Patient reported outcome measures in a cohort of patients at high risk of breast cancer treated by bilateral risk reducing mastectomy and breast reconstruction

BACKGROUND

Many women with increased lifetime risk of developing breast cancer, due to pathogenic gene variants or family history, choose to undergo bilateral risk reducing mastectomies (BRRM). Patient reported outcome measures (PROMS) are an increasingly important part of informed consent but are little studied in women undergoing BRRM.

METHODS

We used a validated PROMS tool for breast reconstruction (BREAST-Q) in 297 women who had BRRM and breast reconstruction, 81% of whom had no malignancy (Benign Group, BG) and 19% in whom a perioperative breast cancer was diagnosed (Cancer Group, CG). 128 women also completed a Hospital Anxiety & Depression Score (HADS) questionnaire to test if preoperative HADS score could predict PROMS outcomes.

RESULTS

Women in the CG had lower PROMS scores for satisfaction with their breasts, nipple reconstruction and sexual wellbeing. Both groups reported equal satisfaction with BRRM outcome and psychosocial well-being. Physical well-being PROMS of the abdomen and chest were high in women in both groups as were scores for satisfaction with the care they received. The CG group reported suboptimal quality of patient information. A higher presurgical HADS anxiety score predicted less favourable postoperative psychosocial well-being despite similar levels of satisfaction with aesthetic outcome.

CONCLUSION

We show a high degree of patient reported satisfaction by woman undergoing BRRM and reconstruction. There was a negative association with a cancer diagnosis on quality of life PROMS and higher preoperative anxiety levels negatively affected postoperative psychosocial well-being. These important findings should be part of the informed consent process during preoperative counselling.

A Predictive Model for Reactive Tube Feeding in Head and Neck Cancer Patients Undergoing Definitive (Chemo) Radiotherapy

AIMS

Careful management of a patient's nutritional status during and after treatment for head and neck squamous cell cancers (HNSCC) is crucial for optimal outcomes. The aim of this study was to develop a model for stratifying a patient's risk of requiring reactive enteral feeding through a nasogastric tube during radiotherapy for HNSCC, based on clinical and treatment-related factors.

MATERIALS AND METHODS

A cohort of consecutive patients treated with definitive (chemo)radiotherapy for HNSCC between January 2016 and January 2018 was identified in the institutional electronic database for retrospective analysis. Patients requiring enteral feeding pretreatment were excluded. Clinical and treatment data were obtained from prospectively recorded electronic clinical notes and planning software.

RESULTS

Baseline patient characteristics and tumour-related parameters were captured for 225 patients. Based on the results of the univariate analysis and using a stepwise backwards selection process, clinical and dosimetric variables were selected to optimise a clinically predictive multivariate model, fitted using logistic regression. The parameters found to affect the probability, P, of requiring a nasogastric feeding tube for >4 weeks in our clinical multivariate model were: tumour site, tumour stage (early T0/1/2 stage versus advanced T3/T4 stage), chemotherapy drug (none versus any drug) and mean dose to the contralateral parotid gland. A scoring model using the regression coefficients of the selected variables in the clinical multivariate model achieved an area under the curve (AUC) of 0.745 (95% confidence interval 0.678-0.812), indicating good discriminative performance. Internal validation of the model involved splitting the dataset 80:20 into training and test datasets 10 times and assessing differences in AUC of the model fitted to these.

CONCLUSIONS

We developed an easy-to-use prediction model based on both clinical and dosimetric parameters, which, once externally validated, can lead to more personalised treatment planning and inform clinical decision-making on the appropriateness of prophylactic versus reactive enteral feeding.

A prospective cohort study on the safety of checkpoint inhibitors in older cancer patients - the ELDERS study

Objective

Older cancer patients are underrepresented in the pivotal trials of checkpoint inhibitors (CPIs). This study aimed to investigate the impact of an ageing immune system on CPI-related toxicity and provide evidence for the role of geriatric assessments with CPI.

Methods

The ELDERS study is a prospective observational study with two cohorts: older (70+ years of age) and younger (<70 years of age). Patients with advanced/metastatic non-small-cell lung cancer or melanoma starting single-agent CPI were eligible. The older cohort was assessed for frailty with Geriatric-8 (G8) screening, which when positive (<15 points) was followed by a holistic set of geriatric assessments. Primary endpoint was the incidence of grade 3-5 immune-related adverse events (irAEs).

Results

One hundred and forty patients were enrolled with 43% being pretreated and pembrolizumab represented 92% of treatments on study. The older cohort had a significantly higher comorbidity burden (P < 0.001) and polypharmacy (P = 0.004). While 50% of older patients had a positive G8 screening, 60% on this frail subgroup had a performance status score of 0 or 1. There was no significant difference in the incidence of irAEs grade 3-5 between older and younger cohorts (18.6% versus 12.9%; odds ratio 1.55, confidence interval 95% 0.61-3.89; P = 0.353). Exposure to systemic steroids due to irAEs was numerically longer for older patients (22 versus 8 weeks; P = 0.208). A positive G8 screening predicted hospital admissions (P = 0.031) and risk of death (P = 0.01).

Conclusions

The use of CPI in older patients was not associated with more high-grade toxicity. The G8 screening identified a subgroup with higher risk of AEs and its implementation should be considered in the context of CPI.

•

The ELDERS is the first prospective study designed to address the safety of immunotherapy in older cancer patients.

•

Older cancer patients had no increased risk of high-grade toxicity with immunotherapy.

•

Management of immune toxicity in older patients is often more challenging, particularly for those more vulnerable/frail.

•

Geriatric assessments in the context of immunotherapy predict clinical outcomes.

•

Comorbidity burden, polypharmacy and the G8 screening identified those with worst outcomes.

Does laminar flow reduce the risk of early surgical site infection in hip fracture patients?

Objective

To determine if there is a difference in the rate of early infection in hip fracture surgery performed under laminar flow and conventional turbulent ventilation.

Method

The impact on the rates of early surgical site infection (SSI) in patients who sustained a hip fracture after our trauma theatre was moved from a laminar to a non-laminar flow theatre was assessed. Data was retrospectively collected for six months prior to the merging of the trauma service and six months after. For each operation: age, gender, American Society of Anesthesiologists (ASA) grade, dementia, diabetes, immunosuppressants, anticoagulation, smoking status, duration of surgery, administration of peri-operative antibiotics, surgeon grade, skin closure method, and SSI were extracted from the hospital electronic notes with input from the trust's SSI surveillance team.

Results

259 hip fracture operations were performed during this period. Seven patients were excluded due to incomplete information. There were 95 patients in the laminar flow group and 157 in the non-laminar flow group. There were no SSIs in the laminar flow group and a 3.2% SSI rate (Fishers exact p = 0.16) in the non-laminar flow group. Three were superficial infections and two deep. This difference was not statistically significant. Patient characteristics were included in a Firth logistic regression model which did not show a significant change in the odds ratio.

Conclusion

A higher incidence of early SSI was found when hip fracture surgery was performed under non-laminar flow conditions but this difference was not statistically significant. Larger studies may change this outcome.

Objective assessment of dermal fibrosis in cutaneous scarring, using optical coherence tomography, high-frequency ultrasound and immunohistomorphometry of human skin

Background

Noninvasive quantitative assessment of dermal fibrosis remains a challenge. Optical coherence tomography (OCT) and high‐frequency ultrasound (HFUS) can accurately measure structural and physiological changes in skin.

Objectives

To perform quantitative analysis of cutaneous fibrosis.

Methods

Sixty‐two healthy volunteers underwent multiple sequential skin biopsies (day 0 and 1–8 weekly thereafter), with OCT and HFUS measurements at each time point supported with immunohistomorphometry analysis.

Results

HFUS and OCT provided quantitative measurements of skin thickness, which increased from uninjured skin (1·18 and 1·2 mm, respectively) to week 1 (1·28 mm, P = 0·01; 1·27 mm, P = 0·02), and compared favourably with haematoxylin and eosin. Spearman correlation showed good agreement between techniques (P < 0·001). HFUS intensity corresponded to dermal density, with reduction from uninjured skin (42%) to week 8 (29%) (P = 0·02). The OCT attenuation coefficient linked with collagen density and was reduced at week 8 (1·43 mm, P < 0·001). Herovici analysis showed that mature collagen levels were highest in uninjured skin (72%) compared with week 8 (42%, P = 0·04). Fibronectin was greatest at week 4 (0·72 AU) and reduced at week 8 (0·56 AU); and α‐smooth muscle actin increased from uninjured skin (11·5%) to week 8 (67%, P = 0·003).

Conclusions

Time‐matched comparison images between haematoxylin and eosin, OCT and HFUS demonstrated that epidermal and dermal structures were better distinguished by OCT. HFUS enabled deeper visualization of the dermis including the subcutaneous tissue. Choice of device was dependent on the depth of scar type, parameters to be measured and morphological detail required in order to provide better objective quantitative indices of the quality and extent of dermal fibrosis.

What's already known about this topic?

Objective studies of the progression of scar formation and the properties of mature scars are necessary in order to evaluate clinical treatment, and for research focused on developing novel methods for management of dermal fibrosis.

Optical coherence tomography (OCT) and high‐frequency ultrasound (HFUS) are two known noninvasive techniques that are used effectively for measuring structural and physiological changes in cutaneous tissue.

What does this study add?

OCT and HFUS are useful tools for noninvasive monitoring of cutaneous fibrosis, enabling quantitative sequential temporal measurements of cutaneous thickness similarly to histology.

OCT attenuation coefficient (better in resolution) and HFUS intensity (better in depth) provide an indication of collagen deposition in skin over the course of healing, supported by immunohistochemical analysis.

Choice of device is dependent upon wound and scar type, the parameters to be measured and the morphological detail required.

https://doi.org/10.1111/bjd.18394 available online

https://www.bjdonline.com/article/Objective-assessment-of-dermal-fibrosis-in-cutaneous-scarring-using-optical-coherence-tomography-high-frequency-ultrasound-and-immunohistomorphometry-of-human-skin/

Abstract P1-11-05: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Watterson D, Purushotham A, Keeley V. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-05.

Abstract P3-03-42: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Purushotham A, Keeley V. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-42.

Abstract P2-06-07: Investigating the role of focal adhesion kinase in regulating CSC activity in invasive ductal carcinoma

Background

Breast Cancer Stem-like Cells (BCSCs) have been associated with tumour development, metastasis and recurrence1. Focal Adhesion Kinase (FAK) is a non-receptor tyrosine kinase classically known for its role in metastasis, proliferation and survival. We have previously shown FAK plays a role in regulating CSC activity in DCIS2. We aimed to investigate FAK and CSC marker expression in a retrospective patient cohort. We aimed to evaluate the effects of FAK inhibition on CSC activity in Invasive Ductal Carcinoma.

Methods

Using a retrospective case-control cohort of 244 patients across a range of molecular phenotypes we evaluated FAK Immunohistochemical expression alongside CSC markers; Aldehyde Dehydrogenase 1 (ALDH1) and Integrin Alpha 6 (ITGa6). FAK expression was measured in IDC cell lines and ALDEFLUOR high expressing cells. FAK was inhibited using 0.5μM VS4718 or SiRNA and CSC activity evaluated in 5 cell lines and 25 patient samples. We determined the effects of 50mg/kg VS4718 for 4 weeks as single agent or in combination with Paclitaxel 7.5mg/kg in a ER-/PR-/HER- Patient Derived Xenograft model (PDX).

Results

Total FAK expression was associated with reduced breast cancer survival. Co-expression of FAK and either BCSC marker was associated with the poorest survival.

FAK and CSC marker expression pFAKtFAKALDH1ITGα6tFAK and ALDH1tFAK and ITGα6Recurrence Risk0.58 (0.31-1.08) p = 0.0842.05 (1.23-3.43) p = 0.0062.21 (1.20-4.05) p=0.0111.54 (0.92-2.23) p=0.107  Breast Cancer Death0.41 (0.12-1.51) p=0.1824.84 (2.33 -10.04) p = &lt;0.0016.58 (1.87-23.10) p=0.0032.23 (1.08-4.58) p=0.03016.7 (3.7-73.9) p=&lt;0.00112.8 (1.37-13.2,) p=0.012Hazard ratios calculated using cox-proportional hazard regression analysis.

pFAK was higher in ALDEFLUOR expressing cells and triple negative cell lines. SiRNA knockout of FAK reduced mammosphere formation, self-renewal and ALDEFLUOR expression from 1.2% to 0.2% (p=&lt;0.01, unpaired t-test) in MDA-MB-231 cells. VS4718 reduced primary mammosphere forming efficiency in all cell lines and reduced self-renewal in ER negative cell lines. FAK inhibition led to a reduction in mammosphere forming efficiency and self-renewal in 25 primary breast cancer specimens as outlined below:

FAK inhibition reduces MFE Primary Breast Cancer samples  ER negative cell lines   ER+/PR+/ Her2-ER-/PR-/Her2+ER-/PR-/Her2-SKBr3MDA-MB-231SUM159Primary mammosphere formation51.1% (n=17)53.2% (n=4)49.6% (n=5)74.1%84.8%67.6%Secondary mammosphere formation45.8% (n=8) 43.9% (n=3)42.1%57.9%47.5%Percentage of mammospheres formed given relative to control. Cell line work, minimum n=6. All above significant p=&lt;0.05, One way Anova used with post hoc Tukeys test.

VS4718 reduced tumour growth, Ki67 staining and CSC activity in our triple negative PDX model. VS4718 administration reduced ex-vivo mammosphere formation, tumour initiating capacity and prevented ALDEFLUOR enrichment when used in combination with Paclitaxel.

Conclusions

FAK, ALDH1 and ITGa6 are associated with increased breast cancer mortality in early breast cancer. Inhibition of FAK reduces CSC activity in vitro and in vivo in cell lines and patient samples. This data suggest that FAK inhibition may be used to reduce CSC activity in triple negative carcinoma.

1. Williams et al, Stem cells 2015.

Citation Format: Timbrell S, Aglan H, Cramer A, Foden P, Weaver D, Pachter J, Farnie G, Clarke R, Bundred N. Investigating the role of focal adhesion kinase in regulating CSC activity in invasive ductal carcinoma [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-06-07.

Abstract P2-07-01: Prediction model for lymphoedema, and effect of Lymphoedema diagnosis on quality of life (QoL) and distant recurrence from breast cancer

Introduction

Lymphoedema develops after surgery in 30% patients. In a prospective, multi-centre UK study, we used a validated perometer arm measurement to determine 1) the factors predicting lymphoedema development and 2) the effect of a lymphoedema diagnosis on QoL and survival.

Methods

Participants (n = 1100) undergoing axillary clearance at 9 centres underwent arm volume measurements pre and post-surgery by perometry, and completed FACT-B+4 and Lymphoedema checklist questionnaires. Relative arm volume increase (RAVI) of &gt;10% diagnosed lymphoedema. Predictors of lymphoedema development were determined using logistic regression, and changes in QoL were assessed using Generalised Estimating Equation (GEE) analyses.

Results

Median patient age was 56 (range 22 to 90) years; 78% received radiotherapy and 65% chemotherapy. Lymphoedema was detected in 21.4% of women by perometry and 24.4% underwent sleeve application by 24 months.

Initial decreases in QoL scores post-surgery were greater in patients with lymphoedema and took longer to return to baseline values (FACT-B p=0.014, TOI p=0.008, ARM subscale p&lt;0.001).

RAVI at 1 month (p&lt;0.001), BMI in three categories (≤25, &gt;25-≤30 and &gt;30, p=0.05), ER status (p=0.05) and number of positive nodes (p&lt;0.001) were used to develop a novel scoring model (AUROC 0.80) to predict lymphoedema. Out of 826 patients used for the model, 75% of patients had low scores (≤1) at 1 month and 11.6% developed lymphoedema by 24 months, whereas 20% who scored moderate risk (1.5-2) had a 31.3% risk and 5% who scored high risk (2.5-4) and had a 66.7% risk. Using the model scores, 75% of patients could be reassured regarding their lymphoedema risk.

Local recurrence was 1.7%. One hundred and twenty-nine patients had died of breast cancer (n=88) or had distant recurrence (n=41) across the study.

Lymphoedema (RAVI≥10%) by 9 months was an independent predictor of post 9 months distant disease-free cancer survival (Table).

Distant Disease Free Survival (DDFS) after Lymphoedema diagnosis Single variableMultivariableVariable (between 3 and 9 months)nHazard ratio (HR) (95% CI)p-valueHR (95% CI)p-valueRAVI ≥ 10% Yes: 105 vs No9552.30 (1.39-3.81)0.0011.73 (1.01-2.96)0.047ER Status Negative: 1719532.94 (1.92-4.49)&lt;0.0011.734 (1.06-2.83)0.028No. positive nodes*9691.07 (1.05-1.09)&lt;0.0011.05 (1.03-1.08)&lt;0.001Adjuvant CT Yes: 654 vs No9630.83 (0.54-1.27)0.390.60 (0.37-0.964)0.035Hormone treatment Yes: 808 vs No9640.45 (0.28-0.72)0.001--Tumour size*9591.02 (1.01-1.024)&lt;0.0011.02 (1.01-1.03)&lt;0.001Grade     0/1: 679611 (-)&lt;0.0011 (-)&lt;0.0012: 428 3.96 (0.54-29.324) 2.69 (0.36-20.33) 3: 436 11.59 (1.61-83.54) 6.91 (0.94-50.90) Undiff: 30 17.58 (2.12-146.184) 12.54 (1.43-109.96) *Per unit increase

Conclusions

Lymphoedema is associated with lasting quality of life deficits and early distant relapse.

Women at low risk of lymphoedema (75%) can be reassured using the scoring model. Early Arm measurements at 1 month post-surgery a useful measurement time to determine lymphoedema risk and enable patients to be reassured (75%) or plan for lymphoedema monitoring.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Purushotham A, Keeley V. Prediction model for lymphoedema, and effect of Lymphoedema diagnosis on quality of life (QoL) and distant recurrence from breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-01.

Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation

To identify the incidence, risk factors and impact on long-term survival of invasive pulmonary aspergillosis (IPA) and Aspergillus colonisation in patients receiving vv-extracorporeal membrane oxygenation (ECMO). A retrospective evaluation was performed of patients receiving vv-ECMO at a tertiary hospital in Manchester (UK) between January 2012 and December 2016. Data collected included epidemiological data, microbiological cultures, radiographic findings and outcomes. Cases were classified as proven IPA, putative IPA or Aspergillus colonisation according to a validated clinical algorithm. One hundred thirty-four patients were supported with vv-ECMO, median age of 45.5 years (range 16.4-73.4). Ten (7%) patients had putative IPA and nine (7%) had Aspergillus colonisation. Half of the patients with putative IPA lacked classical host risk factors for IPA. The median number of days on ECMO prior to Aspergillus isolation was 5 days. Immunosuppression and influenza A infection were significantly associated with developing IPA in a logistic regression model. Cox regression model demonstrates a three times greater hazard of death associated with IPA. Overall 6-month mortality rate was 38%. Patients with putative IPA and colonised patients had a 6-month mortality rate of 80 and 11%, respectively. Immunosuppression and influenza A infection are independent risk factors for IPA. IPA, but not Aspergillus colonisation, is associated with high long-term mortality in patients supported with vv-ECMO.

Chronic pulmonary aspergillosis as a cause of smear-negative TB and/or TB treatment failure in Nigerians

OBJECTIVE

To evaluate chronic pulmonary aspergillosis (CPA) as an alternative diagnosis of smear-negative tuberculosis (TB) and treatment failure in TB patients in Nigeria.

METHODS

We conducted a cross-sectional multicentre survey in human immunodeficiency virus (HIV) positive and negative adult patients at the end of their TB treatment in clinics in Lagos and Ilorin states. All were assessed using clinical examination, chest X-ray (CXR) and aspergillus immunoglobulin G (IgG) serology, and some for sputum fungal culture. CPA was defined as a positive Aspergillus fumigatus IgG titre with compatible CXR or a positive sputum culture of Aspergillus with a visible fungal ball on CXR with symptoms of underlying lung disease.

RESULTS

Of 208 patients recruited between June 2014 and May 2015, 153 (73.6%) were HIV-positive. The mean age was 39.8 years, 124 (59.6%) were female and 39 (18.8%) were unable to work. The median CD4 count was 169.5 cells/ml (range 4-593) in HIV-infected patients with positive Aspergillus IgG. Overall, 109 (52.4%) had documented TB, 140 (67.3%) had a productive cough and 50 had haemoptysis. CPA prevalence was 8.7%; 10 (6.5%) had HIV infection and 8 (14.5%) were HIV-negative (Fisher's exact P = 0.092).

CONCLUSION

CPA is a neglected disease in Nigeria, and most cases match the World Health Organization diagnostic criteria for smear-negative TB.

The Burden of Cognitive Impairment in Patients With End-Stage Renal Disease and Impact on Dialysis Modality Choice

Introduction

Kidney disease is associated with significant cognitive dysfunction. Subjective reports of cognitive ability have not been studied extensively in chronic kidney disease. We investigated the association between objective and subjective cognitive functions in predialysis patients and their association with self-care dialysis modality choice.

Methods

Cross-sectional data from the Barriers to Successful Implementation of Care in Home Haemodialysis study were used for the study of cognition in 220 predialysis patients. The data were used to ascertain the demographics, clinical, laboratory, and neuropsychometric variables. The latter includes Trail Making Tests (TMT) parts A and B, Modified Mini Mental State Examination, and metacognition questionnaire for subjective assessment of one's cognitive ability. The outcome variable was fully assisted and self-care dialysis modality choice.

Results

Within the study cohort, 90 patients chose fully assisted hemodialysis and 114 patients chose self-care dialysis. The median Modified Mini Mental State Examination, TMT part A, and TMT part B scores were greater for the assisted versus the self-care group. Metamemory was not significantly different between groups, but the metaconcentration score was significantly worse in the group choosing assisted dialysis. Higher (i.e., better) metaconcentration scores were significantly associated with the self-care modality choice in the univariate and hierarchical regression analyses. Adjusted and unadjusted analyses showed a significant association between perceived concentration and TMT part B scores (P < 0.01). With every 1.6-minute increase in TMT part B score, there was a 1-unit reduction in metaconcentration score, and the latter was associated with 20% lower odds of choosing self-care dialysis over a fully assisted dialysis modality.

Discussion

Patients' self-perception of cognitive ability is a significant predictor of self-care dialysis modality choice. Subjective report of "metaconcentration" is also strongly associated with poorer outcome on the TMT part B.

Acute medicine targets: when should the clock start and 7-day consultant impact?

BACKGROUND

Early consultant review has been shown to improve outcomes in patients presenting to the Acute Medical Unit (AMU). The Society for Acute Medicine (SAM) clinical quality indicators use the time of arrival on the AMU for target rather than arrival in the Emergency Department (ED) although this is where most acute medical patients present.

AIM

To determine the effect of a 7-day Consultant Acute Physician model on patient waiting times and assess the impact of starting the clock for medical patients at time of ED arrival.

DESIGN

We performed an audit at a University Hospital AMU in the North West of England.

METHODS

Data were collected prospectively for 15 consecutive days in May-June 2013 for all patients presenting to the AMU at University Hospital of South Manchester and were repeated for the same time period in 2014 following the introduction of a new Consultant working model.

RESULTS

Four hundred and five patients were admitted to the AMU in the 2013 cohort compared to 456 in the 2014 cohort. There was a significant improvement in the median waiting time for Consultant review from AMU admission to 5 h 53 min from 8 h 15 min (P < 0.001). The compliance with the SAM quality indicator for Consultant review improved from 88.7 to 93.7% (P = 0.022).

CONCLUSION

A 7-day Acute Physician working model is improving performance with regards to patient waiting times. We suggest that starting the clock for acute medical patients in the ED is a better measure of performance than on arrival to the AMU.