1. Missed opportunities mapping: computable healthcare quality improvement Benjamin Brown Trainee General Practitioner and PhD student Richard Williams, John Ainsworth, Iain Buchan Medinfo, Copenhagen, 21 st August 2013 @BenjaminCBrown Benjamin.Brown@manchester.ac.uk

3. Current practice

4. Missed Opportunities Mapping “failure to deliver a quality standard of clinical care that likely contributes to an adverse outcome that may otherwise have been avoided if it had been achieved”

5. Software Ainsworth J, and Buchan I. COCPIT: A Tool for Integrated Care Pathway Variance Analysis. Studies in health technology and informatics. 2012: 180: 995–9.

6. Demo: hypertension and CVD World-leading cause of death More deaths <75 years that any other condition UK and NW England performs worse than anywhere in developed world 90% of MI risk attributable to modifiable risk factors One of most important is HTN 1/3 adult UK population have HTN - most prevalent risk factor and LTC Clear guidance abundant 2010 UK national health survey: >40% remain ↑BP 44% of patients do not receive guideline rx Therefore, when a hypertensive patient suffers a CVD event it is reasonable to ask: Was there a missed opportunity for this to have been prevented/postponed? What was the association with patient demographics, deprivation and co-morbidities?

7. Demo: methods Salford, UK - 3 rd highest preventable mortality from CVD Fully integrated EHR > 232K people, 53 GPs and 1 hospital All HTN patients suffering CVD events between 2007-12 Whether or not achieved HTN management standards prior

8. Headline figures 3718 patients with CVD events 1186 (32%) – last BP ≥ 140/90 1323 (36%) – average BP ≥ 140/90 382 (10%) – unmeasured two years prior Estimated cost £3.1M ($4.9M)

9. Uncontrolled DeprivationMultimorbidityGenderEthnicity Age Unmeasured

10. Uncontrolled Unmeasured

11. Uncontrolled Unmeasured

12. Conclusions A new model for QI New computational approach Translatable to multiple clinical scenarios Demonstration study Real-life data to test model Directly implementable clinical information Further work Generalisability Clinical significance Virtuous circle

13. Thank you for listening Acknowledgements Dr Matthew Sperrin, Biostatistician Dr Tim Frank, Academic GP Dr Washik Parkar, GP Dr Steve Little, Cardiologist Professor Simon Capewell, Cardiovascular epidemiologist Dr Artur Akbarov, Biostatisician @BenjaminCBrown Benjamin.Brown@manchester.ac.uk