Impact of matching error on linked mortality outcome in a data linkage of secondary mental health data with Hospital Episode Statistics (HES) and mortality records in South East London: a cross-sectional study

Defining severity of personality disorder using electronic health records: short report

Severity of personality disorder is an important determinant of future health. However, this key prognostic variable is not captured in routine clinical practice. Using a large clinical data-set, we explored the predictive validity of items from the Health of Nation Outcome Scales (HoNOS) as potential indicators of personality disorder severity. For 6912 patients with a personality disorder diagnosis, we examined associations between HoNOS items relating to core personality disorder symptoms (self-harm, difficulty in interpersonal relationships, performance of occupational and social roles, and agitation and aggression) and future health service use. Compared with those with no self-harm problem, the total healthcare cost was 2.74 times higher (95% CI 1.66-4.52; P < 0.001) for individuals with severe to very severe self-harm problems. Other HoNOS items did not demonstrate clear patterns of association with service costs. Self-harm may be a robust indicator of the severity of personality disorder, but further replication work is required.

Linking electronic mental healthcare and benefits records in South London: design, procedure and descriptive outcomes

OBJECTIVES

To describe the process and outcomes of a data linkage between electronic secondary mental healthcare records from the South London and Maudsley (SLaM) NHS Foundation Trust with benefits records from the Department for Work and Pensions (DWP). We also describe the mental health and benefit profile of patients who were successfully linked.

DESIGN

A deterministic linkage of routine records from health and welfare government service providers within a secure environment.

SETTING AND PARTICIPANTS

Adults aged≥18 years who were referred to or accessed treatment at SLaM services between January 2007 and June 2019, including those who were treated as part of Improving Access to Psychological Therapies (IAPT) services between January 2008 and June 2019 (n=448 404). Benefits data from the DWP from January 2005 to June 2020.

OUTCOME MEASURES

The linkage rate and associated sociodemographic, diagnostic and treatment factors. Recorded primary psychiatric diagnosis based on International Classification of Diseases (ICD)-10 codes and type of benefit receipt.

RESULTS

A linkage rate of 92.3% was achieved. Women, younger patients and those from ethnic minority groups were less likely to be successfully linked. Patients who had subsequently died, had a recorded primary psychiatric diagnosis, had also engaged with IAPT and had a higher number of historical postcodes available were more likely to be linked. Overall, 83% of patients received benefits at some point between 2005 and 2020. Benefit receipt across the psychiatric diagnosis spectrum was high, over 80% across most ICD-10 codes.

CONCLUSIONS

This data linkage is the first of its kind in the UK demonstrating the use of routinely collected mental health and benefits data. Benefit receipt was high among patients accessing SLaM services and varied by psychiatric diagnosis. Future areas of research are discussed, including exploring the effectiveness of interventions for helping people into work and the impact of benefit reforms.

Data consistency in the English Hospital Episodes Statistics database

BACKGROUND

To gain maximum insight from large administrative healthcare datasets it is important to understand their data quality. Although a gold standard against which to assess criterion validity rarely exists for such datasets, internal consistency can be evaluated. We aimed to identify inconsistencies in the recording of mandatory International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) codes within the Hospital Episodes Statistics dataset in England.

METHODS

Three exemplar medical conditions where recording is mandatory once diagnosed were chosen: autism, type II diabetes mellitus and Parkinson's disease dementia. We identified the first occurrence of the condition ICD-10 code for a patient during the period April 2013 to March 2021 and in subsequent hospital spells. We designed and trained random forest classifiers to identify variables strongly associated with recording inconsistencies.

RESULTS

For autism, diabetes and Parkinson's disease dementia respectively, 43.7%, 8.6% and 31.2% of subsequent spells had inconsistencies. Coding inconsistencies were highly correlated with non-coding of an underlying condition, a change in hospital trust and greater time between the spell with the first coded diagnosis and the subsequent spell. For patients with diabetes or Parkinson's disease dementia, the code recording for spells without an overnight stay were found to have a higher rate of inconsistencies.

CONCLUSIONS

Data inconsistencies are relatively common for the three conditions considered. Where these mandatory diagnoses are not recorded in administrative datasets, and where clinical decisions are made based on such data, there is potential for this to impact patient care.

Validation of the days alive and out of hospital outcome measure after emergency laparotomy: a retrospective cohort study

BACKGROUND

Days alive and out of hospital (DAOH) is a composite, patient-centred outcome measure describing a patient's postoperative recovery, encompassing hospitalisation and mortality. DAOH is the number of days not in hospital over a defined postoperative period; patients who die have DAOH of zero. The Standardising Endpoints in Perioperative Medicine (StEP) group recommended DAOH as a perioperative outcome. However, DAOH has never been validated in patients undergoing emergency laparotomy. Here, we validate DAOH after emergency laparotomy and establish the optimal duration of observation.

METHODS

Prospectively collected data of patients having emergency laparotomy in England (December 1, 2013-November 30, 2017) were linked to national hospital admission and mortality records for the year after surgery. We evaluated construct validity by assessing DAOH variation with known perioperative risk factors and predictive validity for 1 yr mortality using a multivariate Bayesian mixed-effects logistic regression. The optimal postoperative DAOH period (30 or 90 days) was judged on distributional and pragmatic properties.

RESULTS

We analysed 78 921 records. The median 30-day DAOH (DAOH₃₀) was 16 (inter-quartile range [IQR], 0-22) days and the median DAOH₉₀ was 75 (46-82) days. DAOH was shorter in the presence of known perioperative risk factors. For patients surviving the first 30 postoperative days, shorter DAOH₃₀ was associated with higher 1-yr mortality (odds ratio=0.94; 95% credible interval, 0.94-0.94).

CONCLUSION

DAOH is a valid, patient-centred outcome after emergency laparotomy. We recommend its use in clinical trials, quality assurance, and quality improvement, measured at 30 days as mortality heavily skews DAOH measured at 90 days and beyond.

Sociodemographic characteristics associated with parenthood amongst patients with a psychotic diagnosis: a cross-sectional study using patient clinical records

PURPOSE

Estimates of parenthood in individuals with psychosis range from 27 to 63%. This number has likely increased due to the introduction of newer anti-psychotics and shorter hospital stays. The problems of psychosis can affect patients' capacity to offer the consistent, responsive care required for healthy child development. The following research questions were assessed: (1) what proportion of these patients have their children correctly recorded in their clinical notes, (2) what proportion of patients in secondary care with a psychotic diagnosis have children, and (3) what sociodemographic characteristics are associated with parenthood in this population.

METHODS

This study used CRIS (Clinical Record Interactive Search) to search for patients with a diagnosis of non-affective or affective psychosis (F20-29, F31.2 or F31.5) within a UK NHS Trust. A binomial regression model was fitted to identify the variables associated with parenthood.

RESULTS

Fewer than half of the parents in the sample had their children recorded in the correct field in their clinical notes. Of 5173 patients with psychosis, 2006 (38.8%) were parents. Characteristics associated with parenthood included being female, older age, higher socioeconomic status, renting or owning, having ever been married, being unemployed, not being White (British) and not having a diagnosis of schizophrenia.

CONCLUSION

Over one-third of patients with psychosis were parents, and the study indicates that not all NHS Trusts are recording dependants accurately. Many variables were strongly associated with parenthood and these findings may help target interventions for this population.

Effect of trazodone on cognitive decline in people with dementia: Cohort study using UK routinely collected data

OBJECTIVES

Evidence in mouse models has found that the antidepressant trazodone may be protective against neurodegeneration. We therefore aimed to compare cognitive decline of people with dementia taking trazodone with those taking other antidepressants.

METHODS

Three identical naturalistic cohort studies using UK clinical registers. We included all people with dementia assessed during 2008-16 who were recorded taking trazodone, citalopram or mirtazapine for at least 6 weeks. Linear mixed models examined age, time and sex-adjusted Mini-mental state examination (MMSE) change in people with all-cause dementia taking trazodone compared with those taking citalopram and mirtazapine. In secondary analyses, we examined those with non-vascular dementia; mild dementia; and adjusted results for neuropsychiatric symptoms. We combined results from the three study sites using random-effects meta-analysis.

RESULTS

We included 2,199 people with dementia, including 406 taking trazodone, with mean 2.2 years follow-up. There was no difference in adjusted cognitive decline in people with all-cause or non-vascular dementia taking trazodone, citalopram or mirtazapine in any of the three study sites. When data from the three sites were combined in meta-analysis, we found greater mean MMSE decline in people with all-cause dementia taking trazodone compared to those taking citalopram (0·26 points per successive MMSE measurement, 95% CI 0·03-0·49; p = 0·03). Results in sensitivity analyses were consistent with primary analyses.

CONCLUSIONS

There was no evidence of cognitive benefit from trazodone compared to other antidepressants in people with dementia in three naturalistic cohort studies. Despite preclinical evidence, trazodone should not be advocated for cognition in dementia.