NHS Digital Data Release Register - reformatted

Royal College of Anaesthetists

Opt outs honoured: Y

Basis: Section 251 approval is in place for the flow of identifiable data

Format: Identifiable Sensitive

How often: Ongoing

When: unknown — 11/2016

HSCIC Id: DARS-NIC-355855-R4G6G-v0.0

Data: MRIS - Cause of Death Report

Data: MRIS - Cohort Event Notification Report

Data: Hospital Episode Statistics Admitted Patient Care

Output: The linked dataset will be a product of this process and will enhance the quality of the comparative data for the audit in subsequent years.

The NELA is commissioned to produce a "State of the Nation" annual report each year. The first 2 reports utilising patient level information were published in June 2015 & June 2016 and are available to view on the NELA website. Subsequent reports are scheduled to be published yearly.

In order to more widely disseminate the findings of the audit, additional scientific publications will be produced. These outputs will be in the form of peer-review articles and conference presentations.

The results of the audit will also be disseminated at professional medical conferences and in peer-reviewed journals (e.g. BMJ, BJA, ASGBI journal, AAGBI journal) at the time of the launch of the report or shortly after. Publications related to the Audit methods (e.g., a risk-adjustment model) rather than information of clinical practice and outcomes will be published on an ad hoc basis.

In response to participant feedback a Quality Improvement Report Dashboard has been created on the NELA Online Web Tool to assist sites with audit data collection and to promote local Quality Improvement work (Local hospital data can only be viewed by registered local hospital participants). The Quality Improvement Report Dashboard will only provide local units with aggregated information to compare their performance against a national average. The figures available to each unit will be based on their own local data (supplied by the units) and the Dashboard may therefore present small numbers on some occasions. Each individual user has their own login to the webtool which gives them access to only their own hospital local data. To access the webtool they require a username and password.

The first phase of the Dashboard which has now been launched focuses on Case Ascertainment and Patient Demographics. The Patient Demographics section allows local participants to view some basic information on their hospital's population of patients undergoing emergency laparotomy, and how it compares to the audit-wide average. It focuses on characteristics such as patient age and operative urgency.

The Case Ascertainment aims at increasing case completeness and submission by providing a monthly list of cases entered/completed/not completed.

The next phase of the Dashboard will focus much more on Quality Improvement, feeding back key QI indicators and comparing hospital's local data with national audit-wide averages. Some of the measures reported back will include; Documentation of risk, Direct Admission to critical care etc.

The Royal College of Anaesthetists are currently in the process of developing the QI dashboard and hope to make further additions in the next few months.

All outputs will be aggregated with small numbers suppressed and will follow the ONS/HES guide on reporting.

Activities: The RCoA are the principal data processors for NELA and manage the extraction of the records from the NELA IT system.

RCoA will send the file of patient identifiers and the NELA ID to NHS Digital for linkage to HES and ONS fields. Pseudonymised files (of which includes full date of death and Cause of Death (text)) from NHS Digital will contain the HES and ONS fields with the NELA ID variable added. The pseudonymised files of HES / ONS data (including Date of Death and Cause of Death) will be received by the RCS and held on their secure data server.

In all cases, the data received from NHS Digital will not be linked back to the identifiable NELA database held at RCoA. An extract of pseudonymised data of which includes date of death is taken from the NELA database and sent to RCS. This data will be linked to the HES-ONS data via the NELA ID. Date of Death from the NELA database is provided as this includes an important data quality step. There are potential missed linkages if RCS and RCoA do not have this information when processing the data at RCS. This also helps to validate the data entered into NELA. No data provided by NHS Digital is sent to RCoA to correct fields in the NELA database.

A copy of the de-identified data fields along with the unique NELA ID will be analysed by project team members from both RCS and RCoA at the RCS Clinical Effectiveness Unit only. The only identifiable fields received by RCS and RCoA analysts are ONS Date of Death and Cause of death. The full Date of Death is required to be able to calculate survival at multiple time points (30 day, 90 day, etc.). There will be no capacity for RCS / RCoA analysts to use the ONS Date of Death to identify any individual patients.

Analysts from RCS / RCoA who work on the de-identified data set do not have access to the identifiable data set held within the NELA IT system and managed by the RCoA, nor the list of patient identifiers sent to NHS digital for linkage purposes. All individuals with access to the de-identified data are substantively employed by RCoA or RCS. The list of patient identifiers sent to NHS digital is only accessible by a senior member of the RCoA. RCoA or RCS will not be linking HES/ONS data with any other dataset (apart from an extract of NELA). Linkage with any other datasets would be subject to a future application and would be supported by an appropriate legal basis.

The majority of the analysis involving the de-identified linked patient dataset will be conducted by the RCS statisticians who form part of the NELA Project Team. The remainder would consist of statisticians from RCoA would be involved in some of the analysis of the patient-level dataset and will be located at the RCS Clinical Effectiveness Unit to undertake this work. In either case, all individuals with access to the data are substantively employed by either RCoA, or RCS and are required to sign a Confidentiality Agreement before access is granted.

Objective: Emergency abdominal surgery (or emergency laparotomy) is associated with significant morbidity and mortality worldwide. The aim of The National Emergency Laparotomy Audit (NELA) is to enable the improvement of the quality of care of patients undergoing emergency laparotomy by providing high quality comparative information of the clinical practice and outcomes of all NHS providers of emergency laparotomy in England and Wales. NELA is a national clinical audit commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical and Patient Outcomes Programme (NCAPOP).

HQIP have commissioned the Royal College of Anaesthetists (RCoA) to deliver the audit. RCoA are working in partnership with the Clinical Effectiveness Unit of the Royal College of Surgeons (RCS) and therefore make up the NELA project team. HQIP act as data controllers for the national clinical audit but do not have access to any data collected or analysed by the RCoA and RCS who are the data processors. The analysis by the NELA project team will only involve pseudonymised (with exception to full Date of Death and Cause of Death) datasets that combine information submitted by NHS hospitals and data supplied by NHS Digital / ONS. Members of the project team work at either the RCoA or Clinical Effectiveness Unit at the RCS, however analysis of the NHS Digital, ONS, and an extract of pseudonymised NELA data (including full Date of Death obtained via hospitals) will only be processed and stored at RCS.

The RCoA and RCS wish to link the patient records submitted to NELA with the Hospital Episode Statistics (HES) records for those patients. The NELA records relate only to an individual admission, and by linking to inpatient HES data, the Audit will be able to provide more precise and relevant information to NHS hospitals by allowing the RCoA and RCS to describe longer term outcomes (e.g., readmission rates) and to improve RCoA’s and RCS’s risk-adjustment models by using the extensive information on comorbid conditions held within HES. (eg to calculate the Charlson Comorbidity score)

The RCoA and RCS also wish to link the patient records submitted to NELA with the Office for National Statistics (ONS) Death Register on a quarterly basis to enable the Audit to monitor changes in postoperative outcomes (both short and longer-term mortality) for those patients. Access to this linked information will support this national clinical audit to improve the quality of care within NHS hospitals for a high-risk patient group.

The objectives of the Audit are:
1. To enable secondary care providers to improve the delivery of care to patients undergoing emergency laparotomy using information produced by the audit;
2. To provide comparative information on the organisation of care by providers of Emergency Laparotomy.
3. To provide comparative information on patient outcomes following surgery for Emergency Laparotomy.
4. To facilitate the development of effective change (quality improvement) initiatives and thereby spread examples of best practice and help local providers make the best possible use of audit results

In summary, the purpose of this request is to support national clinical audit, quality improvement within hospital, and research on methods to monitor surgical outcomes.
The NELA team is planning to request patient level clinical data from Intensive Care National Audit and Research Centre (ICNARC).

Benefits: The NELA audit is highly relevant to current clinical practice and publications will allow widespread disseminate of the findings amongst health professionals. Linkage to the HES/ONS data allows the Audit to report more extensively on patterns of care beyond the initial hospital admission and longer-term outcomes, such as 90-day mortality. The Audit is able to examine issues such as readmission rates and the most common reasons for these post-discharge complications, e.g.: respiratory complications and anastomotic leaks.

The audit will produce useful indicators that describe the standard of care in a variety of clinical areas. The indicators will identify NHS providers that are performing well and those requiring improvement to the quality of care received by patients.
Ongoing improvement in the processes of care and clinical outcomes should lead to a reduction in the postoperative mortality rates and thus an overall improvement in patient outcomes. Outcomes will be measured by re-auditing individual sites and therefore regular data linkage would be required. It is hoped that this improvement in care would be identified by the end of the currently proposed commissioned audit period (Dec 2018).

The intended audience for the audit annual reports are clinicians, healthcare professionals, Medical Directors, Chief Executives, audit managers, commissioners, NHS England, public and patients. Trusts will use the process indicators and outcomes reported in the annual reports to assess their care against national standards and benchmark against other NHS trusts. This will enable providers to identify areas requiring improvement and take action which in turn will provide a benefit to patient care.

Reporting will identify whether NHS trusts are meeting national guidance such as NICE recommendations and will identify variations in the provision of care. The Audit outcomes such as postoperative mortality are risk-adjusted and any potential outlying trusts are identified as part of the Audit outlier policy.

Any Trust showing as an alarm will be notified which will allow for investigation into the cause; this can be attributable to either data quality issues or clinical practice. This notification will enable the trust to address the cause and either review the data submitted to the Audit or their clinical practice. Any resultant improvements in clinical practice will directly impact on improvements in patient care.

The trust profiles are publically available, providing transparency and enabling patient choice.

Publishing in peer-reviewed journals will allow greater discussion of the strengths and weaknesses of the results, and will provide the benefit of peer-review of the work from third parties.

It is anticipated that the reports produced as a result of the audit will contribute to clinical guidance and national policy.

Source: NHS Digital.