CV patient database – outcomes and pathways analysis

Acute myocardial infarction: Tracking

patients’ journeys and outcomes in a

complex, acute healthcare system

NHS Greater Glasgow and Clyde, Golden Jubilee

National Hospital, University of Glasgow, DataLab

and AstraZeneca UK

This analysis has been performed by AstraZeneca as part of the Joint Working project between NHS Greater Glasgow and Clyde (GGC), Golden Jubilee National

Hospital (GJNH), GGC Managed Clinical Network and AstraZeneca UK Ltd.

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Background

•Reducing cardiovascular mortality

and improving outcomes is a key

focus for NHS Scotland

•Scottish hospitals do not submit

data to Myocardial Ischaemia

National Audit Programme

(MINAP)

•We lack of contemporary data on

service delivery and outcome in

our patients.

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Background

• In Glasgow, electronic patient records have been

implemented in place of paper records

• National Advisory Group for Heart Disease pilot e-Registry

• NHS Greater Glasgow and Clyde (GGC), Golden Jubilee

(GJNH), Glasgow Managed Clinical Network (GMCN) and

AstraZeneca UK (AZ)

= Joint Working Agreement

• MCN involves 6 acute hospitals in NHS GGC (population 1.2

million) and the regional hub for invasive cardiology (GJNH)



Pathway Map

Home

Local HospitalGJNH

Local A&E

1

2

3

4

56

9

Pathway Beginnings

1 – Emergency Direct to GJNH

2 – Local A&E to GJNH

3 – Direct Transfer from local Hospital to GJNH

4 – Elective GJNH admission following discharge and referral from local hospital

5 – Local Hospital only (no referral or GJNH admission)

6 – Elective GJNH admission only (no referral from local hospital or local admission)

Pathway Endings

A – Discharged home (from local or GJNH)

B – Transferred to local hospital before discharge

C – Death in hospital (local or GJNH)



Pilot Objectives

1. Design and create a linked CV patient registry for patients treated across

NHS GGC and GJNH using routinely collected electronic healthcare

records

2. Complete a service evaluation focusing upon the delivery 12 months of

ACS services managed across NHS GGC and the GJNH

3. Establish a robust legacy of quality data collection for CV patients that

can be used for research and service improvement purposes into the

future

4. Project steering committee to make recommendations for optimal

service design and local delivery plan to GMCN and National Advisory

Committee for Coronary Heart Disease



Key Early Activities

•Project steering group - NHS GGC, GJNH, GMCN & AstraZeneca UK

•Permissions from all relevant regional and national bodies

•Joint Working Framework –little financial resource needed

•Records extracted from three sources of electronic patient records from

NHS GGC and GJNH; initially for 3 month period to enable testing of

extract specification and process

•Pilot registry created by Safe Haven at University of Glasgow to link

records extracted

•Methodology for analyses and reports designed by AZ with support of

NHS clinical and technical teams



Pathway Definitions

Pathway Description Admission and Discharge Criteria Additional Criteria

1 Direct (emergency) to GJNHGJNH Admission method either 'Direct to Cardiac Centre‘ or 'Air ambulance transfer'

No referral prior to GJNH admission. Must havevalid discharge recorded

2 Via local A&E to GJNHGJNH Admission method either 'Ambulance to local A&E‘ or 'Self-referral to local A&E'

No referral prior to GJNH admission. Must havevalid discharge recorded

3Local hospital inpatient admission with direct transfer to GJNH

GJNH Admission method either 'Transfer from ward in local hospital’ or 'Already in cardiac centre'

Local Hospital admission and referral prior to GJNH admission. Must have valid discharge recorded.

4Local hospital inpatient admission, discharged home with referral to GJNH

GJNH Admission method either 'Elective admission‘ or 'Direct to cardiac centre'

Local Hospital admission and referral prior to GJNH admission. Local hospital discharge must be ‘Home’.

5 Local hospital treatment onlyAdmission direct to local hospital, dischargedhome or within local hospital

No referral for further activity after local hospital admission or evidence of GJNHadmission. Must have valid discharge recorded.

6 Elective GJNH treatment only

GJNH Admission method either 'Elective admission‘ or 'Direct to cardiac centre‘. Discharge method either 'Discharged home’ or 'Inpatient death'

No referral prior to GJNH admission or evidence of local hospital admission. Must have valid discharge recorded.



Summary of 12 month Data

TRAKCARE:

5445 records

SCI Gateway:

6651 records

CATHI:

7157 records

ExcludedSpells with incomplete data*

Non-IHD Final Diagnosis

*Incomplete Data: Pathway cannot be assigned due to missing information, normally due to start or end of pathway falling outside of current 12

month data window or patient attending from Health Board other than NHS GGC, therefore no TRAKCARE data available in current extract. Also

includes patients where SCI referral was made but there is no evidence of any clinical activity in dataset.

Analysis performed by AstraZeneca as part of the Joint Working project between NHS Greater Glasgow and

Clyde (GGC), Golden Jubilee National Hospital (GJNH), GGC Managed Clinical Network and AstraZeneca UK

Ltd.

Mortality:

862 records

Ischaemic Heart Disease (IHD)

Linked Dataset

Unique Patients: 3186

Distinct Complete Spells: 3438



Example Outputs

9

Asset ID: 594,414.011 Date of Prep: November 2014



NSTEMI Summary

MINAP National Audit Annual Report 2013-141 NHS GGC Health Board Summary Oct 2013-Sept 2014

697 (63%) referred for or had angiography

451 (65%) admitted via emergency services or self-

presentation

48 (11%) angiography within 24hr of

admission

38 (8%) angiography 24-48hr after

admission


admission


admission

238 (53%) angiography >96 hr

after admission

200 (28%) admitted via transfer for specific

treatment

46 (7%) admitted via another or unknown

method



Ltd.



Non ST-Elevation Myocardial Infarction (NSTEMI)



NSTEMI Patients: Spells

by Care Pathway

N=1100

Local A&E

Local Hospital GJNH

Home

1n=30 (3%)

6n=46 (4%)

5n=403 (37%)

2n=6 (1%)

3n=415 (38%)

4n=200 (18%)

Pathway Definition

1 – Emergency Direct to GJNH

2 – Local A&E to GJNH

3 – Local hospital inpatient admission with direct

transfer to GJNH

4 – Local hospital inpatient admission, discharged

home with referral to GJNH

5 – Local Hospital only

6 – Elective GJNH only



Ltd.



2.2(median=1)

8.0(median=4)

7.3(median=6)

3.4(median=3)

11.4(median=6)

0.8(median=0.5)

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

1Direct to GJNH

(n=30)

2Local A&E to

GJNH

(n=6)

3Direct Transfer

(n=415)

4Discharged Home with

Referral(n=200)

5Local Hospital

Only

(n=403)

6Elective GJNH

Only

(n=46)

Mea

n D

ays

in H

osp

ital

Care Pathway

NSTEMI Patients: Mean Days in Hospital by Pathway N=1100



Ltd.

Notes: If a patient has an admission that lasts less than one day (i.e. Admitted and discharged on the same date) then for the purposes of calculation of days in hospital they

have been assigned a duration of 0.5 days for that admission.



99.1% 100.0% 100.0% 100.0% 100.0%

87.0%

49.8%

60.0%

83.3%

54.5%

36.0%

56.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Any Pathway

(n=697)

1Direct to GJNH

(n=30)

2Local A&E to GJNH

(n=6)

3Direct Transfer

(n=415)

4Discharged Home

with Referral

(n=200)

6Elective GJNH Only

(n=46)

Pe

rce

nt

of

Spe

lls i

n t

he

Pat

hw

ay

Care Pathway

NSTEMI Patients: Percentage of Spells Receiving Angiography and Percentage Receiving PCI By Pathway

Angiography

PCI

N=697



Ltd.





Ltd.

<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15-21 >21

1.Direct to GJNH 1.27 0.36 0.27 0.45 0.00 0.09 0.00 0.09 0.00 0.00 0.00 0.09 0.09 0.00 0.00 0.00 0.00

2.Local A&E to GJNH 0.00 0.09 0.00 0.09 0.18 0.00 0.00 0.09 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.09

3.Direct Transfer 0.00 0.73 2.72 5.09 5.09 3.91 4.54 3.18 3.45 1.18 1.64 0.91 1.00 0.45 0.45 2.17 1.17

4.Discharged Home with Referral 0.00 1.09 3.27 7.55 3.64 1.55 0.64 0.18 0.09 0.00 0.00 0.00 0.00 0.09 0.00 0.00 0.09

5.Local Hospital Only 0.45 1.55 2.27 4.36 4.36 3.00 3.18 3.09 1.82 1.36 0.82 0.73 0.64 1.00 0.73 2.91 4.32

6.Elective GJNH Only 3.55 0.36 0.00 0.09 0.18 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

Pe

rce

nt

of

Pa

tie

nts

Days in Hospital

N=1100

NSTEMI: Distribution of Days in

Hospital According to the Pathway



99.1% 100.0% 100.0% 100.0% 100.0%

87.0%

49.8%

60.0%

83.3%

54.5%

36.0%

56.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Any Pathway

(n=697)

1Direct to GJNH

(n=30)

2Local A&E to GJNH

(n=6)

3Direct Transfer

(n=415)

4Discharged Home

with Referral

(n=200)

6Elective GJNH Only

(n=46)

Pe

rce

nt

of

Spe

lls i

n t

he

Pat

hw

ay

Care Pathway

NSTEMI Patients: Percentage of Spells Receiving Angiography and Percentage Receiving PCI By Pathway

Angiography

PCI

N=697



Ltd.



11.2(median=6)

0.6(median=0)

0.3(median=0)

5.0(median=4)

26.0(median=23)

-5.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Any Pathway

(n=651)

1Direct to GJNH

(n=30)

2Local A&E to GJNH

(n=6)

3Direct Transfer

(n=415)

4Discharged Home

with Referral

(n=200)

Me

an D

ays

in t

o A

ngi

ogr

aph

y

Care Pathway

NSTEMI Patients: Mean Days from Acute Admission to Angiography

(Pathways 1-4)N=651



Ltd.

NHS Standard of Care < 72 hours



27%

38%

2%

26% 3%

3%

0%

10%

20%

30%

40%

50%

60%

<140(n=330)

≥140(n=252)

No Score(n=33)

Per

cen

t o

f Pat

ient

s R

efer

red

to G

JNH

GRACE ACS Risk Score Recorded at Time of Referral

NSTEMI Patients: GRACE Score for Patients Referred to GJNH from Local Hospital (Pathways 3 and 4)

4: Discharged Home with Referral

3: Direct Transfer

N=615



Ltd.

GRACE >140 criterion for referral



3.2% 3.4% 5.6% 7.9% 14.2%0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

In Hospital(n=1100)

30 Days(n=941)

90 Days(n=941)

180 Days(n=771)

365 Days(n=288)

Mo

rtal

ity

Rat

e (

Pat

ien

ts w

ith

Dat

a)

Days From Most Recent Admission

NSTEMI Patients: All Cause Mortality (Unadjusted) N=1100

NB – Only for patients with sufficient follow-up for each timeframe



Ltd.



2.3% 2.6% 4.0% 4.7% 8.3%0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

In Hospital(n=1100)

30 Days(n=941)

90 Days(n=941)

180 Days(n=771)

365 Days(n=288)

Mo

rtal

ity

Rat

e (

Pat

ien

ts w

ith

Dat

a)


NSTEMI Patients: Mortality of Cardiovascular Cause (Unadjusted)

N=1100




Ltd.



1.9% 2.3% 3.3% 3.9% 6.9%0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

In Hospital(n=1100)

30 Days(n=941)

90 Days(n=941)

180 Days(n=771)

365 Days(n=288)

% o

f D

eat

hs

in P

atie

nts

wit

h D

ata


NSTEMI Patients: Mortality Due to Ischaemic Heart Disease (Unadjusted)

N=1100




Ltd.





7(median=5)

8(median=6)

7(median=4)

9(median=5)

10(median=5)

8(median=4)

0

2

4

6

8

10

12

14

Glasgow Royal Infirmary(n=289)

Inverclyde Royal Hospital(n=93)

Royal Alexandra Hospital(n=195)

Southern General Hospital(n=59)

Victoria Infirmary(n=161)

Western/Gartnavel Hospitals(n=193)

Mea

n D

ays

in H

osp

ital

NHS GGC Hospital of Origin

NSTEMI Patients: Mean Days in Hospital by Originating Hospital

Vale of Leven Hospital not shown due to low patient numbers (n=2 )



Ltd.







Ltd.

2

3

2

2

3

3

3

3

4

3

4

3

0 5 10 15 20 25 30 35



Royal Alexandra Hospital(n=81)

Southern General Hospital(n=22)

Victoria Infirmary

(n=39)

Western/Gartnavel Hospitals

(n=78)

Mean Days

Re

ferr

ing

Ho

spit

al

NSTEMI Patients Referred with Direct Transfer: Mean Time from Admission to Referral and

from Referral to Treatment by Referring Hospital

Time to Referral

Time from Referral to Treatment

2

3

2

2

3

2

25

14

30

20

22

18

0 5 10 15 20 25 30 35



Royal Alexandra Hospital

(n=47)

Southern General Hospital

(n=14)

Victoria Infirmary(n=44)

Western/Gartnavel Hospitals(n=33)

Mean Days

Re

ferr

ing

Ho

spit

al

NSTEMI Patients Referred via Discharge Home: Mean Time from Admission to Referral and

from Referral to Treatment by Referring Hospital Time to Referral

Time from Referral to Treatment





Moving forward

Aims and objectives for next 12 months

1. Regional ACS eRegisty with automated data collation and reporting systems

2. Development and exploration of expanded dataset to identify new group or pathways of care of clinical significance, e.g. Ambulance Service

3. Investigate additional data sources that could be integrated into the registry to improve the richness of the data

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwix8YeL6_bPAhUDfhoKHXxVDBMQjRwIBw&url=http://www.ed.ac.uk/economics/postgraduate/scottish-graduate-programme-economics&psig=AFQjCNH5GMj7AUQnkLFEMKsxQaX_Dxb0RA&ust=1477515165862902




Innovation in Data Science

Key tenet of SG policy as described in CMO Realistic Medicine publication is “Reducing Variation” but it first needs to be measured

Provide a paradigm shift by developing a timely, on demand real time reporting tool

Immediate focus is GGC & GNJ HB but adaptable nationally

Develop reporting to suit Scottish perspective / needs

Use different data science techniques to explore potential groups or patterns of care of clinical interest

Link to wider datasets to provide richer more detailed information on care and long term outcomes



Real-time on demand reporting

Mortality

CATHi Lab

Scottish

Ambulance

Service

SCI-Gateway

TRAKCare

Approved

NHS Staff

using

existing

software

and access

rights

eRegistry

Dataset

NHS datasets NHS Safe Haven

NHS

Server 1- Linked

identified

datasets

SLA for

data

supply

ETL &

process of

data

Da

ta r

ep

ort

ing



Data Science /

Link to wider datasets

Mortality

CATHi Lab

Scottish

Ambulance

Service

SCI-Gateway

TRAKCare

Approved

researchers in

controlled

Safe Haven

environment

eRegistry

Dataset

NHS datasets NHS Safe HavenServer 1- Linked

identified

datasets

SLA for

data

supplyETL &

process of

data

LP

AC

Ap

pro

ve

d D

ata

ex

tra

cts

Server 2- Linked

anonymised

datasets

Other

datasets



Innovation in Data Science

Apply novel techniques (e.g.

Bayesian techniques, machine

learning, pattern recognition

etc) to derive new insight in

support of clinical decision-

making

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwj21qC_0PbPAhXEWhQKHcVdBDAQjRwIBw&url=http://abcnews.go.com/Health/medical-records-private-abc-news-investigation/story?id%3D17228986&bvm=bv.136593572,d.cWw&psig=AFQjCNGceByBIRnoUkSkfcPoSy5XFyjTbw&ust=1477508031131999

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwj21qC_0PbPAhXEWhQKHcVdBDAQjRwIBw&url=http://abcnews.go.com/Health/medical-records-private-abc-news-investigation/story?id%3D17228986&bvm=bv.136593572,d.cWw&psig=AFQjCNGceByBIRnoUkSkfcPoSy5XFyjTbw&ust=1477508031131999

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjOlvDj6PbPAhUCWxQKHfl0C3QQjRwIBw&url=http://www.bankers-adda.com/computer-skills/networking/&bvm=bv.136593572,d.cWw&psig=AFQjCNHAeOGMPxGa7ngS-GW1BbLL-ilFuQ&ust=1477514353395812

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjOlvDj6PbPAhUCWxQKHfl0C3QQjRwIBw&url=http://www.bankers-adda.com/computer-skills/networking/&bvm=bv.136593572,d.cWw&psig=AFQjCNHAeOGMPxGa7ngS-GW1BbLL-ilFuQ&ust=1477514353395812



Long term outcomes

University of Glasgow MVLS Industrial Partnership PhD with AstraZeneca

Aim: to explore the association of socio-economic status with the process and long-term outcomes of treatment for suspected acute MI

Use data linkage to undertake epidemiological research to better understand the patient journey and factors which influence treatment decisions and outcomes.



The Learning Health System



Next steps

1. Share the outputs – NHS Scotland

2. National Steering Group in Scottish Cardiac Society

3. Support other Boards to develop their own e-Registry, potentially through

Safe Haven

4. National e-Registry

5. Beyond MINAP – all cardiovascular hospitalisation.



Learnings

1. Both clinical and technical representation in steering group is essential to

ensure understanding and delivery of requirements

2. Strong project management needed to drive project forwards to meet

milestones

3. Validation of data (both underlying source and analysis assumptions) is

worth investing in

4. It is possible to create a quality patient registry from existing data

sources, without the need for additional data collection or excessive use

of NHS resources

5. Joint Working between the NHS, academia, and the pharmaceutical

industry can facilitate the delivery of projects that are valuable to the

NHS and patients



Thank you for your attention





Documents

CV patient database – outcomes and pathways analysis