Transcript Pandora's Box

Centralised Data
Extraction from Practices
– Pandora’s Box ?
Dr John Steyn
Clinical eHealth Adviser, Lothian
Retired GP
“The cynic knows the price of
everything, and the value of
nothing”
Oscar Wilde
Data in Primary Care
League
Media
Table
manipulation
Consent
Data in Primary Care
 PTI
 60
– Practice Team Information
Practices – 6% of population
 Data
on 47 practices
 >1,000
practices in Scotland
Primary Care Data
 Primary
Care Clinical Informatics Unit
(PCCIU) – Aberdeen
 ISD
& University of Aberdeen
 Technique
 2009
– 191 Scottish Practices
 GPass
Lothian
Total
126
880,000
General Practices
25,170
to 235
Lothian
 Planned
Admissions – 111,000
 Emergency
Admissions – 75,000
Primary Care Data
GP
– 5,400,000
Health Service – 1,022,000
 Out Patient attendances – 1,013,000
 A&E attendances – 231,000
 NHS 24 contacts – 186,000
 LUCS contacts – 114,000
 Planned Admissions – 111,000
 Emergency Admissions – 75,000
 Community
Primary Care Data
 QOF (Quality & Outcomes Framework)
 GP
– 17.5% are QOF
 Practice
 78%
Nurses – 31% are QOF
of consultations NOT in QOF
Practice – 6,730 list
Prevalence of Disease
 Hypertension
 Asthma
 Kidney Disease
 Heart Disease
 Diabetes
 Stroke
 Prostate cancer
1,234
420
305
300
263
199
26
QOF – Quality and Outcomes
Stroke
Diabetes
 2013
16,319
34,256
 2005
13,907
24,764
17.3%
38.3%
 UP
QOF – Quality and Outcomes
Hypertension
 2013
106,527
 2005
87,498
 UP
21.7%
19,029
QOF – Quality and Outcomes
Heart Disease
 2013
30,222
 2005
32,891
 DOWN
8.1%
QOF – Quality and Outcomes
Hypothyroidism
 2013
23,593
 2005
19,770
 UP
3,823
Primary Care Data

NHS Lothian

Laboratory Data

Methodology incl Info Governance

Thyroid Function Tests
PSA (Prostate Specific Antigen)
Cholesterol
FSH / LH



Thyroid testing
Over 65
%
25
Prevalence
%
4.53
Testing
/ 100 pts
20.4
14.8
2.80
16.5
1
0.37
3.1
Thyroid testing
Over 65
%
24
16
16
15
22
Prevalence
%
4.53
4.49
4.27
3.91
3.89
Testing
/ 100 pts
20.4
38.9
33.8
28.4
22.6
Thyroid testing
Over 65
%
1
3
4
4
7
Prevalence
%
0.37
0.64
0.90
1.03
1.07
Testing
/ 100 pts
6.9
4.8
8.8
5.2
13.0
Primary Care Data
 Laboratory
 Thyroid
Data
Function Tests
 12
highest prevalence of Hypothyroidism
 6 in highest rate of testing
 12
lowest prevalence of Hypothyroidism
 5 in lowest rate of testing
Thyroid - Lessons
 If
don’t test, won’t diagnose
 Informed
 Clinical
comparison with peers
interpretation important
Cholesterol testing
No of Tests / Pts 45
1.08
0.47
0.24
160,720
Cholesterol testing
No of Tests / Pts 45
1.08 KW
0.93 KW
0.93 KW
0.87
0.84
Keep Well
Cholesterol testing
No of Tests / Pts 45
0.24
0.26
0.28
0.29
0.34
High elderly
High elderly
High elderly
Cholesterol - lessons
Clinical interpretation essential
Need to know that no need to
check in over 85’s
Emergency Admissions
 Impact
of minute change in Primary
Care
HF – 962 admitted, 4,500 not admitted
 COPD – 2,230 admitted, 11,300 not admitted

 If
slight increase in admissions,
massive impact
Admissions - In and Out of Hours
GP
In Hours
OOH
NHS 24
Direct
1%
18%
LUCS
NHS 24
Direct
26%
29%
45%
81%
Dementia - Midlothian
Data
on all patients from
Primary Care over 65 with a
coded diagnosis of dementia
Dementia - Midlothian
Nearly a third of hospital
episodes for patients from the
dementia cohort did not include
a code for dementia in any of
the diagnosis fields.
Dementia If hospital records had been used to
define the cohort of dementia
patients, the crude prevalence
would have been 1.6% v 5.4%,
total health and social care
expenditure on the cohort would
have been £5.2m v £12.1m
Primary Care Data
 Consultation
 Consent
 Access

– GP sub-committee, Practice Managers
of Practice
to data - Practice-based server ie remote
Clinically led – TRUST
Primary Care Data
 COPD
– 77 practices
 Information
 Findings
Governance
Data linkage
Primary care data for patient X
Data for record linkage plus UID
Link to data
from other
datasets at
ISD
Remove
identifiers apart
from UID
Clinical data plus UID
Researcher:
combines
anonymised linked
dataset and primary
care clinical data
Results
77 practices
consented (75%)
49% female
7072
patients
51% male
Mean follow up 4.4 years
1838 died
(26%)
1819 admitted
(26%)
940 (51%)
before first
admission
Adjusted hazard ratios with 95% confidence intervals for
primary care interventions
QOF spirometry
HR 0.46 (95% CI: 0.41-0.53)
QOF FEV measured HR 0.43 (95% CI: 0.37-0.49)
QOF flu vaccine HR 0.50 (95%CI: 0.45-0.56)
QOF inhaler checke HR 0.37 (95%CI: 0.32-0.42)
QOF annual review HR 0.27 (95% CI: 0.24-0.31)
Pneumococcal vaccine HR 0.60 (95%CI: 0.54-0.66)
Self-management plan HR 0.17 (95% CI: 0.11-0.26)
Pulmonary rehab HR 0.21 (95% CI:0.14-0.30)
0.1
Avoids or delays hospital admission
1
10
Shorter time to hospital admission
Comparison of effect on admissions
Intervention
Cochrane Schembri
Reviews
(2009)
Lothian
Cohort
Flu vaccine
 (exacerbations) 

Spirometry

FEV measured

Annual Review

 (at diagnosis)
Inhaler check

Self management plan


Pulmonary Rehab


Pneumococcal vaccine
No effect

Conclusions

Range of interventions in primary care
associated with preventing/delaying first
admission for COPD
 Strong evidence for benefits to NHS (as well
as to patients) of what GPs currently do


being further explored by CSO funded work
Coverage of effective interventions is
incomplete

explore which patient groups should be targeted
Primary Care Data
 QIS
/ Healthcare Improvement Scotland
 Parkinson’s
Disease (PD)
 1,112
people with a diagnosis of PD, and
2,517 people receiving Parkinson’s
medication.
 Many
drugs can be used for >1 disease
Primary Care Data
 QOF
coding has QA
 Non-QOF
 Not
coding – quality / complete
coded – Medication
Primary Care Data
– SPIRE – Is this expensive
duplication….
 SG
 HB
- Vision 360 / Emisweb
Conclusions
 Rich
data but need to be aware of limits
 Need clinical input to interpret
 Need local knowledge to interpret
 NOT
Name and Shame
 Help to inform, and learn…..
 Avoid
League Tables – esp uninformed