Newcastle-upon-Tyne Hospitals NHS Foundation Trust

Integrating service, audit and research data to improve patient care


Summary

The rheumatology department at the Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust developed the Earth (Early arthritis) database to facilitate clinical management, audit and research activities. The value of Earth, and of having an embedded database manager in the growing department, in terms of reputation, income, and quality of service, has now been recognised by the Trust Directorate.
Enhanced capacity for clinical audit
The proportion of newly diagnosed RA patients achieving moderate or good EULAR responses during the first 2 months of treatment increased from 59% to 75% between 2013 to 2014 calendar years
 
Cost neutral
Earth is approximately cost-neutral but brings added value for audit, research and quality improvement
 
Download a printable pdf of the case study 

The Challenge

  • National policy demands meeting benchmarks for the management of rheumatic conditions and participation in complex national clinical audit. However, data management is becoming increasingly complex for busy medical departments active in research and audit, with no one size fits all approach available. Patients also need opportunities to engage with productive research, including clinical trials.
  • IT solutions to meet the above challenges, whilst limiting departmental spending, are therefore needed.

The Solution

  • The team developed a bespoke database called Earth (Early arthritis), which is hosted by the Trust and linked to a separate database on the university servers. Earth is managed by a dedicated database manager who is a member of the rheumatology department and therefore integrated with the clinical team.
  • Earth complies with data protection requirements, adheres to Caldicott guidelines, and for research samples ensures compliance with the Human Tissue Act (HTA). It also interfaces with the existing Trust eRecords system, enabling extraction of blood samples results.
  • Earth allows real-time input of detailed specialty-relevant data by staff, such as demographics, outcomes and medications; each member of clinical, clerical and research staff have an appropriate level of access.
  • The database has become an integral part of the department with widespread support at all levels within the department and the Trust. It is routinely used:
    • To monitor the established cohort of ~4,000 RA patients for audit (and research with appropriate consent), including full use within the early arthritis clinic (EAC) and the annual review clinics.
    • In the biologics clinic to facilitate audit and identify suitable patients for clinical trials, and the juvenile idiopathic arthritis service for audit.
    • For automatic letter generation to record all encounters in nurse-led clinics (including disease activity measures) are summarised in paper format suitable for primary care communication, without the need for dictation or typing.

Service Performance and Outcomes

  • Earth functions as an audit tool, capturing outcomes relevant to pathway management and patient care, with data queries able to be run on demand. Earth allows:
    • Easy clinic capacity and demand monitoring eg. major reconfiguration of the early arthritis service, or the evolving young adult service.
    • Audit of effectiveness eg. treatment response outcomes in the nurse-led DMARD escalation clinic service, or treat-to-target using DAS28/EULAR responses
    • Audit of patient safety parameters.
  • The department has been able to maximise recruitment of eligible volunteers for clinical trials, audits and registries, providing equitable access to clinical research studies; the site was amongst the top ten recruiters nationally during 2 quarters of 2015 for national clinical audit for early inflammatory arthritis, and a high recruiter to TACERA, APIPPRA, TRAFIC and the BSRBR-AS registry.
  • Publishing clinical research has been directly facilitated by Earth and a number of manuscripts have been published by the department since 2012.

Financial Performance and Outcomes

  • Earth does not capture cost or resource use data directly. However, the database could be used to help estimate service costs, such as the biologics clinic (including drug costs).
  • Academic funding streams provide substantial financial investment for the database manager’s salary over a 30-month period. The database manager and their position within the rheumatology department was critical to the success of Earth.
  • Software common to both the Trust and University has been used, meaning no significant additional costs have been incurred.
  • Comparing costs of the function of Earth with that if Earth did not exist show it to be cost-neutral day-to-day, but has added value and this does not include commercial study income that has been boosted by Earth.

Patient Focus and Satisfaction

  • Earth has been designed with quality service provision, clinical outcomes, and research with direct relevance to patients in mind.
  • During the development of Earth, clinicians, research staff and the directorate manager attended a meeting of the active local patient group, which is supported by NRAS, to exchange ideas for its development (including research aspects), and uniformly positive feedback was received.

Commissioning Implications


Newcastle’s database Earth is an example of best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:

 

  • Benchmarking in rheumatology – Earth has allowed Newcastle to be one of the most successful recruiters to the National Clinical Audit for rheumatoid and early inflammatory arthritis, which facilitates national comparisons on the benchmarks set out in the NICE QS33, set to reduce variation in clinical practice nationally
  • Create opportunities to participate in research – Earth facilitates translational research, and, as it develops, is now also facilitating clinical/observational research that stands to inform strategies for RA management in the future.  Each patient can be considered against the eligibility criteria for recruiting clinical studies

The Earth database is considered an emerging best practice model for the integration of data management for clinical practice, audit and research. It is fully embedded within the rheumatology department, allowing easy audit on demand, streamlined administration for nurse-led clinics and equitable access to clinical studies.


Service diagram