The COVID-19 pandemic has had high mortality rates in the elderly and frail worldwide, particularly in care homes. This is driven by the difficulty of isolating care homes from the wider community, ...the large population sizes within care facilities (relative to typical households), and the age/frailty of the residents. To quantify the mortality risk posed by disease, the case fatality risk (CFR) is an important tool. This quantifies the proportion of cases that result in death. Throughout the pandemic, CFR amongst care home residents in England has been monitored closely. To estimate CFR, we apply both novel and existing methods to data on deaths in care homes, collected by Public Health England and the Care Quality Commission. We compare these different methods, evaluating their relative strengths and weaknesses. Using these methods, we estimate temporal trends in the instantaneous CFR (at both daily and weekly resolutions) and the overall CFR across the whole of England, and dis-aggregated at regional level. We also investigate how the CFR varies based on age and on the type of care required, dis-aggregating by whether care homes include nursing staff and by age of residents. This work has contributed to the summary of measures used for monitoring the UK epidemic.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Globally, the COVID-19 pandemic has caused unprecedented strain in healthcare systems, but little is known about how it affected patients requiring palliative and end-of-life care from GPs.
To ...evaluate the impact of the pandemic on primary care service use in the last 3 months of life, including consultations and prescribing, and to identify associated factors.
A retrospective cohort study in UK, using data from the Clinical Practice Research Datalink.
The study cohort included those who died between 2019 and 2020. Poisson regression models using generalised estimation equations were used to examine the association between primary care use and patient characteristics. Adjusted rate ratios (aRRs) and 95% confidence intervals (95% CIs) were estimated.
A total of 44 534 patients died during the study period. The pandemic period was associated with an 8.9% increase in the rate of consultations from 966.4 to 1052.9 per 1000 person-months, and 14.3% longer telephone consultation duration (from 10.1 to 11.5 minutes), with a switch from face-to-face to telephone or video consultations. The prescription of end-of-life care medications increased by 6.3%, from 1313.7 to 1396.3 per 1000 person-months. The adjusted rate ratios for consultations (aRR = 1.08, 95% CI = 1.06 to 1.10,
<0.001) and prescriptions (aRR 1.05: 95% CI = 1.03 to 1.07,
<0.001) also increased during the pandemic.
The pandemic had a major impact on GP service use, leading to longer consultations, shifts from face-to-face to telephone or video consultations, and increased prescriptions. GP workload-related issues must be addressed urgently to ease the pressure on GPs.
Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of ...function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care.
A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors.
The cohort comprised 76,704 adults with median age 81 years (IQR 70-88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios aHRs. At 0-28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 95%CI 4.90-7.76), chronic obstructive pulmonary disease (aHR 5.01 95% CI 3.78-6.62), dementia (aHR 5.07 95% CI 3.80-6.77) and liver disease (aHR 9.75 95% CI 6.50-14.6) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 95%CI 1.04-1.39) compared with cancer 'other'. Risks increased with high multimorbidity for non-cancer (aHR 2.57 95% CI 2.36-2.79) and cancer (aHR 2.59 95% CI 2.13-3.15) (reference: lowest).
One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The eight recommendations are: (1) improving expertise and facilities in primary care to strengthen detection of early disease and its treatment, and screening of high-risk patients in the community; ...(2) establishment of acute liver services in district general hospitals linked with 30 regional specialist centres for complex investigations and treatment, and increased provision of medical and nursing training in hepatology; (3) a national review of liver transplantation to ensure better access for patients to increase capacity; (4) specialist paediatric services and continuity of care in transition arrangements for children with liver disease reaching adult life; (5) measures to reduce overall alcohol consumption in the country; (6) promotion of healthy lifestyles to reduce obesity and the burden of non-alcoholic fatty liver disease; (7) elimination of viral hepatitis as a major public health threat by 2030 and a major reduction in the burden of disease for hepatitis B; and (8) increasing awareness of liver disease in the general population and within the National Health Service (NHS), including the work of liver patient support groups. The recently published, comprehensive Global Burden of Disease Study 2015 also includes important data on disease burden for alcohol, obesity, and viral hepatitis in relation to other major non-communicable diseases related to lifestyle issues, including smoking. For many of the recommendations the metrics show little progress in terms of reduced disease burden, although together with the efforts of other bodies and agencies, there has been some movement in that direction.
Objective
To ascertain current trends in the incidence and mortality rates for upper tract urothelial cancer (UTUC) and identify any relationship with age, stage at presentation, social deprivation ...and treatment method.
Patients and Methods
We used national databases to collect the data: incidence, stage and survival data from the National Cancer Data Repository (NCDR) and British Association of Urological Surgeons (BAUS) audit database; mortality data from the Office for National Statistics (ONS); and treatment method data from the Hospital Episodes Statistics (HES).
Results
The incidence of UTUC is increasing (from 1985 to 2009 it increased by 38% in men and 77% in women). It affects mainly those aged >60 years, and diagnoses are increasingly made in those aged >80 years. Diagnoses at advanced stage have increased from 45 to 80%.
Mortality has risen faster than incidence; the overall 5‐year survival rate has dropped from 60 to 48%. Survival is worst in stage IV disease and in patients aged ≥80 years; when analysed by age or stage group, survival rates are unchanged. Nephroureterectomy has increased by 75%, but endoscopic treatment, which only became available part way through the study period, now accounts for 11% of surgical interventions for UTUC, mainly in stage I disease and in the elderly.
Conclusions
Despite sharing its risk factors with bladder cancer, current incidence and mortality trends for UTUC contrast with those in bladder cancer. Increasing use of cross‐sectional imaging may explain some of the identified increased incidence. Higher incidence specifically in people >80 years, together with stage migration to more advanced cancers, are likely to have caused at least some of the observed increased mortality.
Further study is required to answer the questions of whether there are other hitherto unidentified aetiological or prognostic factors; whether less aggressive treatment of UTUCs in the elderly is always justified; and whether the rising frequency of minimally invasive treatment means suboptimum oncological management.
Abstract Background The provision of good quality and equitable end-of-life care is high on the public and political agenda. Hospice is second only to home in terms of preference for place of death ...and scores higher than any other setting for quality of care. However, hospices have been criticised for inequality of access with respect to age, diagnosis, and socioeconomic status. We aimed to describe the demographic characteristics associated with hospice death in England, and assessed how these characteristics have changed over time. Methods In this population-based study (part of the GUIDE_Care project), we included all adults older than 25 years who had died in inpatient hospices in England from 1993 to 2002. We compared deaths in 1998–2002, 2003–07, and 2008–12, with those in 1993–97 using multivariable Poisson regression. Explanatory variables included individual factors (age, sex, marital status, underlying cause of death) and measures of deprivation based on area of residence. Findings 446 615 deaths were included. The annual number of hospice deaths increased from 17 440 in 1993 to 26 032 in 2012, accounting for 3·4% of 519 313 deaths in England in 1993, and 6·0% of 434 105 deaths in 2012. 226 188 hospice decedents (50·6%) were men (mean age 69·9 years, SD 12·4). The likelihood of hospice decedents being in the oldest age group (>85 years) increased from 1993–97 to 2008–12 (Poisson ratio 1·43, 95% CI 1·39–1·48). Only 23 258 hospice decedents (5·2%) had non-cancer diagnoses, though the likelihood of non-cancer conditions increased during the same time period (1·41, 1·37–1·46). The likelihood of hospice decedents being resident in the least deprived quintile also increased (1·25, 1·22–1·29). Interpretation Inequalities among hospice decedents by diagnosis have decreased, although the absolute numbers of non-cancer diagnoses remain very small. Trends in deprivation are concerning, and require further exploration. Funding The GUIDE_Care project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme ( project number 09/2000/58 ).
ObjectivesTo evaluate the accuracy of routine data for costing inpatient resource use in a large clinical trial and to investigate costing methodologies.DesignFinal-year inpatient cost profiles were ...derived using (1) data extracted from medical records mapped to the National Health Service (NHS) reference costs via service codes and (2) Hospital Episode Statistics (HES) data using NHS reference costs. Trust finance departments were consulted to obtain costs for comparison purposes.Setting7 UK secondary care centres.PopulationA subsample of 292 men identified as having died at least a year after being diagnosed with prostate cancer in Cluster randomised triAl of PSA testing for Prostate cancer (CAP), a long-running trial to evaluate the effectiveness and cost-effectiveness of prostate-specific antigen (PSA) testing.ResultsBoth inpatient cost profiles showed a rise in costs in the months leading up to death, and were broadly similar. The difference in mean inpatient costs was £899, with HES data yielding ∼8% lower costs than medical record data (differences compatible with chance, p=0.3). Events were missing from both data sets. 11 men (3.8%) had events identified in HES that were all missing from medical record review, while 7 men (2.4%) had events identified in medical record review that were all missing from HES. The response from finance departments to requests for cost data was poor: only 3 of 7 departments returned adequate data sets within 6 months.ConclusionsUsing HES routine data coupled with NHS reference costs resulted in mean annual inpatient costs that were very similar to those derived via medical record review; therefore, routinely available data can be used as the primary method of costing resource use in large clinical trials. Neither HES nor medical record review represent gold standards of data collection. Requesting cost data from finance departments is impractical for large clinical trials.Trial registration numberISRCTN92187251; Pre-results.
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