A:1 - Realistic Medicine: Whose
Needs Are We Meeting Anyway?
#nhsa1
Variation
Whose needs are we meeting?
Variation: Multiple categories:
1. Variation in Incidence/Prevalence
2. Variation in Process
3. Variation in Outcomes
4. Variation in Intervention Rates.
{Not so in McDonald’s:
63 million meals a day}
1. Variation in Incidence: Bowel Cancer:
Variation in process:
Orthopaedic Day-case Rates
Variation in Outcomes:
Getting back home after hip fracture:
National change since 2012/13
44% to 52%
Hospitals –
a range from 30% to 65% (2015)
100%
80%
60%
40%
20%
0%
Home
Not home
4. Variation in activity:
Cataract surgery rates in NHS England.
x3 fold variation in agestandardised rates in over 65
year olds.
Variation in activity: Hip replacement rates
{Also patient assessed improvement score}
3.5 fold variation in rates.
Cornwall 207
[0.42*]
Hammersmith 67.9
[0.55*]
* Patient assessed improvement
score: Range 0.6(best) to 0.3
(least)
Variation in Intervention Rates:
Lets start with some history:
Dr Alison Glover research
on tonsillectomy rates in
1930s.
Found massive variation
By age 14 between 20%
and 83% of children had
had tonsillectomy
1930s Tonsillectomy:
• Variation of up to x27
times in different areas.
• Higher rates in “upper
classes”
• 60 deaths from “tonsil
related disease”*
• 513 deaths following
tonsillectomy*
*1931-1935
A “controlled” experiment
(so relevant to our times):
Guernica:
First mass aerial bombing of civilians
Luftwaffe. 1937
Depicted by Picasso
4,000 child migrants from Spain
reach Southampton.
2% tonsillectomised.
Health outcomes similar
200 adults also examined
Conflicting opinions:
“In a properly selected case
there is no single operation
in children’s medicine more
successful or that shows
such dramatic results as
that of tonsillectomy”
“One cannot avoid the
conclusion that there is a
tendency for the operation
to be performed as a routine
prophylactic ritual for no
particular reason and with
no particular result”
Dr Dean.
Schools Epidemic Council of
the MRC
{Doctors generally chose less treatment
for themselves than they suggest for
patients.}
{Influenced by attitude to risk, litigation
fear, peer pressure, incentives, industry
promotion etc}
{Patients who are fully informed choose
less treatment and have less regret}
Variation in Healthcare Intervention Rates.
#Strongly evidence based interventions.
Predictable benefit: shouldn’t be much variation
#Preference Sensitive Care.
Uptake driven by patient preference: Individual variation,
but likely to be similar across populations
#Supply Sensitive Care.
Supplier induced: High levels do not relate to better
outcomes: Potentially high source of over-treatment and
generally unwarranted variation.
What are the problems with variation?
Is the observed variation consistent with patient choice?
Equality
Effectiveness
Efficiency
Waste
Benefit/harm ratio may be inappropriate
Under-treatment as well as over-treatment
But we must start with data
Finding Variation:
So you need the benchmarking data
Prof Mahmood Adil
DCH, MPH, CertHEcon, DipHInformatics, MHSM, FRCP (Edin), FFPH, DipIoD
Medical Director
Information Service Division (ISD) & Health Protection Scotland (HPS)
NHS National Services Scotland
Data Saves Lives
Health Intelligence
Our Strength in Scotland
Integrated Data
CHI
SIMD
A&E
Outpatients
Inpatients
Deaths
Day cases
Social Care
SPARRA
Prescribing
Age/gender
Linked File
Information Service Division (ISD)
Supporting You
Data
Intelligence
Routine publications
www.isdscotland.org
•
•
•
•
Discovery
Source
SPIRE
NHS Perform
Innovation
Creating solutions
with collaboration
NSS Discovery
Quality
Improvement
Benchmarking
Performance
Management
www.nssdiscovery.scot.nhs.uk
What is in it?
Scottish and Home Countries
Data
41 Indicators under 2020 Vision
Quality Dimension
Three Data and Security Levels
Level 1
(Non Confidential – Strategic
Overview)
Scottish Data for
all NHS Boards
available
NI data
in
2016/17
Level 2
(Potentially Disclosive - Analytics)
English
Hospitals
data pilot
underway
Level 3
Wales Hospital
data coming
soon
(Confidential – patient
identifiable)
What does it show?
•
•
•
Information at NHS Board, Hospital & specialty level
Authorised users can access more detailed information, including patient level data
Comparisons with Scottish, English and Welsh benchmarking data will be available
within the system
Population Health
Lung Cancer Incidence – 2012
(Health Board of Residence View)
Clinical Outcome Indicators
Lung Cancer – 2013
(Health Board of Residence View)
Discovery – Consultant Team Dashboard
Emergency Readmissions within 28 days for Trauma and Orthopaedics
Comparison of teaching hospitals
Discovery – Consultant Team Dashboard
Emergency Readmissions within 28 days for Trauma and Orthopaedics
Comparison of teaching hospitals
Discovery – Consultant Team Dashboard
Emergency Readmissions within 28 days for Trauma and Orthopaedics
Comparison of consultants at a specific hospital
Discovery – Consultant Team Dashboard
Emergency Readmissions within 28 days for Hip Replacement
Comparison of consultants across hospitals within a Board
Thank you
@mahmoodadil
Lets recap for a moment:
#Strongly evidence based interventions.
Predictable benefit: shouldn’t be much variation
#Preference Sensitive Care.
Uptake driven by patient preference: Individual
variation,
but likely to be similar across
populations
#Supply Sensitive Care.
Supplier induced: High levels do not relate to better
outcomes: Potentially high source of over-treatment
Peripheral angioplasty/stent procedures performed
in an acute setting per 100,000 population, 2014/15
(Source: ISD, NRS)
Diabetic Control:
% with HbA1c over 75 mmol (9%)
Board
Type 1
Type 2
D&G:
31.2%
11.7%
GGC
35.6%
16.2%
Grampian
42.3%
18.1%
Further examples:
– Cystoscopy rates
– Return/New patient out-patient ratios
– Lower GI endoscopies.
– GP referral rates
– Arthroscopies
– Knee replacement rates.
– MRI and CT scans
Conclusion:
• Significant variation exists across Scotland
• It warrants analysis (but take care to do well)
• You know now how to access data
• Start looking at data where your Board appears to be
an outlier
• You may prevent harm and waste, and save resources.
Questions/Comments?