HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals
King's College London · Academic
Expired The latest version ended on 30 January 2023. The September 2026 register still lists the agreement, but its term has passed.
- Reference
- DARS-NIC-44383-L6C0X
- Latest version
- v5.4
- Term of latest version
- 31 January 2022 to 30 January 2023
- Start date
- 1 February 2017
- Data controller
- Sole Data Controller
- Commercial purposes
- No
- Sublicensing
- No
- Files released to date
- 5
Data controllers
Why the data was released
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within Hospital Episode Statistics linked to Civil Registration death data to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent attendance, different patterns of health service utilisation and health outcomes including death.
Aim 2: Explore costs of health service use by Alcohol Related Frequent Attenders (ARFAs).
The two aims are explored by two separate studies outlined below.
Study 1: Natural history of ARFAs- as of January 2021, apart from the follow up of mortality rates using mortality data for the 2011/12 ARFA cohort this study is now complete. This section outlines the full study.
From national Hospital Episodes Statistics (HES) linked to Civil Registration Deaths data (2011/12-2015/16) the researcher will select a cohort of ARFAs and look back at their service use through years 2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code), mode of admission, length of stay, readmissions, age, sex and geography. Through the use of logistic regression, the researcher will identify which of these characteristics are predictors of the outcome “being an ARFA in 2015/16”. The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders. Cause of death data will be analysed to understand whether ARFAs are dying from alcohol related causes or other: this is important to determine so that preventative interventions can be tailored accordingly.
The researcher will also select a cohort of ARFAs from 2011/12 and follow them forwards using HES through to 2015/16 to investigate health outcomes, including death, for ARFAs. A logistic regression model will test various predictors of mortality and poor health outcome (eg presence of alcoholic cirrhosis) for ARFAs and results will be compared to other non-alcohol frequent attenders and other alcohol related non-frequent attenders.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA MP. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency, likelihood (odds ratio) of becoming an ARFA and likelihood of death.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. In addition, the longer-term health outcomes for ARFAs and risk of death will also be used to populate the risk stratification model, which in turn will be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally, and estimates of lives potentially saved by ARFA services.
In order to carry out this study, pseudonymised HES APC from 2011/12 to 2015/16 is required linked to civil registration mortality data so that longitudinal analyses can take place to analyse admissions and long term outcomes of patients including deaths (although HES data includes deaths within hospital, alone it is insufficient to look at deaths for those with frequent alcohol admissions as many take place outside of hospital). Patients within the England HES data set will be categorised in to 4 groups, based on whether they have had an alcohol admission (an admission which includes a wholly attributable alcohol diagnosis code) during each HES year, and whether they have had 3 or more hospital admissions (frequent admissions) in each year. To minimise data a sample of each group will be taken and civil regmortality data requested for the patients in these samples, linked to the HES APC record:
100% of the national ARFA cohort from 2011/12 are included in the sample to ensure that comprehensive analysis of this diverse and complex group is undertaken. Control groups are sized based on a 3:1 ratio of controls to cases.
The mortality data is restricted to individuals found within the HES APC extract and included in each of the 4 samples shown in the table above. Mortality data from 2011/12 until 2015/16 is required in order to calculate death rates during the 5 year period following being diagnosed as an ARFA. Rates for ARFAs are compared to alcohol-related non-frequent attenders, non-alcohol related frequent attenders and non-alcohol non-frequent related attenders for the corresponding period of time.
Study 2: The cost burden associated with ARFAs, As of May 2020, this study is complete. The results of this study have been submitted for publication in a peer reviewed journal (May 2020).
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied bed days) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year.
Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
There are no alternative, less intrusive ways of achieving the purpose for these two studies
The lawful basis for the processing of this information under GDPR is (article 6 (1) (e)) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
South London and Maudsley NHS Foundation Trust (SLAM) are the sole organisation with decision making authority for these studies and the sole organisation that will process data. To clarify, SLAM is the sole Data Controller who also processes the data. The other organisations that form King's Health Partners (King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and King's College London) will be informed of the research findings but have no input into the study design and no control over how data will be processed or the purposes for which it will be used.
The lead researcher for the study is employed by King's College London, which is part of King's Health Partners (together with King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and South London and the Maudsley NHS Trust). As part of the King's College London employment contract, the lead researcher holds an honorary contract with SLAM and a King's Health Partners research passport to conduct research from any other of the NHS Trust sites within King's Health Partners. The lead researcher will be conducting the research from SLAM NHS Trust site where HES data is currently held. SLAM have the necessary IT infrastructure and ability to meet information governance requirements; processing is permitted at the SLAM site only.
Processing activities
NHS Digital reminds all organisations party to this agreement of the need to 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)
South London and the Maudsley (SLAM) are the sole organisation with decision making authority for this study and the sole organisation that will process data. The other organisations that form King's Health Partners (King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and King's College London) will be informed of the research findings but have no input into the study design and no control over how data will be processed or the purposes for which it will be used.
The lead researcher for the study is employed by King's College London, which is part of King's Health Partners (together with King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and South London and the Maudsley NHS Trust). As part of the King's College London employment contract, the lead researcher holds an honorary contract with SLAM and a King's Health Partners research passport to conduct research from any other of the NHS Trust sites within King's Health Partners. The lead researcher will be conducting the research from SLAM NHS Trust site where HES data is currently held. SLAM have the necessary IT infrastructure and ability to meet information governance requirements; processing is permitted at the SLAM site only.
In terms of the data processing pathway:
- The inpatient HES data, Civil registration Death data and bridging file is downloaded from NHS Digital and stored on South London and the Maudsley NHS Trusts Server. The HES and mortality data is held in a database (SQL server) and access is restricted to named individuals according to SLAM's security policy. Storage of the data will be on a storage area network and secured by active directory user group.
- Remote access to the database is permitted, but only through remote access via secure token (so processing is still
carried out on site), and with local printing and downloading disabled.
- Only staff who have signed a confidentiality agreement and have received IG training are permitted access.
- All access to individual files is recorded, and a sample audited to investigate the existence of any adverse incidents, and ensure that appropriate access has been maintained.
- The HES and mortality data is analysed using the STATA MP software tool. Once held, the applicant will view the data from NHS Digital within this software and select a specific cohort within the data for each of the two studies referred to under 'Objectives for processing'. Commonly a process will initially take place to define the particular cohort of interest in terms of e.g. individual diagnostic codes or procedure codes. The researcher will use routinely available filter definitions and a similar control group may be established.
- The applicant then analyses the data, before applying the relevant disclosure controls to any output. Software used will be STATA MP (a local version of the STATA MP Software Tool is being used and not cloud); typically this will involve analysis on several outcome measures, risk adjustment and the construction of
control groups.
- No record level data would be linked to this dataset, but it may be combined with publicly available demographic or geographic data, for example in relation to local Trust performance
- Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only with small numbers suppressed in line with the HES analysis guides.
Under this agreement the data will be transferred to a hosting infrastructure supplied by Microsoft Azure cloud. Once the migration is complete all servers on premises at SLaM will be decommissioned. The data will then be stored only in the Microsoft Azure Cloud and will be accessed via individual user accounts . This is line with SLaM moving its CDLS service away from SLaM servers on to Microsoft Azure cloud: the application to NHS Digital has been approved- NIC 292279-Z2S5T-v6.6
Once migration is complete, all on premise servers will be decommissioned.
Aside from Microsoft Azure cloud providing a hosting infrastructure, SLaM will continue to be the only organisation able to process the data and the use of MS Azure infrastructure is covered within SLaM as a storage and processing location once the transfer of the data has taken place.
SLaM will submit a further application to amend this Agreement to remove SLaM as a storage and processing location once the transfer of the data has taken place.
South London and Maudsley NHS Foundation Trust will not link the data disseminated by NHS Digital to any other data they may already hold.
The data controller must ensure that there are appropriate contracts and controls in place between the organisation and all persons accessing NHS Digital disseminated data. NHS Digital have the right to audit the controls in place under the data sharing agreement.
Expected output
The research findings of the proposed project will be shared within Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts) in order to directly inform the design and purpose of services for ARFAs. The analysis of HES/mortality data will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs e.g. average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as assertive outreach treatment both nationally and locally, informing commissioning of services.
This population risk stratification project is part of a wider project to optimise services for ARFAs at KHP (King's College Hospital, South London and Maudsley and Guys and St Thomas' Trusts), which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at Kings College London (KCL), one of whom leads the alcohol strategy for Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The alcohol strategy steering group includes lay members, service users and other researchers and clinicians working on alcohol-based projects across South London. The principal investigator (PI) reports project progress to the alcohol strategy steering group. The PI and main supervisor (Professor of alcohol and Addictions Psychiatry) are members of the NIHR Applied Research Collaboration South London (ARC South London) and this project forms part of the ARC's alcohol research theme's programme of work, led by the main supervisor. Implementation of evidence-based alcohol interventions is a key priority for all south London local authorities and STPs. The ARC work proactively with the NHS, local authorities charities and patients and the public to maximise and evaluate the impact of implementation of effective interventions both locally and nationally. The South London ARC are also working with NHS services and commissioners from across the UK to implement assertive outreach services. The main supervisor provides advice to government on alcohol and drug misuse strategy and was a member of the Models of Care working group which produced national frameworks for drug and alcohol services in England. The main supervisor is also a member of the WHO Expert Committee on Drug Dependence and Alcohol Problems, and Chair of the NICE guideline development group on management of harmful alcohol use and alcohol dependence.
Work already completed during this project has informed national alcohol strategy and shaped nation guidance "Tackling alcohol misuse in NHS hospitals" , Health Innovation Network, February 2018.
The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication. In addition, lay summaries such as newsletters and blogs (on behalf of the South London Collaboration for Leadership in Applied Health and Care will be produced. Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will also be targeted, initially with findings from the analysis using the HES data, and latterly from the analysis using both the HES and mortality data. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London Collaboration for Leadership in Applied Health Research and Care (NIHR ARC South London) website.
Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guide.
Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact and a BMJ award 2019 for best mental health project.
Other outputs include:
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial "Tackling alcohol misuse in NHS hospitals, Health Innovation Network, Feb 2018 https://www.drugsandalcohol.ie/29084/1/Alcohol_care_in_NHS_hospitals.pdf;
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This was included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which was implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
In 2019 the KHP alcohol team won the BMJ award https://www.slam.nhs.uk/media/news/alcohol-assertive-outreach-team-wins-bmj-award.
Work on the data to date has informed an RCT of assertive outreach treatment for frequent alcohol related hospital admissions, publication of results is due imminently.
Presentations/publications relating to the proposed study made by the applicant to date-
Blackwood R et al, 2020; Prevalence and patterns of hospital use for people with frequent alcohol related hospital admissions, compared to non-alcohol and non-frequent admissions: a cohort study using routine administrative hospital data. Addiction. https://doi.org/10.1111/add.15354
R Blackwood et al, Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trail. BMC Public Health, 2020; 20: 332.
Citations in the series Lancet Commission on Liver Disease in the UK, to inform national alcohol strategy.
Fincham-Campbell S, Kimergard A, Wolstenholme A, Blackwood R et al; A national survey of assertive outreach treatment services for people who frequently attend hospital due to alcohol related reasons in England. Alcohol and alcoholism, 2018 May 1;53(3):277-281
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017 (v2, 2018).
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr R Blackwood, Prof M Lynskey, Prof C Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
South London and Maudsley NHS Foundation Trust have two active patient and public involvement / service user representatives that attend the quarterly management meetings.
South London and Maudsley NHS Foundation Trust link in with the PPI theme of the CLAHRC
South London and Maudsley NHS Foundation Trust have run two large pan-south London PPI alcohol events and have held some smaller consultation meetings and focus groups to tie in with key development stages of our CLAHRC alcohol projects.
South London and Maudsley NHS Foundation Trust have a wider alcohol PPI forum of service user representatives, community organisations and interested members of the public and carers.
The 30 strong forum is South London and Maudsley NHS Foundation Trusts primary method of disseminating research results. Included in that are also London and national service user voice organisations.
Expected measurable benefits
Excess alcohol consumption is a growing public health problem, causing 5.3% of deaths worldwide in those aged under 60 years. In the UK, alcohol use is the fourth greatest risk factor for years lived with disability and is second only to tobacco as the leading preventable cause of ill health, costing the NHS £2.7 billion annually, with 78% on hospital based care.
Alcohol related hospital admissions have doubled in the last 8 years in England and reducing this burden is a key priority of government public health strategy. It is estimated that 1-2% of attendances to UK A&Es are made by ‘frequent attenders’. Studies show that ‘frequent attenders’ to A&E are also frequent users of other health and social care facilities. There has been a recent call for further research into the predictors of frequent use of healthcare services, supporting the notion that these subgroups are not adequately defined.
Alcohol related frequent attenders (ARFAs) are thought to account for 6.7% of frequent attenders. With no singularly defined way of recording and monitoring ARFA hospital admissions/attendances it is difficult to understand the true burden of ARFAs on the NHS. 21 hospitals in England run programmes for ARFAs , with no common method of identifying patients for treatment. By better understanding the characteristics of ARFAs, their patterns of usage of health services and mortality rates through this study, it is hoped it may become possible to identify preventative interventions to avoid further harms to their own health and prior to assimilating high costs to health services.
The outputs of these studies (as previously described in the outputs section) will directly benefit patient and the Trusts within the Kings Health Partners through the development of the risk stratification tool. This will ensure that ARFAs can receive the specialist treatment that they require, affording them direct health benefits in a setting that is more suited to their needs than in an A&E department, but will contribute to a reduction in hospital admissions with concomitant savings to the NHS. No studies so far have looked at the death rates for ARFAs. By including data on death rates in the risk stratification model and costings model, this will produce a more accurate estimate of the potential benefits of ARFA services than has previously been available. In addition, it is not known currently known whether there is a case or need for providing specialist end of life care for ARFAs, and by knowing the extent of mortality amongst the ARFA group, this will help assess need.
It is expected that mortality analysis will be complete and submitted for peer review by December 2021, meaning that risk stratification work can be finalised in the first part of 2022.
Through peer reviewed publication and presentations, the findings will benefit a national audience- see previous section on outputs to date.
Benefits reported so far
This project enabled the number and NHS use of ARFAs nationally to be quantified for the first time (54,369 ARFAs) people, occupying 1,402,600 bed days per year at an annual cost of ARFAs to the NHS of £848m. Furthermore the work was able to demonstrate that ARFA is a "chronic condition"- more than 10% of ARFAs are ARFAs for more than 5 years. ARFAs are higher cost per person than non-alcohol related frequent attenders. These findings have enabled the business case for specialist alcohol treatment for ARFAs (AOT) to be made. The implementation of AOT at £161m serves to save the NHS an estimated £590m per year compared to care as usual. In other words for every £1 spend, £3.66 is saved. Since the introduction of AOT for alcohol patients at Kings College Hospital, there has been a 25% reduction in alcohol admissions between 2015/16 and 2017/18 at King's. This work at KHP with its supporting evidence has led to the inclusion of AOT on PHE's menu of preventative interventions - a nationally published document recommending preventative strategies to commissioners and providers. There are now 37 dedicated ARFA AOT services across the UK.
Early findings of the project described have been presented and disseminated at a number of meetings, nationally and internationally, and through written publications (see outputs section). As a result there is now increased awareness of ARFAs and their needs amongst clinicians, commissioners, providers, politicians and the public across South London, nationally and internationally. Furthermore, the project work has provided evidence that has directly informed national alcohol policy (PHE's menu of preventative interventions) and will shape national policy on liver disease (Lancet Commission on liver disease).
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol.
Benefits of the alcohol project work to date have been recognised nationally and locally: the alcohol team recently received a CLAHRC award for impact and a BMJ award 2019 for best mental health project.
Datasets on the latest version
Legal basis for provision: Health and Social Care Act 2012 – s261(2)(b)(ii)
| Dataset | Type of data | Sensitivity | Frequency | Confidential data |
|---|---|---|---|---|
| Civil Registrations of Death - Secondary Care Cut | Anonymised - ICO Code Compliant | Sensitive | One-Off | Does not include the flow of confidential data |
| HES-ID to MPS-ID HES Admitted Patient Care | Anonymised - ICO Code Compliant | Non-Sensitive | One-Off | Does not include the flow of confidential data |
| HES:Civil Registration (Deaths) bridge | Anonymised - ICO Code Compliant | Non-Sensitive | One-Off | Does not include the flow of confidential data |
| Hospital Episode Statistics Admitted Patient Care (HES APC) | Anonymised - ICO Code Compliant | Non-Sensitive | One-Off | Does not include the flow of confidential data |
Files released
Files released counts only files released externally by DARS. Access granted in NHS England's own systems, such as its Secure Data Environment, is not included.
Patient opt-outs were not applied to any of the 5 files released under this agreement, across every version. About opt-outs
No files recorded as released under the latest version. 5 were released under earlier versions, shown in the version history.
Version history
The register lists each renewal of this agreement as a separate row. This site has 6 versions.
DARS-NIC-44383-L6C0X-v5.4 31 January 2022 to 30 January 2023
- Title
- HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals
- Commercial
- No
- Sublicensing
- No
- Datasets
- 4
- Files released
- 0
Datasets: Civil Registrations of Death - Secondary Care Cut; HES-ID to MPS-ID HES Admitted Patient Care; HES:Civil Registration (Deaths) bridge; Hospital Episode Statistics Admitted Patient Care (HES APC)
What changed from DARS-NIC-44383-L6C0X-v4.6
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2022-01-31 | |
| End date | 2023-01-30 |
Processing activities
[14 paragraphs unchanged]
Under this
Agreement,
agreement
the data will be transferred to a hosting infrastructure supplied by Microsoft
[53 words unchanged]
Azure cloud: the application to NHS Digital has been approved- NIC 292279-Z2S5T-v6.6
[5 paragraphs unchanged]
Unchanged: Objective for processing, Expected output, Expected measurable benefits, Benefits reported.
DARS-NIC-44383-L6C0X-v4.6 20 January 2021 to 19 January 2022
- Title
- HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals
- Commercial
- No
- Sublicensing
- No
- Datasets
- 4
- Files released
- 0
Datasets: Civil Registrations of Death - Secondary Care Cut; HES-ID to MPS-ID HES Admitted Patient Care; HES:Civil Registration (Deaths) bridge; Hospital Episode Statistics Admitted Patient Care (HES APC)
What changed from DARS-NIC-44383-L6C0X-v3.4
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2021-01-20 | |
| End date | 2022-01-19 |
Datasets: + HES-ID to MPS-ID HES Admitted Patient Care
Objective for processing
[4 paragraphs unchanged]
Study 1: Natural history of ARFAs- as of
May 2020,
January 2021,
apart from the follow up of mortality rates using mortality data for the 2011/12 ARFA cohort this study is now complete. This section outlines the full study.
[15 paragraphs unchanged]
Processing activities
[4 paragraphs unchanged]
- The inpatient HES data, Civil registration Death data and bridging file
[15 words unchanged]
Server. The HES and mortality data is held in a database (SQL
Server) within SLAMs infrastructure
server)
and access is restricted to named individuals according to SLAM's security policy.
[6 words unchanged]
on a storage area network and secured by active directory user group.
[9 paragraphs unchanged]
Under this Agreement, the data will be transferred to a hosting infrastructure supplied by Microsoft Azure cloud. Once the migration is complete all servers on premises at SLaM will be decommissioned. The data will then be stored only in the Microsoft Azure Cloud and will be accessed via individual user accounts . This is line with SLaM moving its CDLS service away from SLaM servers on to Microsoft Azure cloud: the application to NHS Digital has been approved- NIC 292279-Z2S5T-v6.6
Once migration is complete, all on premise servers will be decommissioned.
Aside from Microsoft Azure cloud providing a hosting infrastructure, SLaM will continue to be the only organisation able to process the data and the use of MS Azure infrastructure is covered within SLaM as a storage and processing location once the transfer of the data has taken place.
SLaM will submit a further application to amend this Agreement to remove SLaM as a storage and processing location once the transfer of the data has taken place.
[2 paragraphs unchanged]
Expected output
[1 paragraph unchanged]
This population risk stratification project is part of a wider project to optimise services for ARFAs at
KHP,
KHP (King's College Hospital, South London and Maudsley and Guys and St Thomas' Trusts),
which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the
[48 words unchanged]
and clinicians working on alcohol-based projects across South London. The principal investigator
(PI)
reports project progress to the alcohol strategy steering group.
The PI and main supervisor (Professor of alcohol and Addictions Psychiatry) are members of the NIHR Applied Research Collaboration South London (ARC South London) and this project forms part of the ARC's alcohol research theme's programme of work, led by the main supervisor. Implementation of evidence-based alcohol interventions is a key priority for all south London local authorities and STPs. The ARC work proactively with the NHS, local authorities charities and patients and the public to maximise and evaluate the impact of implementation of effective interventions both locally and nationally. The South London ARC are also working with NHS services and commissioners from across the UK to implement assertive outreach services. The main supervisor provides advice to government on alcohol and drug misuse strategy and was a member of the Models of Care working group which produced national frameworks for drug and alcohol services in England. The main supervisor is also a member of the WHO Expert Committee on Drug Dependence and Alcohol Problems, and Chair of the NICE guideline development group on management of harmful alcohol use and alcohol dependence.
The principal investigator and Professor/alcohol strategy lead are also part of the ARFA clinical network for South London, which meets every 6 weeks. The group consists of practitioners and clinicians working with ARFAs so provides direct insight in to the day-to-day treatment and issues for this particular patient group. The principal investigator reports project progress to this group. Finally, the principal investigator's project progress is also monitored on a quarterly basis through King's College London.
Work already completed during this project has informed national alcohol strategy and shaped nation guidance "Tackling alcohol misuse in NHS hospitals" , Health Innovation Network, February 2018.
Project findings using HES data are, as at January 2019, being finalised but, due to the close working arrangements with clinicians described above, will inform service design from the outset.
The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for
publication during early 2019 (with findings including the mortality data to be reported in late 2019).
publication.
In addition, lay summaries such as newsletters and blogs (on behalf of the South London
Academic Health Science Network and
Collaboration for Leadership in Applied Health and Care will be
produced (late 2019).
produced.
Conference and seminar presentations to academic, policy, professional in the fields of
[74 words unchanged]
between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made
[6 words unchanged]
the South London Collaboration for Leadership in Applied Health Research and Care
(CLAHRC)
(NIHR ARC South London)
website.
[1 paragraph unchanged]
Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact and a BMJ award 2019 for best mental health project.
Other outputs include:
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial "Tackling alcohol misuse in NHS hospitals, Health Innovation Network, Feb 2018 https://www.drugsandalcohol.ie/29084/1/Alcohol_care_in_NHS_hospitals.pdf;
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This was included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which was implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
In 2019 the KHP alcohol team won the BMJ award https://www.slam.nhs.uk/media/news/alcohol-assertive-outreach-team-wins-bmj-award.
Work on the data to date has informed an RCT of assertive outreach treatment for frequent alcohol related hospital admissions, publication of results is due imminently.
Presentations/publications relating to the proposed study made by the applicant to date-
Blackwood R et al, 2020; Prevalence and patterns of hospital use for people with frequent alcohol related hospital admissions, compared to non-alcohol and non-frequent admissions: a cohort study using routine administrative hospital data. Addiction. https://doi.org/10.1111/add.15354
R Blackwood et al, Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trail. BMC Public Health, 2020; 20: 332.
Citations in the series Lancet Commission on Liver Disease in the UK, to inform national alcohol strategy.
Fincham-Campbell S, Kimergard A, Wolstenholme A, Blackwood R et al; A national survey of assertive outreach treatment services for people who frequently attend hospital due to alcohol related reasons in England. Alcohol and alcoholism, 2018 May 1;53(3):277-281
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017 (v2, 2018).
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr R Blackwood, Prof M Lynskey, Prof C Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
South London and Maudsley NHS Foundation Trust have two active patient and public involvement / service user representatives that attend the quarterly management meetings.
South London and Maudsley NHS Foundation Trust link in with the PPI theme of the CLAHRC
South London and Maudsley NHS Foundation Trust have run two large pan-south London PPI alcohol events and have held some smaller consultation meetings and focus groups to tie in with key development stages of our CLAHRC alcohol projects.
South London and Maudsley NHS Foundation Trust have a wider alcohol PPI forum of service user representatives, community organisations and interested members of the public and carers.
The 30 strong forum is South London and Maudsley NHS Foundation Trusts primary method of disseminating research results. Included in that are also London and national service user voice organisations.
Expected measurable benefits
[3 paragraphs unchanged]
These
The outputs of these
studies
(as previously described in the outputs section)
will
directly
benefit patient and the Trusts within the Kings Health Partners through the
[87 words unchanged]
of the potential benefits of ARFA services than has previously been available.
In addition, it is not known currently known whether there is a case or need for providing specialist end of life care for ARFAs, and by knowing the extent of mortality amongst the ARFA group, this will help assess need.
It is expected that mortality analysis will be complete and submitted for peer review by December 2021, meaning that risk stratification work can be finalised in the first part of 2022.
Through peer reviewed publication and presentations, the findings will benefit a national audience- see previous section on outputs to date.
Benefits reported
The project described forms one part of wider work going on at King's Health Partners (KHP) and the South London CLAHRC on alcohol. Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
This project enabled the number and NHS use of ARFAs nationally to be quantified for the first time (54,369 ARFAs) people, occupying 1,402,600 bed days per year at an annual cost of ARFAs to the NHS of £848m. Furthermore the work was able to demonstrate that ARFA is a "chronic condition"- more than 10% of ARFAs are ARFAs for more than 5 years. ARFAs are higher cost per person than non-alcohol related frequent attenders. These findings have enabled the business case for specialist alcohol treatment for ARFAs (AOT) to be made. The implementation of AOT at £161m serves to save the NHS an estimated £590m per year compared to care as usual. In other words for every £1 spend, £3.66 is saved. Since the introduction of AOT for alcohol patients at Kings College Hospital, there has been a 25% reduction in alcohol admissions between 2015/16 and 2017/18 at King's. This work at KHP with its supporting evidence has led to the inclusion of AOT on PHE's menu of preventative interventions - a nationally published document recommending preventative strategies to commissioners and providers. There are now 37 dedicated ARFA AOT services across the UK.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact on the basis of work so far including:
Early findings of the project described have been presented and disseminated at a number of meetings, nationally and internationally, and through written publications (see outputs section). As a result there is now increased awareness of ARFAs and their needs amongst clinicians, commissioners, providers, politicians and the public across South London, nationally and internationally. Furthermore, the project work has provided evidence that has directly informed national alcohol policy (PHE's menu of preventative interventions) and will shape national policy on liver disease (Lancet Commission on liver disease).
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial;
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol.
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
Benefits of the alcohol project work to date have been recognised nationally and locally: the alcohol team recently received a CLAHRC award for impact and a BMJ award 2019 for best mental health project.
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This has been included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which is being implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
In 2019 the alcohol team won the BMJ award https://www.slam.nhs.uk/media/news/alcohol-assertive-outreach-team-wins-bmj-award
The annual cost of alcohol-related harm to the NHS is £3.5 billion of which a third is due to alcohol-related hospital admissions. Increasing the number of AAOT has the potential to promote a significant change in alcohol treatment with huge potential savings in costs relating to frequent hospital admissions.
Work on the data to date has informed an RCT of assertive outreach treatment for frequent alcohol related hospital admissions, publication of results is due imminently.
Presentations/publications relating to the proposed study made by the applicant to date-
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017.
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr Ros Blackwood, Prof Michael Lynskey, Prof Colin Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
South London and Maudsley NHS Foundation Trust have two active patient and public involvement / service user representatives that attend the quarterly management meetings.
South London and Maudsley NHS Foundation Trust link in with the PPI theme of the CLAHRC
South London and Maudsley NHS Foundation Trust have run two large pan-south London PPI alcohol events and have held some smaller consultation meetings and focus groups to tie in with key development stages of our CLAHRC alcohol projects.
South London and Maudsley NHS Foundation Trust have a wider alcohol PPI forum of service user representatives, community organisations and interested members of the public and carers.
The 30 strong forum is South London and Maudsley NHS Foundation Trusts primary method of disseminating research results. Included in that are also London and national service user voice organisations.
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within Hospital Episode Statistics linked to Civil Registration death data to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent attendance, different patterns of health service utilisation and health outcomes including death.
Aim 2: Explore costs of health service use by Alcohol Related Frequent Attenders (ARFAs).
The two aims are explored by two separate studies outlined below.
Study 1: Natural history of ARFAs- as of January 2021, apart from the follow up of mortality rates using mortality data for the 2011/12 ARFA cohort this study is now complete. This section outlines the full study.
From national Hospital Episodes Statistics (HES) linked to Civil Registration Deaths data (2011/12-2015/16) the researcher will select a cohort of ARFAs and look back at their service use through years 2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code), mode of admission, length of stay, readmissions, age, sex and geography. Through the use of logistic regression, the researcher will identify which of these characteristics are predictors of the outcome “being an ARFA in 2015/16”. The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders. Cause of death data will be analysed to understand whether ARFAs are dying from alcohol related causes or other: this is important to determine so that preventative interventions can be tailored accordingly.
The researcher will also select a cohort of ARFAs from 2011/12 and follow them forwards using HES through to 2015/16 to investigate health outcomes, including death, for ARFAs. A logistic regression model will test various predictors of mortality and poor health outcome (eg presence of alcoholic cirrhosis) for ARFAs and results will be compared to other non-alcohol frequent attenders and other alcohol related non-frequent attenders.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA MP. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency, likelihood (odds ratio) of becoming an ARFA and likelihood of death.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. In addition, the longer-term health outcomes for ARFAs and risk of death will also be used to populate the risk stratification model, which in turn will be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally, and estimates of lives potentially saved by ARFA services.
In order to carry out this study, pseudonymised HES APC from 2011/12 to 2015/16 is required linked to civil registration mortality data so that longitudinal analyses can take place to analyse admissions and long term outcomes of patients including deaths (although HES data includes deaths within hospital, alone it is insufficient to look at deaths for those with frequent alcohol admissions as many take place outside of hospital). Patients within the England HES data set will be categorised in to 4 groups, based on whether they have had an alcohol admission (an admission which includes a wholly attributable alcohol diagnosis code) during each HES year, and whether they have had 3 or more hospital admissions (frequent admissions) in each year. To minimise data a sample of each group will be taken and civil regmortality data requested for the patients in these samples, linked to the HES APC record:
100% of the national ARFA cohort from 2011/12 are included in the sample to ensure that comprehensive analysis of this diverse and complex group is undertaken. Control groups are sized based on a 3:1 ratio of controls to cases.
The mortality data is restricted to individuals found within the HES APC extract and included in each of the 4 samples shown in the table above. Mortality data from 2011/12 until 2015/16 is required in order to calculate death rates during the 5 year period following being diagnosed as an ARFA. Rates for ARFAs are compared to alcohol-related non-frequent attenders, non-alcohol related frequent attenders and non-alcohol non-frequent related attenders for the corresponding period of time.
Study 2: The cost burden associated with ARFAs, As of May 2020, this study is complete. The results of this study have been submitted for publication in a peer reviewed journal (May 2020).
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied bed days) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year.
Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
There are no alternative, less intrusive ways of achieving the purpose for these two studies
The lawful basis for the processing of this information under GDPR is (article 6 (1) (e)) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
South London and Maudsley NHS Foundation Trust (SLAM) are the sole organisation with decision making authority for these studies and the sole organisation that will process data. To clarify, SLAM is the sole Data Controller who also processes the data. The other organisations that form King's Health Partners (King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and King's College London) will be informed of the research findings but have no input into the study design and no control over how data will be processed or the purposes for which it will be used.
The lead researcher for the study is employed by King's College London, which is part of King's Health Partners (together with King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and South London and the Maudsley NHS Trust). As part of the King's College London employment contract, the lead researcher holds an honorary contract with SLAM and a King's Health Partners research passport to conduct research from any other of the NHS Trust sites within King's Health Partners. The lead researcher will be conducting the research from SLAM NHS Trust site where HES data is currently held. SLAM have the necessary IT infrastructure and ability to meet information governance requirements; processing is permitted at the SLAM site only.
Expected output
The research findings of the proposed project will be shared within Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts) in order to directly inform the design and purpose of services for ARFAs. The analysis of HES/mortality data will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs e.g. average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as assertive outreach treatment both nationally and locally, informing commissioning of services.
This population risk stratification project is part of a wider project to optimise services for ARFAs at KHP (King's College Hospital, South London and Maudsley and Guys and St Thomas' Trusts), which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at Kings College London (KCL), one of whom leads the alcohol strategy for Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The alcohol strategy steering group includes lay members, service users and other researchers and clinicians working on alcohol-based projects across South London. The principal investigator (PI) reports project progress to the alcohol strategy steering group. The PI and main supervisor (Professor of alcohol and Addictions Psychiatry) are members of the NIHR Applied Research Collaboration South London (ARC South London) and this project forms part of the ARC's alcohol research theme's programme of work, led by the main supervisor. Implementation of evidence-based alcohol interventions is a key priority for all south London local authorities and STPs. The ARC work proactively with the NHS, local authorities charities and patients and the public to maximise and evaluate the impact of implementation of effective interventions both locally and nationally. The South London ARC are also working with NHS services and commissioners from across the UK to implement assertive outreach services. The main supervisor provides advice to government on alcohol and drug misuse strategy and was a member of the Models of Care working group which produced national frameworks for drug and alcohol services in England. The main supervisor is also a member of the WHO Expert Committee on Drug Dependence and Alcohol Problems, and Chair of the NICE guideline development group on management of harmful alcohol use and alcohol dependence.
Work already completed during this project has informed national alcohol strategy and shaped nation guidance "Tackling alcohol misuse in NHS hospitals" , Health Innovation Network, February 2018.
The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication. In addition, lay summaries such as newsletters and blogs (on behalf of the South London Collaboration for Leadership in Applied Health and Care will be produced. Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will also be targeted, initially with findings from the analysis using the HES data, and latterly from the analysis using both the HES and mortality data. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London Collaboration for Leadership in Applied Health Research and Care (NIHR ARC South London) website.
Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guide.
Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact and a BMJ award 2019 for best mental health project.
Other outputs include:
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial "Tackling alcohol misuse in NHS hospitals, Health Innovation Network, Feb 2018 https://www.drugsandalcohol.ie/29084/1/Alcohol_care_in_NHS_hospitals.pdf;
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This was included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which was implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
In 2019 the KHP alcohol team won the BMJ award https://www.slam.nhs.uk/media/news/alcohol-assertive-outreach-team-wins-bmj-award.
Work on the data to date has informed an RCT of assertive outreach treatment for frequent alcohol related hospital admissions, publication of results is due imminently.
Presentations/publications relating to the proposed study made by the applicant to date-
Blackwood R et al, 2020; Prevalence and patterns of hospital use for people with frequent alcohol related hospital admissions, compared to non-alcohol and non-frequent admissions: a cohort study using routine administrative hospital data. Addiction. https://doi.org/10.1111/add.15354
R Blackwood et al, Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trail. BMC Public Health, 2020; 20: 332.
Citations in the series Lancet Commission on Liver Disease in the UK, to inform national alcohol strategy.
Fincham-Campbell S, Kimergard A, Wolstenholme A, Blackwood R et al; A national survey of assertive outreach treatment services for people who frequently attend hospital due to alcohol related reasons in England. Alcohol and alcoholism, 2018 May 1;53(3):277-281
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017 (v2, 2018).
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr R Blackwood, Prof M Lynskey, Prof C Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
South London and Maudsley NHS Foundation Trust have two active patient and public involvement / service user representatives that attend the quarterly management meetings.
South London and Maudsley NHS Foundation Trust link in with the PPI theme of the CLAHRC
South London and Maudsley NHS Foundation Trust have run two large pan-south London PPI alcohol events and have held some smaller consultation meetings and focus groups to tie in with key development stages of our CLAHRC alcohol projects.
South London and Maudsley NHS Foundation Trust have a wider alcohol PPI forum of service user representatives, community organisations and interested members of the public and carers.
The 30 strong forum is South London and Maudsley NHS Foundation Trusts primary method of disseminating research results. Included in that are also London and national service user voice organisations.
Benefits reported
This project enabled the number and NHS use of ARFAs nationally to be quantified for the first time (54,369 ARFAs) people, occupying 1,402,600 bed days per year at an annual cost of ARFAs to the NHS of £848m. Furthermore the work was able to demonstrate that ARFA is a "chronic condition"- more than 10% of ARFAs are ARFAs for more than 5 years. ARFAs are higher cost per person than non-alcohol related frequent attenders. These findings have enabled the business case for specialist alcohol treatment for ARFAs (AOT) to be made. The implementation of AOT at £161m serves to save the NHS an estimated £590m per year compared to care as usual. In other words for every £1 spend, £3.66 is saved. Since the introduction of AOT for alcohol patients at Kings College Hospital, there has been a 25% reduction in alcohol admissions between 2015/16 and 2017/18 at King's. This work at KHP with its supporting evidence has led to the inclusion of AOT on PHE's menu of preventative interventions - a nationally published document recommending preventative strategies to commissioners and providers. There are now 37 dedicated ARFA AOT services across the UK.
Early findings of the project described have been presented and disseminated at a number of meetings, nationally and internationally, and through written publications (see outputs section). As a result there is now increased awareness of ARFAs and their needs amongst clinicians, commissioners, providers, politicians and the public across South London, nationally and internationally. Furthermore, the project work has provided evidence that has directly informed national alcohol policy (PHE's menu of preventative interventions) and will shape national policy on liver disease (Lancet Commission on liver disease).
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol.
Benefits of the alcohol project work to date have been recognised nationally and locally: the alcohol team recently received a CLAHRC award for impact and a BMJ award 2019 for best mental health project.
DARS-NIC-44383-L6C0X-v3.4 1 February 2020 to 19 January 2021
- Title
- HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals
- Commercial
- No
- Sublicensing
- No
- Datasets
- 3
- Files released
- 0
Datasets: Civil Registrations of Death - Secondary Care Cut; HES:Civil Registration (Deaths) bridge; Hospital Episode Statistics Admitted Patient Care (HES APC)
What changed from DARS-NIC-44383-L6C0X-v2.27
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2020-02-01 | |
| End date | 2021-01-19 | |
| Civil Registrations of Death - Secondary Care Cut: sensitivity | Sensitive |
Objective for processing
[4 paragraphs unchanged]
Study 1: Natural history of ARFAs
Study 1: Natural history of ARFAs- as of May 2020, apart from the follow up of mortality rates using mortality data for the 2011/12 ARFA cohort this study is now complete. This section outlines the full study.
From national Hospital Episodes Statistics (HES) linked to Civil Registration Deaths data
[24 words unchanged]
yield data on natural history of ARFAs including: co-morbidities (ICD 10 code),
mortality,
mode of admission, length of stay, readmissions, age,
gender
sex
and geography. Through the use of logistic regression, the researcher will identify
[57 words unchanged]
is important to determine so that preventative interventions can be tailored accordingly.
[3 paragraphs unchanged]
Study 2: The cost burden associated with ARFAs
In order to carry out this study, pseudonymised HES APC from 2011/12 to 2015/16 is required linked to civil registration mortality data so that longitudinal analyses can take place to analyse admissions and long term outcomes of patients including deaths (although HES data includes deaths within hospital, alone it is insufficient to look at deaths for those with frequent alcohol admissions as many take place outside of hospital). Patients within the England HES data set will be categorised in to 4 groups, based on whether they have had an alcohol admission (an admission which includes a wholly attributable alcohol diagnosis code) during each HES year, and whether they have had 3 or more hospital admissions (frequent admissions) in each year. To minimise data a sample of each group will be taken and civil regmortality data requested for the patients in these samples, linked to the HES APC record:
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied beddays) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled
100% of the national ARFA cohort from 2011/12 are included in the sample to ensure that comprehensive analysis of this diverse and complex group is undertaken. Control groups are sized based on a 3:1 ratio of controls to cases.
up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
The mortality data is restricted to individuals found within the HES APC extract and included in each of the 4 samples shown in the table above. Mortality data from 2011/12 until 2015/16 is required in order to calculate death rates during the 5 year period following being diagnosed as an ARFA. Rates for ARFAs are compared to alcohol-related non-frequent attenders, non-alcohol related frequent attenders and non-alcohol non-frequent related attenders for the corresponding period of time.
Study 2: The cost burden associated with ARFAs, As of May 2020, this study is complete. The results of this study have been submitted for publication in a peer reviewed journal (May 2020).
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied bed days) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
[2 paragraphs unchanged]
The lawful basis for the processing of this information under GDPR is (article 6) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
There are no alternative, less intrusive ways of achieving the purpose for these two studies
The lawful basis for the processing of this information under GDPR is (article 6 (1) (e)) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
South London and Maudsley NHS Foundation Trust (SLAM) are the sole organisation with decision making authority for these studies and the sole organisation that will process data. To clarify, SLAM is the sole Data Controller who also processes the data. The other organisations that form King's Health Partners (King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and King's College London) will be informed of the research findings but have no input into the study design and no control over how data will be processed or the purposes for which it will be used.
The lead researcher for the study is employed by King's College London, which is part of King's Health Partners (together with King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and South London and the Maudsley NHS Trust). As part of the King's College London employment contract, the lead researcher holds an honorary contract with SLAM and a King's Health Partners research passport to conduct research from any other of the NHS Trust sites within King's Health Partners. The lead researcher will be conducting the research from SLAM NHS Trust site where HES data is currently held. SLAM have the necessary IT infrastructure and ability to meet information governance requirements; processing is permitted at the SLAM site only.
Benefits reported
[9 paragraphs unchanged] In 2019 the alcohol team won the BMJ award https://www.slam.nhs.uk/media/news/alcohol-assertive-outreach-team-wins-bmj-award [1 paragraph unchanged] Work on the data to date has informed an RCT of assertive outreach treatment for frequent alcohol related hospital admissions, publication of results is due imminently. [9 paragraphs unchanged] South London and Maudsley NHS Foundation Trust have two active patient and public involvement / service user representatives that attend the quarterly management meetings. South London and Maudsley NHS Foundation Trust link in with the PPI theme of the CLAHRC South London and Maudsley NHS Foundation Trust have run two large pan-south London PPI alcohol events and have held some smaller consultation meetings and focus groups to tie in with key development stages of our CLAHRC alcohol projects. South London and Maudsley NHS Foundation Trust have a wider alcohol PPI forum of service user representatives, community organisations and interested members of the public and carers. The 30 strong forum is South London and Maudsley NHS Foundation Trusts primary method of disseminating research results. Included in that are also London and national service user voice organisations.
Unchanged: Processing activities, Expected output, Expected measurable benefits.
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within Hospital Episode Statistics linked to Civil Registration death data to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent attendance, different patterns of health service utilisation and health outcomes including death.
Aim 2: Explore costs of health service use by Alcohol Related Frequent Attenders (ARFAs).
The two aims are explored by two separate studies outlined below.
Study 1: Natural history of ARFAs- as of May 2020, apart from the follow up of mortality rates using mortality data for the 2011/12 ARFA cohort this study is now complete. This section outlines the full study.
From national Hospital Episodes Statistics (HES) linked to Civil Registration Deaths data (2011/12-2015/16) the researcher will select a cohort of ARFAs and look back at their service use through years 2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code), mode of admission, length of stay, readmissions, age, sex and geography. Through the use of logistic regression, the researcher will identify which of these characteristics are predictors of the outcome “being an ARFA in 2015/16”. The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders. Cause of death data will be analysed to understand whether ARFAs are dying from alcohol related causes or other: this is important to determine so that preventative interventions can be tailored accordingly.
The researcher will also select a cohort of ARFAs from 2011/12 and follow them forwards using HES through to 2015/16 to investigate health outcomes, including death, for ARFAs. A logistic regression model will test various predictors of mortality and poor health outcome (eg presence of alcoholic cirrhosis) for ARFAs and results will be compared to other non-alcohol frequent attenders and other alcohol related non-frequent attenders.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA MP. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency, likelihood (odds ratio) of becoming an ARFA and likelihood of death.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. In addition, the longer-term health outcomes for ARFAs and risk of death will also be used to populate the risk stratification model, which in turn will be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally, and estimates of lives potentially saved by ARFA services.
In order to carry out this study, pseudonymised HES APC from 2011/12 to 2015/16 is required linked to civil registration mortality data so that longitudinal analyses can take place to analyse admissions and long term outcomes of patients including deaths (although HES data includes deaths within hospital, alone it is insufficient to look at deaths for those with frequent alcohol admissions as many take place outside of hospital). Patients within the England HES data set will be categorised in to 4 groups, based on whether they have had an alcohol admission (an admission which includes a wholly attributable alcohol diagnosis code) during each HES year, and whether they have had 3 or more hospital admissions (frequent admissions) in each year. To minimise data a sample of each group will be taken and civil regmortality data requested for the patients in these samples, linked to the HES APC record:
100% of the national ARFA cohort from 2011/12 are included in the sample to ensure that comprehensive analysis of this diverse and complex group is undertaken. Control groups are sized based on a 3:1 ratio of controls to cases.
The mortality data is restricted to individuals found within the HES APC extract and included in each of the 4 samples shown in the table above. Mortality data from 2011/12 until 2015/16 is required in order to calculate death rates during the 5 year period following being diagnosed as an ARFA. Rates for ARFAs are compared to alcohol-related non-frequent attenders, non-alcohol related frequent attenders and non-alcohol non-frequent related attenders for the corresponding period of time.
Study 2: The cost burden associated with ARFAs, As of May 2020, this study is complete. The results of this study have been submitted for publication in a peer reviewed journal (May 2020).
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied bed days) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year.
Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
There are no alternative, less intrusive ways of achieving the purpose for these two studies
The lawful basis for the processing of this information under GDPR is (article 6 (1) (e)) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
South London and Maudsley NHS Foundation Trust (SLAM) are the sole organisation with decision making authority for these studies and the sole organisation that will process data. To clarify, SLAM is the sole Data Controller who also processes the data. The other organisations that form King's Health Partners (King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and King's College London) will be informed of the research findings but have no input into the study design and no control over how data will be processed or the purposes for which it will be used.
The lead researcher for the study is employed by King's College London, which is part of King's Health Partners (together with King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and South London and the Maudsley NHS Trust). As part of the King's College London employment contract, the lead researcher holds an honorary contract with SLAM and a King's Health Partners research passport to conduct research from any other of the NHS Trust sites within King's Health Partners. The lead researcher will be conducting the research from SLAM NHS Trust site where HES data is currently held. SLAM have the necessary IT infrastructure and ability to meet information governance requirements; processing is permitted at the SLAM site only.
Expected output
The research findings of the proposed project will be shared within Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts) in order to directly inform the design and purpose of services for ARFAs. The analysis of HES/mortality data will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs e.g. average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as assertive outreach treatment both nationally and locally, informing commissioning of services.
This population risk stratification project is part of a wider project to optimise services for ARFAs at KHP, which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at Kings College London (KCL), one of whom leads the alcohol strategy for Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The alcohol strategy steering group includes lay members, service users and other researchers and clinicians working on alcohol-based projects across South London. The principal investigator reports project progress to the alcohol strategy steering group.
The principal investigator and Professor/alcohol strategy lead are also part of the ARFA clinical network for South London, which meets every 6 weeks. The group consists of practitioners and clinicians working with ARFAs so provides direct insight in to the day-to-day treatment and issues for this particular patient group. The principal investigator reports project progress to this group. Finally, the principal investigator's project progress is also monitored on a quarterly basis through King's College London.
Project findings using HES data are, as at January 2019, being finalised but, due to the close working arrangements with clinicians described above, will inform service design from the outset. The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication during early 2019 (with findings including the mortality data to be reported in late 2019). In addition, lay summaries such as newsletters and blogs (on behalf of the South London Academic Health Science Network and Collaboration for Leadership in Applied Health and Care will be produced (late 2019). Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will also be targeted, initially with findings from the analysis using the HES data, and latterly from the analysis using both the HES and mortality data. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) website.
Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guide.
Benefits reported
The project described forms one part of wider work going on at King's Health Partners (KHP) and the South London CLAHRC on alcohol. Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact on the basis of work so far including:
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial;
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This has been included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which is being implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
In 2019 the alcohol team won the BMJ award https://www.slam.nhs.uk/media/news/alcohol-assertive-outreach-team-wins-bmj-award
The annual cost of alcohol-related harm to the NHS is £3.5 billion of which a third is due to alcohol-related hospital admissions. Increasing the number of AAOT has the potential to promote a significant change in alcohol treatment with huge potential savings in costs relating to frequent hospital admissions.
Work on the data to date has informed an RCT of assertive outreach treatment for frequent alcohol related hospital admissions, publication of results is due imminently.
Presentations/publications relating to the proposed study made by the applicant to date-
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017.
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr Ros Blackwood, Prof Michael Lynskey, Prof Colin Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
South London and Maudsley NHS Foundation Trust have two active patient and public involvement / service user representatives that attend the quarterly management meetings.
South London and Maudsley NHS Foundation Trust link in with the PPI theme of the CLAHRC
South London and Maudsley NHS Foundation Trust have run two large pan-south London PPI alcohol events and have held some smaller consultation meetings and focus groups to tie in with key development stages of our CLAHRC alcohol projects.
South London and Maudsley NHS Foundation Trust have a wider alcohol PPI forum of service user representatives, community organisations and interested members of the public and carers.
The 30 strong forum is South London and Maudsley NHS Foundation Trusts primary method of disseminating research results. Included in that are also London and national service user voice organisations.
DARS-NIC-44383-L6C0X-v2.27 7 February 2019 to 31 January 2020
- Title
- HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals
- Commercial
- No
- Sublicensing
- No
- Datasets
- 3
- Files released
- 0
Datasets: Civil Registrations of Death - Secondary Care Cut; HES:Civil Registration (Deaths) bridge; Hospital Episode Statistics Admitted Patient Care (HES APC)
What changed from DARS-NIC-44383-L6C0X-v1.7
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Title | HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals | |
| Applicant organisation | KING'S COLLEGE LONDON | |
| Organisation type | Academic | |
| Start date | 2019-02-07 | |
| Hospital Episode Statistics Admitted Patient Care (HES APC): legal basis | Health and Social Care Act 2012 – s261(2)(b)(ii) | |
| Hospital Episode Statistics Admitted Patient Care (HES APC): common law duty of confidentiality | Does not include the flow of confidential data |
Datasets: + Civil Registrations of Death - Secondary Care Cut; + HES:Civil Registration (Deaths) bridge
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within
hospital episode statistics
Hospital Episode Statistics linked to Civil Registration death data
to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent
attendance and
attendance,
different patterns of health service
utilisation.
utilisation and health outcomes including death.
[3 paragraphs unchanged]
From national Hospital Episodes Statistics (HES)
2011/12 service use pattern of
linked to Civil Registration Deaths data (2011/12-2015/16) the researcher will select
a
pseudonymised
cohort of ARFAs
during 2015/16,
and look back at their service use through years
2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code),
mortality,
mode of admission, length of stay, readmissions, age, gender and geography.
Through the use of logistic regression, the researcher will identify which of these characteristics are predictors of the outcome “being an ARFA in 2015/16”.
The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders.
Cause of death data will be analysed to understand whether ARFAs are dying from alcohol related causes or other: this is important to determine so that preventative interventions can be tailored accordingly.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA SE. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency.
The researcher will also select a cohort of ARFAs from 2011/12 and follow them forwards using HES through to 2015/16 to investigate health outcomes, including death, for ARFAs. A logistic regression model will test various predictors of mortality and poor health outcome (eg presence of alcoholic cirrhosis) for ARFAs and results will be compared to other non-alcohol frequent attenders and other alcohol related non-frequent attenders.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA MP. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency, likelihood (odds ratio) of becoming an ARFA and likelihood of death.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. In addition, the longer-term health outcomes for ARFAs and risk of death will also be used to populate the risk stratification model, which in turn will be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally, and estimates of lives potentially saved by ARFA services.
[1 paragraph unchanged]
Costs of health service usage by the 2015/16 ARFA cohort will be
[17 words unchanged]
of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled
up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year. Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year.
Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
The lawful basis for the processing of this information under GDPR is (article 6) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
Processing activities
The applicant will be undertaking processing activities for this project. The applicant (Consultant in public health medicine/innovation fellow) is trained in health care analytics and epidemiology and is up to date with NHS information governance training (last update June 2016).
NHS Digital reminds all organisations party to this agreement of the need to 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 applicant holds an employment contract with Guy’s and St Thomas’ NHS Trust which is part of King’s Health Partners (together with King’s College Hospital NHS Trust, King's College London and South London and the Maudsley NHS Trust). As part of the Guy’s and St Thomas’ employment contract,the applicant holds a King’s Health Partners’ “research passport” to enable her to conduct research from any other of the NHS Trust sites within King’s Health Partners. The applicant will be conducting the proposed research from South London and the Maudsley (SLAM) NHS Trust site, as firstly this is where she is geographically based for work; and secondly, because SLAM currently host HES data, having the necessary IT infrastructure and ability to meet information governance requirements.
South London and the Maudsley (SLAM) are the sole organisation with decision making authority for this study and the sole organisation that will process data. The other organisations that form King's Health Partners (King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and King's College London) will be informed of the research findings but have no input into the study design and no control over how data will be processed or the purposes for which it will be used.
The lead researcher for the study is employed by King's College London, which is part of King's Health Partners (together with King's College Hospital NHS Trust, Guy's and St Thomas' NHS Trust and South London and the Maudsley NHS Trust). As part of the King's College London employment contract, the lead researcher holds an honorary contract with SLAM and a King's Health Partners research passport to conduct research from any other of the NHS Trust sites within King's Health Partners. The lead researcher will be conducting the research from SLAM NHS Trust site where HES data is currently held. SLAM have the necessary IT infrastructure and ability to meet information governance requirements; processing is permitted at the SLAM site only.
[1 paragraph unchanged]
- The inpatient HES
data, Civil registration Death
data
and bridging file
is downloaded from NHS Digital and stored on South London and the Maudsley NHS Trusts Server. The HES
and mortality
data is held in a database (SQL Server) within SLAMs infrastructure and
[17 words unchanged]
on a storage area network and secured by active directory user group.
[3 paragraphs unchanged]
- All access to individual files is recorded, and a sample audited to investigate the existence of any adverse incidents, and
ensure that appropriate access has been maintained.
ensure that appropriate access has been maintained.
- The HES and mortality data is analysed using the STATA MP software tool. Once held, the applicant will view the data from NHS Digital within this software and select a specific cohort within the data for each of the two studies referred to under 'Objectives for processing'. Commonly a process will initially take place to define the particular cohort of interest in terms of e.g. individual diagnostic codes or procedure codes. The researcher will use routinely available filter definitions and a similar control group may be established.
- The HES data is imported into STATA SE/MP (analytical tool). Once held, The applicant will view the data and select a specific cohort for each individual study. Commonly a process will initially take place to define the particular cohort of interest in terms of e.g. individual diagnostic codes or procedure codes. The researcher will use routinely available filter definitions and a similar control group may be established.
- The applicant then analyses the data, before applying the relevant disclosure controls to any output. Software used will be STATA MP (a local version of the STATA MP Software Tool is being used and not cloud); typically this will involve analysis on several outcome measures, risk adjustment and the construction of
- The applicant then analyses the data, before applying the relevant disclosure controls to any output. Software used will
control groups.
be STATA SE/MP; typically this will involve analysis on several outcome measures, risk adjustment and the construction of control groups.
- No record level data would be linked to this dataset, but it may be combined with publicly available demographic or geographic data, for example in relation to local Trust performance
- No record level data would be linked to this dataset, but it may be combined with publically available demographic or
- Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only with small numbers suppressed in line with the HES analysis guides.
geographic data, for example in relation to local Trust performance
South London and Maudsley NHS Foundation Trust will not link the data disseminated by NHS Digital to any other data they may already hold.
- Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only with small numbers
The data controller must ensure that there are appropriate contracts and controls in place between the organisation and all persons accessing NHS Digital disseminated data. NHS Digital have the right to audit the controls in place under the data sharing agreement.
suppressed in line with the HES analysis guide.
The applicant will be the only person who will access the data. They are a substantive employee of Guys and St Thomas'
which includes in the employment contract a research passport for the other sites in the Kings Health Partners. The data
requested will only be used for the purposes described in this document.
South London and Maudsley NHS Foundation Trust will not link the data disseminated by NHS Digital to any other data
they may already hold.
Expected output
The
research findings of the
proposed project
directly informs the design and purpose of services for ARFAs at
will be shared within
Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS
Trusts).
Trusts) in order to directly inform the design and purpose of services for ARFAs.
The analysis of
HES
HES/mortality data
will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs
eg
e.g.
average age, average level of income deprivation etc which will be used
[37 words unchanged]
as assertive outreach treatment both nationally and locally, informing commissioning of services.
[1 paragraph unchanged]
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at
KCL,
Kings College London (KCL),
one of whom leads the alcohol strategy for Kings Health Partners hospitals
[36 words unchanged]
The principal investigator reports project progress to the alcohol strategy steering group.
The principal investigator and Professor/alcohol strategy lead are also part of the
[34 words unchanged]
particular patient group. The principal investigator reports project progress to this group.
Finally, the principal investigator's project progress is also monitored on a quarterly basis through King's College London.
Finally, the principal investigator’s project progress is also monitored on a quarterly basis through King's College London. Project findings are due to be reported November 2018 but due to the close working arrangements with clinicians described above, will inform service design from the outset.
Project findings using HES data are, as at January 2019, being finalised but, due to the close working arrangements with clinicians described above, will inform service design from the outset. The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication during early 2019 (with findings including the mortality data to be reported in late 2019). In addition, lay summaries such as newsletters and blogs (on behalf of the South London Academic Health Science Network and Collaboration for Leadership in Applied Health and Care will be produced (late 2019). Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will also be targeted, initially with findings from the analysis using the HES data, and latterly from the analysis using both the HES and mortality data. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication by May 2018. In addition, lay summaries such as newsletters and blogs (on behalf of the South London Academic Health Science Network and Collaboration for Leadership in Applied Health and Care will be produced (March 2017-April 2018). Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will be made between March 2017 and November 2018. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) website.
Information about this study and its use of data will be made available to the general public through the South London CLAHRC website.
[1 paragraph unchanged]
Expected measurable benefits
[2 paragraphs unchanged]
Alcohol related frequent attenders (ARFAs) are thought to account for 6.7% of
[39 words unchanged]
method of identifying patients for treatment. By better understanding the characteristics of
ARFAs and
ARFAs,
their patterns of usage of health services
and mortality rates
through this study, it is hoped it may become possible to identify
[7 words unchanged]
their own health and prior to assimilating high costs to health services.
This study
These studies
will benefit
patients
patient
and the Trusts within the Kings Health Partners through the development of the risk
stratification.
stratification tool.
This will ensure that ARFAs can receive the specialist treatment that they
[24 words unchanged]
to a reduction in hospital admissions with concomitant savings to the NHS.
No studies so far have looked at the death rates for ARFAs. By including data on death rates in the risk stratification model and costings model, this will produce a more accurate estimate of the potential benefits of ARFA services than has previously been available.
Benefits reported
Not stated in the previous version; added here.
The project described forms one part of wider work going on at King's Health Partners (KHP) and the South London CLAHRC on alcohol. Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact on the basis of work so far including:
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial;
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This has been included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which is being implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
The annual cost of alcohol-related harm to the NHS is £3.5 billion of which a third is due to alcohol-related hospital admissions. Increasing the number of AAOT has the potential to promote a significant change in alcohol treatment with huge potential savings in costs relating to frequent hospital admissions.
Presentations/publications relating to the proposed study made by the applicant to date-
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017.
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr Ros Blackwood, Prof Michael Lynskey, Prof Colin Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within Hospital Episode Statistics linked to Civil Registration death data to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent attendance, different patterns of health service utilisation and health outcomes including death.
Aim 2: Explore costs of health service use by Alcohol Related Frequent Attenders (ARFAs).
The two aims are explored by two separate studies outlined below.
Study 1: Natural history of ARFAs
From national Hospital Episodes Statistics (HES) linked to Civil Registration Deaths data (2011/12-2015/16) the researcher will select a cohort of ARFAs and look back at their service use through years 2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code), mortality, mode of admission, length of stay, readmissions, age, gender and geography. Through the use of logistic regression, the researcher will identify which of these characteristics are predictors of the outcome “being an ARFA in 2015/16”. The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders. Cause of death data will be analysed to understand whether ARFAs are dying from alcohol related causes or other: this is important to determine so that preventative interventions can be tailored accordingly.
The researcher will also select a cohort of ARFAs from 2011/12 and follow them forwards using HES through to 2015/16 to investigate health outcomes, including death, for ARFAs. A logistic regression model will test various predictors of mortality and poor health outcome (eg presence of alcoholic cirrhosis) for ARFAs and results will be compared to other non-alcohol frequent attenders and other alcohol related non-frequent attenders.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA MP. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency, likelihood (odds ratio) of becoming an ARFA and likelihood of death.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. In addition, the longer-term health outcomes for ARFAs and risk of death will also be used to populate the risk stratification model, which in turn will be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally, and estimates of lives potentially saved by ARFA services.
Study 2: The cost burden associated with ARFAs
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied beddays) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled
up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year.
Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
The lawful basis for the processing of this information under GDPR is (article 6) Function of a public task (by a public organisation) and, because the data is “special category” data, 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.
Expected output
The research findings of the proposed project will be shared within Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts) in order to directly inform the design and purpose of services for ARFAs. The analysis of HES/mortality data will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs e.g. average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as assertive outreach treatment both nationally and locally, informing commissioning of services.
This population risk stratification project is part of a wider project to optimise services for ARFAs at KHP, which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at Kings College London (KCL), one of whom leads the alcohol strategy for Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The alcohol strategy steering group includes lay members, service users and other researchers and clinicians working on alcohol-based projects across South London. The principal investigator reports project progress to the alcohol strategy steering group.
The principal investigator and Professor/alcohol strategy lead are also part of the ARFA clinical network for South London, which meets every 6 weeks. The group consists of practitioners and clinicians working with ARFAs so provides direct insight in to the day-to-day treatment and issues for this particular patient group. The principal investigator reports project progress to this group. Finally, the principal investigator's project progress is also monitored on a quarterly basis through King's College London.
Project findings using HES data are, as at January 2019, being finalised but, due to the close working arrangements with clinicians described above, will inform service design from the outset. The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication during early 2019 (with findings including the mortality data to be reported in late 2019). In addition, lay summaries such as newsletters and blogs (on behalf of the South London Academic Health Science Network and Collaboration for Leadership in Applied Health and Care will be produced (late 2019). Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will also be targeted, initially with findings from the analysis using the HES data, and latterly from the analysis using both the HES and mortality data. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) website.
Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guide.
Benefits reported
The project described forms one part of wider work going on at King's Health Partners (KHP) and the South London CLAHRC on alcohol. Early findings of the project described have been presented and disseminated at a number of meetings and through written publications (see below). As a result there is now increased awareness of ARFAs and their needs amongst clinicians across South London, and once national work described here is complete, the opportunity to disseminate those findings nationally.
In parallel to the work on nature and natural history of ARFAs, a clinical trial of a case management (assertive outreach) approach to treating ARFAs is nearing completion at SLAM/KHP as well as work to tackle stigma associated with alcohol. The alcohol team recently received a CLAHRC award for impact on the basis of work so far including:
-production of an alcohol care implementation guide for NHS hospitals, drawing on local examples including an AAOT and brief interventions, which forms part of a CLAHRC-funded randomised clinical trial;
-developed a national e-learning package for all NHS staff including a powerful film ‘Stories behind the bottle’, which aims to tackle alcohol stigma in the NHS. It is hosted by Health Education England’s e-Learning for Health resource and is available to all NHS staff;
-in collaboration with Our Healthier South East London commissioners and the Health Innovation Network (South London Academic Health Science Network) members of the Alcohol Theme prepared a business case for expanding alcohol interventions in hospitals across south-east London. This has been included in the Sustainability and Transformation Plan for south-east London (OHSEL, 2016);
-at the national level, researchers from the Alcohol Theme supported Public Health England to build a business case for NHS England to produce a national Commissioning for Quality and Innovation (CQUIN) for alcohol screening and brief intervention which is being implemented in 2017-18 in all acute and mental health hospitals in England with the ambition of providing interventions to 900,000 patients and referring 64,000 additional patients to specialist alcohol treatment in the first year.
-The alcohol theme’s work has also been cited in ‘The National Alcohol Policy Evidence Review’ published by Public Health England (PHE, 2016; Burton et al., 2017) and presented to two All Party Parliamentary Groups, and cited in the House of Lords Select Committee on the Licensing Act in 2017 (Drummond, 2017; Drink and Drug News, 2017; House of Lords Select Committee, 2017).
-As a result of long-term engagement with Public Health England, the Alcohol Theme influenced the ‘Local Health and Care Planning: Menu of preventative interventions’ produced by Public Health England (PHE, 2016). The report, which outlines evidence-based, preventive public health interventions to improve the health of the population, selected examples of alcohol interventions to reduce the cost of alcohol related frequent admissions and promote health include:
“Establish Alcohol Assertive Outreach Teams (AAOT) to reduce repeat users of hospital and other services such as police and social services. CCGs and local authorities work together to commission outreach teams in hospitals or the community that complement alcohol care teams by identifying and proactively engaging patients with repeated admissions. AAOT will also work face-to-face with patients to implement tailored care plans that address their alcohol dependence, mental/physical health and welfare needs.”
The annual cost of alcohol-related harm to the NHS is £3.5 billion of which a third is due to alcohol-related hospital admissions. Increasing the number of AAOT has the potential to promote a significant change in alcohol treatment with huge potential savings in costs relating to frequent hospital admissions.
Presentations/publications relating to the proposed study made by the applicant to date-
December 2017: Oral presentation to NIHR CLAHRC National Conference 2017: Tackling alcohol and addictions through applied health research.
October 2017: Poster presentation: International Addictions conference, Lisbon, Portugal. Predicting frequent alcohol admissions to hospital using routinely collected hospital data in South London
Tackling alcohol misuse in NHS Hospitals: a resource pack. HIN April 2017.
Using routinely collected hospital episode statistics (HES) to describe alcohol related frequent attenders (ARFAs) to hospitals
Dr Ros Blackwood, Prof Michael Lynskey, Prof Colin Drummond
The Lancet, Volume 389, Special Issue, S27, 23 February 2017
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30423-3/fulltext
January 2017: Oral presentation to Alcohol Care in Acute Settings Clinical Network (South London) hosted by HIN: The nature and natural history of alcohol related frequent attenders.
DARS-NIC-44383-L6C0X-v1.7 16 October 2017 to 31 January 2020
- Title
- HES data for the analysis of alcohol related frequent attenders to hospitals
- Commercial
- No
- Sublicensing
- No
- Datasets
- 1
- Files released
- 0
Datasets: Hospital Episode Statistics Admitted Patient Care (HES APC)
What changed from DARS-NIC-44383-L6C0X-v0.2
Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.
| Field | Was | Became |
|---|---|---|
| Start date | 2017-10-16 | |
| Hospital Episode Statistics Admitted Patient Care (HES APC): legal basis | Health and Social Care Act 2012 - s261 - 'Other dissemination of information'; Other-Health and Social Care Act 2012 s261 (2)(b)(ii) |
Processing activities
[3 paragraphs unchanged]
- The inpatient HES data is downloaded from NHS Digital and stored on South London and the Maudsley NHS
Trust’s server.
Trusts Server.
The
server
HES data
is held
on-site at SLAM,
in a database (SQL Server) within SLAMs infrastructure
and access is restricted to named individuals according to
SLAM’s
SLAM's
security policy.
Storage of the data will be on a storage area network and secured by active directory user group.
- Storage will be on a storage area network and secured by active directory user group.
- Remote access to the database is permitted, but only through remote access via secure token (so processing is still
- Remote access to the database is permitted, but only through terminal Services via secure token (so processing is still
carried out on site), and with local printing and downloading disabled.
[1 paragraph unchanged]
- All access to individual files is recorded, and a sample audited to investigate the existence of any adverse incidents, and
ensure that appropriate access has been maintained.
- The HES data is imported into STATA SE. Once held in STATA, The applicant will view the data and select a specific cohort for each individual study. Commonly a process will initially take place to define the particular cohort of interest in terms of e.g. individual diagnostic codes or procedure codes. The researchers will use routinely available filter definitions where possible, but may amend these based on the nature of each study’s group of interest. Depending on the research a similar control group may be established.
ensure that appropriate access has been maintained.
- The applicant then analyses the data, before applying the relevant disclosure controls to any output. Software used will be STATA SE; typically this will involve analysis on several outcome measures, risk adjustment and the construction of control groups.
- The HES data is imported into STATA SE/MP (analytical tool). Once held, The applicant will view the data and select a specific cohort for each individual study. Commonly a process will initially take place to define the particular cohort of interest in terms of e.g. individual diagnostic codes or procedure codes. The researcher will use routinely available filter definitions and a similar control group may be established.
- No record level data would be linked to this dataset, but it may be combined with publically available demographic or geographic data, for example in relation to local Trust performance
- The applicant then analyses the data, before applying the relevant disclosure controls to any output. Software used will
- Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only with small numbers suppressed in line with the HES analysis guide.
be STATA SE/MP; typically this will involve analysis on several outcome measures, risk adjustment and the construction of control groups.
The applicant will be the only person who will access the data. They are a substantive employee of Guys and St Thomas' which includes in the employment contract a research passport for the other sites in the Kings Health Partners. The data requested will only be used for the purposes described in this document.
- No record level data would be linked to this dataset, but it may be combined with publically available demographic or
South London and Maudsley NHS Foundation Trust will not link the data disseminated by NHS Digital to any other data they may already hold.
geographic data, for example in relation to local Trust performance
- Outputs are thus produced which consist of aggregate data (or indicator/statistical data) only with small numbers
suppressed in line with the HES analysis guide.
The applicant will be the only person who will access the data. They are a substantive employee of Guys and St Thomas'
which includes in the employment contract a research passport for the other sites in the Kings Health Partners. The data
requested will only be used for the purposes described in this document.
South London and Maudsley NHS Foundation Trust will not link the data disseminated by NHS Digital to any other data
they may already hold.
Benefits reported
Stated in the previous version and removed here.
Yielded Benefits is not a requirement for new applications.
Unchanged: Objective for processing, Expected output, Expected measurable benefits.
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within hospital episode statistics to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent attendance and different patterns of health service utilisation.
Aim 2: Explore costs of health service use by Alcohol Related Frequent Attenders (ARFAs).
The two aims are explored by two separate studies outlined below.
Study 1: Natural history of ARFAs
From national Hospital Episodes Statistics (HES) 2011/12 service use pattern of a pseudonymised cohort of ARFAs during 2015/16, 2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code), mode of admission, length of stay, readmissions, age, gender and geography. The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA SE. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally
Study 2: The cost burden associated with ARFAs
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied beddays) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year. Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
Expected output
The proposed project directly informs the design and purpose of services for ARFAs at Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The analysis of HES will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as assertive outreach treatment both nationally and locally, informing commissioning of services.
This population risk stratification project is part of a wider project to optimise services for ARFAs at KHP, which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at KCL, one of whom leads the alcohol strategy for Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The alcohol strategy steering group includes lay members, service users and other researchers and clinicians working on alcohol-based projects across South London. The principal investigator reports project progress to the alcohol strategy steering group.
The principal investigator and Professor/alcohol strategy lead are also part of the ARFA clinical network for South London, which meets every 6 weeks. The group consists of practitioners and clinicians working with ARFAs so provides direct insight in to the day-to-day treatment and issues for this particular patient group. The principal investigator reports project progress to this group.
Finally, the principal investigator’s project progress is also monitored on a quarterly basis through King's College London. Project findings are due to be reported November 2018 but due to the close working arrangements with clinicians described above, will inform service design from the outset.
The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication by May 2018. In addition, lay summaries such as newsletters and blogs (on behalf of the South London Academic Health Science Network and Collaboration for Leadership in Applied Health and Care will be produced (March 2017-April 2018). Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will be made between March 2017 and November 2018. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London CLAHRC website.
Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guide.
DARS-NIC-44383-L6C0X-v0.2 1 February 2017 to 31 January 2020
- Title
- HES data for the analysis of alcohol related frequent attenders to hospitals
- Commercial
- No
- Sublicensing
- No
- Datasets
- 1
- Files released
- 5
Datasets: Hospital Episode Statistics Admitted Patient Care (HES APC)
Objective for processing
The purpose of processing the data is to ascertain "The nature, natural history and characteristics of alcohol-related frequent attenders", by exploring data held within hospital episode statistics to understand this group of patients better including their health and social care needs. The project has 2 specific aims:
Aim 1: Explore in a sample of hospital attenders, which medical and socio-demographic characteristics are associated with alcohol-related frequent attendance and different patterns of health service utilisation.
Aim 2: Explore costs of health service use by Alcohol Related Frequent Attenders (ARFAs).
The two aims are explored by two separate studies outlined below.
Study 1: Natural history of ARFAs
From national Hospital Episodes Statistics (HES) 2011/12 service use pattern of a pseudonymised cohort of ARFAs during 2015/16, 2014/15, 2013/14, 2012/13, 2011/12. This will yield data on natural history of ARFAs including: co-morbidities (ICD 10 code), mode of admission, length of stay, readmissions, age, gender and geography. The researcher will compare ARFA findings to 3 other groups of patients from 2015/16-2011/12 national HES: non-alcohol-related-frequent attenders, non-alcohol-non-frequent attenders and alcohol-related-non-frequent attenders.
Data on the characteristics of frequent attenders and non-frequent attenders will be analysed using STATA SE. A logistic regression approach will be used to explore the variables derived from HES; demographics, diagnosis and attendance frequency.
The analysis of HES will produce a list of characteristics which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as 'assertive outreach' (specialist mental health services) treatment both nationally and locally
Study 2: The cost burden associated with ARFAs
Costs of health service usage by the 2015/16 ARFA cohort will be calculated per capita (on the basis of 2015/16 tariffs and occupied beddays) and compared to the costs of non-alcohol related frequent attenders. Total costs of ARFAs will be scaled up to national costs based on epidemiological results from study 1. Costs will be calculated from the health service perspective and will not explore full costs of ARFAs to society.
Sensitivity analysis- Using different assumptions and scenarios, how costs vary based on the definition of an ARFA used will be investigated ie comparing the costs to Kings Health Partners (KHP) of ARFAs with varying number of visits per year. Current literature documents multiple ARFA definitions and impact of ARFAs on health services may be important in finalising a definition going forward.
Expected output
The proposed project directly informs the design and purpose of services for ARFAs at Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The analysis of HES will produce a list of characteristics (at aggregated level and will not contain data pertaining to individuals) which are generic to ARFAs eg average age, average level of income deprivation etc which will be used to populate a risk stratification model initially for South London and then nationally. The risk stratification model will then be used to calculate the number of people (ARFAs) who could potentially benefit from accessing ARFA services such as assertive outreach treatment both nationally and locally, informing commissioning of services.
This population risk stratification project is part of a wider project to optimise services for ARFAs at KHP, which includes setting up an assertive outreach services (specialist mental health services) to specifically meet the needs of ARFAs.
The project is directly supervised by 2 Professors of Addictions at the National Addictions Centre based at KCL, one of whom leads the alcohol strategy for Kings Health Partners hospitals (Guys and St Thomas', Kings College and South London and the Maudsley NHS Trusts). The alcohol strategy steering group includes lay members, service users and other researchers and clinicians working on alcohol-based projects across South London. The principal investigator reports project progress to the alcohol strategy steering group.
The principal investigator and Professor/alcohol strategy lead are also part of the ARFA clinical network for South London, which meets every 6 weeks. The group consists of practitioners and clinicians working with ARFAs so provides direct insight in to the day-to-day treatment and issues for this particular patient group. The principal investigator reports project progress to this group.
Finally, the principal investigator’s project progress is also monitored on a quarterly basis through King's College London. Project findings are due to be reported November 2018 but due to the close working arrangements with clinicians described above, will inform service design from the outset.
The outputs from all of the projects will include peer reviewed papers in academic journals which will be submitted for publication by May 2018. In addition, lay summaries such as newsletters and blogs (on behalf of the South London Academic Health Science Network and Collaboration for Leadership in Applied Health and Care will be produced (March 2017-April 2018). Conference and seminar presentations to academic, policy, professional in the fields of public health and addiction sciences and public audiences will be made between March 2017 and November 2018. All reports and presentations will be produced containing aggregate results with small numbers suppressed that show trends over time, differences across providers, commissioners, geographical areas and by patient subgroups and patient characteristics. The results will contain estimated correlations showing associations between patient outcomes and patient characteristics, hospital, institutional, geographic and environmental factors.
Information about this study and its use of data will be made available to the general public through the South London CLAHRC website.
Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guide.
Benefits reported
Yielded Benefits is not a requirement for new applications.
Register history
When this agreement appeared in, or was edited in, each monthly edition of the register. Built by comparing every edition this site holds, the earliest of which is July 2021.
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July 2021 —
already listed in the earliest edition this site holds, so it may be older. 5 versions: DARS-NIC-44383-L6C0X-v0.2, DARS-NIC-44383-L6C0X-v1.7, DARS-NIC-44383-L6C0X-v2.27, DARS-NIC-44383-L6C0X-v3.4, DARS-NIC-44383-L6C0X-v4.6
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October 2021
Amended DARS-NIC-44383-L6C0X-v4.6
- Datasets: + HES-ID to MPS-ID HES Admitted Patient Care
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January 2022
Amended DARS-NIC-44383-L6C0X-v4.6
- Processing activities:
reworded
Show the change
[14 paragraphs unchanged] Under this
agreementAgreement, the data will be transferred to a hosting infrastructure supplied by Microsoft [53 words unchanged] Azure cloud: the application to NHS Digital has been approved- NIC 292279-Z2S5T-v6.6 [5 paragraphs unchanged]
- Processing activities:
reworded
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April 2022
1 version added: DARS-NIC-44383-L6C0X-v5.4
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December 2022
Register-wide edit DARS-NIC-44383-L6C0X-v2.27, DARS-NIC-44383-L6C0X-v3.4, DARS-NIC-44383-L6C0X-v4.6, DARS-NIC-44383-L6C0X-v5.4 — Datasets: legal basis: “
s261(1) and” taken out. Made to 639 agreements in this edition, so it is reported once, on the changes page, and not counted as an amendment of this agreement.
"Amended in place" means NHS England changed the record without issuing a new version number. The register publishes no changelog for those edits; this site infers them by comparing editions. An edit is attributed to the edition it first appears in, not to the date it was made.
Cite this page
NHS England (2026) Data Uses Register, September 2026 edition, agreement DARS-NIC-44383-L6C0X, “HES/Mortality data for the analysis of alcohol related frequent attenders to hospitals”. Read via NHS Data Access Explorer (unofficial), https://healthdatauses.uk/agreements/dars-nic-44383-l6c0x/ (accessed [date]).
This address stays the same, but the page is rebuilt with each monthly edition, so the citation names the edition it shows. Every edition's data is kept in the facts store.
Source: datausesregister_september2026.xlsx, September 2026 edition of the NHS England Data Uses Register. Search that workbook for DARS-NIC-44383-L6C0X to see the original rows.