interview for the Diagnosis of DSM-IV Disorders (SCID) was used as the gold-standard comparator. Complete results were obtained for 235 Burmese-speaking and 275 Sgaw Karen-speaking women. Despite displaying reasonable psychometric properties, a number of shortcomings associated with the RHS-15 limited its utility in this setting. The Likert-type response categories of the RHS-15 proved problematic in this low-literacy population. Combined with the relative superiority and greater ease of administration of the SCID, the RHS-15 is not recommended as the tool of choice for detecting perinatal depression in this setting.

National approaches to collecting patient feedback provide trust level information which although can provide a benchmark for trusts often doesn’t provide information about specific services or patients experiences of pathways of care. This more granular level of data could be more informative for local service development and improvement. This research explored the feasibility and usefulness of such approaches. A conceptual model and standard questionnaire of patient experience was developed that might work across a range of services and pathways of care. Seven trusts were recruited as collaborating sites in which the model and survey instrument was tested. These were from different geographical locations and settings. The impact of the pilot and survey results on the improvement and development of services was evaluated. The service- line approach to capturing patient feedback was generally more feasible and considered of value for service improvement. The collection of patients’ experiences across pathways of care was more challenging in terms of the development of the survey and interpretation of results. However, many sites identified specific actionable areas for improvement. This study has shown that it is possible to develop and apply a standardised survey in a range of services and provides evidence that a consistent unified approach to monitoring patient experiences is feasible. However several methodological problems are acknowledged such as the availability of resources and capacity for improvements to services and care. Evidence is now particularly needed to establish how best to produce positive impact from patient feedback.

Abstract   Objective: To investigate whether Defined Daily Dose/Finished Consultant Episode (DDD/FCE) ratio is sensitive to changes in prescribing patterns and could be used as a prescribing indicator in hospitals. Method: The study comprised two phases. In phase 1 the weekly DDD/FCE ratios for two antibiotics were calculated and monitored in one acute NHS hospital before and after the implementation of prescribing guidelines, which impacted on the use of the antibiotics. In phase 2 data on the use of four antibiotics over one year was collected from fifty-eight medium to large acute hospitals in England, together with corresponding FCE data. DDD/FCE ratios for each antibiotic in each hospital were compared. Main Outcome measure: Whether the DDD/FCE ratio for two antibiotics changed in one hospital following the introduction of prescribing guidelines for these antibiotics. The variability in DDD/FCE ratio for two broad spectrum antibiotics compared to two narrow spectrum antibiotics across a number of acute hospitals in England. Results: In phase 1 the DDD/FCE ratios for the two antibiotics were lower post implementation of the guidelines indicating that the ratio was sensitive to changes in prescribing. In phase 2 the median DDD/FCE ratios of the two broad spectrum antibiotics from all fifty eight hospitals were much higher (0.126, and 0.265) than for the two narrow spectrum antibiotics (0.048, and 0.021), indicating higher use of the broad spectrum antibiotics. Furthermore, the variation in prescribing between the hospitals, as indicated by the inter-quartile range about the median, was greater for the two broad spectrum agents (0.201 and 0.193), than for the narrow spectrum agents (0.06, and 0.042), as was expected. Conclusion: The DDD/FCE ratio is sensitive to changes in prescribing and can reflect differences in the use of antibiotics between hospitals, after accounting for differences in activity. DDD/FCE ratio has the potential to be used to also account for differences in case mix between hospitals although further work is needed in this area. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine the reliability of family and professional assessment of manual ability using the Manual Ability Classification System (MACS) for children with cerebral palsy (CP) in the UK. Families who were taking part in a study measuring the activities and participation of children with CP were invited to classify their child''s manual ability using the MACS. Postal surveys were conducted with the families and health professionals nominated by the families. Perfect agreement was assessed as a percentage; chance-corrected agreement was measured using Cohen''s kappa (κ), and reliability was determined using the intraclass correlation coefficient (ICC). Families of 91/128 (71%) children responded to the survey (53 males, 38 females; mean age 9y 11mo [SD 1y 11mo], range 6–12y) out of whom 88 indicated a single MACS level. Seventy-two children (82%) were classified with spastic CP, 12 (14%) with dyskinesia, two (2%) with ataxia, and two (2%) were not classified. There were 21, 27, 11, 10, and 19 children who were classified by their families in Gross Motor Function Classification System Levels I to V respectively; 14, 30, 18, 13, and 13 children classified by their families in MACS levels I to V. The survey of health professionals generated 60/71 (85%) responses from physiotherapists, 55/58 (93%) responses from paediatricians, and 21/24 (88%) responses from occupational therapists. There was perfect agreement between families and professionals for more than 50% of children; the indices of chance-corrected agreement ranged from κ=0.3 to 0.5, and the reliability coefficients ranged from ICC 0.7 to 0.9. Indices of agreement and reliability between families and professionals were equivalent to those between different professionals. The MACS, therefore, offers a valid and reliable method for communicating about the manual ability of children with CP. Families and professionals may not always agree precisely on a MACS level, particularly if children''s performance of manual tasks varies in different environments. [ABSTRACT FROM AUTHOR]

The aim of this study was to use family-assessed instruments and details of children''s impairments to explore factors affecting the activities and participation of children with cerebral palsy (CP). A postal survey was conducted with families of a geographically defined population of children with CP aged 6 to 12 years. Family-assessed indices of children''s activities and participation were the Activities Scale for Kids (ASK) and Lifestyle Assessment Questionnaire (LAQ-CP). Families also assessed children''s abilities using the Gross Motor Function and Manual Ability Classification Systems (GMFCS; MACS). Details of children''s impairments were available from the 4Child epidemiological database and used with the GMFCS and MACS as explanatory variables in multiple regression analyses to identify their effect on children''s activities and participation. Families of 175/314 (56%) children returned an assessment using the GMFCS and 129 (41%) children participated fully by returning all the questionnaires. Full participants (72 males, 57 females) did not differ from those who did not take part by their age, sex, CP characteristics, or associated impairments: GMFCS Level I–25, Level II–43, Level III–15, Level IV–14, Level V–23; MACS Level I–14, Level II–30, Level III–18, Level IV–13, Level V–13. Scores for the ASK and LAQ-CP Physical Independence and Mobility domains were predicted well by children''s movement, manual, and intellectual disability, and also, to some extent, by the presence of seizures or speech problems. LAQ-CP domains for Economic and Clinical Burden and Social Integration were not well explained by children''s abilities and impairments. Family assessment, therefore, offers a useful method for measuring children''s activities and participation; however, currently available instruments do not fully represent all the domains in the International Classification of Functioning, Disability and Health. Children''s abilities only partially explain their activities and participation. [ABSTRACT FROM AUTHOR]