Routinely collected administrative datasets can be used to identify healthcare resource use and inform strategic planning and policy development. We evaluate a new comprehensive epilepsy admission algorithm using ICD-10 coding data from these administrative datasets against a gold standard and existing admission identification algorithms.All consecutive admissions to a large UK general hospital meeting predefined criteria were identified over a one-month period. Case note review was performed by independent clinicians and admission classi- fied as epilepsy or not epilepsy related. The Liverpool algorithm and a widely used comparator algorithm were applied to the ICD-10 administrative data and compared to clinician classification.In total 205 admissions were identified. Case-note review (gold standard) identified that 35 cases were epilepsy related admissions, and 156 were not epilepsy related. It was not possible to classify 14 admis- sions due to missing or insufficient data. The Liverpool algorithm incorrectly classified only 17 out of 191 admissions compared to 30 incorrectly classified admissions from a comparator algorithm. The Liverpool algorithm demonstrates sensitivity of 85.7% and specificity of 92.3%.Whilst no perfect algorithm is likely to exist, the Liverpool algorithm identifies hospital admissions due to epileptic seizures using administrative data with improved sensitivity and specificity compared to previous methods.james.mitchell@liverpool.ac.uk

IntroductionSeizures are a common presentation in the Emergency Department (ED). Previous rounds of NASH (2011 and 2013) identified major deficiencies in the provision of care and a disconnection between acute medicine and neurology services. Has there been any improvement?MethodsSetting137 Hospital sites across the UK. Participants: 4132 attendances between 01/06/2018– 30/06/2019 were assessed, 61% had a prior diagnosis of epilepsy and 23% presented with suspected first seizure. Outcome Measures: Data were recorded to assess prior care, the acute presentation and subsequent care including referral for specialist review.ResultsFor patients presenting with first seizure an attempt was made to contact an eyewitness in 70.4%. CT Brain was requested in the ED in 66%, which has increased from 45% in NASH 1. Onward referral for specialist review was requested in 64%.For patients with epilepsy 55% had not seen an epilepsy specialist in the previous 12 months. CT Brain was requested in 30%, increasing from 17% in NASH 1. Specialist review was requested for 35% who had not seen a specialist in the previous 12 months and for 44% who had.ConclusionsThere has been little improvement in the past decade. Improvements are urgently needed to improve the wellbeing of patients presenting with seizures, patients with epilepsy and the efficiency of the healthcare system.gpowell@liv.ac.uk34

BACKGROUND:Routinely recorded data held in electronic health records can be used to inform the conduct of randomised controlled trials (RCTs). However, limitations with access and accuracy have been identified. OBJECTIVE:Using epilepsy as an exemplar condition, we assessed the attributes and agreement of routinely recorded data compared to data collected using case report forms in a UK RCT assessing antiepileptic drug treatments for individuals newly diagnosed with epilepsy. METHODS:The case study RCT is the Standard and New Antiepileptic Drugs II (SANAD II) trial, a pragmatic, UK multicentre RCT assessing the clinical and cost-effectiveness of antiepileptic drugs as treatments for epilepsy. Ninety-eight of 470 eligible participants provided consent for access to routinely recorded secondary care data that were retrieved from NHS Digital Hospital Episode Statistics (N=71) and primary and secondary care data from The Secure Anonymised Information Linkage Databank (N=27). We assessed data items relevant to the identification of individuals eligible for inclusion in SANAD II, baseline and follow-up visits. The attributes of routinely recorded data were assessed including the degree of missing data. The agreement between routinely recorded data and data collected on case report forms in SANAD II was assessed using calculation of Cohen's kappa for categorical data and construction of Bland-Altman plots for continuous data. RESULTS:There was a significant degree of missing data in the routine record for 15 of the 20 variables assessed, including all clinical variables. Agreement was poor for the majority of comparisons, including the assessments of seizure occurrence and adverse events. For example, only 23/62 (37%) participants had a date of first-ever seizure identified in routine datasets. Agreement was satisfactory for the date of prescription of antiepileptic drugs and episodes of healthcare resource use. CONCLUSIONS:There are currently significant limitations preventing the use of routinely recorded data for participant identification and assessment of clinical outcomes in epilepsy, and potentially other chronic conditions. Further research is urgently required to assess the attributes, agreement, additional benefits, cost-effectiveness and 'optimal mix' of routinely recorded data compared to data collected using standard methods such as case report forms at clinic visits for people with epilepsy. TRIAL REGISTRATION:Standard and New Antiepileptic Drugs II (SANAD II (EudraCT No: 2012-001884-64, registered 05/09/2012; ISRCTN Number: ISRCTN30294119 , registered 03/07/2012)).

BackgroundClinical trials generally each collect their own data despite routinely collected health data (RCHD) increasing in quality and breadth. Our aim is to quantify UK-based randomised controlled trials (RCTs) accessing RCHD for participant data, characterise how these data are used and thereby recommend how more trials could use RCHD.MethodsWe conducted a systematic review of RCTs accessing RCHD from at least one registry in the UK between 2013 and 2018 for the purposes of informing or supplementing participant data. A list of all registries holding RCHD in the UK was compiled. In cases where registries published release registers, these were searched for RCTs accessing RCHD. Where no release register was available, registries were contacted to request a list of RCTs. For each identified RCT, information was collected from all publicly available sources (release registers, websites, protocol etc.). The search and data extraction were undertaken between January and May 2019.ResultsWe identified 160 RCTs accessing RCHD between 2013 and 2018 from a total of 22 registries; this corresponds to only a very small proportion of all UK RCTs (about 3%). RCTs accessing RCHD were generally large (median sample size 1590), commonly evaluating treatments for cancer or cardiovascular disease. Most of the included RCTs accessed RCHD from NHS Digital (68%), and the most frequently accessed datasets were mortality (76%) and hospital visits (55%). RCHD was used to inform the primary trial (82%) and long-term follow-up (57%). There was substantial variation in how RCTs used RCHD to inform participant outcome measures. A limitation was the lack of information and transparency from registries and RCTs with respect to which datasets have been accessed and for what purposes.ConclusionsIn the last five years, only a small minority of UK-based RCTs have accessed RCHD to inform participant data. We ask for improved accessibility, confirmed data quality and joined-up thinking between the registries and the regulatory authorities.Trial registrationPROSPERO CRD42019123088.

Background: Clinical trials generally each collect their own data despite routinely-collected health data (RCHD) increasing in quality and breadth. Our aim is to quantify UK-based randomised controlled trials (RCTs) accessing RCHD for participant data, characterise how these data are used and thereby recommend how more trials could use RCHD. Methods: We conducted a systematic review of RCTs accessing RCHD from at least one registry in the UK between 2013-2018, for the purposes of informing or supplementing participant data. A list of all registries holding RCHD in the UK was compiled. In cases where registries published release registers, these were searched for RCTs accessing RCHD. Where no release register was available, registries were contacted to request a list of RCTs. For each identified RCT, information was collected from all publicly available sources (release registers, websites, protocol etc.). The search and data extraction was undertaken between Jan-2019 and May-2019. Results: We identified 160 RCTs accessing RCHD between 2013 and 2018 from a total of 22 registries; this corresponds to only a very small proportion of all UK RCTs (approximately 3%). RCTs accessing RCHD were generally large (median sample size 1590), commonly evaluating treatments for cancer or cardiovascular disease. Most of the included RCTs accessed RCHD from NHS Digital (68%), and the most frequently accessed datasets were mortality (76%) and hospital visits (55%). RCHD was used to inform the primary trial (82%) and long-term follow-up (57%). There was substantial variation in how RCTs used RCHD to inform participant outcomes. A limitation was the lack of information and transparency from registries and RCTs with respect to which datasets have been accessed and for what purposes. Conclusions: In the last five years, only a small minority of UK-based RCTs have accessed RCHD to inform participant data. We ask for improved accessibility, confirmed data quality and joined up thinking between the registries and the regulatory authorities. Registration: PROSPERO CRD42019123088

Anti-seizure medications (ASMs) remain the mainstay of the treatment of epilepsy and the majority of patients with epilepsy (60–70%) will achieve a sustained remission from seizures. The number of ASMs has increased dramatically in recent years and there are now over 20 ASMs licensed and available [1]. Given that epilepsy is a chronic condition, often requiring years of treatment, a choice among these drugs requires evidence about longer-term clinical and cost effectiveness, which will come largely from randomized controlled trials (RCTs), in which treatments are compared head to head. Much of this evidence comes from publically funded trials rather than those sponsored by the pharmaceutical industry, whose trials are designed to meet regulatory requirements rather than to inform clinical decision-making. In the EU this currently results in non-inferiority trials assessing six-month remission rate [2,3], whilst in the USA this resulted in short-term trials using a historical control design [4]. More recently, the US FDA has allowed extrapolation of adjunctive therapy RCT data. Approval requires pharmacokinetic studies and recommendations for dosing to achieve levels similar to those obtained in adjunctive therapy. This approach has resulted in approvals for monotherapy for perampanel, eslicarbazepine and brivaracetam, without the need for a separate efficacy trial.

OBJECTIVE:To assess the evolution of antiepileptic drug (AED) treatment patterns and seizure outcomes in England from 2003 to 2016.DESIGN, SETTING AND PARTICIPANTS:Retrospective cohort study of electronic medical records from Clinical Practice Research Datalink and National Health Service Digital Hospital Episode Statistics databases. Patients newly diagnosed with epilepsy were identified and followed until end of data availability. Three eras were defined starting 1 April 2003 (first National Institute for Health and Care Excellence (NICE) guideline); 1 September 2007 (Standard and New Antiepileptic Drugs publication); and 1 January 2012 (second NICE guideline).OUTCOME MEASURES:Time from diagnosis to first AED; AED sequence; time from first AED to first 1-year remission period (no new AED attempts and no seizure-related healthcare events); time from first AED to refractoriness (third AED attempt regardless of reason); Kaplan-Meier analysis of time-to-event variables.RESULTS:4388 patients were included (mean follow-up: 6.8, 4.2 and 1.7 years by era). 84.6% of adults (≥16 years), 75.5% of children (<16) and 89.1% of elderly subgroup (65+) received treatment within 1 year; rates were generally stable over time. Treatment trends included reduced use of carbamazepine (adult first line, era 1: 34.9%; era 3: 10.7%) and phenytoin, earlier line and increased use of levetiracetam (adult first line, era 1: 2.6%; era 3: 26.2%) and lamotrigine (particularly in adults and elderly subgroup), and a larger number of different AEDs used. Valproate use shifted somewhat to later lines. Rates of 1-year remission within 2 years of starting treatment increased in adults (era 1: 71.9%; era 3: 81.4%) and elderly (era 1: 76.1%; era 3: 81.7%). Overall, 55.5% of patients relapsed after achieving 1-year remission. Refractoriness rates remained stable over time (~26% of adults within 5 years).CONCLUSION:Treatment trends often were not aligned with era-relevant guidance. However, our results suggest a slight improvement in epilepsy treatment outcomes over the 13-year period.

OBJECTIVES:To develop prognostic models for risk of a breakthrough seizure, risk of seizure recurrence after a breakthrough seizure, and likelihood of achieving 12-month remission following a breakthrough seizure. A breakthrough seizure is one that occurs following at least 12 months remission whilst on treatment. METHODS:We analysed data from the SANAD study. This long-term randomised trial compared treatments for participants with newly diagnosed epilepsy. Multivariable Cox models investigated how clinical factors affect the probability of each outcome. Best fitting multivariable models were produced with variable reduction by Akaike's Information Criterion. Risks associated with combinations of risk factors were calculated from each multivariable model. RESULTS:Significant factors in the multivariable model for risk of a breakthrough seizure following 12-month remission were number of tonic-clonic seizures by achievement of 12-month remission, time taken to achieve 12-month remission, and neurological insult. Significant factors in the model for risk of seizure recurrence following a breakthrough seizure were total number of drugs attempted to achieve 12-month remission, time to achieve 12-month remission prior to breakthrough seizure, and breakthrough seizure treatment decision. Significant factors in the model for likelihood of achieving 12-month remission after a breakthrough seizure were gender, age at breakthrough seizure, time to achieve 12-month remission prior to breakthrough, and breakthrough seizure treatment decision. CONCLUSIONS:This is the first analysis to consider risk of a breakthrough seizure and subsequent outcomes. The described models can be used to identify people most likely to have a breakthrough seizure, a seizure recurrence following a breakthrough seizure, and to achieve 12-month remission following a breakthrough seizure. The results suggest that focussing on achieving 12-month remission swiftly represents the best therapeutic aim to reduce the risk of a breakthrough seizure and subsequent negative outcomes. This will aid individual patient risk stratification and the design of future epilepsy trials.

There are a number of clinical and non-clinical administrative datasets that routinely record information on individuals in the UK. Access for secondary uses such as clinical research is permitted when health and social care benefit can be demonstrated. Clinical sources of data are commonly accessed to provide data for retrospective observational and record-linkage studies and provide a valid dataset for this purpose. Routinely recorded data may also present advantages to prospective clinical research such as randomised controlled trials (RCTs). The majority of RCTs incur health service costs as clinicians assess participants, record outcomes and complete Case Report Forms – hence using routinely recorded data may provide an efficient alternative method for data collection in addition to reducing the burden on participants. Furthermore, data from non-clinical routine sources may inform outcomes beyond the standard RCT assessments of clinical efficacy and effectiveness. However, limitations with accuracy of coding, confidentiality, ownership and access have previously been identified as significant barriers. This study has assessed the feasibility of accessing clinical and non-clinical routinely recorded data during a RCT assessing treatments for newly diagnosed epilepsy and will assess the agreement and additional benefits of routinely recorded data compared to data collected using standard prospective methods.

Background A breakthrough seizure is one occurring after at least 12 month remission whilst on treatment. Prognostic models for risk of breakthrough seizure, risk of seizure recurrence after breakthrough seizure, and likelihood of achieving 12 month remission following a breakthrough seizure are developed. Methods SANAD compared treatments for patients with newly diagnosed epilepsy. Multivariable regression modelling was used to investigate how clinical factors affect the probability of each outcome. Results Neurological insult, number of tonic-clonic seizures by achievement of 12 month remission, and time taken to achieve 12 month remission were significant factors for risk of breakthrough seizure. Total number of drugs attempted to achieve 12 month remission, time to achieve 12 month remission prior to breakthrough seizure, and breakthrough seizure treatment decision were significant for risk of seizure recurrence following a breakthrough seizure. Gender, age at breakthrough, time to achieve 12 month remission prior to breakthrough, and breakthrough seizure treatment decision were significant for likelihood of achieving 12 month remission after a breakthrough seizure. Conclusions These models help to identify patients most likely to have a breakthrough seizure, to have a recurrence following a breakthrough, and to achieve 12 month remission following a breakthrough. This will aid individual patient risk stratification and the design of future epilepsy trials.

Background In the UK, routinely recorded data may benefit prospective studies including randomised controlled trials (RCTs). In an on-going study, we aim to assess the feasibility of access and agreement of routinely recorded clinical and non-clinical data compared to data collected during a RCT using standard prospective methods. This paper will summarise available UK routinely recorded data sources and discuss our experience with the feasibility of accessing routinely recorded data for participants of a RCT before finally proposing recommendations for improving the access and implementation of routinely recorded data in RCTs. Methods Setting: the case study RCT is the Standard and New Antiepileptic Drugs II (SANAD II) trial, a pragmatic, UK, multicentre, phase IV RCT assessing the clinical and cost-effectiveness of antiepileptic drug treatments for newly diagnosed epilepsy. Participants: 98 participants have provided written consent to permit the request of routinely recorded data. Study procedures: routinely recorded clinical and non-clinical data were identified and data requested through formal applications from available data holders for the duration that participants have been recruited into SANAD II. The feasibility of accessing routinely recorded data during a RCT is assessed and recommendations for improving access proposed. Results Secondary-care clinical and socioeconomic data is recorded on a national basis and can be accessed, although there are limitations in the application process. Primary-care data are recorded by a number of organisations on a de-identified basis but access for specific individuals has not been feasible. Access to data recorded by non-clinical sources, including The Department for Work and Pensions and The Driving and Vehicle Licensing Agency, was not successful. Conclusions Recommendations discussed include further research to assess the attributes of routinely recorded data, an assessment of public perceptions and the development of strategies to collaboratively improve access to routinely recorded data for research. Trial registration International Standard Randomised Controlled Trials, ISRCTN30294119 . Registered on 3 July 2012. EudraCT No: 2012-001884-64. Registered on 9 May 2012.

OBJECTIVES:A breakthrough seizure is one occurring after at least 12 months seizure freedom while on treatment. The Driver and Vehicle Licensing Agency (DVLA) allows an individual to return to driving once they have been seizure free for 12 months following a breakthrough seizure. This is based on the assumption that the risk of a further seizure in the next 12 months has dropped <20%. This analysis considers whether the prescribed 1 year off driving following a breakthrough seizure is sufficient for this and stratifies risk according to clinical characteristics. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: The multicentre UK-based Standard versus New Antiepileptic Drugs (SANAD) study was a randomised controlled trial assessing standard and new antiepileptic drugs for patients with newly diagnosed epilepsy. For participants aged at least 16 with a breakthrough seizure, data have been analysed to estimate the annual seizure recurrence risk following a period of 6, 9 and 12 months seizure freedom. Regression modelling was used to investigate how antiepileptic drug treatment and a number of clinical factors influence the risk of seizure recurrence. RESULTS:At 12 months following a breakthrough seizure, the overall unadjusted risk of a recurrence over the next 12 months is lower than 20%, risk 17% (95% CI 15% to 19%). However, some patient subgroups have been identified which have an annual recurrence risk significantly greater than 20% after an initial 12-month seizure-free period following a breakthrough seizure. CONCLUSIONS:This reanalysis of SANAD provides estimates of seizure recurrence risks following a breakthrough seizure that will inform policy and guidance about regaining an ordinary driving licence. Further guidance is needed as to how such data should be used. TRIAL REGISTRATION NUMBER:SANAD is registered with the International Standard Randomised Controlled Trial Number Register ISRCTN38354748.

There are a number of administrative datasets that routinely record information on individuals in the UK. Such routine or ‘Big Data’ sources record specified data variables that are largely limited to those that enable the intended objectives of the data holder. Routine sources include clinical datasets such as Hospital Episode Statistics (HES) and the Clinical Practice Research Datalink (CPRD). In addition, non-health data is recorded by the Department of Work and Pensions (DWP), HM Revenue and Customs (HMRC) and The Driving and Vehicle Licensing Authority (DVLA) in order to meet the specified objectives of each authority. Routine data applied to clinical research is potentially cost and resource-use effective. Clinical sources of data such as HES and CPRD are commonly accessed to provide data for retrospective observational and record-linkage studies and there are many published examples. However, there is limited evidence on the use of routine data in prospective studies, particularly randomised controlled trials (RCTs). This on-going project aims to assess the feasibility, accuracy, reliability and additional benefits of using data from routine sources for patients participating in the Standard and New Antiepileptic Drugs II RCT. Clinical and health economic outcomes will be examined from sources including HES, CPRD, DWP, HMRC and DVLA and assessed in comparison to data obtained from traditional RCT methods. This presentation will narratively summarise the methods of access, application procedures and limitations encountered thus far with accessing individual-level, linked data from the listed routine data sources.

AIM:Pharmacogenetic studies have identified the presence of the HLA-A*31:01 allele as a predictor of cutaneous adverse drugs reactions (ADRs) to carbamazepine. This study aimed to ascertain the preferences of patients and clinicians to inform carbamazepine pharmacogenetic testing services. METHODS:Attributes of importance to people with epilepsy and neurologists were identified through interviews and from published sources. Discrete choice experiments (DCEs) were conducted in 82 people with epilepsy and 83 neurologists. Random-effects logit regression models were used to determine the importance of the attributes and direction of effect. RESULTS:In the patient DCE, all attributes (seizure remission, reduction in seizure frequency, memory problems, skin rash and rare, severe ADRs) were significant. The estimated utility of testing was greater, at 0.52 (95% CI 0.19, 1.00) than not testing at 0.33 (95% CI -0.07, 0.81). In the physician DCE, cost, inclusion in the British National Formulary, coverage, negative predictive value (NPV) and positive predictive value (PPV) were significant. Marginal rates of substitution indicated that neurologists were willing to pay £5.87 for a 1 percentage point increase in NPV and £3.99 for a 1 percentage point increase in PPV. CONCLUSION:The inclusion of both patients' and clinicians' perspectives represents an important contribution to the understanding of preferences towards pharmacogenetic testing prior to initiating carbamazepine. Both groups identified different attributes but had generally consistent preferences. Patients' acceptance of a decrease in treatment benefit for a reduced chance of severe ADRs adds support for the implementation of HLA-A*31:01 testing in routine practice.

BACKGROUND:Acute central nervous system (CNS) infections, such as meningitis and encephalitis, are neurological emergencies for which accurate diagnosis and prompt treatment improve the outcome. Analysis of the cerebrospinal fluid (CSF) obtained at lumbar puncture (LP) is pivotal to establishing the diagnosis and guiding management. PCR analysis of the CSF is an important method to identify the pathogen. However, recent studies have demonstrated that many patients have inadequate CSF sample collection and analysis. AIMS:To increase the proportion of patients having an LP for a suspected CNS infection for whom the appropriate samples are taken. Secondary aims included to increase the proportion of patients for whom a pathogen was identified. METHODS:The authors developed an LP pack for patients with a suspected CNS infection. They also assessed its impact on diagnosis by comparing practice 6 months before and after its introduction to the medical admissions unit of a large inner city teaching hospital. RESULTS:The authors found that the LP pack reduced major errors in CSF sample collection and improved the diagnosis of acute CNS infections; among those patients who had a CSF pleocytosis, the proportion with a viral or bacterial pathogen identified by PCR was increased after introduction of the pack. DISCUSSION:This study has demonstrated that the introduction of a simple low-cost LP pack into a busy acute medical setting can improve the diagnosis of CNS infections and, thus, guide treatment. Further work is needed to see if these results are more widely reproducible, and to examine the clinical, health and economic impact on overall management of patients with suspected CNS infections.

BACKGROUND Epilepsy is a common neurological condition characterised by recurrent seizures. Most patients respond to conventional antiepileptic drugs, however, around 30% will continue to experience seizures despite multiple antiepileptic drugs. Sulthiame, also known as sultiame, is a widely used antiepileptic drug in Europe and Israel. We present a summary of the evidence for the use of sulthiame as add-on therapy in epilepsy. OBJECTIVES To compare the efficacy and side-effect profile of sulthiame as add-on therapy compared with placebo or another antiepileptic drug. SEARCH METHODS We searched the Cochrane Epilepsy Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov and the WHO ICTRP Search Portal on 11 August 2015. No language restrictions were imposed. We contacted the manufacturers of sulthiame and researchers in the field to seek any ongoing or unpublished studies. SELECTION CRITERIA Randomised controlled add-on trials of sulthiame in people of any age with epilepsy of any aetiology. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted relevant data. The following outcomes were assessed: 1) reduction in seizure frequency of 50% or greater between baseline and end of follow-up; 2) complete cessation of seizures during follow-up; 3) mean seizure frequency; 4) time to treatment withdrawal; 5) adverse drug effects; and 6) quality of life scoring. Primary analyses were intention-to-treat. We present a narrative analysis. MAIN RESULTS We included one trial with 37 participants with a new diagnosis of West syndrome. Sulthiame was given as an add-on therapy to pyridoxine. No data were reported for outcomes 1), 3) or 6). Overall risk ratio with 95% confidence intervals (CI) for complete cessation of seizures during a nine-day follow-up period versus placebo was 0.71 (95% CI 0.53 to 0.96). Meaningful analysis of time to treatment withdrawal and adverse drug effects was not possible due to incomplete data. AUTHORS' CONCLUSIONS Sulthiame may lead to a cessation of seizures when used as an add-on therapy to pyridoxine in patients with West syndrome. The included study was small and had a significant risk of bias which limits the impact of the evidence. No conclusions can be drawn about the occurrence of adverse drug effects, change in quality of life or mean reduction in seizure frequency. No evidence exists for the use of sulthiame as an add-on therapy in patients with epilepsy outside West syndrome. Large, multi-centre randomized controlled trials are necessary to inform clinical practice if sulthiame is to be used as an add-on therapy for epilepsy.

Introduction The optimum role for gastroscopy (OGD) in managing dyspepsia and detecting oesophagogastric cancer (OG-Ca) is controversial. UK general practitioners (GPs) serve a gatekeeper role in selecting dyspeptic patients for OGD. We reported that variation in rates of OGD at the level of GP practise populations is associated with OG-Ca outcome, specifically that low rates are related to risk of poor outcome.[1] We wished to show that GP practises with low OGD rates are likely to be operating more selective referral practise with higher yield of serious pathology. Methods GP practises with ≥1 incident case of OG-Ca were selected, as described.[1.2] Using a two-year download of HES data we identified all elective OGD procedures and obtained practise data to calculate age-sex adjusted OGD rates. Practices were divided into OGD rate tertiles (Low, Medium or High). An algorithm was developed to analyse coded diagnoses for first OGDs, identifying most “serious” condition: (1) OG-Ca, (2) Major acid-peptic diseases, (3) Minor findings (e.g. gastritis), (4) Benign GI neoplasms, (5) Upper GI symptom codes, (6) Miscellaneous (all others). We compared age and proportions with serious disease (categories: 1–2) across the GP practise tertiles. Results 587,256 patients had elective OGD from 6,513 practises serving an adult population of c.39 million. Overall, yield of OG-Ca was 2.1%, major acid-peptic diseases 11.6% and the remaining 86.3% were mainly minor pathologies or symptom codes. Mean OGD rate for Low, Middle, High practises: 4.4 vs 8.1 vs 12.9 per 1,000 population. No difference in age distribution of populations across tertiles. Mean age of patients undergoing OGD was highest for low tertile practises (60.2 vs 59.5 vs 58.4 yrs; p < 0.001) which had highest yield of serious disease: 16,595/108,679 (15.3%) vs 28,177/203,771 (13.9%) vs 36,026/274,806 (13.1%) (p < 0.001). Conclusion Low referring practises appear to target slightly older patients and achieve higher yield of serious disease. Although higher yield may be more consistent with current guidelines, it may also indicate an increased risk of referral at a later stage in the disease process and of poorer OG-Ca outcome.[1] Disclosure of Interest None Declared. References Shawihdi, M., et al. Gastroscopy rate in English general practise populations: association with outcome for oesophagogastric cancer. Gut, 2012. 61(Suppl 2):A19. Shawihdi, M., et al. Emergency Hospital Admission as a Route for Oesophagogastric Cancer Diagnosis: A Marker of Poor Outcome and a Candidate Quality Indicator for Local Services. Gastroenterology, 2011. 140( 5, Supplement 1):S207.