{"id":872,"date":"2022-11-29T15:25:10","date_gmt":"2022-11-29T15:25:10","guid":{"rendered":"https:\/\/bnssghealthiertogether.org.uk\/?page_id=872"},"modified":"2025-12-19T16:07:09","modified_gmt":"2025-12-19T16:07:09","slug":"completed-projects","status":"publish","type":"page","link":"https:\/\/bnssghealthiertogether.org.uk\/sq\/knowledge-hub\/population-health-management\/completed-projects\/","title":{"rendered":"Completed projects using the system-wide dataset for Bristol, North Somerset and South Gloucestershire"},"content":{"rendered":"
Section titled module-1<\/span><\/a>
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Completed projects using the system-wide dataset for Bristol, North Somerset and South Gloucestershire<\/h1>\n <\/div>\r\n <\/section><\/div>
Section titled module-2<\/span><\/a>
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Chronic pain pilot evaluation <\/strong><\/h2>\n

Chronic pain is one of the most common and impactful health problems within our population, yet it is poorly understood and best practice in treatment is not established. A pilot scheme was run to compare a pain management programme against the provision of paid education.<\/p>\n

24 patients attended a 1-hour pain education session (PES) followed by an 8-week pain management programme (PMP) and 91 patients attended just the PES followed by signposting to a range of services. We were then able to compare their NHS and medication use using linked population health management data. The PMP group showed significant reductions in medication use, GP appointments, and overall costs compared to the PES group.<\/p>\n Read a public published paper on chronic pain burden in Bristol, North Somerset and South Gloucestershire<\/a>\n\n

For more information email bnssg.phm@nhs.net.<\/a><\/p>\n <\/div>\r\n <\/section><\/div>

Section titled module-3<\/span><\/a>
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Dementia deep dive<\/strong><\/h2>\n

Dementia is an impactful condition, with a high prevalence (3.2%) in Bristol, North Somerset and South Gloucestershire. We linked data across a range of primary and secondary settings, and described the cohort\u2019s demographics, including age, sex, deprivation, ethnicity, language spoken and geographical spread.\u00a0 We also looked at health conditions and social situations experienced.<\/p>\n

Standardised rates showed that Weston Worle & Villages and South Bristol Localities have significantly high rates of dementia.\u00a0 Socioeconomic deprivation is associated with a higher risk of dementia and this disparity increases with age.\u00a0 The Black ethnic group has a significantly high prevalence.<\/p>\n

There are very high levels of hypertension, anxiety and depression, and painful conditions in the dementia cohort.\u00a0 Given both the impact of Dementia and the complexity of other conditions our analysis revealed the cohort\u2019s cost to the healthcare system was high (\u00a385.2M over the 3-year period).\u00a0 In addition, people with diagnosed dementia made up 55.3% of people aged 80+ on a complex discharge from hospital, and 19.7% of all mental health sections for those aged 60+. This work has been used to suggest improvements to the way Bristol, North Somerset and South Gloucestershire commissions and delivers care for those with Dementia.<\/p>\n

For more information email bnssg.phm@nhs.net<\/a><\/p>\n <\/div>\r\n <\/section><\/div>

Section titled module-4<\/span><\/a>
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Piloting an integrated digital care pathway for patients living with COPD <\/strong>\u200b<\/h2>\n

\u00a0<\/strong>The patient cohort was targeted using PHM approaches to those with high levels of co-morbidities (average 4, median 6 LTCs) and highest utilisation of healthcare services across Bristol, North Somerset and South Gloucestershire, including high volumes of non-elective admissions and emergency attendances. The cohort is associated with higher levels of deprivation (16% are IMD decile 1 and 25% fall into the ONS population segment of \u201chard pressed communities\u201d), are relatively older (average age is 74) and have high smoking rates.\u200b<\/p>\n