Routinely-collected general practice data are complex, but with systematic processing can be used for quality improvement and research.

BACKGROUND: UK general practice is computerised, and quality targets based on computer data provide a further incentive to improve data quality. A National Programme for Information Technology is standardising the technical infrastructure and removing some of the barriers to data aggregation. Routinely collected data is an underused resource, yet little has been written about the wide range of factors that need to be taken into account if we are to infer meaning from general practice data. OBJECTIVE: To report the complexity of general practice computer data and factors that need to be taken into account in its processing and interpretation. METHOD: We run clinically focused programmes that provide clinically relevant feedback to clinicians, and overview statistics to localities and researchers. However, to take account of the complexity of these data we have carefully devised a system of process stages and process controls to maintain referential integrity, and improve data quality and error reduction. These are integrated into our design and processing stages. Our systems document the query, reference code set and create unique patient ID. The design stage is followed by appraisal of: data entry issues, how concepts might be represented in clinical systems, coding ambiguities, using surrogates where needed, validation and pilot-ing. The subsequent processing of data includes extraction, migration and integration of data from different sources, cleaning, processing and analysis. RESULTS: Results are presented to illustrate issues with the population denominator, data entry problems, identification of people with unmet needs, and how routine data can be used for real-world testing of pharmaceuticals. CONCLUSIONS: Routinely collected primary care data could contribute more to the process of health improvement; however, those working with these data need to understand fully the complexity of the context within which data entry takes place.

A study of cardiovascular risk in overweight and obese people in England.

OBJECTIVES: To report current levels of obesity and associated cardiac risk using routinely collected primary care computer data. METHODS: 67 practices took part in an educational intervention to improve computer data quality and care in cardiovascular disease. Data were extracted from 435,102 general practice computer records. 64.3% (229,108/362,861) of people age 15 y and older had a body mass index (BMI) recording or a valid height and weight record that enabled BMI to be derived. Data about cardiovascular disease and risk factors were also extracted. The prevalence of disease and the control of risk factors in the overweight and obese population were compared with those of normal body weight. RESULTS: 56.8% of men and 69.3% of women aged over 15 y had a BMI record. 22% of men and 32.3% of women aged 15 to 24 y were overweight or obese; rising each decade to a peak of 65.6% of men and 57.5% of women aged 55 to 64 y. Thereafter, the proportion who were overweight or obese declined. The prevalence of ischaemic heart disease, diabetes mellitus and hypertension rose with increasing levels of obesity; their prevalence in those who are moderately obese was between two and three times that of the general population. Systolic and diastolic blood pressure, blood glucose even in non-diabetics, cholesterol and triglycerides were all elevated in the overweight and obese population. CONCLUSION: Based on the recorded data over half of men and nearly half of women are overweight or obese. They have increased cardiovascular risk, which is not adequately controlled by current practice.

Pathogenicity of bacterium, Xenorhabdus nematophila isolated from entomopathogenic nematode (Steinernema carpocapsae) and its secretion against Galleria mellonella larvae.

The entomopathogenic bacterium, Xenorhabdus nematophila was isolated from the hemolymph of Galleria mellonella infected with Steinernema carpocapsae. The bacterial cells and its metabolic secretions have been found lethal to the Galleria larvae. Toxic secretion in broth caused 95% mortality within 4 d of application whereas the bacterial cells caused 93% mortality after 6 d. When filter and sand substrates were compared, the later one was observed as appropriate. Similarly, bacterial cells and secretion in broth were more effective at 14% moisture and 25 degrees C temperature treatments. Maximum insect mortality (100%) was observed when bacterial concentration of 4x10(6) cells/ml was used. Similarly, maximum bacterial cells in broth (95%) were penetrated into the insect body within 2 h of their application. However, when stored bacterial toxic secretion was applied to the insects its efficacy declined. On the other hand, when the same toxic secretion was dried and then dissolved either in broth or water was proved to be effective. The present study showed that the bacterium, X. nematophila or its toxic secretion can be used as an important component of integrated pest management against Galleria.

Problems with primary care data quality: osteoporosis as an exemplar.

OBJECTIVE: To report problems implementing a data quality programme in osteoporosis. DESIGN: Analysis of data extracted using Morbidity Information Query and Export Syntax (MIQUEST) from participating general practices' systems and recommendations of practitioners who attended an action research workshop. SETTING: Computerised general practices using different Read code versions to record structured data. PARTICIPANTS: 78 practices predominantly from London and the south east, with representation from north east, north west and south west England. MAIN OUTCOME MEASURES: Patients at risk can be represented in many ways within structured data. Although fracture data exists, it is unclear which are fragility fractures. T-scores, the gold standard for measuring bone density, cannot be extracted using the UK's standard data extraction tool, MIQUEST; instead manual searches had to be implemented. There is a hundredfold variation in data recording levels between practices. Therapy is more frequently recorded than diagnosis. A multidisciplinary forum of experienced practitioners proposed that a limited list of codes should be used. CONCLUSIONS: There is variability in inter-practice data quality. Some clinically important codes are lacking, and there are multiple ways that the same clinical concept can be represented. Different practice computer systems have different versions of Read code, making some data incompatible. Manual searching is still required to find data. Clinicians with an understanding of what data are clinically relevant need to have a stronger voice in the production of codes, and in the creation of recommended lists.

Microbial control of diamondback moth, Plutella xylostella L. (Lepidoptera: Yponomeutidae) using bacteria (Xenorhabdus nematophila) and its metabolites from the entomopathogenic nematode Steinernema carpocapsae.

Cells and cell-free solutions of the culture filtrate of the bacterial symbiont, Xenorhabdus nematophila taken from the entomopathogenic nematode Steinernema carpocapsae in aqueous broth suspensions were lethal to larvae of the diamondback moth Plutella xylostella. Their application on leaves of Chinese cabbage indicated that the cells can penetrate into the insects in the absence of the nematode vector. Cell-free solutions containing metabolites were also proved as effective as bacterial cells suspension. The application of aqueous suspensions of cells of X. nematophila or solutions containing its toxic metabolites to the leaves represents a possible new strategy for controlling insect pests on foliage.

The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care.

BACKGROUND: Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression DESIGN: Cluster randomised controlled trial (CRT) METHODS: This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education. The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD. A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention. CLINICAL TRIALS REGISTRATION: ISRCTN56023731. ClinicalTrials.gov identifier.

Reducing coronary risk by raising HDL-cholesterol: risk modelling the addition of nicotinic acid to existing therapy.

BACKGROUND AND OBJECTIVES: Reduction in total cholesterol (TC) and LDL-cholesterol (LDL-C) forms one of the principal objectives of most cardiovascular secondary prevention strategies. Many patients being treated with statins, however, have significant residual dyslipidaemia, with many having suboptimal HDL-cholesterol (HDL-C) levels. The addition of nicotinic acid to a statin has been shown to improve this profile, although clinical outcome evidence is currently lacking. This study set out to model the impact of nicotinic acid therapy on cardiovascular risk in these patients, based on Framingham risk assessments on a cohort of patients drawn from UK general practitioner records. METHODS: Cardiovascular risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. 23 262 statin-treated patients with established cardiovascular disease or diabetes were identified and their 4-year Framingham risk was estimated. Patients who had either TC or HDL-C outside the desirable range then had their lipid profile adjusted in accordance with the likely performance of nicotinic acid, and the Framingham risk was then re-assessed. RESULTS: Baseline 4-year coronary risk in the group as a whole was 11.5% (95%CI: 11.4-11.6). After adjustment of the lipid profile, this was reduced to 9.7% (95%CI: 9.6-9.8), a reduction in risk of 15.9% (95%CI: 15.1-16.6). When modelling was limited to those with diabetes or an abnormal treated lipid profile, the magnitude of change was increased to 23-29% depending on sex and subgroup. CONCLUSIONS: Risk factor modelling suggests that raising HDL-C levels using nicotinic acid in statin-treated patients is likely to yield significant incremental clinical benefits. The results of clinical trials currently under way are awaited with interest.

Abnormal lipids in high-risk patients achieving cholesterol targets: a cross-sectional study of routinely collected UK general practice data.

BACKGROUND AND OBJECTIVES: Lipid management in UK general practice targets the achievement of total cholesterol (TC) targets in high-risk individuals. Statins alone have a modest effect on non-LDL-C components of the lipid profile, leaving these patients at significant residual cardiovascular (CV) risk. Improving risk further would require the addition of non-statin therapies. This analysis explores what proportion of the UK population with cardiovascular disease (CVD) and TC levels at or below target may still be at risk because of residual dyslipidaemia. METHODS: CV risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. Patients were categorised according to their prior CV history and use of statins. Mean values and proportions achieving treatment targets were assessed for TC, low density lipoprotein (LDL-C), high density lipoprotein (HDL-C) and triglycerides (TG). RESULTS: In all, 48 499 patients with pre-existing CVD or diabetes were identified. 73% of statin-treated patients and 63% of untreated patients had a TC < or =5 mmol/L. 28.6% of patients treated to a TC target had LDL-C>3 mmol/L. Amongst those with both TC and LDL-C treated to target, 22.5% had low HDL-C and 37.2% had high triglyceride (TG). Within this group, more women than men had abnormal HDL-C (25.4 vs. 20.7%; p<0.0001). Patients with diabetes were more likely than non-diabetics to have abnormalities of both HDL-C (28.9 vs. 16.4%; p<0.0001) and triglyceride (44.9 vs. 29.5%; p<0.0001) despite normal TC and LDL-C. CONCLUSIONS: Around 60% of high-risk patients have residual dyslipidaemias despite achieving the Quality and Outcomes Framework (QOF) TC target. New patterns of treatment are required in order to extend lipid management beyond simple total cholesterol lowering.

Ensuring the Quality of Aggregated General Practice Data: Lessons from the Primary Care Data Quality Programme (PCDQ).

BACKGROUND: There are large numbers of schemes that collect and aggregate data from primary care computer systems into large databases. These data are then used for market and academic research. How the data is aggregated, cleaned and processed is usually opaque. Making the method transparent allows researchers to compare methods, and users of the output to better understand the strengths and weaknesses of the data.Objectives To define the stages of the process of aggregating, processing and cleaning clinical data from multiple data sources. METHODS: Identify errors in design, collection, staging, integration and analysis. RESULTS: An eight step process defined: (1) Design (2) DATA: entry, (3) Extraction, (4) Migration, (5) Integration, (6) Cleaning, (7) Processing, and (8) Analysis. CONCLUSIONS: This eight step method provides a taxonomy to enable researchers to compare their methods of data process and aggregation.

Preventing stroke in people with atrial fibrillation: a cross-sectional study.

BACKGROUND: The annual stroke rate in atrial fibrillation is around 5 per cent with increased risk in those with hypertension, diabetes, left ventricular dysfunction and other cardiovascular risk factors. This study set out to identify the patients with atrial fibrillation and modifiable risk factors for stroke. METHOD: Analysis of practice computer data taken from eight general practices (81 811 patients) in the south of England. 944 patients with a diagnosis of atrial fibrillation, of whom 782 (82.8 percent) were aged 65 years and over. RESULTS: The age standardised prevalence of diagnosed atrial fibrillation was 1.23 per cent (1.28 percent for men and 1.18 percent for women). It was much more prevalent in the older population, 8.28 percent and 6.66 percent for males and females over 65, respectively. Cardiovascular co-morbidities were more frequent with increasing age. Blood pressure (BP) was recorded in over 95 per cent of patients with atrial fibrillation though there was scope for improving control; 25 per cent of men and 31 per cent women had a BP over 150/90. Inconsistent recording of ECG and echocardiography made it hard to identify patients with left ventricular dysfunction. Forty six percent of men and 37 percent of women were either being prescribed Warfarin, or had contraindications to its use; of those on Warfarin 75.9 percent have an international normalized ratio in range. Forty four per cent were treated with aspirin. People at high risk of stroke were no more likely to be treated with Warfarin or aspirin than those at moderate risk. CONCLUSIONS: The rate of use of Warfarin remains low, and there is scope for better recording and management of risk factors particularly BP.

Identifying patients with chronic kidney disease from general practice computer records.

BACKGROUND: Chronic kidney disease (CKD) is an important predictor of end-stage renal disease, as well as a marker of increased mortality. The New Opportunities for Early Renal Intervention by Computerised Assessment (NEOERICA) project aimed to assess whether people with undiagnosed CKD who might benefit from early intervention could be identified from GP computer records. METHODS: The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (GFR) and determine stage of CKD in patients from 12 practices in Surrey, Kent and Greater Manchester with SCr recorded in their notes. Further data were extracted on associated co-morbidities and potentially modifiable risk factors. RESULTS: One quarter (25.7%; 28,862/112,215) had an SCr recorded and one in five (18.9%) of them had a GFR <60 ml/min/1.73 m2 (equivalent to Stage 3-5 CKD), representing 4.9% of the population. Only 3.6% of these were recorded as having renal disease. Three-quarters (74.6%; 4075/5449) of those with Stage 3-5 CKD had one or more circulatory diseases; 346 were prescribed potentially nephrotoxic drugs and over 4000 prescriptions were issued for drugs recommended to be used with caution in renal impairment. CONCLUSIONS: Patients with CKD can be identified by searching GP computer databases; along with associated co-morbidities and treatment. Results revealed a similar rate of Stage 3-5 CKD to that found previously in the USA. The very low rate of recording of renal disease in patients found to have CKD indicates scope for improving detection and early intervention.

An educational intervention to improve data recording in the management of ischaemic heart disease in primary care.

BACKGROUND: Gaps in computerized medical records and a lack of a systematic approach to data recording make progress towards achieving quality standards in primary care difficult to demonstrate. The aim of this study was to examine the effect of an educational intervention on data quality in primary care. METHODS: A before-and-after study of key data quality measures was carried out in 87 general practices in eight primary care organizations in England in phase 1 and 84 general practices in phase 2. The subjects were 19,470 patients with ischaemic heart disease in phase 1 and 19,784 patients in phase 2. The main outcome measures were improvement in the completeness and quality of the computerized medical record. Anonymized data were extracted from clinical information systems and processed to produce comparative information on each practice. Data quality workshops were arranged, in which reflection can take place, backed up by summary statistics. Practice visits provided training and personalized feedback of patients needing intervention. RESULTS: In the patients with heart disease, nearly 16,000 new clinical entries were made in the key improvement areas. The percentage of patients advised to quit smoking increased by 49.3 per cent, from 23.6 per cent to 61.9 per cent. There were also significant improvements in many other aspects of management. CONCLUSION: Focused interventions that provide targeted and relevant clinical information can be implemented in primary care. Such interventions can lead to a rise in data quality in primary care, but their effectiveness needs to be further tested in more rigorous research settings such as randomized controlled trials.