MedicineInsight Novel use of electronic health record (EHR) data to - - PowerPoint PPT Presentation

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MedicineInsight Novel use of electronic health record (EHR) data to improve the diagnosis and treatment of chronic hepatitis C in Australian general practice Kendal Chidwick 16 October 2019 Commercial in confidence CHRONIC HEPATITIS C (CHC)

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MedicineInsight

Novel use of electronic health record (EHR) data to improve the diagnosis and treatment of chronic hepatitis C in Australian general practice

Kendal Chidwick 16 October 2019

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CHRONIC HEPATITIS C (CHC) IN AUSTRALIA

Chronic hepatitis C is a major public health threat, leading to liver disease and mortality. New oral direct-acting antiviral (DAAs) have shown cure rates of 95%-99% and are largely well tolerated. DAA regimens PBS listed March 2016, available through GP prescribing (broadening access) Expanded the role of GPs in the management of CHC (new Australian guidelines) Despite this, by the end of 2018 only 30% of the estimated number of people living with CHC in Australia had been treated. People with chronic hepatitis C (CHC) in Australia:

  • 2015: 227,310
  • 2017: 170,000
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UPTAKE OF DAA MEDICINES IN AUSTRALIA

74,600 individuals initiated DAA treatment

  • 2014-18 (33% of 2015 total)

67% men, 33% women Age:

  • 51-60 yrs 33%
  • 41-50 yrs 26%
  • 48% >50 yrs

Ref: Kirby report: Monitoring hepatitis C treatment uptake in Australia June 2019, based on 10% PBS

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CHALLENGES

Primary care workforce development is needed to promote and deliver hepatitis C testing and treatment GP prescribers of DAAs have increased but more are needed:

  • Mar 2016: 8%
  • Oct-Dec 2017: 41%
  • 2018: 39%

There is a pressing need to develop and evaluate GP-centred interventions that increase testing, diagnosis and treatment of CHC.

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WHAT IS MEDICINEINSIGHT?

A large-scale national general practice dataset Flagship program for NPS MedicineWise Extracts longitudinal, de-identified, whole of practice data (including historical data) from clinical information systems (Best Practice and Medical Director) except for progress notes Provides local, state and national level data insights

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GPs opt in

 

Patients opt out

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MEDICINEINSIGHT PRACTICES ACROSS AUSTRALIA

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722

participating general practices

3.5 M

regular patients

5,074

GPs

79 12 131 258 12 158 50 22

Data: July 2019

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MEDICINEINSIGHT DATA GOVERNANCE

Robust data governance framework underpins all activities to ensure:

  • Ownership of data remains with originating general practices
  • Data are collected, stored and shared according to legal and ethical requirements,

and in line with the principle of public good

  • Data conform to a minimum standard of quality prior to use
  • Rigorous information security protocols protect the data

Independent and External Data Governance Committee

  • Provides advice and approval on use and sharing or the MedicineInsight data
  • Members include GPs, researchers, experts on data security, external academics,

privacy, legal and consumer advisors

Program ethics approval

  • MedicineInsight program has been granted ethics approval from RACGP

National Research and Evaluation Ethics Committee (NREEC)

  • The program is in line with other international datasets (including CPRD)

that have generic ethics approvals

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USING MEDICINEINSIGHT TO INFORM EACH STAGE OF THE QUALITY IMPROVEMENT PROCESS

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  • 1. Formative Research

to identify evidence- practice gaps (observational studies)

  • 2. Design and Build Quality

Improvement Intervention (Data driven audit & feedback tool)

  • 3. Deliver Quality

Improvement Intervention (targeted or randomised)

  • 4. Evaluate the impact
  • f the intervention

(RCT using EHR data)

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MedicineInsight: CHC in general practice Stage 1. Observational study to identify evidence practice gaps

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PATIENT FINDING

A novel algorithm for identifying patients with probable or possible CHC using the data from GP systems was developed

  • Searched for the patients most recent recorded diagnosis relating to CHC
  • Additional criteria were applied to confirm CHC in patients whose most recent status was

indeterminate, including:

  • prescriptions,
  • tests, and
  • complications related to CHC.

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MANAGING CHC IN GENERAL PRACTICE

  • MAIN FINDINGS

Results strongly indicated a substantial opportunity for GPs to recall more patients with CHC for confirmation of diagnosis and pre-treatment assessment. Majority of patients with CHC appear suitable for management of HCV in primary care (non-cirrhotic). Proactive reviews of patient records by GPs to identify patients living with HCV infection are critical to maintain treatment momentum.

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MedicineInsight CHC in general practice Stage 2: Design & build education and quality improvement program

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EDUCATIONAL VISITING: SMALL GROUP – MEDICINEINSIGHT DATA

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Cohort of patients with possible or confirmed CHC. Comorbidities MEDICINEINSIGHT PRACTICE AND AGGREGATE REPORTS

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Patients with possible or confirmed CHC who have a record of a HCV RNA test

MEDICINEINSIGHT PRACTICE AND AGGREGATE REPORTS

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Treatments prescribed for patients with confirmed CHC

MEDICINEINSIGHT PRACTICE AND AGGREGATE REPORTS

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PATIENT LISTS FOR RECALL (CASE FINDING)

GPs who are part of MedicineInsight will receive a list of their patients with confirmed or possible CHC for case finding and further assessment

  • Patient name
  • Age
  • Usual GP
  • Date of last encounter
  • Diagnosis as possible or confirmed CHC
  • Record of a HCV RNA test (ever)
  • Reference to Hepatitis B infection (ever)
  • Reference to HIV infection (ever)
  • Record of a HCV genotype test
  • Cirrhosis documented
  • AST and platelet results in the last 2 years
  • Calculated APRI value
  • Last medicine prescribed
  • Date of last medicine prescribed
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MedicineInsight CHC in general practice Stage 3: Delivery of the QI intervention

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2017 - TARGETED DELIVERY OF THE INTERVENTION 104 general practices

Targeted delivery to practices with the greatest potential need for education

  • Practices with high CHC caseloads but low treatment rates were approached

first. Survey results:

  • GP confidence in screening, diagnosis and treatment of hepatitis C increased

significantly

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2019 – RANDOMISED DELIVERY

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300 eligible practices 150 Intervention practices These practices will be offered a visit 150 Control practices These practices will NOT be

  • ffered a visit
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MedicineInsight CHC in general practice Stage 4: Evaluation EQUIP- HEP C Cluster Randomised Controlled Trial

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PRIMARY OBJECTIVE

Evaluate the number of new prescriptions for direct acting antiviral (DAA) therapy over 6 months in practices who received the intervention as compared to control practices who did not receive the intervention. Hypothesis: compared to control practices, those practices randomised to receive the intervention will have a higher number of patients with CHC who initiate DAA

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GOVERNANCE AND ETHICS

Approved by RACGP National Research & Evaluation Ethics Committee on 29 April 2019 (Application number: NREEC 18-015) The independent Data Governance Committee for MedicineInsight approved the study on 3rd December 2018 (Application number: 2018-040) External Independent Advisory Group

  • Dr Anne Balcomb, General Practitioner
  • Prof Gregory Dore, Program Head, Viral Hepatitis Clinical, Research Program, Kirby Institute,

UNSW Australia

  • Prof Anthony Rodgers, Professorial Fellow, Executive Director's Office, George Institute for Global

Health, Professor of Global Health, Faculty of Medicine, UNSW Australia, NHMRC Principal Research Fellow

  • Dr Min Jun, Senior Research Fellow, Renal & Metabolic Division, Scientia Fellow and Senior

Lecturer, Faculty of Medicine, UNSW Sydney, George Institute for Global Health

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STRENGTHS & LIMITATIONS

Large national sample Assist with understanding GPs’ management of hepatitis C, in high and low caseload practices Help with case finding Doesn’t capture clinical activity happening at non-MedicineInsight practice Prescribing information, not what has been dispensed or taken Could not use test result data to define hepatitis C Reliance on recorded diagnosis and indirect indications of CHC status Relies on information being available in fields collected

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CONCLUSIONS

Routinely collected longitudinal GP data can be used across key stages of the quality improvement process The first MedicineInsight randomised controlled trial has commenced We hope to show a benefit of the NPS MedicineWise educational program on the uptake of DAAs to help Australia reach WHO Hepatitis C elimination targets

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ACKNOWLEDGEMENTS

Funding was provided by Gilead Sciences Ltd through an unrestricted educational grant from VentureWise, who commissioned NPS MedicineWise to undertake this work. The studies were conducted with complete independence from Gilead Sciences Ltd and VentureWise, which did not have any input into the design or content of the study

  • r into this presentation.

We thank the patients, general practitioners and general practices who allow the use of de-identified information for MedicineInsight. We thank the advisory group and NPS MedicineWise contributers: Jonathan Dartnell, Jeannie Yoo, Vanessa Simpson, Sharon Lloyd.

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