BMJ medicine最新文献

Objective: To assess whether meeting the NHS best practice tariff standard of care and its constituent elements for hospital admission of adults with acute asthma in England is associated with reduced 30 day and 90 day readmission to hospital.

Design: Nationwide cohort study.

Setting: Secondary care in England, based on data collected from the 2022-23 National Respiratory Audit Programme adult asthma audit, linked with data from Hospital Episode Statistics, 1 April 2022 to 30 June 2023.

Participants: 12 964 patients from 151 hospitals admitted with acute asthma to hospitals in England that took part in the National Respiratory Audit Programme and had their data entered, who were eligible for linkage with Hospital Episode Statistics data, were recorded as male or female sex, and were alive at discharge.

Main outcome measures: 30 and 90 day hospital readmission for asthma or any cause. Association between readmission and meeting best practice tariff standard of care and its constituent elements, adjusted for potential confounders and including a clustering effect for hospital.

Results: 3627 (28.0%) patients were documented as having received the best practice tariff standard of care (a respiratory specialist review within 24 hours of admission and a discharge bundle with key good practice elements). 538 (4.1%) and 1077 (8.3%) patients were readmitted to hospital with asthma within 30 and 90 days, respectively. Receiving best practice tariff standard of care was not associated with either readmission (30 day asthma readmission adjusted odds ratio 0.88 (95% confidence interval (CI) 0.71 to 1.08); 90 day adjusted odds ratio 1.01 (0.87 to 1.17)), and nor was receiving a respiratory specialist review within 24 hours of arrival (30 day adjusted odds ratio 0.92 (0.76 to 1.10); 90 day adjusted odds ratio 1.01 (0.89 to 1.16)). Receiving a discharge bundle was associated with reduced readmission (30 day adjusted odds ratio 0.61 (95% CI 0.50 to 0.75), number needed to treat 68; 90 day adjusted odds ratio 0.77 (0.65 to 0.89), number needed to treat 67), as was receiving a respiratory specialist review at any point (30 day adjusted odds ratio 0.70 (95% CI 0.55 to 0.89), number needed to treat 75). 79.5% of participants who received a respiratory specialist review received a discharge bundle (8596/10 816) compared with 19.4% of those who did not receive a specialist review (417/2148).

Conclusions: In this study, components of the adult asthma discharge bundle were associated with reduced readmission to hospital for asthma. Best practice tariffs should be evidence based to improve quality of care and patient outcomes.

The Chatbot Assessment Reporting Tool (CHART) is a reporting guideline developed to provide reporting recommendations for studies evaluating the performance of generative artificial intelligence (AI)-driven chatbots when summarising clinical evidence and providing health advice, referred to as chatbot health advice studies. CHART was developed in several phases after performing a comprehensive systematic review to identify variation in the conduct, reporting, and method in chatbot health advice studies. Findings from the review were used to develop a draft checklist that was revised through an international, multidisciplinary, modified, asynchronous Delphi consensus process of 531 stakeholders, three synchronous panel consensus meetings of 48 stakeholders, and subsequent pilot testing of the checklist. CHART includes 12 items and 39 subitems to promote transparent and comprehensive reporting of chatbot health advice studies. These include title (subitem 1a), abstract/summary (subitem 1b), background (subitems 2a,b), model identifiers (subitems 3a,b), model details (subitems 4a-c), prompt engineering (subitems 5a,b), query strategy (subitems 6a-d), performance evaluation (subitems 7a,b), sample size (subitem 8), data analysis (subitem 9a), results (subitems 10a-c), discussion (subitems 11a-c), disclosures (subitem 12a), funding (subitem 12b), ethics (subitem 12c), protocol (subitem 12d), and data availability (subitem 12e). The CHART checklist and corresponding diagram of the method were designed to support key stakeholders including clinicians, researchers, editors, peer reviewers, and readers in reporting, understanding, and interpreting the findings of chatbot health advice studies.

Objectives: To investigate maternal mortality in the context of children's social care (CSC) involvement, and to explore the quality of maternity care that women with CSC involvement received.

Design: National cohort study and confidential enquiry.

Setting: MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) national surveillance dataset for deaths that occurred during pregnancy or up to a year after pregnancy, UK, 2014-22.

Participants: 1451 women who died during or in the year after pregnancy in the UK; 420 women (28.9%) had CSC involvement. 47 women's healthcare records were included in the confidential enquiry to describe the care of a random sample of women who died during the perinatal period who had CSC involvement.

Main outcome measures: Rates and causes of maternal deaths by CSC involvement and quality of care.

Results: A third (420/1451, 28.9%) of the women who died during or in the year after pregnancy had CSC involvement for their (unborn) baby. Women with CSC involvement were more likely to be aged ≤20 years (rate ratio 1.85, 95% confidence interval 1.27 to 2.63, compared with those aged 21-29 years), living in the most deprived areas (rate ratio 2.19, 1.42 to 3.50, compared with those least deprived), and less likely to be from black (rate ratio 0.56, 0.35 to 0.84) or Asian ethnic backgrounds (rate ratio 0.26, 0.14 to 0.44, compared with white women) than women who died with no known CSC involvement. Deaths occurred predominantly between six weeks and the year after pregnancy (75%), and higher proportions of deaths were caused by suicide, other psychiatric causes, including substance overdose, and homicide. A confidential enquiry identified that risk assessment and recognition, medication management, coordination of care, and staff competencies were essential components in providing personalised, holistic, and trauma-informed care when dealing with medical and social complexity. Multiple individual and systemic barriers hindered access and engagement with healthcare.

Conclusions: Women with CSC involvement who died during or in the year after pregnancy encountered multiple inequalities and were at an increased risk of maternal mortality from psychiatric causes and homicide. A critical review of current care pathways and policy changes is urgently needed to tailor care to the needs of this group of women and to look at the inequalities that disproportionately affect them.

Chronic pain is the leading cause of years lost to disability worldwide, by a large margin, affecting 20-34% of the world's population. Chronic pain is the target for an increasing number of invasive and expensive treatments, supported by different levels of evidence. At a time when personalised medicine, driven in part by the growth of artificial intelligence, is surging, a scoping review on the factors that affect pain outcomes for procedural interventions is needed. A scoping review is important because placebo controlled trials for the most commonly used treatments consistently show small-to-moderate effect sizes of <0.5 that are often overshadowed by the placebo effect. In this article, personal characteristics, and social and clinical factors that influence surgical and non-surgical procedure pain and functional outcomes are reviewed, their intersectionality is briefly explored, and the evidence base for how dealing with these factors can influence outcomes is outlined.

[This corrects the article DOI: 10.1136/bmjmed-2024-001132.].

Non-inferiority trials aim to show that major disease related outcomes with a new intervention are not importantly worse than with standard care. These trials are useful when the new intervention has some advantages over standard care (eg, toxicity, convenience, or cost). The ability to show non-inferiority, however, is sensitive to the control risk, the outcome frequency under standard care. Two control risk problems are described that can make non-inferiority trials underpowered or uninterpretable, and two ways of tackling these problems are outlined. Firstly, the choice of effect measure used to express the non-inferiority margin is critical: the effect measure must be based on understanding both the clinical setting and the implications for sample size. Which effect measures can lead to smaller or larger sample sizes is shown. Secondly, investigators need to consider, and potentially plan for, the possibility that the observed control risk might differ from the anticipated risk at the design stage of the trial. How the non-inferiority margin can be adapted in the trial analysis in a statistically principled manner is shown.

Investigators, patients, or clinicians knowing which treatment is assigned in pragmatic randomised trials and observational analyses can lead to detection bias (ie, systematic differences in determining outcomes between groups). A structural definition of detection bias with directed acyclic graphs is provided, together with several published examples. Why negative control outcomes are best placed to assess detection bias is discussed, and how to correctly select a negative control outcome for this purpose is explained.

Abstract:

Objective: To provide a comprehensive analysis of initial suicide attempts, covering incidence, risk factors, outcomes, and healthcare use in the month before and the month after the attempts.

Design: Comprehensive analysis of the Swedish population that included three designs: a retrospective cohort study to investigate incidence and healthcare use, a nested case-control study to investigate risk factors, and a matched cohort study to examine subsequent suicide attempts and mortality.

Setting: Comprehensive Swedish national registers that include patient diagnoses from hospitals and specialist outpatient care, and cause of death information updated to the end of 2019.

Participants: 3.7 million people born in Sweden in 1963-98 and followed from age 10 to 57 years.

Main outcome measure: First lifetime suicide attempt identified in patient and death registers using ICD (international classification of diseases) codes for intentional self-harm, any self-harm with lethal methods or requiring hospital admission, or any self-harm resulting in death.

Results: The lifetime risk of an initial suicide attempt in the study population was 4.6%, with greater risk in females and highest risk between ages 18 and 24. One in 10 families in Sweden had at least one family member who attempted suicide. Overdose and poisoning were the most common methods. Previous psychiatric disorders, general medical diseases, and adverse life events were associated with increased risk of initial suicide attempt, while higher socioeconomic status was associated with decreased risk. People with an initial suicide attempt were at substantially increased risk of subsequent attempts (hazard ratio 23.4), death by suicide (16.4), and all cause mortality (7.3). At least 60% of those who made an initial suicide attempt had a healthcare contact in the month before the attempt.

Conclusions: This study provides comprehensive data on the incidence, risk factors, outcomes, and healthcare use of initial suicide attempts in the Swedish population, highlighting the need for systematic prevention efforts for people who have attempted suicide for the first time.

Objective: To investigate the relation between maternal body mass index and hospital admissions for infections in their offspring, and to identify potentially modifiable mediators.

Design: Longitudinal cohort study.

Setting: Born in Bradford longitudinal, multi-ethnic birth cohort, Bradford, UK. Secondary analysis linked to routine hospital admission data, January 2007 to 3 October 2022.

Participants: 9540 singleton births between 2007 and 2011, born to 9037 mothers, followed up from birth to about age 15 years.

Main outcome measures: Total number of hospital admissions related to infections, between birth and age 15 years, in age categories <1 year, 1-4 years, and 5-15 years.

Results: The main study cohort comprised 9540 children and 9037 mothers. About 56% of mothers were overweight or obese. First trimester maternal body mass index was positively associated with rates of hospital admissions for infection across all ages, but associations were significant (P<0.05) only for children born to women with the highest body mass index (obesity grades 2-3). Compared with women with a healthy body mass index, children born to women with obesity grades 2-3 had an adjusted rate ratio of 1.41 (95% confidence interval 1.13 to 1.77) at <1 year and an adjusted rate ratio of 1.53 (1.19 to 1.98) for hospital admissions for infection by age 5-15 years. Similar trends were seen for respiratory and gastrointestinal infections, and multisystem viral infections. Being born by caesarean section and child obesity at aged 4-5 years accounted for 21% and 26% of the association, respectively.

Conclusions: In this study, a modest but consistent association between maternal obesity (grades 2-3) and hospital admissions for infection throughout childhood was found. Healthcare professionals and public health campaigns should continue to support mothers to achieve and maintain a healthy body weight before conception and during the postpartum period.