Eleven key measures for monitoring general practice clinical activity during COVID-19: A retrospective cohort study using 48 million adults’ primary care records in England through OpenSAFELY
- The Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
- Oxford Health Foundation Trust, Warneford Hospital, United Kingdom
- Royal Devon University Healthcare NHS Foundation Trust, United Kingdom
- NHS England, United Kingdom
- Lancashire Teaching Hospitals NHS Foundation Trust, United Kingdom
- Queen Mary University of London, United Kingdom
- Beacon Medical Group, United Kingdom
- Sternhall Lane Surgery, United Kingdom
- Herefordshire and Worcestershire Health and Care NHS Trust, United Kingdom
- TPP, United Kingdom
- EMIS, United Kingdom
Figures
Figure 1
Decile charts of the practice level rate of recorded coding activity per 1000 registered patients in each identified key measure of GP activity between January 2019 and December 2021.
Tables
Table 1
Development of key measures and their associated codelists.
A link to each codelist used to define the final key measure is given; all codelists are openly available for inspection and re-use at opencodelists.org.
| Suggested measure | What is it and why does it matter? | What does the measure capture? | Prior observed CTV3 code(s) | SNOMED codelist development |
|---|---|---|---|---|
| Blood pressure monitoring | A commonly-used assessment used to identify patients with hypertension or to ensure optimal treatment for those with known hypertension. This helps ensure appropriate treatment, with the aim of reducing long-term risks of complications from hypertension such as stroke, myocardial infarction and kidney disease. | Rate of blood pressure monitoring as indicated by recording of systolic blood pressure observable entities resulting from monitoring. | Codes beginning with 24: ‘Examination of cardiovascular system (& [vascular system])’ (Curtis et al., 2023) | QOF codelist for blood pressure monitoring (NHS Digital, 2023b), filtered to systolic codes only† (Codelist) |
| Cardiovascular Disease 10 Year Risk Assessment | A commonly-used risk assessment used to identify patients with an increased risk of cardiovascular events in the next 10 years. QRISK3, 2018 This helps ensure appropriate treatment, with the aim of reducing long term risks of complications such as stroke or myocardial infarction. | Rate of cardiovascular risk assessment as indicated by a recorded code for a 10-year risk score observable entity. | XaQVY: ‘QRISK2 cardiovascular disease 10-year risk score’ (Curtis et al., 2023) | QOF codelist for all cardiovascular risk scoring tools (Codelist) |
| Cholesterol Testing | A commonly-used blood test used as part of a routine cardiovascular disease 10-year risk assessment QRISK3, 2018 and also to identify patients with lipid disorders (e.g. familial hypercholesterolaemia). This helps ensure appropriate treatment, with the aim of reducing long term risks of complications such as stroke or myocardial infarction. | Rate of testing as indicated by a recorded code for a procedure to assess cholesterol level, observable entity returned in response to the assessment or a clinical finding associated with the result. | XE2eD: ‘Serum cholesterol (& level)’ (Curtis et al., 2022b) | 1: Converted existing CTV3 codes previously identified (using Kahootz CTV3 browser) 2: Searched SNOMED-CT for ‘cholesterol’ and selected any codes which related to total cholesterol monitoring/level. (Codelist) |
| Liver Function Testing - Alanine aminotransferase (ALT) | An ALT blood test is one of a group of liver function tests (LFTs) which are used to detect problems with the function of the liver. It is often used to monitor patients on medications which may affect the liver or which rely on the liver to break them down within the body. They are also tested for patients with known or suspected liver dysfunction. | Rate of testing as indicated by a recorded code for a procedure to assess ALT level or the observable entity returned in response to the assessment. | XaLJx: ‘Serum alanine aminotransferase level’ X77WP: ‘Liver function tests’ (Curtis et al., 2022b) | We searched SNOMED-CT for ‘alanine aminotransferase’ and selected all codes with reference to the test measurement/level. (Codelist) |
| Thyroid Testing - Thyroid Stimulating Hormone (TSH) | TSH is used for the diagnosis and monitoring of hypothyroidism and hyperthyroidism, including making changes to thyroid replacement therapy dosing. | Rate of testing as indicated by a recorded code for a procedure to assess TSH level or observable entity returned in response to the assessment. | XaELV: ‘Serum TSH level’ (Curtis et al., 2022b) | We searched SNOMED-CT for the term ‘thyroid stimulating hormone’ and selected all codes with reference to the test measurement/ level, excluding those referring to a specific timescale e.g ‘120 min‘. (Codelist) |
| Full Blood Count - Red Blood Cell (RBC) Testing | RBC is completed as part of a group of tests referred to as a full blood count (FBC), used to detect a variety of disorders of the blood, such as anaemia and infection. | Rate of testing as indicated by a recorded code for a procedure to assess RBC count, observable entity returned in response to the assessment or a clinical finding associated with the result. | Codes beginning with 426: ‘Red blood cell count’ (Curtis et al., 2022b) | We searched for the team ‘red blood cell’, and included all codes relating to ‘count’ and excluding any sub-types of RBC testing. (Codelist) |
| Glycated Haemoglobin Level (HbA1c) Testing | HbA1c is a long term indicator of diabetes control. NICE guidelines recommend that individuals with diabetes have their HbA1c measured at least twice a year. NICE, 2015 Poor diabetic control can place individuals living with diabetes at an increased risk of the complications of diabetes. | Rate of testing as indicated by a recorded code for a procedure to assess HbA1c level, observable entity returned in response to the assessment or a clinical finding associated with the result. | XaPbt: ‘Haemoglobin A1c level - IFCC standardised’ X772q: ‘Haemoglobin A1c level’ (Curtis et al., 2022b) | 1: Converted existing CTV3 codes previously identified (using Kahootz CTV3 browser) 2: Searched for ‘haemoglobin A1c’ and selected any codes related to total HbA1c monitoring/ level, excluding any codes for other purposes, e.g. reference ranges. (Codelist) |
| Renal Function Assessment - Sodium Testing | Sodium is completed as part of a group of tests referred to as a renal profile, used to detect a variety of disorders of the kidneys. A renal profile is also often used to monitor patients on medications which may affect the kidneys or which rely on the kidneys to remove them from the body. | Rate of testing as indicated by a recorded code for the observable entity returned in response to an assessment. | XE2q0: ‘Serum sodium level’ (Curtis et al., 2022b) | 1: Converted existing CTV3 codes previously identified (using Kahootz CTV3 browser) 2: Searched for ‘plasma sodium’ and ‘sodium level’ 3: Limited to codes in current use, and with a numerical value within expected range* (Codelist) |
| Asthma Reviews | The British Thoracic Society and Scottish Intercollegiate Guidelines Network on the management of asthma recommend that people with asthma receive a review of their condition at least annually. If a patient has not been reviewed, it is possible that their asthma control may have worsened, leading to a greater chance of symptoms and admission to hospital. British Thoracic Society, 2021 | Rate of reviews as indicated by a recorded code for an asthma review procedure, the regime used or the completion of an assessment. | Xaleq: ‘Asthma annual review’ (Curtis et al., 2022b) | QOF codelist (Codelist) |
| Chronic Obstructive Pulmonary Disease (COPD) Reviews | It is recommended by NICE that all individuals living with COPD have an annual review with the exception of individuals living with very severe (stage 4) COPD being reviewed at least twice a year. NICE, 2018 If a patient has not been reviewed, it is possible that their COPD control may have worsened, leading to a greater chance of symptoms and admission to hospital. | Rate of reviews as indicated by a recorded code for the regime used. | Xalet: ‘COPD review’ (Curtis et al., 2022b) | QOF codelist (Codelist) |
| Medication Review | Many medicines are used long-term and they should be reviewed regularly to ensure they are still safe, effective and appropriate. Medication review is a broad term ranging from a notes-led review without a patient, to an in-depth Structured Medication Review with multiple appointments and follow-up. The codelist provided captures all types of reviews to give an overview of medication reviews in primary care. | Rate of recording of a code indicating medication review procedure or regime. | Various, including XaF8d: ‘Medication review done’ (Curtis et al., 2023) | QOF codelist (Codelist) |
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QOF = Quality and Outcomes Framework.
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*
This was to avoid double counting where other codes are recorded for the testing activity alongside results being received.
-
†
This was to avoid double counting where both systolic and diastolic codes are recorded together.
Table 2
Cohort description using the latest recorded value for all adult patients who were registered at a general practice at any point between January 2019 and December 2021.
| Characteristic | Category | Number of adult patients (% of total population) |
|---|---|---|
| Total | 48,352,770 (100.0) | |
| Age | 18–19 | 1,398,430 (2.9) |
| 20–29 | 7,685,615 (15.9) | |
| 30–39 | 8,753,520 (18.1) | |
| 40–49 | 7,754,940 (16.0) | |
| 50–59 | 8,025,250 (16.6) | |
| 60–69 | 6,316,120 (13.1) | |
| 70–79 | 5,068,760 (10.5) | |
| 80+ | 3,350,125 (6.9) | |
| Missing | 20 (<0.1) | |
| Sex | M | 24,002,030 (49.6) |
| F | 24,350,740 (50.4) | |
| Ethnicity | South Asian | 3,148,455 (6.5) |
| Black | 1,333,335 (2.8) | |
| Mixed | 604,600 (1.3) | |
| Other | 1,039,730 (2.2) | |
| White | 27,900,210 (57.7) | |
| Missing | 14,326,440 (29.6) | |
| IMD quintile | Most deprived | 9,352,000 (19.3) |
| 2 | 10,061,470 (20.8) | |
| 3 | 9,788,670 (20.2) | |
| 4 | 9,379,320 (19.4) | |
| Least deprived | 9,241,205 (19.1) | |
| Missing | 530,100 (1.1) | |
| Region | East | 5,222,485 (10.8) |
| Midlands | 8,931,820 (18.5) | |
| London | 8,499,335 (17.6) | |
| North East | 5,897,280 (12.2) | |
| North West | 7,421,095 (15.3) | |
| South East | 7,671,845 (15.9) | |
| South West | 4,706,435 (9.7) | |
| Missing | 2,455 (<0.1) | |
| EHR provider | TPP | 28,765,400 (59.5) |
| EMIS | 19,587,370 (40.5) | |
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IMD: index of multiple deprivation, EHR: electronic health record.
Table 3
OpenSAFELY NHS SRO Key Measures and their recorded counts and median rate of activity across practices, January 2019-December 2021.
| Key measure | Number of patients experiencing an event at least once (millions) | Number of events (millions) | Median number of coded events per 1000 registered patients in April 2019 | Median number of coded events per 1000 registered patients in April 2020 (% change vs April 2019) | Median number of coded events per 1000 registered patients in April 2021(% change vs April 2019) | Classification (See Box 1) |
|---|---|---|---|---|---|---|
| Blood pressure monitoring | 27.77 | 79.30 | 65.03 | 9.22 (-85.82) | 37.7 (-42.03) | Sustained drop |
| Cardiovascular Disease 10-Year Risk Assessment | 7.38 | 10.49 | 6.65 | 0.61 (-90.83) | 4.14 (-37.74) | Sustained drop |
| Cholesterol Testing | 16.82 | 32.71 | 23.99 | 1.98 (-91.75) | 20.94 (-12.71) | Recovery |
| Liver Function Testing - Alanine aminotransferase (ALT) | 23.36 | 54.14 | 36.0 | 7.47 (-79.25) | 34.91 (-3.03) | Recovery |
| Thyroid Testing - Thyroid Stimulating Hormone (TSH) | 19.36 | 36.16 | 23.65 | 3.62 (-84.69) | 23.26 (-1.65) | Recovery |
| Full Blood Count - Red Blood Cell (RBC) Testing | 23.82 | 56.95 | 37.88 | 8.85 (-76.66) | 37.13 (-1.98) | Recovery |
| Glycated Haemoglobin A1c Level (HbA1c) Testing | 20.57 | 42.80 | 28.86 | 3.33 (-88.46) | 28.2 (-2.29) | Recovery |
| Renal Function Assessment - Sodium Testing | 25.07 | 65.99 | 43.88 | 9.45 (-78.46) | 41.74 (-4.88) | Recovery |
| Asthma Reviews | 3.41 | 7.15 | 3.61 | 2.17 (-39.89) | 2.76 (-23.55) | Sustained drop |
| Chronic Obstructive Pulmonary Disease (COPD) Reviews | 1.16 | 2.60 | 1.10 | 0.30 (-72.73) | 0.77 (-30.00) | Sustained drop |
| Medication Review | 22.47 | 58.27 | 34.10 | 21.68 (-36.42) | 27.80 (-18.48) | Sustained drop |
Additional files
-
MDAR checklist
- https://cdn.elifesciences.org/articles/84673/elife-84673-mdarchecklist1-v1.pdf
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Supplementary file 1
Counts of the five most commonly used codes within each measure codelist between January 2019 and April 2021.
- https://cdn.elifesciences.org/articles/84673/elife-84673-supp1-v1.pdf
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Eleven key measures for monitoring general practice clinical activity during COVID-19: A retrospective cohort study using 48 million adults’ primary care records in England through OpenSAFELY
eLife 12:e84673.
https://doi.org/10.7554/eLife.84673
