This symposium has been funded by Boehringer Ingelheim PRIMIS Using primary care data for medicines optimisation and safer prescribing Lauren Fensome PRIMIS Pharmacy Management Regional Roadshow – Bristol 16th September This session has been financially sponsored by BI. Editorial control has remained with PRIMIS but the content has gone through a medical/compliance review by BI. This symposium has been funded by Boehringer Ingelheim UK/GEN-151027b September 2015 Asthma Audit Tool Presentation_V1.0 21st August 2014

PRIMIS is a leader in extracting knowledge and value from primary care data, helping to achieve better health outcomes across the UK PRIMIS is a business unit of The University of Nottingham PRIMIS produces highly effective and practical solutions to help people access, understand and use patient data held on GP IT systems by providing: Software and audit tools Membership, training and consultancy services Started in 2000 we got the NHS contract to: Improve use of computers in primary care Improve data quality Fully Funded by NHS Facilitator model Hub and spoke. Central office Nottingham. Developed audit tools and provided training. Change to CCGs facilitators moved roles and our contract changed. 2013 Move to be a commercial business unit Smaller NHS contract Work with sponsors Many of the PRIMIS audit tools are freely available for use in primary care Analysis and reporting at multiple levels Patient Practice population CCG population (or other groupings) Starts with actual patient level data - a unique dataset Our aim is to transform clinical data into meaningful information about the care of patients, which can then be used to make informed decisions We produce clinical data interfaces that have high impact, making data more accessible to those who can drive change Not just about sucking out data, we ‘playback’ at many different levels Empowering colleagues in general practice and CCGs to engage and prioritise unmet clinical need and improve patient care UK/GEN-151027b September 2015 Diabetes Audit Tool Presentation_V2.0 17th July 2014

Free audit tools available from PRIMIS GRASP-AF GRASP-COPD GRASP-HF Diabetes Care Warfarin Patient Safety Asthma Care Currently we have 6 toolkits freely available. The audits that have a * by them have been updated this year so rather than going into detail about the toolkits, I’ll just cover the changes that have happened since the Pharmacy Management conference last November. UK/GEN-151027b September 2015

Downloads by audit (2015) Audit CCGs Practices GRASP AF 204 3105 GRASP COPD 196 2174 GRASP HF 182 1489 Warfarin Patient Safety 187 1639 Diabetes Care 180 1310 Asthma Care 178 1198 There are 211 CCGs in England covering over 7,600 practices UK/GEN-151027b September 2015

Key changes – GRASP AF Driven by CHA2DS2-VASc in support of NICE Includes all OACs Additional functionality within data views Key changes for users are: anticoagulation data on drug type, contraindications declined codes for warfarin, NOAC (novel oral anticoagulants) and anticoagulant NOS (not otherwise specified) have been separated to improve the information available to clinical decision makers the shading of the rows to indicate high and medium risk patients not on anticoagulation is now driven by CHA2DS2-VASc not CHADS2 a new column grouping/ungrouping option has been added to make navigating the datasheet easier separate warfarin and NOAC graphs for both the CHADS2 and the CHA2DS2-VASc scoring systems replace the previous two anticoagulant-use graphs improvements have been made to the installation file, making it quicker and more reliable for practices to update the tool  UK/GEN-151027b September 2015

Key changes – Warfarin Patient Safety The improvements to the tool are: calculations in the data sheet now feature CHA2DS2VASc, which has replaced CHADS2 to reflect changes made in the Quality and Outcomes Framework (QOF) in regards to atrial fibrillation results in the summary sheet now highlight percentage time in therapeutic range (TTR) using a 65% value, rather than 70%. This change was made to reflect the NICE recommendation that any patient with a TTR below 65% should have anticoagulation reassessed. (Please see NICE Atrial fibrillation: the management of atrial fibrillation. NICE guidelines CG180. Published June 2014. www.nice.org.uk/guidance/cg180) CHART Online functionality has been added. Please note: practices can upload but will not be able to see results until there has been sufficient data submitted to populate the online views. NB: CHART Online is a data storage facility with associated online reporting and display functionality that allows benchmarking and comparison both locally and nationally of pseudonymised audit tool results. You can find out more about CHART Online on the PRIMIS website. UK/GEN-151027b September 2015

CHART online – Warfarin Patient Safety UK/GEN-151027b September 2015

GRASP AF top users NHS Aylesbury Vale CCG NHS Barnet CCG NHS Barnsley CCG NHS Blackpool CCG NHS Bolton CCG NHS Chiltern CCG NHS Fylde & Wyre CCG NHS Hambleton, Richmondshire and Whitby CCG NHS Hardwick CCG NHS Lancashire North CCG NHS Luton CCG NHS Mansfield and Ashfield CCG NHS North & West Reading CCG NHS North Derbyshire CCG NHS Salford CCG NHS South Eastern Hampshire CCG NHS South West Lincolnshire CCG NHS Southport and Formby CCG NHS Sunderland CCG NHS Walsall CCG NHS West Hampshire CCG NHS West Leicestershire CCG All of these CCGs have 100% coverage for all of their practices. We will concentrate on three CCGs – Luton, Blackpool and West Hampshire and show you how they did it. UK/GEN-151027b September 2015

UK/GEN-151027b September 2015

Luton CCG case study The objectives for patient care were: earlier detection of AF, through raised awareness in clinical practice better stroke prevention management using the CHADS2 scoring system (and moving towards use of CHA2DS2VASc) reduced AF-related stroke and mortality and the consequences of these on their family, carers, finance and community The objectives for the NHS were: increase detection of undiagnosed AF improved stroke prevention in AF reduced AF-related stroke and subsequent cost of care reduced AF-related stroke admissions to secondary care Practices were incentivised Collaborative approach Important to set measures that can be measured Luton CCG Primary Care Team developed a primary care investment scheme service contract Collaborative approach – practices, CCG and NHE Area Team. Training was provided PRIMIS, supported by BI UK/GEN-151027b September 2015

Project Implementation Awareness sessions for clinicians Training workshops for practice administration staff Install and run AF case finder and GRASP AF Analyse and interpret practice results Re-audit Project management from CCG Project support from SCN Delyth Williams- Quality Improvement Lead Strategic Clinical Networks - Cardiovascular  NHS England East Anglia Area Team UK/GEN-151027b September 2015

Project outcomes AF prevalence rose by 23% Some practices increased their anticoagulant prescribing for high risk patients by 10% Across the CCG, oral anticoagulant prescribing increased by 2.53% Shone the light on skill set disparities across practice staff, which affected practice results Improved data quality – a number of patients were found not to have AF Consequently, some practices actually reduced prescribing of oral anticoagulants due to the systematic reviewing of the diagnosis of patients on the AF register Luton is now looking at reviewing access to oral anticoagulants and local INR pathways. It is also looking at a number of patients who are on warfarin with a TTR less than 65%. UK/GEN-151027b September 2015

Blackpool CCG case study • Population 172,500 • Mortality rates for CVD amongst the highest in the country • Life expectancy is the lowest in the country for men and third worst for women • One of the top 5 most deprived wards in the country • NST for health inequalities visit in 2009 highlighted the following as areas for improvement i. Secondary prevention of CVD ii. Additional treatment for hypertension iii. Warfarin for AF in >65’s UK/GEN-151027b September 2015

Project Implementation Informatics Development Team (Louise Gore) Supported practices in downloading, installing and running the tool Medicines Management (Chris Hill) Clinical Redesign Manager (Jeannie Hayhurst) Provided clinical support to practices through the delivery of training and circulation of information packs UK/GEN-151027b September 2015

Project outcomes Initial results (April 2012) Increased prevalence of AF – 1.6% - 1.75% in first 12/12 Increase of 19% in warfarin prescribing Numbers of high risk patients treated with aspirin or nothing also increased Conclusion - More education needed. Latest results (June 2014) GRASP tools have been run quarterly since, now run remotely by Staffordshire and Lancashire CSU AF prevalence 2.24% Warfarin px increased from 40.51% (2011) to 63.27% (2014) UK/GEN-151027b September 2015

GRASP COPD top users NHS Aylesbury Vale CCG NHS South Eastern Hampshire CCG NHS Chiltern CCG NHS Blackpool CCG NHS Bolton CCG NHS Fareham and Gosport CCG NHS Fylde & Wyre CCG NHS Newbury and District CCG NHS North & West Reading CCG NHS South Reading CCG NHS Trafford CCG NHS Walsall CCG NHS Wokingham CCG All of these CCGs have 100% coverage for all of their practices. Let’s look at how Walsall and Blackpool encouraged their practices to use the GRASP COPD tool. UK/GEN-151027b September 2015

UK/GEN-151027b September 2015

Dashboard from the COPD toolkit Dashboard from the COPD toolkit. One of the Outcome indicator set for CCGs is the number of patients referred for Pulmonary Rehabilitation. You can see this in the top right hand corner. Co-morbidities shows a lot with Asthma as well. Bottom right smoking is of very largely the cause. Treatment by category is divided into the number of inhalers. The more the worse the COPD generally with triple really only recommended where frequent exacerbations or on going symptoms. UK/GEN-151027b September 2015

An example of implementing GRASP COPD to improve patient care UK/GEN-151027b September 2015

An innovative 2 year Local Incentive Scheme Objectives to: decrease unplanned admissions and highlight patients with a primary diagnosis of COPD 3 Components GP to attend monthly Locality commissioning meeting Casefinder and GRASP-COPD use and monthly reporting Practice action planning to improve patient care Practice managers were up skilled to run GRASP Clinical templates were designed for use in consultation The focus of this scheme was two-fold: the CCG Strategy focused on the NHS Outcomes Indicator Set ‘Unplanned hospitalisation for chronic ambulatory care sensitive conditions’ and a need to highlight patients with a primary diagnosis of COPD (the most prevalent condition for patients admitted with chronic ambulatory conditions). In order to address the complexities of this long-term condition a ‘whole system commissioning’ approach was adopted, which incorporated an innovative use of software tools and collaborative working by the CCG’s Primary Care Department staff. The LIS financially rewarded practices for ensuring their COPD patients received - or were offered - the best possible care in line with the latest NICE guidelines. Target measures for practices were linked to the LIS to enable the CCG to have access to a baseline report for each practice at the end of 2012/13. The service specification embedded three components: Component One - GP engagement • A GP representative actively takes part in the CCG’s commissioning agenda and priorities by attending monthly locality meetings. Component Two - Patient case finding and reporting • Each practice was required to run the GRASP-COPD audit tool and provide results on a quarterly basis. Using the audit tool’s case finder element, practices identify patients who might have COPD but have not yet been diagnosed or who are likely to benefit from being screened. Component three - Practice action planning • Practices were required to demonstrate improvement in patient care in line with individual practice action plans. This includes demonstrating improvement in the classification and recording of COPD severity, increased diagnosis rates, a reduction in the number of unplanned hospitalisations and evidence of the care given to patients. Practices were given a template to fill in and the results of the GRASP-COPD audit tool were employed to filter patients. Results • At the start of the LIS, Walsall CCG’s prevalence rate for COPD was 2.1%. By the end of 2013/14 that had risen to 2.5% as a result of case finding activity. Ongoing use of the COPD case finder within the next 12 months will improve the accuracy of the prevalence rate even further. • From the practice actions plans there have been significant improvements in the classification of severity. Historically patients were having a generic coded entry of COPD without their level of severity recorded determined by FEV1 or FEV1 % predicted. • End of year Secondary Uses Service (SUS) data for 2013/14 showed a reduction in related hospital activity. COPD related hospital spells were 1.2% lower than the expected average of 12.99% for the CCG. During the same period, GP practice QOF COPD registers showed an increase of 613 patients as a result of case finding activity in practices. • A range of improvements that can be made in the quality of COPD care provided was highlighted by the collected data. The focus of the 2014/15 LIS is for GP practices to be provided with a dashboard and summary sheet of the 2013/14 data quality audits results, highlighting areas that need to be addressed. This will form the baseline for measuring improvement at the end of financial year 2014/15. The Primary Care team were delighted with how well the scheme had progressed in the first year. Capitalising on the success of this project, the CCG is looking at extending similar schemes to other clinical target areas such as diabetes and atrial fibrillation. Consideration is being given to whether this approach could be replicated at scale across other practices and commissioning organisations. UK/GEN-151027b September 2015

Prevalence rate for COPD has risen to 2.4% Significant improvements in the classification of severity At the end of 2013/14 admission data shows a reduction of 1.2% overall which is a reduction of three hospital spells at the CCG expected average of 12.99% The focus of the 2014/15 LIS is that GP practices will be provided with a dashboard and summary sheet detailing the results of the 2013/14 data quality audits and highlighting areas for the practice to address over the coming year UK/GEN-151027b September 2015

What do these projects have in common? Clinical Champion Stakeholder engagement Local Incentive Scheme What are the added benefits? Education Facilitation Feedback Ensure that the following is specified: Clinical Champion that will make the business case and aid the reason why this piece of work is being done to fellow colleagues Stakeholder engagement – ensuring that all stakeholders are identified and communicated to and that there is Senior Management engagement and project sponsor Local incentive schemes – (LIS) rewarding outcomes and to enable General Practice to free up capacity to deliver change Recognition of how the audit work fits with NHS priorities (medicines optimisation, reducing hospital admissions, PACS, MCPs etc.) and patient benefits and what is in it for me message is developed for instance using the data collected for revalidation A project plan is in place to deliver the programme PDSA cycles break the work down into sizeable chunks and other quality improvement techniques are used. Education is place to help with the review of patients Extra capacity can be drawn into the surgery to help with review of patients if needed (medicines management, external companies and secondary care support) Support for running of the audit tool which educational support, written guides and video walk trough’s Data driving improvement through comparative analysis Facilitation throughout the process UK/GEN-151027b September 2015

UK/GEN-151027b September 2015 Diabetes Audit Tool Presentation_V2.0 17th July 2014

Diabetes Audit Tool Presentation_V2.0 17th July 2014 Visual dashboard view. Access other views from this screen. Audits patient care against current best practice guidelines Reports on the presence of associated complications of diabetes – for all patients with diabetes within the practice Reports on the NICE recommended care processes and the number achieving the related target thresholds for HbA1c, blood pressure and cholesterol Reports on the number of patients currently being treated in line with current NICE recommendations regarding blood glucose lowering therapy UK/GEN-151027b September 2015 Diabetes Audit Tool Presentation_V2.0 17th July 2014

The integrated NICE blood glucose lowering pathway places patients into the relevant part of the pathway. In this view, patients will only appear once. Patients with Type 1 diabetes are excluded from this view. Patients who appear in each red category are potentially not being treated optimally (in accordance with NICE guidance). UK/GEN-151027b September 2015 Diabetes Audit Tool Presentation_V2.0 17th July 2014

The medication safety summary table helps practices examine areas where prescribing (in diabetes) might be sub-optimal from a safety point of view. There are two main groups; those of general prescribing safety and those related to poor renal function. Advice and cautions are taken from the BNF. Medication is analysed from the last six months. eGFR data is based upon the latest entry in the last 12 months. UK/GEN-151027b September 2015 Diabetes Audit Tool Presentation_V2.0 17th July 2014

In this example view: There are a number of patients receiving medication asthma despite not having a diagnosis There are 27 patients with asthma monitoring codes - This looks for codes related to asthma such as asthma severity, emergency admissions due to asthma, asthma management plans, annual asthma reviews or asthma limiting activities/disturbing sleep UK/GEN-151027b September 2015 Asthma Audit Tool Presentation_V2.0 27th August 2014

Asthma case finder: datasheet The datasheet is the most valuable part of the asthma case finder audit tool. It allows access to patient level data, providing relevant information in one place to help clinicians confirm or exclude a diagnosis of asthma. The datasheet can be filtered as desired, to produce specific lists of patients. As an example practices can list patients who have more than one associated feature of asthma by applying a custom filter on the column ‘Count of associated features’ (as shown). There are also 3 pre-set filters within the case finder: Count of medications in L12m - two or more Asthma monitoring code recorded at any time Atopy or allergies recorded at any time UK/GEN-151027b September 2015 Asthma Audit Tool Presentation_V2.0 27th August 2014

Asthma Audit Tool Presentation_V2.0 27th August 2014 Main audit visual dashboard view. You can access the classic view (table) from this screen by clicking on the hyperlink in the top right corner. Audits patient care against current best practice guidelines (British Thoracic Society/Sign guidelines and aspects of NICE quality standards QS25). Calculates the number of patients in each treatment step based upon medication history (not recorded step information). Shows the percentage of active asthma patients with relevant associated features such as depression, COPD, obesity and allergies. Summarises practice achievement of the Royal College of Physicians ‘3 questions’ outcome  measure which assesses asthma patient wellbeing Reports on the number of prescriptions for SABA inhalers. Practices can therefore easily focus on patients receiving high numbers of prescriptions for SABA inhalers. Summarises the numbers of patients seen in A&E, admitted to hospital or referred to a specialist for asthma related problems. It also indicates the number of patients receiving frequent oral steroids who would benefit from review by a specialist. Provides an overview of general asthma management indicators such as smoking history and advice, annual review rates, numbers with a self management plan, inhaler technique assessments and asthma attack rates. Reports on the number of prescriptions issued for inhaled corticosteroids in the last year. Practices can easily identify patients receiving a low number of prescriptions for preventer inhalers. UK/GEN-151027b September 2015 Asthma Audit Tool Presentation_V2.0 27th August 2014

Asthma care: datasheet Both the case finder and main audit (care management) include a comprehensive datasheet. This is arguably the most valuable part of the audit tool. It allows access to patient level data, providing relevant information in one place to help clinicians review asthma care. Pre-set filters are provided for both sets (case finder and main audit) – the main audit pre-set filters are shown here. These filters allows practices to generate relevant lists of patients quickly and easily. Practices can also choose their own filters as desired to generate bespoke lists of patients. UK/GEN-151027b September 2015 Asthma Audit Tool Presentation_V2.0 27th August 2014

Asthma care: datasheet The CHART datasheet contains many columns of relevant data. A full list of available columns is included in the appendices of the audit tool instructional guide. As an example, you can use the columns in the datasheet to compare patients’ calculated treatment step (taken from medication history) with their actual coded step information by comparing the columns Calculated treatment step and Latest recorded therapeutic steps code (shown here). Note that those in red have mismatched information, suggesting that the coded information on treatment step needs updating. Their medication history places the two example patients at step 4 whilst their coded information states step 2. Additionally, many patients do not have any treatment step information coded in their record (blank cells). UK/GEN-151027b September 2015 Asthma Audit Tool Presentation_V2.0 27th August 2014

Questions UK/GEN-151027b September 2015 CHART_Training_Ppt_V1.0 22nd April 2014