Using Information to Close the Primary/Secondary Care Loop- Flu Vaccination Programme
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Transcript of Using Information to Close the Primary/Secondary Care Loop- Flu Vaccination Programme
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Using Information to Close the Primary/Secondary Care Loop-
Flu Vaccination Programme
Arlene Reynolds & Jim McMenaminHealth Protection Scotland
SCIMP, Crieff, November 2013
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Contents
• Influenza as a case study; How can we use routinely gathered data to close the loop and inform patient management? – Aggregate level data
• Flu vaccine uptake & flu consultation Rates– Individual level data
• Determinants of flu vaccine uptake & vaccine effectiveness & risk of death
– Now that kids are to be vaccinated how do we propose to describe the Public Health benefit?
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Why vaccinate against Flu?
• In absence of a flu vaccination programme NHS Scotland would experience significant morbidity and mortality each season*– 900 excess deaths– 4700 excess hospitalisations– 100,000 excess GP consultations
*Extrapolation from - Baguelin M, Flasche S, Camacho A, Demiris N, et al. (2013) Assessing Optimal Target Populations for Influenza Vaccination Programmes: An Evidence Synthesis and Modelling Study. PLoS Med 10(10): e1001527. doi:10.1371/journal.pmed.1001527http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001527
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Flu Vaccine Uptake – a success story…
• Scotland is one of only three EU countries to consistently achieve a vaccine uptake of greater than 75% in those age 65 and over
• Uptake in under 65’s in CMO defined risk groups around 60%
• GP consultation rates for Influenza Like Illness (ILI) vary markedly each season but rates of illness much less in last decade c.f. pre-vaccination programme
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What does Primary Care data tell us?
• Uptake by risk group?• When season starts & magnitude compared
with previous years?• Who is affected most & Where?• What Flu strains are responsible?• If not Flu what is it (and do I need to treat it)?• Is Flu Vaccine protecting the population?
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Cumulative vaccine uptake by risk group over time
season 2012/13
** The size of the pregnant population is derived from GP records on patients with pregnancy code. This results in changes in the population over the course of the season, as pregnancy status of patients changes.
0%
20%
40%
60%
80%
100%
Week40
Week42
Week44
Week46
Week48
Week50
Week52
Week2
Week4
Week6
Week8
Week10
Week12
Week number
Vac
cin
e u
pta
ke (
%)
Over 65
All risk groups (under 65)
Chronic Respiratory Disease
Chronic Heart Disease
Chronic Renal Disease
Chronic Liver Disease
Chronic Neurological Disease
Diabetes
Immuno-compromised
Pregnant/no risk**
Pregnant/at risk**
Carers
How quickly is offer of vaccine taken up?
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When Season Starts & Magnitude?
• Since 2009 daily automated extraction of aggregate data from 99% of all practices on GP consultation rates for Influenza Like Illness (ILI) & Acute Respiratory Infections– Rates vary markedly each season– Timing of peaks in clinical presentations variable
• In the main around the time of the Festive season
• But earlier in 2003/4• And later in 2010/11
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Weekly GP consultation rates for ILI by flu season Scotland
(In 2012/13 = 961 practices)
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GP consultation rates for ILI in Scotland by age group;
weekly rates per 100,000 population, week 40 2012 to week 32 2013
Who is affected most?
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Where? NHS board ILI consultation rates to
16th October 2013
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What Flu strains are responsible?
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If its not Flu what is it?(Do I need to treat it…?)
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The PIPeR cohort – Determinants of
Flu vaccine uptake & Vaccine effectiveness
• Daily Consultation rates for– ILI– ARI (including asthma)– ILIARI (ILI+ARI excluding asthma)
• Weekly download of individual level data from each practice
• 170783 Patients for 2012/13 cohort– Patients registered with 27 GP Practices (25
physical sites) on Sept 1, 2012– 3.3% Scottish Population
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Colours represent the different postcode areas of practice population
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Vaccine Uptake
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Date in 2012/13
Pe
rce
nta
ge
Sep Oct Nov Dec Jan Feb Mar
02
04
06
08
0
0-45-1415-4445-6465-7475+
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Vaccine Uptake
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Date in 2012/13
Pe
rce
nta
ge
Sep Oct Nov Dec Jan Feb Mar
05
10
15
20
FemaleMale
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Vaccine Uptake
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Date in 2012/13
Pe
rce
nta
ge
Sep Oct Nov Dec Jan Feb Mar
05
10
15
20
25
30
012+
Consultations in Previous Season
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Vaccine Uptake
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Date in 2012/13
Pe
rce
nta
ge
Sep Oct Nov Dec Jan Feb Mar
05
10
15
20
UrbanSmall TownsRural
Urban Rural Status
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Vaccine Uptake
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Date in 2012/13
Pe
rce
nta
ge
Sep Oct Nov Dec Jan Feb Mar
05
10
15
20
[1,4](4,8](8,12](12,16](16,20]
Deprivation
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Vaccine Uptake
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Date in 2012/13
Pe
rce
nta
ge
Sep Oct Nov Dec Jan Feb Mar
01
02
03
04
05
0
0-45-1415-4445-64
In a Risk Group
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Vaccine effectiveness
for entire season
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Methods
• Method 1: Test Negative Case Control– GP Sentinel Swabbing Scheme– Interim & End of Season estimate– Adjustment for UK site, time period, sex, flu strain
• Method 2: Cohort method– Weekly download of individual level data from
each practice– Adjustment for a range of confounders– Nested case control (Gold Standard)– (Adhoc investigation of potential adverse reaction)– Linkage to hospital data and deaths
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“Overall trivalent influenza vaccine (TIV) adjusted vaccine effectiveness (VE) against all laboratory-confirmed influenza in primary care was 51% (95% confidence interval (CI): 27% to 68%); TIV adjusted VE against influenza A alone or influenza B alone was 49% (95% CI: -2% to 75%) and 52% (95% CI: 23% to 70%) respectively. Vaccination remains the best protection against influenza. “
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Cohort: Calculation of vaccine effectiveness
• Seasonal Flu Vaccine– Time dependent covariate– 14 days for consultation post vaccine to count
• Time dependent Cox regression• Comparing
– Unvaccinated at time of consultation – Vaccinated at time of consultation.
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VE – Clinical endpoint
Adjusting for age, gender, clinical risk group, deprivation, urban/rural, seasonal vaccination in previous year, number of ILIARI consultations in the previous year.
Period is December 01, 2012 to February 28, 2013
VE - All ages 21.8% (95% CI 1.9 to 37.6)- Age 65+ -35.4% (95% CI -173.9 to 33.1)- At risk 28.6% (95% CI 4.0 to 47.0)
under 65
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Linking primary & secondary care data
• What is the increased risk of death from influenza in clinical risk groups?– Data linkage - primary care, laboratory,
SMR1 & NRO(S) - the SIVE project Severe Acute Respiratory Infections (SARI) due to laboratory confirmed influenza
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What does risk factor analysis of SARI cases tell us?
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Vaccine effect varies for different clinical endpoints – deaths by
season 2000 to 2008/9
“Marked variation of vaccine effectiveness in any one year – need to look at the average effect over time…” NIHR
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Interested in routine flu output?
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Season 2013/14
• Childhood extension of seasonal influenza vaccination programme with LAIV – Fluenz– Phase 1 (of 3)
• All Scottish 2 & 3 year olds ~ 120k• Pilots in primary school (age 4 to 11 years) ~ 100k
• TNCC - Increased swabbing resource (from 2k to 3k samples) to allow better VE by age strata
• Cohort– Increase cohort size from 27 to 47 practices ~ 300 – 350k patients– Expand clinical data to include rotavirus & Zoster?
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Making sense of it all: Modelling, Programme Effectiveness & Benefit Realisation
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Benefit Realisation- Influenza: Then, Now and Next?
IMPACT Measure
Then – No
Programme
Now - Current
Programme
Next - Programme Extension
Health Gain? Next v Now?
Burden*Annual Deaths
900 500 300 200 less
Levels of infection/ risk of transmission
Consultation rates High Mod LowIndirect &
direct
NA 75% (30-70) 75% (50-80)?Indirect &
directVaccine uptake (& Effectiveness)
High Mod Low“supershed
ders” reduced
Transmission
Health Care Utilisation*
Annual Hospitalisations
4700 2700 1600 1100 less
Annual GP Consultation
100000 75000 42000 33000 less
Societal Burden
Health Economic costs
LSHTM LSHTM LSHTMPENSIVe
pilot
* LSTM&H assumptions – 1. Uptake limited to 30% in 2-16 years; 2. Modelling includes indirect benefit through “herd-immunity” protection of adult groups; 3. Census data 2010/11 England & Scotland population estimates as 53 million & 5.3 million respectively
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The future…
• Applicability of public health surveillance programme approach to other vaccine preventable diseases? – E.g. rotavirus, shingles etc– Demonstration of their public health
effectiveness• Single data extraction of primary care data
and linkage with other NHS datasets - SPIRE
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Acknowledgements• Sentinel Swabbing Scheme practices 2012/13
– Bridgeton Health Centre, Aberfeldy & Kinloch Rannoch Medical Practice, Airthrey Park Medical Centre, Kilwinning Medical Practice, Glenfield Medical Practice, Ardach Health Centre, The Cairntoul Practice, Braids Medical Practice, Carnoustie Medical Group, Carstairs Surgery, Bourtreehill Medical Practice, The Craigshill Partnership, Cramond Medical Practice, Barns Medical Practice, Dr Langridge, Alva Medical Practice, Riverview Medical Centre, Greencroft Medical Centre (North), Neilston Medical Centre, The Surgery, Keith Health Centre, Kelso Medical Group, Dr Jabaroo & Partners, Liberton Medical Group, Meadowbank Health Centre (Practice 3), Newton Port Surgery, Primrose Lane Medical Practice, Ranfurly Surgery, Dornoch Medical Practice, Skerryvore Practice, Tweeddale Medical Practice, Dr Blake & Partners, Dunbar Medical Centre, Red Surgery, Riverview Practice,West End Medical Practice, Westgate Medical Practice, Yell Health Centre,Denny Cross Medical Centre
• PIPeR practices 2012/13– Bridgeton Health Centre, Kilwinning Medical Practice, Glenfield Medical Practice,
Waverley Medical Practice, Eden Villa Practice, The Cairntoul Practice, Dr Langridge, Alva Medical Practice, The Health Centre, Riverview Medical Centre, Greencroft Medical Centre (North), Neilston Medical Centre, Dr Jabaroo & Partners, Lochinch Practice, Lochnaw Practice, Loch Ree Practice, Meadowbank Health Centre (Practice 3), Primrose Lane Medical Practice, Dr Cassidy & Partners, Bonnybank Medical Practice, Stevenston Medical Practice , Auchinleck Health Centre, Hospital Hill Surgery, Inverkeithing Medical Group, Denny Cross Medical Centre, Brown Spilg Partnership, Drs Owen, Smith & Johnstone 37