Mongru, R.
Rose, D.F.
Costelloe, C.
Cunnington, A.
Nijman, R.G.
(2022). Retrospective analysis of North West London healthcare utilisation by children during the COVID-19 pandemic. Bmj paediatrics open,
Vol.6
(1),
pp. ?-? (7).
Honeyford, K.
Expert, P.
Mendelsohn, E.E.
Post, B.
Faisal, A.A.
Glampson, B.
Mayer, E.K.
Costelloe, C.E.
(2022). Challenges and recommendations for high quality research using electronic health records. ,
Vol.4,
p. 940330.
show abstract
Harnessing Real World Data is vital to improve health care in the 21st Century. Data from Electronic Health Records (EHRs) are a rich source of patient centred data, including information on the patient's clinical condition, laboratory results, diagnoses and treatments. They thus reflect the true state of health systems. However, access and utilisation of EHR data for research presents specific challenges. We assert that using data from EHRs effectively is dependent on synergy between researchers, clinicians and health informaticians, and only this will allow state of the art methods to be used to answer urgent and vital questions for patient care. We propose that there needs to be a paradigm shift in the way this research is conducted - appreciating that the research process is iterative rather than linear. We also make specific recommendations for organisations, based on our experience of developing and using EHR data in trusted research environments..
Kaura, A.
Trickey, A.
Shah, A.S.
Benedetto, U.
Glampson, B.
Mulla, A.
Mercuri, L.
Gautama, S.
Costelloe, C.E.
Goodman, I.
Redhead, J.
Saravanakumar, K.
Mayer, E.
Mayet, J.
(2022). Comparing the longer-term effectiveness of a single dose of the Pfizer-BioNTech and Oxford-AstraZeneca COVID-19 vaccines across the age spectrum. ,
Vol.46,
p. 101344.
show abstract
Background: A single dose strategy may be adequate to confer population level immunity and protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, especially in low- and middle-income countries where vaccine supply remains limited. We compared the effectiveness of a single dose strategy of the Oxford-AstraZeneca or Pfizer-BioNTech vaccines against SARS-CoV-2 infection across all age groups and over an extended follow-up period. Methods: Individuals vaccinated in North-West London, UK, with either the first dose of the Oxford-AstraZeneca or Pfizer-BioNTech vaccines between January 12, 2021 and March 09, 2021, were matched to each other by demographic and clinical characteristics. Each vaccinated individual was additionally matched to an unvaccinated control. Study outcomes included SARS-CoV-2 infection of any severity, COVID-19 hospitalisation, COVID-19 death, and all-cause mortality. Findings: Amongst matched individuals, 63,608 were in each of the vaccine groups and 127,216 were unvaccinated. Between 14 and 84 days of follow-up after matching, there were 534 SARS-CoV-2 infections, 65 COVID-19 hospitalisations, and 190 deaths, of which 29 were categorized as due to COVID-19. The incidence rate ratio (IRR) for SARS-CoV-2 infection was 0.85 (95% confidence interval [CI], 0.69 to 1.05) for Oxford-Astra-Zeneca, and 0.69 (0.55 to 0.86) for Pfizer-BioNTech. The IRR for both vaccines was the same at 0.25 (0.09 to 0.55) and 0.14 (0.02 to 0.58) for reducing COVID-19 hospitalization and COVID-19 mortality, respectively. The IRR for all-cause mortality was 0.25 (0.15 to 0.39) and 0.18 (0.10 to 0.30) for the Oxford-Astra-Zeneca and Pfizer-BioNTech vaccines, respectively. Age was an effect modifier of the association between vaccination and SARS-CoV-2 infection of any severity; lower hazard ratios for increasing age. Interpretation: A single dose strategy, for both vaccines, was effective at reducing COVID-19 mortality and hospitalization rates. The magnitude of vaccine effectiveness was comparatively lower for SARS-CoV-2 infection, although this was variable across the age range, with higher effectiveness seen with older adults. Our results have important implications for health system planning -especially in low resource settings where vaccine supply remains constrained..
Iregbu, K.
Dramowski, A.
Milton, R.
Nsutebu, E.
Howie, S.R.
Chakraborty, M.
Lavoie, P.M.
Costelloe, C.E.
Ghazal, P.
(2022). Global health systems' data science approach for precision diagnosis of sepsis in early life. The lancet infectious diseases,
Vol.22
(5),
pp. e143-e152.
Kadirvelu, B.
Burcea, G.
Quint, J.K.
Costelloe, C.E.
Faisal, A.A.
(2022). Variation in global COVID-19 symptoms by geography and by chronic disease: A global survey using the COVID-19 Symptom Mapper. ,
Vol.45,
p. 101317.
show abstract
Background: COVID-19 is typically characterised by a triad of symptoms: cough, fever and loss of taste and smell, however, this varies globally. This study examines variations in COVID-19 symptom profiles based on underlying chronic disease and geographical location. Methods: Using a global online symptom survey of 78,299 responders in 190 countries between 09/04/2020 and 22/09/2020, we conducted an exploratory study to examine symptom profiles associated with a positive COVID-19 test result by country and underlying chronic disease (single, co- or multi-morbidities) using statistical and machine learning methods. Findings: From the results of 7980 COVID-19 tested positive responders, we find that symptom patterns differ by country. For example, India reported a lower proportion of headache (22.8% vs 47.8%, p<1e-13) and itchy eyes (7.3% vs. 16.5%, p=2e-8) than other countries. As with geographic location, we find people differed in their reported symptoms if they suffered from specific chronic diseases. For example, COVID-19 positive responders with asthma (25.3% vs. 13.7%, p=7e-6) were more likely to report shortness of breath compared to those with no underlying chronic disease. Interpretation: We have identified variation in COVID-19 symptom profiles depending on geographic location and underlying chronic disease. Failure to reflect this symptom variation in public health messaging may contribute to asymptomatic COVID-19 spread and put patients with chronic diseases at a greater risk of infection. Future work should focus on symptom profile variation in the emerging variants of the SARS-CoV-2 virus. This is crucial to speed up clinical diagnosis, predict prognostic outcomes and target treatment. Funding: We acknowledge funding to AAF by a UKRI Turing AI Fellowship and to CEC by a personal NIHR Career Development Fellowship (grant number NIHR-2016-090-015). JKQ has received grants from The Health Foundation, MRC, GSK, Bayer, BI, Asthma UK-British Lung Foundation, IQVIA, Chiesi AZ, and Insmed. This work is supported by BREATHE - The Health Data Research Hub for Respiratory Health [MC_PC_19004]. BREATHE is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and delivered through Health Data Research UK. Imperial College London is grateful for the support from the Northwest London NIHR Applied Research Collaboration. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care..
Aliabadi, S.
Jauneikaite, E.
Müller-Pebody, B.
Hope, R.
Vihta, K.-.
Horner, C.
Costelloe, C.E.
(2022). Exploring temporal trends and risk factors for resistance in Escherichia coli-causing bacteraemia in England between 2013 and 2018: an ecological study. Journal of antimicrobial chemotherapy,
Vol.77
(3),
pp. 782-792.
show abstract
Abstract
Background
Escherichia coli are Gram-negative bacteria associated with an increasing burden of antimicrobial resistance (AMR) in England.
Objectives
To create a comprehensive epidemiological picture of E. coli bacteraemia resistance trends and risk factors in England by linking national microbiology data sources and performing a longitudinal analysis of rates.
Methods
A retrospective observational study was conducted on all national records for antimicrobial susceptibility testing on E. coli bacteraemia in England from 1 January 2013 to 31 December 2018 from the UK Health Security Agency (UKHSA) and the BSAC Resistance Surveillance Programme (BSAC-RSP). Trends in AMR and MDR were estimated using iterative sequential regression. Logistic regression analyses were performed on UKHSA data to estimate the relationship between risk factors and AMR or MDR in E. coli bacteraemia isolates.
Results
An increase in resistance rates was observed in community- and hospital-onset bacteraemia for third-generation cephalosporins, co-amoxiclav, gentamicin and ciprofloxacin. Among community-acquired cases, and after adjustment for other factors, patients aged >65 years were more likely to be infected by E. coli isolates resistant to at least one of 11 antibiotics than those aged 18–64 years (OR: 1.21, 95% CI: 1.18–1.25; P < 0.05). In hospital-onset cases, E. coli isolates from those aged 1–17 years were more likely to be resistant than those aged 18–64 years (OR: 1.33, 95% CI: 1.02–1.73; P < 0.05).
Conclusions
Antibiotic resistance rates in E. coli-causing bacteraemia increased between 2013 and 2018 in England for key antimicrobial agents. Findings of this study have implications for guiding future policies on a prescribing of antimicrobial agents, for specific patient populations in particular.
.
Venkatraman, T.
Honeyford, K.
Ram, B.
M F van Sluijs, E.
Costelloe, C.E.
Saxena, S.
(2022). Identifying local authority need for, and uptake of, school-based physical activity promotion in England-a cluster analysis. ,
Vol.44
(3),
pp. 694-703.
show abstract
BACKGROUND: School-based physical activity interventions such as The Daily Mile (TDM) are widely promoted in children's physical activity guidance. However, targeting such interventions to areas of greatest need is challenging since determinants vary across geographical areas. Our study aimed to identify local authorities in England with the greatest need to increase children's physical activity and assess whether TDM reaches school populations in areas with the highest need. METHODS: This was a cross-sectional study using routinely collected data from Public Health England. Datasets on health, census and the built environment were linked. We conducted a hierarchical cluster analysis to group local authorities by 'need' and estimated the association between 'need' and registration to TDM. RESULTS: We identified three clusters of high, medium and low need for physical activity interventions in 123 local authorities. Schools in high-need areas were more likely to be registered with TDM (incidence rate ratio 1.25, 95% confidence interval: 1.12-1.39) compared with low-need areas. CONCLUSIONS: Determinants of children's physical activity cluster geographically across local authorities in England. TDM appears to be an equitable intervention reaching schools in local authorities with the highest needs. Health policy should account for clustering of health determinants to match interventions with populations most in need..
Jauneikaite, E.
Honeyford, K.
Blandy, O.
Mosavie, M.
Pearson, M.
Ramzan, F.A.
Ellington, M.J.
Parkhill, J.
Costelloe, C.E.
Woodford, N.
Sriskandan, S.
(2022). Bacterial genotypic and patient risk factors for adverse outcomes in Escherichia coli bloodstream infections: a prospective molecular epidemiological study. ,
Vol.77
(6),
pp. 1753-1761.
show abstract
OBJECTIVES: Escherichia coli bloodstream infections have shown a sustained increase in England, for reasons that are unknown. Furthermore, the contribution of MDR lineages such as ST131 to overall E. coli disease burden and outcome is undetermined. METHODS: We genome-sequenced E. coli blood isolates from all patients with E. coli bacteraemia in north-west London from July 2015 to August 2016 and assigned MLST genotypes, virulence factors and AMR genes to all isolates. Isolate STs were then linked to phenotypic antimicrobial susceptibility, patient demographics and clinical outcome data to explore relationships between the E. coli STs, patient factors and outcomes. RESULTS: A total of 551 E. coli genomes were analysed. Four STs (ST131, 21.2%; ST73, 14.5%; ST69, 9.3%; and ST95, 8.2%) accounted for over half of cases. E. coli genotype ST131-C2 was associated with phenotypic non-susceptibility to quinolones, third-generation cephalosporins, amoxicillin, amoxicillin/clavulanic acid, gentamicin and trimethoprim. Among 300 patients from whom outcome was known, an association between the ST131-C2 lineage and longer length of stay was detected, although multivariable regression modelling did not demonstrate an association between E. coli ST and mortality. Several unexpected associations were identified between gentamicin non-susceptibility, ethnicity, sex and adverse outcomes, requiring further research. CONCLUSIONS: Although E. coli ST was associated with defined antimicrobial non-susceptibility patterns and prolonged length of stay, E. coli ST was not associated with increased mortality. ST131 has outcompeted other lineages in north-west London. Where ST131 is prevalent, caution is required when devising empiric regimens for suspected Gram-negative sepsis, in particular the pairing of β-lactam agents with gentamicin..
Morrell, L.
Buchanan, J.
Roope, L.S.
Pouwels, K.B.
Butler, C.C.
Hayhoe, B.
Tonkin-Crine, S.
McLeod, M.
Robotham, J.V.
Holmes, A.
Walker, A.S.
Wordsworth, S.
STEPUP team,
(2021). Public preferences for delayed or immediate antibiotic prescriptions in UK primary care: A choice experiment. ,
Vol.18
(8),
p. e1003737.
show abstract
BACKGROUND: Delayed (or "backup") antibiotic prescription, where the patient is given a prescription but advised to delay initiating antibiotics, has been shown to be effective in reducing antibiotic use in primary care. However, this strategy is not widely used in the United Kingdom. This study aimed to identify factors influencing preferences among the UK public for delayed prescription, and understand their relative importance, to help increase appropriate use of this prescribing option. METHODS AND FINDINGS: We conducted an online choice experiment in 2 UK general population samples: adults and parents of children under 18 years. Respondents were presented with 12 scenarios in which they, or their child, might need antibiotics for a respiratory tract infection (RTI) and asked to choose either an immediate or a delayed prescription. Scenarios were described by 7 attributes. Data were collected between November 2018 and February 2019. Respondent preferences were modelled using mixed-effects logistic regression. The survey was completed by 802 adults and 801 parents (75% of those who opened the survey). The samples reflected the UK population in age, sex, ethnicity, and country of residence. The most important determinant of respondent choice was symptom severity, especially for cough-related symptoms. In the adult sample, the probability of choosing delayed prescription was 0.53 (95% confidence interval (CI) 0.50 to 0.56, p < 0.001) for a chesty cough and runny nose compared to 0.30 (0.28 to 0.33, p < 0.001) for a chesty cough with fever, 0.47 (0.44 to 0.50, p < 0.001) for sore throat with swollen glands, and 0.37 (0.34 to 0.39, p < 0.001) for sore throat, swollen glands, and fever. Respondents were less likely to choose delayed prescription with increasing duration of illness (odds ratio (OR) 0.94 (0.92 to 0.96, p < 0.001)). Probabilities of choosing delayed prescription were similar for parents considering treatment for a child (44% of choices versus 42% for adults, p = 0.04). However, parents differed from the adult sample in showing a more marked reduction in choice of the delayed prescription with increasing duration of illness (OR 0.83 (0.80 to 0.87) versus 0.94 (0.92 to 0.96) for adults, p for heterogeneity p < 0.001) and a smaller effect of disruption of usual activities (OR 0.96 (0.95 to 0.97) versus 0.93 (0.92 to 0.94) for adults, p for heterogeneity p < 0.001). Females were more likely to choose a delayed prescription than males for minor symptoms, particularly minor cough (probability 0.62 (0.58 to 0.66, p < 0.001) for females and 0.45 (0.41 to 0.48, p < 0.001) for males). Older people, those with a good understanding of antibiotics, and those who had not used antibiotics recently showed similar patterns of preferences. Study limitations include its hypothetical nature, which may not reflect real-life behaviour; the absence of a "no prescription" option; and the possibility that study respondents may not represent the views of population groups who are typically underrepresented in online surveys. CONCLUSIONS: This study found that delayed prescription appears to be an acceptable approach to reducing antibiotic consumption. Certain groups appear to be more amenable to delayed prescription, suggesting particular opportunities for increased use of this strategy. Prescribing choices for sore throat may need additional explanation to ensure patient acceptance, and parents in particular may benefit from reassurance about the usual duration of these illnesses..
Boncea, E.E.
Expert, P.
Honeyford, K.
Kinderlerer, A.
Mitchell, C.
Cooke, G.S.
Mercuri, L.
Costelloe, C.E.
(2021). Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in a UK hospital network. ,
Vol.30
(6),
pp. 457-466.
show abstract
BACKGROUND: Intrahospital transfers have become more common as hospital staff balance patient needs with bed availability. However, this may leave patients more vulnerable to potential pathogen transmission routes via increased exposure to contaminated surfaces and contacts with individuals. OBJECTIVE: This study aimed to quantify the association between the number of intrahospital transfers undergone during a hospital spell and the development of a hospital-acquired infection (HAI). METHODS: A retrospective case-control study was conducted using data extracted from electronic health records and microbiology cultures of non-elective, medical admissions to a large urban hospital network which consists of three hospital sites between 2015 and 2018 (n=24 240). As elderly patients comprise a large proportion of hospital users and are a high-risk population for HAIs, the analysis focused on those aged 65 years or over. Logistic regression was conducted to obtain the OR for developing an HAI as a function of intrahospital transfers until onset of HAI for cases, or hospital discharge for controls, while controlling for age, gender, time at risk, Elixhauser comorbidities, hospital site of admission, specialty of the dominant healthcare professional providing care, intensive care admission, total number of procedures and discharge destination. RESULTS: Of the 24 240 spells, 2877 cases were included in the analysis. 72.2% of spells contained at least one intrahospital transfer. On multivariable analysis, each additional intrahospital transfer increased the odds of acquiring an HAI by 9% (OR=1.09; 95% CI 1.05 to 1.13). CONCLUSION: Intrahospital transfers are associated with increased odds of developing an HAI. Strategies for minimising intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment..
You, J.
Expert, P.
Costelloe, C.
(2021). Using text mining to track outbreak trends in global surveillance of emerging diseases: ProMED‐mail. Journal of the royal statistical society: series a (statistics in society),
Vol.184
(4),
pp. 1245-1259.
Borek, A.J.
Campbell, A.
Dent, E.
Moore, M.
Butler, C.C.
Holmes, A.
Walker, A.S.
McLeod, M.
Tonkin-Crine, S.
STEP-UP study team,
(2021). Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. ,
Vol.2
(1),
p. 104.
show abstract
BACKGROUND: Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. METHODS: We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified 'guiding principles' with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. RESULTS: Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an 'implementation support' website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). CONCLUSIONS: We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance..
Vollmer, M.A.
Radhakrishnan, S.
Kont, M.D.
Flaxman, S.
Bhatt, S.
Costelloe, C.
Honeyford, K.
Aylin, P.
Cooke, G.
Redhead, J.
Sanders, A.
Mangan, H.
White, P.J.
Ferguson, N.
Hauck, K.
Nayagam, S.
Perez-Guzman, P.N.
(2021). The impact of the COVID-19 pandemic on patterns of attendance at emergency departments in two large London hospitals: an observational study. Bmc health services research,
Vol.21
(1),
pp. 1008-?.
show abstract
Background Hospitals in England have undergone considerable change to address the surge in demand imposed by the COVID-19 pandemic. The impact of this on emergency department (ED) attendances is unknown, especially for non-COVID-19 related emergencies. Methods This analysis is an observational study of ED attendances at the Imperial College Healthcare NHS Trust (ICHNT). We calibrated auto-regressive integrated moving average time-series models of ED attendances using historic (2015-2019) data. Forecasted trends were compared to present year ICHNT data for the period between March 12, 2020 (when England implemented the first COVID-19 public health measure) and May 31, 2020. We compared ICHTN trends with publicly available regional and national data. Lastly, we compared hospital admissions made via the ED and in-hospital mortality at ICHNT during the present year to the historic 5-year average. Results ED attendances at ICHNT decreased by 35% during the period after the first lockdown was imposed on March 12, 2020 and before May 31, 2020, reflecting broader trends seen for ED attendances across all England regions, which fell by approximately 50% for the same time frame. For ICHNT, the decrease in attendances was mainly amongst those aged < 65 years and those arriving by their own means (e.g. personal or public transport) and not correlated with any of the spatial dependencies analysed such as increasing distance from postcode of residence to the hospital. Emergency admissions of patients without COVID-19 after March 12, 2020 fell by 48%; we did not observe a significant change to the crude mortality risk in patients without COVID-19 (RR 1.13, 95%CI 0.94-1.37, p = 0.19). Conclusions Our study findings reflect broader trends seen across England and give an indication how emergency healthcare seeking has drastically changed. At ICHNT, we find that a larger proportion arrived by ambulance and that hospitalisation outcomes of patients without COVID-19 did not differ from previous years. The extent to which these findings relate to ED avoidance behaviours compared to having sought alternative emergency health services outside of hospital remains unknown. National analyses and strategies to streamline emergency services in England going forward are urgently needed..
Borek, A.J.
Campbell, A.
Dent, E.
Butler, C.C.
Holmes, A.
Moore, M.
Walker, A.S.
McLeod, M.
Tonkin-Crine, S.
STEP-UP study team,
(2021). Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices. ,
Vol.22
(1),
p. 25.
show abstract
BACKGROUND: Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. METHODS: This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. RESULTS: Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience - participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' - participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities - participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context - various other situational and practical issues were raised with implementing the strategies. CONCLUSIONS: High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation..
Borek, A.J.
Anthierens, S.
Allison, R.
McNulty, C.A.
Lecky, D.M.
Costelloe, C.
Holmes, A.
Butler, C.C.
Walker, A.S.
Tonkin-Crine, S.
(2020). How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals. Journal of antimicrobial chemotherapy,
Vol.75
(9),
pp. 2681-2688.
show abstract
AbstractBackgroundThe Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented.ObjectivesTo understand responses to the QP and how it was perceived to influence antibiotic prescribing.MethodsSemi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically.ResultsThe findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off.ConclusionsCCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation..
Allison, R.
Lecky, D.M.
Beech, E.
Costelloe, C.
Ashiru-Oredope, D.
Owens, R.
McNulty, C.A.
(2020). What antimicrobial stewardship strategies do NHS commissioning organizations implement in primary care in England?. Jac-antimicrobial resistance,
Vol.2
(2).
show abstract
Abstract
Objectives
To identify and explore strategies that English NHS commissioning organizations implemented to improve antimicrobial stewardship (AMS) within primary care.
Methods
Questionnaire sent to the medicines management teams (MMTs) of all 209 clinical commissioning groups (CCGs) in England, in 2017.
Results
A total of 89% (187/209) of all English CCGs responded to the questionnaire; 74% of responding CCGs (123/167) had a prescribing incentive/engagement scheme, with MMTs representing 88% (90/102) considering incentive schemes successful or very successful for prioritizing AMS in primary care, especially when linked to prescribing NHS Quality Premium indicators. AMS audits were considered successful or very successful by 91% (126/138) of responding CCGs, as they identify reasons for inappropriate prescribing and opportunities for future improvement. All responding MMTs (169/169 CCGs) reported feeding back local/national antimicrobial prescribing data to the general practices they commission, 85% (142/168) to their CCG/Commissioning Support Unit (CSU) board and only 33% (56/169) to out-of-hours services. Benchmarking prescribing data was reported as a powerful tool to engage practices, facilitating an element of competition and peer pressure.
Conclusions
National antimicrobial resistance improvement schemes, in particular the NHS England Quality Premium, have influenced CCG improvement priorities. Most CCGs now report successful improvement strategies including the use of both local and national antibiotic prescribing data to motivate improvements; these should be continued and extended to out-of-hours providers. As local audit data have helped to identify reasons for inappropriate prescribing and inform improvement planning, all organizations should adopt this strategy and include it in local quality improvement schemes, ensuring performance reporting to organizational board level.
.
Honeyford, K.
Cooke, G.S.
Kinderlerer, A.
Williamson, E.
Gilchrist, M.
Holmes, A.
Glampson, B.
Mulla, A.
Costelloe, C.
(2020). Evaluating a digital sepsis alert in a London multisite hospital network: a natural experiment using electronic health record data. Journal of the american medical informatics association,
Vol.27
(2),
pp. 274-283.
show abstract
Abstract
Objective
The study sought to determine the impact of a digital sepsis alert on patient outcomes in a UK multisite hospital network.
Materials and Methods
A natural experiment utilizing the phased introduction (without randomization) of a digital sepsis alert into a multisite hospital network. Sepsis alerts were either visible to clinicians (patients in the intervention group) or running silently and not visible (the control group). Inverse probability of treatment-weighted multivariable logistic regression was used to estimate the effect of the intervention on individual patient outcomes.
Outcomes
In-hospital 30-day mortality (all inpatients), prolonged hospital stay (≥7 days) and timely antibiotics (≤60 minutes of the alert) for patients who alerted in the emergency department.
Results
The introduction of the alert was associated with lower odds of death (odds ratio, 0.76; 95% confidence interval [CI], 0.70-0.84; n = 21 183), lower odds of prolonged hospital stay ≥7 days (OR, 0.93; 95% CI, 0.88-0.99; n = 9988), and in patients who required antibiotics, an increased odds of receiving timely antibiotics (OR, 1.71; 95% CI, 1.57-1.87; n = 4622).
Discussion
Current evidence that digital sepsis alerts are effective is mixed. In this large UK study, a digital sepsis alert has been shown to be associated with improved outcomes, including timely antibiotics. It is not known whether the presence of alerting is responsible for improved outcomes or whether the alert acted as a useful driver for quality improvement initiatives.
Conclusions
These findings strongly suggest that the introduction of a network-wide digital sepsis alert is associated with improvements in patient outcomes, demonstrating that digital based interventions can be successfully introduced and readily evaluated.
.
Allison, R.
Lecky, D.M.
Beech, E.
Ashiru-Oredope, D.
Costelloe, C.
Owens, R.
McNulty, C.A.
(2020). What Resources do NHS Commissioning Organisations Use to Support Antimicrobial Stewardship in Primary Care in England?. ,
Vol.9
(4),
p. E158.
show abstract
Professional education and public engagement are fundamental components of any antimicrobial stewardship (AMS) strategy. The National Institute for Health and Care Excellence (NICE), Public Health England (PHE), Health Education England (HEE) and other professional organisations, develop and publish resources to support AMS activity in primary care settings. The aim of this study was to explore the adoption and use of education/training and supporting AMS resources within NHS primary care in England. Questionnaires were sent to the medicines management teams of all 209 Clinical Commissioning Groups (CCGs) in England, in 2017. Primary care practitioners in 168/175 (96%) CCGs received AMS education in the last two years. Respondents in 184/186 (99%) CCGs reported actively promoting the TARGET Toolkit to their primary care practitioners; although 137/176 (78%) did not know what percentage of primary care practitioners used the TARGET toolkit. All respondents were aware of Antibiotic Guardian and 132/167 (79%) reported promoting the campaign. Promotion of AMS resources to general practices is currently excellent, but as evaluation of uptake or effect is poor, this should be encouraged by resource providers and through quality improvement programmes. Trainers should be encouraged to promote and highlight the importance of action planning within their AMS training. AMS resources, such as leaflets and education, should be promoted across the whole health economy, including Out of Hours and care homes. Primary care practitioners should continue to be encouraged to display a signed Antibiotic Guardian poster as well as general AMS posters and videos in practice, as patients find them useful and noticeable..
Pouwels, K.B.
Vansteelandt, S.
Batra, R.
Edgeworth, J.
Wordsworth, S.
Robotham, J.V.
Improving the uptake and SusTainability of Effective interventions to promote Prudent antibiotic Use and Primary care (STEP-UP) Team,
(2020). Estimating the Effect of Healthcare-Associated Infections on Excess Length of Hospital Stay Using Inverse Probability-Weighted Survival Curves. ,
Vol.71
(9),
pp. e415-e420.
show abstract
BACKGROUND: Studies estimating excess length of stay (LOS) attributable to nosocomial infections have failed to address time-varying confounding, likely leading to overestimation of their impact. We present a methodology based on inverse probability-weighted survival curves to address this limitation. METHODS: A case study focusing on intensive care unit-acquired bacteremia using data from 2 general intensive care units (ICUs) from 2 London teaching hospitals were used to illustrate the methodology. The area under the curve of a conventional Kaplan-Meier curve applied to the observed data was compared with that of an inverse probability-weighted Kaplan-Meier curve applied after treating bacteremia as censoring events. Weights were based on the daily probability of acquiring bacteremia. The difference between the observed average LOS and the average LOS that would be observed if all bacteremia cases could be prevented was multiplied by the number of admitted patients to obtain the total excess LOS. RESULTS: The estimated total number of extra ICU days caused by 666 bacteremia cases was estimated at 2453 (95% confidence interval [CI], 1803-3103) days. The excess number of days was overestimated when ignoring time-varying confounding (2845 [95% CI, 2276-3415]) or when completely ignoring confounding (2838 [95% CI, 2101-3575]). CONCLUSIONS: ICU-acquired bacteremia was associated with a substantial excess LOS. Wider adoption of inverse probability-weighted survival curves or alternative techniques that address time-varying confounding could lead to better informed decision making around nosocomial infections and other time-dependent exposures..
Anyanwu, P.E.
Pouwels, K.
Walker, A.
Moore, M.
Majeed, A.
Hayhoe, B.W.
Tonkin-Crine, S.
Borek, A.
Hopkins, S.
Mcleod, M.
Costelloe, C.
(2020). Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study. Bjgp open,
Vol.4
(3),
pp. bjgpopen20X101052-bjgpopen20X101052.
show abstract
BackgroundIn 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%–23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016.AimTo investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design & settingLongitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.MethodLinear generalised estimating equations models were fitted, examining the effect of the 2015–2016 QP on the number of antibiotic items per specific therapeutic group age–sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015–2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015–2016 QP compared with other practices (interaction p<0.001).ConclusionIn high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care..
Boyd, S.E.
Vasudevan, A.
Moore, L.S.
Brewer, C.
Gilchrist, M.
Costelloe, C.
Gordon, A.C.
Holmes, A.H.
(2020). Validating a prediction tool to determine the risk of nosocomial multidrug-resistant Gram-negative bacilli infection in critically ill patients: A retrospective case–control study. Journal of global antimicrobial resistance,
Vol.22,
pp. 826-831.
Skirrow, H.
Wincott, T.
Cecil, E.
Bottle, A.
Costelloe, C.
Saxena, S.
(2019). Preschool respiratory hospital admissions following infant bronchiolitis: a birth cohort study. Archives of disease in childhood,
Vol.104
(7),
pp. 658-663.
show abstract
BackgroundBronchiolitis causes significant infant morbidity worldwide from hospital admissions. However, studies quantifying the subsequent respiratory burden in children under 5 years are lacking.ObjectiveTo estimate the risk of subsequent respiratory hospital admissions in children under 5 years in England following bronchiolitis admission in infancy.DesignRetrospective population-based birth cohort study.SettingPublic hospitals in England.PatientsWe constructed a birth cohort of 613 377 infants born between 1 April 2007 and 31 March 2008, followed up until aged 5 years by linking Hospital Episode Statistics admissions data.MethodsWe compared the risk of respiratory hospital admission due to asthma, wheezing and lower and upper respiratory tract infections (LRTI and URTI) in infants who had been admitted for bronchiolitis with those who had not, using Cox proportional hazard regression. We adjusted hazard ratios (HR) for known respiratory illness risk factors including living in deprived households, being born preterm or with a comorbid condition.ResultsWe identified 16 288/613 377 infants (2.7%) with at least one admission for bronchiolitis. Of these, 21.7% had a further respiratory hospital admission by age 5 years compared with 8% without a previous bronchiolitis admission (HR (adjusted) 2.82, 95% CI 2.72 to 2.92). The association was greatest for asthma (HR (adjusted) 4.35, 95% CI 4.00 to 4.73) and wheezing admissions (HR (adjusted) 5.02, 95% CI 4.64 to 5.44), but were also significant for URTI and LRTI admissions.ConclusionsHospital admission for bronchiolitis in infancy is associated with a threefold to fivefold risk of subsequent respiratory hospital admissions from asthma, wheezing and respiratory infections. One in five infants with bronchiolitis hospital admissions will have a subsequent respiratory hospital admission by age 5 years..
Anyanwu, P.E.
Tonkin-Crine, S.
Borek, A.
Costelloe, C.
(2019). Investigating the mechanism of impact of the Quality Premium initiative on antibiotic prescribing in primary care practices in England: a study protocol. Bmj open,
Vol.9
(8),
pp. e030093-e030093.
show abstract
IntroductionThe persistent development and spread of resistance to antibiotics remain an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England.Methods and analysisThe study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using ordinary least square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics.Ethics and disseminationThis study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple channels will be used in disseminating the findings from this study to academic and non-academic audiences..
Hatcher, J.
Costelloe, C.
Cele, R.
Viljanen, A.
Samarasinghe, D.
Satta, G.
Brannigan, E.
De Barra, E.
Sanderson, F.
Gilchrist, M.
(2019). Factors associated with successful completion of outpatient parenteral antibiotic therapy (OPAT): A 10-year review from a large West London service. International journal of antimicrobial agents,
Vol.54
(2),
pp. 207-214.
Bryce, A.
Costelloe, C.
Wootton, M.
Butler, C.C.
Hay, A.D.
(2018). Comparison of risk factors for, and prevalence of, antibiotic resistance in contaminating and pathogenic urinary Escherichia coli in children in primary care: prospective cohort study. Journal of antimicrobial chemotherapy,
Vol.73
(5),
pp. 1359-1367.
Bou-Antoun, S.
Costelloe, C.
Honeyford, K.
Mazidi, M.
Hayhoe, B.W.
Holmes, A.
Johnson, A.P.
Aylin, P.
(2018). Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis. Journal of antimicrobial chemotherapy,
Vol.73
(10),
pp. 2883-2892.
Lishman, H.
Costelloe, C.
Hopkins, S.
Johnson, A.P.
Hope, R.
Guy, R.
Muller-Pebody, B.
Holmes, A.
Aylin, P.
(2018). Exploring the relationship between primary care antibiotic prescribing for urinary tract infections, Escherichia coli bacteraemia incidence and antimicrobial resistance: an ecological study. International journal of antimicrobial agents,
Vol.52
(6),
pp. 790-798.
Knight, G.M.
Costelloe, C.
Deeny, S.R.
Moore, L.S.
Hopkins, S.
Johnson, A.P.
Robotham, J.V.
Holmes, A.H.
(2018). Quantifying where human acquisition of antibiotic resistance occurs: a mathematical modelling study. Bmc medicine,
Vol.16
(1).
Boyd, S.E.
Moore, L.S.
Gilchrist, M.
Costelloe, C.
Castro-Sánchez, E.
Franklin, B.D.
Holmes, A.H.
(2017). Obtaining antibiotics online from within the UK: a cross-sectional study. Journal of antimicrobial chemotherapy,
Vol.72
(5),
pp. 1521-1528.
Banerjee, K.
Mathie, R.T.
Costelloe, C.
Howick, J.
(2017). Homeopathy for Allergic Rhinitis: A Systematic Review. The journal of alternative and complementary medicine,
Vol.23
(6),
pp. 426-444.
Lishman, H.
Aylin, P.
Alividza, V.
Castro-Sanchez, E.
Chatterjee, A.
Mariano, V.
Johnson, A.P.
Jeraj, S.
Costelloe, C.
(2017). Investigating the burden of antibiotic resistance in ethnic minority groups in high-income countries: protocol for a systematic review and meta-analysis. Systematic reviews,
Vol.6
(1).
Eldridge, S.M.
Costelloe, C.E.
Kahan, B.C.
Lancaster, G.A.
Kerry, S.M.
(2016). How big should the pilot study for my cluster randomised trial be?. Statistical methods in medical research,
Vol.25
(3),
pp. 1039-1056.
show abstract
There is currently a lot of interest in pilot studies conducted in preparation for randomised controlled trials. This paper focuses on sample size requirements for external pilot studies for cluster randomised trials. We consider how large an external pilot study needs to be to assess key parameters for input to the main trial sample size calculation when the primary outcome is continuous, and to estimate rates, for example recruitment rates, with reasonable precision. We used simulation to provide the distribution of the expected number of clusters for the main trial under different assumptions about the natural cluster size, intra-cluster correlation, eventual cluster size in the main trial, and various decisions made at the piloting stage. We chose intra-cluster correlation values and pilot study size to reflect those commonly reported in the literature. Our results show that estimates of sample size required for the main trial are likely to be biased downwards and very imprecise unless the pilot study includes large numbers of clusters and individual participants. We conclude that pilot studies will usually be too small to estimate parameters required for estimating a sample size for a main cluster randomised trial (e.g. the intra-cluster correlation coefficient) with sufficient precision and too small to provide reliable estimates of rates for process measures such as recruitment or follow-up rates. .
Bryce, A.
Costelloe, C.
Hawcroft, C.
Wootton, M.
Hay, A.D.
(2016). Faecal carriage of antibiotic resistant Escherichia coli in asymptomatic children and associations with primary care antibiotic prescribing: a systematic review and meta-analysis. Bmc infectious diseases,
Vol.16
(1).
Lokhmatkina, N.V.
Agnew-Davies, R.
Costelloe, C.
Kuznetsova, O.Y.
Nikolskaya, I.M.
Feder, G.S.
(2015). Intimate partner violence and ways of coping with stress: cross-sectional survey of female patients in Russian general practice. Family practice,
Vol.32
(2),
pp. 141-146.
Stansfeld, S.A.
Kerry, S.
Chandola, T.
Russell, J.
Berney, L.
Hounsome, N.
Lanz, D.
Costelloe, C.
Smuk, M.
Bhui, K.
(2015). Pilot study of a cluster randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee well-being and reduction of sickness absence: GEM Study. Bmj open,
Vol.5
(10),
pp. e007981-e007981.
Banerjee, K.
Costelloe, C.
Mathie, R.T.
Howick, J.
(2014). Homeopathy for allergic rhinitis: protocol for a systematic review. Systematic reviews,
Vol.3
(1).
Hay, A.D.
Costelloe, C.
(2013). Antibiotics for childhood urinary tract infection: can we be smarter?. British journal of general practice,
Vol.63
(609),
pp. 175-176.
Redmond, N.M.
Hollinghurst, S.
Costelloe, C.
Montgomery, A.A.
Fletcher, M.
Peters, T.J.
Hay, A.D.
(2013). An evaluation of the impact and costs of three strategies used to recruit acutely unwell young children to a randomised controlled trial in primary care. Clinical trials,
Vol.10
(4),
pp. 593-603.
show abstract
Background Recruitment to primary care trials, particularly those involving young children, is known to be difficult. There are limited data available to inform researchers about the effectiveness of different trial recruitment strategies and their associated costs. Purpose To describe, evaluate, and investigate the costs of three strategies for recruiting febrile children to a community-based randomised trial of antipyretics. Methods The three recruitment strategies used in the trial were termed as follows: (1) ‘local’, where paediatric research nurses stationed in primary care sites invited parents of children to participate; (2) ‘remote’, where clinicians at primary care sites faxed details of potentially eligible children to the trial office; and (3) ‘community’, where parents, responding to trial publicity, directly contacted the trial office when their child was unwell. Results Recruitment rates increased in response to the sequential introduction of three recruitment strategies, which were supplemented by additional recruiting staff, flexible staff work patterns, and improved clinician reimbursement schemes. The three strategies yielded different randomisation rates. They also appeared to be interdependent and highly effective together. Strategy-specific costs varied from £297 to £857 per randomised participant and represented approximately 10% of the total trial budget. Limitations Because the recruitment strategies were implemented sequentially, it was difficult to measure their independent effects. The cost analysis was performed retrospectively. Conclusions Trial recruiter expertise and deployment of several interdependent, illness-specific strategies were key factors in achieving rapid recruitment of young children to a community-based randomised controlled trial (RCT). The ‘remote’ recruitment strategy was shown to be more cost-effective compared to ‘community’ and ‘local’ strategies in the context of this trial. Future trialists should report recruitment costs to facilitate a transparent evaluation of recruitment strategy cost-effectiveness. .
Costelloe, C.
Lovering, A.
Montgomery, A.
Lewis, D.
McNulty, C.
Hay, A.D.
(2012). Effect of antibiotic prescribing in primary care on meticillin-resistant Staphylococcus aureus carriage in community-resident adults: a controlled observational study. International journal of antimicrobial agents,
Vol.39
(2),
pp. 135-141.
Chalder, M.
Wiles, N.J.
Campbell, J.
Hollinghurst, S.P.
Haase, A.M.
Taylor, A.H.
Fox, K.R.
Costelloe, C.
Searle, A.
Baxter, H.
Winder, R.
Wright, C.
Turner, K.M.
Calnan, M.
Lawlor, D.A.
Peters, T.J.
Sharp, D.J.
Montgomery, A.A.
Lewis, G.
(2012). Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. Bmj,
Vol.344
(jun06 1),
pp. e2758-e2758.
Costelloe, C.
Montgomery, A.A.
Redmond, N.M.
Fletcher, M.
Hollinghurst, S.
Peters, T.J.
Hay, A.D.
(2011). Medicine dosing by weight in the home: can parents accurately weigh preschool children? A method comparison study. Archives of disease in childhood,
Vol.96
(12),
pp. 1187-1190.
Whitburn, S.
Costelloe, C.
Montgomery, A.A.
Redmond, N.M.
Fletcher, M.
Peters, T.J.
Hay, A.D.
(2011). The frequency distribution of presenting symptoms in children aged six months to six years to primary care. Primary health care research & development,
Vol.12
(02),
pp. 123-134.
Costelloe, C.
Metcalfe, C.
Lovering, A.
Mant, D.
Hay, A.D.
(2010). Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. Bmj,
Vol.340
(may18 2),
pp. c2096-c2096.
Hay, A.D.
Costelloe, C.
Redmond, N.M.
Montgomery, A.A.
Fletcher, M.
Hollinghurst, S.
Peters, T.J.
(2008). Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. Bmj,
Vol.337
(sep02 2),
pp. a1302-a1302.
Costelloe, C.
Watson, M.
Murphy, A.
McQuillan, K.
Loscher, C.
Armstrong, M.E.
Garlanda, C.
Mantovani, A.
O’Neill, L.A.
Mills, K.H.
Lynch, M.A.
(2008). IL-1F5 mediates anti-inflammatory activity in the brain through induction of IL-4 following interaction with SIGIRR/TIR8. Journal of neurochemistry,
Vol.105
(5),
pp. 1960-1969.
Hollinghurst, S.
Redmond, N.
Costelloe, C.
Montgomery, A.
Fletcher, M.
Peters, T.J.
Hay, A.D.
(2008). Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): economic evaluation of a randomised controlled trial. Bmj,
Vol.337
(sep09 3),
pp. a1490-a1490.
Alturkistani, A.
Qavi, A.
Anyanwu, P.E.
Greenfield, G.
Greaves, F.
Costelloe, C.
Patient Portal Functionalities and Patient Outcomes Among Patients With Diabetes: Systematic Review. Journal of medical internet research,
Vol.22
(9),
pp. e18976-e18976.
show abstract
Background
Patient portal use could help improve the care and health outcomes of patients with diabetes owing to functionalities, such as appointment booking, electronic messaging (e-messaging), and repeat prescription ordering, which enable patient-centered care and improve patient self-management of the disease.
Objective
This review aimed to summarize the evidence regarding patient portal use (portals that are connected to electronic health care records) or patient portal functionality use (eg, appointment booking and e-messaging) and their reported associations with health and health care quality outcomes among adult patients with diabetes.
Methods
We searched the MEDLINE, Embase, and Scopus databases and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed the full texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tool to assess the risk of bias of the included studies. Data were summarized through narrative synthesis.
Results
Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and health care quality outcomes. Six studies reported e-messaging or email use–associated outcomes, and two studies reported prescription refill–associated outcomes. The reported health outcomes included the associations of patient portal use with blood pressure, low-density lipoprotein cholesterol, and BMI. Few studies reported health care utilization outcomes such as office visits, emergency department visits, and hospitalizations. A limited number of studies reported overall quality of care for patients with diabetes who used patient portals.
Conclusions
The included studies mostly reported improved glycemic control outcomes for patients with diabetes who used patient portals. However, limitations of studying the effects of patient portals exist, which do not guarantee whether the outcomes reported are completely the result of patient portal use or if confounding factors exist. Randomized controlled trials and mixed-methods studies could help understand the mechanisms involved in health outcome improvements and patient portal use among patients with diabetes.
Trial Registration
International Prospective Register of Systematic Reviews (PROSPERO) CRD42019141131; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019141131.
International Registered Report Identifier (IRRID)
RR2-10.2196/14975
.
Alturkistani, A.
Greenfield, G.
Greaves, F.
Aliabadi, S.
Jenkins, R.H.
Costelloe, C.
Patient Portal Functionalities and Uptake: Systematic Review Protocol. Jmir research protocols,
Vol.9
(7),
pp. e14975-e14975.
show abstract
Background
Patient portals are digital health tools adopted by health care organizations. The portals are generally connected to the electronic health record of the health care organization and offer patients functionalities such as access to the medical record, ability to order repeat prescriptions, make appointments, or message the health care provider. Patient portals may be beneficial for both patients and the health care system. Patient portals can widely differ from one context to another due to the differences in the portal functionalities and capabilities and it is anticipated that outcomes associated with the functionalities also differ. Current systematic reviews report outcomes associated with patient portal uptake but do not explicitly specify the patient portal functionalities.
Objective
The aim of this systematic review is to synthesize the evidence on health and health care quality outcomes associated with patient portal use among adult (18 years or older) patients. The review research questions are as follows: What kind of health outcomes do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? and What kind of health care quality outcomes, including health care utilization outcomes, do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)?
Methods
The systematic review will be conducted by searching the MEDLINE, EMBASE, and Scopus databases for relevant literature. The review inclusion criteria will be studies about adult patients (18 years or older), studies only about tethered patient portals, and studies with or without a comparator. We will report patient portal–associated health and health care quality outcomes based on the patient portal functionalities. All quantitative primary study types will be included. Risk of bias of included studies will be assessed using the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials and the National Heart, Lung, and Blood Institute’s quality assessment tools. Data will be synthesized using narrative synthesis and will be reported according to the patient portal functionalities, country, disease, and health care system model.
Results
Searches will be conducted in September 2019, and the review is anticipated to be completed by the end of June 2020.
Conclusions
This systematic review will provide an overview of health and health care quality outcomes associated with patient portal use among adult patients, providing detailed information about the functionalities of the portals and their associations with the outcomes. The review could potentially help patient portal evaluation studies by providing insights into outcomes associated with the different functionalities of patient portals.
Trial Registration
International Prospective Register of Systematic Reviews (PROSPERO) CRD42019141131; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141131
International Registered Report Identifier (IRRID)
PRR1-10.2196/14975
.
Micallef, C.
McLeod, M.
Castro-Sánchez, E.
Gharbi, M.
Charani, E.
Moore, L.S.
Gilchrist, M.
Husson, F.
Costelloe, C.
Holmes, A.H.
An Evidence-Based Antimicrobial Stewardship Smartphone App for Hospital Outpatients: Survey-based Needs Assessment Among Patients. Jmir mhealth and uhealth,
Vol.4
(3),
pp. e83-e83.
Aliabadi, S.
Anyanwu, P.
Beech, E.
Jauneikaite, E.
Wilson, P.
Hope, R.
Majeed, A.
Muller-Pebody, B.
Costelloe, C.
Effect of antibiotic stewardship interventions in primary care on antimicrobial resistance of Escherichia coli bacteraemia in England (2013-18): a quasi-experimental, ecological, data linkage study. The lancet. infectious diseases,
Vol.21
(12),
pp. 1689-1700.
show abstract
Background
Antimicrobial resistance is a major global health concern, driven by overuse of antibiotics. We aimed to assess the effectiveness of a national antimicrobial stewardship intervention, the National Health Service (NHS) England Quality Premium implemented in 2015-16, on broad-spectrum antibiotic prescribing and Escherichia coli bacteraemia resistance to broad-spectrum antibiotics in England.
Methods
In this quasi-experimental, ecological, data linkage study, we used longitudinal data on bacteraemia for patients registered with a general practitioner in the English National Health Service and patients with E coli bacteraemia notified to the national mandatory surveillance programme between Jan 1, 2013, and Dec 31, 2018. We linked these data to data on antimicrobial susceptibility testing of E coli from Public Health England's Second-Generation Surveillance System. We did an ecological analysis using interrupted time-series analyses and generalised estimating equations to estimate the change in broad-spectrum antibiotics prescribing over time and the change in the proportion of E coli bacteraemia cases for which the causative bacteria were resistant to each antibiotic individually or to at least one of five broad-spectrum antibiotics (co-amoxiclav, ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin), after implementation of the NHS England Quality Premium intervention in April, 2015.
Findings
Before implementation of the Quality Premium, the rate of antibiotic prescribing for all five broad-spectrum antibiotics was increasing at rate of 0·2% per month (incidence rate ratio [IRR] 1·002 [95% CI 1·000-1·004], p=0·046). After implementation of the Quality Premium, an immediate reduction in total broad-spectrum antibiotic prescribing rate was observed (IRR 0·867 [95% CI 0·837-0·898], p<0·0001). This effect was sustained until the end of the study period; a 57% reduction in rate of antibiotic prescribing was observed compared with the counterfactual situation (ie, had the Quality Premium not been implemented). In the same period, the rate of resistance to at least one broad-spectrum antibiotic increased at rate of 0·1% per month (IRR 1·001 [95% CI 0·999-1·003], p=0·346). On implementation of the Quality Premium, an immediate reduction in resistance rate to at least one broad-spectrum antibiotic was observed (IRR 0·947 [95% CI 0·918-0·977], p=0·0007). Although this effect was also sustained until the end of the study period, with a 12·03% reduction in resistance rate compared with the counterfactual situation, the overall trend remained on an upward trajectory. On examination of the long-term effect following implementation of the Quality Premium, there was an increase in the number of isolates resistant to at least one of the five broad-spectrum antibiotics tested (IRR 1·002 [1·000-1·003]; p=0·047).
Interpretation
Although interventions targeting antibiotic use can result in changes in resistance over a short period, they might be insufficient alone to curtail antimicrobial resistance.
Funding
National Institute for Health Research, Economic and Social Research Council, Rosetrees Trust, and The Stoneygate Trust..
Venkatraman, T.
Honeyford, K.
Costelloe, C.E.
Bina, R.
M F van Sluijs, E.
Viner, R.M.
Saxena, S.
Sociodemographic profiles, educational attainment and physical activity associated with The Daily Mile™ registration in primary schools in England: a national cross-sectional linkage study. Journal of epidemiology and community health,
Vol.75
(2),
pp. 137-144.
show abstract
Objective
To examine primary school and local authority characteristics associated with registration for The Daily Mile (TDM), an active mile initiative aimed at increasing physical activity in children.
Design
A cross-sectional linkage study using routinely collected data.
Setting
All state-funded primary schools in England from 2012 to 2018 (n=15,815).
Results
3,502 of all 15,815 (22.1%) state-funded primary schools in England were registered to do TDM, ranging from 16% in the East Midlands region to 31% in Inner London. Primary schools registered for TDM had larger mean pupil numbers compared with schools that had not registered (300 vs 269, respectively). There was a higher proportion of TDM-registered schools in urban areas compared with non-urban areas. There was local authority variation in the likelihood of school registration (intraclass correlation coefficient: 0.094). After adjusting for school and local authority characteristics, schools located in a major urban conurbation (OR 1.46 (95% CI 1.24 to 1.71) urban vs rural) and schools with a higher proportion of disadvantaged pupils had higher odds of being registered for TDM (OR 1.16 (95% CI 1.02 to 1.33)). Area-based physical activity and schools' educational attainment were not significantly associated with registration to TDM.
Conclusion
One in five primary schools in England has registered for TDM since 2012. TDM appears to be a wide-reaching school-based physical activity intervention that is reaching more disadvantaged primary school populations in urban areas where obesity prevalence is highest. TDM-registered schools include those with both high and low educational attainment and are in areas with high and low physical activity..
Borek, A.J.
Anthierens, S.
Allison, R.
Mcnulty, C.A.
Anyanwu, P.E.
Costelloe, C.
Walker, A.S.
Butler, C.C.
Tonkin-Crine, S.
On Behalf Of The Step-Up Study Team,
Social and Contextual Influences on Antibiotic Prescribing and Antimicrobial Stewardship: A Qualitative Study with Clinical Commissioning Group and General Practice Professionals. Antibiotics (basel, switzerland),
Vol.9
(12).
show abstract
Antibiotic prescribing in England varies considerably between Clinical Commissioning Groups (CCGs) and general practices. We aimed to assess social and contextual factors affecting antibiotic prescribing and engagement with antimicrobial stewardship (AMS) initiatives. Semi-structured telephone interviews were conducted with 22 CCG professionals and 19 general practice professionals. Interviews were audio-recorded, transcribed, and analyzed thematically. Social/contextual influences were grouped into the following four categories: (1) Immediate context, i.e., patients' social characteristics (e.g., deprivation and culture), clinical factors, and practice and clinician characteristics (e.g., "struggling" with staff shortage/turnover) were linked to higher prescribing. (2) Wider context, i.e., pressures on the healthcare system, limited resources, and competing priorities were seen to reduce engagement with AMS. (3) Collaborative and whole system approaches, i.e., communication, multidisciplinary networks, leadership, and teamwork facilitated prioritizing AMS, learning, and consistency. (4) Relativity of appropriate prescribing, i.e., "high" or "appropriate" prescribing was perceived as relative, depending on comparators, and disregarding different contexts, but social norms around antibiotic use among professionals and patients seemed to be changing. Further optimization of antibiotic prescribing would benefit from addressing social/contextual factors and addressing wider health inequalities, not only targeting individual clinicians. Tailoring and adapting to local contexts and constraints, ensuring adequate time and resources for AMS, and collaborative, whole system approaches to promote consistency may help promote AMS..
Anyanwu,
Borek,
Tonkin-Crine,
Beech,
Costelloe,
Conceptualising the Integration of Strategies by Clinical Commissioning Groups in England towards the Antibiotic Prescribing Targets for the Quality Premium Financial Incentive Scheme: A Short Report. Antibiotics,
Vol.9
(2),
pp. 44-44.
show abstract
Background: In order to tackle the public health threat of antimicrobial resistance, improvement in antibiotic prescribing in primary care was included as one of the priorities of the Quality Premium (QP) financial incentive scheme for Clinical Commissioning Groups (CCGs) in England. This paper briefly reports the outcome of a workshop exploring the experiences of antimicrobial stewardship (AMS) leads within CCGs in selecting and adopting strategies to help achieve the QP antibiotic targets. Methods: We conducted a thematic analysis of the notes on discussions and observations from the workshop to identify key themes. Results: Practice visits, needs assessment, peer feedback and audits were identified as strategies integrated in increasing engagement with practices towards the QP antibiotic targets. The conceptual model developed by AMS leads demonstrated possible pathways for the impact of the QP on antibiotic prescribing. Participants raised a concern that the constant targeting of high prescribing practices for AMS interventions might lead to disengagement by these practices. Most of the participants suggested that the effect of the QP might be less about the financial incentive and more about having national targets and guidelines that promote antibiotic prudency. Conclusions: Our results suggest that national targets, rather than financial incentives are key for engaging stakeholders in quality improvement in antibiotic prescribing..
Kyaw, B.M.
Tudor Car, L.
van Galen, L.S.
van Agtmael, M.A.
Costelloe, C.E.
Ajuebor, O.
Campbell, J.
Car, J.
Health Professions Digital Education on Antibiotic Management: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Journal of medical internet research,
Vol.21
(9),
pp. e14984-e14984.
show abstract
Background
Inappropriate antibiotic prescription is one of the key contributors to antibiotic resistance, which is managed with a range of interventions including education.
Objective
We aimed to summarize evidence on the effectiveness of digital education of antibiotic management compared to traditional education for improving health care professionals’ knowledge, skills, attitudes, and clinical practice.
Methods
Seven electronic databases and two trial registries were searched for randomized controlled trials (RCTs) and cluster RCTs published between January 1, 1990, and September 20, 2018. There were no language restrictions. We also searched the International Clinical Trials Registry Platform Search Portal and metaRegister of Controlled Trials to identify unpublished trials and checked the reference lists of included studies and relevant systematic reviews for study eligibility. We followed Cochrane methods to select studies, extract data, and appraise and synthesize eligible studies. We used random-effect models for the pooled analysis and assessed statistical heterogeneity by visual inspection of a forest plot and calculation of the I2 statistic.
Results
Six cluster RCTs and two RCTs with 655 primary care practices, 1392 primary care physicians, and 485,632 patients were included. The interventions included personal digital assistants; short text messages; online digital education including emails and websites; and online blended education, which used a combination of online digital education and traditional education materials. The control groups received traditional education. Six studies assessed postintervention change in clinical practice. The majority of the studies (4/6) reported greater reduction in antibiotic prescription or dispensing rate with digital education than with traditional education. Two studies showed significant differences in postintervention knowledge scores in favor of mobile education over traditional education (standardized mean difference=1.09, 95% CI 0.90-1.28; I2=0%; large effect size; 491 participants [2 studies]). The findings for health care professionals’ attitudes and patient-related outcomes were mixed or inconclusive. Three studies found digital education to be more cost-effective than traditional education. None of the included studies reported on skills, satisfaction, or potential adverse effects.
Conclusions
Findings from studies deploying mobile or online modalities of digital education on antibiotic management were complementary and found to be more cost-effective than traditional education in improving clinical practice and postintervention knowledge, particularly in postregistration settings. There is a lack of evidence on the effectiveness of other digital education modalities such as virtual reality or serious games. Future studies should also include health care professionals working in settings other than primary care and low- and middle-income countries.
Clinical Trial
PROSPERO CRD42018109742; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=109742
.
Bryce, A.
Hay, A.D.
Lane, I.F.
Thornton, H.V.
Wootton, M.
Costelloe, C.
Global prevalence of antibiotic resistance in paediatric urinary tract infections caused byEscherichia coliand association with routine use of antibiotics in primary care: systematic review and meta-analysis. Bmj,
,
pp. i939-i939.
Costelloe, C.
Williams, O.
Montgomery, A.
Dayan, C.
Hay, A.
Antibiotic Prescribing in Primary Care and Antimicrobial Resistance in Patients Admitted to Hospital with Urinary Tract Infection: A Controlled Observational Pilot Study. Antibiotics,
Vol.3
(1),
pp. 29-38.
Barnes, T.R.
Leeson, V.C.
Paton, C.
Costelloe, C.
Simon, J.
Kiss, N.
Osborn, D.
Killaspy, H.
Craig, T.K.
Lewis, S.
Keown, P.
Ismail, S.
Crawford, M.
Baldwin, D.
Lewis, G.
Geddes, J.
Kumar, M.
Pathak, R.
Taylor, S.
Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial. Health technology assessment,
Vol.20
(29),
pp. 1-46.
show abstract
BackgroundNegative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions.ObjectiveTo establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia.DesignA multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up.SettingAdult psychiatric services, treating people with schizophrenia.ParticipantsInpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity.InterventionsEligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study.Main outcome measuresThe primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich’s Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale.ResultsNo therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference –1.3, 95% confidence interval –2.5 to –0.09). There were no statistically significant differences between the two treatment arms over 48-week follow-up in either the health economics outcomes or costs, and no differences in the frequency or severity of adverse effects, including corrected QT interval prolongation.LimitationsThe trial under-recruited, partly because cardiac safety concerns about citalopram were raised, with the 62 participants recruited falling well short of the target recruitment of 358. Although this was the largest sample randomised to citalopram in a randomised controlled trial of antidepressant augmentation for negative symptoms of schizophrenia and had the longest follow-up, the power of statistical analysis to detect significant differences between the active and placebo groups was limited.ConclusionAlthough adjunctive citalopram did not improve negative symptoms overall, there was evidence of some positive effect on avolition/amotivation, recognised as a critical barrier to psychosocial rehabilitation and achieving better social and community functional outcomes. Comprehensive assessment of side-effect burden did not identify any serious safety or tolerability issues. The addition of citalopram as a long-term prescribing strategy for the treatment of negative symptoms may merit further investigation in larger studies.Future workFurther studies of the viability of adjunctive antidepressant treatment for negative symptoms in schizophrenia should include appropriate safety monitoring and use rating scales that allow for evaluation of avolition/amotivation as a discrete negative symptom domain. Overcoming the barriers to recruiting an adequate sample size will remain a challenge.Trial registrationEuropean Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2009-009235-30 and Current Controlled Trials ISRCTN42305247.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 29. See the NIHR Journals Library website for further project information..
Hay, A.
Redmond, N.
Costelloe, C.
Montgomery, A.
Fletcher, M.
Hollinghurst, S.
Peters, T.
Paracetamol and ibuprofen for the treatment of fever in children: the PITCH randomised controlled trial. Health technology assessment,
Vol.13
(27).
Lyons, A.
Griffin, R.J.
Costelloe, C.E.
Clarke, R.M.
Lynch, M.A.
IL-4 attenuates the neuroinflammation induced by amyloid-β in vivo and in vitro. Journal of neurochemistry,
Vol.101
(3),
pp. 771-781.
Honeyford, K.
Coughlan, C.
Nijman, R.
Expert, P.
Burcea, G.
Maconochie, I.
Kinderlerer, A.
Cooke, G.
Costelloe, C.
Changes in Emergency Department Activity and the First COVID-19 Lockdown: A Cross-sectional Study. Western journal of emergency medicine,
Vol.22
(3).