Acute kidney injury (AKI) severe enough to require dialysis is increasing and associated with high mortality, yet robust information about temporal epidemiology of AKI requiring dialysis in England is lacking. In this retrospective observational study of the Hospital Episode Statistics (HES) data set covering the entire English National Health Service, we identified all patients with a diagnosis of AKI requiring dialysis between 1998 and 2013. This incidence increased from 774 cases (15.9 per million people) in 1998-1999 to 11,164 cases (208.7 per million people) in 2012-2013. The unadjusted in-hospital case-fatality was 30.3% in 1998-2003 and 30.2% in 2003-2008, but significantly increased to 41.1% in 2008-2013. Compared with 2003-2008, the multivariable adjusted odds ratio for death was higher in 1998-2003 at 1.20 (95% CI: 1.10-1.30) and in 2008-2013 at 1.13 (1.07-1.18). Charlson comorbidity scores of more than five (odds ratio 2.35; 95% CI: 2.20-2.51) and emergency admissions (2.46 (2.32-2.61) had higher odds for death. The odds for death decreased in patients over 85 years from 4.83 (3.04-7.67) in 1998-2003 to 2.19 (1.99-2.41) in 2008-2013. AKI in secondary diagnosis and in other diagnoses codes had higher odds for death compared with AKI in primary diagnosis code in all three periods. Thus, the incidence of AKI requiring dialysis has increased progressively over 15 years in England. Improvement in case-fatality in 2003-2008 has not been sustained in the last 5 years.

SummaryAimsEpidemiology studies of acute kidney injury (AKI) have focused on cases requiring dialysis but those not requiring dialysis represent the majority. To address this gap, we interrogated hospital episode statistics (HES) to investigate population trends in temporal epidemiology of AKI not requiring dialysis between 1998 and 2013.MethodologyIn this retrospective observational study of HES data covering the entire English National Health Service, we identified 1,136,167 AKI events, not requiring dialysis, diagnosed between 1998 and 2013. We explored the effect of age, gender, ethnicity, Charlson's comorbidity score (CCS), method of admission, diagnosis period and AKI in diagnosis codes on temporal changes in the incidence and case‐fatality of AKI with specific examination of its predictors.ResultThe incidence of AKI increased from 15,463 cases (317 pmp) in 1998–1999 to 213,700 cases (3995 pmp) in 2012–2013. There was increase in proportion of people over 75 years from 51.1% in 1998–1999 to 63.4% in 2012–2013. Overall unadjusted case‐fatality decreased from 42.3% in 1998–2003 to 27.1% in 2008–2013, p < 0.001. Compared with 1998–2003, the multivariable adjusted odds ratio for death was 0.64 in 2003–2008 (95% CI 0.63–0.65) and 0.35 in 2008–2013 (95% CI 0.34–0.35). Odds for death were higher for patients over 85 years (2.93; 95% CI 2.89–2.97), CCS of more than five (2.75; 95% CI 2.71–2.79), emergency admissions (2.14; 95% CI 2.09–2.18) and AKI in the secondary diagnosis code (1.35; 95% CI 1.33–1.36) and AKI in other diagnoses codes (2.17; 95% CI 2.15–2.20).ConclusionsIn England, the incidence of AKI not requiring dialysis has increased and case‐fatality has decreased over last 15 years. Efforts to reduce the incidence of AKI and improve survival should focus on elderly people, emergency admissions and those with multi‐morbidity.

ObjectiveWith the advent of screening tests, it was hypothesised that milder cases of coeliac disease coming to diagnosis might have reduced risk of mortality. An earlier publication did not support this view. We have re-examined this issue employing a larger number of patients followed for a further 8 years.DesignPatients with coeliac disease from Southern Derbyshire, UK, were followed prospectively from 1978 to 2014 and included those diagnosed by biopsy and serology. Causes of death were ascertained. Standardised mortality ratios were calculated for all deaths, cardiovascular disease, malignancy, accidents and suicides, respiratory and digestive disease. Ratios were calculated for individual causes. Analysis centred on the postdiagnosis period that included follow-up time beginning 2 years from the date of coeliac disease diagnosis to avoid ascertainment bias. Patients were stratified according to date of diagnosis to reflect increasing use of serological methods.ResultsAll-cause mortality increase was 57%. Mortality in the serology era declined overall. Mortality from cardiovascular disease, specifically, decreased significantly over time. Death from respiratory disease significantly increased in the postdiagnosis period. The standardised mortality ratio for non-Hodgkin’s lymphoma was 6.32, for pneumonia 2.58, for oesophageal cancer 2.80 and for liver disease 3.10. Survival in those who died after diagnosis increased by three times over the past three decades.ConclusionsSerological testing has impacted on the risk of mortality in coeliac disease. There is an opportunity to improve survival by implementing vaccination programmes for pneumonia and more prompt, aggressive treatments for liver disease.

ObjectiveTo determine trends in diagnosis of coeliac disease (CD) in patients attending a single centre 1958–2014 and provide figures for prevalence and incidence in those born in Derby city over 4 decades. To explore a link between deprivation and prevalence and characteristics of CD in Asians.DesignAn unselected, consecutive series of 2410 adult patients with CD diagnosed in the catchment area of the Derby hospitals was identified. 1077 born within Derby city identified by postcodes was used to determine changes in prevalence and incidence over 4 decades. 191 patients were Asian. Population numbers were obtained from National Census information.ResultsIn the quinquennium 2010–2014, 20 times more patients were diagnosed than during 1975–1979. 27% were diagnosed at ≥60 years. A paucity of diagnoses in young men was observed. Women were diagnosed most often in age band ≥35<45, 15 years earlier than men. The largest increase in diagnosis rates occurred in young women and the elderly. In 2014, overall prevalence was 1:188; women 1:138. 4.6% of the variation was attributed to deprivation. Diagnosis rates in Asians increased markedly although only 5% were diagnosed at ≥60 years, much lower than for whites.ConclusionsThe dramatic increase in number of patients with CD presents challenges for follow-up and new models of care need to be explored. Healthcare workers should be alert to the diagnosis in young men and elderly Asians. A dedicated coeliac clinic is an excellent facility to increase diagnosis rates.

Purpose – The purpose of this paper is to describe the development of a digital tool in an English county striving towards a vision of integrated information that is used to underpin an increasingly integrated future of health and social care delivery.\ud Design/methodology/approach – It discusses the policy context nationally, the origins and implementation of the initiative, the authors’ experiences and viewpoint highlighting key challenges and learning, as well as examples of new work undertaken.\ud Findings – In all, 12 health and care organisations have participated in this project. The ability for local commissioners and providers of services to now understand “flow” both between and within services at a granular level is unique. Costs are modest, and the opportunities for refining and better targeting as well as validating services are significant, thus demonstrating a return on investment. Key learning includes how organisational development was equally as important as the implementation of innovative new software, that change management from grass roots to strategic leaders is vital, and that the whole system is greater than the sum of its otherwise in-silo parts. Practical implications – Data linkage initiatives, whether local, regional or national in scale, need to be programme managed. A robust governance and accountability framework must be in place to realise the benefits of such as a solution, and IT infrastructure is paramount.\ud Social implications – Organisational development, collaborative as well as distributed leadership, and managing a change in culture towards health and care information is critical in order to create a supportive environment that fosters learning across organisational boundaries.\ud Originality/value – This paper draws on the recent experience of achieving large-scale data integration across the boundaries of health and social care, to help plan and commission services more effectively. This rich, multi-agency intelligence has already begun to change the way in which the system considers service planning, and learning from this county’s approach may assist others considering similar initiatives