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GPRD 2010

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GPRD 2010

  1. 1. Using electronic patient level data in Primary Care Research: stories from our General Practice Research Database experience Evangelos Kontopantelis1 Tim Doran1 Stephen Campbell1 Jose Valderas2 Martin Roland3 Mark Harrison1 David Reeves1 1 National Primary Care Research and Development Centre University of Manchester 2 Department of Primary Health Care, University of Oxford 3 General Practice and Primary Care Research Unit, University of Cambridge NPCRDC, 15th June 2010 Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 1 / 39
  2. 2. Outline 1 Background Electronic patient records (EPR) Quality and Outcomes Framework Primary Care databases 2 GPRD Data details Extracting the information 3 Our research Synopsis Disease prevalences Clinical quality indicator performance Exception reporting Co-morbidity and workload 4 Summary Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 2 / 39
  3. 3. Background Electronic patient records (EPR) Times are changing! Tarzan no want computer Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 4 / 39
  4. 4. Background Electronic patient records (EPR) Advantages of using EPRs ...and disadvantages They have the potential to bring huge benefits to patients. can speed up clinical communication. reduce the number of errors. assist doctors in diagnosis and treatment Quality of research can be augmented with the added level of detail. patient level factors can be taken into account. subgroup analyses are made easy. statistically, analyses can be more powerful. But... (even more) confidentiality issues arise. the structure of the data might require much work and advanced computer skills. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 5 / 39
  5. 5. Background Electronic patient records (EPR) What is happening in the UK ...it may take a while though Implementing EPR systems is one of the main aims of the 10-year National Programme for Information Technology (NPfIT), launched in 2002. Connecting for Health, the organisation responsible for delivering NPfIT. The main idea is to create a shared patient record divided into two levels: the Detailed Care Record (DCR) - held locally. the Summary Care Record (SCR) - held nationally. Initially, it will hold only basic info (allergies, adverse reactions & prescriptions). Project core is the development of a national system which will involve replacing obsolete local IT systems across the NHS and linking up-to-date systems together. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 6 / 39
  6. 6. Background Quality and Outcomes Framework Computers and GPs DO mix! if lucky you can still get scribbled illegible notes on your prescription A voluntary pay-for-performance program (QOF) kicked off in 2004 with the introduction of a new GP contract, which required practices to become computerised. A high percentage of practices was already computerised by then (helped by PCTs, own initiative etc). Initial investment £1.8 bn for 3 years (increasing GP income by up to 25%) motivated laggard practices. Now over 99.9% of English practices are computerised and participating in QOF (but using various systems: Emis, Seetec, ViSion etc). READ codes - a coded thesaurus of clinical terms - enable GPs to make effective use of the systems and leave freetext behind. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 7 / 39
  7. 7. Background Quality and Outcomes Framework QOF details according to the rumour mill the scheme that pays GPs to do their job...twice General practices rewarded for achieving a set of quality targets for patients with several chronic conditions. Aim was to increase overall quality of care and to reduce variation in quality between practices. 146 quality indicators. Clinical care for 10 chronic diseases (76 indicators). Organisation of care (56 indicators). Additional services (10 indicators). Patient experience (4 indicators). Into the 7th year now (01Mar10/31Apr11); cost for the first 6 years was well above the estimate at £5.8 bn approx. QOF is reviewed at least every two years. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 8 / 39
  8. 8. Background Quality and Outcomes Framework Some of the indicators for diabetic patients. Percentage of diabetics... with a record of HbA1c in previous 15 months (3p). in whom last HbA1c is ≤7.4 in previous 15m (16p). who have a record of BP in the past 15m (3p). in whom the last BP is ≤145/85 (17p). with a rec of serum creatinine testing in previous 15m (3p). who have a record of total cholesterol in previous 15m (3p). whose last measured total cholesterol in previous 15m is ≤5mmol/l (6p). who have had influenza immunisation in the preceding 1Sep-31Mar (3p). Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 9 / 39
  9. 9. Background Primary Care databases The General Practice Research Database GPRD - not for profit Established in 1987, with only a handful of practices. Since 1994 owned by the Secretary of State Health. In April 2010: 545 active practices (ViSion system only). 11.20M patients. Sample of 100k patients can be obtained for ’free’ (MRC funds up to 50 approved academic proposals per year). Costs vary for larger samples; our 600k patients sample cost £32,000 and is tied to a specific - albeit vague - research proposal (QOF related). Access to the whole database is offered (ability to extract data for approved projects) and costs £127,000 per annum. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 10 / 39
  10. 10. Background Primary Care databases The Health Improvement Network database THIN - commercial A collaboration between In Practice Systems Ltd (INPS) and EPIC. In April 2010: 428 active practices (ViSion system only, 50-60% overlap with GPRD). 8.70M patients. Usually offered under a 4-year licence which costs £119,000. Similar to GPRD (judging by a very small sample) and they promise to offer more patient characteristics (using the patient’s home postcode). Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 11 / 39
  11. 11. GPRD Data details The single source of truth... ...not Sorry, you are not in the database Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 13 / 39
  12. 12. GPRD Data details Why we needed GPRD Interested in longitudinal data from 1999 to 2007: 270 active practices with GPRD in the whole period. We set out to measure the effect of QOF on incentivised and non-incentivised aspects of clinical quality of primary care. We needed GPRD since there are considerable advantages over the NHS published QOF data (QMAS): data availability prior to the introduction of QOF ability to construct non-incentivised indicators of quality ability to focus on a gender or specific age groups. Sampled 1,000 patients from each of 100 ’representative’ UK practices. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 14 / 39
  13. 13. GPRD Data details The 100,000 patients ’free’ sample Database broken down to numerous tables, because of the volume of the data (4GB). Text files need to be imported into powerful analysis/database management software. Some of the information available: Patient birthyear, sex, marital status, smoking/drinking status, height, weight and BMI. Clinical, referral, therapy, test, immunisation and consultation events. All events are entered in codes (lookup tables available). Everything (likely to be recorded by a GP) can be identified; provided one knows which codes to look for and in which tables! BUT a manual search on all the codes is not possible (the READ codes alone are 98,031) and automated processes are required. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 15 / 39
  14. 14. GPRD Data details The main GPRD tables and relationships between them Event files. Clinical: all medical history data (symptoms, signs and diagnoses). Referral: information on patient referrals to external care centres. Immunisation: data on immunisation records. Therapy: data relating to all prescriptions issued by a GP. Test: data on test records. Lookup files. Medical codes: READ codes, 98,031 available. Product codes: 77,198 available. Test codes: 304 available. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 16 / 39
  15. 15. GPRD Extracting the information Our approach Size of the tables prohibits looking at codes one by one. Instead we use search terms to identify potentially relevant codes in the lookup tables and create draft lists. Example (Search terms for diabetes) String search in Medical codes: ’diab’ ’mell’ ’iddm’ ’niddm’. READ code search in Medical codes file: ’C10’ ’XaFsp’. String search in Product codes file: ’insulin’ ’sulphonylurea’ ’chlorpropamide’ ’glibenclamide’. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 17 / 39
  16. 16. GPRD Extracting the information Our approach ...continued Clinicians go through the draft lists and select the relevant codes. Three sets of codes are created, corresponding to: QOF criteria. Conservative criteria. Speculative criteria. Using the finalised code lists we search for events in the Clinical, Referral, Immunisation, Therapy and Test files. The whole process involves much work in code writing, therefore usage of an appropriate statistical package like STATA or SAS is essential. Diabetes code example Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 18 / 39
  17. 17. GPRD Extracting the information Moving on to the bigger sample Once all the processes were in place and we were ’confident’ about our estimates... ...code lists were communicated to GPRD and they extracted a snapsot of the database using the specific codes. Final GPRD sample holds data on 660,565 patients, from 150 ’representative’ UK practices. Power analyses on the original sample informed our decision on the numbers of practices and patients required. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 19 / 39
  18. 18. Our research Synopsis It all starts with a grant... They're harmless when they're alone but get a bunch of them together with a research grant and watch out Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 21 / 39
  19. 19. Our research Synopsis What GPRD has done for us after some convincing... Estimated year on year prevalence scores for various conditions. Generated trends for practice performance on clinical quality indicators. Examined the effect of QOF on incentivised and non-incentivised aspects of quality of primary care. Investigated the reasons of exception reporting in QOF (and their timing). Created co-morbidity mappings of the available patients. Measured the workload associated with each condition (including co-morbidities). Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 22 / 39
  20. 20. Our research Disease prevalences Prevalence Based on conservative criteria 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 Percentage Prevalence Asthma CHD COPD Depression Diabetes Hypertension Hypothyroidism Osteoarthritis Osteoporosis Stroke Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 23 / 39
  21. 21. Our research Clinical quality indicator performance QOF measurement/recording indicator example DM11: % who have a record of BP in the previous 15 months (3p). Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 24 / 39
  22. 22. Our research Clinical quality indicator performance QOF treatment indicator example DM18: % who have had influenza immunisation in the preceding 1 Sep-31 Mar (3p). Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 25 / 39
  23. 23. Our research Clinical quality indicator performance QOF outcome indicator example DM6: % in whom last HbA1C is ≤7.4 in the previous 15 months (16p). Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 26 / 39
  24. 24. Our research Clinical quality indicator performance Inc vs non-inc clinical aspects of primary care Two aspects to clinical indicators: a disease condition (e.g. diabetes, CHD). a care activity (e.g. influenza vaccination, BP control). Three indicator classes, in terms of incentivisation: (A) Condition & process incentivised within QOF (28 ind) (B) Condition or process incentivised (13 ind) (C) Neither condition nor process incentivised (7 ind) Three different types of activities: clinical processes related to measurement (PM/R). e.g. blood pressure measurement clinical processes related to treatment (PT). e.g. influenza immunisation intermediate outcome measures (I). e.g. control of HbA1c to 7.4 or below We end up with 48 indicators in six indicator groups. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 27 / 39
  25. 25. Our research Clinical quality indicator performance Inc vs non-inc clinical aspects of primary care A-PM/R: fully inc recording process. Hypertension & BP A-PT: fully inc treatment process. COPD & influenza immunisation A-I: fully incentivised indermediate outcome. DM & BP of 145/85 or less B-PM/R: partially inc recording process. PAD & total cholesterol B-PT: partially inc treatment process. CRD & influenza immunisation C-PT: non-inc treatment process. back pain & strong analgesics 20 30 40 50 60 70 80 90 100 % 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 Year A−PM/R (17) A−PT (6) A−I (5) B−PM/R (9) B−PT (4) C−PT (7) using group means of indicator means (by practice) in brackets, the number of indicators in each group Percentage scores Indicator group performance Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 28 / 39
  26. 26. Our research Clinical quality indicator performance Inc vs non-inc clinical aspects of primary care Short term (2004/05): Overall, all three groups of fully incentivised indicators exhibited performance above the pre-QOF expectation. (from 1.1% to 38.2% with 4 smoking indicators having uplifts of over 30%). Partially incentivised Measurement/Recording indicators demonstrated significantly lower than expected gains, on average. Long term (2006/07): Overall, the three fully incentivised groups continued to perform above the expectation, although none exceeded 4%. The three partially incentivised and non-incentivised groups displayed significantly negative uplifts, on average. Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 29 / 39
  27. 27. Our research Exception reporting Exceptions timing Exception reporting is considered a safeguard against patient discrimination. There is interest in... the patients who are excepted from QOF. whether practices use ER as a ’gaming’ tool (timing/reason). ’met exceptions’. 0200400600800 Frequency April 04M ay 04 June 04July 04 August04 Septem ber04 O ctober04 N ovem ber04 D ecem ber04 January 05 February 05 M arch 05April 05M ay 05 June 05July 05 August05 Septem ber05 O ctober05 N ovem ber05 D ecem ber05 January 06 February 06 M arch 06April 06M ay 06 June 06July 06 August06 Septem ber06 O ctober06 N ovem ber06 D ecem ber06 January 07 February 07 M arch 07 first record of exception reporting in year, for each patient using GPRD Exceptions over time, ages 60+ Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 30 / 39
  28. 28. Our research Exception reporting Exceptions timing 0 10 20 30 40 50 60 70 80 90 100 % 01ja n2006 01apr2006 01ju l2 006 01oct2006 01ja n2007 01apr2007 Date Reported achievement, excluding all exceptions IQR Total exception reporting rate IQR % of unmet exceptions in exception total Excluding all exceptions RA & ER for STROKE8 STROKE8: % of stroke patients with last chol meas ≤5mmol/l Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 31 / 39
  29. 29. Our research Exception reporting Exceptions QOF conditions multimorbidity Multimorbidity count No Yes Total % ER No Yes Total % ER No Yes Total % ER 0 0 934 934 ‐ 0 624 624 ‐ 0 1,085 1,085 ‐ 1 70,177 1,843 72,020 2.6% 72,411 2,216 74,627 3.0% 71,278 2,889 74,167 3.9% 2 22,910 1,330 24,240 5.5% 24,239 1,558 25,797 6.0% 25,896 1,815 27,711 6.5% 3 10,003 765 10,768 7.1% 10,514 892 11,406 7.8% 11,987 1,049 13,036 8.0% 4 4,084 448 4,532 9.9% 4,345 487 4,832 10.1% 5,491 627 6,118 10.2% 5 1,421 232 1,653 14.0% 1,581 223 1,804 12.4% 2,204 296 2,500 11.8% 6 450 82 532 15.4% 498 100 598 16.7% 845 144 989 14.6% 7 103 27 130 20.8% 155 28 183 15.3% 298 69 367 18.8% 8 28 6 34 17.6% 31 9 40 22.5% 75 13 88 14.8% 9 3 1 4 25.0% 4 2 6 33.3% 20 5 25 20.0% 10 ‐ 2 0 2 0.0% 5 1 6 16.7% Total 109,179 5,668 114,847 4.9% 113,780 6,139 119,919 5.1% 118,099 7,993 126,092 6.3% 2006/072004/05 2005/06 Exception reported Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 32 / 39
  30. 30. Our research Exception reporting Exceptions reasons and ’met exceptions’ 40 50 60 70 80 90 100 Percentages of 'met exceptions' in total / by reason of exception 0 10 20 30 40 50 60 70 80 90 100 Percentages of 'met exceptions' in total / by reason of exception no consent/refusal unsuitable/contraindicated Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 33 / 39
  31. 31. Our research Co-morbidity and workload Co-morbidity co-morbidites Thursday October 1 12:14:12 2009 Page 1 ___ ____ ____ ____ ____tm /__ / ____/ / ____/ ___/ / /___/ / /___/ Statistics/Data Analysis User: Evan Project: GPRD conservative estimates (where applicable) and QOF year 2006/07 CHD DM Strk 45+ HRT Lith Dem Depr Asth COPD PAD HT 17.6 17.2 8.4 94.2 3.1 0.2 1.2 22.8 9.0 4.4 2.4 56.2 56.4 59.0 29.3 19.9 20.6 40.0 19.8 17.7 40.1 58.2 CHD 20.3 12.4 98.1 1.9 0.1 1.7 24.9 10.5 7.5 4.6 20.8 27.4 9.5 3.7 5.3 17.5 6.8 6.5 21.3 35.1 DM 8.5 88.6 1.7 0.3 1.2 24.0 9.4 4.4 3.1 18.2 8.4 3.4 9.7 12.3 6.3 5.6 12.1 23.4 Stroke 97.5 1.3 0.1 4.9 27.6 9.0 7.1 4.7 4.3 1.2 2.0 22.6 3.4 2.5 9.1 16.3 45orover 4.4 0.2 0.9 21.5 7.5 3.4 1.2 91.3 78.5 99.7 59.8 47.3 97.9 96.7 HRT 0.3 0.1 38.7 11.2 2.0 0.5 4.9 0.5 5.2 3.4 2.8 1.8 Lithium_therapy 2.4 76.9 9.7 2.2 0.8 0.6 0.5 0.2 0.2 0.2 Dementia 32.0 5.2 4.7 2.9 0.8 0.3 1.3 2.2 Depression 9.9 2.9 1.0 22.6 30.7 28.3 Asthma 9.3 0.8 42.8 10.2 COPD 4.4 12.0 first row for each condition/activity: denominator indicated by row second row for each condition/activity: denominator indicated by column i.e. first observation indicates the % of patients with HyperTension, who also have CHD Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 34 / 39
  32. 32. Our research Co-morbidity and workload Workload - consultation type number of appointments Freq. Percent Freq. Percent Freq. Percent Acute visit 1,955 0.35 1,889 0.31 1,771 0.27 Administration 88,119 15.97 102,014 16.69 119,900 18.24 Casualty Attendance 1,021 0.19 985 0.16 897 0.14 Clinic 22,694 4.11 23,901 3.91 24,506 3.73 Discharge details 1,614 0.29 1,476 0.24 1,580 0.24 Emergency Consultation 940 0.17 759 0.12 731 0.11 Follow‐up/routine visit 1,226 0.22 864 0.14 746 0.11 Letter from Outpatients 31,075 5.63 37,500 6.14 39,482 6.01 Mail from patient 482 0.09 954 0.16 953 0.14 Mail to patient 477 0.09 757 0.12 711 0.11 Night visit, Deputising service 18 0 15 0 12 0 Night visit, Local rota 17 0 4 0 2 0 Other 89,128 16.15 103,406 16.92 112,331 17.09 Out of hours, Non Practice 854 0.15 994 0.16 1,289 0.2 Out of hours, Practice 58 0.01 58 0.01 115 0.02 Repeat Issue 109,711 19.88 110,196 18.03 107,029 16.28 Results recording 66,433 12.04 78,722 12.88 88,764 13.51 Surgery consultation 122,964 22.29 131,625 21.54 136,425 20.76 Telephone call from a patient 6,664 1.21 7,552 1.24 8,026 1.22 Telephone call to a patient 3,443 0.62 3,977 0.65 4,130 0.63 Third Party Consultation 2,841 0.51 3,456 0.57 7,861 1.2 Total 551,734 100 611,104 100 657,261 100 Freq. Percent Freq. Percent Freq. Percent Acupuncturist 0 0 359 0.06 467 0.08 2006/07 2006/07 2005/06 2005/06 2004/05 2004/05 Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 35 / 39
  33. 33. Our research Co-morbidity and workload Workload - health worker number of appointments Freq. Percent Freq. Percent Freq. Percent Freq. Percent Freq. Percent Freq. Percent ncturist 0 0 359 0.06 467 0.08 Hospital Nurse 22 0 29 0.01 21 0 strator 39,242 7.71 49,713 8.71 53,876 8.71 Interpreter/Link Worker 7 0 7 0 20 0 nt 6,614 1.3 7,754 1.36 8,779 1.42 Locum 10,816 2.13 10,310 1.81 10,550 1.71 ate 4,026 0.79 5,127 0.9 3,652 0.59 Maintenance staff 55 0.01 8 0 15 0 ss Manager 923 0.18 1,020 0.18 1,417 0.23 Midwife 167 0.03 282 0.05 349 0.06 odist 189 0.04 92 0.02 59 0.01 Other Health Care Professional 24,900 4.9 31,283 5.48 36,573 5.91 ercial Deputising service 22 0 18 0 35 0.01 Partner 93,973 18.47 104,501 18.32 115,918 18.74 unity Nurse 1,651 0.32 1,930 0.34 2,569 0.42 Pharmacist 2,157 0.42 2,195 0.38 2,040 0.33 unity Psychiatric Nurse 209 0.04 133 0.02 133 0.02 Physiotherapist 299 0.06 349 0.06 240 0.04 ter Manager 3,125 0.61 3,964 0.69 4,933 0.8 Practice Manager 20,396 4.01 21,616 3.79 21,337 3.45 tant 414 0.08 342 0.06 444 0.07 Practice Nurse 54,697 10.75 60,036 10.52 61,118 9.88 llor 833 0.16 779 0.14 765 0.12 Receptionist 150,926 29.67 165,525 29.02 187,014 30.23 an 263 0.05 291 0.05 277 0.04 School Nurse 166 0.03 136 0.02 150 0.02 ser 12,444 2.45 15,482 2.71 15,779 2.55 Secretary 31,762 6.24 31,376 5.5 30,654 4.96 Manager 695 0.14 189 0.03 58 0.01 Senior Partner 37,152 7.3 42,289 7.41 43,544 7.04 istrar 8,116 1.6 10,374 1.82 12,385 2 Social Worker 2 0 0 0 3 0 Education Officer 34 0.01 26 0 49 0.01 Sole Practitioner 2,208 0.43 2,716 0.48 3,131 0.51 Visitor 176 0.03 221 0.04 204 0.03 Total 508,681 100 570,472 100 618,558 100 2004/05 2005/06 2006/07 2004/05 2005/06 2006/07 Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 36 / 39
  34. 34. Summary Overview So, GPRD then? Advantages... Patient level data; breakdown by age, sex, year of diagnosis etc Data on many time points are available. We are able to extract/create data not available anywhere else. Available now (with trustworthy data for a few years back). Disadvantages... Too much work! Not cheap. Only a sample of all English practices participates. Practices are anonymised and controlling analyses for practice characteristics can be a struggle. Absolute reliance on codes and GPs getting them right... Quality of data before the introduction of QOF is questionable. Too much work! (but you become everyone’s new best friend...) Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 38 / 39
  35. 35. Summary Still a long way to go! Something goes around something but that's as far as I've got... Comments: e.kontopantelis@manchester.ac.uk Kontopantelis (NPCRDC) GPRD & patient level data 15 June 2010 39 / 39

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