Faculty Bibliography

Early recognition, identification and treatment of children with attention deficit hyperactivity disorder (ADHD) can reduce detrimental outcomes and redirect their developmental trajectory. We aimed to describe variations in age of ADHD diagnosis and stimulant prescribing among general practitioner practices in a nationwide network and identify child, parental, household and general practice factors that might account for these variations. Cross-sectional study of children aged under 19 years registered within a general practice in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network in 2016, RCGP RSC has a household key allowing parent and child details to be linked. Data from 158 general practices and 353 774 children under 19 were included. The mean age of first ADHD diagnosis was 10.5 years (95% CI 10.1 to 10.9, median 10, IQR 9.0-11.9) and the mean percentage of children with ADHD prescribed stimulant medications among RCGP RSC practices was 41.2% (95% CI 38.7 to 43.6). There was wide inter-practice variation in the prevalence of diagnosis of ADHD, the age of diagnosis and stimulant prescribing. ADHD diagnosis is more likely to be made later in households with a greater number of children and with a larger age difference between adults and children. Stimulant prescribing for children with ADHD was higher in less deprived practices. Older parents and families with more children fail to recognise ADHD and may need more support. Practices in areas of higher socio-economic status are associated with greater prescribing of stimulants for children with ADHD.

The mechanisms underlying the adverse cardiovascular effects of increased salt intake are incompletely understood, but parallel increases in serum sodium concentration may be of importance. The aim of this retrospective cohort study was to investigate the relationship between serum sodium, hypertension and incident cardiovascular disease (CVD). Routinely collected primary care data from the Royal College of General Practitioners Research and Surveillance Centre were analysed. A total of 231,545 individuals with a measurement of serum sodium concentration at baseline were included. Exclusion criteria were: age < 40 years; abnormal serum sodium; diabetes mellitus; prior CVD event; stage 5 chronic kidney disease; and liver cirrhosis. The primary outcome was incident CVD (myocardial infarction, acute coronary syndrome, coronary revascularisation, stroke, transient ischaemic attack or new heart failure diagnosis) over 5 years. There was a 'J-shaped' relationship between serum sodium concentration and primary cardiovascular events that was independent of established risk factors, medications and other serum electrolytes. The lowest cardiovascular risk was found with a serum sodium between 141 and 143 mmol/l. Higher serum sodium was associated with increased risk in hypertensive individuals, whereas lower concentrations were associated with increased risk in all individuals. Therefore, alterations in serum sodium concentration may be a useful indicator of CVD risk. Higher serum sodium could have a direct effect on the vasculature, particularly in hypertensive individuals. Lower serum sodium may be a reflection of complex volume and neuroendocrine changes.

OBJECTIVES/OBJECTIVE:Respiratory infections are associated with acute exacerbations of asthma and accompanying morbidity and mortality. In this study we explore inter-practice variations in respiratory infections in children with asthma and study the effect of practice-level factors on these variations. DESIGN/METHODS:Cross-sectional study. SETTING/METHODS:We analysed data from 164 general practices in the Royal College of General PractitionersResearch and Surveillance Centresentinel network in England. PARTICIPANTS/METHODS:Children 5-12 years. INTERVENTIONS/METHODS:None. In this observational study, we used regression analysis to explore the impact of practice-level determinants on the number of respiratory infections in children with asthma. PRIMARY AND SECONDARY OUTCOME MEASURES/UNASSIGNED:We describe the distribution of childhood asthma and the determinants of upper/lower respiratory tract infections in these children. RESULTS:83.5% (137/164) practices were in urban locations; the mean number of general practitioners per practice was 7; and the mean duration since qualification 19.7 years. We found almost 10-fold difference in the rate of asthma (1.5-11.8 per 100 children) and 50-fold variation in respiratory infection rates between practices. Larger practices with larger lists of asthmatic children had greater rates of respiratory infections among these children. CONCLUSION/CONCLUSIONS:We showed that structural/environmental variables are consistent predictors of a range of respiratory infections among children with asthma. However, contradictory results between measures of practice clinical care show that a purely structural explanation for variability in respiratory infections is limited. Further research is needed to understand how the practice factors influence individual risk behaviours relevant to respiratory infections.

BACKGROUND:Hypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database. METHODS AND FINDING/UNASSIGNED:We carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4-18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1-25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5-38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8-47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion. CONCLUSIONS:Substantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.

OBJECTIVES/SPECIFIC AIMS: Determine timing of risk of readmissions within 30 days among patients first discharged to a skilled nursing facilities (SNF) after heart failure hospitalization and subsequently discharged home. METHODS/STUDY POPULATION: This was a retrospective cohort study of patients with SNF stays of 30 days or less following discharge from a heart failure hospitalization. Patients were followed for 30 days following discharge from SNF. We categorized patients based on SNF length of stay (LOS): 1-6 days, 7-13 days, 14-30 days. We then fit a piecewise exponential Bayesian model with the outcome as time to readmission after discharge from SNF for each group. Our event of interest was unplanned readmission; death and planned readmissions were considered as competing risks. Our model examined 2 different time intervals following discharge from SNF: 0-3 days post SNF discharge and 4-30 days post SNF discharge. We reported the hazard rate (credible interval) of readmission for each time interval. We examined all Medicare fee-for-service (FFS) patients 65 and older admitted from July 2012 to June 2015 with a principal discharge diagnosis of HF, based on methods adopted by the Centers for Medicare and Medicaid Services (CMS) for hospital quality measurement. RESULTS/ANTICIPATED RESULTS: Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home [median age, 84 years (IQR; 78-89); female, 61.0%]; 13,257 (19.2%) were discharged with home care, 54,328 (80.4%) without. Median length of SNF admission was 17 days (IQR; 11-22). In total, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge; median time to readmission was 9 days (IQR; 3-18). The hazard rate of readmission for each group was significantly increased on days 0-3 after discharge from SNF compared with days 4-30 after discharge from SNF. In addition, the hazard rate of readmission during the first 0-3 days after discharge from SNF decreased as the LOS in SNF increased. DISCUSSION/SIGNIFICANCE OF IMPACT: The hazard rate of readmission after SNF discharge following heart failure hospitalization is highest during the first 6 days home. Length of stay at SNF also has an effect on risk of readmission immediately after discharge from SNF; patients with a longer length of stay in SNF were less likely to be readmitted in the first 3 days after discharge from SNF.

INTRODUCTION/BACKGROUND:Acute gastroenteritis (AGE) is a highly transmissible condition. Determining characteristics of household transmission will facilitate development of prevention strategies and reduce the burden of this disease.We are carrying out this study to describe household transmission of medically attended AGE, and explore whether there is an increased incidence in households with young children. METHODS AND ANALYSIS/UNASSIGNED:This study used the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care sentinel network, comprising data from 1 750 167 registered patients (August 2017 database). We conducted a novel analysis using a 'household key', to identify patients within the same household (n=811 027, mean 2.16 people). A 25-year repeated cross-sectional study will explore the incidence of medically attended AGE overall and then a 5-year retrospective cohort study will describe household transmission of AGE. The cross-sectional study will include clinical data for a 25-year period-1 January 1992 until the 31 December 2017. We will describe the incidence of AGE by age-band and gender, and trends in incidence. The 5-year study will use Poisson and quasi-Poisson regression to identify characteristics of individuals and households to predict medically attended AGE transmitted in the household. This will include whether the household contained a child under 5 years and the age category of the first index case (whether adult or child under 5 years). If there is overdispersion and zero-inflation we will compare results with negative binomial to handle these issues. ETHICS AND DISSEMINATION/UNASSIGNED:All RCGP RSC data are pseudonymised at the point of data extraction. No personally identifiable data are required for this investigation. The protocol follows STrengthening the Reporting of OBservational studies in Epidemiology guidelines (STROBE). The study results will be published in a peer-review journal, the dataset will be available to other researchers.

Background: Catheter ablation has become an increasingly common elective therapy for symptomatic atrial fbrillation (AF). Few data are available regarding outcomes of urgent AF ablation performed during AF related hospital admission, and the impact of these procedures on healthcare utilization. Objective: To evaluate patient characteristics, procedural outcomes, and impact on healthcare utilization in patients undergoing urgent AF ablation. Methods: Procedural outcomes of patients undergoing urgent frst-time AF ablation during an AF related hospital admission between 1/2014 and 8/2017 at a single tertiary care medical center were compared to those of 2:1 matched control patients undergoing frst-time elective AF ablation. An inverse probability weighted marginal structural model was constructed and the weighted means of the average hospital days and number of hospital visits in the six-months post ablation were compared. Results: 25 patients (1% of frst-time AF ablations) underwent an urgent procedure. There were no major procedural complications in either group. Incidence of arrhythmia recurrence within one year was similar in urgent and elective patients (20% vs. 18%, respectively, p=0.85). Urgent ablation patients had a greater number of hospital utilization days in the 6-months pre-ablation (mean 8.9+/-4.5 vs 2.6+/-1.1, p<.001) and a similar number of hospital utilization days in the 6-months post-ablation (1.8+/-4.5 vs 0.59+/- 1.07, p=.05) The marginal structural model of the change in number of hospital visits due to being in the urgent ablation group was-0.924 (-1.43 to-0.41; P <0.001). Conclusion: Urgent ablation for treatment resistant, symptomatic AF is feasible and safe with procedural outcomes were similar to those of elective AF ablation. There is and increased rate of healthcare utilization in prior to ablation in the urgent group, and a statistically signifcant reduction in healthcare utilization following urgent AF ablation. Defning the cost-effectiveness of and optimal patient selection for urgent ablation requires further investigation

Background: Paper-based Early Recovery after Surgery (ERAS) path-ways have been shown to reduce length of stay, but there have been limited evaluations of electronic health record (EHR) based pathways. The objective of this study was to evaluate whether ERAS processes implemented with a novel pathway activity integrated with the EHR (E-Pathway) can reduce costs without resulting in increased 30 day readmissions. Methods: We performed a retrospective cohort study of surgical patients age>= 18 years hospitalized at an academic medical center from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing elective procedures with similar length of stay as colon surgery (3-5 days). The E-Pathway was based on a pathway template developed by a common EHR vendor (Epic Systems, Verona, WI) with content developed by a multidisciplinary team based on ERAS principles. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay (O:E LOS) and 30 day readmissions to our hospital. For both groups, we performed an interrupted time series with segmented regression analysis with month being the unit of time. We used gamma regression for cost models and logistic models for the secondary outcomes. Results: We included 823 (470 and 353 in the pre-and post-intervention, respectively) colon surgery patients and 3415 (1,819 and 1,596 in the pre-and post-intervention) surgical control patients. Among the colon surgery cohort, we observed no changesin cost eitheratbaseline [-0.1% (95% CI-0.8%, 0.5%) per month] or with immediate introduction of the pathway. However, there was statistically significant (p = 0.040) decrease in costs of 1.3% (0.6% to 2.5%) per surgical encounter per month over the 18 month post intervention period. The surgical comparator group had no change in cost either at baseline or at the time of intervention and had a nonsignificant decrease in monthly costs of 0.6% (p = 0.231) post-intervention. There was statistically significant (p = 0.039) decrease in the O:E slope after the intervention of 1.49% per surgical encounter per month. The surgical comparator group had a nonsignificant (p = 0.761) increase in slope of 1.87%. For the 30 day readmission rates, there were no statistically significant changes in either the colon surgery or control groups. Conclusions: Our study is the first, to our knowledge, to report on the outcomes of a novel sophisticated E pathway integrated into an EHR. Following implementation of the E-pathway for colon surgery patients, we observed decreasing direct variable costs and O:E LOS over time. These improvements were not observed among comparable surgical patients. Consequently, as institutions continue to place increased emphasis on standardization of best practice care, E-pathways can be powerful vehicles to support those changes in the new EHR-centric care model

BACKGROUND:The Royal College of General Practitioners Research and Surveillance Centre comprises more than 150 general practices, with a combined population of more than 1.5 million, contributing to UK and European public health surveillance and research. OBJECTIVE:The aim of this paper was to report gender differences in the presentation of infectious and respiratory conditions in children and young adults. METHODS:Disease incidence data were used to test the hypothesis that boys up to puberty present more with lower respiratory tract infection (LRTI) and asthma. Incidence rates were reported for infectious conditions in children and young adults by gender. We controlled for ethnicity, deprivation, and consultation rates. We report odds ratios (OR) with 95% CI, P values, and probability of presenting. RESULTS:Boys presented more with LRTI, largely due to acute bronchitis. The OR of males consulting was greater across the youngest 3 age bands (OR 1.59, 95% CI 1.35-1.87; OR 1.13, 95% CI 1.05-1.21; OR 1.20, 95% CI 1.09-1.32). Allergic rhinitis and asthma had a higher OR of presenting in boys aged 5 to 14 years (OR 1.52, 95% CI 1.37-1.68; OR 1.31, 95% CI 1.17-1.48). Upper respiratory tract infection (URTI) and urinary tract infection (UTI) had lower odds of presenting in boys, especially those older than 15 years. The probability of presenting showed different patterns for LRTI, URTI, and atopic conditions. CONCLUSIONS:Boys younger than 15 years have greater odds of presenting with LRTI and atopic conditions, whereas girls may present more with URTI and UTI. These differences may provide insights into disease mechanisms and for health service planning.