Modelling the Frailty Patient Pathway

The University of Warwick and Shrewsbury and Telford Hospital Trust (SaTH) are undertaking a study as part of their drive to improve pathways for older people with complex needs, and wish to undertake modelling of hospital older patient pathways. The study is funded by the Warwick Collaborative Postgraduate Research Scholarship Scheme. The scheme funds a University of Warwick student to undertake research under the supervision of the University. Whilst the PhD student (formerly a Masters student at the University of Kent) is under sole supervision by the University of Warwick, SaTH originally instigated the work, are contributing to the nature of the work by providing advice and guidance on the aims of the research, and are supporting dissemination of the findings. The University of Warwick (i.e. the PhD student and supervisor) will have sole access to the record level data requested of/supplied by NHS Digital. SaTH will not have access to the data.

This research seeks to answer the following questions: what are the patient pathways followed by complex older patients and what are the associated effect on the health outcomes and resource utilisation. The main aim of this research is to determine the typology of older patient pathways and determine the association between these pathways and their health outcomes. This research aims to inform on the care trajectories of complex older patients in hospital to determine the variations that exist between their care trajectories, within groupings of older patients, the causes of these variations and the effect on outcomes and resource use. The University of Warwick contend that utilization of healthcare services can be grouped into a limited number of care trajectories. Knowledge of care trajectories and their components may be used to adjust treatment goals, enhance healthcare management, and improve efficiency and cost-effectiveness, resulting in higher value of care. Identifying care trajectories as well as parameters associated with trajectories (that is, their correlates) could have important clinical and administrative implications, such as treatment planning and allocation of resources. This information will be of value to efforts in establishing consistent processes that meet the needs of this patient population either by service redesign or by creating new services.

This research will contribute to existing literature on modelling and segmentation of patient pathways. However, this research is new in that it focuses on older patients and uses Hospital Episode Statistics data to capture actual flows and uncover hidden workflows. This research aims to utilise the Hospital Episode Statistics dataset to extract the patterns of care that represent the actual patient journeys of older people presenting with complex needs and uncover unknown workflows. Hospital Episode Statistics include data fields that define a patient’s previous and subsequent healthcare contacts. Therefore, it is possible to build the care trajectories of patients spanning from the main points of entry to inpatient acute care and finally discharge. Hospital Episode Statistics data from 2011/12-2016/17 is therefore requested on individuals aged 65 years and above at the start of the episode. The data years requested will allow for the analysis of the evolution of the care trajectories and trends in resource use.

NHS Digital will securely transfer the pseudonymised dataset consisting of the Outpatient, A&E and Admitted Patient Care records to the University of Warwick. The University will store data on a server at the University, which will be accessed at the University by the PhD student and supervisor only, as per the data sharing agreement. The datasets will be held on a password protected and encrypted drive at the University.

Linkage of the data provided by NHS Digital is not required, and is therefore not permitted under this agreement. There will be no requirement or attempt to re-identify individuals from the data. The data will not be made available to any third parties other than in the form of aggregated outputs with small numbers suppressed in line with the HES Analysis Guide.

The analysis undertaken by the project is monitoring the evolution of the utilisation of hospital services over time to develop comprehensive measures of long-term health trajectories and describe disparities in long-term health transitions and trajectories to examine individual or subgroup differences in health.

The data is minimised by age (i.e. those aged over 65 years of age), by the number of data fields required (41% for HES Admitted Patient Care, 61% for HES accident and emergency, and 48% for HES Outpatients), and by region (East and West Midlands of England only). Older patients with complex needs commonly present at hospital with non-specific symptoms/conditions. Therefore, the study requires wide ranging hospital episode data of individuals aged above 65 years and above not restricted to specific types of episodes.

The study requires only pseudonymised data. All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

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). NHS Digital draws to the attention of the University of Warwick that NHS Digital regards the University of Warwick as being responsible for the actions and omissions of the PhD student.

The expected outputs from this study is a methodology for longitudinal care pathway analysis using administrative data and a typology of older patient emergency care pathways. Outputs from the study are to be realised at the completion of the PhD thesis. All outputs will contain only data that is aggregated in lined with the HES analysis guide. The key audiences for this research are commissioning organisations, academics and the public. The dissemination strategy is as detailed below.

The typology of care pathways will reveal information about core treatment processes and can be used to support decision making in terms of demand profiling that can aid in care process redesign towards patient focused care and care co-ordination actions on the mix of resources required based on patient presentations. Therefore, the typology of care pathways will be disseminated through presentations will be made to various steering group meetings made up of NHS service providers within and across CLAHRC as well as to an International Scientific Dissemination group through NIHR CLARHC. NIHR CLAHRC is an initiative to create lasting and effective collaboration across health and social care organisations, universities and local authorities with the aim of improving services delivered to patients. Theme 5 - Implementation and Organisational Studies is aimed at providing insights into management and implementation of service change process. NIHR CLAHRC runs a news blog that has a membership of over 800 people comprising of academic and NHS service providers and is circulated widely via social media. Lastly, NIHR CLAHRC has a number of Patient and Public Involvement advisors who engage with community groups to raise awareness and disseminate knowledge about its research activities. This engagement also involves participating in public facing events such as the Birmingham University Research Think-tank Pop-up. In line with NIHR ‘make it clear’ campaign a lay summary of the research findings will be published on NIHR CLAHRC website and circulated widely through social media and NIHR CLAHRC Patient and Public Involvement Advisors.

The methodology will be disseminated to the NHS-R community. This is a community that promotes the use of Research in the NHS. The community runs a blog that reaches analyst and service providers in the NHS. Additionally, Academic research paper(s) will be published in high impact, peer-reviewed journals on the study methodology and the typology of emergency care pathways. The target peer review journals are the BMC Healthcare Service Research, Health Services Management Research, Health Care Management Science and Operations Research for Health Care; European Journal of Operations Research. Targeted conferences are Informs Healthcare 2019, YoungOR 2019 and HSRUK Conference.

Lastly, the full PhD thesis will be available for download from the University of Warwick’s open access Warwick Research Archive Portal; Warwick WRAP.

The aim of the research project arose is to improve services for older people with complex needs. Analysis of hospital care trajectories of complex older patients is not available elsewhere. The study will contribute to the novel use of administrative hospital data to understand the complexity of older patients in the context of general flow through the main portals of entry into the main ward areas and back to the community. Complex older patients are characterised as having heterogeneous needs and therefore have many configurations of healthcare utilisation within their episodes of care. However, disparities between episodes of care can be limited to local context and patient characteristics. Therefore, differences among episodes of care can be grouped into care trajectories made up of a series of contiguous healthcare services. Synthesis of care trajectories and their corresponding effect on outcomes of complex older patients and associated resource use will support service re-configurations and design by understanding this patient population needs that can be assessed by clustering care trajectories according to patient profiles and assessing disparities in hospital care consumption between the emerging groups.

Understanding the care trajectories of older people can help care providers configure services to improve the care of older people in and outside of the hospital. For clinicians, the identification of patient and disease characteristics associated with specific trajectories enables clinicians to identify and perhaps predict complex cases that may require special attention or a greater use of healthcare services. For administrators, identifying trajectories allows for more accurate budget planning and allocation of resources based on service utilization rates. Lastly, the care trajectories can be used as an evidence-based tool to identify patient and disease characteristics associated with greater use of healthcare resource, to plan and allocate resources based on service utilisation or isolate problem areas. The results and findings of this project will be disseminated widely via the methods described above, targeting practitioners, academic audiences, and patients/the general public.

Yielded Benefits is not a requirement for new applications.