Julia Hippisley-Cox

BIOGRAPHY

Julia qualified with distinction from Sheffield University Medical School in 1989 where she was awarded the Prize in Medicine, Surgery, General Practice and Obstetrics and Gynaecology. In 1995 she was awarded a distinction in the MRCGP examination and awarded FRCGP in 2005. She became a Member of the Royal College of Physicians in 1994, and a Fellow in 2013. She was appointed as Lecturer at the University of Nottingham in 1995, Senior Lecturer in 1999, Reader in 2004. She was promoted to Professor of Clinical Epidemiology & General Practice in 2005 where she stayed until her appointment to a Chair at the University of Oxford in 2019.

DECLARATIONS

JHC has a 50% shareholding in ClinRisk Ltd, co-owning it with her husband, who is a director.  As a shareholder and spouse of a director she has a financial and family interest in the ongoing and future success of the company.  The company licences software both to the private sector and to NHS bodies or bodies that provide services to the NHS (through GP electronic health record providers, pharmacies, hospital providers and other NHS providers).  This software implements algorithms developed from access to the QResearch database during her time at the University of Nottingham

NATIONAL AWARDS

2021    John Perry Award, British Computer Society. Outstanding Contribution to NHS IT.
2021    Health Service Journal Award Best Use of Technology Award for QCOVID risk stratification. 
2021    Florence Nightingale Award for Excellence in Health Care Analytics, Health Foundation & RSS
2021    Royal College of General Practitioners. COVID paper of the year in 2020
2021    BMJ Heart best paper of the year ‘Risk of severe COVID-19 disease with ACE inhibitors
2019    BMJ Best Research Paper of the Year “HRT and Risk of Thrombosis”
2018    Royal College of General Practitioners paper of the year’s CVD category for QRISK3
2017    Level 10 Silver Clinical Excellence Award renewal
2013    Dr John Perry Prize, British Computer Society, outstanding contribution to NHS IT
2012    Royal College of General Practitioners, Research Paper of the Year in the cancer category
2009    John Fry Award (RCGP) for promoting the discipline of general practice through research and publishing.

RESEARCH AND IMPACT

Julia's research interests are very broad and include large scale clinical epidemiology, drug safety and the development of risk prediction algorithms using electronic databases from general practices. She is the co-founder of the QResearch database which is one of the largest clinical research databases worldwide. By 2022, it has doubled in size to to cover over 1500 GP practices, representing approximately 25% of the UK population. The database is also linked to hospital, mortality & cancer data, COVID test results, COVID-19 vaccination and ICNARC ICU data. She has developed and validated risk prediction algorithms for a range of diseases including cardiovascular disease, cancer fracture, diabetes and other conditions. These tools are now widely used across the NHS.

QCOVID NHS risk assessment tool

I led development of the CMO commissioned QCOVID tool to identify patients at risk of severe COVID-19 outcomes. This was implemented by NHS Digital in Feb 21 to risk stratify entire population of England adding 1.5M to the Shielded Patient List and prioritised 800K people for early vaccination. We pioneered the 1st known precision scalable public health intervention internationally establishing new re-usable infrastructure/approach. It is QCovid was implemented as a clinical calculator for use with UK and US patients & GP to personalise risk improve decisionmaking & guide interventions.

It is published as an NIHR impact case study winning 4 national awards 

COVID-19 vaccine safety 

I published the UK’s largest COVID-19 vaccine safety studies, covering > 38M people including 2 papers in Nat Medicine & 1 BMJ. This provide UK’s 1st peer reviewed evidence of association between COVID-19 vaccination (a) myocarditis (b) Guillain Barre syndrome (c) thrombosis though these risks were lower than the risk following SARS-CoV-2 infection. The results were used immediately by SAGE, UK, EU & US drug regulators to quantify risks & benefits of COVID-19 vaccinations.

Improving cancer care to support the NHS Long Term Plan.

In 2017/8, I was an expert witness to the All-Party Parliamentary Group on Pancreatic Cancer. & delivered the keynote lecture at the launch of the report in the Houses of Parliament. The report “The Need for Speed: diagnosing pancreatic cancer earlier, giving patients a chance of living better for longer’ included recommendations on the use of GP decision support tools to improve early diagnosis of cancer. 2020/1.

Reducing risk of dementia

Our 2019 paper on risk of dementia associated with anticholinergic drugs is highly cited & the 2nd most viewed paper. The editor said “These findings are definitely practice changing & could lead doctors to dramatically curtail use of anticholinergic drugs.”  This is referenced in international guidelines e.g 5^thCanadian Consensus Conference on the Diagnosis & Treatment of Dementia.Reducing the risk of later-life dementia and used in a national public advice campaign including use of videos to support public messaging. Medicines professionals used videos to actively help care home residents reduce risk & burden of anticholinergic medicine winning a national award.  This involved implementing an innovative pathway on the wards of their local Trust & training multiple primary care healthcare professionals with feedback that videos helped increase awareness of risks of anticholinergic drugs, supporting triage for structured medication review

NATIONAL HEALTH POLICY AND USE OF QPREDICTION TOOLS IN CLINCAL PRACTICE

Inclusion in national guidelines  

Several of the tools have been recommended for use in clinical practice in NICE guidance. In 2014 QRisk2 was recommended as the sole risk tool of choice to assess cardiovascular disease risk in the NICE Cardiovascular disease guideline [CG181, 2014]. New recommendations in the updated NICE guideline on hypertension in adults [NG136, 2019] include use of QRisk scores to inform antihypertensive treatment. 

 QDiabetes is recommended in NICE guidance on the prevention of type 2 diabetes [PH38, 2017]. The 2016 NICE guideline on multimorbidity [NG56, 2016] recommends using QAdmissions to identify adults with multimorbidity who are at risk of adverse events such as unplanned hospital admission or admission to care homes. Other recommendations in guidelines include QFracture in NICE guidance [CG146, 2017] and the Scottish Intercollegiate Guideline Network (SIGN) national clinical guideline on osteoporosis management [SIGN 142; 2015] which has a key recommendation that to quantify fracture risk “Fracture-risk assessment should be carried out, preferably using QFracture”. This assessment is then used to target pharmacological, and non-pharmacological treatments to reduce fracture risk.  

Implementation into clinical computer systems

All of the tools are publicly accessible, and most including QRisk2, QDiabetes, QFracture, QCancer, QStroke and QAdmissions have been integrated into the major UK GP clinical system (EMIS) which supplies computer systems to over 55% of GP practices in England, covering a population in excess of 30,000,000 people. 

 The tools are also available as free open-source software (see links in section 2) to facilitate transparency, further research and use internationally. Google analytics show that since 2014, there have been over 2,000,000 hits to the QPrediction websites, with hits from most countries worldwide. 

Some tools have also been implemented in other GP clinical systems and by other suppliers including occupational health, pharmacy, secondary care and the private sector. For example, Wellpoint health kiosks which use QRisk3 are currently deployed in many occupational settings throughout the UK including the Ministry of Defence, Department of Health, DVLA, Kent County Council, Scottish Power, Scottish Water.  

Use and recommendations in clinical practice  

QRisk is integral to policy guidance and practice such as currently being used in NHS Health checks, a national programme offering health checks to adults in England aged 40 to 74. It is designed to help prevent and detect early signs of heart disease, kidney disease, Type 2 diabetes and dementia and incorporates assessment of cardiovascular disease risk. Over 6,000,000 people in England received an NHS Health check between 2013 and 2017. 

 The QRisk lifetime version of the tool is used by Public Health England on its NHS One You website to estimate heart age, with the aim of increasing awareness of heart health and acting as an incentive to make simple lifestyle changes. This was widely publicised by Public Health England in September 2018. By June 2017 the website had been viewed by approximately 2,900,000 people, with approximately 1,200,000 completions of the tool. 

QCancer is designed to prompt GPs to think about diagnosis of cancer and refer high risk patients to hospital sooner, with the aim of patients being diagnosed at an earlier stage when there are more treatment options likely to improve survival. The QCancer tool is recommended by Cancer Research UK, and its use is being facilitated by Macmillan which has successfully piloted the tool and is promoting its use as a cancer decision support tool in clinical practice across the country. 

 Evaluations and evidence of benefits

In the NHS Health Check prevention programme in England people with a 10-year QRisk score of 10% or more are considered to be high risk of cardiovascular disease and are offered lifestyle advice, behaviour change support and considered for statin treatment. A microsimulation study by researchers at the University of Cambridge estimated that in England each year the programme is preventing approximately 300 premature deaths (before age 80) and resulting in an additional 1,000 people being free of cardiovascular disease, dementia, and lung cancer at age 80 years. The study also found that the programme has a greater absolute impact on health for people living in the most deprived areas, accordingly the programme as a whole is reducing health inequalities. 

An independent study in the Lancet compared four strategies for determining eligibility for blood pressure treatment, including one based solely on blood pressure values, two strategies based on NICE hypertension guidelines (2011 and 2019) which consider a combination of QRisk2 scores, blood pressure measurements and medical conditions, and one based on using a threshold for QRisk2 scores alone. The study estimated that 322,921 cardiovascular events would be avoided in the UK over 10 years using QRisk2 scores alone to determine eligibility for blood pressure-lowering treatment compared with 233,152 events based on the 2011 NICE guideline, and 270,233 for the 2019 NICE guideline. It concluded that a risk-based strategy using QRisk2 scores was the most efficient strategy, and could prevent over a third more cardiovascular disease events than the 2011 NICE guideline and a fifth more than the 2019 NICE guideline.

 A Public Health England feasibility review in 2016 of tools for identifying people at high risk of developing diabetes in NHS Health Checks found QDiabetes to be more accurate than the method used in NHS Health Checks at the time based on body mass index and blood pressure. For example, the sensitivity was 66% using QDiabetes compared with 57%. QDiabetes is now one of the validated risk assessment tools for diabetes included in the NHS Health Check programme.

An international guideline panel has proposed using QCancer colorectal cancer scores to identify people with increased risk (15-year risk above 3%) for colorectal cancer screening rather than a strategy of screening all people aged 50 to 79 years. This recommendation was based on a modelling study and a linkedsystematic review of the benefits, harms, and burdens of colorectal screening. The modelling study predicted that in people with a QCancer risk score of 3% an estimated 5 to 6 colorectal cancer deaths would be prevented over 15 years per 1000 people screened. The panel proposed QCancer as it is “one of the best performing models for both men and women”, and because it has been externally validated, has good calibration, is available as on online calculator and can predict risk over a 15-year time horizon.