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Abstract
Introduction Specialist centres have been developed to deliver high-quality Hepatology care. However, there is geographical inequity in accessing these centres in the United Kingdom (UK). We aimed to assess the impact of these centres on decompensated cirrhosis patient outcomes and understand which patients transfer to specialist centres.
Methods A UK multicentred retrospective observational study was performed including emergency admissions for patients with decompensated cirrhosis in November 2019. Admissions were grouped by specialist/non-specialist centre designation, National Health Service region and whether a transfer to a more specialist centre occurred or not. Univariable and multivariable comparisons were made.
Results 1224 admissions (1168 patients) from 104 acute hospitals were included in this analysis. Patients at specialist centres were more likely to be managed by a Consultant Gastroenterologist/Hepatologist on a Gastroenterology/Hepatology ward. Only 24 patients were transferred to a more specialist centre. These patients were more likely to be admitted for gastrointestinal bleeding and were not using alcohol. Specialist centres eliminated regional variations in mortality which were present at non-specialist centres. Low specialist Consultant staffing numbers impacted mortality at non-specialist centres (aOR 2.15 (95% CI 1.18 to 4.07)) but not at specialist centres. Hospitals within areas of high prevalence of deprivation were more likely to have lower specialist Consultant staffing numbers.
Conclusions Specialist Hepatology centres improve patient care and standardise outcomes for patients with decompensated cirrhosis. There is a need to support service development and care delivery at non-specialist centres. Formal referral pathways are required to ensure all patients receive access to specialist interventions.
- cirrhosis
- health service research
Data availability statement
Data are available upon reasonable request.
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Data availability statement
Data are available upon reasonable request.
Footnotes
Collaborators Oliver D Tavabie, King’s College Hospital NHS Foundation Trust; Jane Abbott, Barts Health NHS Trust; Kushala WM Abeysekera, University Hospitals Bristol and Weston NHS Foundation Trust Vinay K Balachandrakumar; Kris Bennett, University Hospitals Plymouth NHS Foundation Trust; Paul Brennan, NHS Tayside; Ryan Buchanan, University Hospital Southampton NHS Foundation Trust; Amritpal Dhaliwal, University Hospitals Birmingham; Vasileios Galanakis, Cambridge University Hospitals; Tim Hardy, South Tees Hospitals NHS Foundation Trust; Rebecca Harris, Nottingham University Hospitals NHS Trust; Victoria T Kronsten, King’s College Hospital NHS Foundation Trust; Jess Leighton, Newcastle Upon Tyne NHS Foundation Trust; Wenhao Li, Barts Health NHS Trust; James Liu Yin, King’s College Hospital NHS Foundation Trust; Lucia Macken, University Hospitals Sussex NHS Foundation Trust; Thomas Marjot, Oxford University Hospitals NHS Foundation Trust; James B Maurice, Barts Health NHS Trust; Hannah McDowell, Belfast Health and Social Care Trust; Janardhan Navaratnam, Cardiff and Vale University Health Board; Keith Pohl, Royal Devon and Exeter NHS Foundation Trust; Jeremy S Nayagam, King’s College Hospital NHS Foundation Trust; Emma Saunsbury, Royal United Hospital Bath NHS Foundation Trust; Jennifer Scott, NHS Lothian; Abhishek Sheth, Nottingham University Hospitals NHS Trust; Ricky Sinharay, Cambridge University Hospitals; Giovanna Sheiybani, Gloucestershire Hospitals NHS Foundation Trust; Mohsan Subhani, Nottingham University Hospitals NHS Trust; Lucy Turner, Leeds Teaching Hospital NHS Trust; Helen White, Bolton NHS Foundation Trust; Nekisa Zakeri, Royal Free NHS Foundation Trust; Vinay K Balachandrakumar, Liverpool University Hospitals NHS Foundation Trust Charlotte Cook; Nadir Abbas, Queen Elizabeth Hospital Birmingham; Abdullah Abbasi, Royal Stoke University Hospital; Rahman Abdul, Royal Stoke University Hospital; Mohamed Abdulaziz, University Hospital of North Durham; Duaa Abduljabbar, Worcestershire Royal Hospital; Robbie Adamson, Yeovil District Hospital; Danielle Adebayo, Royal Berkshire Hospital; Aditya Kumar Adhikarla, Countess of Chester Hospital; Maciej Adler, Aberdeen Royal Infirmary; Salman Ahmad, Chelsea and Westminster NHS Foundation Trust; Shayan Ahmed, Russells Hall Hospital; Mostafa Afifi, Chorley and South Ribble Hospital and Royal Preston Hospital; Ali Akram, Chelsea and Westminster NHS Foundation Trust; Balqees Al Radhi, Northumbria Healthcare NHS Foundation Trust; Ismaeel Al-Talib, Walsall Manor Hospital; Jolomi Alele, Hereford County Hospital; Alaa Mohammed Ali, South Tees Hospitals NHS Foundation Trust; Safa Almusai, Guy’s and St Thomas’ NHS Foundation Trust; Victoria Appleby, Leeds Teaching Hospital NHS Trust; Huma Asmat, Bedford Hospital; Sarah Astbury, Arrowe Park Hospital; Ali Atkinson, Cumberland Infirmary; Fakhirah Badrulhisham, North Devon District Hospital; Alexandra Ball, Arrowe Park Hospital; Moses Banfa, Cumberland Infirmary; Jeevan Barn, Sunderland Royal Hospital; Shahnaz Begum, Luton and Dunstable Hospital; Katherine Belfield, Bristol Royal Infirmary; Oliver Bendall, Royal Cornwall Hospital; Rajan Bhandari, Gateshead Health NHS Foundation Trust; Prashan Bhatti, Kingston Hospital; Meg Bradley, Royal Surrey County Hospital; Edward Brown, Gateshead Health NHS Foundation Trust; Kathleen Bryce, Royal Free Hospital; Laura Burke, Leeds Teaching Hospital NHS Trust; Roisin Campbell, Forth Valley Royal Hospital; Tamsin Cargill, Royal Berkshire Hospital; Geraldine Carroll, South Tyneside District Hospital; James Cartledge, Homerton University Hospital; Devnandan Chatterjee, Chelsea and Westminster NHS Foundation Trust; Rayan Chaundry, Basingstoke and North Hampshire Hospital; Zeshan Choudhry, James Paget University Hospital; Kathleen Clare, Forth Valley Royal Hospital; Jeremy Cobbold, John Radcliffe Hospital; Robert Coburn, Ulster Hospital Dundonald; Fintan Corvan, Craigavon Area Hospital; Rebecca Cox, Chorley and South Ribble Hospital and Royal Preston Hospital; Darren Craig, South Tees Hospitals NHS Foundation Trust; John Creamer, North Bristol NHS Foundation Trust; Christopher Curran, Ayrshire University Hospital; Shanika De Silva, Russells Hall Hospital; Laurence Dean, Tunbridge Wells Hospital; Jayne Dillon, Leeds Teaching Hospital NHS Trust; Rebecca Dunn, North Tees and Hartlepool NHS Foundation Trust; Robert Eckersley, Homerton University Hospital; Gidveig Eike, Hull University Teaching Hospital; Amul Elagib, Worcestershire Royal Hospital; Ayman Elkholi, Whipps Cross Hospital; Omar Elshaarawy, Royal Liverpool University Hospital; Sarah Faloon, Newham University Hospital; Francis Fan, Kettering General Hospital; Mohammad Fazili, North West Anglia NHS Foundation Trust; Denzil Fernandes, South Tees Hospitals NHS Foundation Trust; James Fox, Aintree University Hospital; Matthew Foxton, Chelsea and Westminster NHS Foundation Trust; Waqas Gaba, Aintree University Hospital; Girish Gaikwad, Darlington Memorial Hospital; Abishek Gairola, Northumbria Healthcare NHS Foundation Trust; Charles Gallaher, King’s College Hospital and Princess Royal University Hospital; Nisham Gautam, Walsall Manor Hospital; Lewis Germain, Mid-Yorkshire Hospitals NHS Trust; Ben Giles, Queen Alexandra Hospital; Ceri Gill, Southport and Formby District General Hospital; Ben Glover, Queen Alexandra Hospital; John Glover, Leicester Royal Infirmary; David Gomez, New Cross Hospital; Michael Gomez, Royal Berkshire Hospital; Victoria Gordon, University Hospitals Coventry and Warwickshire; Sarah Gormley, Musgrove Park Hospital; John Goulder, Whipps Cross Hospital; Simran Goyal, Homerton University Hospital; Olivia Greenham, Luton and Dunstable Hospital; Sarah Guthrie, Royal Bolton Hospital and Stepping Hill Hospital; Richard Hackett, Chelsea and Westminster NHS Foundation Trust; Yazan Haddadin, Royal Sussex County Hospital and Worthing Hospital; Andreas Hadjinicolaou, North West Anglia NHS Foundation Trust; Jonathan Hall, Ealing Hospital; Tasnuma Haque, Sandwell and West Birmingham Hospitals NHS Trust; Catherine Hart, Royal Surrey County Hospital; Syed Mujtaba Hasnain Nadir, Royal Bolton Hospital; James Hassall, Prince Charles Hospital; Sundas Hasan, Leicester Royal Infirmary; George Hawker-Bond, John Radcliffe Hospital; Jake Hawkyard, Gateshead Health NHS Foundation Trust; Scott Healey, Grange University Hospital; Catherine Hornby, Royal London Hospital; Mohammed Hamza, Leicester Royal Infirmary; MD Humayun, Queen’s Hospital Romford; John Hutchison, Mid-Yorkshire Hospitals NHS Trust; Zahra Iftikhar, James Cook University Hospital; Asem Ismail, Russells Hall Hospital; Joel James, Royal Cornwall Hospital; Laura Jopson, Northumbria Healthcare NHS Foundation Trust; Dipal Juthani, Luton and Dunstable Hospital; Philippa Kaina, Royal London Hospital; Aadil Karim, Walsall Manor Hospital; Syed Misbah Karim, Worthing Hospital; Vaishnavi Kashyap, University Hospital Lewisham; Mohamed Kassab, Aintree University Hospital; Dev Katarey, The Whittington Hospital; Lee Kenny, Newcastle Upon Tyne NHS Foundation Trust; Georgina Kerry, St George’s University Hospital NHS Foundation Trust; Adnan Khan, Darlington Memorial Hospital; Ayesha Khan, University Hospital Lewisham; Azab Khan, Queen’s Hospital Romford; Muhammad Taha Khan, Leeds Teaching Hospital NHS Trust; Tahir Khan, Broomfield Hospital; Aseil Khatib, Kettering General Hospital; Mohammad Fawad Khattak, Conquest Hospital; Ji Jade King, Newham University Hospital; Mohammed Korani, Wrightington Wigan and Leigh NHS Foundation Trust; Sreelakshmi Kotha, Guy’s and St Thomas’ NHS Foundation Trust; Emily Kooner, East and North Hertfordshire NHS Trust; Wai Liam Lam, Hereford County Hospital; Mohammed Lateef, Newcastle upon Tyne Hospitals NHS Foundation Trust; Damien Leith, Glasgow Royal Infirmary; Angela Liaros, Leeds Teaching Hospital NHS Trust; Floyd Lourenco, Kingston Hospital and University Hospital Lewisham; Annabel Lyles, Leeds Teaching Hospital NHS Trust; Midusa Mahenthiran, Basildon and Thurrock University Hospitals; Ciaran Magee, Altnagelvin Area Hospital; Daniel Maggs, Royal United Hospital Bath NHS Foundation Trust; Aarani Mahalingam, Broomfield Hospital; Rizwan Mahmood, Russells Hall Hospital; Mandour Omer Mandour, Guy’s and St Thomas’ NHS Foundation Trust and St George’s University Hospital NHS Foundation Trust; Namita Manocha, Sunderland Royal Hospital; Dina Mansour, Gateshead Health NHS Foundation Trust; Daniella Marks, Perth Royal Infirmary; Ciara Martin, Ealing Hospital; Harry Martin, University College London Hospital; Iana Martin, Princess Alexandra Hospital NHS Trust; Katherine Martin, Manchester Royal Infirmary; Sachan Maruthan, Royal Free Hospital; Rhys Masin, The Whittington Hospital; Denise Mason, Arrowe Park Hospital; Charmaine Matthews, Royal Liverpool University Hospital and Warrington Hospital; Athina Mavrou, Ealing Hospital; Ema Maxan, Croydon University Hospital; Dominic Maxfield, South Tyneside District Hospital; Emma McAvoy, North Tees and Hartlepool NHS Foundation Trust; Kirsty McColl, Forth Valley Royal Hospital; Hannah McCaughan, Craigavon Area Hospital; Roger McCorry, Royal Victoria Hospital; John McGoran, Altnagelvin Area Hospital; Stewart McDonald, South West Acute Hospital; Stewart McIlwane, Ulster Hospital Dundonald; Olivia Meakin, Royal Bolton Hospital; Leila Mebarek, University Hospital Lewisham; Hannah Merrill, Salford Royal Hospital; Stephanie Michail, Royal Liverpool University Hospital; Pedram Modarres, North Bristol NHS Foundation Trust; Alaa Mohamedali, James Cook University Hospital; Yaser Mohammed, Conquest Hospital; Zakiuddin Mohammed, Basildon and Thurrock University Hospitals; Jaiganesh Mohan, Warrington Hospital; Chloe Monnier, Royal Sussex County Hospital; Eilis Moran, Royal Victoria Hospital; Gary Morrison, Altnagelvin Area Hospital; Francesca Moroni, Aberdeen Royal Infirmary; Anas Msaddi, Royal Sussex County Hospital; Sarah Mutar, Northumbria Healthcare NHS Foundation Trust; Luis Neto-Pereira, Luton and Dunstable Hospital; Ismail Nahed, University Hospital of North Durham; Jennifer Ng, Ealing Hospital; Chinonso Nwoguh, Basingstoke and North Hampshire Hospital; Rebecca O’Kane, Daisy Hill Hospital; Sohail Omar, Basildon and Thurrock University Hospitals; Abosede Ososanya, Wrightington Wigan and Leigh NHS Foundation Trust Jessiya Veliyankodan Parambil; Jay Patel, Bedford Hospital; Marinos Pericleous, Royal Surrey County Hospital; Zeshan Pervais, Walsall Manor Hospital; Anju Phoolchund, University Hospital Southampton; Julian Pietrzycki, Glasgow Royal Infirmary; Lushen Pillay, Princess Alexandra Hospital NHS Trust; Kiran Prabhu, Queen Elizabeth Hospital Woolwich; Yesita Rizky F. Putri, University Hospitals Coventry and Warwickshire; Umang Qazi, Worthing Hospital; Khizar Khalid Rafique, St George’s University Hospital NHS Foundation Trust; Krithivasan Raman, North West Anglia NHS Foundation Trust; Vaishali Ranade, Victoria Hospital, NHS Fife; Francesca Rastelli, Manchester Royal Infirmary; Elizabeth Ratcliffe, Wrightington Wigan and Leigh NHS Foundation Trust; Deepa Rattehalli, Russells Hall Hospital; Tufail Raza, Royal Stoke University Hospital; Amir Razak, Prince Charles Hospital; Arun Raghuraman, King’s College Hospital and Princess Royal University Hospital; George Read, Royal Bournemouth Hospital; Anne Robins, Norfolk and Norwich University Hospital; Simon Rushbrook, Norfolk and Norwich University Hospital; Mohamed Salama, Northumbria Healthcare NHS Foundation Trust; Louise St. Aimee, Croydon University Hospital; Ramasamy Saravan, Macclesfield District General Hospital; Srishti Sarkar, University Hospital Southampton; Solange Serna, Kettering General Hospital; Hassnain Shahzad, Mid-Yorkshire Hospitals NHS Trust; Mohammed Shamsaldeen, Darlington Memorial Hospital; Mohammed Sharip, East and North Hertfordshire NHS Trust; Jessica Shearer, York District Hospital and Hull University Teaching Hospital; Adam Sheikh, Glasgow Royal Infirmary; Michelle Sherwin, Leighton Hospital; Nidhi Shintre, Broomfield Hospital; Saket Singhal, Sandwell and West Birmingham Hospitals NHS Trust; Rohit Sinha, Sunderland Royal Hospital; Gloria Smith, Manchester Royal Infirmary; Ria Smith, North Devon District Hospital; Joanne Spicer, Worcestershire Royal Hospital; Johannes Spoor, Queen Elizabeth University Hospital Glasgow; Shiva Sreenivasan, South West Acute Hospital; Amar Srinivasa, Worcestershire Royal Hospital; Ankur Srivastava, North Bristol NHS Foundation Trust; Georgia Stagg, Whipps Cross Hospital; Jatinder Stanley, Broomfield Hospital; Jason Stevenson, Warrington Hospital; Daniel Stokes, New Cross Hospital; Robert Stroud, University Hospitals Coventry and Warwickshire; Hiba Suliman, Macclesfield District General Hospital; Marium Sultana, Leicester Royal Infirmary; Nikki Summers, Arrowe Park Hospital; Chloe Sutherland, Hull University Teaching Hospital; Rachael Swann, Queen Elizabeth University Hospital Glasgow; Lynne Sykes, Salford Royal Hospital; Mostafa Taha, King’s College Hospital and Princess Royal University Hospital; Kwei Eng Tan, South Tees Hospitals NHS Foundation Trust; Zohaib Tariq, Queen’s Hospital Romford; Joshua Jun Ming Tay, Queen Elizabeth University Hospital Glasgow; Alison Taylor, Queen Elizabeth Hospital Woolwich; Amit Thakor, Luton and Dunstable Hospital; James Tsang, Royal London Hospital; Zaccharie Tyler, Basildon and Thurrock University Hospitals; Esther Unitt, University Hospitals Coventry and Warwickshire; Edward Volcek, Princess Alexandra Hospital NHS Trust; Jack Wischhusen, Bedford Hospital; Iona Watson, Homerton University Hospital; Chris Watters, Countess of Chester Hospital; Gemma Wells, Royal Free Hospital; Monika Widlak, University Hospitals Coventry and Warwickshire; Matthew Williams, James Paget University Hospital; Hazel Woodland, University Hospital Southampton; Louise Wren, Broomfield Hospital; Souzana Xyda, North Tees and Hartlepool NHS Foundation Trust; Julian Yeh, Sandwell and West Birmingham Hospitals NHS Trust; Alison Young, Forth Valley Royal Hospital; Jack Shie Jie Yuan, The Whittington Hospital; Guruprasad Aithal, Nottingham University Hospitals NHS Trust; William Bernal, King’s College Hospital NHS Foundation Trust; John Dillon, NHS Tayside; Brian Hogan, King’s College Hospital NHS Foundation Trust; Stuart McPherson, Newcastle Upon Tyne NHS Foundation Trust; Rebecca Jones, Leeds Teaching Hospital NHS Trust; Ian Rowe, Leeds Teaching Hospital NHS Trust; Victoria Snowdon, Cambridge University Hospitals.
Contributors Guarantor: Oliver D Tavabie. Study conceptualisation: Jane Abbott, Kushala WM Abeysekera, Kris Bennett, Paul Brennan, Ryan Buchanan, Amritpal Dhaliwal, Vasileios Galanakis, Tim Hardy, Rebecca Harris, Victoria T Kronsten, Jess Leighton, Wenhao Li, James Liu Yin, Lucia Macken, Thomas Marjot, James B Maurice, Hannah McDowell, Janardhan Navaratnam, Keith Pohl, Jeremy S Nayagam, Emma Saunsbury, Jennifer Scott, Abhishek Sheth, Ricky Sinharay, Giovanna Sheiybani, Mohsan Subhani, Oliver D Tavabie, Lucy Turner, Helen White, Nekisa Zakeri. Study design/management: Vinay K Balachandrakumar, Tim Hardy, Rebecca Harris, Janardhan Navaratnam, Emma Saunsbury, Oliver D Tavabie, Data collection: Nadir Abbas, Abdullah Abbasi, Rahman Abdul, Mohamed Abdulaziz, Duaa Abduljabbar, Kushala WM Abeysekera, Robbie Adamson. Danielle Adebayo, Aditya Kumar Adhikarla, Maciej Adler, Salman Ahmad, Shayan Ahmed, Mostafa Afifi, Ali Akram, Balqees Al Radhi, Ismaeel Al-Talib, Jolomi Alele, Alaa Mohammed Ali, Safa Almusai, Victoria Appleby, Huma Asmat, Sarah Astbury, Ali Atkinson, Fakhirah Badrulhisham, Vinay K Balachandrakumar, Alexandra Ball, Moses Banfa, Jeevan Barn, Shahnaz Begum, Katherine Belfield, Oliver Bendall, Rajan Bhandari, Prashan Bhatti, Meg Bradley. Paul Brennan, Edward Brown, Kathleen Bryce, Laura Burke, Roisin Campbell, Tamsin Cargill, Geraldine Carroll, James Cartledge, Devnandan Chatterjee, Rayan Chaundry, Zeshan Choudhry, Kathleen Clare, Jeremy Cobbold, Robert Coburn, Fintan Corvan, Rebecca Cox, Darren Craig, John Creamer, Christopher Curran, Shanika De Silva, Laurence Dean, Jayne Dillon, Rebecca Dunn, Robert Eckersley, Gidveig Eike, Amul Elagib, Ayman Elkholi. Omar Elshaarawy, Sarah Faloon, Francis Fan, Mohammad Fazili, Denzil Fernandes, James Fox, Matthew Foxton, Waqas Gaba, Girish Gaikwad, Abishek Gairola, Vasileios Galanakis, Charles Gallaher, Nisham Gautam, Lewis Germain, Ben Giles, Ceri Gill, Ben Glover, John Glover, David Gomez, Michael Gomez, Victoria Gordon, Sarah Gormley, John Goulder, Simran Goyal, Olivia Greenham, Sarah Guthrie, Richard Hackett. Yazan Haddadin, Andreas Hadjinicolaou, Jonathan Hall, Tasnuma Haque, Tim Hardy, Rebecca Harris, Catherine Hart, Syed Mujtaba Hasnain Nadir, James Hassall, Sundas Hasan, George Hawker-Bond, Jake Hawkyard, Scott Healey, Catherine Hornby, Mohammed Hamza, MD Humayun, John Hutchison, Zahra Iftikhar, Asem Ismail, Joel James, Laura Jopson, Dipal Juthani, Philippa Kaina, Aadil Karim, Syed Misbah Karim, Vaishnavi Kashyap, Mohamed Kassab. Dev Katarey, Lee Kenny, Georgina Kerry, Adnan Khan, Ayesha Khan, Azab Khan, Muhammad Taha Khan, Tahir Khan, Aseil Khatib, Mohammad Fawad Khattak, Ji Jade King, Mohammed Korani, Sreelakshmi Kotha, Emily Kooner, Wai Liam Lam, Mohammed Lateef, Damien Leith, Wenhao Li, Angela Liaros, Floyd Lourenco, Annabel Lyles, Midusa Mahenthiran, Ciaran Magee, Daniel Maggs, Aarani Mahalingam, Rizwan Mahmood, Mandour Omer Mandour. Namita Manocha, Dina Mansour, Daniella Marks, Thomas Marjot, Ciara Martin, Harry Martin, Iana Martin, Katherine Martin, Sachan Maruthan, Rhys Masin, Denise Mason, Charmaine Matthews, Athina Mavrou, Ema Maxan, Dominic Maxfield, Emma McAvoy, Kirsty McColl, Hannah McCaughan, Roger McCorry, John McGoran, Stewart McDonald, Hannah McDowell, Stewart McIlwane, Olivia Meakin, Leila Mebarek, Hannah Merrill, Stephanie Michail. Pedram Modarres, Alaa Mohamedali, Yaser Mohammed, Zakiuddin Mohammed, Jaiganesh Mohan, Chloe Monnier, Eilis Moran, Gary Morrison, Francesca Moroni, Anas Msaddi, Sarah Mutar, Janardhan Navaratnam, Luis Neto-Pereira, Ismail Nahed, Jennifer Ng, Chinonso Nwoguh, Rebecca O’Kane, Sohail Omar, Abosede Ososanya, Jay Patel, Marinos Pericleous, Zeshan Pervais, Anju Phoolchund, Julian Pietrzycki, Lushen Pillay, Kiran Prabhu. Yesita Rizky F. Putri, Umang Qazi, Khizar Khalid Rafique, Krithivasan Raman, Vaishali Ranade, Francesca Rastelli, Elizabeth Ratcliffe, Deepa Rattehalli, Tufail Raza, Amir Razak, Arun Raghuraman, George Read, Anne Robins, Simon Rushbrook, Mohamed Salama, Louise St. Aimee, Ramasamy Saravan, Srishti Sarkar, Emma Saunsbury, Solange Serna, Hassnain Shahzad, Mohammed Shamsaldeen, Mohammed Sharip, Jessica Shearer, Adam Sheikh, Giovanna Sheiybani, Abhishek Sheth. Michelle Sherwin, Nidhi Shintre, Saket Singhal, Rohit Sinha, Ricky Sinharay, Gloria Smith, Ria Smith, Joanne Spicer, Johannes Spoor, Shiva Sreenivasan, Amar Srinivasa, Ankur Srivastava, Georgia Stagg, Jatinder Stanley, Jason Stevenson, Daniel Stokes, Robert Stroud, Mohsan Subhani, Hiba Suliman, Marium Sultana, Nikki Summers, Chloe Sutherland, Rachael Swann, Lynne Sykes, Mostafa Taha, Kwei Eng Tan. Zohaib Tariq. Joshua Jun Ming Tay, Alison Taylor, Amit Thakor, James Tsang, Zaccharie Tyler, Esther Unitt, Edward Volcek, Jack Wischhusen, Iona Watson, Chris Watters, Gemma Wells, Monika Widlak, Matthew Williams, Hazel Woodland, Louise Wren, Souzana Xyda, Julian Yeh, Alison Young, Jack Shie Jie Yuan. Data analysis: Jane Abbott, Kushala WM Abeysekera, Wenhao Li, Abhishek Sheth, Ricky Sinharay, Giovanna Sheiybani, Oliver D Tavabie. Manuscript preparation: Kushala WM Abeysekera, Amritpal Dhaliwal, Tim Hardy, Victoria T Kronsten, Wenhao Li, Thomas Marjot, James B Maurice, Jeremy S Nayagam, Oliver D Tavabie, Nekisa Zakeri. Senior advisers: Guruprasad Aithal, William Bernal, John Dillon, Brian Hogan, Stuart McPherson, Rebecca Jones, Ian Rowe, Victoria Snowdon.
Funding Guts UK (TRN2021_03).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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