Using prescribing health and population data to describe the health of a locality: the development and evaluation of a locality health profile

21

IJPP 2006, 14: 21–30© 2006 The AuthorsReceived May 13, 2005Accepted October 17, 2005DOI 10.1211/ijpp.14.1.0004ISSN 0961-7671

Original Papers

Using prescribing health and population data to describe the health of a locality: the development and evaluation of a locality health profile

Douglas Steinke, Susan Burney, Marion Bennie and Steve Hudson

Abstract

Objective To develop and evaluate a pharmaco-epidemiological and public health profile thatwill aid in the determination and evaluation of the health and pharmaceutical needs of a localpopulation with the National Health Service (NHS). Method Two local health areas (known as local health care co-operatives (LHCCs)) in NHS Lothianwith diverse population characteristics had health profiles formally developed using prescribing,hospitalisation and other public health data. The integrated report was able to highlight morbidityissues in each LHCC that could be acted on by either LHCC management or local pharmacy groups. Asteering committee and focus groups were used in the design and evaluation process. An evaluationsurvey of participants including LHCC management, community and LHCC pharmacists and otherhealthcare professionals was conducted with the main outcome measure being the relative utility ofthe health profile. Key findings Participants evaluating the health profiles found them informative and useful indecision making and planning for the locality. Participants anticipated using prescribing data tofill information gaps in other datasets and/or provide a primary care perspective to health in thelocality. Conclusions Health profiles were developed from prescribing health and population data thatwere shown to be meaningful and useful to local health authority management and otherhealthcare professionals. The health profiles contained information that could be used toinform decisions or identify areas where further investigation may be required to find out whya particular anomaly is occurring. In Scotland, the focus of a new community pharmacy contractis on the dual elements of chronic disease management and public health contributions,through prevention of disease and/or limitation of disease impact. There is an urgent need todevelop tools that help to inform professional interventions involving pharmacists, and therebyimprovements to multidisciplinary co-operation. This study suggests a means of describing thepopulation characteristics for informing a network of community pharmacists about publichealth priorities within their LHCC.

The Scottish Executive’s White Paper, ‘Designed to care: renewing the National HealthService in Scotland’ (December 1997) confirms the continuing development of a prim-ary care-led National Health Service (NHS).1 The public health White Paper ‘Towards aHealthier Scotland’ established the priority for primary care development to achieverevised national targets for major causes of morbidity in the population.2 A major publichealth priority in these strategies is to address variations in healthcare and to targetill-health associated with socially deprived neighbourhoods. The difficulties for primarycare groups (PCGs) in England in meeting these needs have been discussed, and thesame problems occur in Scotland.3,4

The Scottish Executive published ‘Improving Health in Scotland: the challenge’(March 2003), giving a framework for action to ensure health improvement is achievedin Scotland.5 This document empowers the NHS to build the capacity of the publichealth workforce to deliver Scotland’s health improvement activities in a holistic

Introduction

NHS, National Services Scotland, Edinburgh, Scotland, UK

Douglas Steinke, research pharmacist Susan Burney, head of healthcare information group

Lothian NHS Board, Edinburgh, Scotland, UK

Marion Bennie, consultant in pharmaceutical public health

University of Strathclyde, Glasgow

Steve Hudson, professor of pharmaceutical care

Correspondence: Professor Steve Hudson, Department of Pharmaceutical Sciences, Strathclyde Institute of Biomedical Sciences, University of Strathclyde, 27 Taylor Street, Glasgow, G4 0NR, Scotland, UK. E-mail: [email protected]

Acknowledgements: The project was partially funded by a grant from the Scottish Executive Health Department (Pharmacy). We would like to thank the Steering Committee for their time and commitment to the project and the two local health area co-operatives who gave permission to use their data in the study and provided feedback. We would like to thank the North East Edinburgh Local Healthcare Co-operatives for providing a clinical practice base during the study period.

IJPP14(1).book Page 21 Wednesday, February 1, 2006 4:33 PM

22 The International Journal of Pharmacy Practice, March 2006

fashion. The targeted public health workforce includesthose working in public health, health promotion, the widerNHS and also those in local government. Additionally, theNHS is tasked to continue to develop methods for theapplication of integrated public health data to inform healthimprovement interventions at national and local levels. Thenew information systems will enable the sharing of data inan accessible and relevant form, allowing communityhealth to be assessed, needs to be identified and responsesto be formulated.

‘The Review of the Public Health Function in Scotland’(December 1999) recognises the health improvement role ofpharmacists in providing safe and effective pharmaceuticalcare, while fostering health promotion and disease preven-tion.6 Pharmacists engage with communities beyond theNHS environment by contributing to the wider public healthagenda and, whether working in community or hospitalpractice, they are ‘hands-on’ public health practitioners.Community pharmacy is sited at the heart of the com-munity, where it can gain particular understanding of theneeds of the local population through daily interactions withthe public.

The public health role in community pharmacy has beenrecognised in a changing NHS pharmacy contract in Scot-land.7 Public health activities are one of the ‘essential phar-maceutical care services’ that will have terms of referenceand remuneration defined within the core contract. Theseterms will outline how pharmacists can improve the rangeand quality of care provided to patients through the develop-ment of existing skills within the pharmacy. Increasingemphasis is being placed on the clinical management of anindividual patient’s condition and wider healthcare needs.‘The Right Medicine: a strategy for pharmaceutical care inScotland’ highlighted the potential importance of extendedroles and input from pharmacists in the healthcare ofthe population.8 Community pharmacy provides a familiarnon-threatening environment where advice and expertise onmedicines, lifestyle issues and health management can begiven to the public.

Aim

The aim of this study was to develop and evaluate a phar-maco-epidemiological and public health profile that will aidin the determination and evaluation of the health and pharma-ceutical needs of a local population.

Study population

The populations, registered with general practitioners (GPs)in two local health areas in NHS Lothian (Edinburgh) whichhave a diverse population and geographical characteristics,were used in the development of the health profile, usingprescribing data to supplement other public health data,such as mortality and activity data. NHS Lothian (one of 15geographically demarcated administrative health areas inScotland known as health boards (HBs)) has a population of

approximately 800000 people. At the time of the study, theHB was divided across eight local health care co-operatives(LHCCs) with varying populations ranging from 81000 to165000 (LHCCs being subdivisions of the HB). TheLHCCs were selected based on existing links with theresearchers.

Database development

Information relevant to LHCCs is stored and issued from anational NHS database. By accessing national databases,information was gathered from public health, death, hospitaladmission and prescription claims datasets for LHCCs,NHS Lothian and Scotland areas. The information wasplaced in a secure primary database of health service, popu-lation and drug usage information (using the MicrosoftAccess program).

Hospital admission and discharge data were obtainedfrom National Health Service National Services Scotland(NHS NSS) for all inpatients discharged from an NHS hos-pital in Scotland in the study period. Day case, day surgery,outpatient and emergency visits were not included. The datawere manipulated to obtain the number of people admittedto hospital (not the episodes of care) and aggregated intomajor International Classification of Diseases (ICD-10 ver-sion) codes for disease groups, to avoid small numbers foreach admission code. For example, various types of lungcancer that were listed were combined into one group called‘lung neoplasm’.

The NHS prescription claims database contains routinelycollected information from dispensed prescriptions forNHS payment to community pharmacy contractors. Onlyinformation that is needed to pay the contractor is collected;for example, medicine name, strength, amount dispensed,date and prescribing doctor. This information is used to pro-duce performance reports (e.g. Scottish Prescribing Analy-sis (SPA)) and various budget and volume analyses. TheNHS prescription claims database is not patient specific;data cannot be identified to individual patients, the lowestaggregation being at ‘prescriber’ level. Prescription data forthe health profiles were aggregated to LHCC level for inclu-sion in the health profile, to prevent any violation of dataprotection and person identification.

Defined daily doses (DDDs) were used to describe drugutilisation in the health profiles, instead of the customarycost and number of prescriptions from prescription claimsdata (e.g. as found in the Scottish Prescribing Analysisreports). It was evident that numbers of prescriptions maygive a misrepresentation of the scale of utilisation, becausethe volume of drug use is not included in the variable.The DDD calculation accounts for the number of tablets(or volume of medication) and strength of medication dis-pensed. This is especially useful where liquid, solid andmetered dose formulations of varied strength can be givenfor a single medicine e.g. salbutamol. DDDs provide anestimate of the number of people dispensed prescriptionmedication in each LHCC and comparison area.9 The pre-scribing information had the number of DDDs calculated foreach LHCC, the NHS Lothian Board area and the Scottishpopulation.

Methods


March 2006, The International Journal of Pharmacy Practice 23

Census data were obtained for the LHCCs and comparisonareas from the website of the General Registers Office inScotland (GROS) (www.gro-scotland.gov.uk/). Informationwas downloaded into the primary database for further ana-lysis. Some census data were explored by geographicalinformation systems to produce maps for the LHCCs, in orderto view and analyse the census data from a geographical pointof view. All datasets and their sources used for the health pro-files are found in Table 1.

Drug group identification

Calculation and comparison of all medicines used in primarycare was not feasible in the health profile. A list of medicinesor groups of medicines that might be expected to reflectvariations in local health profiles had to be identified andrationalised for the project. A preliminary study provided acomprehensive examination of 128 candidates, which identi-fied 36 drugs or drug groups that had shown statistically signi-ficant differences in prescribing between two contrastingLHCCs of high deprivation (Carstairs category 5–7) and lowdeprivation (Carstairs category 1) respectively (populations15500 and 36900) (personal communication, A Muir, 2000,University of Strathclyde, Department of Pharmaceutical Sci-ences). These prescribed items were supplemented by othersidentified from a literature search to identify possible drug/druggroup items that may be informative for healthcare profession-als. This study was not designed to validate such prescriptionitem information as indicators of quality or as proxies forestimating disease prevalence. The study aimed to decide on aprocess of selective reporting of prescribing information withinthe context of a wider public health dataset. The intention wasto construct a dataset that could inform local debate abouthealth needs and service development. The drug groups arelimited in only being able to give information on conditionsthat are diagnosed and treated with medication.

A list of candidate drugs/drug groups was circulated to aselected group of clinical pharmacists in Scotland, whowere asked to evaluate and prioritise drugs/drug groups intheir disease specialty for use as potential indicators of thepresence of disease or pharmaceutical care needs within thehealth profile. Using modified consensus methods, a list of

drug groups that were judged to be clinically useful to iden-tify the health and pharmaceutical care needs of a popula-tion was identified.

Analysis of data

Information from the primary database was exported toSTATA version 7 (STATA corporation, USA) for completeanalysis.10 Information from each GP practice was aggre-gated to LHCC level by linking the practice code to theLHCC. The prescribing information file containing a uniquedrug code and quantity of medication dispensed was mergedwith a bespoke DDD file containing a unique drug code andDDD factor, to calculate the DDDs for the specific medica-tion formulation.

A full project application including the data handlingand focus group investigations was submitted for ethicalapproval, but since no patient- or practitioner-identifiabledata were used in this study, formal ethics approval was notneeded.

Development of the LHCC health profiles

Versions of the health profiles were developed and modifiedover time, with guidance from the project’s steering commit-tee. The committee met regularly to discuss aspects of thehealth profiles, inclusion and exclusion of informationdepending on its relevance, interpretation of the information,and finally structural organisation of the health profile. Theproject’s steering committee comprised senior staff represent-atives from primary care, University of Strathclyde (Depart-ment of Pharmaceutical Sciences) and NHS LothianDepartment of Public Health.

Evaluation of the health profiles

The project evaluation systematically and objectively askedfor opinions on the format and utility of the health profile.Evaluation meetings were arranged for two main groups ofpeople: the LHCC management and other healthcare groups.

Evaluation by LHCC management The management team for each LHCC was invited to parti-cipate in the evaluation of the health profiles for their area.Members of the LHCC management team included eight per-sons as representatives from the healthcare professionals(health visitor, district nurse, practice nurse, community phar-macist, primary care pharmacist, community care worker,public health practitioner and public involvement worker)plus two senior managers, a clinical director and representa-tives from the lead GPs.

At the beginning of the evaluation, the focus group mem-bers were asked to complete a pre-evaluation survey, whichwas designed to identify their present use of information, andthe quality of data used. The evaluation meeting progressedto show participants the contents of the health profile, how itwas formatted and how the information could be used. Afacilitated discussion brought together ideas on how thehealth profile could be used in their work. Finally, before par-ticipants left the evaluation meeting, a post-evaluation survey

Table 1 Datasets used in the primary database for the health profiles

Dataset Source

Population by age and sex Census Ethnicity Census Deprivation category and

population estimates General Register Office Scotland

(GROS) mid-year estimates Mortality data GROS death register Deprivaton Carstairs deprivation categories Deprivation by sex Carstairs deprivation categories Household information Small area statistics (census) Accidental mortality GROS Cancer mortality GROS death register Practice information NHS National Services Scotland (NSS)Prescribing information Prescribing team information, NHS NSSHospital admissions

(for people) Scottish Morbidity Record-01, NHS NSS



was completed enquiring about the possible utility of thehealth profile.

Evaluation by other healthcare groups Other healthcare providers were also invited to comment andevaluate the health profiles. These groups included primarycare pharmacists, community pharmacists through pharmacylocality groups (a group of community and hospital pharma-cists working within the LHCC boundary) and the NHSLothian Department of Public Health. These groups weregiven a detailed presentation and a shortened version of thepost-evaluation form to complete.

LHCC description

Two LHCCs were approached and agreed to develop andevaluate the health profile. LHCC-1 has a population ofapproximately 100000 people, with 96165 people registeredwith a GP in the LHCC (Table 2). LHCC-2 has a populationof approximately 139000 people, with 126 541 people regis-tered with a GP in the LHCC. LHCC-2 was different indemographic characteristics from LHCC-1 (i.e. level of afflu-ence),11 which allowed for comparison of informationbetween LHCCs that may be sensitive to gradients in popula-tion characteristics. Data from the four practices that hadexcluded themselves from membership of LHCC-2 at itsinception (Table 2) were excluded from the analysis. Sincethe four practices were not therefore currently managed bythe LHCC management team, discussion of the data fromthose practices was not considered appropriate by the team.

Database development

The information for the primary database was readily and eas-ily obtainable. Co-operation between the database administra-tors was maximised by explaining the project and its potentialin primary care management in the future. A large amountof data manipulation and statistical analysis was needed to

provide information for the health profile. The project revealedthe need for a pool of available skilled people to ensure a qual-ity end-product if it were to become a large-scale endeavour.

Drug groups used in the health profile

Table 3 details the drug groups that were evaluated and prior-itised by the clinical pharmacists using modified consensusmethods and agreed by the project’s steering committee.

The total DDDs for non-steroidal anti-inflammatory drugs(NSAIDs) and the trend (5-year) of antibiotic use (items/10000 population per year) were also included in the analysisand reported in the health profile, but not as specific druggroups.

LHCC health profiles

The final version of the health profiles contained chapters ofinformation relating to the mortality and population charac-teristics of the LHCC, as well as a chapter relating to health

Results

Table 2 Information regarding the LHCCs in the study

LHCC-1 LHCC-2

Approximate population 96 165 12 6541 No of GP practices within the LHCC 14 19 No of GP practices not with the

LHCC 0 4

No of GPs in LHCC 59 87 No of GPs not with LHCC 0 17 Deprivation category (count)1, n (%)

1 (least deprived/most affluent) 0 19 908 (15)2 5547 (7) 43 939 (33)3 10 669 (13) 40 171 (30)4 43 270 (54) 13 624 (10)5 16 543 (21) 348 (1)6 4332 (5) 07 (most deprived/least affluent) 0 14 686 (11)

Table 3 The drug groups used in the development of the healthprofiles

Disease or disorder Drug group

Cardiovascular disease Bendrofluazide Renin–angiotensin drugs and others Beta-blockers Digoxin Nitrates, Ca2+, K+ channel agents Glyceryl trinitrate (GTN) Oral anticoagulants Antiplatelet agents (aspirin and others) Lipid-lowering agents Statins Total cardiovascular DDDs Diabetic disorders Short-acting insulin Intermediate and long-acting insulin Sulphonylureas Biguanides Respiratory disease β2-agonists Inhaled corticosteroids Antimuscarinics and combinations Central nervous system

disordersHypnotics and anxiolytics Benzodiazepine hypnotics Benzodiazepine anxiolytics Antipsychotics Tricyclics and related drugs Monoamine-oxidase inhibitors Selective serotonin re-uptake inhibitors Methadone

Gastrointestinal disorders Proton pump inhibitors H2 antagonists Other important diseases Thyroxine Dopaminergic drugs Antiepileptics Oestrogen/hormone replacement

therapy Bisphosphonates Gold therapy



of the population. A final version of the health profile andfinal report with validation and evaluation information maybe obtained from the corresponding author. Mortality dataincluded standardised yearly trends of all-cause mortality,accidental death and cancer deaths. The LHCC populationcharacteristics included an age profile, distribution of depri-vation by postcode sector, ethnic distribution and residentcharacteristics.

The health information chapter contained death, hospital-isation and prescribing data from the individual LHCC intable and graph form with explanations. Appendix 1 illus-trates the information presented in the health profile for car-diovascular disease for LHCC-1 (Section 2 of the LHCC-1health profile). Key points are given at the end of each sec-tion demonstrating how the data can be used and inter-preted. Other diseases represented in the health profile aregiven in Table 3.

A one-page summary of the prescribing data was givenat the end of the health information. The percentage differ-ence between the LHCC and the HB was calculated andgraphed (funnel graph) showing the relative amount of dif-ference and the direction this difference takes from the HBrate of prescribing. Figure 1 shows the summary informa-tion for two disease areas for LHCC-2. Drug groups thatmay need further investigation were identified depending onthe percentage difference from the HB prescribing rate, andthe absolute difference in DDDs per 10000 population peryear. For example, a drug group that may require furtherinvestigation has a greater than 10% difference in theDDD rate between the LHCC and the HB value and adifference between 3000 and 18000 DDDs per 10000population per year. The inclusion and exclusion criteria foreach level of investigation were developed in a subgroup ofthe steering committee, and tested on data available to thecommittee.

Evaluation of the health profiles by the LHCC management

There were 19 pre-evaluation surveys and 18 post-evaluationsurveys completed by the two LHCC management teams atthe presentation of the health profiles. Pre-evaluation surveyresponses showed the following problems with the informa-tion: It was not easy to locate (32%), it needed to be madepertinent to the user’s locality (58%) or it needed to be com-bined from different sources (63%). Post-evaluation survey,respondents found the health profile was easy to understandin terms of the information (83%) or statistics (78%) it con-tained. The statistics were found to be presented in a usefulformat (67%) and aggregated to a level seen as most useful(94%). Compared with other sources, the information in thehealth profile was very/quite easy to locate (95%), and wasseen to be very/quite relevant (100%). Half of the respond-ents indicated they would like updates of the profiles to bemade annually.

Overall, in the past participants used various sources ofinformation in their work depending on the informationneeded, ranging from national to local databases and personalcontacts (e.g. police). However, they found that the statistics

from these sources were not always presented in a format thatwas easy to understand or use. One participant commentedthat his past source of information ‘is not presented to answermy question’.

After viewing and discussing the health profile, the major-ity of participants found the information presented relevant totheir work and easy to understand. One participant wrote howthe health profiles ‘illustrate local difficulties well’, whileanother participant commented that the health profile ‘raiseslots of questions’.

Evaluation of the health profiles by other healthcare groups

A concise presentation about the health profile was given tomembers of other healthcare groups and discussion fol-lowed. A shorter version of the survey was given to partici-pants at the end of the presentation. A total of 45participants received this version of the survey; 11 from theprimary care pharmacists’ group (NHS Lothian region), 12from the Lothian NHS Board Department of Public Healthand 22 from pharmacist locality groups, NHS Lothian.Respondents were given the opportunity to agree with anyof a series of descriptors of the health profile. Descriptorsmost often used (from a total n = 122) were ‘interesting’(28%), ‘useful’ (28%), ‘relevant’ (23%) and ‘helpful’(18%). ‘Simple’ (3%) or ‘cumbersome’ (0%) were rarelyselected.

After one of the pharmacy locality group presentations,the community pharmacists used the information from thehealth profile to inform their next public health campaign.For example, the pharmacists used the health profile to decidewhether a cardiovascular or diabetes pharmaceutical care pro-gramme should be developed in the locality. The data in thehealth profile indicated that more impact might be obtained ifa diabetic programme were adopted, because of the popula-tion age profile, number of prescriptions encashed for oraldiabetic medicines and the number of patients hospitalisedwith an ICD-10 code for type 2 diabetes. The lead of thepharmacy locality groups commented ‘[all] groups appreci-ated the input and found the subject matter of the talks abso-lutely fascinating’.

Health profiles were developed using prescribing, hospi-talisation and other public health data for two LHCCs inNHS Lothian. From an extensive literature review, thesehealth profiles are the first examples of bringing such datasources together in one document to be used by manage-ment and practitioners to inform health and pharmaceuti-cal care decisions in a locality. In evaluation, theparticipants found the health profiles informative and use-ful in decision making and planning. Participants used pre-scribing data to fill information gaps found in otherdatasets and/or provide a primary care perspective tohealth in the locality.

Discussion


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Strengths and limitations

Every project has strengths and limitations, and some havebeen identified in this project. The paper format of thehealth profile was identified as a possible limitation to theproject’s further success. This may be overcome by produc-ing the health profile as an active internet document (webdocument). This would provide information at the desktopand be readily available. A search mechanism could be usedto find information quickly. With a web document, links touseful sites or documents could be incorporated into thehealth profile, providing more information to the user in aparticular area. An example would be links to hypertensionguidelines in the cardiovascular disorders section of thehealth profile. Furthermore, with web technology, the usercould download and/or manipulate the data, adjusting forlocal variation. Another asset of the web document wouldbe that the provider could easily and cost-effectively updatethe information regularly.

A primary strength of the health profile was that it waswritten in a ‘user-friendly’ language. The information waspresented and explained in plain language so as not to intimi-date the user with pages of statistical information and compli-cated graphs. The health profile also had key pointsincorporated in each section to help interpret the healthinformation and show how other information (e.g. populationcharacteristics) can be used to fill information gaps.

Level of data aggregation

Some participants anecdotally commented that they pre-ferred the health profile information aggregated to generalpractice level. These general practice comparisons withinthe LHCC would be useful for the management of practicevariability or provide information about disease at a localcommunity. However, measures compared between generalpractices in primary care have to be derived from practiceswith similar characteristics. Differences in practice popula-tion characteristics (e.g. morbidity) affect the demandsplaced on the service and, in particular, the outcomes fromtreatment. Various patient characteristics have been recog-nised as important in increasing risk, such as age, diseaseseverity, co-morbidities and past medical history.12 Generalpractice-level data, therefore, would be useful for highlylocalised profiling, but may not be useful when generalisedto larger populations, because of the variation in patientcharacteristics.

Community health index number and the prescription

At present, NHS Scotland collects the minimum informationfrom the dispensed prescription to facilitate reimbursementpayment to contractors. In the future, additional informationwill be captured and stored in the prescription warehouse.This will include the community health index (CHI) numberfrom electronically read prescriptions, allowing patient-specific record linkage with other datasets to take place.The most powerful information that could be obtainedfrom patient-specific prescription information is the ability to

identify the initial prescription and dates of the subsequentrepeat prescriptions. It would then be possible to determinethe number of people exposed, and the rate of exposure in apopulation. At present, estimates of the number of peopleexposed can be calculated using the DDDs or using cost(gross ingredient cost) as a proxy.

Another strength would be the ability to link records withoutcomes data, allowing pharmacovigilance, drug-safety andpharmaco-epidemiology studies. A difficulty with analysingmedicines data is that many medicines can be used for morethan one indication, disease or condition. The prescriptiondoes not have the indication for the medicine recorded, andsimple inferences cannot be made. For example, car-bamazepine can be used for epileptic seizure control, but itcan also be used for neuropathic pain. With CHI-identifiedmedicines information, the ability to link the prescription datawith hospital admissions and other information provides aclearer image of patient care, medicines utilisation andoutcomes.

Comparable initiatives

Published research studies have investigated morbidity andmortality using databases of specific populations. Thegroups with outcomes of interest are identified from largeNorth American population-based healthcare databases suchas Medicaid and Medicare (USA); provincial health data-bases like Saskatchewan, Quebec and Manitoba (Canada);and the large European-based healthcare databases such asthe General Practice Research Database (GPRD, UK),IMS-Mediplus (UK), Odense (Denmark), PHARMO (theNetherlands) and MEMO (Scotland). These databases havebeen validated and used for many pharmaco-epidemiologi-cal studies linking medicines exposure to outcomes, and arepowerful research tools because data are patient specific.That is, each piece of data is allocated a unique identifier topermit patient-specific record linkage of medicines informa-tion with outcomes.

However, the data used in the health profiles were thosethat are readily provided by the NHS in Scotland. These dataare routinely collected and primarily used in payment forservices provided and quality assurance purposes. The pre-scription claims data are not patient specific, and so the actualnumber of patients taking a particular medicine could not becalculated. Therefore the estimate of utilisation, the defineddaily dose, was used. The lack of a unique identifier does notpermit the linking of prescribing with any hospital dischargeinformation, and thus raises concerns about the validity of theindication for use. Prescribing analysis reports produced bythe NHS from the claims data (prescription analysis and cost(PACT), and Scottish prescribing analysis (SPA)) giveinformation on prescribing volume and costs for a particularpractice compared to the rest of the health area. These reportsdo not include hospitalisations or population characteristicsof the practice, and are primarily used for quality assurancepurposes and budgeting.

The health profile in the present study was developed toinclude population characteristics, hospitalisation and mortal-ity information, so that all data could be used in decisionmaking and be provided in one document or site. The health



profiles were purposefully developed not to be a qualityassurance tool but to be an information tool to identify dis-ease areas either in need of medical and pharmaceutical care,or where further investigation may be needed to identify andexplain unexpected findings in the data.

National priorities

The ‘Review of Public Health Function in Scotland’ (1999)identified a key challenge for public health – conversion ofthe wealth of data into information that is accessible, relevantand meaningful to many different audiences.13 The formerPublic Health Institute in Scotland (PHiS) has taken the firststeps towards a comprehensive national public health data-base, combining routine data on the determinants of healthand health outcomes, as well as new data sources on tradi-tionally weaker areas, for example on the wellbeing and thesocial environment. Morbidity of the population, however, isdifficult to use at the local governmental level because theinformation is difficult to obtain. Prescribing data could beused as a proxy for disease, because medicines use in primarycare may be more directly linked to morbidity in thecommunity.

To date, the public health contribution from pharmacy haslargely focused on the management of prescribed medicines,common ailments, promotion of health lifestyles and provi-sion of general health advice. These are essential activitiesthat embrace core professional public health roles for manypharmacists. However, they reflect a uni-professional culturefocused on the individual patient. As a profession, pharmacyhas a solid base for its public health aspirations, but there isnow a need to take this forward.14

The NHS has to optimise the use of its professionalexpertise, and increase multidisciplinary team working.With the extension of prescribing rights to pharmacists,development and involvement of pharmaceutical careschemes in community pharmacies, and strategies out-lined in ‘The Right Medicine: a strategy for pharmaceuti-cal care in Scotland’ and ‘Pharmacy for Health: the wayforward for pharmaceutical public health in Scotland’,8,15

the community pharmacist will have extended responsi-bilities and will need the tools to adequately perform thetasks required of them. Effective disease managementrequires information about the population that not onlyshows those in need, but also demonstrates areas of thepopulation that are in need of or benefiting from pharma-ceutical care. Health profiles provide population healthdata that allow informed and directed decisions to bestdevelop pharmaceutical care schemes, especially inprimary care.

Conclusions

Health profiles were developed from prescribing health andpopulation data that were meaningful and useful to localhealth authority management and other healthcare profession-als. The health profiles contained information that would be

used to inform decisions or identify areas where furtherinvestigation may be required to investigate anomalies in thedata. The project was born out of the aspirations for com-munity pharmacists to adopt a locally strategic approach.This approach targets pharmacists’ endeavours towardslocally recognised patient groups, which have thus far beenpoorly quantified and incompletely characterised. In Scot-land, the focus of a new community pharmacy contract is onthe dual elements of chronic disease management and publichealth contributions, through prevention of disease and/orlimitation of disease impact along with continued carethrough daily pharmacy activities. There is an urgent need todevelop tools that help to inform professional interventionsinvolving pharmacists and thereby improvements to multidis-ciplinary co-operation. The introduction of computerised net-working may provide an electronic environment to facilitateco-operation among healthcare professionals to address spe-cific public health issues. This project helps to providegreater information on the public health context within whichcommunity pharmacists can contribute with their local know-ledge and specific information specialty.

1 Scottish Executive. Designed to Care: renewing the NHS inScotland. Edinburgh: Scottish Office Department of Health;December 1997.

2 Scottish Executive. Towards a Healthier Scotland. Edinburgh:Scottish Office Department of Health; February 1999.

3 Gilley J. Meeting the information and budgetary requirementsof primary care groups. BMJ 1999;318:168–9.

4 Majeed A. Accurate information may be difficult to produce.BMJ 1999;318:169–70.

5 Improving Health in Scotland: the Challenge. Edinburgh: TheScottish Executive; 2003.

6 The Review of the Public Health Function in Scotland.Edinburgh: The Scottish Executive; 1999.

7 Modernising NHS community pharmacy in Scotland. Consulta-tion paper. Edinburgh: The Scottish Executive; 2004.

8 The Right Medicine: a strategy for pharmaceutical care inScotland. Edinburgh: The Scottish Executive; 2002.

9 Strom B, editor. Pharmacoepidemiology, 2nd ed. Toronto:Wiley Press; 1994.

10 STATA version 7. Stata Corporation, Texas USA. www.stata.com (accessed 24 October, 2005).

11 Carstairs V. Deprivation and health in Scotland. Health BullEdinb, 1990;8:162–75.

12 Powell AE, Davies HTO, Thomson RG. Using routine compar-ative data to assess the quality of health care: understanding andavoiding common pitfalls. Qual Saf Health Care 2003;112:122–8.

13 Review of Public Health Function in Scotland. Edinburgh:Scottish Executive; 1999.

14 Asghar MN, Jackson C, Corbett J. Specialist pharmacists inpublic health: are they the missing link in England? Pharm J2002;268:22–5.

15 Pharmacy for Health: the way forward for pharmaceuticalpublic health in Scotland. Glasgow: Public Health Institute inScotland; 2002.

References



Cardiovascular deaths

Information is provided from the national data collectionschemes General Registrar’s office, death register and theScottish Morbidity Records 01 (SMR01) for hospital admis-sions and discharges. The period of observation is fromNovember 1, 2000 to October 31, 2001. Figure 2 gives thestandardised death rates from ischaemic heart disease (IHD)for LHCC-1. Table 4 gives the number of people admitted tohospital with an admission code of cardiovascular disease.This table contains the disease headings (like chapter head-ings; ischaemic heart disease ICD-10 codes I20–I25) for eachof the cardiovascular diseases. Table 5 contains the top fiveadmissions for cardiovascular disease at a more disease spe-cific level (e.g. I20 angina, I21 acute myocardial infarction)for LHCC-1.

Cardiovascular-related hospitalisations

Cardiovascular-related drug prescribing

Table 6 contains an analysis of prescribing data from the sameperiod of time for the British National Formulary (BNF) chap-ter for cardiovascular drugs (Chapter 2). The number of DDDsper 1000 LHCC population per month gives a broad estimateof the number of patients seen by the practice per month. Thenumber of DDDs per 10 000 LHCC population per year is pro-vided, to permit comparison with Lothian and Scotland.

Appendix 1 A section from LHCC-1 health profile showing content for cardiovascular disorders

Section 2: Cardiovascular disease

050

100150200250300350

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

LHCC-1Lothian

Figure 2 Standardised death rates from IHD in LHCC-1 and Lothian,all ages. Rates per 100000 males or females respectively; data weredirectly standardised against Standard European Population. Source:General Register Office of Scotland.

Table 4 People admitted to hospital for cardiovascular diseasesa

aPersons who have been discharged from hospital with a specificICD-10 code, not the number of episodes of care for that ICD-10 code. Source: SMR01, NHS NSS (Nov 2000–2001).

Disease coding (ICD-10 headings)

LHCC-1 n (%) Lothian n (%)

Cerebrovascular disease 266 (22.0) 2606 (23.0) Rheumatic heart disease 6 (0.5) 75 (0.7) Hypertensive diseases 26 (2.2) 170 (1.5) Ischaemic heart diseases 415 (34.4) 3848 (33.9) Pulmonary heart disease 32 (2.7) 263 (2.3) Other heart disease 268 (22.2) 2409 (21.2) Diseases of the circulatory

system 18 (1.5) 134 (1.2)

Diseases of the veins and not elsewhere

174 (14.4) 1831 (16.1)

Total number of admissions (% of population)

1205 (1.3) 11336 (1.4)

Table 5 Top five admissions for cardiovascular diseasesa

aPeople that have been discharged from hospital with a specific ICD-10 code, not the number of episodes of care for that ICD-10 code. CI: confidence interval. Source: SMR01, NHS NSS (Nov 2000–Oct 2001).

ICD-10 disease coding LHCC-1 (%, n = 1205) Lothian (%, n = 11336) Odds ratio (95% CI)

Angina pectoris 166 (13.8) 1595 (14.1) 0.89 (0.76–1.04) Chronic ischaemic heart disease 134 (11.1) 1167 (10.3) 0.98 (0.82–1.17) Heart failure 110 (9.1) 865 (7.6) 1.08 (0.89–1.32) Acute myocardial infarction 107 (8.9) 984 (8.7) 0.93 (0.76–1.13) Atrial fibrillation and flutter 86 (7.1) 808 (7.1) 0.91 (0.73–1.13)



Table 6 LHCC-1 (n = 96 165) compared with Lothian (n = 81 9720) and Scotland (n = 5.12 million)

aSignificantly different from the HB DDD value at a statistical P ≤ 0.05.Source: prescribing data from NHS NSS (Nov 2000–Oct 2001).

Cardiovascular disease DDDs per 1000 LHCC population per month

DDDs per 10000 LHCC population per year

DDDs per 10000 Lothian population per year

DDDs per 10000 Scottish population per year

Bendrofluazide 930 111 622a 139 283 149 981 Renin–angiotensin drugs + others 1205 144 544a 170 249 192 382 Beta-blockers 694 83 276a 119 062 133 845 Digoxin 141 16 928 18 319 19 215 Nitrates, Ca2+, K+ channel agents 1503 180 372a 212 795 289 206 Glyceryl trinitrate 147 17 664a 22 573 31 863 Oral anticoagulants 67 8001a 9884 11 009 Antiplatelet agents (aspirin and

others) 1256 150 662a 167 778 233 844

Lipid-lowering agents 744 89 290a 105 633 131 817 Statins 713 85 517a 101 200 126 858 Total cardiovascular DDDs 7693 9 231 742a 1 116 735 1 389 588

Panel 1 Key points from cardiovascular disease information

• LHCC-1 cardiovascular mortality and hospital admissions are similar to Lothian data. • The age profile of LHCC-1 shows a higher proportion of 30–45 year olds than Lothian. If these remain in the area, future services for primary

prevention and care of cardiovascular disease may be an important consideration. • The use of cardiovascular medicines in the LHCC-1 is much lower than in Lothian and may possibly be worth further investigation. Drugs of

particular interest are bendrofluazide, renin–angiotensin drugs, beta-blockers and nitrates.


Documents

Using prescribing health and population data to describe the health of a locality: the development and evaluation of a locality health profile