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Whats new in Q: Qfeedback, QFracture, QCancer
Julia Hippisley-CoxSessional GP
EpidemiologistDirector QResearch
Director ClinRisk Ltd
EMIS NUG conferenceSeptember 2010Warwick University
Acknowledgements EMIS & EMIS Practices contributing data Many GPs & nurses for suggestions,
piloting University of Nottingham Academic colleagues ClinRisk Ltd (software) THIN (validation data) Oxford University – independent validation
Update on QSurveillance QFeedback Update on QScores
◦ QIntervention◦ QFracture◦ Qcancer
General discussion
Overview
QSurveillance
Real time infectious diseases surveillance system
Vaccine uptake reporting system History
◦ 2004 - Pilot study on QResearch in 2004◦ 2005 - Upgraded to online QFLU◦ 2006 – Separate Flu vaccine service◦ 2007 – Separate Pneumo vaccine service◦ 2007 – upgraded to QSurveillance Avon floods◦ Included prospective consent for data extraction in
emergency Key part of HPA and DH emergency response
QSurveillance: Overview
Age/sex aggregated data 100-150 indicators Infectious diseases Vaccine uptake – flu, pneumo, MMR Daily, weekly, monthly, quarterly, annual
reports No patients can be identified Counts < 5 suppressed
QSurveillance data extraction
JHC custodian & responsible to practices, profession, ethics etc
No patients identifiable Counts < 5 suppressed Process for new indicators:
◦ Practice consent covers additional data extracted to support emergency response
◦ consult with relevant agency re need, ethics and advisory board (including NUG)
QSurveillance Governance
Practice consent Oversight board/review mechanism with
NUG representation Robust safeguards in place to protect
patients and practices Practices able to switch it on or off Practice can access and benefit from
data extracted
Governance Principles
Incredibly busy with flu pandemic Daily reporting over 10 months Unexpectedly high demand across NHS Detailed coverage by media Under resourced Need to ensure its scalable, resilient,
properly resourced. Decision to industrialise it Ensure practices can access and
benefit from data
QSurveillance: pandemic
Qfeedback System
QScores
Risk prediction tools - purpose
Population level ◦ Risk stratification ◦ Identification of rank ordered list of patients for
recall or reassurance
Individual assessment◦ Who is most at risk of preventable disease?◦ Who is likely to benefit from interventions?◦ What is the balance of risks and benefits for my
patient?◦ Enable informed consent and shared decisions
Overview Qscores - disease outcomesDisease outcomes Status
QRISK (CVD) QDScore (diabetes) QFracture QKidney (CKD3b+) Qcancer Range of other
significant outcomes
published published published published completed In progress
Different approach needed Assess baseline risk of outcomes Then how they change with interventions Use RCTs and meta analyses for benefits Use database analyses for unintended effects Starting with commonly used drugs e.g
◦ Statins◦ Antidepressants◦ HRT◦ Warfarin◦ Antipsychotics◦ NSAIDS
Overview - risk/benefit interventions
Vascular Risk Engine: Requirements Identify patients at high risk of vascular
disease◦ CVD◦ Diabetes ◦ Stage 3b,4, 5 Kidney Disease
Assessment of individual’s risk profile Risks and benefits of interventions
◦ Weight loss◦ Smoking cessation◦ BP control◦ Statins
QRISK2 www.qrisk.org
Risk of CVD & “Heart age” Extensively reviewed and externally validated Now included in
◦ QOF ◦ DH Vascular Guidance◦ NICE
Widespread use across NHS Nearly all GP systems, many pharmacies, some
hospitals, NHS Choices, Supermarkets, Occupational Health etc
Also free Open Source and Closed Software
QDScore – risk of Type 2 diabeteswww.qdscore.org
Predicts risk of type 2 diabetes Published in BMJ (2009) Independent external validation by Oxford
University Needed as epidemic of diabetes & obesity Evidence diabetes can be prevented Evidence that earlier diagnoses associated
with better prognosis.
QKidney – risk of renal failurewww.qkidney.org Set of algorithms
◦ Identifies those at risk of CKD3b+ End Stage Renal Failure
◦ Published BMC 2010 So we can then
◦ Identify high risk ◦ Modify risk factors◦ Avoid nephrotoxic drugs◦ Monitor more closely◦ Prevent deterioration◦ Improve outcomes
Risks and Benefits Statins(presented at NUG 2009) Two recent papers:
◦ Unintended effects statins (BMJ, 2010)◦ Individualising Risks & Benefits of Statins (Heart,
2010)
Conclusions: ◦ New tools to quantify likely benefit from statins◦ New tools to identify patients who might get rare
adverse effects eg myopathy for closer monitoring
Why integrated tool CVD, diabetes, CKD?
Many of the risk factors over overlap Many of the interventions overlap But different patients have different risk profiles
◦ Smoking biggest impact on CVD risk◦ Obesity has biggest impact on diabetes risk◦ Blood pressure biggest impact on CKD risk
Help set individual priorities Development of personalised plans and
achievable target
Primary prevention CVD:(slide from NICE website)
Offer information about: • absolute risk of vascular disease • absolute benefits/harms of an
intervention
Information should:• present individualised risk/benefit
scenarios• present absolute risk of events
numerically• use appropriate diagrams and text
Qintervention www.qintervention.org
QFracture
Osteoporosis major cause preventable morbidity & mortality.
2 million women affected in E&W 180,000 osteoporosis fractures each year 30% women over 50 years will get vertebral
fracture 20% hip fracture patients die within 6/12 50% hip fracture patients lose the ability to live
independently 1.8 billion is cost of annual social and hospital care
QFracture: Background
29
30
Patients with Symptomatic Vertebral Fractures
Wake Early
Hard to Stand
Hard to Bend
Daily Analgesia
In Constant Pain
Not Worth Living
0 10 20 30 40 50 60 70 80
% Patients
Scane et al, Osteoporosis Int 1994; 4: 89-92.
Effective interventions exist to reduce fracture risk
Challenge is better identification of high risk patients likely to benefit
Avoiding over treatment in those unlikley to benefit or who may be harmed
Some guidelines recommend BMD but high cost and low specificity
Other guidelines recommend using 10 year risk of fracture
QFracture: challenge
Cohort study using patient level QResearch database
Similar methodology to QRISK Published in BMJ 2009 Algorithm includes established risk factors Undertook validation against FRAX Developed risk calculator which can - identify high risk patients for assessment - show risk of fracture to patients
QFracture: development
QFracture vs FRAX comparisonQFracture FRAX
Primary care Works better in EMIS Open Source No funding Includes extra risk factors eg
◦ Falls◦ CVD◦ Type 2 diabetes◦ Asthma◦ Antidepressants◦ Detail smoking/Alcohol ◦ HRT
Selected cohorts Over-predicts in EMIS Not published Industry sponsored NOGG guidance
64 year old women Heavy smoker Non drinker BMI 20.6 Asthma On steroids Rheumatoid H/O falls
Clinical example
Vit D
+ cal
cium
Bisp
hosp
h
Hip p
rote
ctor
s
HRT (o
ut o
f fas
hion
)0
5
10
15
20
BeforeAfter
Effect of interventions to reduce fracture risk in our example 64 year old women with a 20% fracture risk(note: her QRISK CVD risk is 18%)
Need to quantify risks of interventions Few large long term safety studies Bisphosphonates may increase risk of
◦ Oesophageal cancer◦ Atrial fibrillation◦ Osteonecrosis of jaw◦ Atypical fracture◦ ? Other outcomes
Key thing for my patient is ◦ Baseline risk of fracture◦ Likely benefit of intervention◦ risk of adverse effects of intervention
What is the overall risk/benefit ratio?
Balancing risks vs benefits
QCancer
Tools to predict risk of range of common cancers
Risk stratification: Identify those who need regular screening Identify those who need ad hoc assessment
Patient communication Background risk with family history – may be reassuring Risk of cancer with “alarm” symptoms Risks of cancer with smoking as decision aid for smoking
cessation Current Ex smoker Non smoker
QCancer scores
QCancer ScoresCancers Alarm symptoms
Breast cancer Prostate Colorectal Oesophageal Renal/bladder Lung Ovary Uterus
Breast lump Prostatism Rectal bleeding Dysphagia Haematuria Haemoptysis Abdo pain/distension Post menopausal
bleeding
See www.qresearch.org for Information about QResearch database Academic papers Technical & statistical documents Open source software Patient information Clinician information Power points presentations Information on how to contribute to the
database (or email [email protected] )
Questions Comments Suggestions Feedback
Discussion