Project Summary

Project Title

General Project Information

Project Type

Approval Type

Planned Project Start Date

Planned Project End Date

Overall Status

Project Summary

<div class="ck-content" data-wrapper="true" dir="ltr" style="--ck-image-style-spacing: 1.5em; --ck-inline-image-style-spacing: calc(var(--ck-image-style-spacing) / 2); font-family: 'Segoe UI','Helvetica Neue',sans-serif; font-size: 9pt;"><div style="font-family:'Segoe UI','Helvetica Neue',sans-serif;font-size:9pt;"><span style="font-family:Calibri,sans-serif;font-size:11pt;"><span style="line-height:107%;">Urinary Tract Infection (UTI) is common in all healthcare settings. There is considerable variation in how UTI is diagnosed in clinical practice, but a recently developed research reference standard allows a benchmarking exercise to be undertaken. The research reference standard could also be described as a 'gold standard'.&nbsp;</span></span></div><div style="font-family:'Segoe UI','Helvetica Neue',sans-serif;font-size:9pt;">&nbsp;</div><div style="font-family:'Segoe UI','Helvetica Neue',sans-serif;font-size:9pt;"><span style="font-family:Calibri,sans-serif;font-size:11pt;"><span style="line-height:107%;">We plan to use routinely available data from electronic health records (Barts Health Data Platform), to ascertain how current practice compares against the internationally agreed research reference standard. This may identify opportunities for better diagnosis, leading to better care and a reduction in antibiotic related side effects and antimicrobial resistance for older people with possible UTI at Barts Hospitals.</span></span></div></div>

Detailed Project Description

<div data-wrapper="true" style="font-family:'Segoe UI','Helvetica Neue',sans-serif; font-size:9pt"><div><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Urinary Tract Infection (UTI) is common in all healthcare settings. There is considerable variation in how UTI is diagnosed in clinical practice, but a recently developed research reference standard allows a benchmarking exercise to be undertaken. We plan to use routinely available data from electronic health records (Barts Health Data Platform), to ascertain how current practice compares against the internationally agreed research reference standard. This may identify opportunities for better diagnosis, leading to better care and a reduction in antibiotic related side effects and antimicrobial resistance for older people with possible UTI at Barts Hospitals</span></span></span></div></div>

Requested Data Summary

<div data-wrapper="true" style="font-family:'Segoe UI','Helvetica Neue',sans-serif; font-size:9pt"><div><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Barts’ Cerner Millenium System (CMS) contains structured coding of clinical events and related results, in the form of SNOMED codes have the potential to automate a large portion of the ‘structure and standardise’ process to create a cohort of people with possible UTI available for analysis (16).</span></span></span><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Minimum criteria defining entry into the cohort will be:</span></span></span><ul style="margin-bottom:13px">	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Unplanned consultation at Barts Health (including emergency department, acute medical units across the Royal London, Whipps Cross and Newham)</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Aged 65+</span></span></span></li></ul><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will then aim to identify people in whom the assessing clinician suspects UTI might be implicated. Candidate UTI related clinical search terms include (17):</span></span></span><ol style="margin-bottom:13px">	<li style="margin-bottom:11px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Urinary Tract Infection (UTI)/pyelonephritis/cystitis. Other search terms might be included if we can make use of Natural Language Processing to automate the search, for example dysuria/urinary frequency/incontinence/urinary retention/urosepsis/suprapubic pain/flank pain/perineal pain/painful prostate exam/prostatitis/haematuria</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Acute illness with a urinary catheter present.</span></span></span></li></ol><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Search terms will be developed iteratively through manual reviews of clinical summaries until informational saturation is achieved. Case note reviews to agree on additional search terms to be included will be undertaken by trainees in geriatric medicine in parallel. Disagreements will be resolved through discussion, with a third more senior geriatrician helping adjudicate where disagreement persists. Overall agreement will be reported using kappa statistics.</span></span></span><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Additional structured data (which will also be required to construct the research reference standard) might also serve as useful additional search terms:</span></span></span><ul style="margin-bottom:11px">	<li style="margin-bottom:11px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Urine and/or blood cultures growing the following organisms: Enterobacterales, Pseudomonas aeruginosa, Staphylococcus saprophyticus</span></span></span></li></ul></div></div>

Technical Description

<div data-wrapper="true" style="font-family:'Segoe UI','Helvetica Neue',sans-serif; font-size:9pt"><h2 style="margin-top:3px"><span style="font-size:13pt"><span style="line-height:107%"><span style="font-family:&quot;Calibri Light&quot;,sans-serif"><span style="color:#2f5496"><span style="font-weight:normal">Objective 1 Constructing an electronic cohort of older people with possible UTI</span></span></span></span></span></h2><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Barts’ Cerner Millenium System (CMS) contains structured coding of clinical events and related results, in the form of SNOMED codes have the potential to automate a large portion of the ‘structure and standardise’ process to create a cohort of people with possible UTI available for analysis (16).</span></span></span><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Minimum criteria defining entry into the cohort will be:</span></span></span><ul style="margin-bottom:13px">	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Unplanned consultation at Barts Health (including emergency department, acute medical units across the Royal London, Whipps Cross and Newham)</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Aged 65+</span></span></span></li></ul><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will then aim to identify people in whom the assessing clinician suspects UTI might be implicated. Candidate UTI related clinical search terms include (17):</span></span></span><ol style="margin-bottom:13px">	<li style="margin-bottom:11px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Urinary Tract Infection (UTI)/pyelonephritis/cystitis. Other search terms might be included if we can make use of Natural Language Processing to automate the search, for example dysuria/urinary frequency/incontinence/urinary retention/urosepsis/suprapubic pain/flank pain/perineal pain/painful prostate exam/prostatitis/haematuria</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Acute illness with a urinary catheter present.</span></span></span></li></ol><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Search terms will be developed iteratively through manual reviews of clinical summaries until informational saturation is achieved. Case note reviews to agree on additional search terms to be included will be undertaken by trainees in geriatric medicine in parallel. Disagreements will be resolved through discussion, with a third more senior geriatrician helping adjudicate where disagreement persists. Overall agreement will be reported using kappa statistics.</span></span></span><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Additional structured data (which will also be required to construct the research reference standard) might also serve as useful additional search terms:</span></span></span><ul style="margin-bottom:11px">	<li style="margin-bottom:11px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Urine and/or blood cultures growing the following organisms: Enterobacterales, Pseudomonas aeruginosa, Staphylococcus saprophyticus</span></span></span></li></ul><h2 style="margin-top:3px"><span style="font-size:13pt"><span style="line-height:107%"><span style="font-family:&quot;Calibri Light&quot;,sans-serif"><span style="color:#2f5496"><span style="font-weight:normal">Objective 2 Segmenting the cohort using the research reference standard</span></span></span></span></span></h2><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will ascertain in what proportion overall the reference standard could be estimated defined (arbitrarily) as having at least one item from each of the domains: symptoms, systematic criteria, pyuria and urine cultures.</span></span></span><br><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will describe the discharge diagnosis following the acute care episode alongside the research reference standard to check for agreement.</span></span></span><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will also be able to check overall agreement comparing definite/probable/possible UTI vs definitely no UTI in the research reference standard against a discharge diagnosis of UTI vs other (two by two table to calculate positive and negative agreement and kappa scores).</span></span></span><h2 style="margin-top:3px"><span style="font-size:13pt"><span style="line-height:107%"><span style="font-family:&quot;Calibri Light&quot;,sans-serif"><span style="color:#2f5496"><span style="font-weight:normal">Objective 3 Process and outcome measures by research reference standard</span></span></span></span></span></h2><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Important baseline covariates to be captured:</span></span></span><ul style="margin-bottom:13px">	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Demographics</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">National Early Warning Score (NEWS) 2(18)</span></span></span></li></ul><ul style="margin-bottom:13px">	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Clinical Frailty Score(19) (or if not reliably captured (to be expected), we could generate a Hospital Frailty Risk Score(20-22) or Charlson Comorbidity Index(23))</span></span></span></li></ul><h3 style="margin-top:3px"><span style="font-size:12pt"><span style="line-height:107%"><span style="font-family:&quot;Calibri Light&quot;,sans-serif"><span style="color:#1f3763"><span style="font-weight:normal">Process measures</span></span></span></span></span></h3><ul style="margin-bottom:13px">	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">Pre-hospital anti-microbial prescriptions</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">New prescriptions of antimicrobials</span></span></span></li>	<li style="margin-bottom:13px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:Calibri,sans-serif">AntiMicrobial Resistance (AMR) related hospital acquired harms: diarrhoea, nausea, vomiting, clostridial infection, new antimicrobial resistance event (e.g. identification of multidrug resistant pathogens)</span></span></span></li></ul><h3 style="margin-top:3px"><span style="font-size:12pt"><span style="line-height:107%"><span style="font-family:&quot;Calibri Light&quot;,sans-serif"><span style="color:#1f3763"><span style="font-weight:normal">Patient, carer and service outcomes</span></span></span></span></span></h3><ul style="margin-bottom:11px">	<li style="margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Service outcomes: length of stay, readmission at 30/90/365 days</span></span></span></li>	<li style="margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Mortality: length of stay, readmission at 30/90/365 days</span></span></span></li>	<li style="margin-bottom:11px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">New admission to long term care at 30/90/365 days</span></span></span></li></ul></div>

Public and Patient Involvement and Engagement Summary

<div data-wrapper="true" style="font-family:'Segoe UI','Helvetica Neue',sans-serif; font-size:9pt"><div><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">For this project and a related diagnostic accuracy study we are developing, we have spoken to over 30 people who have had or cared for someone with a UTI. They were members of six PPI forums based in Wales, London, Sheffield, Southampton and Oxford. They believe this research is ‘absolutely needed’ and has the potential to improve the lives of patients and their families. They felt strongly that:</span></span></span><ol style="margin-bottom:8px">	<li style="margin-bottom:8px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Diversity of PPI members was crucial in terms location, setting and ethnic group.</span></span></span></li>	<li style="margin-bottom:8px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">Involvement of carers and relatives was important, especially in those with reduced mental abilities.</span></span></span></li>	<li style="margin-bottom:8px; margin-left:8px;list-style-position:inside"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">The results of this study should help to raise awareness of UTI symptoms in older people.</span></span></span></li></ol><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will work with the Academic Centre for Healthy Ageing PPI group.</span></span></span></div></div>

Reporting

<div data-wrapper="true" style="font-family:'Segoe UI','Helvetica Neue',sans-serif; font-size:9pt"><div><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">This will be – to our knowledge – the first use of the research reference standard applied to clinical practice. We anticipate that it will highlight significant discrepancies in current diagnostic practice compared to the research reference standard. We anticipate describe significant harms from over-prescribing in older adults who do not have UTI (according to the research reference standard). It will provide evidence of the need for better near-patient diagnostic tests for UTI in older people.</span></span></span><br><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:Calibri,sans-serif">We will publish the findings in a high impact journal such as Age &amp; Aging. We will also share the findings locally through clinical governance structures, regionally through AMR associated bodies including public health teams, nationally through the BGS meeting and internationally through the European Geriatric Medicine Society meeting.</span></span></span></div></div>

Contact Points

Project Lead Name

Project Lead Position

Project Lead Email

Lead Organisation Name

Lead Organisation Address

The Royal London HospitalWhitechapel Road,

Secure Data Environment (SDE)

Will you be using the BH SDE

NoYes

Details of the location and IT system (the SDE) where the data extract will be kept and processed.