Quality achievement and disease prevalence in primary care predicts regional variation in renal replacement therapy (RRT) incidence: an ecological study.

BACKGROUND: Diabetes Meillitus (DM) and hypertension (HT) are important causes of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is the standard active treatment. Financially, incentivized quality initiatives for primary care include pay-for-performance (P4P) in DM and HT. Our aim was to examine any effect of disease prevalence and P4P on RRT incidence and regional variation. METHODS: The incidence of RRT, sex and ethnicity data and P4P disease register and achievement data were obtained for each NHS locality. We calculated correlation coefficients for P4P indicators since 2004/05 and socio-demographic data for these 152 localities. We then developed a regression model and regression coefficient (R(2)) to assess to what extent these variables might predict RRT incidence. RESULTS: Many of the P4P indicators were weakly but highly significantly correlated with RRT incidence. The strongest correlation was 2004/05 for DM prevalence and 2006/07 for HT quality. DM prevalence and the percentage with blood pressure control in HT target (HT quality) were the most predictive in our regression model R(2) = 0.096 and R(2) = 0.085, respectively (P < 0.001). Combined they predicted a fifth of RRT incidence (R(2) = 0.2, P < 0.001) while ethnicity and deprivation a quarter (R(2) = 0.25, P < 0.001). Our final model contained proportion of population >75 years, DM prevalence, HT quality, ethnicity and deprivation index and predicted 40% of variation (R(2) = 0.4, P < 0.001). CONCLUSION: Our findings add prevalence of DM and quality of HT management to the known predictors of variation in RRT, ethnicity and deprivation. They raise the possibility that interventions in primary care might influence later events in specialist care.

Using routinely collected data to evaluate a leaflet campaign to increase the presentation of people with memory problems to general practice: a locality based controlled study.

BACKGROUND: The Alzheimer's Society wished to raise awareness that people with memory problems may benefit from early assessment and diagnosis, so that appropriate measures could be put in place and management improved. OBJECTIVE: To use routinely collected data to determine whether a leaflet campaign to raise awareness of memory problems would result in increased presentation of people with memory problems to their GPs. METHOD: A locality was identified which met the criteria for locating the pilot intervention. A neighbouring locality was identified which used the same secondary care service and could serve as a comparator. Anonymised routinely collected computer data were gathered before and after the intervention. RESULTS: The intervention locality had a much greater proportion of elderly patients and a higher proportion had memory problems recorded at baseline (OR 1.67; 95% CI 1.47-1.91; P<0.001). In both localities just under 40% of people with memory problems had blood tests. Approximately 80% would be referred to secondary care, and this was more likely for those in the intervention group (OR 1.29; 95% CI 0.99-1.93; P=0.044). However, the use of antidepressants was greater in the control locality; 34% vs 9% (OR 0.19; 95% CI 0.13-0.27; P<0.001). Whilst the absolute number of people prescribed cholinesterase inhibitors was greater and increased more in the intervention practices, the proportion of people with memory problems prescribed was not significantly greater (OR 1.21; 95% CI 0.77-1.89; P=0.38). The increased prescribing in the intervention practices was due to people restarting therapy. From a lower baseline there was a greater increase in the control locality for all variables for which we had a before and after measure. CONCLUSIONS: During a leaflet campaign the recording and management of memory problems increased. However, there was greater improvement in the control locality. This study demonstrates the importance of including a control group and the strengths of routine primary care data.

The roles of policy and professionalism in the protection of processed clinical data: a literature review.

BACKGROUND: Routinely collected clinical data is increasingly used for health service management, audit, and research. Even apparently anonymised data are subject to data protection. The relevant principles were set out in a treaty of the Council of Europe and subsequent policy has been based on these. However, little has been written about implementing policy and the role of health informaticians in this process. OBJECTIVE: To define the elements of an effective implementation policy; the role of the health informatician in protecting processed clinical data. METHODS: We performed a literature review of bibliographic databases, a manual search of the major medical informatics associations' websites, relevant working groups and an affiliated journal. Fifty-four papers relevant to implementation were identified. RESULTS: The effective implementation of policy requires consideration of technical, organisational, personnel and professional issues. However, there is no clearly defined formula for successful implementation of data protection policy. CONCLUSIONS: Patients and professionals need a system they can trust, and processes that can be easily incorporated into everyday practice. The lack of a core generalisable theory or strong professional code in health informatics limits the ability of the health informaticians to implement policy.

Variation in clinical coding lists in UK general practice: a barrier to consistent data entry?

BACKGROUND: Routinely collected general practice computer data are used for quality improvement; poor data quality including inconsistent coding can reduce their usefulness. OBJECTIVE: To document the diversity of data entry systems currently in use in UK general practice and highlight possible implications for data quality. METHOD: General practice volunteers provided screen shots of the clinical coding screen they would use to code a diagnosis or problem title in the clinical consultation. The six clinical conditions examined were: depression, cystitis, type 2 diabetes mellitus, sore throat, tired all the time, and myocardial infarction. We looked at the picking lists generated for these problem titles in EMIS, IPS, GPASS and iSOFT general practice clinical computer systems, using the Triset browser as a gold standard for comparison. RESULTS: A mean of 19.3 codes is offered in the picking list after entering a diagnosis or problem title. EMIS produced the longest picking lists and GPASS the shortest, with a mean number of choices of 35.2 and 12.7, respectively. Approximately three-quarters (73.5%) of codes are diagnoses, one-eighth (12.5%) symptom codes, and the remainder come from a range of Read chapters. There was no readily detectable consistent order in which codes were displayed. Velocity coding, whereby commonly-used codes are placed higher in the picking list, results in variation between practices even where they have the same brand of computer system. CONCLUSIONS: Current systems for clinical coding promote diversity rather than consistency of clinical coding. As the UK moves towards an integrated health IT system consistency of coding will become more important. A standardised, limited list of codes for primary care might help address this need.

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.

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.