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Alcohol Improvement Programme Early Implementers’ Conference2 December 2009Data Workshop

Joanna CoppingChris GibbinsVerity Bellamy

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Outline of presentation

• How NI39 is calculated

• Latest trends in NI39 for England

• How to calculate NI39 fro your own PCT/LA

• NI 39 in Nottingham

• How PCTs can reach their NI39 target- discussion

• Ready Reckoner version 5

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How alcohol admissions indicator is calculated

• PSA 25.2, VSC26, NI39• Developed in 2007• Broader measure – includes conditions partially attributable to alcohol• Based on review of epidemiological literature by NWPHO• Produced set of conditions caused by alcohol and corresponding attributable

fractions

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The measure

ICD code ICD name

M F M F M F M F M F M F M F M FE24.4 Alcohol-induced pseudo-Cushing's syndrome 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00G31.2 Degeneration of nervous system due to alcohol 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00G62.1 Alcoholic polyneuropathy 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00G72.1 Alcoholic myopathy 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00I42.6 Alcoholic cardiomyopathy 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00K29.2 Alcoholic gastritis 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00K70 Alcoholic liver disease 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00K86.0 Chronic pancreatitis (alcohol induced) 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00F10 Mental and behavioural disorders due to use of alcohol 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00T51.0 Ethanol poisoning 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00T51.1 Methanol poisoning 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00T51.9 Toxic effect of alcohol, unspecified 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00X45 Accidental poisoning by and exposure to alcohol 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00W00-W19 Fall injuries 0.00 0.00 0.22 0.14 0.22 0.14 0.22 0.14 0.22 0.14 0.22 0.14 0.12 0.04 0.12 0.04W24-W31 Work/machine injuries 0.00 0.00 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07 0.07W32-W34 Firearm injuries 0.00 0.00 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25W65-W74 Drowning 0.00 0.00 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34W78-W79 Inhalation of gastric contents/Inhalation and ingestion of food causing obstruction of the respiratory tract 0.00 0.00 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25X00-X09 Fire injuries 0.00 0.00 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38 0.38X31 Accidental excessive cold 0.00 0.00 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25 0.25X60-X84, Y10-Y33 Intentional self-harm/Event of undetermined intent 0.00 0.00 0.34 0.35 0.34 0.33 0.35 0.34 0.37 0.34 0.36 0.32 0.31 0.25 0.27 0.20X85-Y09 Assault 0.00 0.00 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27 0.27§§ Pedestrian traffic accidents 0.00 0.00 0.35 0.16 0.45 0.19 0.46 0.21 0.46 0.21 0.23 0.03 0.23 0.03 0.23 0.03§ Road traffic accidents (driver/rider) 0.00 0.00 0.21 0.09 0.33 0.15 0.24 0.12 0.24 0.12 0.09 0.03 0.09 0.03 0.09 0.03V90-V94 Water transport accidents 0.00 0.00 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20V95-V97 Air/space transport accidents 0.00 0.00 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16 0.16O03 Spontaneous abortion 0.00 0.00 0.00 0.23 0.00 0.21 0.00 0.22 0.00 0.21 0.00 0.20 0.00 0.15 0.00 0.12K22.6 Gastro-oesophageal laceration-haemorrhage syndrome 0.00 0.00 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47 0.47K73, K74 Chronic hepatitis, not elsewhere classified and Fibrosis and cirrhosis of liver 0.00 0.00 0.77 0.67 0.76 0.59 0.74 0.60 0.79 0.59 0.77 0.57 0.71 0.48 0.61 0.38K85, K86.1 Acute and chronic pancreatitis 0.00 0.00 0.27 0.19 0.27 0.16 0.26 0.16 0.30 0.16 0.27 0.14 0.22 0.10 0.16 0.07I85 Oesophageal varices 0.00 0.00 0.77 0.67 0.76 0.59 0.74 0.60 0.79 0.59 0.77 0.57 0.71 0.48 0.61 0.38C00-C14 Malignant neoplasm of lip, oral cavity and pharynx 0.00 0.00 0.50 0.40 0.50 0.35 0.49 0.36 0.53 0.35 0.50 0.33 0.44 0.26 0.36 0.20C15 Malignant neoplasm of oesophagus 0.00 0.00 0.32 0.23 0.31 0.20 0.30 0.20 0.34 0.20 0.32 0.18 0.26 0.14 0.20 0.10C32 Malignant neoplasm of larynx 0.00 0.00 0.34 0.25 0.33 0.21 0.32 0.22 0.36 0.21 0.34 0.20 0.28 0.15 0.22 0.11C18 Malignant neoplasm of colon 0.00 0.00 0.05 0.03 0.05 0.03 0.04 0.03 0.05 0.03 0.05 0.03 0.04 0.02 0.03 0.01C20 Malignant neoplasm of rectum 0.00 0.00 0.08 0.06 0.08 0.05 0.08 0.05 0.09 0.05 0.08 0.05 0.07 0.03 0.05 0.03C22 Malignant neoplasm of liver and intrahepatic bile ducts 0.00 0.00 0.16 0.11 0.15 0.10 0.15 0.10 0.17 0.10 0.16 0.09 0.13 0.07 0.10 0.05C50 Malignant neoplasm of breast 0.00 0.00 0.00 0.09 0.00 0.08 0.00 0.09 0.00 0.09 0.00 0.08 0.00 0.06 0.00 0.04I10-I15 Hypertensive diseases 0.00 0.00 0.34 0.24 0.33 0.19 0.32 0.20 0.37 0.20 0.34 0.18 0.27 0.13 0.20 0.09I47-I48 Cardiac arrhythmias 0.00 0.00 0.35 0.36 0.36 0.35 0.37 0.35 0.38 0.35 0.37 0.33 0.34 0.27 0.30 0.22G40-G41 Epilepsy and Status epilepticus 0.00 0.00 0.56 0.64 0.58 0.59 0.58 0.61 0.61 0.61 0.61 0.57 0.51 0.45 0.42 0.35I60-I62, I69.0-I69.2 Haemorrhagic stroke 0.00 0.00 0.31 0.20 0.30 0.15 0.27 0.15 0.34 0.15 0.30 0.13 0.24 0.10 0.16 0.06I63-I66, I69.3, I69.4 Ischaemic stroke 0.00 0.00 0.16 0.03 0.13 0.00 0.08 0.00 0.18 0.00 0.12 0.00 0.06 0.00 0.00 0.00L40 excluding cirrhosis L40.5 Psoriasis 0.00 0.00 0.34 0.33 0.34 0.33 0.35 0.33 0.36 0.32 0.35 0.31 0.33 0.26 0.30 0.22

Alcohol Attributable Fraction0-15 16-24 25-34 35-44 45-54 55-64 65-74 75+

13 wholly attributable conditions

(attributable fraction of 1)

31 partially attributable conditions

(attributable fraction less than 1)

Example: cancer of oesophagus

Women aged 16-24, AF = 0.23

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Applied to NHS Information Centre’s data on Hospital Episodes

• Admission episodes for residents; valid sex and age; classpat = 1,2,5• Any mention of alcohol related diagnosis (not just primary diagnosis)

7.56Total =• If more than one in episode, use largest AF – eg I10X = 0.34; G409 = 0.61

• Count of admissions; not patients (‘whole admission equivalent’)• To get rate, use ONS resident population estimates: http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106

Attributable fractions for the non-data minded!

2 NI39 admissions =

Ethanol poisoning2 X Epilepsy4 X

Hypertension10 XBreast cancer25 X

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Improving access and understanding

• DH releases of data:– Q1 2009/10– Final 2008/09– Subsequent quarters about five months after end of quarter

• NWPHO sub-analyses– 2007/08: December– 2008/09: January

• Confidence intervals - scoping• HES ARA variable

– Currently undergoing user acceptance testing

• ARA tool– Feed admission level data in (from HES or SUS). Calculates attributable fractions and standardised rates.– Available on Alcohol Learning Centre: http://www.alcohollearningcentre.org.uk/Topics/Latest/Resource/?cid=5369

• Ready Reckoner– Assist PCTs to select interventions to reduce alcohol admissions. 4 high impact changes. – Also on ALC: http://www.alcohollearningcentre.org.uk/Topics/Browse/Commissioning/Data/?parent=5113&child=5109

• System Dynamics Model• Support to regions with trajectories

Pre-announced release dates

More than just headline figures

Better flagging of data quality issues

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Latest data - England

• National, regional and local figures for 2008/09 will be placed on the NWPHO within the next couple of weeks.

• Information presented has not been fully validated.

• Rate of admissions in 2008/09 was 1583 per 100,000 population, a 7.5% increase on 2007/08. This does not deliver the improvement of less than 5.5% that we were are aiming to achieve in our PSA, which was based on information about local actions.

• It is an improvement on the projected increase of 8.0%.

• This is higher than the rate suggested by the provisional figures currently on the web site.

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Latest data - England

• National, regional and local figures for Q1 of 2009/10 also being placed on the NWPHO site within the next fortnight.

• Forecast outturn for 2009/10 based on Q1 data only is more pessimistic.

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Latest data

• There is some variation between regions and considerable variation between PCTs.

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Conditions accounting for increase

• Alcohol-specific conditions account for a quarter of the admissions, largely unchanged. Has grown by 81% since 2002/03, compared with 85% for all alcohol-related admissions.

• Acute events account for 10% of the total, down slightly.

• Accidents and injury, violence and cancers have each increased by less than average.

• Hypertensive disease accounts for 35% of the total, up from 27% in 2002/03. Has grown by 145% since 2002/03.

• Some due to better diagnosis and improvements in coding

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• Males account for over 60%

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• Some growth in elective at expense of “other emergency”, but majority still emergency via A&E

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Change between provisional and final

• Considerable change in South West and, to lesser extent, East Mids. • Former due to problems with data flow from North Bristol NHS Trust.• Six PCTs saw revisions of more than five per cent.

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Local PCT analysis of NI39 – Nottingham City data

NI 39 in NottinghamThe NI39 rate in Nottingham City is consistently significantly higher than either the East Midlands or England average

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Trajectory to WCC target

Understanding NI39

• In 2007/08 the rate of hospital admissions for alcohol related harm was 1778 admissions per 100,000 population

• This is 4871 ‘NI39 admissions’

• but 10,614 individuals....

• and 15,611 actual admissions to hospital...

• Important to understand the difference between admissions and individuals

2007/08 – by age and sex• Highest contribution to individuals is from older women• However, the highest contribution to NI39 admissions is from middle aged men

Alcohol specific admissions by age and sex• Age and sex breakdown for alcohol specific admissions in Nottingham shows a very different pattern, highlighting males of most age groups

NI39 admissions by main cause – top 10 causes in Nottingham City

• In Nottingham City in 2007/08 over 90% of NI39 admissions were due to the top 10 causes• The greatest overall contributor was hypertensive diseases (25%) followed by mental and behavioural disorders caused by alcohol (22%) and cardiac arrhythmias (15%)• There are differences in cause of admission by sex

Trends in cause – top 10 causes•Number of NI39 admissions increased by 16.7% between 2002/03 to 2007/08 (695.5 more admissions). The table below shows trends in the top 10 causes• almost half of this increase is due to an increase in mental and behavioural disorders, 30% due to hypertensive diseases and over 20% due to alcohol liver disease• Since 2002/03 NI 39admissions for chronic hepatitis and fibrosis of the liver have increased by 207% and alcoholic liver disease by 81%

Emergency versus elective admissions• 72% of NI39 admissions in Nottingham were emergency admissions, 25% elective•Mental and behavioural disorders are cause over a quarter of emergency NI39 admissions, hypertensive diseases 22% and cardiac arrhythmias 16%.•. Less than 600 individuals had mental and behavioural disorders compared to almost 3000 with hypertension

Readmissions•2419 individuals admitted more than once resulting in 7416 readmissions • Cause of admission taken from the first incidence of admission•Hypertension accounts for 35% of readmissions and cardiac arrhythmias for 17.5%• More useful to look at emergency readmissions?

Emergency readmissionsHypertensive diseases and cardiac arrhythmias account for over 60% of emergency readmissions in Nottingham

Bed daysThe top 10 contributors to bed days in Nottingham City are shown below; hypertension (41%), cardiac arrhythmias (20%) and falls (12%) being highest

Zero bed daysWe also looked at zero bed days (admissions not passing through midnight). The top 10 are shown below. Hypertension was highest (30.8%) followed by psoriasis (11.4%)

How do we reduce our rising rates of alcohol related admissions?

• Men contribute more to NI39, especially middle aged

• Most admissions are emergencies (72%) • Main conditions that contribute:-Hypertensive disease (25%) and responsible for 20% of cause of increase in NI39-Mental& behavioural (22%) and responsible for 46% of cause of increase in NI39-Cardiac arrhythmias (15%) and responsible for 16% of cause of increase in NI39-Epilepsy (8%)-Alcohol liver disease (7%)

• Increases over 6 years most obvious in liver diseases

Possible interventions- what would you do?

• Target the men (NB they don’t usually seek health care)• Most come as emergencies so key opportunity for Emergency

Department (IBA) and alcohol liaison team• Hypertensive disease- but also asking GPs to improve

detection. IBA may reduce incidence but will take time• Mental & behavioural (includes intoxication, harmful use, intoxication,

withdrawal, DTs, psychosis, amnesia)- improved alcohol treatment services should help

• Cardiac arrhythmias, epilepsy, liver disease- Alcohol workers in outpatient clinics, train medical & nursing staff in IBA

• Epilepsy- specialist alcohol nurse in community neurology team

• OTHERS e.g divert the admissions elsewhere?

Ready Reckoner version 5

Chris to demonstrate