*Health Informatics Centre: Using routine data to support clinical research

Prof Peter Donnan, Dr Colin McCowanPopulation Health SciencesUniversity of Dundee

Holds patient specific datasets for entire population of Tayside (since early 90s) & Fife (last few years)Encashed prescribingHospital admissionsDemographic datasetCancer registryDatasets are linked, anonymised and made available for approved research projects

HIC DatasetsDispensed prescriptions 1993-date (variable completeness)Dental datasets local, nationalWalker dataset: across 3 generations, linked via Ninewells obstetric records 1/3 with CHILab data (bacteriology, haematology, biochemistry, etc) 1992 onSpecialty data on patients with diabetes, cardiovascular, COPD, thyroid & liver disease; maternity, neonatal, geriatric, child health, mental health, cancerSMR datasets from Information Statistics Division of NHS ScotlandGeneral Registrar Office data: date & cause of deathScottish Index of Multiple Deprivation

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Community Health Index NumberDate of Birth GenderCheck digit 07 10 64 02 5 0

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Drug data-CHILab data-CHIDrug data-CHILab data-CHIData linkage and anonymisationEnter data, find CHIDrug data, lab dataFully anonymised but linked dataCHI labelled dataFully identifiable dataPaper prescription Lab result -IDDrug data, lab dataDrug data, lab data Paper prescription -IDPaper prescription-IDLab result -IDLab result-IDDrug data-CHILab data-CHIDrug data, lab data-CHIAnalysisFind CHILink using CHIAcademiaHICNHSDrug data, lab data-CHIDrug data, lab data-CHIDeleteCHI

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Information governance and HICPhysical security: Isolation of servers holding identifiable data, of those working with it; Reliable backup and recovery mechanismsSeparation of functions on NHSNet, JANET

Privacy model:Inherited from NHS Scotlands Information Systems DivisionEvaluated by EU Data Protection expert Petra Wilson: the proper legal framework for the use of anonymisation techniques as demonstrated by MEMO (BMJ 2004)

Governed by Confidentiality & Privacy Advisory Committee Same pt. representative chair as ISD Privacy Advisory CommitteeMembers include lawyer, GP, Caldecott Guardian

Management tools:Standard Operating ProcedureProblem reporting mechanism on intranetProject management system enforces SOPAnnual external audit by information security experts + table of issues reviewed monthly by HIC Exec

Benefits of HIC DataPopulation basedNo socio-economic biasSocio-economic statusMostly single centre treatmentOutcomes dataGRO : all cause & disease specific mortalityHospital Discharge, Cancer Registry etcSpecialist data sets: research & clinicalPrescribing, lab results

Prescribing to older people

Aims & Research Questions To investigate if there are differences in potentially inappropriate medications between older people living in their own home compared with people living in nursing or residential homes

To determine if there are differences in prescribing and meeting Beers criteria guidelines between patients by place of residence for all classes and by individual criterionTo assess whether receiving a PIM was associated with an increased risk of deathTo examine any differences in PIM prescribing by practice

Beers Criteria for potentially inappropriate medication in the elderlyLimited clinical trial evidence of use of drugs in the elderly.Current guides to assess potentially inappropriate prescribing based on expert consensus e.g. Beers Criteria.The Beers criteria are one of the most widely used consensus criteria for medication use in older adults (last updated 2003), although there is increasing concern about their appropriateness

DrugConcernSeverity Rating (High or Low)AmitryptylineBecause of its strong anticholinergic and sedation properties, amitryptyline is rarely the antidepressant of choice for elderly patients.HighNon-Cox-Selective NSAIDS:Naproxen, PiroxicamHave the potential to produce GI bleeding, renal failure, high blood pressure and heart failure.High

Methods Identifying the populationCare home addresses obtained from the relevant local authorities & other sourcesCompared to electronic register of addresses held by NHS Tayside on all patients 377 addresses were manually checked where there was still uncertainty if they aplied to a care homePatients classed as living at home if address did not match any of those on the addresses of the care home list Patients classed as in care if their address matched one from the care home list

MethodsPrescriptionsPrescriptions were obtained for all patients dispensed in 2005 and 2006. Information available included, Patient Chi Number, Drug Name, Prescription Date, Formulation Code, Strength, Quantity, Directions, BNF Code and prescribing practice.BNF categories (Drug Class)BNF codes were grouped according to class of drugs e.g.4.2.1 - Antipsychotic drugs, or5.1.1.3 - Broad-spectrum penicillins

Descriptive statistics of patients aged 65 -99 years, 2005-2006

At HomeIn CareNumber of Patients (%)65,742 (93.5)4,557 (6.5)Mean Age (std dev)75.2 (6.8)84.5 (7.5)Age Categories n (%)66-7020,034 (30)239 (5)71-8031,148 (47)1,065 (23)81-9012,934 (20)2,176 (48)91-991,626 (2)1,077 (24)Female sex n (%)37,497 (57.0)3,296 (72.3)No. of deaths (%)5,321 (8.1)1,790 (39.3)Mean no. of prescriptions (95% CI)66.7 (66.28-67.22)113 (110.37-115.56)Mean no. of drug classes (95% CI)8.8 (8.73-8.82)11.6 (11.39-11.77)

Relationship between receiving a PIM with variables of interest

Explanatory variableOdds Ratio (95% CI)UnadjustedAdjusted*Age Categories n (%)66-701.01.071-801.16 (1.12-1.21)0.91 (0.88-0.95)81-901.18 (1.13-1.24)0.76 (0.72-0.80)91-990.98 (0.89-1.07)0.65 (0.58-0.72)Male1.01.0Female1.37 (1.33-1.42)1.22 (1.17-1.26)Polypharmacy (No. of drug classes)1.19 (1.18-1.19)1.19 (1.19-1.19)At home1.01.0In care1.32 (1.24-1.40 )0.94 (0.87-1.01)

CriteriaAt Home %In Care %Odds Ratio (95% CI)Severity RatingUnadjustedAdjusted*Long Acting Benzodiazepines6.3611.131.85 (1.68-2.04)1.62 (1.45-1.81)HighNitrofurantoin2.465.842.46 (2.15-2.81)1.52 (1.30-1.76)HighFluoxetine2.104.832.37 (2.05-2.74)2.25 (1.91-2.65)HighMuscle Relaxants1.693.842.32 (1.97-2.73)1.42 (1.19-1.70)HighAmitryptyline7.765.990.76 (0.67-0.86)0.59 (0.51-0.67)HighNSAIDs3.921.560.39 (0.31-0.49)0.42 (0.33-0.54)HighGastrointestinal antispasmodic1.060.920.87 (0.63-1.18)0.70 (0.51-0.98) High

Practice level prescribing of Beers Criteria drugs

Potentially Inappropriate MedicationsExceptions will exist within the datasete.g.- Patients may be on a short course of long acting benzodiazepines.- Patients may be on low doses of amitrptyline.-A patient may be on NSAIDS while awaiting a hip replacement.

Key FindingsOlder patients in care have higher numbers of prescriptions and drugs from more classes than those living at homeAround 1/3 of Taysides older population have potentially inappropriate medications according to Beers CriteriaAfter allowing for age, sex and number of drug classes there were no differences in overall potentially inappropriate medications between patients in care and those at homePolypharmacy is a consistent risk factor associated with potentially inappropriate medicationsThe Beers Criteria as a screening tool may not be appropriate although some individual criteria show differences which may be important and need more investigationBarnett et al. BMJ Qual Saf 2011;20:275-281 doi:10.1136/bmjqs.2009.039818

Psychoactive drug use in older peopleAntipsychotics used for Behavioural and Psychological Symptoms of DementiaNot very effectiveIncreasing evidence they are harmfulLittle evidence about how commonly usedAlso interested in use of hypnotics, anxiolytics, anti-depressants and long-acting benzodiazepines

AimThe aim of this study was to examine prescribing for psychoactive medications for patients living in care homes compared to patients living at home

MethodsResidents of care homes identified as before with recorded date of entry notedExtracted all dispensed prescriptions for psychoactive drugs 2005-2006. Examined prescribing for 1 Jan 25 Mar 2005Hypnotics (BNF 4.1.1)Anxiolytics (BNF 4.1.2)Oral anti-psychotics (BNF 4.2.1)Tricyclic and related antidepressants (BNF 4.3.1)SSRI antidepressants (BNF 4.3.3)Other antidepressants (BNF 4.3.4)Examined prescribing for patients admitted to care homes across the study period

Patient DemographicsOf those in care, 49% in nursing homes, 39% residential homes, 12% mixed typeBased on patients alive on 25 March 2005

At HomeIn Care No. of Patients66,494 (95.9)2,813 (4.1)Mean Age75.3 years84.5 yearsFemale57.4%72.9%

Prescribing in 12 week period

Living at homeLiving in careMean no. of items dispensed7.19 (7.12-7.25)15.66 (15.11-16.20)Mean no. of drug classes received4.02 (3.99-4.04)5.65 (5.49-5.80)

Psychoactive prescribing in past 12 weeksAny psychoactive medication : At home 15.5%, In Care 41.7%, OR 3.09 (2.84-3.35)

Chart1

13.26

6.42.7

16.61.2

7.65.2

13.23.6

In Care

At home

Sheet1

In CareAt home

Hypnotics13.26

Anxiolytics6.42.7

Oral anti-psychotics16.61.2

Tricyclics7.65.2

SSRIs13.23.6

To resize chart data range, drag lower right corner of range.

When are drugs started?1,715 (2.4%) patients were admitted to a nursing home in 2005-2006

No of patients (%)Started at homeHypnotics473 (28)72%Anxiolytics343 (20)70%Oral anti-psychotics500 (29)72%Tricyclics223 (13)75%SSRI431 (25)73%

Oral anti-psychotics500 patients with an admission 2005-2006 were prescribed an oral antipsychotic28% initiated +/- 30 days of admissionHalf initiated in 30 days prior to admissionHalf initiated in first 30 days after admissionMedian duration of use 280 days (IQR 30-613)299 (60%) taking oral anti-psychotics for 6 months or longer

Oral anti-psychotics

No of patients Duration >= 180 daysContinuousOR for stopping(%)(%)(%)OR (95%CI)>30 days prior to admission282 (56) 215 (76) 62 (22) 1.0Within 30 days prior to admission70 (14) 29 (41) 27 (39) 0.50 (0.28-0.88)Within 30 days after admission71 (14) 30 (42) 25 (35) 0.53 (0.30-0.94)> 30 days after admission77 (15) 25 (32) 24 (31) 0.73 (0.41-1.30)

ConclusionsPatients in care are more likely to be prescribed psychoactive drugsContrary to expectation, usually initiated before admissionHigh rates of anti-psychotic use, and once started prescribing is usually prolongedFurther work should investigate why drug initiation occurs, duration of use, and whether prescribing is appropriately reviewed

ConclusionsThere is increased use of potentially harmful drugs for patients in care compared to the communityFurther work should investigate why drug initiation occurs, if it is based on new diagnosis and whether it is short or long term use

AcknowledgementsProf Bruce Guthrie, Prof Tom Fahey, Dr Stella Clark, Dougie McPhail, Dr Karen Barnett, Prof Peter Davey, Prof Frank Sullivan, Marie Pitkethley, Dr Claire Stubbings, Dr Parker MaginAlison Bell, Chris Hall & Duncan Heather at the Health Informatics Centre for supplying and managing the routine data

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