Clinical Operational
Research Unit
Annual report
2011
Contents
Introduction.....................................................
3
The team.........................................................
4
Example research projects in 2011.................
5
Publications in 2011........................................
8
Forthcoming publications................................
12
Selected presentations in 2011.......................
13
Working with the best: our collaborators.........
14
Our sources of funding....................................
14
2
Introduction
Welcome to the 2011 annual report of
the UCL Clinical Operational Research
Unit (CORU).
We are a team of researchers dedicated
to applying a range of operational
research, mathematical modelling and
other analytical approaches to problems
in health. As can be seen from the
examples given in this report, we work
on a wide variety of problems. Projects
range from those concerning maternal
and neonatal health in low income
countries to work with local clinicians
aiming to improve their services.
reduction in
deaths
Right coronary sinus
Noncoronary
sinus
Right coronary sinus
Left
coronary
sinus
Left
coronary
sinus
Noncoronary
sinus
One unifying feature of our work is a
commitment to working in close
collaboration with others (clinicians,
managers, other academics and
government) to ensure that our work is
informed by their expertise and that our
findings can be communicated
effectively to key audiences.
This commitment can be seen in the
healthy level of publications we
contribute to in the medical press as
well as in the technical press. In addition
to these academic publications, we
devote considerable time and energy to
active dissemination and knowledge
transfer, undertaking a number of
consultancy exercises and distributing
useful software tools.
I hope you find this report interesting. If
you want further detail on any of our
projects or are interested in how
operational research may be able to
help tackle specific problems in health
policy or health and social care, do get
in touch.
Martin Utley
Director
3
The Team
Professor Martin Utley
Dr Christina Pagel
Martin joined CORU in 1996 with a PhD
in high-energy physics and has since
worked on a wide variety of problems in
health and health care. Martin acts as
scientific advisor to the National
Confidential Enquiry into Patient
Outcome and Death and edits
Operations Research for Health Care.
Christina joined CORU in 2005 after 3
years as a post-doctoral space-physicist
in Boston. In 2008, she was promoted to
Senior Research Fellow and began
leading our work on global health. In
addition to this, she is currently working
on projects related to health protection
policy and paediatric cardiac surgery.
Dr Christos Vasilakis
Dr Sonya Crowe
Christos has qualifications in operational
research and computer science and
over ten years of experience as a
researcher in health systems. Christos
joined CORU in 2007 as a Principal
Research Fellow and is currently
working on projects related to hospital
acquired infections and pharmacy.
With a PhD in experimental condensed
matter physics, Sonya worked for the
Government Operational Research
Service as a senior OR analyst at the
Department of Health before joining
CORU in 2009. She is working on
projects related to health protection
policy, clinical risk models and global
health.
Professor Tom Treasure
Tom joined CORU following a long and
successful career as a cardiothoracic
surgeon. In his honorary role, Tom
contributes his considerable experience
and clinical knowledge to our work as
well as conducting his own research to
improve the evidence base for thoracic
surgery.
Mr Chris Sherlaw-Johnson
Chris spent many years at CORU,
notably working on cervical cancer
screening and monitoring clinical
outcomes. He now leads a team within
the surveillance division of the Care
Quality Commission and is an Honorary
Senior Research Fellow within the unit.
Professor Steve Gallivan
With a PhD in pure mathematics, Steve
started his OR career in traffic
engineering before transferring his skills
to health. He served as Director of
CORU between 1995 and 2007,
devoting his time since then to research.
In 2009, Steve was awarded the
Canadian Operational Research
Society’s Harold Lardner prize.
Contact details
Clinical Operational Research Unit
4 Taviton Street
London
WC1H 0BT
Tel: +44(0)20 7679 4506
Fax: +44(0)20 7813 2814
Email: m.utley@ucl.ac.uk
4
Example research projects in 2011
CORU conducts research on a wide
range of topics. Some of the research
projects that the unit was engaged in
during 2011 are described below.
Cancer prevalence in the UK
Exploring strategies for reducing
maternal and neonatal mortality in
low income countries
VLAD
Cumulative number of lives saved
compared to baseline Neonatal
Mortality Rate of 58
160
Control arm
140
Intervention arm
image courtesy of Kings College London
120
100
start of trial
80
60
40
20
Month/Year
0
-20
-40
May
2005
November
2005
May November
2006
2006
May
2007
November
2007
May
2008
We assisted in the design and analysis
of several trials on the effect of
community women’s groups on neonatal
deaths in South Asia and have
promoted the use of graphical tools for
monitoring clinical outcomes in this
context. Also, we estimated the number
of births that will take place in SubSaharan Africa and Asia that will not be
attended by a skilled birth attendant
over the coming decade.
In work funded by Macmillan Cancer
Support, CORU worked with colleagues
at the Thames Cancer Registry to
estimate and characterise cancer
prevalence survivorship in the UK and to
generate projections of cancer
prevalence over the coming decades.
See publications 1, 12, 31
Evaluating the role of pneumococcal
vaccine in an influenza pandemic
See publications 5, 10, 42, 46
Assisting the work of NCEPOD
The National Confidential Enquiry into
Patient Outcome and Death (NCEPOD)
is an organisation dedicated to
improving clinical outcomes through the
production of research reports based on
confidential summaries of cases
provided by practicing surgeons,
anaesthetists and physicians. We
advise NCEPOD in the design of studies
and in the analysis and reporting of
data.
We published a mathematical model for
estimating the number of deaths and
hospitalisations that could be avoided by
use of a vaccine against pneumonia in
the advent of an influenza pandemic.
This work directly informed the policy
process within Department of Health.
See publications 40, 41
See publication 4
5
Monitoring and feedback of surgical
wound infection data
CORU software to facilitate the routine
feedback to clinical teams of surgical
wound surveillance data was used by
clinicians at University College London
Hospital to identify and explore
differences in wound infection rates
across surgeons within a department.
the opportunity costs and the fact that,
for some patients, this burdensome
intervention will prove unavailing.
See publications 11, 43
Navigating the evidence on health
financing options for low and middle
income countries
See publication 7
Modelling adherence to medication
Over half of patients with chronic
conditions do not take their medication
as prescribed. As part of a long-term
collaboration with researchers from the
School of Pharmacy, we’ve developed a
modelling framework to explore the
impact of different patterns of adherence
behaviour and of the patient-prescriber
interaction.
We worked with colleagues at the UCL
Centre for International Health and
Development and Save the Children to
review the published evidence on the
impact and feasibility of different models
of health financing. We then helped to
develop a web based tool that will allow
policy makers to explore and navigate
the evidence generated by the literature
review with respect to their own contexts
and priorities.
See publication 2
See publication 54
Mathematical analysis concerning
the use of bridging technologies in
heart transplantation programmes
We are working with surgeons,
cardiologists and intensivists to address
a number of questions raised by the
availability of ”bridging” technologies
that can be used to prolong the life of
some children awaiting heart
transplantation. Bridging can increase
the chance of an individual patient
receiving a transplant and of a donated
organ being used. However, these
benefits need to be considered
alongside the impact on other patients,
Estimating the number of clinical
cases of vCJD attributable to blood
transfusion
Estimated number cases per year
2
1
0
1990
2000
2010
2020
2030
2040
2050
2060 2070
Year
As part of a responsive programme of
work on Health Protection Policy for the
Department of Health, we developed a
simple modelling framework for
6
estimating the number of vCJD cases
attributable to transfusion of infective
blood. The model has been used by DH
to explore the implications of different
beliefs around the key unknowns in this
complex problem and to gauge the
potential impact of different countermeasures.
outcomes. We are currently working
with three surgical units to pilot the use
of the model in monitoring risk-adjusted
outcomes.
An external stent for the Marfan aorta
Right coronary sinus
Right coronary sinus
See publication 39
The surgical removal of pulmonary
metastases in colorectal cancer
patients
image courtesy of Dr Sally Barrington
The surgical removal of pulmonary
metastases in patients with colorectal
cancer has become common practice.
We have been engaged in a programme
of research to challenge the evidence
cited in support of this practice and to
provide better evidence as to whether
surgery confers benefit that outweighs
the harmful effects of the operation. This
has culminated in the launch of a
randomised controlled trial.
See publications 16, 55
Risk-modelling in paediatric heart
surgery
Noncoronary
sinus
CORU worked with surgeons and
intensivists at Great Ormond Street
Hospital for Children and with the
Central Cardiac Audit Database to
develop a model for partial riskadjustment of short-term surgical
Left
coronary
sinus
Noncoronary
sinus
We have continued to contribute to the
evaluation of a new form of surgical
management for the most dangerous
manifestation of Marfan syndrome. The
construction and placement of a
bespoke external stent to prevent aortic
dissection is the result of an exciting
collaboration between engineers,
surgeons and radiologists.
See publications 3, 34, 47
Workforce planning in a cardiac
intensive care unit
Admissions
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ECMO admissions
6
External admissions
5
Internal admissions
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Audit and clinical governance in adult
cardiac surgery have benefited greatly
from the existence of a widely accepted
model for the risk of peri-operative death
and tools developed within CORU for
monitoring risk-adjusted outcomes.
Left
coronary
sinus
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consultant available
As one of several short exercises
working with consultant intensivists to
make more use of the data they collect,
we compared patterns of admission to
cardiac intensive care to staffing levels
by time of day and day of week. This
work informed decisions regarding
future staffing of the unit concerned.
See publication 22
7
Publications in 2011
Copies of all publications are available on request.
1. Maddams J, Utley M, Moller H (2011), A person-time analysis of hospital activity
among cancer survivors in England, British Journal of Cancer 105:S29-S37.
2. Pagel C, Utley M, Kembhavi G, Brikci N, Pulkki-Brannstrom A, Dutoit X, SkordisWorral J (2011), Helping decision makers navigate the evidence around health
financing, in Eds Barlow J, Trimcev B, Global health infrastructure – challenges
for the next decade, proceedings of the 4th HaCIRIC International Conference,
September 2001, Manchester, UK.
3. Treasure T, Golesworthy T, Pepper J, Ruiz F, Gallivan S (2011) Prophylactic
surgery of the aortic root in Marfan Syndrome: reconsideration of the decision
making process in the era of customised external aortic root support, Journal of
Vascular and Endovasc Surgery 18:215-23.
4. Crowe S, Utley M, Walker G, Grove P, Pagel C (2011) A model to evaluate mass
vaccination against pneumococcus as a countermeasure against pandemic
influenza, Vaccine 29(31):5065-77.
5. Tripathy P, Nair N, Mahapatra R, Rath S, Kumar Gope K, Rath S, Bakpai A,
Singh V, Nath V, Ali S, Kumar Kundu A, Choudhury D, Ghosh S, Sarbani S,
Sinha R, Pagel C, Cosello A, Houweling TAJ, Prost A (2011) Community
mobilisation with women's groups facilitated by Accredited Social Health Activists
(ASHAs) to improve maternal and newborn health in underserved areas of
Jharkhand and Orissa: study protocol for a cluster-randomised controlled trial.
Trials 12:182.
6. Treasure T, Lang-Lazdunski L, Waller D, Bliss JW, Tan C, Entwistle J, Snee M,
O'Brien M, Thomas G, Senan S, O.Byrne K, Kilburn LS, Spicer J, Landau D,
Edwards J, Coombes G, Darlison L, Peto J (2011) Extra-pleural pneumonectomy
versus no extra-pleural pneumonectomy for patients with malignant pleural
mesothelioma: clinical outcomes of the Mesiothelioma and Radical Surgery
(MARS) randomised feasibility study, Lancet Oncology 12(8):763-72.
7. Vasilakis C, Wilson APR, Haddad FS (2011) Automating the monitoring of
surgical site infections using variable life-adjusted display charts, Journal of
Hospital Infection 79:119-24.
8. Rammohan KS, Pai RB, Treasure T (2011) Management of the pleural space
early after pneumonectomy. In: Mark K Ferguson, editor. Difficult Decisions in
Thoracic Surgery: an evidence based approach. 2nd ed. London: Springer
Verlag; p. 161-4.
9. Vuylsteke A, Pagel C, Gerrard C, Reddy B, Nashef S, Utley M (2011) The
Papworth Bleeding Risk Score: a stratification scheme for identifying cardiac
8
surgery patients at risk of excessive early postoperative bleeding, European
Journal of Cardiothoracic Surgery 39(6):924-30.
10. Pagel C, Prost A, Lewycka S, Das S, Colbourn T, Mahapatra R, Azad K, Costello
A, Osrin D (2011) Intracluster correlation coefficients and coefficients of variation
for perinatal outcomes from five cluster-randomised controlled trials in low and
middle-income countries: results and methodological implications, Trials 12:151.
11. Gallivan S, Crowe S (2011) Paediatric Cardiac Transplantation - a suitable case
for renewal theory? In: Harper P, Knight V, Vieira I, Williams J eds., Operational
Research Informing National Health Policy; pp:243-254, ISBN:978-0-9569158-01.
12. Maddams J, Utley M, Moller H (2011) Levels of acute health service use among
cancer survivors in the United Kingdom, European Journal of Cancer 47:221120.
13. Vasilakis C, Chaussalet T, Baker R (2011) Editorial: IMA Health 2010, Health
Care Management Science 14(3): 213-4.
14. Treasure T (2011) Reducing the risk of venous thromboembolism in patients with
acute stroke: more evidence from the CLOTS Trial Collaboration, J Neurol
Neurosurg Psychiatry 82(10):1063-4.
15. Treasure T (2011) The Mesothelioma and Radical Surgery (MARS): a
randomised controlled trial of extrapleural pneumonectomy for malignant pleural
mesothelioma Kardiochirurgia i Torakochirurgia Polska;8(3):313-7.
16. Fiorentino F, Vasilakis C, Treasure T (2011) Clinical reports of pulmonary
metastasectomy for colorectal cancer: a citation network analysis British Journal
of Cancer 104:1085–1097.
17. Reddy B, Pagel C, Vuylsteke A, Gerrard C, Nashef S, Utley M (2011) An
operational research approach to identify cardiac surgery patients at risk of
severe post-operative bleeding Health Care Management Science 14(3):215-22.
18. Treasure T, Internullo E, Fiorentino F, Van Raemdonck D, Van Schil P, DeCamp
M, Wood D, Utley M (2011) A survey of opinions and beliefs concerning surgery
for malignant pleural mesothelioma amongst 802 members of the European
Association for Cardio-Thoracic Surgery (EACTS), the European Society of
Thoracic Surgeons (ESTS) and the Society of Thoracic Surgeons (STS),
Interactive CardioVascular and Thoracic Surgery 12:341-346.
19. Tan C, Utley M, Paschalides C, Pilling J, Robb JD, Harrison-Phipps K, LangLazdunski L, Treasure T (2011) A prospective randomized controlled study to
assess the effectiveness of CoSeal to seal air leaks in lung surgery, European
Journal of Cardiothoracic Surgery 40:304-8.
9
20. Teh E, Fiorentino F, Tan C, Treasure T (2011) A systematic review of lungsparing extirpative surgery for pleural mesothelioma, Journal of the Royal
Society of Medicine 104(2):69-80.
21. Treasure T, Chong L-Y, Sharpin CE (2011) Perioperative prophylaxis again
venouos thrombo-embolism in major lung resection. In: Mark K Ferguson, editor.
Difficult Decisions in Thoracic Surgery: an evidence based approach. 2nd ed.
London: Springer Verlag.
22. Brown K, Pagel C, Pienaar A, Utley M (2011) The relationship between workload
and medical staffing levels in a paediatric cardiac intensive care unit, Intensive
Care Medicine 37(2):326-333.
23. Utley M, Pagel C, Peters M, Petros A, Lister P (2011) Does triage to critical care
during a pandemic necessarily result in more survivors? Critical Care Medicine
39(1):179-183.
24. Reynolds M, Vasilakis C, McLeod M, Barker N, Mounsey A, Newton S, Jacklin A,
Dean Franklin B (2011), Using discrete event simulation to design a more
efficient hospital pharmacy for outpatients, Health Care Management Science 14:
223-236.
25. Sobolev B, Sanchez V and Vasilakis C (2011) Systematic review of the use of
computer simulation modeling of patient flow in surgical care, Journal of Medical
Systems 35:1-16.
26. Treasure T (2011) Cardiac Surgery: pushing the limits, In: Bynum W, Bynum H,
eds., Great Discoveries in Medicine. London: Thames & Hudson; p. 240-5.
27. Tsang V, Utley M (2011) Invited commentary on paper by Bojan et al, Annals of
Thoracic Surgery 92(3):957.
28. Treasure T, Macbeth F (2011) Response to the article "pulmonary resection for
metastatic gastric cancer" by Kemp et al., Journal of Thoracic Oncology 6(4):836.
29. Treasure T, Hillerdal G, Utley M (2011) LUCADA: a valuable resource but there
are questions it cannot answer, Thorax 66(12):1023-4.
30. Gallivan S, Utley M (2011) A technical note concerning emergency bed demand,
Health Care Management Science 14(3):250-2.
31. Fiorentino F, Maddams J, Møller H, Utley M (2011) Modelling to estimate future
trends in cancer prevalence, Health Care Management Science 14(3):262-6.
32. Utley M, Worthington D (2011) Capacity Planning, in Handbook of Healthcare
System Scheduling, Ed Hall R, Springer, New York, ISBN 978-1-4614-1733-0, pp
11-30.
33. Treasure T, Utley M (2011) Assessing Cardiothoracic Surgery: Practical
Examples, in Randomized Clinical Trials of Nonpharmacologic Treatments, Eds.
Boutron I, Revaud P, Moher D, Chapman and Hall, ISBN 9781420088014.
10
34. Treasure T, Pepper JR (2011) Aortic root surgery in Marfan syndrome, Heart
97(12):951-2.
35. Treasure T, Senan S (2011) The need for randomized trials in mesothelioma:
let's walk the talk, Oncologist 16(3):261-3.
36. Treasure T, Hasan A, Yacoub M (2011) Is there a risk in avoiding risk for
younger patients with aortic valve disease? BMJ 342:d2466.
37. Vasilakis C (2011) The first 50 years are the difficult ones: challenges and
opportunities for operational research in health. In: Keynote Papers, YOR17, ed
Monks T, Operational Research Society: Birmingham, pp. 26-8.
38. Bliss JM, Coombes G, Darlison L, Edwards J, Entwistle J, Kilburn LS, Landau D,
Lang-Lazdunski L, O'Brien M, O'Byrne K, et al. (2011) The MARS feasibility trial:
conclusions not supported by data - Authors' reply, Lancet Oncology
12(12):1094-5.
We contributed to the following paper submitted to the Department of Health
Advisory Committee on Dangerous Pathogens
39. Blood-borne transmission of vCJD: re-examination of scenarios.
In addition, members of CORU contributed to the following reports
40. National Confidential Enquiry into Patient Outcome and Death (2011)
Perioperative care: knowing the risk, NCEPOD, London, ISBN 978-0-9560882-60.
41. National Confidential Enquiry into Patient Outcome and Death (2011) Are we
there yet: A review of organisational and clinical aspects of children’s surgery,
NCEPOD, London, ISBN 978-0-9560882-5-3.
11
Forthcoming publications
42. Crowe S, Utley M, Costello A, Pagel C (forthcoming) How many births in subSaharan Africa and South Asia will not be attended by a skilled birth attendant
between 2011 and 2015? BMC Pregnancy and Childbirth.
43. Crowe S, Pagel C, Bull K, Fenton M, Vasilakis C, Gallivan S, Utley M
(forthcoming) Using a mathematical model to assist with the management of
paediatric heart transplant waiting lists: a case study, IMA Journal of
Management Mathematics.
44. Richards DA, Bower P, Pagel C, Weaver A, Utley M, Cape J, Pilling S, Lovell K,
Gilbody S, Leibowitx J, Ownes L, Paxton R, Hennessy S, Simpson A, Gallivan S,
Tomson D, Vasilakis C (forthcoming) Delivering stepped care: an analysis of
implementation in routine practice.
45. Tan C, Treasure T, Utley M (forthcoming) Reply to D'Andrilli and Rendina,
European Journal of Cardio-Thoracic Surgery.
46. Pagel C, Prost A, Nair N, Tripathy P, Costello A, Utley M (forthcoming)
Monitoring mortality trends in low-resource settings, Bulletin of the World Health
Organisation.
47. Treasure T, Pepper J, Golesworthy T, Mohiaddin R, Anderson RH (forthcoming)
External aortic root support: NICE guidance, Heart.
48. Treasure T, Farewell V (forthcoming) Minimization in interventional trials: great
value but residual vulnerability, Journal of Clinical Epidemiology.
49. Kotiadis K, Tako A, Rouwette E, Vasilakis C, Gandhi P, Wegstapel H and Webb
P (forthcoming) Using a model of the performance measures in Soft Systems
Methodology (SSM) to take action: a case study in health care, Journal of the
Operational Research Society.
50. Utley M, Editorial (forthcoming) Operations Research for Health Care.
51. Treasure T (forthcoming) Oligometastastic cancer: an entity, a useful concept, or
a therapeutic opportunity? Journal of the Royal Society of Medicine.
52. Morton D, Treasure T (forthcoming) GRIST: Growing Recruitment into
Interventional and Surgical Trials. Journal of the Royal Society of Medicine.
53. Russell C, Treasure T (forthcoming) Counting the cost of cancer surgery for
advanced and metastatic disease, British Journal of Surgery.
54. Vasilakis C, Pagel C, Gallivan S, Barber N and Utley M (forthcoming) Agentbased modelling and simulation in patient adherence to medication: a proof-ofconcept study. In: Proceedings of the 6th Operational Research Society
Simulation Workshop (SW12).
12
55. Treasure T, Fallowfield L, Lees B, Farewell V (forthcoming) Pulmonary
metastasectomy in colorectal cancer: the PulMiCC trial Thorax.
56. Pagel C, Richards D and Utley M (forthcoming) A mathematical modelling
approach for systems where the servers are almost always busy Computational
and Mathematical Methods in Medicine.
Selected presentations 2011
The first 50 years are the difficult ones: challenges and opportunities for operational
research in health, Young OR Conference, Nottingham, June 2011.
Paediatric Cardiac Transplantation - a suitable case for renewal theory? Operational
Research Applied to Health Services (ORAHS), Cardiff, July 2011.
Modelling to support Health Protection Policy, Operational Research Applied to Health
Services (ORAHS), Cardiff, July 2011.
Helping decision makers navigate the evidence around health financing, HaCIRIC
International Conference, Manchester, September 2011.
The development of a mortality risk model to adjust for case-mix in paediatric cardiac
surgery, Operational Research Society annual meeting, Nottingham, September 2011.
Dodgy burgers, bad blood: is “mad cow” disease an issue? UCL bite size lecture series,
December 2011.
In addition to conference presentations, Christina Pagel gave three talks to London Alevel students on studying mathematics at university and beyond.
13
Working with the best: our collaborators
The contributions of our clinical collaborators and academic partners are essential to
CORU's research. In 2011 we benefited in particular from collaborations with
Professor Nick Barber
Professor Bryony Dean Franklin
London School of Pharmacy
Imperial College Healthcare NHS Trust
Professor Henrik Møller
Kings College London
Mr Jacob Maddams
Kings College London
Professor Dave Richards
The University of Exeter
Mr Victor Tsang
Great Ormond Street Hospital for Children
Dr Peter Wilson
University College London Hospital
The Thoracic Unit
Guy's Hospital
Professor Anthony Costello
UCL Institute of Child Health
Dr Audrey Prost
UCL Institute of Child Health
Dr Kate Brown
Great Ormond Street Hospital for Children
Dr Kate Bull
Great Ormond Street Hospital for Children
Dr Alain Vuylsteke
Dr Matt Fenton
Professor Lesley Fallowfield
Professor Vern Farewell
Ms Carol Tan
Dr Paula Lister
Dr David Cunningham
Papworth Hospital
Great Ormond Street Hospital for Children
University of Sussex
MRC Biostatistics Unit
St George’s Hospital
Great Ormond Street Hospital for Children
Central Cardiac Audit Database
Dr Peter Bennett
Department of Health
Dr Peter Grove
Department of Health
Dr Guy Walker
Department of Health
Dr Tom Barlow
Department of Health
Our sources of funding
In 2011, work at CORU was supported by the Department of Health Policy Research Programme,
the National Institute of Health Research (NIHR) Health Services Research Programme, the
Health Foundation, Macmillan Cancer Support, the Central Cardiac Audit Database, Cancer
Research UK, Great Ormond Street Hospital NHS Trust and Save the Children.
14