Prof. Tom fahey

Division of Population Health Sciences

Royal College of Surgeons in IrelandColáiste Ríoga na Máinleá in Éirinn

How research participation enhances patient care

Tom FaheyHRB Centre for Primary Care Research & RCSI Medical School


Outline of talk

• Importance of research & teaching

• Quality of care- observational epidemiology

• Quality of care- proposed solutions




(1) Importance of research & teaching

• Self evident

• Enables critical thought, reflection & review of clinical practice


General practice

• “Sign of a coherent discipline is one that does its own research and teaching”

Iona Health, President RCGP



(2) Quality of care- observational epidemiology

• Potentially inappropriate prescribing (PIP)

• Between practice variation

• Prescribing at the primary/secondary care interface


Background

• Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP)

– 64 clinically significant criteria– Drug-drug and drug-disease interactions– Doses and durationSTOPPA. Cardiovascular System1. Digoxin at a long-term dose > 125μg/day with impaired renal

function∗(increased risk of toxicity).

2. Loop diuretic for dependent ankle oedema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery usually more appropriate).


Results-PIP prevalence rates RoI (n=338,801)

STOPP % n

ONE PIP 25% 83,959

TWO PIP 8% 27,392

> THREE PIP 3% 10,103

OVERALL PIP 36% 121,454

Cahir et al. Brit J Clin Pharm 2010:69;543-552


Association between the number of different drug classes (polypharmacy) and PIP (STOPP) in 2007 (95% CI)-RoI

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10+

No of drug classes (vs none)

Od

ds r

ati

o

* Linear and quadratic trend p<0.0001

Five highest prevalence rates -RoI(n=338,801)

STOPP DESCRIPTION PREV % OR GENDER(F vs M)

OR AGE(>75 vs 70-74)

Gastrointestinal

PPI > 8 weeksfull therapeutic dose (dose reduction, discontinuation)

16.69% 0.80(0.78-0.81)

1.05(1.02-1.07)

Musculoskeletal

NSAID >3M (simple analgesics preferable)

8.76% 1.25(1.22-1.28)

0.78(0.76-0.81)

CNS >1M Long-acting benzodiazepines(risk of falls, fractures)

5.22% 1.72(1.65- 1.78)

0.89(0.87-0.92)

Duplicates NSAIDs, SSRIs, Antidep, ACE, Loop diuretics, opioids(optimisation of monotherapy)

4.78% 1.19(1.15-1.23)

0.74(0.71-0.76)

Cardiovascular Beta-blocker with COPD(risk of increased bronchospasm)

2.34% 0.53 (0.51-0.56)

0.84(0.80-0.89)


Cost of PIP-RoI

• Gross cost of PIP for one year (2007) €38,664,640

• Total expenditure (gross cost, VAT,+pharmacist dispensing fee) €45,631,319

• Total expenditure accounted for 9% of overall expenditure on pharmaceuticals in those aged ≥ 70 years in 2007







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11.

41.

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Antibiotics 2-nd line (J01) Statins (C10)

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CV: 27.6% SCV: 5.80 *** CV: 15.5% SCV: 0.95 ***

Between-practice variation- Ireland PCRS data


Practice variation- alternative drug classes







General practice

“In general practice the people stay and the diseases come and go. In hospital the

diseases stay and the people come and go”

Iona Health, President RCGP



Medicines management- primary/secondary interface

• Poor transcription• Indication unclear and not linked to

medication• Appropriateness unclear• Poor communication- no formal summary

record• Polypharmacy


(3) Quality of care- proposed solutions

• Clinical Decision Support

• Irish Primary Care Research Network (IPCRN)

• Engage in Professional Competence requirements


Health informatics- levels of functionality

• 1 Record keeping– Medical records– Patient

scheduling– Appointments

• 2 Coding & prescribing– Morbidity coding– Drug prescribing– Drug interaction

• 3 Communication– Laboratory– Health

professional & patient

• 4 Clinical knowledge– CDSS– Decision aids– Comparative

clinical data


Implementation of research evidence


Computerized clinical decision support systems (CDSSs)

• Information systems designed to improve clinical decision making

• Key elements:– Integration EPR– Computerized knowledge base– Provide patient-specific information– Software algorithm


CDSS- level of functionality


CDSS prescribing primary/secondary interface

• Prescribing error– Indication, ordering, interactions, allergies– Transcription– Dispensing– Co-ordination & monitoring

• Evidence-based– Clinical & prescribing knowledge base

• Patient focussed– Patient information leaflet

• Comparative clinical data– Quality improvement & monitoring


Optimizing Prescribing for Older People in Primary Care: a cluster randomized controlled trial- OPTI-SCRIPT

Assess the effectiveness of point of care CDSS that incorporates prescribing alerts with alternative recommendations for GPs in reducing potentially inappropriate prescribing (PIP) in older people in Irish primary care


Decision support- prescribing recommendations

Have there been any adverse effects that may be related to this drug combination?

Is there an alternative drug that can be taken? Alternatives for Verapamil include Diltazam and Amlodipine.

Consider stopping.

For Patient safety reasons and due to a lack of evidence of positive benefit, combined use of beta-blockers and Verapamil is not recommended.

Negotiate discontinuation of either/both drug with patient/carer outlining the benefits of the change.

NO

YES

NO YES


Decision support- comparative data


(3) Quality of care- proposed solutions

• Clinical Decision Support

• Irish Primary Care Research Network (IPCRN)

• Engage in Professional Competence requirements


Structure and ICT framework of Irish Primary Care Research Network

Application/Web Server

Database Server

GP PracticeGP Practice GP Practice

PC PC PC

Secure Internet

Department of General Practice Network

GP Practices with Internet Access

GP Application Resources

RCSI


The TRANSFoRm Project


Define study eligibility criteria – electronic primary care research network (Epcrn)


Gather study data - case report forms -ePCRN


Generation of comparative clinical data


Conclusions

• Engagement with research & teaching is an important marker of professional engagement

• Enables critical thought, reflection & review of clinical practice

• Opportunities at a local, national and international level


Acknowledgments

• Caitriona Cahir• Kathleen Bennett• Derek Corrigan• Brian Cleary• Deirdre Murphy• Marie Bradley

• Sean Higgins• Ronan McDonnell• Borislav Dimitrov• Claire Keogh• Emma Wallace• Udo Reulbach


• http://www.hrbcentreprimarycare.ie/

Date post:	14-Dec-2014
Category:	Health & Medicine
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Prof. Tom fahey

Health & Medicine