What can health informatics offer to improve the management of infection?

Prof Peter Davey

Community Health Sciences Division,College of Medicine, Nursing and Dentistry

www.dundee.ac.uk/hicp.g.davey@chs.dundee.ac.uk

1/15

Agenda• UK’s unique opportunities for research

with routine data• What is the added value of individual data

versus aggregate data?• Examples of record linkage studies from

primary and secondary care• What kind of information do we need to

make a difference to prevention and management of infection?

• What are SIRN’s plans for the future?2/15

3/15

UKCRC R&D Advisory Group to Connecting for Health Report2007

Within the UK, Scotland has pioneered systems of linkage since the mid 1970’s, when a far-sighted director of public health introduced the Community Health Index, the Scottish equivalent of the NHS number, and made it his mission to get this used in all NHS settings.

It is clear that Scotland has developed an enviable system and has much experience and expertise to share with other UK countries.

Experience in Denmark suggest that a population of perhaps 5 million may mark the upper limit of what is technically manageable. So it may be preferable to expand and link existing databases such as those in Manchester, Wirral and eastern Scotland, and create new ones, rather than attempting to build one repository for all of the UK’s medical information.”

4/15

Prof James Crooks Dr Ronnie Graham

October 1978• A uniform method

for indexing patient records in primary and secondary care will transform services and research, leading to a more integrated approach to health care.

October 1978

• “It might, then, be reasonable to suppose that a new system of information distribution would precede change in practice. It is however, abundantly clear to even the casual observer that our medical information handling has changed little with administrative restructuring.”

8/15www.dundee.ac.uk/hic

9/15

Trimethoprim resistance study

Donnan P et al, BMJ 2004

CHI number present on 93% of lab records

Complete data on prescribing etc. in 97%

of patients in Ninewells catchment area

Association between prevalence of trimethoprim resistant bacteria in urine & practice level variables

• Analysis of practice level data obscured important associations between antibiotic prescribing and resistance.– Wide practice variation in resistance (26-50% of

bacteria isolated) and prescribing (67-357 prescriptions per 100 practice patients).

– At practice level, no association of prescribing with resistance (P = 0.101)

– At the patient level resistance was significantly associated with exposure to trimethoprim (P < 0.001) or to other antibiotics (P = 0.002).

• The results show the added value of individual patient data for research on the outcomes of prescribing.

10/15

Ecological fallacy – variation in drug use at the

population level correlates poorly with individual

patient outcome

11/15

In response to: Donnan et al Br Med J 328:1297, 2004.

Leading the way in Europe:

http://www.eu-burden.info/burden/pages/home.php

MRSAMSSA

Blood Cultures

Admitted to unit/hospital

Community

Other +ves

Analysis:HAI As A Time Dependent Variable

0 1

2 3 4 5

No HAI

HAI

Discharge DischargeDeath Deathchange LOS is an R package to:• describe any multistate model• compute and visualize transition probabilities• compute and visualize change in LOSHAI, hospital-acquired infection; LOS, length of stay Wangler M et al. R News 6;2, May 2006

Design BURDEN WP5 & WP 7

• Two matched cohort studies:–Hospital acquired, drug resistant

bacteraemia & controls–Hospital acquired drug sensitive

bacteraemia & controls• Matched by ward & calendar

date (within 7 days)

WP 5 & WP 7• Four comparisons:1.Full cohort vs two randomly

selected comparators2.Electronic vs case note

comorbidity3.90 day mortality vs in hospital

mortality and 30 day4.Additional burden of readmission

http://www.idrn.org/antimicrobial_prescribing.php

Association Between Antibiotic Prescribing and Complications of RTI

Presentation Complication Risk without antibiotics, per 10,000 treated

Number Needed to Treat

Sore throat Scarlet feverQuinsy

314

10,9144,520

Otitis media Mastoiditis 3 Not effectiveURTI Pneumonia 14 15,817LRTI Pneumonia 196 73

Age 0-45-15

16-64>65

14612114747

What kind of information do we need to make a difference?• What might work?

– Modelling interventions (prevention, diagnosis or management)

– Unintended as well as intended consequences– Patient, professional and policy maker

perspectives• How can we maximise the impact of

interventions on practice?• How should we evaluate interventions?• What is the impact of context?

19/15

The Cycle of Patient Information

• Ann: using information to help patients make decisions

• Brenda: Improving the patient’s journey of care

• David: Involving people in research

• Joan: Do people become resistant to antibiotics?

• Morag: using information to promote oral health

• Dr Menzies: confidentiality and privacy

Core Principles of HIC

• PrivacyNo individual patient or practitioner can be traced from data sent to / held by HIC without permission

• TransparencyClear standard operating procedures applied across diseases and geographical areas

• InvolvementProduce value to contributors of data

Collaborative Research Scotland

Integrating knowledge on HCAIs

Scientific knowledge

Clinical application and experience Social and

Organisational insights Patient & Public

perspectives

Integrated real-time clinical information systems

Knowledge mobilisation for patient benefit