1. Information to Support Practice Based Commissioning SEPHIG 10/11/2008

2. The Hampshire Clinical Data Repository Clinical Data Repository contains: –GP records Read codes and values –Hospital Letters/ Pathology reports/ Radiology reports/ PAS –Additional clinical records OT and SAP Cancer MDT record

3. GP Record (Read codes) (c800,000) Hospital records Pathology Radiology Correspondence (c 8 million documents) Clinical Data Repository (CDR) OT/CN/ PT/Pod SAP Clinical view Analytical Clinical Data Repository (ACDR) IP/OP/A&E CMDS (Other data sets?) Care Pathway Reports Prevalence GP and hospital activity Clinical outcome CDR Patient Index EXETER NHS REGISTER

4. Analytical data repository Includes Commissioning data sets A&E Outpatient In patient/ day case Potential for other data tables ( e.g. Cancer MDT, Single Assessment, OT record etc)

5. Volumes 7.6 Million documents from SUHT/PHT on 696,000 patients 160 Million GP record entries on 850,000 patients 282,000 of 1.26 million patients have both hospital and GP data 200 users making 12,000 record accesses/ month

6. What’s the USP of the CDR? Clinical Support: –Web based shared clinical record –Up to date and accessible wherever patient is seen –Read only and writeable forms Analysis –Across the whole pathway of care Primary  Secondary  Tertiary  Primary –Detail of process of care Pathology tests, medical imaging, referral –Detail of clinical severity Biochemistry/ Haematology/ Blood Pressure / Spirometry

7. GP records Flat file: Date of entry Read Code Read code text Code Value(if appropriate) Code Units(if appropriate) NHS Number (encrypted)

8. Hospital records Portsmouth: (16 feeds) –Haslar –Queen Alexandra Imaging/ Medical Physics/ Biochemistry/ Haematology/ MAU discharge Southampton (13 feeds) Imaging/ Biochemistry/ Haematology

9. CMDS feeds Extracted from PCT systems monthly as flat files (patient identifiers excluded/ encrypted) A&E Out patients In patient/ day cases

10. Pseudonymisation NHS Number encrypted Post Code converted to Output area Tables to have cells with values less that 3 suppressed

11. Development of Reports Care pathway based: –Single pathway points How many Diabetic patients have HbA1c/ BP/ Cholesterol in last year How many patients have HbA1c below X/ BP below x/y, cholesterol < x etc –Whole pathway How many patients meet all pathway criteria for –Diagnostic work up –Annual monitoring –Assessment of complications

12. Development of reports(2) Analysis of episodes of care: Link events over time for individual patients Calculate annual costs of diagnostics/ treatments

13. Diabetes Care Pathway Objectives Identify key steps in delivery of care Identify ways to measure success at these key steps Identify the reports required to measure

14. Diabetes Diagnosed Initial assessment Routine monitoring of diabetes and management of risk factors Management of complications RenalOphthalmicCardiacVascularNeurologicalPregnancy Prioritisation of Potential Indicators

15. New Diabetic diagnosed (Fasting BS > 7 or random BS > 11 * 2) Expected processIndicatorFrom CDR? Prescribe hypoglycaemic drug or dietary advice Evidence of hypoglycaemic Rx or dietary advice yes Prescribe glucose monitoring kit Evidence of glucose monitoring kit Rx Are repeat prescriptions filled at regular and appropriate intervals. yes Assess BMI/ waist measurement/ BP/ Pulses/ Sensation/ Are measurements in clinical record within 3 months of diagnosis yes Measure Cholesterol, Creatinine, U&E, HbA1c,ACR, LFT, TF Are measurements in clinical record within 3 months of diagnosis yes Nutrition adviceIs there a record of referral to dietician yes Diabetes educationIs there a record of Education (e.g. DESMOND) ? yes ? code available

16. Routine Monitoring of diabetic/ outcomes of risk factor management:(1) Expected processIndicatorFrom CDR? Measure BP,Annually Record of hypotensive Rx if BP> 140/85 on 3 readings How many >140/85 Yes Assess pulsesAnnually if all present Referral if absent below ankle How many with absent ankle pulses Yes Renal functionAnnual Creatinine/ eGFR Type 1 record of annual test for microalbuminuria Type 2 record of annual test for macroalbuminuria How many Creatinine >150 Yes Measure BMI/ waistlineAnnual Record of dietary advice/activity if > 30 How many BMI > 30 ?Yes

19. Routine Monitoring of diabetic/ outcomes of risk factor management:(2) Foot diseaseAnnual foot risk score Referral if established foot disease (ulcer, Charcot joint) How many abnormal sensation ?Yes HbA1cAnnually 6 monthly if between 7.5 and 9.5 Refer to diabetes clinic if >9.5 How many HbA1c > 9.5/ 7.5 Yes Cholesterol/ triglycerides/ Cholesterol/HDL ratio Annually if < 5, else 3 yearly Prescription of statins if > 5 How many > 5 Yes EyesAnnual retinal screening If abnormal, evidence of action to optimise glucose control and blood pressure If preproliferative/ proliferative or macular disease referral to ophthalmologists yes ? Yes ? yes

20. Handover for juvenile diabetics Expected processIndicatorFrom CDR? Handover to be appropriate for patient and agreed with them. Distribution of age at handover? yes Continuity between paediatric and adult care Duration of overlap between paediatric and adult clinic attendance. ? Yes Management of disease during transition (14- 21) DNA rate at clinics Emergency admissions/ A&E attendances Yes

23. Management of complications/ outcomes of complications(1) ComplicationIndicatorFrom CDR? Renal failureNumber of patients on dialysis Number of renal arteriograms ? yes yes CataractNumber of cataract extractions < 70yes Diabetic RetinopathyNumber of registered blind Number of retinal ablation treatments/ patient yes ?? Cardio vascular problemsHow many MIs/ number of deaths due to MI If CV symptoms, how many referrals to cardiology How many revascularisation/ stents How many with symptoms of angina If AMI/ Angina how many referred to cardiac rehab Yes Peripheral neuropathyNumber of patients with abnormal skin sensation ? yes

24. Management of complications/ outcomes of complications(2) Peripheral vascular disease/ foot disease How many referrals to vascular surgery How many foot ulcers/ Charcot joint disease How many amputations How many arteriograms How many referrals to podiatry Yes ? PregnancyHow many referred to conjoint clinic by 10 weeks gestation How many receive pre- pregnancy counselling How many normal pregnancies have gestational diabetes screening How many birth weights within normal limits How many assisted deliveries ? Yes Yes yes

26. Next Steps Checking data quality/ consistency with QOF Discussing reports with PBC groups Developing Stroke pathway reports Considering other potential analyses. Feedback to get complete GP/ Hospital coverage