Supporting health services research activity in the School of Health and Population Sciences at the University of Birmingham

This Data Sharing Agreement permits the retention and processing of the data provided under previous iterations of this Agreement for the purpose of completing the projects described below. The projects are expected to be completed by 30 April 2022 and after this time, the University of Birmingham must destroy the data and confirm destruction to NHS Digital.

The following describes the projects for which the data may be used. The descriptions are as provided in the original application to NHS Digital in 2018.

Project (1) To deliver a programme of applied health services research under the Collaboration for Leadership in Applied Health Research and Care programme (CLAHRC). This is an NIHR-funded programme in which the leading academic health care institutions in the UK work with the NHS and other providers of health and social care, in a programme of multiple themed research streams (the themes which require data from NHS Digital are "Maternity and Child Health", and "Research Methods"). In the case of the West Midlands CLAHRC, this involves answering research questions about patient flows through secondary care systems and the resulting outcomes in the West Midlands population. To do this, the University of Birmingham ("the University") needs contextual data on the English acute hospital population to make valid comparisons, using metrics such as length of stay, in-hospital mortality rates and readmission applied to various groups of patients, determined by epidemiology, demography or service use derived from HES data. To achieve this, the University need to look at longitudinal trends in hospital use in the population. Pragmatically, the University decided that, owing to data quality and completeness, 2007/8 would be used as the first year of observation, so data from that point on is required to complete this work.

Much of the work undertaken is traditional academic research, principally cross-sectional observational studies resulting in peer reviewed publications. However, the University will also be undertaking 'action research' and service evaluation in response to changes in service configuration. This activity will generate outputs whose main aim is to communicate assessments of service quality safety and cost-effectiveness to stakeholders, such as monograph reports and other forms of 'grey' literature. There is a deliberate degree of permeability in the University’s NIHR work programmes between research and service evaluation in accordance with the wishes of the commissioner and the guiding philosophy of CLAHRC. Examples of research questions are given in the Processing Activities section below.

Project (2) The University of Birmingham is leading an NIHR-funded project, the High Level Specialist Led Acute Care project to determine the impact of different models of consultant working at weekends on the excess mortality in acute hospitals that occurs in patients admitted during these times. This project started in 2014 with a proposed conclusion date of 31st January 2019. Owing to delays in obtaining the data required to complete the study, the researchers were granted an extension of one year by the funders. The Government’s seven day services initiative remains an important policy development and senior stakeholders in the NHS, the Department of Health and the Academy of Royal Colleges have expressed the view that it is imperative that this work be delivered. It will include an analysis of trends in hospital mortality from 2007-2008 onwards and will examine the association between a measure of specialist intensity captured in approximately 120 acute trusts in England, and in-hospital mortality in financial year 2013/14 to provide a baseline analysis. The University of Birmingham will go on to repeat the analysis until the end of the project to measure how this association changes over time as the Seven Day Services implementation extends throughout the service. None of these above activities are commercial. None involve for-profit work, commercialisation of research outputs or the development of intellectual property.

Record level data will not be shared with any third party and only used by the University of Birmingham. No commercial organisation is involved in any of this work.

GDPR Legal Basis:

Article 6(1)(e): processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller;

Article 9(2)(j): processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject.

No new data will be supplied under this Agreement. This Agreement permits the retention and reuse of data previously supplied under an earlier version of this Agreement for the purpose of completing the projects described above. Once complete (expected by 30 April 2022), the University of Birmingham must destroy the data and confirm destruction to NHS Digital.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).

The University of Birmingham will not link the data provided by NHS Digital to anything other than aggregated data, and only where this does not increase the risk of re-identification.

HES APC data was originally supplied (2007/07 to 2014/15) without a 30-day mortality flag. The additional data supplied included this flag. It was supplied as a single field which could be linked back to the earlier years of HES data, greatly assisting with mortality analysis.

For (1 - CLAHRC) above:

• Use the HES Inpatient, Outpatient and A&E data to derive directly standardised rates of admissions in various diagnostic groups defined by HRGs, main diagnostic profiles or surgical procedures. This will be done in a SQL server database using T-SQL. Aggregate data will then be presented in tabular form and as graphs and charts either as background and context setting in academic papers or as the substantive output where the objective is simply to present descriptive data.

• Use the HES admitted patient care and A&E data to construct statistical models to test specific hypotheses about the association between changes to service configuration in uses (see next section for specific examples of studies). Processing will consist of building analysis data sets using T-SQL from raw HES data in our SQL server warehouse, in flat file format, and then performing statistical analysis (typically generalised linear modelling, logistic regression and in the case of less common outcomes, Poisson regression using STATA and R).

• Use the HES admitted patient care and A&E data to construct statistical models to test specific hypotheses about the association between environmental, spatial and demographic characteristics of specific populations and localities and service use and outcome (see next section for specific examples of studies). Processing will consist of building analysis data sets using T-SQL from raw HES data in our SQL server warehouse, in flat file format, and then performing statistical analysis (typically generalised linear modelling, logistic regression and in the case of less common outcomes, Poisson regression using STATA and R. Some use of spatial analysis involving analysis sets produced as above, will be performed using ArcGIS geographical information systems software and R.

• For clarity, no other organisations which are involved in the CLAHRC are permitted to access or process the data from NHS Digital, other than where it is aggregated (with small numbers suppressed in line with the HES Analysis Guide).

For (2 - HiSLAC) above:

• A multi-level model of hospital mortality and its association with a range of variables captured in the HES Inpatient and A&E data sets and a measure of specialist intensity captured by a point prevalence survey in a sample of approximately 120 hospitals. For context, the University of Birmingham will also be building a more general model of mortality based on the supplied HES data. This will require historical data going back to financial year 2007/08. analysis sets will be captured from HES data stored in an SQL data warehouse and then used to build logistic regression models of mortality in which co-variates include demographic, clinical (diagnoses, co-morbidities), service (provider as random effect), temporal (before during or after reforms) and staffing as determined by the point prevalence data described above. Analysis sets will be captured from HES data using T-SQL and modelling will be undertaken using STATA.

• Produce counts of emergency admissions by day of week for all non-specialist acute Trusts, and, in some cases sites within Trusts, to provide denominators for a calculation of specialist consultant hours worked per 10 emergency admissions for a number of time periods across the life of the study.

For (1 - CLAHRC) above:

An evaluation of how three natural experiments arising from three changes in service configuration change affect demand for Emergency Department (ED) attendance namely an ED closure, an ED relocation and the opening of a Minor Injury Unit. This builds on existing work carried out in the Department which has been published in peer-reviewed scientific literature by the applicant. (Rudge GM, Mohammed MA, Fillingham SC, Girling A, Sidhu K, Stevens AJ (2013) The Combined Influence of Distance and Neighbourhood Deprivation on Emergency Department Attendance in a Large English Population: A Retrospective Database Study. PLoS ONE 8(7): e67943. https://doi.org/10.1371/journal.pone.0067943)

Owing to the pressure of work mainly on the HiSLAC project below this has not yet been completed.

A report on bariatric surgery uptake in the Region compared to the rest of England. Specifically modelling uptake and assessing the differential association between estimates population obesity, socio-economic status, proximity to provider and demographic factors. Owing to the delays in receiving HES data, a smaller study was undertaken using data provided by service providers in two health economies (Bhanderi, Shivam, et al. "Influence of social deprivation on provision of bariatric surgery: 10-year comparative ecological study between two UK specialist centres." BMJ open 7.10 (2017): e015453). This study was used as a proof of concept but one of the study recommendations was that there was a need to complete a study to explore inequalities in service provision nationally. This was also noted by peer reviewers of the paper. Thus far there has not been time and resource in the work programme to undertake this analysis.

A study of patient pathways for paediatric allergy services, including a systematic review, and assessment of current use of and demand for allergy services and a health economic assessment of different models of service delivery. This will include assessment of demand, temporal trends and current patterns of service contact using HES. This will include of design of a West Midlands service pathway. This work was delivered and a paper has been written for submission to a peer reviewed journal. However, feedback from reviewers stated that there was a need to provide extra context and provide an all England analysis to show the trends which have been observed in the West Midlands in an appropriate national context. This was planned to be done before April 2020.

A longitudinal observational study into outcomes in child and maternal health. The study has published a paper on neonatal admissions (Jones, Eleanor, et al. "Hospitalisation after birth of infants: cross sectional analysis of potentially avoidable admissions across England using hospital episode statistics." BMC paediatrics 18.1 (2018): 390) A study of maternal outcomes after giving birth to develop a risk prediction model is ongoing. Analysis has been completed and a paper is being prepared for peer reviewed publication. Due to staff absence, publication was delayed until the second half of 2020.

For (2 - HiSLAC) above: Owing to delays in obtaining the necessary data, the study was granted a one year non-funded extension by the NIHR to complete this very important study. Thus far eight papers have been published by this study (including 3 protocols):

• Aldridge, Cassie, et al. Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. The Lancet 388.10040 (2016): 178-186

• Bion, Julian, et al. Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays. BMJ open 7.12 (2017): e018747.

• Sun, Jianxia, et al. Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust. BMJ Qual Saf 28.3 (2019): 223-230.

• Chen, Yen-Fu, et al. The magnitude and mechanisms of the weekend effect in hospital admissions: a protocol for a mixed methods review incorporating a systematic review and framework synthesis. Systematic Reviews 5.1 (2016): 84.

• Chen, Yen-Fu, et al. Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis. BMJ open 9.6 (2019): e025764

• Tarrant, Carolyn, et al. The weekend effect in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings. BMJ open 7.4 (2017): e016755.

• Sutton, Elizabeth, et al. Quality and safety of in-hospital care for acute medical patients at weekends: a qualitative study. BMC health services research 18.1 (2018): 1015.

The study is still to publish the final three planned papers, one reporting the results of the case note review, another reporting the results of a risk adjustment model over a decade of observation using national data, and an econometric analysis. All of these require longitudinal trend analysis of all cause hospital mortality over the entire period of the study. The first of these three papers has been completed and has recently been submitted for consideration to the New England Journal of Medicine. The remaining two were expected to be in production until mid-2020

The final report to the funder was in the process of being written and was expected be completed by 31st January 2020 critically examining the implementation of high-intensity specialist-care. The combination of objective and experiential data this project will deliver is a powerful method for engendering change. The decision-making processes and change management activities for each Trust can be streamlined by using the reference and guidance material from this project, saving money and effort. The subsequent outcomes from implemented changes, both within the project in Phase 3, and inspired by the results of the project, will benefit a substantial number of patients.

For (1) CLAHRC above

The CLAHRC is funded by the NIHR, and the importance and benefit of undertaking this work was described to NIHR as follows:

** Service Theme: Maternity and child health

Proposed outputs from the research and the impacts anticipated (including the intended audience, how the impacts will be achieved and the likely timeframe):

The University of Birmingham intends to publish its findings in peer reviewed papers in internationally respected journals over years 3-5. The work will be presented at local, national and international conferences: the first being done in such a way as to encourage collaboration and networking. Uptake of the findings will be promoted through the AHSN [Academic Health Science Network] and other communities of practice and through the national network of specialist children's hospitals of which BCH [Birmingham Children’s Hospital] is a member.

Proposed implementation of applied health research into clinical practice across the health community that will be pursued within the proposed Theme using the matched funding, including an overview of how these relate to the overall strategy:

The IOS [Implementation and Organisational Studies] theme is embedded in the maternal and child health theme as follows: one of the four IOS Research Fellows will be part of the theme, working alongside the theme Research Fellows, Leadership & Diffusion Fellows and Patient Leaders. The IOS affiliated Research Fellow will carry out applied research in absorptive capacity, leadership and use of patient experience for service development within one or more of the studies. This will provide situated education on implementation science methodology and implementation issues as the need arises. The theme will draw on behavioural science expertise through an additional Research Fellow within IOS, who is an expert in such matters. Finally, the University of Birmingham will draw upon management consultancy expertise from Warwick Business School and Health Services Management Centre (Birmingham) e.g. to engineer a more integrated service along lean methodology or to develop distributed leadership for innovation

Description of proposals for activities to facilitate the implementation of research findings across the health community, including the rationale and an outline of the process and methodology by which this approach to implementation will be evaluated:

The rationale is to improve care to women and children by both supporting changes in practice identified from evidence and evaluating service change as robustly as possible. Identification of topic areas is a dialogue between CLAHRC researchers and service leads. Similar methodologies to those used in CLAHRC pilot will be used. For example, the Birthplace findings around safety of place of birth were co-written in a language clinical staff understood: changes in the configuration of services will take longer but have been facilitated by this initiative. The Trusts identified that membrane sweeping to reduce labour induction (NICE recommendation) was not being done as recommended. Training for clinical staff was co-designed and evaluated using a step-wedge design. The introduction of an induction of labour suite was supported by CLAHRC researchers, together with evaluation of the current move to enable women to go home during the early phase of induction of labour. Both have fed back evaluations of service innovations locally and disseminated findings at national conferences and workshops (innovations include advice and guidance referrals, location of care, barriers to discharge, hospital delivery of health promotion advice). Some of the work and future programmes impact on mental health and the University of Birmingham will therefore collaborate with the Centre for Public Mental Health and Applied Healthcare Research described under the next theme.

** Support and Cross-cutting Theme: Research methods

Proposed outputs from the research and the impacts anticipated (including the intended audience, how the impacts will be achieved and the likely timeframe):

The outputs will be grant applications and papers but equally importantly learning from this theme will be incorporated in the leadership courses for which both the Health Services Management Centre and Warwick Business School conduct on a large scale. An example of a key audience that can be reached through these courses is boards of NHS hospitals including non-executive directors who must assimilate quality related data. The University of Birmingham’s PPI representative machinery will form another highly relevant audience as will clinicians and managers that can be reached through the AHSN. The University of Birmingham also wishes to erode the epistemic wall that sometimes separates qualitative and quantitative researchers and will do so through the integrated model for service development and evaluation.

For (2) HiSLAC above:

The research is funded by the NIHR, and the importance and benefit of undertaking this was described as follows:

This research is important because of the large number of patients who stand to benefit and because the research literature indicates the need for a large-scale study to provide secure evidence about the best way to improve care out of hours.

Patients admitted to hospital out-of-hours are exposed to greater risk of error and adverse events because they experience multiple transitions in the location of care (for example, from the Emergency Department to the Acute Medical Unit to general acute wards, or to the Intensive Care Unit (Fig 3 in the HiSLAC Protocol), each transition involving discontinuities and gaps in communication. In the Royal College of Physicians’ specialist survey, 28% reported that they considered continuity of care to be poor in their own hospital [RCP London 2012 (2)]. The impact of poor process control is amplified at weekends because of reduced specialist input and lack of supporting resources, particularly in ordinary acute wards. The putative week-end effect can thus be plausibly explained by suboptimal specialist staffing of hospitals out-of-hours and during the continuum of care after acute admission.

Acutely ill patients represent a major challenge for health services in terms of volume, risk, safety, costs, and impact on elective care pathways. They also cross traditional disease-specific boundaries of specialist practice as many have multiple co-morbid diseases. As stated above, they experience multiple transitions and discontinuities in care. The acutely ill patient pathway is presented conceptually in Fig 3 with approximate numbers of patients and outcomes.

Emergency admissions are estimated to cost the NHS around £11bn per year [Blunt 2010]. In 2008-9 there were 5m emergency admissions to hospitals in England, a rise of 11.8% since 2004/5, and representing 35% of all hospital admissions [Blunt 2010]. This has increased to 5.2M emergency admissions for 2010 and 2011 [Hospital Episode Statistics 2011-2012]. Given the additional (unquantified) numbers of elective hospital admissions who become acutely ill during their hospital stay and require urgent or enhanced levels of care (such as admission to intensive care units), the acutely ill patient population is the single largest group of patients in NHS hospitals. The overall mortality rate at hospital discharge or 30 days is 0.7% for elective hospital admissions but a recent report from the Information Centre for Health and Social Care, reported that the 30 day mortality rate following non-elective (urgent and emergency) admission was approximately 3.7% in the period 1 April 2011 to 31 March 2012. Of these, 75.7% of these deaths occurred in hospital and the remainder after discharge [Information Centre 2013].for emergency admissions is reported to range from 3.6% [HES data 2011] to 5% [Blunt 2010]. Mortality risk is much higher for specific conditions such as myocardial infarction (12.5% mortality for hospitalised patients with acute MI) [Smolina BMJ 2012], stroke (around 20%) [McKinney 2011], fractured proximal femur (10%) [Wu 2011], and septic shock (30-40%) [Levy 2010]. These patients should not be additionally burdened by avoidable morbidity and mortality associated with admission to hospital out-of-hours.

The deficiencies in structure and care processes described above are those over which specialists can exert the greatest effect – diagnosis, critical thinking, organisation of care, and access to timely investigation and treatment. The study by Baines et al (2013) that greatest avoidable harm came from diagnostic errors adds weight to the principle of specialist-led care. It is notable that acute care interventions which have been specifically designed to substitute for specialist involvement such as critical care outreach [McGaughey 2007] and ‘hospital at night’ [Hospital at Night 2010] have not impacted strongly on patient outcomes. The ‘weekend effect’ may be diminished when the disease process has a well-defined care pathway likely to include 7-day specialist input [Byun 2012; Kazley 2010; Kevin 2010; Myers 2009, Smolina 2012, Al-Lawati 2012, Jneid 2008, McKinney 2011] (Appendix 1). The Royal College of Physicians (RCP) evaluation of specialist input into acute medical admissions [Lambourne 2012] found that amongst the 61% of responding Trusts, case mix-adjusted mortality rates were lower in hospitals with specialists dedicated to the on-call work, working in blocks of several days, and offering two formal patient reviews a day. A single centre study has shown that improving structures and processes by integrating the medical assessment unit with the emergency department to permit higher intensity specialist-led care is associated with a sustained and significant reduction in overall hospital standardised mortality ratios [Boyle 2012]. In summary, the majority of studies show that weekend admission to hospital is associated with an increased case mix-adjusted mortality risk and more errors in care. The impact may be even more adverse for patients perceived initially as low-risk who subsequently deteriorate, either from misdiagnosis or systemic failure to track physiology and trigger a prompt response. The feature which distinguishes hospitals at nights and weekends from weekdays is the reduction in intensity of specialist input.

** Plans for disseminating the findings of this research:

The main research outputs will be presented through the collaborating NHS, professional and public organisations to their respective constituencies and networks through regular reports, peer-reviewed scientific publications and presentations at scientific meetings. Information on the link between process quality and outcomes will be translated into generalisable learning and sustained change in practice through the competency-based training programmes for acute care medical specialities. An example of this approach is the international training programme for intensive care medicine (www.CoBaTrICE.org)the development of which was led by the chief investigator (JB)in a highly successful Leonardo programme funded project.

The impact of the research outputs (below) will be of value to health service policy makers and funders, patients and the public, the professions, and to quality improvement and human factors scientists. The findings will be of interest internationally as well as in the UK. The University of Birmingham has ensured that the key constituencies are represented in the project team, including PPI reps, the clinical communities and professional organisations, the Department of Health and Medical Directorate, health services and sociology researchers, and groups focussed on promoting professional leadership (Faculty of Medical Leadership & Management).

The combination of objective and experiential data is a powerful method for engendering change. The expectation is to engender shared understanding between clinicians and managers of the barriers to and facilitators of major service reconfiguration through the triangulation of quantitative and qualitative data on process and outcome.

Generalisable experiential learning from the adopting hospitals lends itself to a peer-support model of diffusion and sustainability [Woolhouse 2012]. While not the immediate focus of this application, in contingent Phase 3 the Academy of Medical Royal Colleges may take the opportunity to develop a collaborative support network through the professional lead organisations and with the additional guidance of the Advisory Board, so that HiSLAC-Adopting hospitals will act as Promoters for others in their immediate proximity through the development of partnerships.

To enhance dissemination and impact, the evidence synthesis published by the Health Foundation on challenges in quality improvement research [Dixon-Woods 2012] will be taken into account. Substantial project time will be invested in stakeholder engagement and in developing consensus on the correct metrics for measuring the impact of HiSLAC. There will be a minimisation of ‘top-down’ approaches to project management, capitalising on existing networks of clinicians with experience in front-line acute care and building on that community; and ethnographic observations will be used to promote reflective learning and to identify and minimise unintended consequences.

** Expected Output of Research/Impact:

The main research outputs will include:

• Information on current provision of specialist-led care throughout NHS acute hospitals in England, the extent of national variation, the use of physician assistants, and plans for change.

• National standards and definitions of quality of specialist-led care, and measurement metrics.

• Development of a generic framework for acutely ill patient pathways

• Novel data on the relationship between specialist-led care and specific patient outcomes, for example on CPR rates or length of stay.

• A better understanding of the interplay between weekend and weekday admission and the intensity of specialist-led care.

• Insights into the mechanisms for the link between weekend admission and suboptimal outcomes.

• Evidence for improvement in patient outcomes with the introduction of higher-intensity specialist-led care during national roll-out in Phase 3.

• An economic model to determine whether the impact of the intervention justifies or even fully offsets the workforce costs.

• A more detailed and nuanced understanding from the ethnographic study of the relationship between contextual factors and innovation uptake.

If the theory that increasing the amount of care provided by specialists at the weekend will improve patient outcomes to a level in-line with those for weekday admissions is correct, developing a solid evidence base and implementation guidance material will significantly assist hospitals in making the business case for, and implementing, high-intensity specialist-care. The combination of objective and experiential data this project will deliver is a powerful method for engendering change. The decision-making processes and change management activities for each Trust can be streamlined by using the reference and guidance material from this project, saving money and effort. The subsequent outcomes from implemented changes, both within the project in Phase 3, and inspired by the results of the project, will benefit a substantial number of patients.

The University of Birmingham anticipates building additional research alliances as the project unfolds, with particular emphasis on the development of care pathway mapping tools, and educational interventions to promote reflective learning. The PPI representatives will be key players in these developments.

For CLAHRC (above) Child and Maternal Health theme. The University has published a study showing that there has been a significant growth in neonatal admissions between 2007/8 and 2014/15 (Jones, E, Taylor, R, Rudge, G, MacArthur, C, Jyothish, D, Simkiss, D & Cummins, C 2018, 'Hospitalisation after birth of infants: cross sectional analysis of potentially avoidable admissions across England using hospital episode statistics', BMC Pediatrics, vol. 18, 390. https://doi.org/10.1186/s12887-018-1360-z) however nearly 80% of the increase consists of potentially avoidable conditions. This has promoted a high level discussion about admission avoidance in this patient group amongst commissioners and providers of care.

A study which has been completed, but not yet published, of a national eight-year cohort of emergency readmission following birth events. This will provide important national evidence about the socio-economic gradient in maternal post-natal complications. This is expected to lead to an assessment of inequalities in service provision amongst providers and policy makers.

CLAHRC (above) Support and Cross-cutting Theme: The University has produced a comprehensive report on the emergency care needs of the population of Worcestershire which has been used internally by both commissioners locally and NHS England to inform the development of acute services in the area.

For (2 - HiSLAC) above:

The University has published a paper in The Lancet which is the first study in a national health system to quantify specialist involvement in the care of emergency admissions at weekends and weekdays, and to analyse this with weekend and weekday admission mortality rates (Aldridge, C, Bion, J, et. Al, 2016, ‘Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study’, Lancet, vol. 388, 178-186). The University has found no correlation across different Trusts between the mortality risk for emergency admissions at weekends and the relative levels of specialist involvement on Sundays and Wednesdays. This provides the context for phase 2 of the study which will evaluate the whole-system secular change during the implementation of 7 day services from 2014 to 2018.

For the NIHCE Evidence Assessment Centre (a purpose on the original application, which ended in 2017).

The commissioners of this project, felt that HES analysis could be used instead of specialist registries in a number of initiatives to monitor diffusion of novel technologies, and felt this to be an effective low-cost alternative. The University of Birmingham was able to demonstrate in case studies in areas such as extra corporal carbon dioxide removal in intensive care and in the use of ultra-radical surgery in treating advanced ovarian cancer, that this was not the case, and that coding lag meant that OPCS coding lacked both the sensitivity and specificity for this task. In the case of extracorporeal carbon dioxide removal made this clear in the peer reviewed literature. See A United Kingdom Register study of in-hospital outcomes of patients receiving extracorporeal carbon dioxide removal (ECCO2R). Cummins, Carole; Bentley, Andrew; McAuley, Danny; McNamee, James; Patrick, Hannah; Barrett, Nicholas, Journal of the Intensive Care Society, 19.10.2017. As a result, a strategic decision was made to commission specialist registries instead. This will support the implementation of new technologies to guideline more effectively than relying on routing data surveillance.