Comparative effectiveness of a second-line biologic in patients with ulcerative colitis: vedolizumab followed by an anti-TNF versus anti-TNF followed by vedolizumab

BackgroundSequential drug treatment with biological agents in ulcerative colitis (UC) is becoming increasingly complex. There are few studies comparing head-to-head outcomes in second-line treatments. The study assesses whether using anti-tumour necrosis factor (anti-TNF)-α therapy following the α4β7 integrin blocker vedolizumab (VDZ) or VDZ after an anti-TNF has more favourable clinical outcomes in UC in a real-world outpatient setting.MethodsPatients with UC who were exposed to first-line anti-TNF (adalimumab or infliximab) or VDZ who subsequently switched to the alternate class between May 2013 and August 2020 were identified by reviewing patient databases at 10 hospitals. Data were collected retrospectively using patient records. Baseline demographics, disease activity indices, biochemical markers, endoscopic Mayo score, colectomy rates, treatment persistence and urgent hospital utilisation composite endpoint (UHUC) rates were examined over a 52-week period.ResultsSecond-line week 52 treatment persistence was higher in the VDZ group (71/81, 89%) versus the anti-TNF group (15/34, 44%; p=0.0001), as were week 52 colectomy-free survival (VDZ: 77/80, 96%, vs anti-TNF: 26/32, 81%; p=0.009), week 52 UHUC survival (VDZ: 68/84, 81%, vs anti-TNF: 20/34, 59%; p=0.002) and week 52 corticosteroid-free clinical remission (CFCR) rates (VDZ: 22/34, 65%, vs anti-TNF: 4/20, 20%; p=0.001).ConclusionCompared with second-line anti TNF usage, the VDZ second-line cohort had significantly higher 52-week treatment persistence, UHUC survival, higher colectomy-free survival rates and higher week 52 CFCR. These data suggest that VDZ is an effective biologic in UC as a second-line therapy after anti-TNF exposure. It highlights the effect of biological order on clinically important outcomes.

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone

IntroductionThe COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone.MethodsMixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student’s t-test. Qualitative data were analysed using thematic analysis.ResultsFrom Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship.ConclusionThe study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.

Spiritual distress: symptoms, quality of life and hospital utilisation in home-based palliative care

ObjectivesThe purpose of this study was to use a spiritual screening question to quantify the prevalence of spiritual distress (SD) in a large cohort of seriously ill patients at admission to home-based palliative care (HBPC) and to examine the associations between SD with symptom burden, quality of life and hospital-based utilisation up to 6 months after admission to HBPC.MethodsData for this cohort study (n=658) were drawn from a pragmatic comparative-effectiveness trial testing two models of HBPC. At admission to HBPC, SD was measured using a global question (0–10-point scale: none=0; mild=1–4; moderate-to-severe=5+); symptoms and quality of life were measured with the Edmonton Symptom Assessment Scale (ESAS) and PROMIS-10. Hospital utilisation was captured using electronic records and claims. Median regression and proportional hazard competing risk models assessed the association between SD with symptoms and quality of life, and hospital utilisation, respectively.ResultsNearly half of the patients/proxies reported some level of SD. Increasing SD was significantly associated with higher symptom burden (increase of 7–14 points on ESAS) and worse mental well-being (decrease of 2.7 to 4.6 points on PROMIS-10-mental) in adjusted models. Compared with patients/proxies who reported no SD, those with at least some level of SD were not at increased risk for hospital-based utilisation over a median follow-up period of 2 months.ConclusionWhile SD is cross-sectionally associated with worse symptoms and mental well-being, it did not predict downstream hospital-based utilisation. Our results highlight the importance of assessing for and managing SD in patients with serious illness.

Healthcare inequalities in emergency visits and hospitalisation at the end of life: a study of 395 019 public hospital records

ObjectivesTo investigate whether there were any socioeconomic disparities in utilisation of hospital care services during end of life in Hong Kong.MethodsSecondary data analyses were conducted using frequency of the accident and emergency (A&E) department visits and hospital admissions during the last year of life in all public hospitals from 2004 to 2014 in Hong Kong. A total of 1 237 044 A&E records from 357 853 patients, and 1 878 982 admission records from 375 506 patients were identified for analyses. In total, 395 019 unique deceased patients were identified from both datasets.ResultsRegression analyses showed that comprehensive social security assistance (CSSA) recipients used A&E services 1.29 times more than the non-recipients. Being either a CSSA recipient or an elderly home resident was more likely to be admitted to hospitals and stayed longer. Elderly home residents tended to stay longer than those from the community in the earlier months during the last year of life regardless of CSSA status; however, non-elderly home residents surpassed the residents in the duration of stay at hospitals towards the later months of the last year of life. There were also significant differences in hospital utilisation across various districts of residence.ConclusionsPeople of lower socioeconomic position tend to have higher emergency visits and hospitalisation during their last year of life in Hong Kong, implying the presence of health inequality during end of life. However, due to Hong Kong’s largely pro-rich primary care system, the predominantly public A&E and inpatient services may inadvertently act as a mitigator of such health inequalities.

Understanding the impact and causes of ‘failure to attend’ on continuity of care for patients with chronic conditions

Aim To understand the impact and causes of ‘Failure to Attend’ (FTA) labelling, of patients with chronic conditions. Background Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended. Method The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation. Results Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient’s capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap. Conclusion The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase ‘Failure to Attend’ has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase “appointment did not proceed” to replace FTA. Implications for Nursing management This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term ‘appointment did not proceed.’

A Country Level Analysis Comparing Hospital Capacity and Utilisation During the First COVID-19 Wave Across Europe

Background: The exponential increase of SARS-CoV-2 infections during the first wave of the pandemic created an extraordinary overload and demand on hospitals, especially on intensive care units (ICUs), across Europe. European countries have taken different measures to surge ICU capacity, but little is known on the extent. A country level analysis was conducted to compare hospitalisation rates of COVID-19 patients in acute and intensive care and the levels of surge capacity for intensive care beds across 16 European countries and Lombardy region during the first wave of the pandemic (28 February to 31 July).Methods: We used data on infection rates and numbers of current and/or cumulative COVID-19 patients in acute and intensive care in 16 countries and Lombardy region to analyse the burden on hospitals during the first wave of the COVID-19 pandemic. Data on COVID-19 hospitalisations was continuously extracted since 20 March, 2020 from publicly available sources. To evaluate whether hospital capacities were exceeded, we retrieved information on hospital and ICU surge capacity. Treatment days and mean length of hospital stay were calculated to assess hospital utilisation by COVID-19 patients during the first wave. Results: Pre-pandemic hospital and ICU capacity varied widely across countries. In no studied country did the utilisation of acute care bed capacity by COVID-19 patients exceed 38.3%. However, the Netherlands, Sweden, and Lombardy would not have been able to treat all COVID-19 patients during the first wave without ICU surge capacity. Indicators of hospital utilisation were not consistently related to the numbers of SARS-CoV-2 infections. The mean number of hospital days associated with one SARS-CoV-2 case ranged from 1.3 (Norway) to 11.8 (France). Conclusion: In many countries, the increase of ICU capacity was important to accommodate the high demand for intensive care during the first COVID-19 wave. Our study indicates that SARS-CoV-2 incidence is not the only aspect when it comes to the burden of hospital care for COVID-19 but rather the utilisation of hospital resources as shown by cumulative hospital days and mean length of stay during the first wave. Indicators presented in this study could inform forecasting models, especially in regard to necessary surge capacity.

Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study

IntroductionPeople living with dementia (PLWD) are more likely to experience hospitalisation events (hospitalisation, rehospitalisation) than those without dementia. Many hospitalisation events, particularly rehospitalisation within 30 days of discharge, are thought to be avoidable. Yet our understanding of dementia-specific risk and protective factors surrounding avoidable hospitalisation is limited to specific intersetting transitions and predominantly clinician perspectives. Broader insights are needed to design accessible and effective solutions for reducing avoidable hospitalisations. We have designed the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) Study to address these gaps. The objectives of the SUPPORT Study are to elicit and examine family caregiver, community and hospital providers’ perspectives on avoidable hospitalisation events among PLWD, and to identify opportunities for effective prevention.Methods and analysisWe will conduct a multisite, descriptive qualitative study to interview around 100 family caregivers, community and hospital providers. We will identify and sample from regions and communities with higher socio-contextual disadvantage and hospital utilisation, and will aim to recruit individuals representing diverse racial/ethnic backgrounds. Interviews will follow a descriptive qualitative design in conjunction with constant comparison techniques to sample divergent situations and events. We will employ a range of analytical approaches to address specific research questions including thematic (inductive and deductive), comparative and dimensional analysis. Interviews will be conducted individually or in focus groups and follow a semistructured interview guide.Ethics and disseminationThe study is approved by the University of Wisconsin-Madison Institutional Review Board. Informed consent procedures will incorporate steps to evaluate capacity to provide informed consent in the event that participants express concerns with thinking or memory or demonstrate challenges recalling study details during the consent process to ensure capacity to consent to participation. A series of publicly available reports, seminars and symposia will be undertaken in collaboration with collaborating organisation partners.

Prevalence, determinants and knowledge about herbal medicine and non-hospital utilisation in southwest Nigeria: a cross-sectional study

ObjectivesTo examine the prevalence, determinants, safety perceptions, effectiveness and knowledge of herbal medicines (HMs) and reasons for non-hospital utilisation.DesignCross-sectional study.SettingEkiti state, southwest Nigeria.ParticipantsA representative sample (n=1600) of adults (18 years or above) currently living in Ekiti state, southwest Nigeria for at least 2 years, at the time of study.ResultsThe majority of the respondents (85% n=1265) have used HMs in the last 2 years. Across economic classes use, middle income (88.3%) was the highest (p<0.001), suggesting poverty is not a major factor, even with income inequality. Their use was the most common among respondents with a primary level of education (91.4%, p=0.001); and 100% use (p=0.009) of respondents practising African traditional religion; farmers and those 70 years or above. Our study also reveals more men (p<0.001) used HMs (89.9%) than women (78.6%) and effectiveness was a major reason for use (39.6%) followed by affordability (31.9%). Although the majority of the respondents (90%) knew the difference between certified and uncertified HMs, uncertified ones were the most commonly used (37.3%) in the population.ConclusionAlthough there is a cultural history of HM use within the study population, the choice of use was based on their effectiveness. Therefore, a scientifically valid analysis of this claim within the study population may help achieve a cheaper and affordable healthcare alternative which will be safe. This is important, considering that uncertified HMs were chosen over certified ones, even though a large majority of respondents were aware of differences and likely consequences. This study highlights the need for further investment by the government, individuals and corporate stakeholders in HM research and improvement of conventional healthcare system. This is in addition to public health awareness on the danger of use of uncertified herbal products.