Studies and Research

On this page, listed below in alphabetical order, you will find summaries of GIRFT research papers and studies which have been published in various academic journals and publications.

Academic Content

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Acute and General Medicine and Emergency Medicine

British Journal of Surgery

Emergency hospital admissions among patients awaiting elective treatment in England were quantified using linked national datasets, revealing substantial variation across specialties and procedures in emergency admission rates whilst waiting for surgery.

Key observations:

A significant proportion of patients experience emergency admissions while waiting for surgery
Variation between pathways is considerable. The highest emergency admission rates per 52 weeks waiting were for urinary stent procedures (0.71), endoscopic retrograde cholangiopancreatography (0.63), and urinary catheter care (0.55)
For 9 of the 41 procedures studied, average emergency care bed use whilst waiting for surgery exceeds bed use for the planned procedure. The procedures with the highest emergency bed use per elective bed use were ureteric stones management (4.59), colonoscopy (2.80), and ablation/cardioversion (2.05).
Suggests missed opportunities for earlier intervention and prioritisation

These findings underline the risks associated with prolonged waiting times and the need for more effective risk-based prioritisation.

Future Healthcare Journal

Possible futures of acute medical care in the NHS: a multispecialty approach

This is a review paper based on the observations of the NHS GIRFT programme Emergency Medicine and Acute and General Medicine team during deep dive visits to NHS hospital trusts across England. The review identifies that some fundamental aspects of acute medical care are not provided at all trust, resulting in preventable hospitalisation and over-use of emergency departments.

Areas where deficiencies were found include care outside hospital, appropriately sized, staffed, located and configured acute medical units, multi-speciality same-day emergency care (SDEC) pathways, multidisciplinary care on wards and readmission prevention.
The use of SDEC pathways should be expanded and rolled out across England.
‘Hospital at home’ (or virtual ward) services are developing and require local evaluation. Digital technologies make it possible to provide acute care in and across more settings.
Addressing the fundamentals of acute medical care, evaluating new service opportunities, strong clinical and managerial partnerships, better data for analytics, and a multi-speciality, multi-professional approach will enable a better level of care to be achieved.

Emergency Medicine Journal

Association between delays to patient admission from the emergency department and all-cause 30-day mortality

Delays to timely admission from emergency departments are known to harm patients. This study used data from the Hospital Episodes Statistics dataset to assess and quantify the increased risk of death resulting from delays to inpatient admission from emergency department in England.

Between April 2016 and March 2018, 26.7 million people attended an ED, with 7.5 million patients admitted (5.2 million individual patients).
The crude 30-day mortality rate was 8.7%.
A linear increase in mortality was found from 5 hours after time of arrival at the emergency department up to 12 hours (when accurate data collection ceased).

Future Healthcare Journal

The association of demographics, frailty and multiple health conditions with outcomes from acute medical admissions to hospitals in England: exploratory analysis of an administrative dataset

This study aims to investigate the association between key case-mix indicators and outcomes for adults from the age of 16 admitted to hospital with an acute medical condition in England.

The study found that:

Frailty was the most important variable in the index, followed by multiple health conditions and patient age.
The mean case-mix score across hospital trusts in England ranged from 5.3 to 7.8.

Anaesthesia and perioperative medicine

British Journal of Anaesthesia

Hospital length of stay, 30-day emergency readmissions and the role of the DrEaMing enhanced recovery pathways in colonic and rectal surgery in England

This research study examines if staying in hospital for a shorter amount of time in England leads to more emergency readmissions in the 30 days after having surgery on parts of the large bowel. The authors are also interested in finding out if a specific care bundle (drinking, eating, and mobilising or DrEaMing) when offered by the treating hospital within the 24 hours after the operation influences patient outcomes. This was a retrospective analysis of observational data from the Hospital Episode Statistics dataset for England recorded between 01 April 2014 and 31 March 2024.

The study finds that:

In there were 124,580 colonic and 87,036 rectal surgery patients in England during the included time period.
Shorter hospital stays were significantly associated with a lower rate of 30-day emergency readmission.

In hospitals offering the DrEaMing care bundle, patients tended to leave hospital earlier and did not have to come back due to complications after their surgery.

British journal of surgery

Variation in surgery postponement rates in the NHS in England

This small test study looks at how often and why planned surgeries in England are postponed before they even take place. It is an analysis of clinical audit data from 16 NHS trusts in England collected during a two-week period in March 2024.

The main findings of the study are:

Of 8,000 case notes that were reviewed, there were 7.3% postponements of planned surgeries.
Postponement rates across trusts varied from 1.0% to 31.9%.
The time it took from referral to assessment before surgery was significantly shorter for day-case patients, urgent patients, patients without early screening and patients without a ‘to come in’ date in place.
Majority of postponements for routine patients (85.7%) happened for medical reasons.
Half of all routine patients waited over 94 days, and a quarter of patients waited 198 days from being added to a patient tracking list to pre-surgery assessment.

Cardiology

Heart

Getting It Right First Time (GIRFT): transforming cardiology care

This paper sets out the case for the GIRFT programme in cardiology and the potential benefits to the specialty of following the GIRFT methodology to drive change, improve outcomes for patients and increase service efficiency.

Clinical coding

British Journal of Neurosurgery

Variation in diagnostic coding for cervical decompression procedures was identified across England, with a substantial proportion of patients assigned non-specific or inappropriate codes.

Coding accuracy varied according to surgical approach and case complexity, limiting the reliability of data used for benchmarking and service improvement.

Strengthening standardised coding practices is essential to support high-quality data and consistent system-level insight.

BMJ Health and Care Informatics

Data consistency in the English Hospital Episodes Statistics database

To gain maximum insight from large administrative healthcare datasets it is important to understand their data quality. This study reports inconsistencies in the recording of mandatory diagnostic codes within the Hospital Episodes Statistics dataset in England.

Three exemplar medical conditions where recording is mandatory once diagnosed were chosen: autism, type II diabetes mellitus and Parkinson’s disease dementia. We identified the first occurrence of the code for each condition for a patient during the period April 2013 to March 2021 and in subsequent hospital spells.
For autism, diabetes and Parkinson’s disease dementia respectively, 43.7%, 8.6% and 31.2% of subsequent spells had inconsistencies.
Coding inconsistencies were highly correlated with non-coding of an underlying condition, a change in hospital trust and greater time between the spell with the first coded diagnosis and the subsequent spell.
For patients with diabetes or Parkinson’s disease dementia, the code recording for spells without an overnight stay were found to have a higher rate of inconsistencies.
Where these mandatory diagnoses are not recorded in administrative datasets, and where clinical decisions are made based on such data, there is potential for this to impact patient care.

International Journal of Medical Informatics

Data quality and autism: Issues and potential impacts

This was a sub-study of a larger study looking at data inconsistencies across a range of conditions. This study looked at recording of autism on hospital admission in more detail.

Data were available for 172,324 unique patients who had been recorded as having an autism diagnosis on first admission between April 2013 and March 2021.
In total, 43.7 % of subsequent spells were found to have inconsistencies. The features most strongly associated with inconsistencies included greater age, greater deprivation, longer time since the first spell, change in provider, shorter length of stay, being female and a change in the main specialty description.
For patients who died in hospital, inconsistencies in their final spell were significantly associated with being 80 years and over, being female, greater deprivation and use of a palliative care code in the death spell.
Such inconsistencies have the potential to distort our understanding of service use in key demographic groups of people with autism.

COVID-19

Clinical Otolaryngology

Utilisation of tracheostomy in patients with COVID-19 in England: Patient characteristics, timing and outcomes

The aim of this study was to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes.

The study’s findings included:

Tracheostomy is safe and advantageous for critical care COVID-19 patients.
Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.
In patients that survived, earlier timing of tracheostomy (≤14 days post admission to critical care) was significantly associated with shorter length of stay.

EClinical Medicine

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme

The aim of this study was to investigate the extent of variation in COVID-19 outcomes between NHS trusts and regions in England using data from March–July 2020.

Key findings were:

After adjusting for covariates, the extent of the variation in-hospital mortality rates between hospital trusts and regions was relatively modest.
Trusts with the largest baseline number of beds and a greater proportion of patients admitted to critical care had the lowest in-hospital mortality rates.
There is little evidence of clustering of deaths within hospital trusts.

Lancet Regional Health - Europe

Changes in COVID-19 in-hospital mortality in hospitalised adults in England over the first seven months of the pandemic: An observational study using administrative data

This was a follow-up of our earlier study and compared outcomes for hospital patients with COVID-19 in the early and late stages of the first wave of the pandemic in England.

Key findings were:

Compared to patients in March-May, patients in June-September were younger, more likely to be female and of Asian ethnicity, but less likely to be of Black ethnicity.
Adjusted in-hospital mortality rates declined from 33–34% in March to 11–12% in September.
From March-May to June-September the relative odds of death in patients with a diagnosis of metastatic carcinoma increased, but decreased for males, patients with obesity and diabetes.

Lancet Respiratory Medicine

Patient factors and temporal trends associated with COVID-19 in-hospital mortality in England: an observational study using administrative data

This was one of the first studies published anywhere in the world to describe COVID-19 outcomes for hospital patients on an entire country or large region.

The study provided evidence that:

91,541 adult patients with COVID-19 were discharged during March-May 2020, with 28,200 (30·8%) in-hospital deaths.
Adjusted in-hospital mortality improved from 52·2% in the first week of March to 16·8% in the last week of May 2020.
Mortality rates in Black and Black British ethnicity patients were no higher than for White ethnicity patients, once they were admitted to hospital.
That in-hospital mortality rates for Asian and Asian British ethnicity patients were slightly higher than for White patients.

Thorax

COVID-19 hospital activity and in-hospital mortality during the first and second waves of the pandemic in England: an observational study

We aimed to examine the profile of, and outcomes for, all people hospitalised with COVID-19 across the first and second waves of the pandemic in England

The study’s findings included:

Over the 13 months (March 2020 to March 2021), 374 244 unique patients had a diagnosis of COVID-19 during a hospital stay.
Adjusted mortality rates fell from 40%–50% in March 2020 to 11% in August 2020 before rising to 21% in January 2021 and declining steadily to March 2021.
Improvements in mortality rates were less apparent in older and comorbid patients.
Although mortality rates fell for all ethnic groups from the first to the second wave, declines were less pronounced for Asian and Black African ethnic groups.

Thrombosis Research

Venous thromboembolism in patients hospitalised with COVID-19 in England

The aim of this study was to detail the incidence of venous thromboembolism (VTE) in patients hospitalised with COVID-19 in England

The study’s findings included:

Over the first 13 months of the pandemic, 374,244 unique patients had a diagnosis of COVID-19 during a hospital stay, of whom 17,346 (4.6%) had a recorded diagnosis of VTE.
VTE was more commonly recorded in patients aged 40–79 years, males and in patients of Black ethnicity.
Recorded VTE diagnosis was associated with longer hospital stay and higher adjusted in-hospital mortality.

Interactive Journal of Medical Research

Frailty, comorbidity and associations with in-hospital mortality in older COVID-19 patients: an exploratory study of administrative data

Older adults have worse outcomes following hospitalisation with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes.

This study used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for patients aged 65 years and over hospitalised with COVID-19 in England. In total, 215,831 patients were included.
The most important frailty items in predicting mortality were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items were cancer, heart failure, and renal disease.
The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.

Emergency Medicine Journal

Role of hospital strain in determining outcomes for people hospitalised with COVID-19 in England

This study investigated the role of strain on hospital services on outcomes for patients admitted to hospital with COVID-19.

All unique patients aged ≥18 years in England with a diagnosis of COVID-19 admitted to hospital between 1 July 2020 and 28 February 2021 were included. Bed-strain was calculated as the number of beds occupied by patients with COVID-19 divided by the maximum COVID-19 bed occupancy during the study period. This was calculated for every patient during their stay
There were 253,768 unique hospitalised patients with a diagnosis of COVID-19 during a hospital stay. Patient admissions peaked in January 2021 (n=89,047). The crude mortality rate peaked slightly earlier in December 2020 (26.4%).
After adjustment for covariates, the mortality rate in the lowest and highest quartile of bed-strain was 23.6% and 25.3%, respectively. For the lowest and the highest quartile of bed-strain, adjusted mean length of stay was 13.2 days and 11.6 days, respectively in survivors and was 16.5 days and 12.6 days, respectively in patients who died in hospital.
High levels of bed-strain were associated with higher in-hospital mortality rates, although the effect was relatively using our measure.
Shorter hospital stay during periods of greater strain may partly reflect changes in patient management.

International Journal of Data Science and Analytics

Nosocomial infection and COVID-19 using machine learning

This study looked to model hospital acquired COVID-19 infection rates across the first year of the pandemic in England using a machine learning approach.

From the Hospital Episodes Statistics database, we identified 374,244 adult hospital patients in England with a diagnosis of COVID-19 and discharged between March 1, 2020, and March 31, 2021.
The model estimated a mean hospital acquired infection rate of 10.5%, with a peak close to 18% during the first wave, but much lower rates (7%) thereafter.
Hospital acquired infections were highly correlated with longer hospital stay, high trust capacity strain, greater age and a higher degree of patient frailty.
Hospital acquired infections were associated with higher mortality rates and more severe COVID-19 sequelae, including pneumonia, kidney disease and sepsis.

The Annals of the Royal College of Surgeons in England

Association of day-case rates with post COVID-19 recovery of elective laparoscopic cholecystectomy activity across England

This study aimed to find out how the levels of an elective surgical procedure that removes the gallbladder after which the patient can go back home on the same day (elective laparoscopic cholecystectomy) have recovered after the COVID-19 pandemic.

The study’s findings included:

Compared to 2019, by December 2022, activity levels for the whole of England had returned to 88.2% of pre-pandemic levels.
The Southwest region stood out as having recovered activity levels the most, with activity at 97.3% of pre-pandemic levels during 2022.
The Southwest also had the highest post-pandemic day-case rate at 74.9% of all patients seen as a day-case during 2022; this compares with an England average of 65.3%.

Cranial neurosurgery

British Journal of Neurosurgery

The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery in England: analysis of an administrative dataset for the Getting It Right First Time programme

The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. There are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery.

Data were available for 4,590 endoscopic transsphenoidal pituitary procedures conducted in England between April 2013 and March 2019.
After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year, post-procedural haemorrhage and length of stay greater than the median.
A higher trust volume was associated with reduced risk of post-procedural haemorrhage, but with none of the other patient outcomes studied.
Thresholds for minimum annual surgeon volume should be set, but should be guided by practical, operational and technical consideration and take into account the views of patients and their families.

Diabetes

Diabetes Research and Clinical Practice

Diabetes specialist nurse support, training and ‘virtual’ advice reduces district nurse visits and improves outcomes for people with diabetes requiring visits for insulin administration

The authors of this study sought to find out how a community diabetes specialist nurse supporting district nurses in home visits for insulin administration for people with diabetes impacts outcomes for patients and costs to the NHS.

The main findings of this study are:

The number of patients with low or high blood sugar levels reduced significantly when a community diabetes specialist nurse supported district nurses to optimise care.
The number of visits by a district nurse or need for acute hospital services also noticeably decreased.
Estimated savings through fewer visits by a district nurse and reduced insulin usage and hospital service use totalled £1.9 million annually.

Ear, nose and throat surgery

Anaesthesia

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme

This study looked at the safety of paediatric tonsillectomy when performed as a day-case.

The study’s findings included:

There was a lower day-case rate in specialist paediatric ENT trusts (50%) than at non-specialist trusts (62%). This was likely due to their more complex case mix and longer travel distances for patients.
Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories.
We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes.

Clinical Otolaryngology

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset

As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may help reduce waiting lists. This study aimed to provide evidence that day-case surgery is safe for endoscopic sinus surgery (ESS).

Over a five-year period, data were available for 49,223 patients operated on across 129 NHS hospital trusts in England.
In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/15 to 78.7% in 2018/19.
Day-case patients had lower rates of 30-day emergency readmission.
Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar.

Elective surgical hubs

The Bulletin of the Royal College of Surgeons of England

Elective surgical hubs for helping the recovery of elective services: a national survey in England

This paper presents findings of the first evaluation of elective surgical hubs in England, a high-volume low-complexity programme set up by Getting It Right First Time as part of NHS England’s recovery after the Covid-19 pandemic. The authors look at the frequency, location and organisation of these hubs, as well as the care they provide in different contextual settings.

The authors found that:

There are 87 elective surgical hubs in England.
Most of these hubs were located in London, the Midlands and the South East of England.
The contextual setting of hubs within healthcare providers varied widely.
Two-fifths (43%) were configured as stand-alone, 34% as integrated and 23% as ringfenced hubs.
Half (49%) were established before 2019.
Seventy-six per cent of hubs catered for patients attending for either day-case or inpatient surgery.
The majority (72%) covered multiple specialties, with 80% specialising in trauma and orthopaedic surgery.
Two-fifths (43%) provided enhanced care.

Endocrinology

British Journal of Surgery

Volume-outcome relationship for adrenalectomy: analysis of an administrative dataset for the Getting It Right First Time Programme

The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume.

The study’s findings included:

Only one third of surgeons (who operated on just over a half of all patients) performed at least six adrenalectomy procedures in the previous year.
For open surgery, emergency readmission rates fell from 15.2% to 6.4% for surgeons and from 13.2% to 6.1% per cent for trusts between the lowest- and highest-volume categories.
Significant, but less dramatic falls were also seen for minimally invasive surgery.

Gland Surgery

Improving outcomes for patients following adrenal surgery: the importance of addressing unwarranted variation in surgical volumes

This article is a summary of recent research findings in relation to volume-outcome relationships for adrenal surgery.

Observed volume-outcome relationships in adrenal surgery were placed within the context of unwarranted variation in clinical practice.
The need for data from outside the United States was emphasised.
Minimising unwarranted variation in service provision and patient outcomes is likely to be an important part of the recovery of elective services following the COVID-19 pandemic.

JAMA Surgery

Volume-Outcome Associations for Parathyroid Surgery in England

This study investigated volume-outcome associations for parathyroid surgery in England.

The study’s findings included:

Across the period, the number of surgeons conducting parathyroid surgery changed little.
Repeat parathyroid surgery at 1 year was significantly associated with surgeon volume, but not trust volume, in the previous 12 months.
Extended hospital stay, hypoparathyroidism/calcium disorder, and postprocedural complications were also associated with lower surgeon volume.

Langenbeck's Archives of Surgery

The volume and outcome relationship for thyroidectomy in England

The aim of this study was to investigate outcomes in England in relationship to hospital and surgeon annual volumes for total thyroidectomy.

The study’s findings included:

There is significant correlation between surgeon volume and clinical outcome for total thyroidectomy. Larger volume surgeons had reduced levels of post-surgical complications; length of stay > 2 and > 4 days; emergency readmission at 30 days; and hypoparathyroidism, vocal cord palsy, stridor, and tracheostomy at 1-year post-surgery.
For hospital volume a relationship was less obvious and less consistent across outcome measures. Larger hospital volume was associated with lower levels of emergency readmission at 30 days and hypoparathyroidism at 1 year.
The relationship between surgeon annual volume and outcomes was approximately linear, and a low-volume threshold could not be defined.

Diabetes Research and Clinical Practice

Improving the outcomes for people with diabetes undergoing surgery: An observational study of the Improving the Peri-operative Pathway of People with Diabetes (IP3D) intervention

This observational study investigates how effective an intervention is to improve the care of people with diabetes having elective surgery when implemented across multiple organisations.

The study found that:

Before implementation of the intervention 23.8% of patients had day-case surgery. This rate rose to 33.4% after implementation.
For in-patients, length of stay decreased from 3.2 days before implementation to 2.5 days after implementation.
There were also significant improvements in patient experience, hypo- and hyper-glycaemic events, wound complications and diabetes related complications.

General surgery

Surgical Endoscopy

Conversion from planned day case to inpatient care for elective laparoscopic cholecystectomy remains common across England, with substantial variation between providers.

Key drivers of conversion to inpatient stay include:

Older age and comorbidity
Higher surgical complexity
Socioeconomic deprivation
Lower volume surgery

Around one in four patients required an overnight stay. Improving patient selection and pathway design offers a clear opportunity to increase the reliability of day case surgery.

Colorectal Diseases

National data show considerable variation in ileostomy reversal following rectal cancer surgery, with only around two-thirds of patients undergoing reversal within 18 months.

Delayed or absent reversal was associated with frailty, deprivation and postoperative complications, pointing to inequities in access. These findings emphasise the need to review pathways and strengthen shared decision-making to support more timely and equitable care.

British journal of surgery

Variation in use and safety of day case and inpatient care for elective thryroid lobectomy was analysed using national data across England.

Key findings:

Marked variation in day-case rates
Lower readmission rates in day-case settings
No evidence of worse outcomes, even in higher day case adoption trusts
Strong support for safe delivery in appropriately selected patients

This highlights a clear opportunity to expand day case pathways and reduce unwarranted variation in service delivery.

Hernia

Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data

Increasing day-case rates for high volume, low complexity procedures which can be performed as day-case surgery in most patients will help to increase patient throughput and service efficiency. This study used administrative data to investigate factors associated with patients planned as day-case who converted to in-patient stay. Reducing conversion to in-patient stay rates will be important if day-case rates are to be maintained or increased.

All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified from the Hospital Episodes Statistics dataset for England.
Of the 351,528 repairs identified, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions.
Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and being operated on by a low-annual volume surgeon.
Post-procedural complications were strongly associated with conversion.
Across the 42 Integrated Care Boards in England, model-adjusted conversion rates varied from 3.3% to 21.3%, suggesting unwarranted variation.
Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates and increase day-case rates across England.

The Bulletin of the Royal College of Surgeons of England

Elective surgical hubs for helping the recovery of elective services: a national survey in England

This paper presents results from the first national survey to identify where and how many elective surgical hubs exist and how they provide care.

The key findings of this study included that

Across 65 acute NHS trusts in England, 87 elective surgical hubs were identified.
Most elective surgical hubs were in London, the Midlands and the Southeast of England.
The contextual setting of hubs within healthcare providers varied widely.
Majority of elective surgical hubs cared for patients attending either day-case or inpatient surgery.
The majority (72%) covered multiple specialties, with 80% specialising in trauma and orthopaedic surgery.

Hernia

Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes

This study is about elective surgery to repair places where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall. It aims to explore how much day-case rates of this surgery vary across healthcare providers in England vary and find out how safe the procedure is.

The study’s findings are:

Between 1 April 2014 and 31 March 2022, 79.1% of all elective repair surgeries carried out were day-case procedures.
During the 2021–22 financial year, the highest day-case rate for an Integrated Care Board was 93.8% and the lowest 66.1%.
Day-case surgery was associated with significantly lower rates of 30-day emergency readmission and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge.
Rates of 30-day emergency readmission were significantly lower in Integrated Care Boards with high rates of day-case surgery than in Integrated Care Boards with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates.

The American Surgeon

A Ventral Hernia Management Pathway; A “Getting It Right First Time” approach to Complex Abdominal Wall Reconstruction

This study combines knowledge gained through a literature review with the authors’ experience in abdominal wall reconstruction (AWR) managed by multidisciplinary teams. The authors describe their current AWR pathway, including the checklists and information documents they use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes and best practice.

Litigation

Clinical Otolaryngology

Otorhinolaryngology litigation in England: 727 clinical negligence cases against the National Health Service

This study looked at the incidence and characteristics of otorhinolaryngology clinical negligence claims in England.

This was a retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otorhinolaryngology between April 2013 and April 2018.
A total of 727 claims were identified with an estimated potential cost of £108 million. The mean cost of a claim was £148 923.
Head and neck surgery was the subspecialty with the highest number of claims (n = 313, 43%) and highest cost (£51.5 million) followed by otology (n = 171, £24.5 million) and rhinology (n = 171, £13.6 million).
59% of claims were associated with an operation where mastoid surgery and endoscopic sinus surgery (both 46 procedures) were equally associated with the greatest number of claims.
The most frequent causes for clinical negligence claims included failure or delay to diagnose (25%), failure or delay to treat (19%), intra-operative complications (18%) and failure of the consent process (15%).
This study highlights the importance of robust pathways in out-patient diagnostics and the consenting process in order to deliver better patient care and reduce the impact of litigation.

Journal of Laryngology and Otology

Lessons from rhinology and facial plastic surgery clinical negligence claims in England 2013-2018.

This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018.

There were 171 rhinology related claims with a total estimated potential cost of £13.6 million.
Over three quarters of all rhinology claims were associated with surgery.
Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172,978). Unnecessary pain (33.9%) and unnecessary operation (28.1%) were the most common patient injuries.
Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology.

Journal of Laryngology and Otology

What can be learned from litigation in otology? A review of clinical negligence claims in England 2013-2018

This study was a retrospective review of all clinical negligence claims in otology in England held by National Health Service Resolution between April 2013 and April 2018.

There were 171 claims in otology, with a potential cost of £24.5 million. Over half of these were associated with hearing loss.
Stapedectomy was the highest mean cost per claim operation at £769 438.
The most common reasons for litigation were failure or delay in treatment (23%), failure or delay in diagnosis (20%), intra-operative complications (15%) and inadequate consent (13%).

International Journal of Pediatric Otorhinolaryngology

Litigation in paediatric otorhinolaryngology: Lessons in improving patient care

This was a retrospective review of all clinical negligence claims within paediatric otolaryngology (0–17 years inclusive) in the NHS in England between April 2013 and March 2020.

There were 100 claims in pediatric otorhinolaryngology accounting for an estimated potential total cost of just under £49 million with an average of 14 claims per year.
52% of claims were related to an operation. Cause codes ‘Operator Error/Intra-Op Problem’, ‘Diathermy Injury’ and ‘Failure to Warn – Consent’ were the most common.
The most common operation cited in a claim was tonsillectomy with an average cost per claim of £47,084.
There were 21 claims coded as either ‘failure to diagnose’ or ‘failure to treat’ in relation to cholesteatoma, with an average cost per claim of £61,086.
Opportunities exist to reduce patient morbidity, mortality and improve the patient experience through litigation data analysis.

BJS Open

Litigation in breast surgery: unique insights from the English National Health Service experience

This study was a review of litigation claims in breast surgery with the aim of identifying opportunities to improve clinical practice and patient safety

All general and plastic surgical claims specifically for breast surgery notified to NHS Resolution between April 2012 and April 2018 were reviewed.
Ac total of 449 relating to breast surgery were identified and reviewed. The median number of claims over the six-year period per NHS trust was two. The most frequent causes of litigation were dissatisfaction with cosmetic outcome (26.9%) and patient-reported delays in diagnosis (26.9%).
A large proportion of claims related to breast implant surgery (17.4%)
Issues regarding consent/communication were common (15.4%).
The estimated annual cost of breast surgery litigation claims ranged from £5.6 million to £9.6 million.
Patient-reported delays in diagnosis and dissatisfaction with cosmetic outcome are the most common causes of litigation related to breast surgery. These key themes should be the focus for workforce learning, with the aim of improving patient care and experience.

Journal of Laryngology and Otology

Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data

This paper describes thyroid surgery related litigation claims in the NHS from April 2015 to March 2020, to establish learning points in order to improve patient care and minimise litigation risk.

Sixty claims were identified. Thirty-eight claims (63.3%) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349.
Claims related to diagnostic issues were most common (n= 19).
Of claims associated with operative causes (n= 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited.
Utilisation of well-established protocols will likely reduce litigation in thyroid surgery.

British Dental Journal

Hospital dentistry litigation in England: clinical negligence claims against the NHS 2015-2020

A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to hospital dentistry between April 2015 and April 2020.

A total of 492 claims were identified, with an estimated potential cost of £14 million.
The most frequent causes for clinical negligence claims included failure/delay in treatment (n = 175; £3.9 million), inappropriate treatment (n = 56; £1.8 million) and failure to warn/obtain informed consent (n = 37; £1.5 million). Wrong site surgery was cited in 33 claims.
The most frequent injury reported was dental damage (n = 197; £4.3 million), unnecessary pain (n = 125; £2.3 million) and nerve damage (n = 52; £2.4 million).
A focus on patient safety measures and effective communication may help to improve patient outcomes and reduce the burden of litigation claims on the NHS.

Ophthalmology

Litigation in Ophthalmology against the National Health Service in England

This was a retrospective review of all clinical negligence claims within ophthalmology in the NHS in England between April 2013 and March 2018.

Over the five-year period, 1254 ophthalmology claims were reported, costing an estimated £193 million. The annual cost increased from £28.1 million to £40.2 million over the five years.
The most common subspecialty involved in litigation was cataract surgery (24%), followed by vitreoretinal surgery (10%) and medical retina (10%). Paediatric ophthalmology accounted for only 14 claims (1%) but had the highest mean cost per claim of £1.7 million.
Failure/delay in treatment (30%) and failure/delay in diagnosis (16%) were the most common causes with costs of £70.0 million and £45.8 million respectively. Other visual problems (45%), blindness (25%), and “unnecessary pain” (10%) were the most commonly coded injuries.
A lack of timely diagnosis or treatment accounts for a significant proportion of clinical negligence claims in ophthalmology. This reinforces the importance of improving referral pathways, risk stratification, and clinical governance to prioritise resources to those with sight-threatening disease.

Bone and Joint 360

Clinical negligence: is orthopaedics learning from it?

Over ten years from 2006/07 to 2016/17 the UK National Audit Office reported that the number of clinical negligence claims across the NHS had doubled from 5,300 to 10,600 with a quadrupling of cost from £0.4 billion to £1.6 billion. This study looked at the number of cost of claims in orthopaedics following the publication of the GIRFT National Report for orthopaedics in 2015. The report made specific recommendations regarding how to reduce claims volumes in orthopaedics.

In a four-year period immediately following the initial orthopaedic GIRFT visits, an 25.7% fall in claim numbers has been observed in orthopaedics (1,617 in 2013/14 to 1,202 in 2017/18). This was accompanied by a 14.8% fall in associated costs (175.9 in 2013/14 to 146.8 in 2017/18).
This fall in orthopaedics is set against a large increase in the number of claims and costs in other specialties.
The decline in the number and costs associated with claims in orthopaedics is encouraging. Efforts should be increased to reduce costs and number of claims in other clinical areas.

European Spine Journal

Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS

This study looked at the incidence and characteristics of spinal surgery clinical negligence claims in England.

This study was a retrospective review of 978 clinical negligence claims held by NHS Resolution against spinal surgery cases identified from claims against ‘Neurosurgery’ and ‘Orthopaedic Surgery’.
Clinical negligence claims in spinal surgery were estimated to cost £535.5 million over this five-year period.
The most common causes for claims were related to clinical judgement and timing of diagnosis and intervention (52%), interpretation of results/clinical picture (26%), unsatisfactory outcome to surgery (19.6%), fail to warn/informed consent (8.1%) and ‘never events’ (including wrong site surgery or retained instrument post-operation) (2.7%).
Clinicians and managers should share experience from clinical negligence claims to improve outcomes for patients and reduce the burden of these claims on the NHS.

Evaluations

Read GIRFT evaluations

Mental Health Rehabilitation

BJPsych Open

Outcomes for COPD patients with serious mental health illness

There is some evidence that patients with serious mental illness (SMI) who are admitted to hospital for a reason unconnected to their SMI and poorer outcomes than otherwise similar patients without a SMI. This study looked at outcomes for patients with and without a SMI admitted to hospital in England where the primary reason for admission was a physical illness (chronic obstructive pulmonary disease).

Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI.
Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. Despite being younger, the burden of comorbidity was similar between the SMI and non-SMI groups.
After adjusting for age, sex, frailty, and other important variables, SMI was associated with significantly greater risk long hospital stay and 30-day emergency readmission but not with in-hospital mortality.
Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.

Net zero and sustainability

Cardiovascular and interventional radiology

Within interventional radiology services there is significant opportunity to reduce healthcare-related carbon emissions, with multiple points across the patient pathway where environmental impact can be minimised.

Drawing on existing evidence and practice, this work identifies targeted actions to optimise resource use, reduce waste and embed sustainability into routine care.

A whole-service approach can deliver environmental benefits alongside improvements in efficiency, productivity and health equity.

BMJ Evidence-Based Medicine

This paper sets out GIRFT's Environmental Lessons Learned and Applied (ELLA) framework. The ELLA framework provides a structured approach to identifying, prioritising and implementing decarbonisation interventions across clinical pathways.

It enables teams to identify emissions hotspots, align environmental action with clinical priorities and deliver scalable, context-specific improvements, supporting sustainable healthcare while maintaining high-quality patient care.

British Journal of Urology International

Linked supplier and NHS data reveal wide variation in the lifespan of reusable flexible cystoscopes across hospitals in England.

Factors influencing longevity include:

Decontamination processes
Staff expertise and availability
Storage and handling practices

Some service models achieved substantially greater device use, highlighting opportunities to reduce costs and improve sustainability through better equipment management.

BMJ Leader

Streamlining care pathways for shoulder dislocations can deliver substantial environmental and operational benefits. Using clinical audit data from St George's hospital in London, this study identifies where unnecessary steps in care can be removed.

Key findings:

Potential carbon savings of over 80 kgCO₂e per patient
Reduced duplication and inefficiencies in emergency pathways
Scalable impact across the NHS if implemented widely

This demonstrates how pathway redesign can support net zero goals while improving efficiency.

Lancet Regional health Europe

Carbon emissions from clinical activities by speciality in secondary and tertiary care in England: an exploratory cross-sectional analysis of routine administrative data

This study analyses the carbon emissions of activities in different clinical specialties in hospital care in the NHS in England performed during the financial year 2022/23.

The authors found that:

In total, 17,024,278 hospital admissions and 101,973,593 outpatient attendances were included in the analysis.
Outpatient attendances accounted for 45% of the measured carbon emissions.
Of the remaining 55% relating to admitted patient care, emergency admissions accounted for 45%, in-patient planned activity 7% and day case activity 3%.
General internal medicine, trauma and orthopaedics and general surgery were the three highest carbon emitting specialties, largely due to high patient numbers.

BJU International

Perspectives in technology: All STEPS count: an integrated framework for net zero urological care

This paper reviews evidence to guide the sustainable delivery of high-quality urological care using the STEPS framework (an acronym for low-carbon care across ‘Settings and Treatments, Efficiency, Prevention and System change’).

The highlight findings of this review paper are:

Tackling carbon hotspots identified in operating theatres: anaesthetic gases, consumables and electricity use is key to reducing carbon emissions of urological surgery.
Outside of operating theatres, opportunities to reduce carbon emissions are through one-stop clinics, day-case surgery, appropriate use of virtual appointments and streamlined pathways, with potential additional benefits in terms of cost, efficiencies, and patient outcome improvements.
There was a paucity of evidence demonstrating the implementation of climate change action as part of routine service delivery.
Embedding sustainability across organisational processes and ways of working requires actions to upskill, engage and enable the workforce to deliver and to establish clinical leadership.

British Journal of Urology International

Improving environmental sustainability in urology as a resident

Healthcare is a major contributor to carbon emissions globally. In the UK healthcare is responsible for 4-5% of all greenhouse gas emissions. Although the problem can seem insurmountable, this paper highlights areas where resident doctors can contribute meaningfully to reducing the environmental impact of urological care. Areas of suggested focus include:

Education and advocacy – Being an advocate for more sustainable practice, including greater use of re-usable, rather than single use equipment.
Audit and feedback – the trainee-led BAUS/GIRFT baseline audit of environmentally sustainable practice is an example of how this can inform and drive change.
Research and innovation – developing new, more sustainable, pathways and identifying and mitigating hotspots.
Multidisciplinary collaboration across teams and specialties – residents are well placed to lead this work as they rotate across different organisations and teams.
Operational and clinical practice changes – This includes, being aware of local Green Plans, Implementing current and future GIRFT Greener pathways guidance and guidance from other organisations.

Anaesthesia

Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint

This article sets out what the Getting It Right First Time programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

BMJ Open

Carbon footprint of hospital laundry: a life-cycle assessment

This study assessed greenhouse gas emissions from a large regional hospital laundry unit supplying hospitals in Southwest England emitted in 2020–21 and 2021–22 financial years, and modelled ways in which these can be reduced. The mean carbon footprint of processing one laundry item was expressed in terms of the global warming potential over 100 years as carbon dioxide equivalents (CO2e).

The study found that:

Average annual laundry unit greenhouse gas emissions were 2947 t CO2e.
Average greenhouse gas emissions were 0.225 kg CO2e per item-use and 0.5080 kg CO2e/kg of laundry.
Natural gas use contributed 75.7% of on-site greenhouse gas emissions.
Boiler electrification using national grid electricity for 2020–2022 would have increased greenhouse gas emissions by 9.1%. By 2030 this would reduce annual emissions by 31.9% based on the national grid decarbonisation trend.
Per-item transport-related greenhouse gas emissions reduce substantially when heavy goods vehicles are filled at ≥50% payload capacity.
Single-use laundry item alternatives cause significantly higher per-use greenhouse gas emissions, even if reusable laundry were transported long distances and incinerated at the end of its lifetime.

Global Spine Journal

Trends Over Time in the Use, Carbon Footprint and Costs of Facet Joint Injections and Medial Branch Blocks to Manage Lumbar Pain in England: Retrospective Analysis of an Administrative Dataset

This retrospective analysis aims to investigate changing sustainable practice over a six-year period in the use of repeated injection of anaesthetics (and steroids) in or near lower back spinal joint spaces to temporarily block pain signals from reaching the brain. Patient data were extracted from the Hospital Episodes Statistics database for the period 1st April 2015 to 31st March 2021.

Findings of the study included:

Within the dataset, 6.6% of patients had either two injections within 180 days or three injections within one year.
First injections fell from 42,511 in 2015/16 to 13,368 in 2019/20, as did the number of repeat injections: 4,018 to 424 for the same period.
If all years had the same carbon footprint as 2019/20, 2.8 kilotons of CO2e would have been saved over the five years, enough to power 2,575 average UK homes for 1 year.
The financial cost of injections decreased from £27.6 million in 2015/16 to £7.9 million in 2019/20.

The Annals of the Royal College of Surgeons of England

Carbon savings associated with changing surgical trends in total knee arthroplasty in England: a retrospective observational study using administrative data

This study aims to estimate the reduction in carbon emissions due to changing trends in the care of patients undergoing common surgical procedures, including total knee replacement. This was a retrospective analysis of Hospital Episode Statistics data from 1 April 2013 to 31 March 2022 on adults undergoing elective primary total knew replacement in England.

The study’s key findings were:

Over the study period, the median length of stay reduced from four to three days, the proportion of patients undergoing surgical diagnostic imaging performed within a year before total knee replacement surgery fell from 5.9% to 0.5% and the number of early revisions and emergency readmissions also fell.
The per-patient carbon footprint reduced from 378.8kgCO2e to 295.2kgCO2e over this time. If all the study patients had the same carbon footprint as the average patient in 2021/2022, 32.4kilotons CO2e would have been saved, enough to power 29,509 UK homes for one year.

BJU International

The carbon footprint of the perioperative transurethral resection of bladder tumour pathway

This study evaluated the carbon footprint of the care pathway to diagnose and treat bladder cancer and model potential greenhouse gas emissions reduction strategies.

The study found that:

The median carbon footprint at the time of the surgical procedure was 131.8 (119.8–153.6) kg of carbon dioxide equivalent.
Major pathway categories contributing to greenhouse gas emissions were surgical equipment (22.2%), travel (18.6%), gas and electricity (13.3%), and anaesthesia/drugs and associated adjuncts (27.0%), primarily due to consumable items and processes.
Readily modifiable greenhouse gas emission hotspots included patient travel for assessment before the operation, glove use, catheter use, irrigation delivery and extraction, and mitomycin C (a type of chemotherapy drug) disposal.
Greenhouse gas emissions were higher for those admitted as inpatients after surgery.

Eye

The carbon footprint of cataract surgery pathways in England: an observational study using administrative data

The aim of this study is to investigate the estimated difference between the carbon footprint of the Getting It Right First Time (GIRFT) High Volume Low Complexity (HVLC) pathway for cataract surgery and current practice.

The study found that:

The England average carbon footprint was 100.0 kgCO2e.
Had all Integrated Care Boards adhered to the GIRFT High Volume Low Complexity pathway, then 17.5 kilotonsCO2e would have been saved in 2021–22.
The main limitation of this study is that only key elements of the cataract surgery pathway were included in the analysis.

Applied Health Economics and Health Policy

Estimated Carbon Savings from Changing Surgical Trends in Primary Elective Total Hip Arthroplasty in England: A Retrospective Observational Study

The aim of this study is to investigate how changes in key aspects of clinical practice over the last eight years have contributed towards reducing the per-patient carbon footprint of elective total hip replacement.

The study’s key findings are:

The per-patient carbon footprint associated with the primary THA (index) procedure fell by around 25% from 2014/15 to 2021/22.
Length of stay was by far the largest contributor to this decline, falling from 169.1 kgCO2e to 117.6 kgCO2e per patient from 2014/15 to 2021/22.
Absolute declines in the carbon footprint associated with emergency readmissions, revisions and outpatient attendances were more modest.
If all patients in all years had the 2021/22 average carbon footprint, then carbon equivalent to powering 19,976 UK homes for 1 year would have been saved.

Nature Reviews Urology

Measuring and improving the cradle-to-grave environmental performance of urological procedures

This paper reviews studies that assessed the environmental impact of clinical care procedures in urology which is a resource intensive clinical area. The authors conclude that there are environmental benefits of minimising travel, decarbonising electricity sources, reducing the use of single use plastics, and designing efficient care pathways in urology.

European Urology Open Science

Potential carbon savings with day-case compared to inpatient transurethral resection of bladder tumour surgery in England: a retrospective observational study using administrative data

The National Health Service (NHS) in England has set a net-zero target for carbon emissions it controls directly by 2040 and for all carbon emissions by 2045. Increasing use of day-case surgery pathways may help in meeting this target. This study investigated the potential carbon saving associated with moving from in-patient stay to day-case bladder tumour surgery.

Of 209,269 TURBT procedures conducted in England between April 2013 and March 2022, 41 583 (20%) were classified as day-case surgery.
The day-case rate increased from 13% in 2013/14 to 31% in 2021/22.
This increase in day-case rates over the nine year study period was estimated to have save 2.9 million kg CO₂ equivalents (equivalent to powering 2716 homes for 1 year).
We calculated that potential carbon savings for the financial year 2021/22 if all hospitals in England achieved the upper-quartile day-case rate would be enough to power 198 homes for 1 year.

Nursing/theatres

Nursing Management

Exploring the roles of nursing associates and theatre assistant practitioners in operating departments

This paper presents the results of a service evaluation to provide clarity about the roles and responsibilities of registered nursing associates and theatre assistant practitioners (TAPs) in hospital operating theatres. Data collected from surveys and interviews with staff in operating departments in England show that there is significant variation in the roles and responsibilities of nursing associates and TAPs and that there is a need for clear guidance to support their future deployment.

Oral and maxillofacial surgery

British Journal of Oral and Maxillofacial Surgery

Can elective surgery for mandibular and zygomatic complex fractures reduce overall hospital stay without compromising outcomes? Analysis of administrative datasets by the GIRFT programme.

When patients attend the emergency department with facial fractures that require surgery and are immediately admitted, surgery can be delayed as theatre time is prioritised for other more urgent patients. One solution is to send the patient home and admit them as an elective patient at a later date. This study investigated outcomes of patients admitted directly and those seen as elective patients following fracture of the mandible or zygomatic complex.

The study’s findings included:
For both mandibular and zygomatic complex fractures there was substantial variation between NHS trusts in the proportion of patients admitted for swift elective surgery.
Elective admission was independently associated with shorter overall stay and lower emergency readmission rates.
We found no evidence that delays to definitive surgery through elective admission had a negative impact on emergency readmission rates.

Orthopaedic surgery

The Knee

The introduction of regional revision knee arthroplasty networks in England is associated with early improvements in care delivery and outcomes for complex surgery.

Key findings:

Reduction in low-volume surgical practice
Improvements in one-year re-revision rates
Shorter hospital stays in some regions

Outcomes varied by region and patient complexity increased over time, but overall trends suggest that networked models can support more consistent and higher-quality care.

Journal of Hand Surgery (European Volume)

Performing carpal tunnel release outside traditional operating theatre settings provides a safe and lower-cost alternative model of care.

Key findings:

No increase in emergency readmissions or repeat procedures in trusts with out of theatre models of care
Cost reductions of approximately 40% per case
Feasible delivery in lower-resource clinical environments

These findings support shifting appropriate procedures to more efficient settings while maintaining patient safety.

Archives of Orthopaedic and Trauma Surgery

The safety of same-day discharge following primary knee arthroplasty was evaluated using national data, comparing outcomes with patients requiring overnight admission.

Up to end of financial year 2022/23, same-day discharge was relatively rare. Of 398,771 patients included, 3,718 (0.9%) were discharge on the same day that they were admitted. Rates of same-day discharge increased from 0.5% in 2017/18 to 1.6% in 2022/23.

Outcomes improved as adoption of same-day discharge increased, with lower complication rates and no significant difference in mortality.

These findings support broader uptake in appropriately selected patients and highlight an opportunity to expand efficient care models.

Knee Surgery Sports Traumatology Arthroscopy

Low confidence in the cumulative evidence for the existence of a volume–outcome relationship after revision total knee replacement: A systematic review and meta-analysis

This review paper aims to find out if there is a link between the number of procedures a hospital or surgeon performs and the outcomes for patients after an operation to replace or repair a failed knee implant.

The key findings are:

A total of 10 studies with data from 1993 to 2021 were included.
The quality of the evidence available on this topic was generally low.
There was no clear evidence of a relationship between the number of procedures conducted in a hospital or by a surgeon and the need for further knee surgery.
There was a relationship between higher number of operations in a hospital and adverse events arising from the surgery.
There was no association between number of procedures conducted by a surgeon and patient reported outcomes.

Shoulder & Elbow

Volume-outcome relationships for primary total elbow arthroplasty surgery in England: Analysis of the hospital episode statistics dataset

The aim of this study is to find out how the number of operations completed in a surgical unit and by surgeons to replace damaged bones in the elbow joint with artificial components for the first time impacts on clinical outcomes for patients and the service itself. For this, the authors analyse data in the Hospital Episodes Statistics database (HES) for planned and emergency surgery between January 2014 and December 2023.

The main results of this study are:

There were 4,101 surgeries done in 123 trusts within the included study period.
Patients having to come back for further treatments (revision surgery) after their operation was not associated with how many such operations the surgical unit or surgeon completed in a year.

How long patients had to stay in hospital after their operation was significantly associated with how many such operations the surgical unit and surgeon completed in a year. Patients were more likely to stay in hospital for more than three days when their surgeon performed no more than 10 operations per year.

The Knee

The effect of minimum volume recommendations on surgeon activity for first revision total knee replacement: an analysis of 2009–2019 United Kingdom National Joint Registry data

This article investigates if there were any changes in how many first-time surgeries to replace or repair a failed knee implant were done after the publication of a report which identified where surgeons did few such operations in England. Another aim of this study is to compare the annual number of operations done by early career surgeons who work in surgical units completing either low or higher numbers of these operations. The authors analyse data from the United Kingdom National Joint Registry collected between 1st January 2009 and 31 December 2019.

The authors found that:

In total, 21,067 patients were included over the study period.
During the included time frame, only 8.6% of surgeons replaced or repaired a failed knee implant on average at least 15 times a year.
There was an increase in the number of operations a surgeon performed for non-severe or life-threatening cases.

New surgeons working in surgical units in which fewer surgeries are done have 42% lower chance of reaching 15 operations per year compared to those working in units where more operations are done.

The Annals of The Royal College of Surgeons of England

Comparison of orthopaedic specialty registrar training opportunities in trusts with and without an elective surgical hub: a review of administrative data

During the COVID-19 pandemic in England, orthopaedic surgery trainees had fewer training opportunities because of periods of elective surgery suspension. The authors of this paper aim to explore training opportunities for orthopaedic trainees in NHS trusts with and without access to an elective surgical hub. For this, they completed a retrospective analysis of administrative data from eLogbook and Hospital Episodes Statistics collected between April 2017 and March 2023.

The results of this study are:

1,755 trainees acted as first surgeon in 125,759 procedures during the included study period.
NHS trusts with access to an elective surgical hub offered significantly more training opportunities for surgical trainees compared with non-hub trusts.
Where there were more training opportunities, most of the increase in trainee involvement was associated with more senior trainees (ST6-8).
The proportional increase was not enough to offset the decline in the absolute number of procedures conducted In the NHS by trainees following the end of the COVUID-19 pandemic. Movement of NHS-funded activity from the NHS to private providers is at least part of the reason for the fall in the number of orthopaedic procedures conducted in NHS hospitals.

Knee surgery, sports traumatology, arthroscopy

Higher hospital volume reduces early failure rates in single-stage revision TKR for infection: An analysis of the United Kingdom National Joint Registry and National Administrative Databases

The aim of this paper is to find out if the more patients a hospital treats to replace or repair a failed knee implant, the better the outcome for their patients. The research focusses on patients undergoing this surgery for the first time with infection of the knee. The authors use data from the United Kingdom National Joint Registry, Hospital Episode Statistics and National Patient Reported Outcome Measures. Patients undergoing procedures between 1 January 2009 and 30 June 2019 are included.

The main findings of the paper are:

During the included time period, 1,477 patients underwent surgery to replace or repair their knee implant for the first time because of infection across 267 surgical units and 716 surgeons.
The more a hospital performed the surgery, the lower the risk of an additional (revision) surgery.
The risk of additional surgery decreased amongst hospitals performing at least 3 surgeries a month compared to those doing 12 surgeries in a year at most.
The variation of the number of surgeries a hospital performed in a year was not associated with unfavourable or harmful outcomes for patients within 3 months after their treatment.

Although data on patient reported outcomes were available, in only 7% of patients undergoing knee surgery could the data be linked to a patient reported outcome measure. This mean that modelling of the data was not possible.

Knee surgery, sports traumatology, arthroscopy

Higher surgeon volume reduces early failure in first time revision of non-infected total knee arthroplasty: An analysis using data from the United Kingdom National Joint Registry

The aim of this paper is to find out if the more patients a surgeon treats to replace or repair a failed knee implant, the better the outcome for their patients. The research focusses on patients undergoing this surgery for the first time without an infection of the knee. The authors use data from the United Kingdom National Joint Registry, Hospital Episode Statistics and National Patient Reported Outcome Measures. Patients undergoing procedures between 1 January 2009 and 30 June 2019 are included.

The main findings are:

During the included time period, 8695 patients underwent replacement or repair of their knee implant for the first time across 389 surgical units and 1204 surgeons.
The more a surgeon performed the surgery, the lower the risk of an additional (revision) surgery.
The risk of additional surgery was less amongst surgeons performing more than or equal 9 surgeries in a year compared to those doing less than 9 in that time period.

BMJ Open

What is the impact of longer patient travel distances and times on perioperative outcomes following revision knee replacement: a retrospective observational study using data for England from Hospital Episode Statistics

This study focusses on retrospective data accessed through the Hospital Episode Statistics (HES) database from patients undergoing surgery to replace or repair a failed knee implant between 1 January 2016 and 31 December 2019. The authors investigate how long and far patients need to travel to receive this complex treatment in specialised care centres and explores concerns of how this travel impacts on patient outcomes.

The study found that there is no association between increasing travel distance and time on outcomes for patients undergoing surgery to replace or repair a failed knee implant.

Journal of Arthroplasty

An Analysis of a National Administrative Dataset Demonstrating No Evidence of Increase in Elective Primary Total Hip Arthroplasty Dislocation Rates When Postoperative Hip Precautions are Not Used

This study evaluated the impact on patient outcomes of stopping hip precautions in patients undergoing total hip replacement surgery. Outcomes of interest were dislocation rates, emergency readmissions and length of stay.

The study’s findings included:

No increase in 180-day dislocation rates or 30-day emergency readmission rates after stopping hip precautions.
There was a significant immediate change in median length of stay from 4 to 3 days on stopping hip precautions.
Potential benefits include reduced costs, faster recovery for patients and more efficient bed usage.

Journal of Arthroplasty

Fixation Method and Subsequent Revision Rates for Elective Primary Hip Arthroplasty in People Aged 70 Years and Older: Analysis of National Administrative Data Sets by the UK Getting It Right First Time Programme

This study looked at the evidence to support a key GIRFT recommendation from the orthopaedic surgery national report regarding use of uncemented hip fixation in people aged 70 years and older undergoing primary total hip arthroplasty.

The study’s findings included:

Revision rates at 1-7 years follow-up for patients aged 70 years and older undergoing primary total hip replacement were significantly higher for uncemented fixation compared to cemented or hybrid fixation.
Although mortality rates were higher for patients with cemented fixation this was most likely due to the greater age of the population rather than the fixation method used.
Revision rates in trusts where uncemented fixation predominated were not significantly lower for uncemented fixation compared to all other fixation methods.

Bone and Joint Journal

The impact of a Revision Arthroplasty Network on patient outcomes: Analysis of a national administrative data set in England

Summary

Revision total knee and hip revisions are complex procedures with higher rates of re-revision, complications, and mortality compared to primary procedures. It is recommended that such procedures be conducted in specialist revsion hubs. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes.
The EMSON revision network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England.
Between April 20111 and March 2018, 57,621 revision hip and 33,828 revision knee procedures were performed across England. Of these,1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within EMSON.
Re-revision rates within one year for revision hips were 7.3% and 6.0%, and for revision knees were 11.6% and 7.4% pre- and post-intervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for revision hips and from 11.7% to 9.7% for knee revisions for the rest of England.
The improvement in re-revision rates across the study period were greater for EMSON than for the rest of England.

Journal of Arthroplasty

Implant use for primary hip and knee arthroplasty: are we getting it right first time?

In England, a large variety of orthopaedic prostheses and methods of fixation are currently being used in hip and knee replacement surgery. This study looked at the survival of these prostheses relative to their cost.

The 8th Annual Report from the National Joint Registry (2011) reporting on prostheses used in 2010 was analysed.
There has been a decline in the proportion of cemented total hip replacements over the five years to 2010. Uncemented total hip replacements were the most common form of primary hip replacement in this period. This was despite cemented total hip replacements demonstrating the lowest revision rate at seven years (3.8%).
There was substantial variation in survivorship across prosthesis types, suggesting there is scope to reduce the variety of prosthesis used across the NHS, reduce costs of procurement and improve patient outcomes.

Orthopaedic Surgery

Factors associated with poorer outcomes for posterior lumbar decompression and or/or discectomy: an exploratory analysis of administrative data

This study aimed to identify factors associated with poorer patient outcomes for lumbar decompression and/or discectomy (PLDD).

The study’s findings are:

For the primary outcome, greater age, female sex, surgery over two spinal levels and the comorbidities chronic pulmonary disease, connective tissue disease, liver disease, diabetes, hemi/paraplegia, renal disease and cancer were all associated with emergency readmission within 90 days.

Pathology

British Journal of Haematology

Prevention of hospital-associated venous thromboembolism - Insight from the Getting It Right First Time thrombosis survey in England

A national Venous Thromboembolism (VTE) Prevention Programme was introduced in England in 2010, with limited subsequent study of its impact. Whilst the National Outcomes Framework reports VTE deaths related to hospitalisation annually, there are little data regarding VTE prevention practice or non-fatal VTE associated with hospitalisation. This study reports the first national thrombosis survey undertaken in collaboration with the GIRFT programme.

98 Hospital trusts participated in at least one survey, contributing data regarding VTE prevention in 9553 patients.

Anti-coagulant thromboprophylaxis was prescribed to 88% of patients when indicated, with 8.1% of patients missing doses.
Written patient information was provided to 31%.
Of 4595 episodes of hospital associated VTE, 13% were considered potentially preventable.
The survey highlights the success of the national programme and areas for improvement in delivery of thromboprophylaxis and patient information.

Renal Medicine

Nephrology Dialysis Transplantation

Centre variation in mortality following post-hospitalisation acute kidney injury: Analysis of a large national cohort

This study describes the development of a case mix-adjusted 30-day mortality indicator for patients with post-hospitalisation acute kidney injury. The case-mix adjusted measure will allow a better comparison of outcomes when comparing healthcare providers across England.

A total of 250,504 post-hospitalisation acute kidney injury episodes were studied across 103 NHS hospital trusts between January 2017 and December 2018.
The mean 30-day mortality rate was 28.6%. Adjusted mortality rates for 12 trusts were above and 11 below the expected range, suggesting some unwarranted variation in outcomes.
Presentation at trusts with a co-located specialist nephrology service was associated with a lower mortality risk.
The findings have allowed trusts with high mortality rates to be identified and supported in improving outcomes through the adaptation of best practice care pathways to suit the local situation.

Spinal surgery

Archives of Osteoporosis

An observational study of vertebroplasty and kyphoplasty for osteoporotic spinal fractures: utilisation and outcomes in England using an administrative dataset

Vertebroplasty and balloon kyphoplasty are commonly used to treat osteoporotic spinal fractures. Kyphoplasty is widely used, but it is more expensive than vertebroplasty and outcomes are thought to be similar. This study reviewed outcomes for vertebroplasty and balloon kyphoplasty for the surgical treatment of osteoporotic spinal fracture.

We reviewed 5,792 vertebroplasty and 3,136 balloon kyphoplasty procedures conducted in England over a 7-year period.
In the 63 NHS hospital trusts that conducted more than 20 procedures during the study period, the proportion of procedures conducted as balloon kyphoplasty varied from 0 to 100%.
There was no difference in outcomes between vertebroplasty and balloon kyphoplasty patients or between trusts performing ≥ 70% and ≤ 30% of procedures as balloon kyphoplasty.

Global Spine Journal

Safety of Same-Day Discharge Posterior Lumbar Decompression and/or Discectomy: An Observational Study Using Administrative Data from England

This study analysed data from the Hospital Episodes Statistics dataset for England to evaluate whether posterior lumbar decompression/discectomy (PLDD) was safe when performed as a same-day discharge procedure in low-complexity, low risk patients.

Data were available for 45,814 PLDD performed across 103 hospital trusts of which 7,914 (17.3%) were performed as same-day discharge.
Same-day discharge rates varied from 87.7% to 0% across the 90 hospital trusts that operated on more than 50 patients during the study period.
Fourteen (15.6%) trusts had same-day discharge rates above 30% and 57 (63.3%) trusts had same-day discharge rates below 10%.
The odds of emergency hospital readmission within 90 days were lower for same-day discharge patients.
There was no difference in outcomes for patients seen at trusts with a same-day discharge rate of ≥30% compared to trusts with a same-day discharge rate of ≤10%.

European Spine Journal

Multiple injections for low back pain: What's the future?

This was a systematic review that examined the strength of evidence that multiple facet joint injections (FJIs) and medial branch blocks (MBBs) are effective in treating low back pain.

Three studies were identified that investigated the efficacy of multiple FJIs or MBBs.
None of these studies reported sustained positive outcomes at long-term follow-up.
There is a paucity of good evidence supporting the efficacy of multiple FJIs and MBBs in treating low back pain.

Surgical Site Infection

Annals of the Royal College of Surgeons of England

Getting It Right First Time: the national survey of surgical site infection rates in NHS trusts in England

Data were available for 45,814 PLDD performed across 103 hospital trusts of which 7,914 (17.3%) were performed as same-day discharge.
Same-day discharge rates varied from 87.7% to 0% across the 90 hospital trusts that operated on more than 50 patients during the study period.
Fourteen (15.6%) trusts had same-day discharge rates above 30% and 57 (63.3%) trusts had same-day discharge rates below 10%.
The odds of emergency hospital readmission within 90 days were lower for same-day discharge patients.
There was no difference in outcomes for patients seen at trusts with a same-day discharge rate of ≥30% compared to trusts with a same-day discharge rate of ≤10%.

Annals of the Royal College of Surgeons of England

Getting It Right First Time: national survey of surgical site infection 2019

This paper reports the findings of the second Getting it Right First Time (GIRFT) national surgical site infections survey for orthopaedic and spinal surgery.

Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019.
A total of 309 infections were reported from orthopaedics, and 58 infections were reported from spinal surgery.
Surgical site infection rates have remained low compared with the earlier 2017 GIRFT survey.
Primary shoulder replacement reported the lowest infection rate (0.4%) and revision shoulder replacement the highest (2.5%) rates.
The elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full surgical site infection prevention bundle to minimise the risk of infection and improve patient outcomes.

Urology

British Journal of Urology International

An observational study of volume–outcome effects for robot-assisted radical prostatectomy in England

The aim of this study was to investigate outcomes for robot-assisted radical prostate surgery (RARP) in England relative to annual surgeon and hospital trust volume.

The study’s findings included:

The proportion of procedures conducted as RARPs increased from 53.2% in 2013 to 92.6% in 2018.
There was a significant relationship between 90-day emergency hospital readmission and trust and surgeon annual volume
From lowest to highest volume category there was a decline in the adjusted proportion of patients readmitted as an emergency at 90 days from 10.6% to 7.0% for trusts and from 9.4% to 8.3% for surgeons.

British Journal of Urology International

Understanding volume-outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

This study looked at evidence for the GIRFT recommended minimum annual volume for nephrectomy and cystectomy surgery in England.

Key findings of the study were:

There was little evidence of trust or surgeon volume influencing readmission rates or mortality.
There was some evidence of shorter length of hospital stay for high-volume surgeons for both procedures.
The current level of centralisation of nephrectomy and cystectomy surgery is appears to be sufficient to maintain good outcomes.

Journal of Clinical Urology

Transurethral resection of bladder tumour as day-case surgery: Evidence of effectiveness from the UK Getting it Right First Time (GIRFT) programme

This study, published in 2019 looked at the safety of day-case transurethral resection of bladder tumour (TURBT) surgery in England.

Key findings were:

In 2017-18 only 17.9% of TURBT procedures were conducted as day-case surgery with substantial variation in rates of day-case surgery across NHS trusts in England.
Comparing trusts with the highest and lowest rates of day-case surgery there were no differences in the profiles of the patients seen or in outcomes.
Patients undergoing TURBT as day-case surgery have at least as good outcomes as those having an overnight stay.

Journal of Clinical Urology

To what extent have key recommendations from the Getting It Right First Time programme for Urology in England been implemented?

A Journal of Clinical Urology study, published in 2021, which investigated the impact of the GIRFT programme on three specific recommendations from the Urology national report.

The study’s findings included:

The proportion of transurethral resection of bladder tumour (TURBT) surgery carried out as day cases more than doubled following a GIRFT visit.
GIRFT had a significant impact on reducing the use of hospital beds for overnight stays.
A significant change in trend was observed in stent use to manage to ureteric stones, following a GIRFT visit
The usage of ureteroscopy or Extracorporeal Shock Wave Lithotripsy (ESWL) increased significantly after GIRFT visits, suggesting a more efficient use of resources through reduced return admissions, offering definitive treatment at an earlier stage, and improvements to patient quality of life.

Journal of Evaluation in Clinical Practice

Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme

The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume.

The study’s findings included:

Only one third of surgeons (who operated on just over a half of all patients) performed at least six adrenalectomy procedures in the previous year.
For open surgery, emergency readmission rates fell from 15.2% to 6.4% for surgeons and from 13.2% to 6.1% per cent for trusts between the lowest- and highest-volume categories.
Significant, but less dramatic falls were also seen for minimally invasive surgery.

BJU International

The Getting It right First Time (GIRFT) programme in urology; rationale and methodology

This paper provides an overview of the Getting it Right First Time (GIRFT) programme and describes how applying its methodology has led to a set of clinical improvement recommendations in urology for which the GIRFT Academy has developed a set of guides on how best to act upon them. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices.

BJU International

Trends in day-case bladder outflow obstruction surgery: a study using Hospital Episode Statistics

This study describes the current development of day-case bladder outflow obstruction surgery in England and outlines day-case surgery practices across England focussing on the types of operation performed and how safe they are. The study was a retrospective observational analysis of Hospital Episode Statistics and UK Office for National Statistics data, looking at relevant data between 1 January 2017 and 30 June 2022.

The key findings were:

Day-case patients were younger, with fewer comorbidities.
There was a linear day-case rate increase from 8.3% (January 2017) to 21.0% (June 2022).
Day-case rates improved for 92 out of 117 trusts in 2021–22 compared with 2017.
Three of the six trusts with the highest day-case rates performed predominantly day-case transurethral resection of the prostate, and the other three laser surgery.
Nationally, prostatic urethral lift and vapour surgery had the highest day-case rates (80.9% and 38.1%).
Most inpatient operations were transurethral resection of the prostate.
There were reduced odds of 30-day readmission after day-case bladder outflow obstruction surgery, no difference for day-case vs inpatient transurethral resection of the prostate, and reduced odds following day-case laser operations.

International Journal of Medical Informatics

Comparing reported management of ureteric stones between clinical audit and administrative datasets: An opportunity to streamline clinical audit

This study compared recorded patient management between a clinical audit and administrative dataset for patients presenting with ureteric stones in England and assessed the feasibility of using administrative data for routine audit.

The study’s key findings are:

The two cohorts were well matched for age, but with a higher proportion of females in the administrative dataset.
Recorded treatment received was similar in both cohorts, other than for ureteroscopy, which was significantly under recorded in the administrative dataset.

Vascular surgery

European Journal of Vascular and Endovascular Surgery

Editor's Choice - Volume-Outcome Relationships in Elective Abdominal Aortic Aneurysm Surgery: Analysis of the UK Hospital Episodes Statistics Database for the Getting It Right First Time (GIRFT) Programme

This study investigated whether a volume–outcome relationship exists for elective abdominal aortic aneurysm (AAA) surgery in England.

Key findings of the study were:

For open AAA surgery, lower trust annual volume was associated with higher 30-day emergency re-admission rates and higher 30-day mortality, and lower surgeon annual volume was associated with higher 30-day mortality and length of hospital stay greater than the median.
For endovascular AAA surgery, lower surgeon annual volume was associated with not having an overnight stay in critical care.
Overall, there was strong evidence of a volume–outcome relationship for open surgery but not for endovascular surgery.

European Journal of Vascular and Endovascular Surgery

Outcomes for Angioplasty and Bypass Lower Limb Revascularisation Procedures for Limb Salvage in England: Findings from the Getting It Right First Time Programme

The GIRFT national report for vascular surgery recommended that, for carefully selected patients, angioplasty may have better patient outcomes and be amore efficient than bypass surgery in lower limb revascularisation for limb salvage. This study used observational data to compare outcomes for the two procedures.

Data for 98,109 procedures were extracted from the Hospital Episodes Statistics database for England for a seven-year period: 1 April 2011 – 31 March 2018.
For non-diabetic patients, one year amputation free survival was higher for angioplasty than for bypass. For diabetic patients, there was no difference in outcomes.
One year amputation rates, 30-day emergency re-admission rates, and length of stay were all lower for angioplasty, and 30-day revascularisation rates were lower for bypass for both diabetic and non-diabetic patients.
Although far from definitive due to differences in demographics and presentation between the two groups, in carefully selected patients, angioplasty may be a preferable alternative to bypass surgery. Future clinical trials may provide more definitive data.