To enhance the care of frail patients, we have worked in close collaboration with the NHS to develop an innovative data dashboard, now accessible to all GP practices across the Lothian region.
The pilot project
Led by Dr Stephen Carty, nine practices in North-East Edinburgh aimed to improve the care of frail patients through the better use of data.
The project first had to address the reliable recording of frailty within patient notes. This can be challenging since frailty is the result of many symptoms and indicators, including: muscle loss/weakness; slow walking speed; fatigue; falls; incontinence; visual impairment; susceptibility to medication side-effects; and so on. Therefore, the project team developed training for GPs around the identification and clinical assessment of frailty according to the Rockwood Clinical Frailty Scale, which supports the diagnosis of mild, moderate, or severe frailty.
This training improved practitioner attention on, and understanding of, frailty – including the recording of the level of frailty within medical notes. Importantly, this vital step established a more data-informed approach to GP decision-making.
DataLoch’s contribution
At DataLoch, we collaborated with NHS Lothian Analytical Services to transfer GP requirements into a new frailty dashboard which provides monthly data at an individual practice and cluster level. It extracts GP data on frailty coding, recording of falls, as well as polypharmacy reviews (assessments of whether all medications prescribed to a patient are still necessary and safe).
Our initial design allowed the possibility for potential later improvements in light of further GP feedback, such as linking further datasets, and data about prescriptions and secondary care activity (e.g. falls with fractures, Emergency Department visits, etc).
Initial impact
The improved recording of frailty by GPs is an important first step in enhancing patient care. From June 2020 to June 2021, the number of patients coded as frail increased four-fold from 250 to 1,042 across the nine participating practices.
In combination with the frailty dashboard, this information allows GPs to proactively undertake polypharmacy reviews for these patients. Those who are more frail are likely to be prescribed several medications by different healthcare professionals to treat various conditions. Conducting polypharmacy reviews ensures that all prescriptions are still appropriate and working as they should for the individual patient.
Follow-up efforts and successes
The NHS Lothian Analytical Services team has since integrated the frailty dashboard into practice and is developing it further to ensure the dashboard supports any future quality improvement work within NHS Lothian. Using a simplified data-collection template, more GP clusters in the Lothian region are recording relevant patients as frail to allow appropriate follow-ups, such as polypharmacy reviews.
A related polypharmacy project that focussed on improving the frailty dashboard for the Edinburgh region saw 452 polypharmacy reviews carried out. Of these, 88 patients had a reduced anticholinergic burden after review, with another 62 patients having their dose of a single medicine with high anticholinergic burden reduced. (Anticholinergic medications are commonly used to treat a number of conditions, but have increased risks of side-effects if taken in significant quantities over time: see this NHS advisory notice for more detail.)
Improved support for GPs and their patients has already been demonstrated by the original project. Building on this will further enhance patient care as the frailty dashboard is more widely adopted and improved.
Case Studies
