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  • 1. Evidence Based Decision Making in Primary Care & Public HealthWorking with GP data for health improvement inWales - realities and reactionsOctober 2011Presenter: 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%COPDPresenter: Dr Paul Myres Primary Care Quality& Information Service (PCQIS)
  • 6. Prevalence – variation –Stroke TIA health board, local authority, GPpractice 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 2.520 2.0 2.0 Percentage Percentage Wales = 1.3%15 Wales = 1.3% 1.5 1.510 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 interval200 age standardised* % crude % Wales* % 20 age standardised* % crude % Wales* % 18 20 18150 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 prevalenceDistribution of GP practice age standardised prevalencefor 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 ofprevalence• 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 2002520 Age standardised rate per 1000 patients 15015 10010 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 messagesfrom effectiveness section“The systematic, evidence based management of chronic disease inprimary care settings can make a significant contribution to the preventionof 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 indicatorSource: 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)
  • 20. treatments are effectiveinappropriate variation is minimised Wales QoF 2009/10 indicator to register BP05 Wide variation in coverage of Cases as a Percentage of Total number of patients on the 90 80 management of Blood register for the indicator pressure to target 70 hypertensives register 60 Wales GP practices Average 50 2SD limits 3SD limits Health Board Practices 40 0 500 1000 1500 2000 2500 3000 3500 BP05 Profile of Register relating to indicator Health Boards & Wales Total num ber of patients on the register for the indicatorSource: QOF 2009/10 Treated Exceptions Exclusions Not Treated 100%Patients who are 90% 80% 15876 0 3392 17683 0 3647 22492 0 4650 12305 0 2447 10033 0 2089 13028 0 2880 5567 0 1125 96984 0 20230 70%eligible but not 60% 50% 40%reaching evidence 30% 20% 10%based target 0% 60714 Abertaw e Bro Morgannw g University 71342 Aneurin Bevan LHB 81864 Betsi Cadw aladr University LHB 46268 Cardiff and Vale University LHB 37658 Cw m Taf LHB 46951 Hyw el Dda LHB 16056 Pow ys LHB 360853 Wales LHB Local Health Board Presenter: Dr Paul Myres Primary Care Quality & Information Service (PCQIS)
  • 21. What can we use? StrokeComparative QOF prevalence of Stroke(inc TIA) , Crude per 1,000 Comparative QOF prevalence of Stroke(inc TIA) , EASR per 1,000 registeredregistered patients, Wales GP practices March 2010 patients, Wales GP practices March 2010 Wales GP practices Average Wales GP practices Average 2SD limits 3SD limits 2SD limits 3SD limits Most Deprived Practices (Townsend top 5th) Most Deprived Practices (Townsend top 5th) 50 50 Rate per 1,000 Practice registered population per Year Rate per 1,000 Practice registered population per Year 40 40 30 30 20 20 10 10 0 0 0 5000 10000 15000 20000 25000 0 5000 10000 15000 20000 25000 Practice registered population Practice registered population Produced by Public Health Wales Observatory using Audit + WEB Crude rate/1000 Note: Population is adjusted due to Standardisation Calculations source QOF Age standardised rate/1000 source Audit+ Presenter: Dr Paul Myres Primary Care Quality & Information Service (PCQIS)
  • 22. What can we use? - Hypertension Comparative QOF prevalence of BP(Hypertension) , EASR per 1,000 Comparative QOF prevalence of BP(Hypertension) , EASR per 1,000 registered patients, Wales GP practices March 2010 registered patients, Wales GP practices March 2010 Wales GP practices Average Wales GP practices Average 2SD limits 3SD limits 2SD limits 3SD limits Most Deprived Practices (Townsend top 5th) Most Deprived Practices (Townsend top 5th) 210 210 200 Rate per 1,000 Practice registered population per Year 200Rate per 1,000 Practice registered population per Year 190 190 180 180 170 170 160 160 150 150 140 140 130 130 120 120 110 110 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 0 5000 10000 15000 20000 25000 0 5000 10000 15000 20000 25000 Practice registered population Practice registered population Produced by Public Health Wales Observatory using Audit + WEB Note: Population is adjusted due to Standardisation Calculations Crude rate/1000 source QOF Age standardised rate/1000 source Audit+ Presenter: Dr Paul Myres Primary Care Quality & Information Service (PCQIS)
  • 23. EASR per 1000 registered population COPD Using data from Audit Plus Health Board Annual Report Rate per 1,000 Practice registered population per Wales GP practices - GP Practice Prevalence of 50 Average 2SD limits COPD 3SD limits 40 Health Board All Wales Practices age standardised Year 30 prevalence of COPD with Health Board practices highlighted. Control chart shows outliers to focus 20 Health Board activity. 10 Health Board Local Authority Areas - Practice Prevalance V Deprivation (Confidence intervals shown for EASR) 0 Crude_1000 EASR_1000 Tow nsend score 0 5000 10000 15000 20000 25000 Practice registered population 5ths Deprivation (From Wales Practices ranked 1 m ost to 5 least) 5 4 5 5 5 5 5 3 3 3 3 5 3 4 4 3 5 5 3 2Source: Audit + 31 march 2010 Rate per 1000 Registered Patients 35 11 Deprivation (Townsend Score)Note: Population is adjusted due to Standardisation Calculations 9 30 7 25 5 3Audit Plus provides us with age specific data 20 1 -1 15on prevalence to calculate age standardise 10 -3 -5 -7rates. This is a better comparator than crude 5 0 -9 -11rates provided through the normal QOF data BCU Flintshire W91001 BCU Flintshire W91005 BCU Flintshire W91013 BCU Flintshire W91015 BCU Flintshire W91017 BCU Flintshire W91018 BCU Flintshire W91021 BCU Flintshire W91032 BCU Flintshire W91036 BCU Flintshire W91037 BCU Flintshire W91039 BCU Flintshire W91044 BCU Flintshire W91051 BCU Flintshire W91055 BCU Flintshire W91060 BCU Flintshire W91607 BCU Flintshire W91618 BCU Flintshire W91626 BCU Flintshire W91636 BCU Flintshire W94627outputs. The chart to the right comparesprevalence with deprivation at GP practicelevel for one county of the Health Board Insert name of presentation on Master Slide
  • 24. Input to the Health Board – Primary Care Annual ReportExamination of aggregate activity against QOF indicators; example Patients who have had a Fev1 past 15 months (ie measure of severity of the condition). Evidence suggestsofthat relating to indicator Health Boards & Wales be monitored COPD10 Profile Register deterioration should Treated Exceptions Denominator Not Treated 100% 857 971 1895 639 751 669 296 6078 90% Compariso 1974 1770 1010 379 10899 80% 2658 1670 1438 0 0 0 0 0 0 0 70% 0 60% 50% n Health Boards & 40% 30% Wales 20% 10% 7612 9022 11161 4925 5563 5287 2197 45767 0% Abertaw e Bro Aneurin Bevan LHB Betsi Cadw aladr Cardiff and Vale Cw m Taf LHB Hyw el Dda LHB Pow ys LHB Wales Morgannw g University University LHB University LHB LHB Local Authority area (form er LHB) COPD10 Profile of Register relating to indicator Local Authority Areas Treated Exceptions Exclusions Not Treated 100% 167 102 302 238 317 165 358 113 0 168 0 269 310 236 478 161 151 600 259 119 291 296 0 0 0 0 0 0 403 0 575 0 0 0 0Comparing 0 0 0 0 0 0 0 219 208 444 270 0 500 569 593 812 662 237 422 395 0 671 339 1255 296 379 80% 626 454 415 491 642former LHB 60% 40% 20% 2431 2222 2959 1676 2955 1086 1964 1341 1280 1931 1981 2009 1923 2037 3540 1385 1172 4391 2507 1158 1622 2197 0% Pembrokeshire RCT Glamorgan Monmouthshire Neath Port Carmarthenshire Wrexham Flintshire Denbighshire Ceredigion Merthyr Caerphilly Bridgend Torfaen Gwynedd Cardiff Newport Blaenau Gwent Conwy Powys Anglesey Swansea Vale Of Talbot Local Authority area (form er LHB)
  • 25. Examining Wales QoF 2009/10 indicator to register COPD10 practice variation 100 90 & activity against Cases as a Percentage of Total number of patients on the 80 70 the COPD register register for the indicator 60 50 40 30 Wales GP practices 20 Average 2SD limits 10 3SD limits Health Board Practices 0 0 100 COPD10 Profile of Register relating to indicator Local Authority 800 200 300 400 500 600 700 Areas Total num ber of patients on the register for the indicator Treated Exceptions Exclusions Not Treated Source: QOF 2009/10100% 2 0 3 1 0 1 0 1 13 20 21 0 5 19 16 5 2 0 0 10 19 17 0 20 13 10 0 43 0 42 19 0 0 0 6 9 0 0 0 0 0 3 10 11 0 46 26 11 10 2180% 24 67 11 8 9 0 48 0 16 41 44 0 17 0 9 67 460% 25 040% 7 0 520% 173 192 94 125 147 101 188 70 56 125 50 67 54 44 16 134 148 75 23 25 39 27 25 11 0% BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire BCU Flintshire W91001 W91005 W91013 W91015 W91017 W91018 W91021 W91029 W91032 W91036 W91037 W91039 W91040 W91044 W91046 W91051 W91055 W91060 W91607 W91610 W91618 W91626 W91636 W94627 GP practices in local authority area Local Authority area (form er LHB)
  • 26. PCQIS & 1000 Lives Plus Programme LHBs will be required • To set appropriate local targets for the reduction of harm • To demonstrate participation and sign up to coding of clinical data, process of data entry and sign up to mini- collaborative – Anticoagulation Monitoring – Chronic Heart Failure (Wrexham project) – Atrial Fibrillation – Reducing Falls – Healthchecks for those with learning disability Toolkits completed or in progress to support these
  • 27. INR Audit Management profile – Health Board Comparison Locus of monitoring Anticoagulation Monitoring Monitored in Primary C are Monitored in Secondary C are Shared C are: Anticoagulation Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Abertawe Aneurin Betsi C ardiff and C wm Taf Hywel Dda Powys LHB Wales Bro Bevan LHB C adwaladr Vale LHB LHB Morgannwg University University University LHB LHB LHB Insert name of presentation on Master Slide
  • 28. INR Audit Profile of Clinical Indications- Health Board Comparison Profile of Clinical indications recorded (specification Groups) Venous complications of pregnancy and the puerperium for those who have been initiated on Anti Coagulation Valves of the heart and adjacent structures & have a recorded clinical indication (Shades of Blue Most common) operations Retinal Vein Thrombosis 100% Pulmonary embolism 90% Ptophylaxis DVT post op (hip surgery, fractures) 80% Ptophylaxis DVT post op (general surgery) Phlebitis and thrombophlebitis 70% Other heart valve disease 60% Other chronic rheumatic endocardial disease 50% Mitral Valve diseases 40% Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation MI/coronary artery/venous thrombo-embolism Atrial Fibrillation Atrial Fibrillation 30% External Resuscitation (C ardioversion) 20% Diseases of mitral and aortic valves 10% C oronary angioplasty/stent 0% Atrial Fibrillation Aneurin Bevan Wales Powys LHB University LHB Hywel Dda LHB Betsi Cadwaladr Cwm Taf LHB Cardiff and Vale Abertawe Bro University LHB University LHB Morgannwg LHB Insert name of presentation on Master Slide
  • 29. INR Audit 1000 Lives Adverse event criteria Health Board Comparison Number of patients v 1000 lives Adverse Event Criteria Monitoring reg Adverse event after initiation % Adverse event in previous 12 m% Adverse event in previous month% 2500 50% 45% 2162 % with Adverse Event 2000 40%Numbers on Monitoring 2075 35% 1795 1500 30% Register 1482 25% 1000 20% 1061 15% 500 10% 415 415 5% 0 0% Abertawe Bro Aneurin Bevan Betsi C adwaladr C ardiff and Vale C wm Taf LHB Hywel Dda LHB Powys LHB Wales Morgannwg LHB University LHB University LHB University LHB Health Board Number of patients read from left axis (black) % against monitoring registers right axis (red) Denominator is Monitoring Register Insert name of presentation on Master Slide
  • 30. INR Audit Target INR recorded Health Board Comparison Volume of Patients with Clinical Indication (by Clinical Indication) V % with Target INR recored on Clinical System BCUHB & Wales Reg %Target recrd BC UHB %Target recrd Wales 7000 10% 6024 9% 6000 8% 5000 7% 6% 4000 5% 3000 4% 2000 1549 3% 1427 1089 983 2% 1000 661 759 786 786 216 1% 54 54 0 0 50 19 0 0% Atrial Fibrillation post op (general Ptophylaxis DVT mitral and aortic stroke/TIA Mitral Valve Pulmonary Valves of the Other heart valve Ischaemic embolism operations diseases structures heart and adjacent Diseases of surgery) valves disease Number of patients read from left axis (black) % against monitoring registers right axis (red)Denominator is with recorded clinical indication for disease group Insert name of presentation on Master Slide
  • 31. Epilogue – Data from Audit +• Audit + funded from GMS money• Data extraction is not free any new project needs to be funded• Data extraction needs approval from Audit + stake holders including GPC Wales new Information governance machinery to be satisfied• Data extraction should be of benefit to the general medical contractor Presenter: Dr Paul Myres Primary Care Quality & Information Service (PCQIS)
  • 32. Clinical Governance PracticeSelf Assessment ToolObjectives for the production of a web based tool: • To be used by practices to review progress made in the development of CG processes within their practices • To provide assurance to HBs of the same • That can be referred to by inspecting bodies, such as HIW as evidence that appropriate CG activity is occurring in practices • That can support revalidationPrimary Care Quality andInformation Service
  • 33. Content • Patient experience – environment, access • Health & Safety – infection control, waste, premises, security • Risk management – clinical risk, business risk • Clinical effectiveness – guidelines, audit • Prescribing • Relationships with external bodies • Workforce – skills, recruitment, appraisal, training • LeadershipPrimary Care Quality andInformation Service
  • 34. Clinical Governance Practice SelfAssessment Tool 2010/11• Uptake 11 questions for 2010/11:• 489 Practices in Wales• 223 (45%) Practices completed• 113 in progress (not submitted)• 153 practices not startedPrimary Care Quality and InformationService
  • 35. Clinical Governance Tool Uptake 2010-11 Health Board Comparison (based on the 11 questions suggested for 2010/11) Completed Started Not Started100% 790% 12 15380% 29 37 2170% 1160% 54 11350% 22 17 11440% 18 4230% 35 22320% 35 1310% 12 6 4 0% Abertawe Bro Aneurin Bevan LHB Betsi Cadwaladr Cardiff and Vale Cwm Taf LHB Hywel Dda LHB Powys LHB Wales Morgannwg University LHB University LHB University LHB Health Board Primary Care Quality and Information Service
  • 36. Clinical Governance Tool 2010/11 (Betsi Cadwaladr - Wrexham @ 31/07/11) Number of Practices @ Each Maturity Level (Initial 11 Questions) Not answered Level 0 Level 1 Level 2 Level 3 Level 4 Level 5100% 1 1 1 1 2 2 2 2 290% 4 2 1 6 2 2 3 5 380% 7 4 2 670% 11 6 6 2 4 460% 7 4 7 4 550% 3 540% 9 10 6 9 6 630% 7 5 8 820% 7 110% 5 4 4 2 2 4 3 3 1 1 1 1 0% RAISING CONCERNS COMMUNICATION SAFEGUARDING ALERTS AND REPORTING WASTE MANAGEMENT EQUITY OF ACCESS CHAPERONE INFECTION CONTROL RISK ASSESSMENT 2.1a AVAILABILITY OF CLINICAL EXAMINATION AND 14.1a PATIENT SAFETY CONSULTATIONS 4.1a CONSENT FOR CHILDREN SYSTEMS TREATMENT 5.1a 10.1a 17.1a 22.1a 3.1a 23.1a 13.2a 13.1a Primary Care Quality and Information Service
  • 37. 2.1a AVAILABILITY OF CONSULTATIONS Not answered Level 0 Level 1 Level 2 Level 3 Level 4 Level 5100% 1 290% 29 10 11 480% 370% 260% 33 3 9 450% 10 440% 21 730% 6 8 320% 21 4 1 810% 4 9 2 0% 1 1 Aneurin Bevan Abertawe Bro Betsi Cardiff and Cwm Taf LHB Hywel Dda Powys LHB 3.1a EQUITY OF ACCESS LHB Morgannwg Cadwaladr Vale LHB University LHB University LHB University LHB Not answered Level 0 Level 1 Level 2 Level 3 Level 4 Level 5 100% 3 15 2 90% 8 1 1 4 80% 1 3 21 12 70% 6 60% 1 6 32 1 50% 2 1 11 40% 3 15 30% 25 1 20% 7 8 10% 1 3 1 20 4 0% 2 Aneurin Bevan Abertawe Bro Betsi Cardiff and Cwm Taf LHB Hywel Dda Powys LHB LHB Morgannwg Cadwaladr Vale LHB University LHB University LHB University LHB Primary Care Quality and Information Service
  • 38. Quality Assurance in General Practice – what do you want to know?• Is the contract delivered - Core, QOF, Additional Services, Enhanced Services ,• How “good” is care - acceptability, equitability, efficacy, appropriateness, value for money• How can we help practices improve their processes and outcomesPrimary Care Quality and Information Service
  • 39. Practice and Locality/ Network Profiling• Audit plus • Referrals• QOF • Hospital data• CGPSAT • No of staff WTEs• Questionnaires • List size per notional• Complaints and WTE incidents • Deprivation• Immunisations • Income/Cost per• Risk assessment patientPrimary Care Quality and Information Service
  • 40. QA Process DATA (trends and patterns/ outcomes – avoid scoring Analysis by LHB (MDT) Support•PCSS•IMA•CPD•Clinical Director Trained•AMD Targeted Assessors eg•?Team Coach Visit LHB, Lay, PM,•?Mentor GP•?Hit Squad Action Unacceptable Plan IMAs PM Investigation Performanc Nurse (More detail, diagnostic) assessor e Procedures Primary Care Quality and Information Service
  • 41. Q I Process DATA (trends and patterns/ outcomes)– Review by practice Support Benchmark Evidence Guidelines Tests ofCollaboration Reflect change Patient Decide how to do better PDSA cyclesinvolvement Revise Ask for help Action Plan IMAs PM Redo Nurse Implement your revisions assessor Primary Care Quality and Information Service