Process modelling of NHS cardiovascular waiting lists in response to the COVID-19 pandemic

OBJECTIVE

To model the referral, diagnostic and treatment pathway for cardiovascular disease (CVD) in the English National Health Service (NHS) to provide commissioners and managers with a methodology to optimise patient flow and reduce waiting lists.

STUDY DESIGN

A systems dynamics approach modelling the CVD healthcare system in England. The model is designed to capture current and predict future states of waiting lists.

SETTING

Routinely collected, publicly available data streams of primary and secondary care, sourced from NHS Digital, NHS England, the Office of National Statistics and StatsWales.

DATA COLLECTION AND EXTRACTION METHODS

The data used to train and validate the model were routinely collected and publicly available data. It was extracted and implemented in the model using the PySD package in python.

RESULTS

NHS cardiovascular waiting lists in England have increased by over 40% compared with pre- COVID-19 levels. The rise in waiting lists was primarily due to restrictions in referrals from primary care, creating a bottleneck postpandemic. Predictive models show increasing point capacities within the system may paradoxically worsen downstream flow. While there is no simple rate-limiting step, the intervention that would most improve patient flow would be to increase consultant outpatient appointments.

CONCLUSIONS

The increase in NHS CVD waiting lists in England can be captured using a systems dynamics approach, as can the future state of waiting lists in the presence of further shocks/interventions. It is important for those planning services to use such a systems-oriented approach because the feed-forward and feedback nature of patient flow through referral, diagnostics and treatment leads to counterintuitive effects of interventions designed to reduce waiting lists.

155 Tibial Malrotation Following Intramedullary Nailing: A Literature Review

Aim

The use of intramedullary nail fixation remains the operation of choice for managing unstable and displaced tibia diaphyseal fractures. The literature shows that although commonly performed, there is not a standard approach when performing intramedullary nailing of the tibia; it could be hypothesised that this lack of standardisation may be contributing to the noted complications. This systematic review will look into intramedullary nailing of the tibia in all its parts, from identification of patients through to the surgical procedure techniques and finally the intra- and post-operative complications.

Method

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Search terms included “tibial intramedullary nail” OR “tibial intramedullary rod” OR “tibial IM nail” OR “tibial interlock” AND “malrotation”, and “tibial intramedullary nailing” OR “tibial im nail” OR “tibial interlock” OR “tibial rod” AND “malrotation”.

Results

Eleven studies were considered in the final analysis, with a total number of 425 fractures (n=429, mean ± 95% CI=39 (21.2–56.8)). All included patients were treated with tibial intramedullary nail devices, and 110 showed some degree of malrotation postoperatively (n=110, mean ± 95% CI=10.1 (4.26–15.9)). Expressed as a percentage, a mean of 34.1% of patients had malrotation (mean ± 95% CI: 34.1 (15.8–52)).

Conclusions

This systematic review revealed there are gaps in the literature and in the management process of these patients and suggested that a systematic approach using ‘Get It Right First Time’ (GIRFT), intraoperative assessment, validated assessment tools, and imaging postoperatively should be used to improve outcomes.

Aortic stenosis post-COVID-19: a mathematical model on waiting lists and mortality

OBJECTIVES

To provide estimates for how different treatment pathways for the management of severe aortic stenosis (AS) may affect National Health Service (NHS) England waiting list duration and associated mortality.

DESIGN

We constructed a mathematical model of the excess waiting list and found the closed-form analytic solution to that model. From published data, we calculated estimates for how the strategies listed under Interventions may affect the time to clear the backlog of patients waiting for treatment and the associated waiting list mortality.

SETTING

The NHS in England.

PARTICIPANTS

Estimated patients with AS in England.

INTERVENTIONS

(1) Increasing the capacity for the treatment of severe AS, (2) converting proportions of cases from surgery to transcatheter aortic valve implantation and (3) a combination of these two.

RESULTS

In a capacitated system, clearing the backlog by returning to pre-COVID-19 capacity is not possible. A conversion rate of 50% would clear the backlog within 666 (533-848) days with 1419 (597-2189) deaths while waiting during this time. A 20% capacity increase would require 535 (434-666) days, with an associated mortality of 1172 (466-1859). A combination of converting 40% cases and increasing capacity by 20% would clear the backlog within a year (343 (281-410) days) with 784 (292-1324) deaths while awaiting treatment.

CONCLUSION

A strategy change to the management of severe AS is required to reduce the NHS backlog and waiting list deaths during the post-COVID-19 'recovery' period. However, plausible adaptations will still incur a substantial wait to treatment and many hundreds dying while waiting.

890 Bilateral Acetabular Fractures Induced by An Epilepticseizure In a Paediatric Patient: A Unique Case Andits Management

Bilateral acetabular fractures following epileptic seizures are a rare but known occurrence in adults, with an 18.5% mortality rate. These fractures occurring post epileptic seizures have not been previously documented in children. We report a case of a 13-year-old boy who presented to hospital via ambulance following two violent generalised tonic–clonic seizures in a postictal state, metabolically acidotic and a low haemoglobin. Acute abdomen was suspected, and the patient underwent a CT scan which showed bilateral acetabular fractures with central dislocations of both femoral heads and free fluid in the abdomen. The patient underwent initial damage control intervention with insertion of bilateral distal femur skeletal traction. Definitive fixation of the acetabular fractures occurred 1 week later with an open reduction internal fixation with novel supra- pectineal plates using a Pfannenstiel incision. We use this report to increase awareness of significant pelvic injuries in paediatric patients post epileptic seizures.

Atypical mycobacterium infection of sternoclavicular joint: A unique case

We report a rare case of atypical Mycobacterium intracellulare infection encountered in a left sternoclavicular joint of an immunocompetent patient. The 34-year-old female patient presented with a one-year history of left sternoclavicular joint pain and swelling. The patient had multiple radiological investigations, which were suspicious for an infective cause. The patient had a biopsy of the joint, which returned showing acid-fast bacilli. The patient consequently received a prolonged course of medical treatment for M. intracellulare.

SAT0173 A SYSTEMATIC LITERATURE REVIEW INFORMING THE 2019 UPDATE OF THE JOINT EUROPEAN LEAGUE AGAINST RHEUMATISM AND EUROPEAN RENAL ASSOCIATION–EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION (EULAR/ERA-EDTA) RECOMMENDATIONS FOR THE MANAGEMENT OF LUPUS NEPHRITIS

Background:

Lupus nephritis (LN) affects ~ 40% of patients with systemic lupus erythematosus (SLE) and is associated with significant morbidity. New data has emerged since the publication of the EULAR/ERA-EDTA recommendations for the management of LN, involving a multidisciplinary panel of experts.

Objectives:

To analyze the current evidence, in order to inform the 2019 update of the EULAR/ERA-EDTA recommendations for the management of LN.

Methods:

According to the EULAR standardised operating procedures, a Medline systematic literature review (SLR) was performed, from January 2012 until 31 December 2018. The final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including the LoE of the 2012 recommendations.

Results:

We identified 542 relevant articles. High-quality evidence supports the use of immunosuppressive treatment for class III and IV LN (LoE 1a) there is moderate quality evidence for immunosuppression in pure class V LN, with nephrotic-range proteinuria (LoE 2b). Treatment should aim for a 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (< 500-700 mg/day) at 12 months (LoE 2a-2b). Strong evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) for the initial treatment of class III/IV LN (LoE 1a,Table); Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a,Table). There is little evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease due to LN, all methods of kidney replacement treatment have been used, but transplantation is accompanied by the most favourable outcomes (LoE 2b).

Table.

Randomized trials for induction therapy in LN

Conclusion:

There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment. There is low quality evidence to guide treatment of class V, monitoring and optimal duration of immunosuppression.

Disclosure of Interests: :

Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Myrto Kostopoulou: None declared, Kim Cheema: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, Dimitrios Boumpas: None declared

OP0163 2019 UPDATE OF THE JOINT EUROPEAN LEAGUE AGAINST RHEUMATISM AND EUROPEAN RENAL ASSOCIATION–EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION (EULAR/ERA-EDTA) RECOMMENDATIONS FOR THE MANAGEMENT OF LUPUS NEPHRITIS

Background:

Up to 40% of systemic lupus erythematosus (SLE) patients develop kidney disease, which represents a major cause of morbidity.

Objectives:

To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN).

Methods:

We followed the EULAR standardised operating procedures for the publication of treatment recommendations. Delphi-based methodology led to 15 questions for systematic literature review (SLR), which was undertaken by three fellows.

Results:

The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNI), and management of end-stage-kidney-disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7gr/24h with [near-]normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3g/day, or mycophenolic acid at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500mg x6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1g/24h despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations.

Conclusion:

The updated recommendations intend to inform rheumatologists, nephrologists, patients, national professional societies, hospital officials, social security agencies and regulators about the treatment of LN based on most recent evidence.

Disclosure of Interests:

Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Myrto Kostopoulou: None declared, Kim Cheema: None declared, Hans-Joachim Anders: None declared, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Ingeborg Bajema Consultant of: GSK, John N. Boletis Grant/research support from: GSK, Pfizer, Paid instructor for: GSK, Abbvie, UCB, Enorasis, Eleni Frangou: None declared, Frederic Houssiau Grant/research support from: UCB, Consultant of: GSK, Jane Hollis: None declared, Alexandre Karras: None declared, Francesca Marchiori: None declared, Stephen Marks: None declared, Gabriela Moroni: None declared, Marta Mosca: None declared, Ioannis Parodis: None declared, Manuel Praga: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Vladimir Tesar: None declared, Maria Trachana: None declared, Ronald van Vollenhoven Grant/research support from: AbbVie, Amgen, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline (GSK), Janssen Research & Development, LLC, Lilly, Pfizer, Roche, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB and Vertex, Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GlaxoSmithKline, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Alexandre Voskuyl: None declared, Y.K. Onno Teng Grant/research support from: GSK, Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, Bernadette van Leeuw: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, Dimitrios Boumpas: None declared

Evaluation of a multidisciplinary Tier 3 weight management service for adults with morbid obesity, or obesity and comorbidities, based in primary care

A multidisciplinary Tier 3 weight management service in primary care recruited patients with a body mass index ≥40 kg·m(-2) , or 30 kg·m(-2) with obesity-related co-morbidity to a 1-year programme. A cohort of 230 participants was recruited and evaluated using the National Obesity Observatory Standard Evaluation Framework. The primary outcome was weight loss of at least 5% of baseline weight at 12 months. Diet was assessed using the two-item food frequency questionnaire, activity using the General Practice Physical Activity questionnaire and quality of life using the EuroQol-5D-5L questionnaire. A focus group explored the participants' experiences. Baseline mean weight was 124.4 kg and mean body mass index was 44.1 kg·m(-2) . A total of 102 participants achieved 5% weight loss at 12 months. The mean weight loss was 10.2 kg among the 117 participants who completed the 12-month programme. Baseline observation carried forward analysis gave a mean weight loss of 5.9 kg at 12 months. Fruit and vegetable intake, activity level and quality of life all improved. The dropout rate was 14.3% at 6 months and 45.1% at 1 year. Focus group participants described high levels of satisfaction. It was possible to deliver a Tier 3 weight management service for obese patients with complex co-morbidity in a primary care setting with a full multidisciplinary team, which obtained good health outcomes compared with existing services.

The effect of age on pressure flow parameters in women with lower urinary tract symptoms

This study aimed to evaluate changes in voiding with age in women with different urodynamic diagnoses. Correlation was used to analyse the association between age and voiding parameters (maximum flow rate, voided volume, flow rate centile and maximum detrusor pressure - PdetMax) in 896 datasets. Multivariate analysis was used to analyse the data further by age group and diagnosis - urodynamic stress incontinence (USI); detrusor overactivity (DO); mixed USI and DO; no urodynamic abnormality. Results showed that diagnosis accounts for a significant amount of variation in all four of the dependent variables Age group shows a significant effect on voiding volume but does not show significant effects on any other variable studied. There is no significant interaction term in any of the analyses, meaning that age and diagnosis do not appear to function together, e.g. age does not relate to flow rate centile, maximum flow rate or PdetQMax. It was concluded that the data suggest that there is no significant change in voiding function related to age. In the elderly, the main alteration in voiding is due to a higher prevalence of DO.

Learning from the design and development of the NHS Safety Thermometer

Quality issue

Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available.

Initial assessment

We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally.

Choice of solution

We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients.

Implementation

The NHS ST survey instrument was developed in a learning collaborative involving 161 organizations (e.g. hospitals and other delivery organizations) using a Plan, Do, Study, Act method.

Evaluation

Testing of operational definitions, technical capability and use were conducted and feedback systems were established by site coordinators in each participating organization. During the 17-month pilot, site coordinators reported a total of 73 651 patient entries.

Lessons learned

It is feasible to obtain national data through standardized reporting by site coordinators at the point of care. Some caution is required in interpreting data and work is required locally to ensure data collection systems are robust and data collectors were trained. Sampling is an important strategy to optimize efficiency and reduce the burden of measurement.

Abstract PD04-06: Molecular Phenotypes of DCIS predict Invasive and DCIS recurrence

Introduction: Molecular phenotypes of invasive breast cancer predict early recurrence and survival. DCIS exhibits similar phenotypes but their frequency and clinical significance remain uncertain. To determine whether molecular phenotypes of DCIS predict recurrence, 273 women (median age 57 years) with primary DCIS who were screened for or entered DCIS trials (Iressa/Lapatinib/ERISAC) in one unit from 1990–2010 were studied.

Methods: HER2, oestrogen receptor (ER) and progesterone receptor (PR) expression within primary DCIS were established using immunohistochemistry within the trial protocols. HER2 was scored 0 (absent) to 3 (maximum). Scores ≥2 were taken as positive if amplified on FISH testing. ER and PR scored positive if ≥5% of cells stained. 64.2% patients were ER positive, 43.3% were HER2 positive and 31.8% were high-grade lesions. 94 underwent mastectomy whilst 185 had BCS.

Results: There was an overall recurrence rate of 20.14% after a median follow-up period of 74 months (range 12–240). Of these recurrences, 36.4% were invasive. Conservation surgery (BCS) was used in 185 women who suffered 47 recurrences. Molecular phenotype predicted local recurrence by Log Rank analysis (P &lt; 0.01) and invasive recurrences (P &lt; 0.016) overall and in the BCS group remained predictive of invasive recurrence (p &lt;0.005) and overall recurrence (p &lt; 0.001).

Ambulatory oxygen improves the effectiveness of pulmonary rehabilitation in selected patients with chronic obstructive pulmonary disease

The effect of ambulatory oxygen use during pulmonary rehabilitation (PR) has not yet been clearly established, but many studies have shown benefit from oxygen acutely. Two small studies to date demonstrated no clear benefit when oxygen was used in patients who desaturated on exertion during a PR programme. One study showed the benefit of using oxygen during PR in patients who were normoxic at rest and desaturated to a minimum of 88% on exertion. We conducted a single-blind, randomised controlled trial comparing PR undertaken either with or without ambulatory oxygen, in those with demonstrable benefit from oxygen at baseline. Subjects from three PR services were recruited who, during baseline assessment, desaturated by more than 4% and to less than 90% on exertion, and walked 10% or more further with ambulatory oxygen on endurance shuttle walk test. Patients were randomised to either room air or oxygen via portable cylinder, titrated to optimise pulse oxygen saturation but up to a maximum flow rate of 6 L/min. All patients then completed a twice weekly, 6- to 7-week PR programme. Data were analysed as per protocol. Totally 51 patients completed the study. At the end of PR, both groups improved with PR, with patients in the oxygen group demonstrating a highly statistically significantly greater mean improvement in endurance walking distance than the controls, 490 m (95% confidence interval 228–750; p ≤ 0.001), as well as clinically, although not statistically, significant changes in quality of life. The use of ambulatory oxygen during a 6- to 7-week PR programme greatly improved endurance walking distance in patients who desaturated on exertion with a positive acute response to ambulatory oxygen at baseline.

Is a practice incremental shuttle walk test really necessary?

The incremental and endurance shuttle walking tests (ISWT and ESWT) are measures of exercise tolerance commonly used in pulmonary rehabilitation (PR). A practice ISWT is advocated but often omitted by PR centres. We aimed to investigate the effect of such an omission within a clinical PR service. Between October 2002 and October 2008, 392 patients attending PR completed a practice ISWT and an ISWT. Results showed that patients walked significantly further on ISWT compared to practice ISWT (p ≤ 0.001). A significant difference in ESWT level was found between those calculated from practice ISWT and those calculated from ISWT (p ≤ .001). Despite a visual trend towards a negative relationship between distance walked at baseline (practice ISWT) and magnitude of the difference between the two walks, this did not meet statistical significance (p = 0.409). Absence of a practice ISWT could lead to possible clinical misjudgements.

Quality Observatories: using information to create a culture of measurement for improvement

In June 2008 High Quality Care for All was published, a blueprint for the delivery of NHS services in the future with quality of care put firmly at the heart of the principles guiding the NHS. Measurement of quality was identified as a crucial aspect of achieving delivery, enabling clinical teams to focus on where they need to improve most, and monitor the effects of interventions and initiatives. To date, the South East Coast Quality Observatory has developed over 80 benchmarking tools, products and analyses which contribute to the goal of delivery high quality analysis in a way that can be understood and utilized effectively by all levels of staff in a variety of clinical and managerial settings to evidence and drive improvement and innovation across organizations and local health economies. Patient safety, as a fundamental aspect of high quality care, makes up a significant part of this output, focusing on key topic areas that can deliver the best, and safest, results for patients. The following sets out details of a selection of the patient safety areas that the Quality Observatory has focused on and describes the analysis undertaken and, crucially, the key outcomes linked to its publication and usage.

Ontogenetical and histochemical studies on the translator apparatus in Calotropis procera R. Br. I. The retinaculum

Translator apparatus consists of 2 parts--the corpusculum, which is attached to the margin of the stigmatic head between the anthers, and a pair of arms by which the corpusculum is attached to the pollinia of the adjacent anther halves. Retinaculum spans the lateral blade of the corpusculum to the acellular beak of the pollinium. Ontogenetically, it is the secretory product of the stigma along the secondary stigmatic groove. Histochemically, it is composed of lipid, lignin, cutin and a little amount of proteins. Retinaculum, like corpusculum, is stigmatic in origin, but differs histochemically from the latter being composed mainly of lipo-protein complex and lacking phenolic compounds.