[show abstract][hide abstract] ABSTRACT: To assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales.
A multi-method study comprising (1) focus groups and interviews with NHS Chief Pharmacists and (2) an electronic survey of medical, nursing and clinical governance directors.
Acute sector respondents agreed that the medication outputs had a major impact on patient safety. Pharmacists welcomed national support for medication safety improvement, despite the resulting workload. Medical Directors were much less likely to be aware of alerts and Rapid Response Reports (RRRs) than their nursing and clinical governance colleagues. One key finding was the inability of around half of NHS trusts to communicate effectively and reliably with their junior doctors.
Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safety.
[show abstract][hide abstract] ABSTRACT: To undertake a baseline study of the management of anticoagulants in order to allow later comparison of the impact of the National Patient Safety Agency (NPSA) patient safety alert (including a new patient held record) published in April 2007.
A multimethod study comprising semistructured interviews in 20 acute trusts and a telephone/email survey of general practitioners (GPs).
The authors found a high degree of consensus concerning a number of problems in the management of anticoagulation services. Consultant haematologists and chief pharmacists expressed concern about the level of competence of junior medical and nursing staff and the quality of patient discharge from general inpatient wards. Patients were regularly discharged before being stabilised on Warfarin, pre-discharge information was not always given, patient-held records were not reliably completed nor follow-up arrangements made. At the ward level, there was some confusion about the responsibility for completing the yellow book on discharge and little awareness of the role of GPs in providing a monitoring service. GPs were largely dissatisfied with the quality of discharge information.
The baseline data present a significant cause for concern in the management of warfarin prior to the publication of the NPSA safety alert.
Quality and Safety in Health Care 08/2010; 19(4):295-7. · 2.16 Impact Factor
[show abstract][hide abstract] ABSTRACT: national policy recommends routine re-assessment of disabled patients and their carers at 6 months after stroke onset. The clinical and resource outcomes of this policy were investigated.
prospective, single-blind, randomised controlled trial in two centres.
a total of 265 patients with a disabling stroke and their carers.
a structured re-assessment system for patients and their carers at 6 months post-stroke or existing care.
primary: patient independence (Frenchay activities index) and carer stress (general health questionnaire 28). Secondary: activities of daily living, mood state, satisfaction with services, carer strain index, health and social service resource use and costs.
independence at 12 months post-stroke was similar in both groups (Frenchay activities index, adjusted mean difference 0.64; 95% confidence interval -0.74-2.02). Emotional distress in carers was similar in both groups (general health questionnaire 28, mean difference 0.02; 95% confidence interval -0.95-1.00). Results for the secondary outcome measures and total mean costs were similar for both groups. The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days.
the structured, systematic re-assessment for patients and their carers was not associated with any clinically significant evidence of benefit at 12 months. Health and social care resource use and mean cost per patient were broadly similar in both groups.
International Standard Randomised Controlled Trial Register; number: ISRCTN55412871.
Age and Ageing 07/2009; 38(5):576-83. · 3.82 Impact Factor
[show abstract][hide abstract] ABSTRACT: to compare the cost effectiveness of post-acute care for older people provided in community hospitals with general hospital care.
cost-effectiveness study embedded within a randomised controlled trial.
seven community hospitals and five general hospitals at five centres in the midlands and north of England. Participants: 490 patients needing rehabilitation following hospital admission with an acute illness. Intervention: multidisciplinary team care for older people in community hospitals.
EuroQol EQ-5D scores transformed into quality-adjusted life years; health and social service costs during the 6-month period following randomisation.
there was a non-significant difference between the community hospital and general hospital groups for changes in quality-adjusted life-year values from baseline to 6 months (mean difference 0.048; 95% confidence interval -0.028 to 0.123; P = 0.214). Resource use was similar for both groups. The mean (standard deviation) costs per patient for health and social services resources used were comparable for both groups: community hospital group 8,946 pounds ( 6,514 pounds); general hospital group 8,226 pounds ( 7,453 pounds). These findings were robust to sensitivity analyses. The incremental cost-effectiveness ratio estimate was 16,324 pounds per quality-adjusted life year. A cost effectiveness acceptability curve suggests that if decision makers' willingness to pay per quality-adjusted life year was 10,000 pounds, then community hospital care was effective in 47% of cases, and this increased to only 50% if the threshold willingness to pay was raised to 30,000 pounds.
the cost effectiveness of post-acute rehabilitation for older people was similar in community hospitals and general hospitals.
Age and Ageing 06/2008; 37(5):513-20. · 3.82 Impact Factor
[show abstract][hide abstract] ABSTRACT: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care.
Randomized, controlled trial.
Seven community hospitals and five general hospitals in the midlands and north of England.
Four hundred ninety patients needing rehabilitation after hospital admission with an acute illness.
Multidisciplinary team care for older people in community hospitals.
The primary outcome was the Nottingham extended activities of daily living scale (NEADL); secondary outcomes were the Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, mortality, discharge destination, 6-month residence status, and satisfaction with services.
Loss of independence at 6 months was significantly less likely in the community hospital group (mean adjusted NEADL change score group difference 3.27; 95% confidence interval 0.26-6.28; P=.03). The results for the secondary outcome measures were similar for the two groups.
Postacute community hospital rehabilitation care for older people is associated with greater independence.
Journal of the American Geriatrics Society 01/2008; 55(12):1995-2002. · 3.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report findings from a qualitative study to identify patient views of community hospital care. We consider how far these were in accord with the hospital staffs' views. This constituted part of a wider randomized controlled trial (RCT). The methodological challenges in seeking to identify patient satisfaction and in linking qualitative findings with trial results are explored.
A sample of 13 patients randomized to the community hospital arm of the RCT joined the qualitative study. Official documentation from the hospital were accessed and six staff interviewed to identify assumptions underlying practice.
Analysis of interviews identified a complex picture concerning expectations These could be classified as ideal, realistic, normative and unformed. The hospital philosophy and staff views about service delivery were closely in harmony, they delivered rehabilitation in a home-based atmosphere. The formal, or 'hard', process of rehabilitation was not well understood by patients. They were primarily concerned with 'soft' or process issues--where and how care was delivered.
We identify a model of community hospital care that incorporates technical aspects of rehabilitation within a human approach that is welcomed by patients. If patients are to be able to participate in making informed decisions about care, the rationale for the activities of staff need to be more clearly explained. Recommendations are made about the appropriate scope of qualitative findings in the context of trials and about techniques to access patient views in areas where they have difficulty in expressing critical impressions.
Journal of Evaluation in Clinical Practice 03/2007; 13(1):95-101. · 1.51 Impact Factor
[show abstract][hide abstract] ABSTRACT: To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions.
Cost effectiveness analysis within a randomised controlled trial.
Community hospital and district general hospital in Yorkshire, England.
220 patients needing rehabilitation after an acute illness for which they required admission to hospital.
Multidisciplinary care in the district general hospital or prompt transfer to the community hospital.
EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation.
The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group 7233 pounds sterling (euros 10,567; 13,341 dollars) (5031 pounds sterling), district general hospital group 7351 pounds sterling(6229 pounds sterling), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of 10,000 pounds sterling per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is 30,000 pounds sterling per QALY.
Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.
BMJ (Clinical research ed.). 08/2006; 333(7561):228.
[show abstract][hide abstract] ABSTRACT: To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital.
Randomised controlled trial.
Care in a community hospital and district general hospital in Bradford, England.
220 patients needing rehabilitation after an acute illness that required hospital admission.
Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital.
Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carer's satisfaction with services.
The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups.
Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital.
BMJ (Clinical research ed.). 09/2005; 331(7512):317-22.
[show abstract][hide abstract] ABSTRACT: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE).
Interrupted time series analysis, review of case notes, survey, and interviews.
Acute and primary care trusts in England and Wales.
All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts.
Rates of prescribing and use of procedures and medical devices relative to evidence based guidance.
6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued.
Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.
BMJ (Clinical research ed.). 10/2004; 329(7473):999.