This document discusses SPARRA (Scottish Patients at Risk of Readmission & Admission), a risk prediction algorithm, and its use in identifying high-risk patients for anticipatory care planning (ACP) in primary care practices. It provides an overview of SPARRA, how practices can use SPARRA risk scores to target patients for ACPs, and details on evaluating ACPs and related Quality and Outcomes Framework indicators. The document also addresses practical considerations for practices in accessing SPARRA data and limitations of the current SPARRA model.

1. SPARRA and anticipatory care planning
in primary care
Gavin MacColl ISD Scotland

2. Overview
• Context
• Overview anticipatory care planning &
SPARRA
• Practice data
• Practicalities
• Evaluation & Feedback

3. Context – GMS contract
• Health and Social Care Integration
– Integrated adult health and social care budgets - Health Boards and Local
Authorities
– A requirement on Partnerships (currently CHPs) to strengthen the role of
clinicians and care professionals, along with the third and independent
sectors, in the planning and delivery of services
• 2013/2014 GMS contract
– Focus primary care resources on the most vulnerable patients in the
community
– Support and value the work of the wider Primary Health Care Team based
around the GP practice
– Anticipatory Care Planning (ACP) activity to replace QP QOF indicators
on A&E and emergency pathways
– 6 new QOF indicators focus on at risk patients, with a focus on
ACP/polypharmacy

4. SPARRA
• SPARRA - Scottish Patients at Risk of Readmission &
Admission
• Risk prediction algorithm developed using logistic
regression on a patient level dataset
• SPARRA Version 3, launched in January 2012
• SPARRA scores (%) calculated quarterly
• Data for patient risk stratification provided to Health Boards
and to General Practices

5. SPARRA V3 Risk Factors & Datasets
Outpatient
(1 year)
Emergency Department
(1 year)
Prescribing
(1 year)
Outcome Year
(1 year)
OUTCOME PERIOD
Hospitalisation
(3 years)
PRE-PREDICTION PERIOD
Psychiatric Admission
(3 years)
Any recent admissions to
a psychiatric unit ?
Any A&E
attendances in
the past year?
What type of
outpatient
appointments did
the patient have?
Any prescriptions for e.g.
dementia drugs? Or
substance dependence?
How many outpatient
appointments?
What age is the patient?
How many previous
emergency admissions
has the patient had?
How many
prescriptions?
Any previous admissions
for a long term condition
(such as epilepsy?

6. Three Sub-Cohorts
New cohorts …..
• Long Term Conditions
– aged 16-74
• Frail Elderly
– aged 75+
• Younger Emergency Department
– aged 16-55
– At least one ED attendance in previous 12 months
…. new opportunities …

7. SPARRA for Case Finding
• Maximise value of anticipatory care by targeting patients
most likely to benefit from interventions (medium-high risk)
• First, stratify the population; SPARRA stratifies on basis of
risk of hospital admission
• SPARRA lists help identify patients who may benefit from
preventative approach & to ensure that patients are known
to the relevant services

8. SPARRA - ACP - KIS
Anticipatory Care
Plan
Polypharmacy/
Medicine
Review
SPARRA
Patient Listing
Key Information
Summary
Provide the relevant
community interventions
Evaluation
~40,000 patients

9. SPARRA & Polypharmacy
• CEL36 and appropriate prescribing
• Age 75+
• SPARRA risk score 40-60%
• On medications from 10+ BNF Sections
• Prescribed at least one high risk medicine
2.1 – Positive inotropic drugs 2.2 – Diuretics
2.4 – Beta-blockers 2.5 – Hypertension and heart-failure
2.8 – Anticoagulants and protamine 2.9 – Antiplatelets
4.1 – Hypnotics and anxiolytics 4.2 – Antipsychotics
4.3 – Antidepressants 10.1 – Drugs used in rheumatic diseases and gout
Polypharmacy/
Medicine
Review

10. ACP - KIS
Anticipatory Care
Plan
Key Information
Summary
Signpost/ refer/ provide the relevant
community interventions
• Support for self-management
• Homecare / re-ablement
• Carer support
• Peer support / befriending
• Falls prevention
• Exercise
• Telehealth / telecare
• Housing adaptations and equipment
• Other health and care supports

11. SPARRA - ACP - KIS
Key Information
Summary

12. Practice Data: QOF Indicators for
High Risk Patients
“The practice produces a list of 5% of patients in the practice, who
are predicted to be at significant risk of unscheduled admission or
unscheduled care.”
o Average practice: 5,550 patients 5%: ~280 patients
“The contractor identifies a minimum of 15% (in 2014/15, 30%) of
those patients from the list produced in indicator above who would
most benefit from, and creates, an Anticipatory Care Plan (the ACP
must include a poly-pharmacy review)”
o 15% at risk population for ACP: ~40 patients

13. Practice Data: Indicative numbers
~ 5% of practice population

14. Practice Data
• Use SPARRA as a screening tool to identify at risk patients
• Suggested focus on 40-60% grouping for patient ACP selection
• Clinical judgement should also be used with SPARRA scores
• Iterative process – new and untested in QOF

15. Version 3 Model & Limitations
• Quarterly risk scores for around 80% of population
• Predictive of 95% of emergency admissions overall
• Timeliness - deaths data should be accurate at time of data extract –
requires early review of data
• Limitations of using SMR data, e.g. issues with coding of LTCs and data
quality / primary vs. secondary care information
• In future, use primary care data for LTC?
• Automation and monthly production of data (iSPARRA)

16. How do you get your data?
• Push (Health Boards) vs. Pull (SPARRA
online)

17. Evaluation – Board/CHP Level
• Case studies/Evidence Base
• Aberdeenshire CHP: 65+ ‘Stay well’ & ACPs
• NHS Fife: COPD, Heart failure, polypharmacy
• NHS Highland*: Nairn Case Finder
• Glasgow City CHP: >65 and 60%+ risk, 1+chronic
conditions
*Baker A et al Br J Gen Pract. 2012 Feb;62(595):e113-20.

18. Evaluation of ACP & 4 QOF
indicators
• Internal practice review the data on emergency admissions provided
by the Board and the learning from at least 25% of the Anticipatory
Care Plans (ACPs) completed
• External peer review with either a group of local practices, or
practices from the Board area, data on emergency admissions shared
learning from at least 25% of the ACPs; proposes areas for internal
practice improvement or service design improvements for the Board

19. Evaluation of ACP and QOF
• Multi-disciplinary meetings during the 2013/2014 FY to review
active management plans, identify learning needs and related
changes in patient management. These meetings should be open to
professionals who support the practice's patients.
• Practice reports annually to the Board on internal practice and
wider Board system changes that may benefit patients. The report
will include Significant Events Reviews (SERs) on 1/1000 patients, to
a maximum of 3 per practice, of patients with ACPs from the cohort,
who were admitted during the year, after their ACP had been created

20. Future
• Local risk prediction (GP data)
• Social care data and availability
• SPARRA and telehealth
• Improvements:
– to SPARRA itself – automated SPARRA
– how data is accessed and used

21. Contacts / Acknowledgements
• ISD SPARRA team:
– Website:
– www.isdscotland.org/sparra
– E-mail: nss.isdLTC@nhs.net