Myocardial Ischaemia National Audit Project (MINAP): Improving data capture and use across South Wales

Transcription

1 Myocardial Ischaemia National Audit Project (MINAP): Improving data capture and use across South Wales Author Owner Document Reference Alison Turner Cardiovascular Audit and Primary Care Nurse South Wales Cardiac Network South Wales Cardiac Network Myocardial Ischaemia National Audit Project (MINAP) Data Capture Executive Summary Background The Myocardial Ischaemia National Audit Project (MINAP) is, managed by the National Institute for Cardiac Outcomes and Research (NICOR) and is one of the largest registry databases in the world. It collects data on the patient heart attack pathway from call for help to intervention for Acute Coronary Syndrome (ACS) patients admitted to hospital. This includes both ST elevation Myocardial Infarction (STEMI) patients, more recently those suffering non-stemi (NSTEMI) and unstable angina. National public reports are published yearly, to demonstrate the performance of the NHS and how it cares for heart attack patients against national standards. Data from MINAP is utilised to drive and guide treatment and service improvement across the UK. Summary Full participation in MINAP by Local Health Boards (LHBs) is required by the NHS Wales Outcome and Delivery Framework 2014/15. Data entry into the MINAP database varies significantly across South Wales, with some hospitals collecting and entering data more completely than others. This results in the MINAP report misrepresenting the picture of patient care for heart attack in Wales. In order to demonstrate the inaccuracies in MINAP, this report, compares data collected in South Wales hospitals and entered onto the MINAP database to that collected by the Patient Episodes Database for Wales (PEDW). It highlights the inaccuracy and significant variation in data collected between South Wales hospitals and how this undermines the potential for using this database as a resource to enhance service improvement. An inaccurate view of cardiac services in South Wales may compromise investment in deficient services and compromise patient care and gives a misleading view of services to the NHS Wales and the public.

2 Contents Page(s) Executive Summary Cover 1. Current Acute Cardiac Events: MINAP/PEDW Activity 3 2. Results 4 3. Discussion and recommendations 6 4. Examples of using MINAP data for local service improvement 7 5. National and local MINAP Reports 7 6. Conclusions and recommendations 8 7. Other Considerations 8 8.References and associated documents 9 SWCN South Wales MINAP Data Capture Report Page 2 of 9 Final 12/06/2014

3 1. Current Acute Cardiac Events: MINAP/PEDW Activity Rationale Entries into the MINAP database by individual hospitals each year did not seem to reflect expected activity. Previous reports for past 2 years have shown no improvements to data quality, consistency or even whether the audit data was being used. Information requested from the Patient Episodes Database for Wales (PEDW) was used to examine cardiac events coded from each hospital and cross check this against the MINAP database and expected activity, to assess MINAP data capture, use, validity and credibility. PEDW data is generated from discharge codes, selected according to the patients discharge summary. There are primary, secondary and sometimes tertiary or more diagnoses. MINAP data is collected for any ASC event a patient may experience in hospital, regardless as to whether this event was the cause of the admission. If the event is recoded and therefore coded anywhere on the discharge summary, it should be included in the MINAP database. Method Data was downloaded from the Cardiac Network level access to the MINAP dataset for South Wales, and the equivalent time period of data requested from PEDW. NHS numbers were requested alongside the Acute Coronary Syndrome (ACS) entries on both datasets to allow accurate links to be made. Caldicott guardians were approached in all South Wales Local Health Boards to obtain the necessary authorisation for these to be accessed. The data was examined to reduce duplicates as many entries had patients with several diagnostic codes (e.g. NSTEMI and unstable angina). Codes for nonemergency diagnoses were removed if not considered to be an acute event. The data therefore included all patients suffering from an acute cardiac event regardless of admission ward or initial admission diagnosis. A baseline overview of this data was then examined, with a direct simple comparison of numbers per hospital coded on PEDW with acute cardiac events against those entered onto the MINAP database. PEDW Codes used were: I20.0 Unstable Angina I21 All Acute Myocardial Infarctions I22 All subsequent Myocardial Infarctions I24.9 Acute Ischaemic Heart Disease SWCN South Wales MINAP Data Capture Report Page 3 of 9 Final 12/06/2014

4 3. Results Numbers entered onto the MINAP database have changed markedly between and This is unlikely to be a reflection on patient populations/acute cardiac events and would suggest inaccuracy, and/or failure to enter the true number of patients onto the MINAP database. 800 Numbers entered onto MINAP by year UHW RGw Morr WGH PCH NH Llan BGH GGH POW PPH RGl NPT Sing Fig 1: Number of patients entered onto the MINAP database per hospital comparing and With most STEMI patients now being transferred directly to an interventional centre, there would be an expected reduction in numbers entered onto the MINAP database in the DGHs and the equivalent increase in numbers entered into the interventional centre s database (Morriston and University Hospital of Wales (UHW)). This does not appear to be reflected in the expected activity for each hospital relative to each other and catchment areas. This prompted the further more formal look at expected activity per hospital compared to that recorded on MINAP. SWCN South Wales MINAP Data Capture Report Page 4 of 9 Final 12/06/2014

5 No on MINAP No on PEDW Fig 2: Comparison of number of patients coded with Acute Cardiac Event on PEDW database, compared with the number entered onto the MINAP database per hospital This was then illustrated graphically to see the percentage of patients included per hospital for ease of comparison Fig 3: Percentage of patients ts entered onto the MINAP database compared to number of events according to the PEDW database discharged with an Acute Cardiac Event SWCN South Wales MINAP Data Capture Report Page 5 of 9 Final 12/06/2014

6 Investment in resources to capture and enter data onto the MINAP database was linked to the best performing hospitals for data entry. For example, WGH has approximately 7 hours of dedicated clinical time allocated to MINAP data collection and a further 5 hours a week dedicated to MINAP data entry/administration. Bronglais have had no data entry onto the MINAP database since December Morriston hospital, in this time period, was only entering STEMI patients onto the MINAP database. 4. Discussion Coding The consistency of PEDW coding has been questioned and needs to be taken into consideration when looking at these results, not only for those patients eligible for entry onto the MINAP dataset, but also for those eligible to be entered onto the National Heart Failure Audit (Khand et al. 2005). Hospital coding systems still utilise codes that reflect the old definition of MI, such as transmural infarction and no codes exist for the newer definitions (Joint European Society of Cardiology/American College of Cardiology Committee (2000)). Hospital discharge letters usually use the new definitions of NSTEMI and STEMI that subsequently have to be transposed to fit the old definitions by the coding teams. A comprehensive, standardised explanation of definitions for coders would be valuable. Service Improvement MINAP data collection is undertaken in hospitals in various ways with a large disparity in investment, both in people, time and finances. These appear to be directly linked to the number of events recorded. Where time/people/funds are allocated to dedicated time for cardiac audit, more events are recorded. This does not always reflect advantageously to that hospital, especially in DGH s where outcomes for those who are not suitable for intervention will be worse (such patients are often not transferred because of co-morbidities). Those who have not passed through a Cardiac Care Unit (CCU) may not be recorded as well as those who have had an acute cardiac event as an inpatient, but transfer to a CCU has not been possible or appropriate (such as ITU patients, some orthopaedic patients). All hospitals should record all acute cardiac events regardless of admission ward or status. Without such data, service improvement issues cannot be addressed and quality standards such as seen by a cardiologist will be falsely represented. Adequate investment in cardiac audit, proportional to activity, is vital to enable this. Complete and reliable data capture MINAP data collection is time consuming. The output from this national audit is invaluable for service improvement. Although it is a National audit, the data can be easily downloaded and examined locally. If regularly scrutinised, trends can be seen in local issues and addressed, but this is only possible if the data captured is complete and reliable. Meaningful benchmarking across Health Boards and nationally will only be possible if the data captured is complete. There has been significant progress in cardiac care in Wales particularly with the introduction of the 24/7 primary PCI services in South Wales. Without accurate reflection of this in publicly accessible reports, the true extent of the improvements will not be evident and work cannot be undertaken to replicate improvements in other aspects of care for cardiac patients. A single repository for data relating to acute cardiac events and intervention would SWCN South Wales MINAP Data Capture Report Page 6 of 9 Final 12/06/2014

7 provide an invaluable resource for service improvement, that can be used both locally and nationally, but this needs to be clinically interpreted, reliable and accurate. Regular local clinical and audit meetings to examine and take forward service improvements demonstrated by MINAP data examination are needed. 5. Examples of using MINAP data for local service improvement One clear example of using MINAP data for service improvement can be seen when looking at door/call-to-needle times (D/CTN) when thrombolysis was first line treatment for STEMI. One hospital had initial poor CTN times at 23%. By arranging multidisciplinary educational meetings 6 weekly, examining all STEMI admissions (with paramedics, A&E, CCU, Cardiologist) times were improved to 67%. Many patients were missing an admission glucose which again was flagged up by scrutinising MINAP data. By liaising with the biochemistry department and providing robust, clear data outlining the problem, a cardiac admission profile was created to enable this to be carried out routinely on admission, raising this from approx 40% to 88%. Several audits for medical students have been equipped from data provided by MINAP. CCUs no longer need to collect as much data for individual audits when these can be collected as part of MINAP. Smaller audits for this patient group can be run alongside MINAP as there is scope to use user definable fields to run sub-audits over smaller timescales. The vast data collected enables a central mine of information regarding acute cardiac admissions, which can be interrogated to improve local outcomes as well as equip a National reliable dataset for overarching service improvement and research. The current application notes are contained in Appendix 3 to show the data collected, highlighting its potential for local examination. 6. National and local MINAP Reports do not reflect current care The current standard reports that can be easily generated from MINAP for local use do not reflect the current trends in acute cardiac care, particularly for DGHs. These still include reperfusion times, which are not as applicable to the DGH as there were before the advent of 24/7 ppci. Improvements to this have been requested to the National Institute of Cardiac Research (NICOR) who co-ordinate and manage the MINAP database nationally. By making these more locally usable, this will make MINAP a more effective resource. Annual Public reports are generated and widely disseminated. There is a newly formed patient participation group to reflect what data the public would like to see from these reports. Hopefully a clinical perspective can run alongside this. The South Wales Cardiac Network will continue to liaise with NICOR to improve this. SWCN South Wales MINAP Data Capture Report Page 7 of 9 Final 12/06/2014

8 7. Conclusions & Recommendations - Wales MINAP is the major national clinical audit of heart attack and should reflect current activity accurately. It also has tremendous potential to support service improvement, both nationally and locally, but the data collected needs to be complete and robust. To improve the data collected across Wales the following recommendations are made: 1. Every hospital should have dedicated clinical time allocated and funded to enable complete data collection of ALL acute cardiac events in hospital. This would necessitate approximately 5-7 hours of clinical time per 200 acute cardiac events for data collection hours a week of clinical audit time for data entry. 2. There should be regular clinical meetings to examine MINAP data locally and regionally to underpin local service improvement. 3. A uniform approach to data collection should be used across South Wales to ensure complete data capture, by utilising troponin lists and coding lists. 4. A Network overview to link with NICOR should be maintained to enable Wales to influence developments with the MINAP Steering Committee, such as improved and more suitable reporting, to reflect changes in practice. 5. A comprehensive, standardised explanation of new definitions of Myocardial infarction (i.e. STEMI, NSTEMI) for coders would be valuable, equating these to the old definitions currently used. Ideally, new codes that reflect the new definitions should be generated. 6. The South Wales Cardiac Network continues tom liaise with NICOR to improve the standard reports currently generated from MINAP. 8. Other considerations - National Updating coding Integration of national cardiac databases MINAP is only one of many national cardiac audits. Integration of these both nationally and locally could enable more productive outcomes and ease data collection. As there are many inter-hospital transfers, particularly for NSTEMI patients, this pathway should be reflected more effectively. Better integration of databases such as BCIS and MINAP; MINAP and the cardiac rehabilitation audits would streamline data collection and minimise double/triple data collection / entry for the same patients. Streamlining local data and sharing data across the patient pathway The South Wales Cardiac Network and Morriston Hospital are currently working to look at reducing the need to input data potentially in 3 hospitals for the same patient. For example, Patient X could be admitted to Bronglais Hospital with a confirmed NSTEMI, transferred to Morriston Hospital for their interventional procedure, the transferred to Glangwilli General Hospital prior to discharge home. This would currently necessitate a full MINAP entry from the 3 hospital concerned with this Patient X s care, with an additional entry onto the BCIS database for the cardiac intervention. Currently hospitals can only access their own MINAP data entries. This means that until a discharge letter is received, the interventions undertaken for patients are unknown. From the DGH perspective, if a patient admitted from them is taken to an interventional centre (approx 70-80% of most ACS DGH admissions) they will not be able to trace the entire patient pathway of care through MINAP, making audit trails difficult. With the success of the inpatient e-referral system, much of the data needed to populate both the e-referral and the MINAP entry are replicated. There is tremendous potential, with NICOR s support, to streamline data capture. SWCN South Wales MINAP Data Capture Report Page 8 of 9 Final 12/06/2014

9 9. References Joint European Society of Cardiology/American College of Cardiology (2000) Myocardial Infarction redefined a consensus document of the Joint European Society of Cardiology/American College of Cardiology for the Redefinition of Myocardial Infarction. European Heart Journal 21: Khand AU, Shaw M, Gemmel I and Cleland JG (2005) Do discharge codes underestimate hospitalisation due to heart failure? Validation study of hospital discharge coding for heart failure. European Journal of Heart Failure 7(5): Associated Documents Myocardial Infarction National Audit Project (MINAP): Overview for Hywel Dda 2011(attachment1) Myocardial Infarction National Audit project (MINAP): Overview for Hywel Dda 2012 update (attachment2) MINAP Public Report MINAP Public report MINAP Public Report lives+ Improving Acute Coronary Syndromes NHS Wales National Clinical Audit and Outcomes Review Plan 2012/13 Acknowledgement to Marc Thomas for his invaluable IT support SWCN South Wales MINAP Data Capture Report Page 9 of 9 Final 12/06/2014