1. Evidence Based Decision Making in Primary Care & Public Health
Working with GP data for health improvement in
Wales - realities and reactions
October 2011
Presenter: Dr of presentation on Master
Insert name Paul Myres Primary Care Quality &
Information Service (PCQIS)
Slide

2. What information do we have -
Predicting/ Identifying Areas of Risk
& Good Practice: Practice Profiling
• QOF • Referrals
• Audit • Hospital data
• Questionnaires • No of staff WTEs
• Complaints and • List size per
incidents notional WTE
• Immunisations • Deprivation
• Risk assessment • Income/Cost per
patient

3. Audit+ – What it is
• A centrally funded and supported software tool for
General Practices to:
– improve data quality
– standardise reporting
– support clinical governance
– Measures and contributes to health improvement
• A standardised cross-GP system tool
– Non-mandatory
• Only 3 opt outs out of 484 Welsh practices
– Complies with NHS standards - Read code driven
– Enables comparison between General Practices irrespective of GP system
supplier
• General Practice focused
– Supports LHBs and the rest of NHS Wales as a by-product

4. Audit+ Highlights
– Primary Care Quality Information Service (PCQIS) quality
improvement toolkits
• e.g. INR (Warfarin) Monitoring Directed Enhanced Service
– also supporting 1000 lives initiative
– PCQIS Quality & Outcomes „Prevalence‟
• Age/sex standardised analysis
– PHW Communicable Disease Surveillance Centre
• Seasonal Flu Vaccination Reporting
– 96.3% practices automatically reported in 2009/10
• Weekly Communicable Disease reporting
– Switched to daily for pandemic H1N1 flu surveillance
– On a daily basis 85% practices across Wales reported
• H1N1 Flu Vaccination Reporting
– Rapidly deployed and updated module in line with evolving JCVI
priority groups for vaccination

5. Findings Headline crude rates for diagnosed
conditions
2.0% Stroke TIA
4.1% coronary heart disease
14.9% hypertension
4.8% diabetes
6.6% asthma
2.0%COPD
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

6. Prevalence – variation –Stroke TIA health board, local authority, GP
practice
QOF prevalence of stroke/transient ischaemic attack
(TIA) by local authority area, 2009/10 QOF prevalence of stroke/transient ischaemic attack
Produced by Public Health Wales Observatory 95% confidence interval
using data from Audit+ web (TIA) by health board, 2009/10
Produced by Public Health Wales Observatory 95% confidence
using data from Audit+ web interval
Range of GP practice prevalence age standardised* % crude % Wales* %
Stroke & TIA Wales March 2010 3.0 age standardised* % crude % Wales* %
25
2.5
2.5
20
2.0
2.0
Percentage
Percentage
Wales = 1.3%
15
Wales = 1.3% 1.5
1.5
10
1.0
1.0
0.5
5
0.5
0.0 0.0
0
Denbighshire
Ceredigion
Swansea
Newport
Carm arthenshire
Monm outhshire
Isle of Anglesey
Torfaen
Flintshire
Cardiff
Blaenau Gwent
Cwm Taf
The Vale of Glam organ
Powys
Betsi Cadwaladr
Abertawe Bro
Neath Port Talbot
Pem brokeshire
Conwy
Gwynedd
Bridgend
Merthyr Tydfil
Powys
Caerphilly
Hywel Dda
Aneurin Bevan
Rhondda Cynon Taff
Wrexham
Cardiff and Vale
European age standardised rates (EASR) per 1000 registered population
Morgannwg
* age standardised to European standard population
* age standardised to European standard population
The range is 1.0% to 1.6% of The range from 1.2% to 1.4%
Range from 0.4% to 2.3% of of the registered population,
the population. registered patients.
Crude rates again show more Crude prevalence figures show
variation ranging from 1.6% more variation ranging from
to 2.6% of registered patients. 1.7% to 2.2%
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

7. Prevalence – variation – hypertension health board & local authority
QOF prevalence of hypertension by local authority,
2009/10 QOF prevalence of hypertension by health board,
Range of GP practice prevalence Produced by Public Health Wales Observatory
95% confidence
2009/10
interval
Hypertension Wales March 2010 using data from Audit+ web Produced by Public Health Wales Observatory 95% confidence
using data from Audit+ web interval
200
age standardised* % crude % Wales* %
20 age standardised* % crude % Wales* %
18 20
18
150
16
16
14
Wales = 11.1% 14
Percentage
12
Percentage
Wales = 11.1%
100
12
10
10
8
8
6
6
50
4
4
2 2
0 0
0
Denbighshire
Ceredigion
Swansea
Carm arthenshire
Newport
Monm outhshire
Isle of Anglesey
Flintshire
Torfaen
Cardiff
Blaenau Gwent
The Vale of Glam organ
Neath Port Talbot
Pem brokeshire
Conwy
Powys
Betsi Cadwaladr
Bridgend
Abertawe Bro
Gwynedd
Merthyr Tydfil
Powys
Caerphilly
Cwm Taf
Wrexham
Rhondda Cynon Taff
Aneurin Bevan
Hywel Dda
European age standardised rates (EASR) per 1000 registered population
Morgannwg
Cardiff and Vale
* age standardised to European standard population
* age standardised to European standard population
Range from 3.2% to 20.0% percent ranges from 10.2% to 12.9%
The range is 8.8% to 13.3% of the registered population
of the population. of registered patients.
Crude prevalence show more
crude rates show more variation ranging from 12.4% to
variation ranging from 11.5% 16.4%
to 17.5% of registered patients.
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

8. Results – variation – Gp practices applying S.P.C.
Distribution of GP practice age standardised
prevalence
Distribution of GP practice age standardised prevalence
for Hypertension around the Welsh mean.
for Stroke around the Welsh mean.
Number of all practices v range of prevalance Number of all practices v range of prevalance
No Pracs Min EASR/1000 Max EASR/1000 Ave EASR/1000 No pracs Min EASR/1000 Max EASR/1000 Ave EASR/1000
160 250 350 25
140
300
200 20
EASR per 1000 registered patients
120
EASR per 1000 registered patients
250
Number of practices
Number of practices
100
150 15
200
80
331
137 150
100 10
60 118
108
100
40
50 5
50
20 38
31
18 43 25 15
0 0 0 0
>-3 >-2<-3 between +2 & -2 >+2<+3 >+3 >-3 >-2<-3 between +2 >+2<+3 >+3
Standard deviations from Wales hypertension prevalance mean & -2
Standard deviations from Wales stroke&TIA prevalance mean
Hypertension 52% (226) Stroke & TIA 8% (33)
practices > 3 standard practices > 3 standard
deviations of Wales mean deviations of Wales mean
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

9. Geographical patterns of prevalence - health board
comparison Hypertension QOF v WHS
QOF prevalence of hypertension by health board,
2009/10
Produced by Public Health Wales Observatory 95% confidence Adults who reported currently being treated for high
using data from Audit+ web interval blood pressure (hypertension), health boards, 2008
and 2009
age standardised* % crude % Wales* % Produced by Public Health Wales Observatory
using Welsh Health Survey data
20
30
18
Age standardised+ percentage
16 25
14 Wales = 19.7%
Percentage
Wales = 11.1% 20
12
10 15
8
6 10
4
5
2
0 0
Aneurin Bevan
Betsi Cadwaladr
Powys
Abertawe Bro
Hywel Dda
Cwm Taf
Cardiff and Vale
Powys
Betsi Cadwaladr
Abertawe Bro
Cwm Taf
Morgannwg
Aneurin Bevan
Hywel Dda
Cardiff and Vale
Morgannwg
* age standardised to European standard population
+ age standardised to Wales population
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

10. Geographical patterns of prevalence - health board
comparison Stroke QOF v WHS
QOF prevalence of stroke/transient ischaemic attack
(TIA) by health board, 2009/10
Produced by Public Health Wales Observatory 95% confidence Adults who reported having ever been treated for
using data from Audit+ web interval stroke, Wales health boards, 2008 and 2009
Produced by Public Health Wales Observatory using Welsh Health Survey
age standardised* % crude % Wales* % data
4
2.5
Age standardised+ percentage
2.0 3
Wales = 2.5%
Percentage
Wales = 1.3%
1.5
2
1.0
1
0.5
0.0 0
Aneurin Bevan
Betsi Cadwaladr
Powys
Abertawe Bro
Cwm Taf
Hywel Dda
Cardiff and Vale
Cwm Taf
Powys
Betsi Cadwaladr
Abertawe Bro
Morgannwg
Hywel Dda
Aneurin Bevan
Cardiff and Vale
Morgannwg
* age standardised to European standard population + age standardised to Wales population
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

11. Hypertension V Stroke prevalence
Prevalence hypertension v stroke (inc TIA)
200
180
160
140
120
100
80
60
40
20
0
5 10 15 20 25
Stroke
European age standardised rates per 1000 registered patients
source Audit+ 2010
Primary Care Quality Information Service

12. Findings - Geographical patterns of
prevalence
• The QOF prevalence of diagnosed chronic conditions shows broadly an
expected geographical pattern,
– higher prevalence in more deprived areas such as Cwm Taf and
– lower prevalence in less deprived areas such as Powys.
• Some consistency in the relative position of health board and local
authority areas between QOF and the Welsh Health Survey (WHS).
• Some inconsistent such as
– relatively low prevalence of diagnosed stroke or transient ischaemic
attack (TIA) in Blaenau Gwent,
– relatively low prevalence of diagnosed asthma in Cwm Taf
– relative position for asthma and COPD inconstant with WHS in
Carmarthenshire
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

13. Deprivation V Prevalence
Stroke/TIA Hypertension
200
25
20
Age standardised rate per 1000 patients
150
15
100
10
50
5
-10 -5 0 5 10 -10 -5 0 5 10
Deprivation (Townsend 2001) Deprivation (Townsend 2001)
In this instance the co-efficient value for In this instance the co-efficient value for
Wales is 0.23 Although this association is Wales is 0.35, Although this association is
statistically significant, it is so weak it falls statistically significant, it shows a weak
into the little or no association grade positive correlation or association
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

14. Examining the correlation
between age standardised
prevalence & deprivation
Data from 2006 shows a Weak
positive correlation over all from
206 practices from North, Mid &
West Wales
Spearman Rank Correlation Coefficient By LHB for COPD EASR V Practice Townsend Score
Project Sample
DENBIGHSHIRE
Correlation shown by the former
WREXHAM
LHBs contributing data (Green Bars
ANGLESEY
are the LHBs and the Red overall)
GWYNEDD
POWYS
SWANSEA
NEATH PORT TALBOT
CEREDIGION
PEMBROKESHIRE
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1 EASR per 1000 registered patients. Spearman
COPD Strong Negative Weak Negative(Upper limit) Weak positive (upper limit) Rank correlation co-efficient used
Strong Positive Weak Negative (Lower Limit) Weak Positive (low er Limit)

15. Findings Deprivation V Prevalence
Many conditions demonstrate the expected association with
deprivation, although this association is weak
Calculation of practice deprivation scores may underestimate the
correlation as practice catchment populations span areas of
mixed deprivation levels
It can also highlight pockets of deprivation where a single
practice may serve one specific area of deprivation in, an
otherwise affluent area.
Student populations demonstrate deprived characteristics
through the Townsend index.
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

16. Is QOF providing an equitable service : CHD QOF register coverage V deprivation
GP practices(Wales); Coverage of the QOF CHD register 2009/10 GP practices(Wales); Coverage of the QOF CHD register 2009/10
CHD05 patients with BP recorded (previous 15 months) CHD06 patients last BP (previous 15 months) 150/90 or less
100 100
90 90
80 80
% QOF register covered
70 70
60 least deprived 5th 60
mid three 5ths most deprived 5th
50 50 least deprived 5th mid three 5ths most deprived 5th
40 40
30 30
20 20
10 10
0 0
-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11
Recording BP Cholesterol
Deprivation (Townsend 2001)
-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11
Management BP Cholesterol
Deprivation (Townsend 2001)
GP practices(Wales); Coverage of the QOF CHD register 2009/10
GP practices(Wales); Coverage of the QOF CHD register 2009/10
CHD08 patients last total cholesterol (previous 15 months) 5mmol/l or less
CHD07 patients with record of total cholesterol (previous 15 months)
100
100
90
90
80 80
% QOF register covered
70 70
60 60
50 least deprived 5th mid three 5ths most deprived 5th 50
40 40 least deprived 5th mid three 5ths most deprived 5th
30 30
20 20
10 10
0 0
-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11
-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11
Deprivation (Townsend 2001)
Deprivation (Townsend 2001)

17. Primary care annual report key messages
from effectiveness section
“The systematic, evidence based management of chronic disease in
primary care settings can make a significant contribution to the prevention
of disability and deaths from these conditions.”
LHBs must ensure that:-
•practices have effective case finding approaches
•unmet need is identified and managed
•treatments are effective
•inappropriate variation is minimised
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)

18. Crude rate per 1000 registered patients
AB, 46
CV, 35
Pow, 42
ABMU, 47
CwnTaf , 43
BCU, 39
done?
2007
HywelDda, 43
2008
increasing but look at
QOF more work to be
2009
prevalence model v current
Crude Diabetes prevalence
2010
Mean Health Board Crude prevalance growth 2007-11 Diabetes
9.5%
Isle of Anglesey
4.78%
8.9%
Gwynedd
3.99%
& Information Service (PCQIS)
10.4%
Conwy
2011
5.04%
55
48
56
41
50
52
53
9.6%
Denbighshire
4.81%
8.5%
Flintshire
4.43%
8.5%
Wrexham
4.16%
9.7%
Powys
4.55%
8.6%
Ceredigion
4.29%
9.5%
Pembrokeshire
5.14%
9.5%
Carmarthenshire
5.47%
8.8%
Swansea
APHO Model
4.80%
Presenter: Dr Paul Myres Primary Care Quality
9.8%
Neath Port Talbot
5.81%
9.1%
Bridgend
5.46%
8.5%
QOF register
The Vale of Glamorgan
4.51%
2010 Welsh Counties
7.4%
Cardiff
3.74%
9.2%
Case finding
Rhondda, Cynon, Taff
4.97%
9.9%
Merthyr Tydfil
4.70%
APHO modeled data V Actual QOF registers
9.0%
Caerphilly
5.33%
for 2011 report
10.0%
Blaenau Gwent
6.04%
9.2%
Torfaen
5.61%
Diabetes example
8.9%
Monmouthshire
4.69%
9.0%
Newport
5.07%

19. Unmet need is identified and managed QOF COPD 08 flu immunisation
QOF performance
Wales QoF 2009/10 COPD08
Register performance
Wales QoF 2009/10 Indicator to register COPD08
100
100
Cases as a Percentage of Total Number of patients qualifying
Cases as a Percentage of Total number of patients on the
90
for indicator nett of contract exclusions & Exceptions
90
80
70 80
register for the indicator
60
50 70
40
60
30
Wales GP practices Wales GP practices
Average Average
20
2SD limits 50 2SD limits
3SD limits 3SD limits
10
Health Board Practices Health Board Practices
0 40
0 100 200 300 400 500 600 700 0 100 200 300 400 500 600 700 800
COPD08 Num erator Total num ber of patients on the register for the indicator
Source: QOF 2009/10 Source: QOF 2009/10
Unmet need ? Ave QOF coverage 90% + Coverage of register 78%
Presenter: Dr Paul Myres Primary Care Quality
& Information Service (PCQIS)