starting point – what do we know? (nationally)
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The ‘wicked’ problem of alcohol - insights from the data
Newcastle upon TyneNorth TynesideNorthumberland
Lynda SeeryPublic Health Specialist
Starting point – what do we know?(Nationally)
Needs Assessment• National Indicator set –
NWPHO• Hospital admissions for
Alcohol-related harm: Understanding the dataset
Service Review• Models of Care for Alcohol
Misusers (MoCAM)• Effectiveness review• QuADS, DANOS• HubCAPP,
www.alcohollearningcentre.org.uk
• National Alcohol Treatment Monitoring System
• The Alcohol Needs Assessment Research Project (ANARP)
Top priority – do we know what is happening locally?
a) Local Needs Assessment?b) Multiple strategies across the patch (all at various stages) - Prevention - Early intervention and treatment - Enforcement and control - Partnershipc) Local Service Review?
How are we measuring progress? - Are we using effective measures? - Short, medium and long term impact – where does the evidence lie? - Alcohol-related hospital admissions
Analysis of hospital admissions
• complex indicator• requested dataset 1/7/08 – 31/3/09• all admissions with any of the 3 codes
identified within the spell of care (not necessarily primary diagnosis)
– F10 mental & behavioural disorders due to alcohol
– K70 alcoholic liver disease– T51 intoxication
Individual patient record• postcode level• up to 7 identified codes accepted (but some patients have up to
14 attached codes)
• 1.00 - wholly attributable to alcohol (main focus)
• 1411 admissions (707) patients• between 141 – 202 admissions each qtr• Costs = £2.5m• 943/1411 readmissions (66.8%)• 239/707 patients readmitted (33.8%)• 153 males & 86 females• 468/707 patients admitted once (66.2%)• age breakdown
NewcastleProportion of population in each age group. Newcastle population as a whole and Newcastle admissions 1/4/07 - 31/3/09
<15
<15
15-24
15-24
25-34
25-34
35-44
35-44
45-54 45-54
55-64
55-6465-74
65-7475-8475-8485+ 85+
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Newcastle population Newcastle admissions
North TynesideProportion of population in each age group. North Tyneside population as a whole and North Tyneside admissions
<15
<15
15-24
15-24
25-34
25-34
35-44
35-44
45-5445-54
55-64
55-64
65-74
65-7475-8475-8485+ 85+
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
North Tyneside population North Tyneside admissions
NorthumberlandProportion of population in each age group. Northumberland population as a whole and Newcastle admission 1/4/07 - 31/3/09
<15
<15
15-24
15-24
25-34
25-34
35-44
35-44
45-54
45-54
55-6455-64
65-74
65-7475-84
75-8485+ 85+
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Northumberland population Northumberland admissions
Segmentation - understanding the patient layers
The ‘patient layers’ fall into the following categories:
• Patients admitted to hospital for 1 day or less (no overnight stay)
• Patients admitted only once
• Patients admitted once for intoxication / patients re-admitted for intoxication
• Patients with multiple re-admissions for alcohol-related harm (harmful and dependent drinkers)
• Patients with chaotic lifestyles accessing hospital services across the 3 PCT/Local Authority areas
• Patients with severe ongoing/end stage illness
Patients admitted once only for 1 day or 8 hours or less
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Newcastle PCT North Tyneside PCT Northumberland CT
Admissions by top 10 alcohol related conditions - North of Tyne 1/4/07 - 31/3/09(patient admitted once for 1 day or less)
Stomach or Duodenum Disorders
Ingestion Poisoning or Allergies
Epilepsy
Syncope or Collapse
Gastrointestinal Bleed
Sprains, Strains, or Minor Open Wounds
Chronic Pancreatic Disease
Chest Pain
General Abdominal Disorders
Poisoning, Toxic, Environmental
Example of intoxication record
Codes listedT40 (primary
diagnosis)poisoning by drugs, medicaments and biological substances
X620 intentional self harmT51 intoxication/toxic effects of
substances non medicinal as to source
S099 injuries to headW19 fallF101 harmful use
‘Frequent users’ or re-admissions to hospital
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Newcastle PCT North Tyneside PCT Northumberland CT
Re-admissions by top 10 alcohol related conditions - North of Tyne 1/4/07 - 31/3/09(239 frequent users accounting for 943 admissions )
Stomach or Duodenum Disorders
Gastrointestinal Bleed
Chronic Obstructive PulmonaryDisease or Bronchitis
General Abdominal - DiagnosticProcedures
Pancreatic Disorders
Drainage of Ascites
Poisoning, Toxic, Environmental
General Abdominal Disorders
Chronic Liver Disorders
Chronic Pancreatic Disease
Example of re-admission recordCodes listedK703 (primary
diagnosis)Diseases of the liver
F102 Dependence syndromeI10X Hypertensive diseasesJ459 Chronic lower respiratory diseasesR18X Symptoms and signs involving the
digestive system and abdomenZ720 Persons encountering health services in
other circumstancesZ867 Persons with potential health hazards
related to family and personal history and certain conditions influencing health status
Phase 1• Initial target groups
– patients re-admitted for intoxication
- Patients with multiple re-admissions for alcohol-related harm (harmful and dependent drinkers)
Significant 20
– Patients with chaotic lifestyles accessing hospital services across the 3 PCT/Local Authority areas
North of Tyne 12
Male FemaleNewcastle 44 49North Tyneside 22 22Northumberland 17 25
Mapping the services and initiatives• Tier system
– MoCAM (Models of Care for Alcohol Misusers) – Prevention/Early Intervention – implementing
IBAs (across primary care & multi agency)– Treatment – Community services & emerging
alcohol workforce• Virtual team working across primary care, mental health,
acute services, social care, voluntary sector, – Enforcement – management of environment &
night time economy • requires more cohesiveness and connectivity with
community services– Rehabilitation – very small numbers– Care Pathway
Improvement methodology• Multi agency care plans
– (individuals may have a single dominant condition i.e. alcohol but may be known to different agencies)
• Community Open clinics (walk in, self refer, referred into from any other service) – Professionals available at clinics, clinical & mental health staff,
social care, housing, benefits
• Assertive Outreach • STR workers (Support, time and recovery workers)
• Wider use of IBAs (multi agency)• Emerging workforce (i.e. new roles, liaison, co-ordination,
systems approach to service delivery)
• Flexible approach, learning (i.e. PDSA cycles)
Repeated use of the PDSA cycleChanges that result in improvement
Hunches
Theories
Ideas
Sequential building of knowledge under a wide range of conditions
Very small scale testFollow up tests
Wide scale tests of change
Implementation of Change
Spread
A P
S D
PDSA stage
• PDSA cycle 1 – hospital admission analysis– learning has allowed us to ask more questions
• PDSA cycle 2– We have filtered through the records and have taken a layer to
examine more closely so we are now beginning the process of assessing the actual records of individuals with multiple admissions to determine those patients who may benefit from more joined up multi agency services
Future work – focused/targeted work• development of a whole system approach to alcohol related
harm - multi stranded work
• establish a North of Tyne Care Pathway
• community services established and adapted to meet the need - targeted work (demographics already known)
• working up from granular level up into communities has the highest potential for positive impact
• multi agency training – raise awareness, develop skills and competencies
• systematic, cohesive approach across locality and wider geographic area
How hard can it be?
•Pace •Purpose •Passion
Questions?
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