Changes in English medication safety indicators throughout the COVID-19 pandemic: a federated analysis of 57 million patients’ primary care records in situ using OpenSAFELY

  1. Louis Fisher
  2. Lisa E. M. Hopcroft
  3. Sarah Rodgers
  4. James Barrett
  5. Kerry Oliver
  6. Anthony J. Avery
  7. Dai Evans
  8. Helen Curtis
  9. Richard Croker
  10. Orla Macdonald
  11. Jessica Morley
  12. Amir Mehrkar
  13. Seb Bacon
  14. Simon Davy
  15. Iain Dillingham
  16. David Evans
  17. George Hickman
  18. Peter Inglesby
  19. Caroline E. Morton
  20. Becky Smith
  21. Tom Ward
  22. William Hulme
  23. Amelia Green
  24. Jon Massey
  25. Alex J. Walker
  26. Chris Bates
  27. Jonathan Cockburn
  28. John Parry
  29. Frank Hester
  30. Sam Harper
  31. Shaun O’Hanlon
  32. Alex Eavis
  33. Richard Jarvis
  34. Dima Avramov
  35. Paul Griffiths
  36. Aaron Fowles
  37. Nasreen Parkes
  38. Ben Goldacre
  39. Brian MacKenna

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Abstract

Objective

To describe the impact of the COVID-19 pandemic on safe prescribing, using the PINCER prescribing indicators; to implement complex prescribing indicators at national scale using GP data.

Design

Population based cohort study, with the approval of NHS England using the OpenSAFELY platform.

Setting

Electronic health record data from 56.8 million NHS patients’ general practice records.

Participants

All NHS patients registered at a GP practice using TPP or EMIS computer systems and recorded as at risk of at least one potentially hazardous PINCER indicator between September 2019 and September 2021.

Main outcome measure

Monthly trends and between-practice variation for compliance with 13 PINCER measures between September 2019 and September 2021.

Results

The indicators were successfully implemented across GP data in OpenSAFELY. Hazardous prescribing remained largely unchanged during the COVID-19 pandemic, with only small reductions in achievement of the PINCER indicators. There were transient delays in blood test monitoring for some medications, particularly ACE inhibitors. All indicators exhibited substantial recovery by September 2021. We identified 1,813,058 patients at risk of at least one hazardous prescribing event.

Conclusion

Good performance was maintained during the COVID-19 pandemic across a diverse range of widely evaluated measures of safe prescribing.

Summary box

WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Primary care services were substantially disrupted by the COVID-19 pandemic.

  • Disruption to safe prescribing during the pandemic has not previously been evaluated.

  • PINCER is a nationally adopted programme of activities that aims to identify and correct hazardous prescribing in GP practices, by conducting manual audit on subgroups of practices.

WHAT THIS STUDY ADDS

  • For the first time, we were able to successfully generate data on PINCER indicators for almost the whole population of England, in a single analysis.

  • Our study is the most comprehensive assessment of medication safety during the COVID-19 pandemic in England, covering 95% of the population using well-validated measures.

  • Good performance was maintained across many PINCER indicators throughout the pandemic.

  • Delays in delivering some medication-related blood test monitoring were evident though considerable recovery was made by the end of the study period.

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  1. ScreenIT

    SciScore for 10.1101/2022.05.05.22273234: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Software and Reproducibility: Data management and analysis was performed using the OpenSAFELY software libraries and Python, both implemented using Python 3.8.
    Python
    suggested: (IPython, RRID:SCR_001658)
    A federated analysis involves carrying out patient-level analysis in multiple secure datasets, then later combining them: codelists and code for data management and data analysis were specified once using the OpenSAFELY tools; then transmitted securely to the OpenSAFELY-TPP platform within TPP’s secure environment, and separately to the OpenSAFELY-EMIS platform within EMIS’s secure environment, where they were each executed separately against local patient data; summary results were then reviewed for disclosiveness, released, and combined for the final outputs.
    EMIS’s
    suggested: None
    Decile charts were drawn using Seaborn and matplotlib.
    matplotlib
    suggested: (MatPlotLib, RRID:SCR_008624)

    Results from OddPub: Thank you for sharing your code and data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: This study has a range of strengths, some unprecedented. The scale and completeness of the data in the OpenSAFELY platform is greater than that through any other route for accessing GP data: other approaches either offer substantially fewer active current patients, in a data download onto researchers’ local machine (such as Clinical Practice Research Datalink); or only contain a small derived subset of information in the GP record (such as the GPES dataset extracted and disseminated by NHS Digital). Previous audits for compliance with PINCER or similar measures and indicators in primary care rely on manual audit within a practice, or analyses on data downloaded from a group of practices. By contrast OpenSAFELY executes analyses in a secure environment inside the EHR provider data centre, across the full set of all structured data in the GP record including all tests, prescriptions, diagnostic codes and referrals. In addition, although the underlying GP data is stored in two very different settings (TPP and EMIS) analyses written once in OpenSAFELY then execute in each setting identically, with the outputs aggregated afterwards, in a process known as “federated analytics”. Overall this represents a unique, national platform able to capture the patient journey for 57 million people in England whilst prioritising patient privacy. A second strength is the transparency and reproducibility of the analysis: as with all OpenSAFELY analyses, the complete set...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • No funding statement was detected.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  2. Version published to 10.1101/2022.05.05.22273234v1 on medRxiv