analysis/report.ipynb

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    "## Monitoring the incidence and management of inflammatory arthritis in England "
   ]
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   "cell_type": "markdown",
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    "Autoimmune inflammatory arthritis (IA) encompasses an overlapping group of conditions, including rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axSpA) and undifferentiated IA. Early diagnosis of IA and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDs) improves outcomes for patients and increases the likelihood of remission.\n",
    "\n",
    "In England and Wales, the quality of care for people with IA is benchmarked in the [National Early Inflammatory Arthritis Audit](https://www.rheumatology.org.uk/practice-quality/audits/neiaa) (NEIAA). Metrics benchmarked include time from primary care referral to initial rheumatology assessment, and time to initiation of a DMARD. Howevever, mandatory data collection in NEIAA was paused during the pandemic, preventing comparisons of care.\n",
    "\n",
    "The aim of this report is to use the OpenSAFELY platform to replicate key metrics from NEIAA, and assess the impact of COVID-19 on care delivery for people with IA in England.\n",
    "\n",
    "All of the results below are from a study population consisting of all patients aged 18 or over who are registered at a TPP general practice."
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 96,
   "metadata": {},
   "outputs": [],
   "source": [
    "from IPython.display import Image, Markdown\n",
    "import json\n",
    "import pandas as pd\n",
    "import numpy as np\n",
    "from IPython.display import HTML, display, Markdown"
   ]
  },
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   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "### Incidence of inflammatory arthritis diagnoses"
   ]
  },
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   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "This graph shows the monthly incidence of newly recorded IA diagnoses in England, as specified by these codelists ([RA](https://www.opencodelists.org/codelist/user/markdrussell/new-rheumatoid-arthritis/535a8249/), [PsA](https://www.opencodelists.org/codelist/user/markdrussell/psoriatic-arthritis/6c69f57e/), [axSpA](https://www.opencodelists.org/codelist/user/markdrussell/axial-spondyloarthritis/057968b4/), [undifferentiated IA](https://www.opencodelists.org/codelist/user/markdrussell/undiff-eia/459a5829/)). The denominator for calculating incidence was all adults registered with a TPP general practice in April 2019 (17.7 million)."
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  },
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   "execution_count": 97,
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       "\t<text x=\"3406.59\" y=\"1832.85\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\">Total EIA diagnoses</text>\n",
       "\t<text x=\"3406.59\" y=\"1952.87\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\">RA</text>\n",
       "\t<text x=\"3406.59\" y=\"2072.88\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\">PsA</text>\n",
       "\t<text x=\"3406.59\" y=\"2192.77\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\">AxSpA</text>\n",
       "\t<text x=\"3406.59\" y=\"2312.78\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\">Undifferentiated IA</text>\n",
       "</svg>"
      ],
      "text/plain": [
       "<IPython.core.display.SVG object>"
      ]
     },
     "execution_count": 97,
     "metadata": {},
     "output_type": "execute_result"
    }
   ],
   "source": [
    "from IPython.core.display import SVG\n",
    "SVG(filename=\"../output/figures/incidence_twoway_rounded.svg\")"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "The number of IA diagnoses and corresponding incidence (per 10,000 adult population) are reported in the table below, separated by year of diagnosis."
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 98,
   "metadata": {},
   "outputs": [
    {
     "data": {
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       "<table border=\"1\" class=\"dataframe\">\n",
       "  <thead>\n",
       "    <tr>\n",
       "      <th></th>\n",
       "      <th colspan=\"2\" halign=\"left\">All IA diagnoses</th>\n",
       "      <th colspan=\"2\" halign=\"left\">Rheumatoid arthritis</th>\n",
       "      <th colspan=\"2\" halign=\"left\">Psoriatic arthritis</th>\n",
       "      <th colspan=\"2\" halign=\"left\">Axial spondyloarthritis</th>\n",
       "      <th colspan=\"2\" halign=\"left\">Undifferentiated IA</th>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th></th>\n",
       "      <th>Count</th>\n",
       "      <th>Incidence</th>\n",
       "      <th>Count</th>\n",
       "      <th>Incidence</th>\n",
       "      <th>Count</th>\n",
       "      <th>Incidence</th>\n",
       "      <th>Count</th>\n",
       "      <th>Incidence</th>\n",
       "      <th>Count</th>\n",
       "      <th>Incidence</th>\n",
       "    </tr>\n",
       "  </thead>\n",
       "  <tbody>\n",
       "    <tr>\n",
       "      <th>April 2019/2020</th>\n",
       "      <td>64580</td>\n",
       "      <td>36.5</td>\n",
       "      <td>16155</td>\n",
       "      <td>9.1</td>\n",
       "      <td>16410</td>\n",
       "      <td>9.3</td>\n",
       "      <td>15925</td>\n",
       "      <td>9.0</td>\n",
       "      <td>16090</td>\n",
       "      <td>9.1</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th>April 2020/2021</th>\n",
       "      <td>51970</td>\n",
       "      <td>29.4</td>\n",
       "      <td>12975</td>\n",
       "      <td>7.3</td>\n",
       "      <td>13025</td>\n",
       "      <td>7.4</td>\n",
       "      <td>13035</td>\n",
       "      <td>7.4</td>\n",
       "      <td>12935</td>\n",
       "      <td>7.3</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th>April 2021/2022</th>\n",
       "      <td>38970</td>\n",
       "      <td>22.0</td>\n",
       "      <td>9770</td>\n",
       "      <td>5.5</td>\n",
       "      <td>9685</td>\n",
       "      <td>5.5</td>\n",
       "      <td>9800</td>\n",
       "      <td>5.5</td>\n",
       "      <td>9715</td>\n",
       "      <td>5.5</td>\n",
       "    </tr>\n",
       "  </tbody>\n",
       "</table>"
      ],
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     },
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   ],
   "source": [
    "table = pd.read_csv(\"../output/tables/diag_count_byyear.csv\")\n",
    "table_subset = table.loc[[0, 1, 2], [\"total_diag_round\", \"incidence_total_diag_round\", \"ra_diag_round\", \"incidence_ra_diag_round\", \"psa_diag_round\", \"incidence_psa_diag_round\", \"axspa_diag_round\", \"incidence_axspa_diag_round\", \"undiff_diag_round\", \"incidence_undiff_diag_round\"]]\n",
    "table_subset[[\"incidence_total_diag_round\", \"incidence_ra_diag_round\", \"incidence_psa_diag_round\", \"incidence_axspa_diag_round\", \"incidence_undiff_diag_round\"]] = table_subset[[\"incidence_total_diag_round\", \"incidence_ra_diag_round\", \"incidence_psa_diag_round\", \"incidence_axspa_diag_round\", \"incidence_undiff_diag_round\"]].astype(float).round(1)\n",
    "table_subset.columns = pd.MultiIndex.from_tuples([('All IA diagnoses', 'total_diag_round'), ('All IA diagnoses', 'incidence_total_diag_round'), ('Rheumatoid arthritis', 'ra_diag_round'), ('Rheumatoid arthritis', 'incidence_ra_diag_round'), ('Psoriatic arthritis', 'psa_diag_round'), ('Psoriatic arthritis', 'incidence_psa_diag_round'), ('Axial spondyloarthritis', 'axspa_diag_round'), ('Axial spondyloarthritis', 'incidence_axspa_diag_round'), ('Undifferentiated IA', 'undiff_diag_round'), ('Undifferentiated IA', 'incidence_undiff_diag_round')])\n",
    "table_subset.rename(columns = {'diagnosis_year':'Diagnosis year', 'total_diag_round':'Count', 'incidence_total_diag_round':'Incidence', 'ra_diag_round':'Count', 'incidence_ra_diag_round':'Incidence', 'psa_diag_round':'Count', 'incidence_psa_diag_round':'Incidence', 'axspa_diag_round':'Count', 'incidence_axspa_diag_round':'Incidence', 'undiff_diag_round':'Count', 'incidence_undiff_diag_round':'Incidence'}, inplace = True)\n",
    "table_subset.rename(index = {0:'April 2019/2020', 1:'April 2020/2021', 2:'April 2021/2022'}, inplace = True)\n",
    "display(\n",
    "    HTML(table_subset.to_html(index=True)),\n",
    "    )"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "### Time from referral to initial rheumatology assessment"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "#### National trends"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "Shown in the table below is the median time, in days, from primary care referal to initial assessment in a rheumatology outpatient appointment for patients with new IA diagnosis, separated by year of diagnosis and by disease subtype.\n",
    "\n",
    "Data are shown for all patients with new IA diagnoses who had their first rheumatology appointment captured and who had a minimum of 12 months of follow-up. Rheumatology outpatient clinic were defined by the [410 treatment function code](https://www.datadictionary.nhs.uk/attributes/treatment_function_code.html). Primary care referral was defined as the date of last primary care appointment before the first rheumatology appointment."
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 99,
   "metadata": {},
   "outputs": [
    {
     "data": {
      "text/html": [
       "<table border=\"1\" class=\"dataframe\">\n",
       "  <thead>\n",
       "    <tr style=\"text-align: right;\">\n",
       "      <th></th>\n",
       "      <th>April 2019/20</th>\n",
       "      <th>April 2020/21</th>\n",
       "      <th>April 2021/22</th>\n",
       "    </tr>\n",
       "  </thead>\n",
       "  <tbody>\n",
       "    <tr>\n",
       "      <th>All IA diagnoses</th>\n",
       "      <td>251</td>\n",
       "      <td>426</td>\n",
       "      <td>592</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th>Rheumatoid arthritis</th>\n",
       "      <td>244</td>\n",
       "      <td>392</td>\n",
       "      <td>516</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th>Psoriatic arthritis</th>\n",
       "      <td>247</td>\n",
       "      <td>411</td>\n",
       "      <td>689</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th>Axial spondyloarthritis</th>\n",
       "      <td>249</td>\n",
       "      <td>454</td>\n",
       "      <td>592</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <th>Undifferentiated IA</th>\n",
       "      <td>258</td>\n",
       "      <td>433</td>\n",
       "      <td>571</td>\n",
       "    </tr>\n",
       "  </tbody>\n",
       "</table>"
      ],
      "text/plain": [
       "<IPython.core.display.HTML object>"
      ]
     },
     "metadata": {},
     "output_type": "display_data"
    }
   ],
   "source": [
    "table = pd.read_csv(\"../output/tables/table_median_bydiag_rounded_to21.csv\")\n",
    "table_subset = table.loc[[5,6,7,8,9], [\"p50_2019\", \"p50_2020\", \"p50_2021\"]]\n",
    "table_subset.rename(columns = {'p50_2019':'April 2019/20', 'p50_2020':'April 2020/21', 'p50_2021':'April 2021/22'}, inplace = True)\n",
    "table_subset.rename(index = {5:'All IA diagnoses', 6:'Rheumatoid arthritis', 7:'Psoriatic arthritis', 8:'Axial spondyloarthritis', 9:'Undifferentiated IA'}, inplace = True)\n",
    "display(\n",
    "  HTML(table_subset.to_html(index=True)),\n",
    "   )"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "Time-series analysis demonstrating the proportion of IA patients who received their first rheumatology outpatient appointment within 3 weeks of primary care referral. Trends before and after the first COVID-19 lockdown in England (March 2020) are shown. "
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 100,
   "metadata": {},
   "outputs": [
    {
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       "\t<text x=\"4155.84\" y=\"2518.45\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\" text-anchor=\"middle\">Oct 2021</text>\n",
       "\t<line x1=\"542.70\" y1=\"2402.50\" x2=\"4155.84\" y2=\"2402.50\" style=\"stroke:#A0A0A0;stroke-width:7.20\"/>\n",
       "\t<text x=\"2349.27\" y=\"2671.81\" style=\"font-family:'Helvetica';font-size:79.92px;fill:#000000\" text-anchor=\"middle\">Date of first rheumatology appointment</text>\n",
       "</svg>"
      ],
      "text/plain": [
       "<IPython.core.display.SVG object>"
      ]
     },
     "execution_count": 100,
     "metadata": {},
     "output_type": "execute_result"
    }
   ],
   "source": [
    "from IPython.core.display import SVG\n",
    "SVG(filename=\"../output/figures/ITSA_diagnostic_delay_GP_newey.svg\")"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "#### Regional trends"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "Box plot showing the regional variation in rheumatology assessment times for new IA patients, following primary care referral. Results are compared by time period: Year 1 (1 April 2019 to 31 March 2020); Year 2 (1 April 2020 to 31 March 2021); Year 3 (1 April 2021 to 30 Sept 2021)."
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 101,
   "metadata": {},
   "outputs": [
    {
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       "</svg>"
      ],
      "text/plain": [
       "<IPython.core.display.SVG object>"
      ]
     },
     "execution_count": 101,
     "metadata": {},
     "output_type": "execute_result"
    }
   ],
   "source": [
    "from IPython.core.display import SVG\n",
    "SVG(filename=\"../output/figures/regional_qs2_bar_GP_merged.svg\")"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "### Time to first prescription of a DMARD in primary care"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "#### National trends"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "Time-series analysis demonstrating the proportion of IA patients who were prescribed conventional synthetic DMARDs (csDMARD; e.g. methotrexate) in primary care within 6 months of their first rheumatology appointment. Decreases were observed in March 2020 and April 2020, corresponding to the start of the first COVID-19 lockdown in England. Trends before March 2020 and after May 2020 are compared in the following graph. \n",
    "\n",
    "Data are shown for all patients with new diagnoses of RA, PsA or undifferentiated IA who had their first rheumatology appointment captured and a minimum of 12 months of follow-up. Data for patients with axSpA are not included, due to small numbers of patients receiving csDMARDs. Only primary care-issued prescriptions for DMARDs are captured (representing shared care prescribing between primary and secondary care); secondary care-issued prescriptions are not currently captured. "
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       "</svg>"
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      "text/plain": [
       "<IPython.core.display.SVG object>"
      ]
     },
     "execution_count": 102,
     "metadata": {},
     "output_type": "execute_result"
    }
   ],
   "source": [
    "from IPython.core.display import SVG\n",
    "SVG(filename=\"../output/figures/ITSA_csDMARD_delay_newey_sensitivity.svg\")"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "#### Regional trends"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "Box plot showing the regional variation in time to first csDMARD prescription in primary care. Results are compared by time period: Year 1 (1 April 2019 to 31 March 2020); Year 2 (1 April 2020 to 31 March 2021); Year 3 (1 April 2021 to 30 Sept 2021). "
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 103,
   "metadata": {},
   "outputs": [
    {
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       "</svg>"
      ],
      "text/plain": [
       "<IPython.core.display.SVG object>"
      ]
     },
     "execution_count": 103,
     "metadata": {},
     "output_type": "execute_result"
    }
   ],
   "source": [
    "from IPython.core.display import SVG\n",
    "SVG(filename=\"../output/figures/regional_csdmard_bar_merged.svg\")"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "### Choice of first DMARD"
   ]
  },
  {
   "cell_type": "markdown",
   "metadata": {},
   "source": [
    "For IA patients who were prescribed at least one csDMARD in primary care within 12 months of diagnosis, this table shows the choice of first medication. \n",
    "\n",
    "Data are shown for patients with new diagnoses of RA, PsA or undifferentiated IA who had their first rheumatology appointment captured and a minimum of 12 months of follow-up. Data for patients with axSpA are not included, due to small numbers of patients receiving csDMARDs. Only primary care-issued prescriptions for DMARDs are captured (representing shared care prescribing between primary and secondary care); secondary care-issued prescriptions are not currently captured. "
   ]
  },
  {
   "cell_type": "code",
   "execution_count": 104,
   "metadata": {},
   "outputs": [
    {
     "data": {
      "text/html": [
       "<table border=\"1\" class=\"dataframe\">\n",
       "  <thead>\n",
       "    <tr style=\"text-align: right;\">\n",
       "      <th>First csDMARD</th>\n",
       "      <th>April 2019/20 (%)</th>\n",
       "      <th>April 2020/21 (%)</th>\n",
       "      <th>April 2021/22 (%)</th>\n",
       "    </tr>\n",
       "  </thead>\n",
       "  <tbody>\n",
       "    <tr>\n",
       "      <td>Hydroxychloroquine</td>\n",
       "      <td>19.7</td>\n",
       "      <td>18.2</td>\n",
       "      <td>13.3</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <td>Leflunomide</td>\n",
       "      <td>20.3</td>\n",
       "      <td>20.3</td>\n",
       "      <td>26.7</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <td>Methotrexate</td>\n",
       "      <td>40.0</td>\n",
       "      <td>40.7</td>\n",
       "      <td>43.3</td>\n",
       "    </tr>\n",
       "    <tr>\n",
       "      <td>Sulfasalazine</td>\n",
       "      <td>20.0</td>\n",
       "      <td>20.8</td>\n",
       "      <td>16.7</td>\n",
       "    </tr>\n",
       "  </tbody>\n",
       "</table>"
      ],
      "text/plain": [
       "<IPython.core.display.HTML object>"
      ]
     },
     "metadata": {},
     "output_type": "display_data"
    }
   ],
   "source": [
    "table = pd.read_csv(\"../output/tables/first_csdmard_rounded.csv\")\n",
    "table_subset = table.loc[:, [\"first_csDMARD\", \"percent_2019\", \"percent_2020\", \"percent_2021\"]]\n",
    "table_subset.rename(columns = {'first_csDMARD':'First csDMARD', 'percent_2019':'April 2019/20 (%)', 'percent_2020':'April 2020/21 (%)', 'percent_2021':'April 2021/22 (%)'}, inplace = True)\n",
    "display(\n",
    "    HTML(table_subset.to_html(index=False)),\n",
    "    )"
   ]
  }
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