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Multiple Long-term conditions prevalence in England

A new paper that OBH has contributed to as part of the NHS England Multiple Long-Term Conditions (MLTC/Multimorbidity) Analytical Workstream, ‘Prevalence of Multiple Long-Term Conditions (Multimorbidity) in England: A Whole Population Study of over 60 million people’, has been published in the Journal of the Royal Society of Medicine. 

Our study sought to determine the prevalence of multiple long-term conditions (MLTC) (defined as having two or more of 35 long-term conditions) at the whole English population level, stratifying by age, sex, socioeconomic status and ethnicity. The study uses the National ‘Bridges to Health’ Segmentation Dataset, which contains linked data for c.60 million individuals registered with a general practice in England and alive on 31st March 2020. 

We found that the overall prevalence of MLTC was 14.8% (8,878,231), varying from 0.9% (125,159) in those aged 0-19 years to 68.2% (1,905,979) in those aged 80 years and over. There were large numbers of combinations of conditions in each age group ranging from 5,936 in those 0-19 years to 205,534 in those aged 80 years and over. The prevalence of each condition in those with MLTC varied between age groups; in individuals aged 0-19 years, asthma, autism and epilepsy were dominant, while in individuals aged 20-49 years, depression and asthma were dominant and in individuals aged 50-59 years, hypertension and depression were dominant. In individuals aged 60-69 years, 70-79 years and 80+ years, cardiometabolic factors and osteoarthritis were dominant.

This study provides useful insight into the burden across the English population to assist health service delivery planning, however the heterogeneity of MLTC presents challenges for delivery optimisation.

 

Read more here: https://journals.sagepub.com/doi/10.1177/01410768231206033

Find out more about the underlying dataset used for this work, see here: https://outcomesbasedhealthcare.com/nhse-segmentation-dataset-reference-guide/

‘Identifying Populations with Chronic Pain in Primary Care’ Paper Published

A new paper from a research partnership between Guy’s & St Thomas’​ Foundation, King’s College London and Outcomes Based Healthcare on ‘Identifying populations with chronic pain in primary care: developing an algorithm and logic rules applied to coded primary care diagnostic and medication data’ has been published in BMC Primary Care.

Estimates of chronic pain prevalence using coded primary care data have previously been lower than rates reported in community surveys. Our aim was to develop and test an algorithm combining medication codes with selected diagnostic codes to estimate chronic pain prevalence using coded primary care data. The resulting algorithm for chronic pain – based on four overarching criteria – was run on primary care data from 41 GP Practices in Lambeth (total population of 386,238 GP registered adults). The study found 16.6% (64,135) were identified as people with chronic pain. This definition demonstrated notably high rates in Black ethnicity females, and higher rates in the most deprived, and older population.

Our study demonstrates that it may be possible to establish more representative prevalence estimates using structured data than has been previously achieved. The use of logic rules therefore offers the potential to move systematic identification and population-based management of chronic pain into mainstream clinical practice at scale, and subsequently support improved management of symptom burden for people experiencing chronic pain.

Read the full article here: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-023-02134-1

OBH and All Together Better Sunderland publish joint Population Health Management Case Study

In partnership with All Together Better (ATB) Sunderland, Outcomes Based Healthcare have jointly published a case study which provides reflections on the progress of the ATB Sunderland ‘Outcomes’ programme, and shares learning from Sunderland’s Population Health Management journey to date.  

ATB Sunderland is an alliance of out of hospital providers and commissioning organisations, who partnered with OBH in 2019 to develop capabilities and draw on expertise in outcome measurement. Over the past four years ATB Sunderland and OBH, have developed a unique person-level linked longitudinal primary and secondary care segmentation dataset for the population, using the internationally recognised ‘Bridges to Health’ Segmentation Model to their population. This dataset now underpins one of the richest longitudinal records of whole population health outcomes data of its kind, measuring outcomes on a monthly basis from April 2013 to March 2022. 

ATB Sunderland and OBH also built a comprehensive Outcomes Framework which includes 27 outcomes, aligned to key strategic areas of Sunderland CCG’s transformation programme and scope of services. This includes a unique set of outcome measures called ‘HEALTHSPAN®’, which can show whether people are in good health, and for what portion of their lives. Population-level ‘HEALTHSPAN®’ developed by OBH over the last five years is an objective whole population outcome measure of the amount of time individuals spend in good health. This is used to indicate the success of health and care systems in helping keep people healthy for the greatest possible proportion of their lives. 

The outcomes data is visualised in OBH’s Outcomes Platform, an online tool accessible to ATB clinicians and those working in the ATB alliance. The Outcomes Platform is part of ATB’s growing Population Health Management (PHM) programme. Insights are used to understand the health and care needs of the local population and to proactively plan services for different groups of people within the population. 

To read the full report, click here

To read the executive summary, click here

OBH, the full nine years!

Last week saw OBH’s 9th birthday. I often take this point each year to reflect on where we are on OBH’s original mission; to support health and care systems in […]

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OBH featured in the DIT Digital Health Playbook ‘Beyond 100’

OBH has been featured in the Department for International Trade (DIT) Digital Health Playbook ‘Beyond 100’.

The Digital Health Playbook showcases UK innovators in the fields of Data & Analytics, Systems & Transformation, Healthy Aging.OBH were selected based on our track-record of working collaboratively within Healthcare UK (DIT), our innovation in digital health, and our commitment to export and expand internationally.

Find out more and see the full Playbook here: https://bit.ly/3HnSAQw

Defining multimorbidity article published

The final output of work conducted by a research partnership between Guy’s & St Thomas’​ Foundation King’s College London and Outcomes Based Healthcare on defining multimorbidity within local areas has been published in BMC Family Practice!

Defining multimorbidity has proved elusive in spite of attempts to standardise definitions. For locally based studies, the definition may need to better reflect local demographic, inequality and morbidity patterns.

We aimed to define multimorbidity for an inner-city, multi-ethnic, deprived, younger population typical of many large cities. We present a process and criteria for selecting LTCs to be included within a locality-based consensual definition of multimorbidity.

Redefining multimorbidity for an urban context has many important implications for understanding the progression of LTCs. Understanding how they relate to each other within an urban context is vital. The paper also introduces research currently underway to explore potential ‘gateway conditions’ which, if managed appropriately, might potentially delay or prevent progression to other conditions.

Read the full article here: https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-021-01477-x 

Value-Based Healthcare Report feature by Creasphere

We have been featured in the Creasphere Insights Report on insights and trends in value-based healthcare alongside other organisations working in this space. 

Our mission to drive health system improvement through the measurement and incentivisation of health outcomes that matter most to people and patients is at the centre of all our work. So it’s brilliant to see this important report highlighting the potential to improve health systems through this approach.

Take a look at the Creasphere Insights Report here: https://bit.ly/3Ny7585

OBH awarded a prestigious Queen’s Award for Enterprise!

We are thrilled to reveal that Outcomes Based Healthcare has been awarded a highly prestigious Queen’s Award for Enterprise, for “outstanding achievements in Innovation”!

Innovation is integral to OBH’s mission to drive health system improvement through measurement and incentivisation of health outcomes. In fact, we haven’t stopped innovating since OBH started 8 years ago… from creating our Segmentation Engine that drives the OBH Outcomes Platform, to developing HEALTHSPAN® as a way of measuring a population’s healthy lifespan, to supporting the NHS in the pandemic, and our ongoing commitment to supporting the work of the All-Party Parliamentary Group for Longevity, #teamOBH really has been busy.

We are so grateful to everyone who has supported us over the years and feel honoured to be part of #TheQueensAwards for Enterprise 2021. Read about why OBH has been awarded a Queen’s Award here – find us on page 30!

Finally, congratulations to all our fellow #QueensAwards winners!

Happy 8th Birthday OBH!

It feels like a long time ago that we set out with OBH- in fact, 8 years ago exactly! The original mission was to help solve one of the biggest problems in healthcare- enabling effective measurement and payment systems for prevention, and what really matters to people. In short, their health outcomes. We’ve grown over the years and the way we go about that mission has evolved, but we’re still innovating around that core purpose.

It’s been a busy year supporting the NHS in the pandemic, and we have been delighted to support some fabulous organisations in their work. Last week saw the release of the Levelling up Health Report by the All-Party Parliamentary Group for Longevity alongside their work on the Business for Health Index. We remain committed to supporting this work in whatever way we can.

OBH are also delighted to have worked with King’s College London on the recent flagship report addressing drivers of Multiple Long Term Conditions, published by Guy’s and St Thomas’ Foundation.

Thank you to OBH’s friends, supporters and team for supporting us over the last 8 years!

OBH is a strategic partner with NHS England on the #COVID19 Data and Analytics Community!

We’re so excited to announce that OBH are now a strategic partner with NHS England on the #COVID19 Data & Analytics Community! Lots of exciting collaborative #segmentation #analytics work to come – understanding & deriving meaningful insight into population health at a local, regional and national level!

More information on the #futureNHS Data and Analytics for Covid-19 workspace can be found here.

Launch of the Population and Person Insight (PaPI) report to improve understanding of patient healthcare needs!

OBH are thrilled to announce the launch of the Population and Person Insight dashboard! #TeamOBH have been working in partnership with NHS England and NHS Improvement, and NHS Arden & GEM CSU on a data-driven approach to understanding and deriving meaningful insight into population health. The dashboard has been developed using national datasets – including secondary care, emergency care, community services and specialised services data – to group patients into segments based on common healthcare needs.

Understanding the population by cohorts of those with similar health and care needs is integral to a more person-focussed health system. Using the Bridges to Health segmentation dataset, this tool enables deeper insight into people who are healthy, people with long term conditions, people with disability, as well as those people who are nearer the end of life with cancer, organ failure, frailty and dementia.

The interactive tool contains a series of views so that users can easily explore and interrogate these population segments at a national, regional, system, CCG and PCN level.

With four years’ worth of data, users can also drill down into acute utilisation, cost and outcomes by segment to support service planning and redesign. Visualisations by age, ethnicity, deprivation and socio-demographic classification help to easily identify cohorts for further investigation and analysis.

In response to the current pandemic, a COVID-19 view was also developed with the aim of aiding NHS restoration and recovery programmes by helping systems to identify their vulnerable populations who have one or more ‘at risk’ conditions to inform decision-making around shielding and planning for the largest vaccination programme in the history of the NHS.

Sukhmeet Panesar, Deputy Director of Strategy and Development at NHS England and NHS Improvement said: “The NHS generates a huge amount of data which can be used to drive improvements in care and how services are run. By providing health and care systems with data which is grouped by population segments we can support NHS and local authority leaders to plan effective services and interventions based on meeting the healthcare needs, risks and priorities of their patients and citizens.”

Ayub Bhayat, Chief Data Officer at Arden & GEM said: “The population and person insight report acts as a diagnostic tool for every level of the system, enabling commissioners and providers to spot opportunities for further analysis and intervention. By providing a starting point for population health management approaches, we can then work with local areas to refine the model with their local intelligence and benchmark emerging opportunities.”

Dr Nasrin Hafezparast, Chief Clinical Data Officer at Outcomes Based Healthcare said: “The internationally-recognised Bridges to Health segmentation model provides a person-centred approach. By using this approach as the foundation for the new report we can categorise the entire population of 62 million people into eight segments, with 55 subsegment or condition registries on a monthly basis, over the past 4 years. It includes a first ever view of population-level healthy lifespan, or HEALTHSPAN®. The report also incorporates feedback from a wide range of groups including clinicians to ensure the data is meaningful.”

The report, which was launched on 15 February, is available to healthcare commissioners and providers within the NHS ViewPoint analytical application.

For more information about the report, and the wider population and person insight workstream, visit the dedicated FutureNHS workspace.

OBH awarded supplier status on G-Cloud 12!

We are very happy to announce that the Government’s Crown Commercial Service has again awarded Outcomes Based Healthcare supplier status on the latest Digital Marketplace platform, G-Cloud 12!

The OBH® Outcomes Platform is available as a Cloud Software Service & provides users with person-centred health outcome measures at a population and cohort/condition level, including OBH’s core prevention outcomes: HEALTHSPAN®. The Platform is powered by OBH’s® Segmentation Engine – an essential, core backbone for population health management data analytics work across different local NHS & local authority organisations, and their health and care partners. The Segmentation Engine is now also available as a ‘stand alone’ module, for more experienced NHS & local authority analytical teams, who wish to incorporate population segmentation datasets into their existing analytics work.

Based on the foundations of the Bridges to Health segmentation model, both solutions provide person-centred, meaningful insights for specific population segments & care pathways.

Find us on G-Cloud 12:
-OBH® Outcomes Platform (https://lnkd.in/daaNepF)
-OBH® Segmentation Engine (https://lnkd.in/dyU7wJf)

Diabetes #COVID19 mortality & risk in England paper published in The Lancet Diabetes and Endocrinology!

Fantastic to see NHSE England and Public Health England’s #diabetes #COVID19 mortality & risk in England paper published in The Lancet Diabetes and Endocrinology!

The whole population study used the Bridges to Health National Population Segmentation dataset developed in partnership between Outcomes Based Healthcare, NHS England, Arden and Gem CSU and Public Health England to identify co-morbidities and ethnicity.

One of the many brilliant examples of the power of #healthanalytics in creating actionable insights to support the national response to Covid-19 – driven by a multidisciplinary team of clinicians, analysts, researchers and more!

Read the full paper here.

 

National HEALTHSPAN and Lifespan modelling in the UK features in Longevity Trends 2020 Report!

Published by the Longevity Leaders in August 2020, the report summarises the most important trends in longevity research to date that businesses, policy makers, scientists and the general population should be aware of.

Having recently presented at the Longevity Leaders World Congress 2020 on National HealthSpan and Lifespan modelling in the UK, CEO Rupert’s presentation was summarised in this edition of the Longevity Trends Report. Making reference to OBH’s objective HEALTHSPAN® measure which monitors population-level changes in the proportion of life spent in good health, the whitepaper highlights the importance of applying an objective approach to measuring individual health status, covering whole populations.

With evidence suggesting that more people are being diagnosed with significant long-term conditions earlier in their lives, and living with them for longer than we had previously thought, measuring the progression of ill health and population level changes over a life course has never been more important.

Read the full report here.

OBH awarded grant by UK government to fund project – Outcomes Risk Scores for Covid-19 Vulnerable Populations!

OBH are delighted to announce that we have been awarded a grant by the UK government to fund our project – Outcomes Risk Scores for Covid-19 Vulnerable Populations!

Rapidly repurposing the robust foundations of the Bridges to Health national population segmentation model developed in conjunction with NHS England, Public Health England and Arden and Gem CSU, the development of Covid-19 Risk scores will allow an enhanced understanding of the relative and independent risk factors relating to #Covid-19. This analysis will enable the risk profile of local areas to be accurately assessed and stratified according to the latest emerging evidence, and also support our understanding of the effect of age and ethnicity on Covid-19 complications, independent of comorbidities.

The Innovate UK Covid-19 Rapid Response competition received a record 8,600 applications, investing £40 million to support UK businesses to focus on emerging or increasing needs of society and industries during and following the #Covid-19 pandemic. Find out more about our Covid-19 work here!

Rupert speaks at the Longevity Leaders World Congress on National HealthSpan and Lifespan modelling in the UK!

In keeping with the somewhat virtual world most of us continue to live in, CEO Rupert spoke at the Longevity Leaders World Congress 2020 via livestream this week on the topic of “Data-dive: National HealthSpan and Lifespan modelling in the UK”!

OBH recently contributed to the All-Party Parliamentary Group for Longevity ‘The Health of the Nation’ national strategy for #HealthierLongerLives, and Rupert discussed the importance of applying an objective approach to measuring individual health status, covering whole populations. This evidence suggests that more people are being diagnosed with significant long-term conditions earlier in their lives, and living with them for longer than we had previously thought. So measuring the progression of ill health and population level changes over a life course has never been more important.

Using routinely collected, linked longitudinal health and care data, from multiple ‘real world’ care settings, OBH’s objective HEALTHSPAN® measure monitors population-level changes in the proportion of life spent in good health.

More information here!

Juliana presents at the IBRAVS Knowledge Agenda on Value-Based Healthcare in England – Implementation at Population Level!

Speaking live from London to an audience over 5000 miles away (!), COO Juliana recently presented at the IBRAVS Knowledge Agenda 2020, on the topic: Value-Based Healthcare in England – Implementation at Population Level.

As part of a webinar series aimed at improving our understanding of what “value in health” really means, Juliana provided a whistle-stop tour of the current VBHC landscape in the UK, the importance of segmentation according to clinical needs at a whole population level, and the application of VBHC initiatives and segmentation within the context of Covid-19.

To find out more (and if your Portuguese is up to scratch!) click the link to the full video now available to watch on Youtube!

HAPPY SEVENTH BIRTHDAY OBH!

As we mark our birthday virtually this year against the backdrop of the current pandemic, we’d like to thank all of our amazing OBH supporters, advisors and friends who’ve been part of our exciting journey measuring what matters most in health over past 7 years! Here are a few highlights from what has definitely been the busiest (and more recently, the most unpredictable!) year yet…. including the prospect of potentially taking on some clinical work again amongst the data analytics work for some of us.

Over the past 12 months, OBH have been working with NHS England on the implementation of an actionable, common, data-driven approach to population segmentation. In collaboration with NHS Arden and GEM Commissioning Support Unit and the Data, Analysis and Intelligence Service (DAIS) at NHSE/I, the programme of work seeks to build a common framework for segmentation by developing the ‘Bridges to Health’ segmentation model using data sources from the National Commissioning Data Repository (NCDR).

Building on the solid foundations of this person-centred data model, over the past few weeks we’ve been very busy adjusting the model to address the immediate needs of the COVID-19 pandemic response. This aims to support work to establish the populations currently thought to be most ‘vulnerable’ to severe illness from COVID -19. Find out more here.

Back in February, which already seems like a completely different era, we were delighted to have contributed to the APPG ‘The Health of the Nation’ national strategy for #HealthierLongerLives! We look forward to continuing to support this important work, applying OBH’s objective HealthSpan™ and HealthyLifespan® Index at a population level to meet the government’s mission of five extra healthy years by 2035. Given recent events, ensuring a renewed focus on the prevention of ill-health, whilst narrowing the gap between the richest and the poorest seems more urgent than ever. Read the full report here.

Having been selected to participate in the Health Data Research UK Sandbox in September 2019, we look forward to continuing this work involving the use of linked, longitudinal health data to measure and validate OBH’s HealthSpan™ and HealthyLifespan® index measures throughout the future. Find out more here.

And last but not least, we had a great time hosting our second clinical associates network event at the Health Foundry back in October! It was fantastic to see so many members of the #obhnetwork community and welcome some new faces too.

Despite current events, we look forward to seeing what the next year has to hold in what we hope will be a slightly less strange time for everyone! From everyone in the OBH team, we’d like to thank you again for all your support over the past 7 years. We hope you, your families and colleagues keep safe and well.

#OBHis7 #outcomes #healthspan

Launch of the All Party Parliamentary Group for Longevity national strategy for #HealthierLongerLives!

OBH are delighted to have contributed to the APPG ‘The Health of the Nation’ national strategy for #HealthierLongerLives, launched in February 2020!

OBH’s objective HEALTHSPAN® and HEALTHY LIFESPAN® Index measures use routinely collected, population-level, linked longitudinal health & care data across multiple care settings. These accurately measure the proportion of people’s lives which are spent in good health – either at national, regional or local level. By applying such metrics at a population level, we are able to gain a comprehensive and objective understanding of the health of the nation. This includes the health and care expenditure associated with improvements or deteriorations in HEALTHSPAN.

We look forward to continuing to support this fantastic work to meet the government’s mission of five extra healthy years by 2035, ensuring a renewed focus on the prevention of ill-health, while narrowing the gap between richest and poorest.

Read the full report here: https://appg-longevity.org/events-publications.

Outcomes, HEALTHSPAN and more at the second OBH Clinical Associates Network event!

In October, OBH were delighted to host the second Clinical Associates Network event at the Health Foundry!

Senior Analysts Ellie and Rose kicked off with OBH’s latest work on population segmentation and HealthSpan measurement. They discussed the importance of baseline measures and real-time measurement when monitoring outcomes, as well as the adaptation of the Bridges to Health segmentation model to allow local health and care systems to configure their segments according to their priorities.

Bob Klaber then followed with a fantastic overview of his work on the Connecting Care for Children programme, highlighting the importance of building relationships across providers and people, summarising key design prinicples to consider when organising care models for children and young people.

It was fantastic to see so many members of the #obhnetwork community and welcome some new faces too….we look forward to hosting the next event!

Read more about the OBH Clinical Associates Network here.