NHS Digital Data Release Register - reformatted

Intensive Care National Audit & Research Centre (ICNARC)

Project 1 — DARS-NIC-96444-N2B7K

Opt outs honoured: No - consent provided by participants of research study (Reasonable Expectation, Consent (Reasonable Expectation))

Sensitive: Sensitive

When: 2018/06 — 2019/08.

Repeats: Ongoing, One-Off

Legal basis: Health and Social Care Act 2012 – s261(7), Other - Health and Social Care Act 2012 - s261(1) and s261(2)(c)

Categories: Identifiable

Datasets:

  • MRIS - List Cleaning Report

Objectives:

The 65 Trial is a pragmatic, multi-centre, parallel group randomised clinical trial (RCT) aiming to evaluate the clinical and cost-effectiveness of permissive hypotension (a mean arterial pressure (MAP) target range 60-65 mmHg whilst receiving vasopressors) in critically ill patients aged 65 years or over with vasodilatory hypotension. This research is important to patients and the NHS because of emerging evidence from a meta-analysis suggesting that using a lower MAP target (permissive hypotension) to guide vasopressor treatment may increase survival in older critically ill patients. The prior research has involved too few patients to fully test this idea and therefore guide clinical decision-making, and a large clinical trial (this trial – the 65 Trial) is needed to provide robust evidence as to the effectiveness of using a lower MAP target to guide treatment in critical care. The 65 Trial is funded by the National Institute for Health Research, Health Technology Assessment Programme (reference: 15/80/39), sponsored and managed by the Intensive Care National Audit & Research Centre (ICNARC) (reference: 01/05/17) and aims to include 2,600 participants from approximately 65 NHS adult, general critical care units across England, Wales and Northern Ireland. The primary objective for processing NHS Digital data in this application is to provide important outcome data for the 65 Trial. The outcomes for the trial are: Primary outcomes: • all-cause mortality at 90 days (clinical evaluation) • incremental net monetary benefit (INB), evaluated at the NICE recommended threshold of £20,000 per quality-adjusted life year (QALY), at 90 days (economic evaluation) ICNARC are requesting patient status (i.e. dead, alive, unknown/unable to link) and date of death (if applicable) from NHS Digital to directly contribute to the clinical evaluation primary outcome data (all-cause mortality at 90 days post-randomisation) and the ‘duration of survival to longest available follow-up’ secondary outcome data. Fact of death (as opposed to date of death) would not be sufficient to address these outcomes, as a date is required to calculate the duration of survival. In addition, participants are actively followed-up and sent questionnaires by the 65 Trial team at ICNARC at 90 days and then one year post-randomisation. Given the nature of critical illness, unfortunately some participants will pass away during the trial follow-up period. Participant status and date of death obtained from NHS Digital will therefore allow the researcher to ascertain whether contact at these follow-up time-points is appropriate. Where ICNARC finds out that a participant has passed away, no contact will be made - helping to ensure relatives are not caused undue distress by no longer appropriate contact. Following the end of participant recruitment for the 65 Trial, ICNARC would also like to link the 65 Trial data with Hospital Episode Statistics (HES) data – to provide data to contribute to the integrated economic evaluation. This will be subject to an amendment to this agreement. ICNARC is an independent health research charity which aims to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate. ICNARC requires data from NHS Digital for the purposes of these legitimate interests. Processing personal data is necessary for ICNARC's legitimate interests which are described in this application. The data to which access is requested are proportionate and necessary to achieve those interests. ICNARC have completed a legitimate interests assessment (LIA) and are satisfied that the interests of the data subjects do not override our legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm. The data subjects interests and fundamental rights are protected through appropriate minimisation of fields and patient records being processed; pseudonymisation to minimise any risk of identifying individuals; protection of the data in a secure environment, and guaranteeing secure destruction at any stage at the request of NHS Digital or after a defined period on completion of the project. ICNARC have assessed this against the ICO’s checklist (https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/lawful-basis-for-processing/legitimate-interests/) and are content that the requirements are met.

Yielded Benefits:

The 65 Trial completed patient recruitment in March 2019 and follow-up is ongoing. Following completion of data collection, the database will be locked, analysis conducted and papers/reports prepared for publication in high impact peer reviewed medical journals (according to the timeline outlined previously). The protocol for the 65 Trial, along with the Statistical Analysis Plan, were both accepted for publication the Journal of the Intensive Care Society in March 2019 and are anticipated to be published in the coming months.

Expected Benefits:

The 65 Trial is a pragmatic, multi-centre, randomised clinical trial to evaluate the clinical and cost-effectiveness of permissive hypotension (mean arterial pressure (MAP) target range 60-65 mmHg whilst receiving vasopressors) in critically ill patients aged 65 years or over with vasodilatory hypotension. There is genuine uncertainty as to which MAP target should be used in critically ill patients in critical care units. It is not yet known whether permissive hypotension is clinically and cost-effective (this is what the 65 Trial will provide information on) but - it is anticipated that if the strategy of permissive hypotension is found to be clinically and cost-effective, that implementation of these outputs into national and international clinical guidelines and subsequently into the NHS will lead to improvements in monitoring and titration of vasopressors in the critical care unit, ensuring a reduction in the potentially unnecessary exposure to vasopressors in elderly patients. This will reduce the burden on patients and their carers and to the NHS. This will need an effective implementation strategy. Active and wide dissemination of the results of the 65 trial will be an important part of this strategy – and will begin upon publication of the primary trial results (estimated to be published before summer 2020). A number of approaches have been identified, including: involving stakeholders; providing evidence in an integrated and graded way; taking account of the context and identifying the elements relevant to decision making, e.g. benefits, harms and costs; making recommendations as specific as possible; and using a multifaceted approach.

Outputs:

The results of the 65 trial will be both widely and actively disseminated. ICNARC has access to both patients and their families and close friends from its recent collaboration in two modules (http://www.healthtalk.org/intensive_care/) for the award-winning website Healthtalk (http://www.healthtalk.org/). In addition, ICNARC works with the Intensive Care Unit Support Teams for Ex-Patients (ICUsteps), the intensive care patient support charity, already collaborating on the Family Reported Experiences Evaluation Study funded by the NIHR Health Services & Delivery Research Programme. The 65 Trial team at ICNARC will work with both Healthtalk and ICUSteps to ensure the results of the trial are fed-back to patients. In addition, the results will also be available to patients and the public via the ICNARC website (www.icnarc.org). Furthermore, ICNARC has established strong links with the critical care community, which include: a large network of NHS critical care units (>250) in the UK through its National Audit Programme and CTU; close links with the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS), the representative body in the UK for critical care professionals (ICNARC has representation on the ICS Council and membership of the ICS Research Committee); close links with the British Association of Critical Care Nurses (BACCN) and the Royal College of Nursing Critical Care and In-flight Nursing Forum (RCN CCINF); representation on the NIHR Comprehensive Clinical Research Network Critical Care Specialty Group; and being one of the founding organisations of the UK Critical Care Research Group. The results of the 65 trial will be presented at: regional critical care network meetings; national professional conferences (e.g. ICS, BACCN, RCN CCINF); the ICNARC Case Mix Programme Annual Conference; the Annual Meeting of the UK Critical Care Research Forum; and national and international critical care conferences/meetings. This dissemination plan will ensure that the results of the 65 Trial are fed back to those delivering and organising care (e.g. nurses, doctors, managers) in the NHS (and across the world), allowing for any learning from the 65 Trial to influence clinical practice for the benefit of critically ill patients. [Note: It will not be possible to identify any individual participating patient in any trial reports or presentations]. A comprehensive report will be submitted to the NIHR for publication in the peer reviewed, open access Health Technology Assessment journal and will include recommendations for future policy, practice and research. The results will also be submitted for publication in a high-impact, widely-read, open-access (where possible), general medical journal, such as the New England Journal of Medicine (where the last two large ICNARC trials have been published). Both of these reports will be submitted for publication in October 2019, and expected to be published before summer 2020. All data presented/reported will be aggregated at a national level, with small numbers suppressed in line with HES analysis guide. It will not be possible to identify any individual participating patient in any reports, articles or presentations.

Processing:

On a monthly basis, for accruing trial participants, an authorised member of the 65 Trial team at the ICNARC CTU will provide one excel spreadsheet, securly via SEFT, to NHS Digital. The excel spreadsheet will contain participants’ 65 Trial number, name, date of birth, postcode and NHS number. These data are identifiable, provided at record level and sent to NHS Digital on a monthly basis while the trial is ongoing. The cohort size is between 1,500 and 2,600. NHS Digital will then link these data to create a list cleaning report to confirm each patients’ status (at that point in time), and, if relevant, date of death. NHS Digital will provide an excel spreadsheet to an authorised member of the 65 Trial team at the ICNARC CTU that contains the following: 65 Trial number, patient status, and death of death (if relevant). NHS Digital should also indicate where it has not been possible to complete linkage (e.g. unable to link). These data are pseudonymised, returned with a study id and provided at record level. The data received from NHS Digital will be incorporated into the record level 65 Trial database, stored on secure servers, managed by Red Technology Ltd, on behalf of ICNARC. In addition, ICNARC will regularly back-up the data through Disaster Recovery Service Ltd (DRS). Both Red Technology Ltd and DRS are contractors authorised by ICNARC and whom both have sufficient security assurances in place. Red Technology UK and Disaster Recovery UK employees will not access the data. The data will be analysed by authorised members of the 65 Trial team at the ICNARC CTU. All outputs will be aggregated at a national level, with small numbers suppressed in line with HES analysis guide. It will not be possible to identify any individual participating patient in any reports, articles or presentations. Once analysis and primary dissemination is complete, the data will be archived for five years. After five years, data will be anonymised, and identifiable data confidentially destroyed from all locations (ICNARC, Red Technology Ltd and DRS). All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).


Project 2 — DARS-NIC-46844-W5V5G

Opt outs honoured: N

Sensitive: Sensitive

When: 2017/09 — 2018/02.

Repeats: Ongoing

Legal basis: Informed Patient consent to permit the receipt, processing and release of data by the HSCIC

Categories: Identifiable

Datasets:

  • MRIS - Flagging Current Status Report
  • MRIS - Cohort Event Notification Report

Objectives:

The objective for processing these data are to aid the follow-up of patients in the Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients (POPPI) cluster-randomised controlled trial. Data obtained from NHS Digital will be used only to ascertain whether patients taking part in the trial are still alive at six months (the follow-up time point for the POPPI trial). Where ICNARC find out that a patient has passed away, no contact will be made - helping to ensure relatives are not caused undue stress by no longer appropriate contact. The POPPI trial is funded by the National Institute for Health Research Health Services and Delivery Research Programme (funding reference 12/64/124) and is carrying out a clinical and cost-effectiveness evaluation of a nurse-led preventative psychological intervention for patients in intensive care, with the aim of reducing the burden of serious psychological morbidity at six months (which include post-traumatic stress disorder, anxiety and depression). Patients surviving to six months after providing informed consent are sent a follow-up questionnaire (which contains the primary outcome and some secondary outcomes for the trial). Primary outcomes: To evaluate, Patient-reported PTSD symptom severity at six months and Incremental costs, quality adjusted life years and net monetary benefit Secondary outcomes: To compare: Days alive and free from sedation to day 30, Duration of critical care unit stay and Depression at six months. Post traumatic Diagnostic Scale score of greater than 18 points at six months and Health-related quality of life at six months

Expected Benefits:

The main benefit for the data being requested is to ensure that no further contact is made by the POPPI trail with participants who have passed away helping to ensure relatives are not caused undue stress by no longer appropriate contact. Studies indicate high rates of serious psychological morbidity (e.g. post-traumatic stress disorder, anxiety and depression) amongst patients after their stay in a critical care unit. Early psychological assessment of risk and subsequent intervention/support are both key to reduce longer-term psychological morbidity. The Psychological Outcomes following a nurse-led Preventative Psychological Intervention for critically ill patients (POPPI) cluster-randomised controlled trial sets out to inform the NHS on improving both access to, and delivery of, services to ensure that critically ill patients receive both psychological assessment and intervention/support in a cost-effective manner. The POPPI complex intervention includes creating a more therapeutic environment for patients in the critical care unit, assessing consenting patients for acute psychological stress and, for those identified as acutely stressed, delivering three one to one stress support sessions (which are delivered by a specially trained POPPI nurse). It is not yet known whether this intervention is beneficial for patients (this is what the trial will determine) or cost-effective for the NHS, but if this intervention is found to be clinically and cost-effective, the results of the trial will have a high impact on critical care services in the UK and internationally, particularly as there is no current routine care pathway to address the psychological morbidity of critical care patients in the UK. The primary results of the trial are estimated to be published in March 2018.

Outputs:

The output for the purpose of this request will be the cohort dataset with information about who has passed away and details of the GP practice for all members. This will then be used to enable the appropriate follow up questionnaire to be sent out to all living participants of the POPPI Trial. For the POPPI trail itself the team will prepare and submit a report to the funder - National Institute for Health Research (NIHR) Health Services and Delivery Research Programme. Clinical trials funded by the NIHR are published in the open-access (free of charge) NIHR Journal's Library (http://www.journalslibrary.nihr.ac.uk/), meaning the results can be accessed by patients, carers, clinicians and researchers alike. The estimated publication date for the NIHR report is March 2018. Articles will also be submitted to relevant scientific journals (e.g. medical journals and psychology journals). It will not be possible to identify any person who has taken part in the study in any reports or articles. The results of the POPPI trial will be both widely and actively disseminated. A full detailed report of the POPPI trial will be submitted to the National Institute for Health Research for publication in the peer reviewed, open access Health Services and Delivery Research Programme journal (due to be published in March 2018). The primary results will also be submitted for publication in March 2018 in an high-impact, widely-read, general medical journal, such as the New England Journal of Medicine (this is where the last two large ICNARC trials have also been published). In addition, the results of the POPPI trial will be presented at: regional critical care network meetings; national professional conferences; the Annual Meeting of the ICNARC Case Mix Programme; the Annual Meeting of the UK Critical Care Research Forum; and national and international critical care and clinical and health psychology conferences/meetings. This dissemination plan will ensure that the results of the trial are fed back to those delivering and organising care (e.g. nurses, doctors, managers) in the NHS (and across the world), allowing for any learning from the trial to influence clinical practice for the benefit of critically ill patients. The trial results will also be available to patients and the l public via the ICNARC website (www.icnarc.org) and a press release. [Note: It will not be possible to identify any individual participating patient in any trial reports or presentations].

Processing:

Patients providing informed consent to take part in the POPPI trial have agreed for identifiable information to be collected about them. For patients reaching six months in the trial and who are believed to be alive, their date of birth, postcode, NHS number and patient ID number will be provided to NHS Digital. NHS Digital will then link these identifiers to national records and send back a spread sheet confirming the latest status for each patient, and if relevant, the date of latest posting. The General Practice (GP) code field has been requested to facilitate the follow-up of patients in the trial. Where a patient has not responded to the follow-up questionnaire, the POPPI trial team will contact the patients GP practice to confirm or update contact details. The GP code will be used by the POPPI trial team to enable the patient’s GP practice to be identified rapidly, and ensure follow-up is completed timely. Updated data will then be added to the secure POPPI trial database to ensure no contact is attempted with patients who have passed away. Data collected from NHS Digital will be used only by a limited number authorised individuals in the POPPI trial team who are employed by ICNARC with a legitimate need to use the data (i.e. sending the questionnaires and conducting analysis of the data). Only substantive employees of ICNARC will access the data supplied by NHS Digital. Outputs from the study will contain only aggregate level data with small numbers suppressed in line with HES analysis guide. Red Technology UK and Disaster Recovery UK employees will not access the data. ICNARC will act to preserve patient confidentiality and will not disclose or reproduce any information by which patients could be identified. Data will not be used for commercial purposes, provided in record level form to any third party, and not used for direct marketing.


Project 3 — DARS-NIC-399287-T3X7W

Opt outs honoured: No - data flow is not identifiable (Consent (Reasonable Expectation))

Sensitive: Sensitive, and Non Sensitive

When: 2021/04 — 2021/04.

Repeats: One-Off

Legal basis: Health and Social Care Act 2012 – s261(2)(c)

Categories: Anonymised - ICO code compliant

Datasets:

  • Civil Registration - Deaths
  • Hospital Episode Statistics Admitted Patient Care
  • Emergency Care Data Set (ECDS)
  • Hospital Episode Statistics Outpatients

Objectives:

FIRST-ABC is a master protocol of two pragmatic randomised clinical trials (RCTs) aiming to evaluate the clinical and cost-effectiveness of the use of High Flow Nasal Cannula (HFNC), as compared with Continuous Positive Airway Pressure (CPAP), when used as the first-line mode of non-invasive respiratory support in two distinct clinical scenarios: 1. in critically ill children requiring non-invasive respiratory support for an acute illness (step-up RCT); and 2. in critically ill children requiring non-invasive respiratory support within 72 hours of extubation following a period of invasive ventilation (step-down RCT). Both HFNC and CPAP are currently routinely used across the NHS. This research is important to patients and the NHS because there is currently limited high-quality evidence to support whether HFNC or CPAP should be used as the first line mode of non-invasive respiratory support in critically ill children. In addition, previous research has also not studied the use of these interventions in the two distinct clinical scenarios outlined above. High quality evidence from RCTs is therefore urgently needed to help guide clinical decision making and to inform paediatric critical care clinicians and the wider NHS on the clinical and cost-effectiveness of HFNC versus CPAP – evidence which FIRST-ABC aims to provide. FIRST-ABC is funded by the National Institute for Health Research (NIHR), Health Technology Assessment Programme. NIHR do not determine the purpose or the manner in which the data will be processed. FIRST-ABC is sponsored by Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) and managed/coordinated by the Intensive Care National Audit & Research Centre (ICNARC). The health economic analysis will be completed by a health economist based at the London School of Hygiene and Tropical Medicine (LSHTM) on behalf of GOSH and ICNARC. FIRST-ABC aims to include a total of 1,200 children (600 in the step-down RCT and 600 in the step-up RCT, randomised to either HFNC or CPAP) from around 25 NHS paediatric critical care units across England, Wales and Scotland. NHS Digital data is requested for all cohort members who have had health events of interest within England and Wales. Processing personal data is necessary for ICNARC's legitimate interests which are described in this agreement. The data to which access is requested are proportionate and necessary to achieve those interests. ICNARC has completed a legitimate interests assessment (LIA) and is satisfied that the interests of the data subjects do not override ICNARC’s legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm. The data subjects interests and fundamental rights are protected through appropriate minimisation of fields and patient records being processed; pseudonymisation to minimise any risk of identifying individuals; protection of the data in a secure environment, and guaranteeing secure destruction at any stage at the request of NHS Digital or after a defined period on completion of the project. The primary objective for processing NHS Digital data in this application is to provide important outcome data for FIRST-ABC. The outcomes for the trial are: Primary outcome: • Time to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free of all forms of respiratory support. Secondary outcomes: • Mortality at paediatric intensive care unit (PICU) / high dependency unit (HDU) discharge, day 60 and day 180 • Rate of (re)intubation at 48 hours • Duration of PICU/HDU and hospital stay • Patient comfort, during randomised treatment and during non-invasive respiratory support (i.e. HFNC and/or CPAP), assessed using the validated COMFORT-B score • Proportion of patients in whom sedation is used during non-invasive respiratory support • Parental stress, in hospital at the time of consent at/around 24-48 hours, measured using the Parental Stressor Scale: PICU • Health-related quality of life (HrQoL) at six months using age-appropriate Pediatric Quality of Life Inventory (Peds-QL) and the Child Health Utility 9D (CHU-9D) questionnaires Cost effectiveness analysis (CEA) outcomes: • Total costs at six months • Quality-adjusted life years (QALYs) at six months • Incremental net monetary benefit gained at a willingness-to-pay of £20,000 per QALY at six months associated with HFNC versus CPAP The following NHS Digital data will be processed: Mortality (date of death), and selected fields from Hospital Episode Statistics (HES) Admitted patient care (APC) and HES Outpatients (OP) datasets, and the Emergency Care Data Set (ECDS) - these data will be unsuppressed, pseudonymised and provided at record level. The data is required to be provided at record level as it will be linked to the individual FIRST-ABC Study participant trial data using the FIRST-ABC trial number. Linking the FIRST-ABC data with HES and ECDS data from NHS Digital will contribute to the integrated economic evaluation to assess the cost-effectiveness of the first line use of HFNC versus CPAP. ICNARC have carefully reviewed the HES data dictionary to ensure that the data requested is the minimum required to meet the study objectives. Only those which are essential to meet the objectives of the research have been chosen. Specifically, HES OP, HES APC and ECDS data will be used to understand the economic impact of HFNC versus CPAP. Selected fields are those anticipated to drive potential differences in costs and resource utilisation between the groups and will be important in assessing the cost effectiveness of HFNC versus CPAP. Patient dates of death (if applicable) are requested from NHS Digital to directly contribute to the clinical evaluation secondary outcome data (mortality at various time-points) (primary purpose). In addition, parents of trial participants are actively followed-up and sent a questionnaire by the FIRST-ABC trial team at ICNARC at six months post-randomisation. Given the nature of critical illness, unfortunately some participants will pass away during the trial follow-up period. Where the trial team learns that a participant has passed away, no contact will be made with parents - helping to ensure parents and relatives are not caused undue distress by no longer appropriate contact (secondary purpose). In line with the timescales stated in the study outcomes, only six months of NHS Digital data will be requested for each study participant from their randomisation date (180 days from the date of randomisation). Both the step-down RCT and step-up RCT commenced patient recruitment in August 2019. Recruitment for the step-down RCT finished in May 2020 and the final participant will have been in the trial for six months as of November 2020 (the final data collection timepoint for this cohort). Therefore, only data from years 2019/2020 and 2020/2021 is required for the step-down RCT cohort. The recruitment period for the step-up RCT is planned to complete in January 2022 (given no delays) and subsequently the final patient in this cohort will have been in the trial for six months at the end of July 2022. Therefore, data from the following years will be needed for the step-up RCT cohort: 2019/2020, 2020/2021, 2021/2022 and 2022/2023. The decision to initiate non-invasive respiratory support is most often made during a time-sensitive emergency situation, where any delay in commencing treatment could be detrimental to the patient and the scientific validity of the trial. This makes attempts to obtain fully informed prior consent from parents/legal guardians during such an emergency situation inappropriate and could cause additional stress to families who are already very distressed by their child’s critical illness. In addition, both modes of non-invasive respiratory support evaluated as first-line treatment in this study (CPAP and HFNC) are relatively safe, commonly used and in current clinical practice - only determined by individual clinician preferences. Considering these reasons, a deferred consent model (‘research without prior consent’) has been utilised in the FIRST-ABC Study, a model that has been found to be acceptable to parents/guardians as well as clinicians in several previous RCTs conducted in the paediatric critical care setting. This consent model has been informed and refined by extensive patient and public involvement (PPI) work and is based on the CONseNt methods in paediatric Emergency and urgent Care Trials (CONNECT) study guidance. The East of England – Cambridge South Research Ethics Committee - who are specifically flagged and expertly positioned to review research involving children in the NHS - has granted the use of the research without prior consent model to FIRST-ABC. All of the reasons outlined above demonstrate that there are no alternative, less intrusive ways of achieving the study purposes than linking FIRST-ABC data with NHS Digital data. ICNARC is an independent health research charity which aims to help improve the quality of critical care through audit, research and education with, and in the interests of, patients and those who care for them. ICNARC requires data from NHS Digital for the purposes of these legitimate interests. ICNARC process data for this study under the legitimate interest legal basis. This is because ICNARC is a registered charity and the data processing described here is to support scientific and statistical research. Specifically, data is processed under the following articles of the Data Protection Act 2018: Article 6 (1) (f) Legitimate interests: the processing is necessary for your legitimate interests or the legitimate interests of a third party unless there is a good reason to protect the individual’s personal data which overrides those legitimate interests. The data is required for a research project - and therefore ICNARC process the special category data (health data) under the following article of GDPR - 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. Great Ormond Street Hospital for Children NHS Trust rely on Articles 6 (1) (e) – “public interest” and 9 (2) (j) – “scientific research” as the legal bases under GDPR. The organisations involved in this application as follows: ICNARC – joint data controller, manages the study (as the Clinical Trials Unit), holds the study data and will conduct the primary analyses (i.e. a data controller who are also processing the data); Exponential-E are a contractor of ICNARC’s and provide the servers (including back-ups) on which data will be processed by ICNARC staff; London School of Hygiene and Tropical Medicine (LSHTM) is where the study health economist is based who will conduct the health economic analyses; Great Ormond Street Hospital for Children NHS Trust, as trial sponsor, is joint data controller but will not receive or process any trial data (including any data from NHS Digital). The trial management group includes members from the following organisations: Great Ormond Street Hospital for Children NHS Trust, University College London, Great Ormond Street Institute of Child Health, Birmingham Women's and Children's NHS Foundation Trust, University of Salford, University Hospitals Bristol NHS Foundation Trust, University of Leeds, LSHTM, and ICNARC. However, only ICNARC and LSHTM will receive and process study data.

Expected Benefits:

Nearly three-quarters of the 20,000 critically ill children admitted to UK paediatric intensive care units (PICUs) each year receive some form of respiratory support (invasive and/or non-invasive), making it the most common treatment provided in PICU. Both HFNC and CPAP are routinely used in NHS practice, but there is genuine uncertainty as to whether HFNC or CPAP should be used as the first line mode of non-invasive respiratory support in critically ill children in paediatric critical care units. It is not yet known whether HFNC is clinically and cost-effective, as compared to CPAP (this is what FIRST-ABC will tell us) but - it is anticipated that if either mode of non-invasive respiratory support is found to be clinically and cost-effective, that implementation of these outputs into national and international clinical guidelines and subsequently into the NHS will lead to improvements in the delivery of respiratory support in paediatric critical care unit, ensuring first line use of non-invasive respiratory support is informed by robust and high quality randomised evidence. PICU beds are a highly valuable NHS resource, demand for which regularly outstrips supply, leading to delays in the provision of critical care to sick children. It is anticipated that if HFNC is found to be clinically and cost-effective, implementation of these outputs into clinical guidelines and subsequently into the NHS will help accelerate its adoption in non-critical care areas, improve patient flow into and out of the PICU and promote more efficient utilisation of PICU beds. On the other hand, if HFNC was shown to be less effective and associated with longer PICU stay, this finding could also have profound implications for the optimal use of scarce NHS resources. The FIRST-ABC health economic evaluation will provide information on the cost-effectiveness of HFNC versus CPAP which will be used by policy makers, managers and clinicians in the NHS. All of the above will help to reduce the burden on patients, their carers and the NHS. This will need an effective implementation strategy. Active and wide dissemination of the results of FIRST-ABC will be an important part of this strategy and will begin upon publication of the primary trial results (see ‘Specific outputs expected, including target date’ for further details). A number of approaches have been identified, including: involving stakeholders; providing evidence in an integrated and graded way; taking account of the context and identifying the elements relevant to decision making, e.g. benefits, harms and costs; making recommendations as specific as possible; and using a multifaceted approach. Dissemination will be lead by the chief investigator working closely with ICNARC CTU and supported by other members of the trial management group. Dissemination of the step-down RCT results will commence in the second half of the 2021. Dissemination of the step-up RCT results will commence in early 2023. In line with ICNARC’s legitimate interest of processing data for research and statistical purposes - the public (e.g. future critically ill paediatric patients) and the NHS will receive the benefits of the processing. Results of FIRST-ABC will help to guide paediatric critical care clinicians and the wider NHS on the clinical and cost-effectiveness of HFNC versus CPAP.

Outputs:

The results of FIRST-ABC will be both widely and actively disseminated. The research team has strong links with the PICU community via the Paediatric Intensive Care Society (PICS), PICS Study Group (PICS-SG), and the NIHR CRN: Children Clinical Studies Group (CSG) in Anaesthesia, Intensive Care and Cardiology, and similarly with the nursing community through the British Association of Critical Care Nurses (BACCN), the Royal College of Nursing Critical Care and In-flight Nursing Forum (RCN CCINF) and the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The research team also has links with the Healthcare Quality Improvement Partnership national audit programme through the Paediatric Intensive Care Audit Network (PICANet). The findings from our work will be presented at national and international conferences, potentially including the Annual Conference of the Royal College of Paediatrics and Child Health, the World Congress of Pediatric Intensive Care, PICS Annual Scientific Meeting, American Association of Pediatrics Conference, ESPNIC Annual Meeting, and British Association of Critical Care Nurses (BACCN). A comprehensive report will be submitted to the NIHR for publication in the peer reviewed, open access Health Technology Assessment journal and will include recommendations for future policy, practice and research. The results will also be submitted for publication in in a high-impact, widely-read, open-access (where possible), general medical journal, such as the New England Journal of Medicine or the Journal of the American Medical Association. The primary results of each RCT will be submitted for publication following the completion of recruitment and follow-up (anticipated to be January 2022 for the step-down RCT and January 2023 for the step-up RCT). The NIHR report will be submitted for publication in January 2023. We would anticipate publication of results within six months of these submission dates. Evidence to inform future clinical guidelines arising out of the research will be published and disseminated to professional societies concerned with the care of children presenting with acute illness, including PICS and the Royal College of Paediatrics and Child Health. Presentation slides will be prepared for use by the study team or others in disseminating the research findings. The results of the study will be disseminated to patients and their families, facilitated by the co-applicants, members of the research team who have links with PICS and the NIHR CSG, and via Family Groups we have liaised with already. The FIRST-ABC research team has worked closely with patient representatives throughout the study conduct. Two parents of children who received breathing support are co-applicants on FIRST-ABC grant application and have actively contributed to the study design and procedures, including the use of deferred consent as well as the development of study documents (for example, Patient Information Sheets). The Trial Management Group and the Trial Steering Committee include Patient and Public Involvement representatives as members. These collaborations will continue to ensure dissemination of the results to patients and the public. A study website and posts on ICNARC’s social media accounts (ICNARC has more than 7,000 followers on Twitter) will also be utilised to actively publicise progress with the research and disseminate our findings. In addition to disseminating the results to patients and their families - this dissemination plan will ensure that the results of FIRST-ABC are fed back to those delivering and organising care (e.g. nurses, doctors, managers) in the NHS (and across the world), allowing for any learning from FIRST-ABC to influence clinical practice for the benefit of critically ill patients. All data presented/reported will be aggregated at a national level, with small numbers suppressed in line with HES analysis guide. It will not be possible to identify any individual participating patient in any reports, articles or presentations. The FIRST-ABC protocol has been published in British Medical Journal (BMJ) Open and the statistical analysis plan has been published in Trials (please see the references below). Richards-Belle A, et al. FIRST-line support for assistance in breathing in children (FIRST-ABC): a master protocol of two randomised trials to evaluate the non-inferiority of high-flow nasal cannula (HFNC) versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care. BMJ Open. 2020 Aug 4;10(8):e038002. doi: 10.1136/bmjopen-2020-038002. Orzechowska, I., Sadique, M.Z., Thomas, K. et al. First-line support for assistance in breathing in children: statistical and health economic analysis plan for the FIRST-ABC trial. Trials 21, 903 (2020). https://doi.org/10.1186/s13063-020-04818-w

Processing:

For consented participants discharged alive from hospital for the admission from which they were recruited into the FIRST-ABC study, data from NHS Digital are requested to contribute to the analysis of the study outcomes, alongside separate trial data collected from hospital records at participating sites, and reported outcomes from the participants themselves. To obtain pseudonymised record level HES APC, HES OP, ECDS and Civil Registration (Deaths) data from NHS Digital, an authorised member of the FIRST-ABC Study team at the ICNARC CTU will provide identifiable record level data on a spreadsheet to NHS Digital via Secure Electronic File Transfer on two separate occasions. These spreadsheets will contain the following data fields: FIRST-ABC Trial number, date of randomisation (start date for calculating the six-month follow-up period), full name, date of birth, NHS number and postcode. Cohort data retrieval from NHS Digital will occur at two time points. Cohort data retrieval number one is for the step-down RCT cohort. This will occur upon the sign off of the data sharing agreement. This cohort will contain maximum of 600 patients (participants who passed away in hospital, declined or withdrawn consent will not be submitted). Patients in this cohort were recruited between August 2019 and May 2020. The final participant will have been in the trial for six months as of November 2020 (the final data collection timepoint for this cohort). Therefore, to ensure each participant has six months of HES/ECDS data, data from years 2019/2020 and 2020/2021 are required for the step-down RCT cohort. Civil Registrations (Deaths) data will be provided at the same time as HES/ECDS data. Cohort data retrieval number two is for the step-up RCT cohort. This will occur once the last patient recruited in this cohort will have been in the trial for six months. This cohort will contain maximum of 600 patients (participants who passed away in hospital, declined or withdrawn consent will not be submitted). The recruitment commenced in August 2019 and is anticipated to complete in January 2022 (given no delays). This will mean that the final patient in this cohort will have been in the trial for six months at the end of July 2022. Therefore, to ensure each participant has six months of HES/ECDS data, data from years 2019/2020, 2020/2021, 2021/2022 and 2022/2023 are required for the step-up RCT cohort. Civil Registrations (Deaths) will be provided approximately 6 weeks after the final patient follow-up date. Members of the FIRST-ABC Study team at ICNARC will access the trial data and NHS Digital data via secure ICNARC databases, including using a VPN connection when working remotely. Remote access is required in line with national UK Government guidance during the COVID-19 pandemic to work from home wherever feasible. All members of the ICNARC FIRST-ABC Study team work on ICNARC-provided devices that are password protected and encrypted to the secure standard required by the UK regulator for data protection. All study data are stored in databases or folders where access is restricted to authorised essential members of the FIRST-ABC study team only. The data is held on secure servers provided by Exponential-E. ICNARC will also regularly back-up the data through Exponential-E. Exponential-E is an IT contractor authorised by ICNARC with ISO 27001 security assurances in place. A small number of named members in the FIRST-ABC study team at ICNARC will link up the identifiable trial data with the mortality status and date of death (where applicable) from the Civil Registrations (Deaths) file provided by NHS Digital. This is in line with reasonable expectations of the parents of trial participants, as outlined in ‘Objectives for Processing’. The FIRST-ABC study team at ICNARC will additionally create a fully pseudonymised trial dataset which will be linked to both the pseudonymised deaths data, and the pseudonymised HES/ ECDS data from NHS Digital using the unique trial number field. Linking the FIRST-ABC trial data with the NHS Digital data will allow ICNARC to complete analysis of mortality at various time points – one of the secondary outcomes of the study. The pseudonymised linked record level dataset will also be made available to the health economist, who is part of the FIRST-ABC study team, based at the London School of Hygiene and Tropical Medicine (LSHTM) who will conduct the health economic evaluation. To minimise the risk of re-identification of study participants, the pseudonymisation process for the trial data will include the following: allocated trial numbers and site codes will be replaced by new identifiers, the link between actual trial numbers/site code will be held securely by ICNARC and not shared with LSHTM; Date of birth will be used to calculate calendar age (in months and/or years) at randomisation, only calculated age and not date of birth will be shared with LSHTM; All dates of any events post-randomisation (including hospital discharge and death) will be removed from the dataset and replaced by calculated fields indicating the elapsed time from randomisation; Date of randomisation will not be included. The same method will be used to remove dates of any pre-randomization events. All free text fields will either be removed from the dataset before transfer, or individual entries will be checked and any identifiable information (including patient, staff or hospital names) will be removed. The subsequent analyses will directly answer the trial research questions and achieve the purpose of finding out whether HFNC is non-inferior to CPAP for the benefit of future NHS patients. The data is held on secure servers at LSHTM. Data will be stored in an on-site data safe and data will only be accessed by authorised individuals within LSHTM. There will be no requirement or attempt by the team at LSHTM to reidentify individuals. All data processing will only be carried out by substantive employees of named data controllers and processors who have been appropriately trained in data protection and confidentiality. The essential members of the study team at LSHTM will access the data through a secure link via designated LSHTM password protected computer whilst working from home. The data will be stored in a folder where access is restricted to essential members of the study team only. Remote access is required in line with national UK Government guidance during the COVID-19 pandemic to work from home wherever feasible.


Project 4 — DARS-NIC-379807-P3R7Z

Opt outs honoured: Yes - patient objections upheld (Section 251)

Sensitive: Non Sensitive, and Sensitive

When: 2016/09 — 2019/04.

Repeats: Ongoing, One-Off

Legal basis: Section 251 approval is in place for the flow of identifiable data, Approved researcher accreditation under section 39(4)(i) and 39(5) of the Statistical Registration Service Act 2007 , Health and Social Care Act 2012 – s261(1) and s261(2)(b)(ii)

Categories: Anonymised - ICO code compliant, Identifiable

Datasets:

  • Hospital Episode Statistics Admitted Patient Care
  • Office for National Statistics Mortality Data
  • Civil Registration - Deaths
  • HES:Civil Registration (Deaths) bridge

Objectives:

High quality care is at the centre of the NHS. National clinical audit has a key role to play in ensuring high quality care, particularly in areas of health care, such as emergency and critical care, where patient choice does not, and cannot, play a significant part. Sophisticated and accurate risk prediction models are key in underpinning fair comparisons among health care providers. They can also enable risk-adjusted observational research and risk stratification in randomised controlled trials. This study is a follow-on to a previous study that addressed risk prediction modelling in three clinical areas: • adult general critical care; • adult cardiothoracic critical care; and • in-hospital cardiac arrest. The previous study made substantial steps forward in enabling fair comparisons among health care providers in all three areas, with immediate translation of the research outputs into routine practice, but has also identified important and essential new directions for further epidemiological and methodological research. This application is to support a research study funded by the NIHR Health Services and Delivery Research Programme in 2015 that aims to better understand of the following: 1. epidemiology of critical illness, and 2. risk factors for and consequences of critical illness. Increased understanding of these areas and using data linkage with other routinely collected data sources will lead to improvements the risk models used to underpin national clinical audits for: 1. adult general critical care; 2. cardiothoracic critical care; and 3. in-hospital cardiac arrest. The research study is being conducted by researchers from the Intensive Care National Audit & Research Centre (ICNARC), an independent registered charity (charity number: 1039417) which aims to improve critical care services in the UK through a programme of national clinical audits and research studies. ICNARC coordinates two national clinical audits: the Case Mix Programme for adult critical care and the National Cardiac Arrest Audit (coordinated jointly with the Resuscitation Council UK) for in-hospital cardiac arrest. In addition to data linkage with HES/ONS data, the project includes data linkage with other national clinical audits – the UK Renal Registry, the National Diabetes Audit and the National Adult Cardiac Surgery Audit – and representatives from these audits are included in the study team. Once the project is completed, the feasibility and cost of establishing regular, routine data linkage between these data sources will be investigated.

Yielded Benefits:

Yielded benefits to date are minimal, as the final linked datasets are yet to be received. Initial models have been developed for longer term mortality following critical care using the initial data extract, however these require updating (as the original extract did not include the full follow-up for mortality) and validating using the additional year of data prior to publication. Models have also been developed for use of critical care following an in-hospital cardiac arrest. These also require further updating and validating with the additional data. All other aspects are yet to commence due to awaiting the required data.

Expected Benefits:

Adult general critical careData linkage between the Case Mix Programme and death registrations will enable ICNARC to develop risk models to predict longer term mortality following an episode of critical illness. Data linkage between the Case Mix Programme and the National Diabetes Audit will enable ICNARC to establish whether acute severity of hyperglycaemia or other risk factors are associated with the likelihood of developing Type 2 diabetes. The occurrence of acute kidney injury (or acute renal failure) is common among critically ill patients and associated with high mortality, and has been strongly linked with subsequent end-stage renal disease. Data linkage between the Case Mix Programme and the UK Renal Registry will enable ICNARC to evaluate this relationship in the UK and develop risk models to predict the requirement for long-term renal replacement among survivors of critical illness in the UK. Data linkage with HES will enable ICNARC to estimate the cost of subsequent hospitalisations and its association with severity and/or duration of critical illness and other risk factors. Adult cardiothoracic critical care Linkage to death registrations from ONS will enable ICNARC to extend risk models for cardiothoracic critical care to predict longer term mortality. Data linkage with HES will enable ICNARC to estimate the cost of subsequent hospitalisations and its association with severity and/or duration of critical illness and other risk factors. In-hospital cardiac arrest Data linkage between National Cardiac Arrest Audit and the Case Mix Programme will allow ICNARC to better understand patterns of critical care, resource use and organ support following successful resuscitation and develop prediction models for likely resource use. Data linkage to ONS will enable ICNARC to extend risk models to predict longer term mortality. Finally, data linkage with HES will enable ICNARC to estimate the cost of subsequent hospitalisations and its association with the measured risk factors. If regular routine data linkage is established, this would permit the risk models and outcome measures developed in this project to be adopted into the national clinical audits to improve the benchmarking of adult critical care and in-hospital cardiac arrest in the UK.

Outputs:

The planned outputs of the project are as follows: 1. A final report on the entire project to be published as a monograph in the NIHR journal, Health Services and Delivery Research. Target date for submission: 15/08/2017. The report will include only aggregate level data on subgroups comprising thousands of patients and will not include any small numbers; therefore small sample suppression will therefore not be required. 2. Journal articles for peer-reviewed scientific journals. A minimum of three journal articles are planned, reporting on the separate areas of the project (adult critical care, cardiothoracic critical care and in-hospital cardiac arrest. However, given the large amount of work planned within each of these areas, it may be appropriate to split one or more of these into more than one article. Target dates for submission: March 2016 to August 2017. Journal articles will include only aggregate level data on subgroups comprising thousands of patients and will not include any small numbers; therefore small sample suppression will therefore not be required. 3. Presentations at professional and scientific conferences, to include the Annual Meeting of the Case Mix Programme (April 2016 and April 2017), the Annual Meeting of the National Cardiac Arrest Audit (October 2016 and October 2017) and the Annual Congress of the European Society of Intensive Care Medicine (October 2017). Presentations will include only aggregate level data on subgroups comprising thousands of patients and will not include any small numbers; therefore small sample suppression will therefore not be required. 4. The final linked anonymised dataset will be retained and stored securely on ICNARC's servers for 10 years. Requests for additional analyses based on this dataset will be managed by ICNARC's independent Data Access Advisory Group in accordance with the MRC Good Practice Principles for Sharing Individual Participant Data from Publically Funded Clinical Trials. Any additional analyses will be restricted to the overall purpose of better understanding the epidemiology of and outcomes from, critical illness. All outputs will be restricted to aggregate data with small numbers supressed in line with the HES analysis guide. 5. Each national clinical audit will retain and securely store the datasets linking each local key with the common key, enabling future studies of linked data to be undertaken subject to necessary REC/Section 251 approvals. Outputs will be shared with the relevant national audit providers. All outputs will be restricted to aggregate data with small numbers supressed in line with the HES analysis guide. Any requests to access data from this project are restricted to those that fall within the overall purpose of the project (to better understand the epidemiology of, and outcomes from, critical illness) and data will only be released in aggregate or summary form with small numbers supressed unless with the express prior permission of HSCIC. Any such permission for the onward sharing of record level data would be subject to a future application.

Processing:

HSCIC will undertake a bespoke data linkage between the linked HES/ONS dataset and external datasets from five national clinical audits: the ICNARC Case Mix Programme (for adult critical care), the National Cardiac Arrest Audit, the UK Renal Registry, the National Diabetes Audit and the National Adult Cardiac Surgery Audit. The index datasets (defining inclusion in the final pseudonymised dataset for analysis) will be the ICNARC Case Mix Programme and the National Cardiac Arrest Audit. The data linkage process will work as follows: each national clinical audit provider will upload to HSCIC's secure file sharing platform datasets consisting of the available identifiers for patients included in each national clinical audit together with an anonymous local key permitting linkage back to locally held data for the audit. HSCIC will link the datasets and return to each national clinical audit provider a dataset consisting of the local key, a common key (permitting linkage across all the datasets) and a binary field indicating whether that patient was identified in either the ICNARC Case Mix Programme or National Cardiac Arrest Audit. The local key is used by the individual audit providers to identify the relevant record within their individual audit systems when it is retuned from the HSCIC along with a common key. The national audit providers do not receive any data other than the two keys and the binary field. Each national audit provider external to ICNARC will then supply direct to ICNARC a pseudonymised dataset of the clinical fields required for the project together with the common key only for those patients identified in either the ICNARC Case Mix Programme or National Cardiac Arrest Audit. HSCIC will provide to ICNARC (via the secure file sharing platform) a pseudonymised data extract of HES/ONS data together with the common key only for patients identified in either the ICNARC Case Mix Programme or National Cardiac Arrest Audit. ICNARC will use the common key to link the data extracts provided by the national audit providers and HSCIC with pseudonymised data extracts from the ICNARC Case Mix Programme and National Cardiac Arrest Audit to create the final linked project dataset. Prior to linkage, ICNARC will pseudonymise the data extracts from the ICNARC Case Mix Programme and National Cardiac Arrest Audit by: replacing date of birth with age in years; and replacing post code with area level deprivation measures. The original datasets do not include patients’ names or full addresses. Once the data are linked, ICNARC will conduct a final pseudonymisation will take place by replacing date of birth with age in years, replacing the date of admission to the critical care unit or date of in-hospital cardiac arrest with the month and year, replacing all other dates in the dataset (including date of death) with the number of days relative to these index dates, replacing post code with area level deprivation measures and replacing hospital/critical care unit names with anonymous identifiers. Consequently, this final pseudonymised dataset will contain no patient identifiable data. The final linked project dataset will be analysed by statisticians at ICNARC (as named in the ONS application). The analyses will describe the epidemiology of, and risk factors for, and develop and validate risk prediction models for, the following outcomes: For admissions to adult critical care units (from the ICNARC Case Mix Programme): mortality at 30 days, 90 days and 1 year (from ONS); time to death (from ONS); new diagnosis of diabetes post-critical care (from the National Diabetes Audit); new diagnosis of end-stage renal disease post-critical care (from the UK Renal Registry); hospital resource use and costs post-critical care (from HES). For admissions to cardiothoracic critical care units (from the ICNARC Case Mix Programme): mortality at discharge from acute hospital; mortality at 30 days, 90 days and 1 year (from ONS); time to death (from ONS); hospital resource use and costs post-critical care. For these analyses, additional risk factor data will be obtained from the National Adult Cardiac Surgery Audit. For patients experiencing in-hospital cardiac arrest (from the National Cardiac Arrest Audit): return of spontaneous circulation (ROSC) for greater than 20 minutes; survival to hospital discharge; survival to 30 days, 90 days and 1 year (from ONS); time to death (from ONS); critical care resource use post-arrest (from the ICNARC Case Mix Programme); Hospital resource use and costs post-arrest (from HES). For these analyses, additional risk factor data will be obtained from HES. Initial data linkage will be undertaken for data from 1 April 2009 to 31 March 2015. These data will be used to describe the epidemiology and develop the risk prediction models. The data linkage will be updated one year later for data from 1 April 2015 to 31 March 2016. These data will be used to validate the risk prediction model


Project 5 — DARS-NIC-184951-D1G8R

Opt outs honoured: Yes - patient objections upheld (Section 251)

Sensitive: Non Sensitive

When: 2019/02 — 2019/02.

Repeats: One-Off

Legal basis: Health and Social Care Act 2012 – s261(7)

Categories: Anonymised - ICO code compliant, Identifiable

Datasets:

  • Civil Registration - Deaths
  • Hospital Episode Statistics Admitted Patient Care

Objectives:

The Renal Replacement Anticoagulation Management (RRAM) study is an observational study that has been designed to utilise high quality routinely collected clinical data, in order to compare the clinical and cost-effectiveness of changing to citrate anticoagulation for continuous renal replacement therapy (CRRT) in adult intensive care units (ICU). This research is important to patients and the NHS as there is currently a rapid change occurring within the NHS, whereby traditional heparin based anticoagulation for CRRT is being replaced by citrate based methods. This is being done without any evidence that citrate is superior to heparin in terms of clinical or cost-effectiveness. This study will make the most of an efficient design using available data to clarify the effect of changing to citrate-based anticoagulation on health and economic outcomes in normal clinical practice to help determine whether the change should be encouraged or stopped. The RRAM study is funded by the National Institute for Health Research, Health Technology Assessment Programme (HTA 16/111/136), is managed and sponsored by the Intensive Care National Audit & Research Centre (ICNARC) and will include data from approximately 85,000 patients that were admitted to an adult general ICU in England or Wales between 1 April 2009 and 31 March 2017. The chief investigator for this NIHR funded study is from the University of Oxford and Oxford University NHS Trust/John Radcliffe Hospital. Their role and responsibilities are to co-ordinate the study and will be providing data for the health economics aspect of the study. This will be completed separately to the data linkage and analysis described in this application which will take place at ICNARC only. Oxford will not have access to data provided by NHS Digital data. The “legitimate interests” relied upon are of healthcare research. This is because the data processing described here is to support scientific and statistical research. ICNARC has conducted a legitimate interests assessment to confirm processing is necessary for the purposes of the legitimate interests. ICNARC have assessed this against the ICO’s checklist (https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/lawful-basis-for-processing/legitimate-interests/) and are content that the requirements are met and has been reviewed by NHS Digital. Purpose Test: are you pursuing a legitimate interest? ICNARC is an independent charity committed to providing high quality information through their national clinical audits, where hospitals/critical care units use information from reports to help them improve care; through research, where data are collected to answer specific questions or to test theories. Necessity Test: is the processing necessary for that purpose? Processing personal data is necessary for ICNARC's legitimate interests which are described in this application. The data to which access is requested are proportionate and necessary to achieve those interests. Balancing Test: do the individual’s interests override the legitimate interest? ICNARC have completed a legitimate interests assessment (LIA) and are satisfied that the interests of the data subjects do not override our legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm. The data subjects interests and fundamental rights are protected through appropriate minimisation of fields and patient records being processed; pseudonymisation to minimise any risk of identifying individuals; protection of the data in a secure environment, and guaranteeing secure destruction at any stage at the request of NHS Digital or after a defined period on completion of the project. The primary outcome for the processing of NHS Digital data in this application is to provide important outcome data for this study. The outcomes of the study are: Primary outcomes: • All cause mortality at 90 days (clinical effectiveness) • Incremental net monetary benefit at 1 year (cost effectiveness) Secondary outcomes: • All-cause mortality at hospital discharge, 30 days and one year • Days of renal, cardiovascular, and advanced respiratory support • ICU and hospital length of stay • New dialysis-dependent renal disease at one year • Estimated lifetime incremental cost-effectiveness ICNARC are requesting linked data for a cohort of patients who received CRRT in an adult general ICU in England or Wales between 1 April 2009 and 31 March 2017. Eligible patients will be identified using the following inclusion criteria: aged 16 and over; admitted to an adult or general ICU in England and Wales, which participates in the ICNARC case mix programme, between 01/04/2009 and 31/03/2017; and in receipt of CRRT for at least one calendar day during the ICU stay. It is estimated that 85,000 patients would be included within the project. ICNARC are requesting patient status (i.e. dead, alive, unknown/unable to link) and date of death (where applicable) from NHS digital via linkage to Civil Registration death data for all patients in the cohort to directly contribute to the clinical evaluation of the primary outcome (90-day all-cause mortality) and the secondary outcomes of all-cause mortality at 30 days and one year. In addition, ICNARC are requesting linkage to HES inpatient data to obtain health care usage for linked patients that will be used to calculate the incremental cost-effectiveness at 1 year (primary cost effectiveness outcome) and estimate lifetime cost effectiveness. NHS Digital will also perform third party linkage to the UK Renal Registry (UKRR) for all patients in the cohort to identify diagnosis of new dialysis-dependent renal disease. The UKRR are not considered a data processor as they are only supplying direct patient identifiers to NHS Digital for data linkage and will not receive any HES/Civil Registration death data for linked patients.

Expected Benefits:

The RRAM study aims to determine the clinical and cost-effectiveness of regional citrate anticoagulation (RCA) versus systemic heparin anticoagulation (SHA) for continuous renal replacement therapy (CRRT) in patients treated in an ICU. Currently there is a rapid shift towards the use of RCA for CRRT amongst NHS hospitals, however there is little evidence that it is superior to SHA in terms of clinical outcomes and cost-effectiveness. The benefits to the NHS may be very large. ICNARC estimate these results will apply directly to 95% of UK intensive care units (ICUs) who between them treat 17,000 patients per year for acute kidney injury with about 190,000 patient-days of continuous renal replacement therapy (CRRT) delivered at an estimated cost of £1000-£1200 per patient-day. The study will provide the first accurate cost-effectiveness analysis of regional citrate anticoagulation (RCA) and systemic heparin anticoagulation (SHA) in the NHS. If the results show that RCA is less effective and more costly than SHA, curbing the spread of RCA will benefit both patients and NHS funds. In contrast, if RCA is more effective and less costly both patients and the NHS will benefit from a more effective, cheaper treatment. However, it is more likely RCA is either less effective and less costly, or more effective and more costly. In this case the benefits to the NHS budget and the patient benefit go in different directions and the overall benefit depends on willingness to pay for clinical benefit. Both patients and the NHS will benefit from identifying the best mode of anticoagulant treatment for CRRT in patients in the ICU. If neither treatment is clinically superior, benefits will be gained by identifying which treatment is most cost-effective when considering hospitalisations. This will need an effective implementation strategy. Active and wide dissemination of the results of the RRAM study will be an important part of this strategy and will begin upon publication of the primary study results (estimated to be published around September 2019). A number of approaches have been identified, including: involving stakeholders; providing evidence in an integrated and graded way; taking account of the context and identifying the elements relevant to decision making, e.g. benefits, harms and costs; making recommendations as specific as possible; and using a multifaceted approach.

Outputs:

The planned outputs of the project are as follows: 1. A final report on the entire project to be published as a monograph in the NIHR journal, Health Technology Assessment programme. Target date for submission is 30/06/2019. Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guidance. 2. The results of the study will be published in a peer reviewed journal and will conform to the RECORD standards – an agreed set of ‘rules’ for reporting research studies based on routinely-collected data. Target date for submission: September 2019. However, given the large amount of work planned within each area of the study it may be appropriate to split the data into more than one article. Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guidance. 3. Presentations at professional and scientific conferences, including the Annual Meeting of the Case Mix Programme (April 2019), the annual UK Kidney Week meet meeting (May 2019), and the UK Intensive Care Society (ICS) State of the Art Meeting (December 2019). Outputs will contain only aggregate level data with small numbers suppressed in line with the HES analysis guidance. 4. The final linked pseudonymised dataset will be retained and stored securely on ICNARC’s servers for 5 years. Any requests for additional analyses based on this dataset would be subject to an amendment to this agreement and approval by NHS Digital. 5. ICNARC has access to both patients and their families and close friends from its recent collaboration in two modules (http://www.healthtalk.org/intensive_care/) for the award-winning website Healthtalk (http://www.healthtalk.org/). In addition, ICNARC works with the Intensive Care Unit Support Teams for Ex-Patients (ICUsteps), the intensive care patient support charity, already collaborating on our Family Reported Experiences Evaluation Study funded by the NIHR Health Services & Delivery Research Programme. The RRAM team at ICNARC will work with both Healthtalk and ICUSteps to ensure the results of the study are fed-back to patients. In addition, the results will also be available to patients and the public via the ICNARC website (www.icnarc.org).

Processing:

In summary ICNARC are requesting three data linkages: 1. Patient status/date of death via linkage to Civil Registration data for all patient in the CMP. 2. Linkage to the HES APC data for all patients in the CMP. 3. NHS Digital to carry out third party linkage to the UKRR data for all patients who match in the CMP. The study id only will be returned to UKRR and UKRR will send the clinical data to ICNARC. ICNARC will used the study id to link the returned HES and Civil Registration data and UKRR data to the relevant clinical data from the CMP database to create a final dataset for analysis. NHS Digital will link direct patient identifiers provided from the CMP by ICNARC to HES, Civil Registration and UKRR datasets. The data linkage will process as follows: 1. ICNARC will identify eligible patients from the CMP database between 1 April 2009 and 31 March 2017 and will upload to NHS Digital a file containing a study ID (for identification in the CMP) and the following direct patient identifiers; NHS number, date of birth and postcode. 2. In parallel, UKRR will provide NHS Digital with a file containing the same direct patient identifiers for patients in the UKRR between 1 April 2009 and 31 March 2017 plus a local UKRR ID. The local ID will allow for linkage back to the locally held audit data. The transfer of direct patient identifiers from ICNARC and the UKRR to NHS Digital is covered by the Section 251 approval (18/CAG/0070) for the RRAM study. 3. NHS Digital will match direct patient identifiers from the CMP with those supplied from the UKRR and return to ICNARC and the UKRR a linkage file containing the local ID (to the UKRR) and study ID (allowing for linkage across all the datasets) for all matched records. NHS Digital will also perform linkage for all patients within the CMP to HES (containing information on hospitals admissions for all matched patients between CMP and HES datasets) and Civil Registration (deaths) (containing death data for all matched patients between the CMP and Civil Registration) datasets. The local ID will be used by the UKRR to identify the relevant records within their individual audit system when it is returned by NHS Digital along with a study ID. This means that the UKRR will not receive any data other than the two ID’s. For the ICNARC CMP, the study ID will act as the local ID. 4. The UKRR will then provide ICNARC a file containing the clinical fields (with no direct patient identifiers) required for the project along with the study ID for those patients identified in the CMP. In parallel, NHS Digital will provide ICNARC a file containing agreed HES (containing information on hospitals admissions for all matched patients between CMP and HES datasets) and Civil Registration (deaths) (containing mortality data or all matched patients between the CMP and Civil Registration dataset (deaths)) data together with the study ID for patients identified in the ICNARC CMP. 5. ICNARC will use the study ID to link the data extracts provided by the UKRR and NHS Digital with the relevant clinical data from the ICNARC CMP to create the final dataset. Once the data are linked, ICNARC will pseudonymise the dataset by replacing date of birth with age in years, replacing the date of admission to critical care unit with month and year, replacing all other dates in the dataset (including date of death) with the number of days relative to these index dates, replacing postcode with area level deprivation measures, and replacing hospital/critical care unit names with anonymous identifiers. Consequently, the final pseudonymised dataset will contain no patient identifiable data. 6. The final linked project dataset will be analysed by statisticians at ICNARC, all of whom are substantive employees. The analysis will follow interrupted time series analysis techniques to compare the clinical effectiveness of a change to citrate anticoagulation on; all-cause mortality at 90-days, 30-days, and one year; number of days receiving renal, cardiovascular, and advanced respiratory support; ICU length of stay; and development of new-dialysis renal disease at one year. In summary ICNARC are requesting three data linkages: 1. Patient status/date of death via linkage to Civil Registration data for all patient in the CMP. 2. Linkage to the HES APC data for all patients in the CMP. 3. NHS Digital to carry out third party linkage to the UKRR data for all patients who match in the CMP. The study id only will be returned to UKRR and UKRR will send the clinical data to ICNARC. ICNARC will used the study id to link the returned HES and Civil Registration data and UKRR data to the relevant clinical data from the CMP database to create a final dataset for analysis. The data received from NHS Digital will be incorporated into the RRAM study database, stored on secure servers, managed by Red Technology Ltd, on behalf of ICNARC. In addition, ICNARC will regularly back-up the data through Disaster Recovery Service Ltd (DRS). Both Red Technology Ltd and DRS are contractors authorised by ICNARC and whom both have sufficient security assurances in place. Future linkage to the Patient Episode Database for Wales (PEDW) will take place in order to obtain inpatient data for patients treated in Welsh hospitals. This linkage will be performed separately to the NHS Digital linkage described above. This linkage will not involve the transfer of UKRR or NHS Digital data away from ICNARC. 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).