1. The collaborative approach was structured in three phases:
Data driven quality improvement 
in primary care
Towards collaborative management of risky polypharmacy in primary care
Scottish Improvement Science
Collaborating Centre
Madalina Toma, Research Fellow1
Jason Tang, Research Fellow1,3
Chris Blantern, Facilitator
Nicola M Gray, Associate Director for Programmes and Evaluation1
Tobias Dreischulte, Lead Pharmacist for Research and Development1,2,3
1. Scottish Improvement Science Collaborating Centre (SISCC),
School of Nursing and Health Sciences, University of Dundee
2. Tayside Medicines Unit, NHS Tayside
3. Quality, Safety and Informatics Research Group, Population Health Sciences Division, University of Dundee
The Data Driven Quality Improvement in Primary Care study (DQIP2) is part of the Scottish Improvement Science Collaborating Centre (SISCC), bringing together a research and development team from NHS Tayside, University of Dundee and the third sector, to deliver a step change in improving existing systems that manage high-risk polypharmacy across NHS Tayside and beyond.
Background
The DQIP1 trial showed that an informatics tool that identifies and facilitates the review of patients at high risk of harm can reduce risky prescribing of antiplatelets and non-steroidal anti-inflammatory drugs by GPs and related emergency admissions. Pharmacist support in conducting medication reviews is one way of enabling sustainable implementation of the DQIP approach at scale, but requires careful planning and support from general practice
staff as well as service users.
The collaborative approach was structured in three phases:
Introduction and context
t The project leads shared the origins, rationale and potential value of the project via plenary
presentations.
1.Collaborative enquiry (past & present)
Moderated discussion in 4 stakeholder groups
(6 GPs, 3 practice managers, 3 pharmacists, 9 service users)
about what are the factors that currently affect risky
polypharmacy and drug related harm. Results were
recorded on flip charts and shared with the wider group.
Aims and objective
The aim of the DQIP2 programme is to identify effective strategies to facilitate sustainable implementation at scale and this part of the programme aimed to test the acceptability and utility of a participatory approach to stimulate and facilitate the design of practice specific processes for the multi-disciplinary management of patients with risky polypharmacy.
2. Imagining the future
Road map exercise in 3 mixed stakeholder groups
(2 GPs, 1 practice manager, 1 pharmacist and 3 service users)
using pre-prepared process cards and postit notes to consider how the new DQIP2 process of change might work in practice. Each emerging map was then shared with the wider group.
The collaborative approach
The design of the DQIP2 intervention is informed by a pilot and optimisation study in
six general practices. To initiate the collaborative process, we held a structured meeting with relevant professionals (6 GPs, 3 pharmacists and 3 practice managers from six practices in one Scottish health board) as well as 9 patient participants.
Feedback and evaluation
The acceptability and perceived utility of the workshop was evaluated via a structured survey, de-briefing statements and follow up phone interviews. Overall, the collaborative approach was highly valued and all participants found the meeting comprehensive, feasible and acceptable. However, healthcare practitioners also described pragmatic factors that might hinder efficiency and utility, highlighting the need for dedicated time for professionals to work together within their practice group to develop the agreed action plans and increase the overall effectiveness in stimulating the adoption of the intervention.
3. Action proposals (Making it happen) Moderated discussion in 3 professional stakeholder groups (6 GPs, 3 practice managers, 3 pharmacists from each practice)
to formulate actions plans (Who?, When?, How?) and identify barriers and facilitators to implementing DQIP2
in clinical practice
References
Guthrie B,, Dreischulte T, e al. High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice. BMJ 2011;342: d3514
Guthrie, B.,, Dreischulte, T. et al The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995–2010. BMC Med. 2015; 13:7
Dreischulte T., Guthrie B., et al, Safer Prescribing-A Trial of Education, Informatics, and Financial Incentives. New England Journal of Medicine, 374(11), pp
Next steps
The approach will be optimised and rolled out as of August 2017 accounting for the identified difficulties of finding a format that suits a variety of audiences and the specific aims of the project. Preliminary data will assess the extent to which the approach has stimulated desired changes in practice, any barriers or facilitators encountered and the reductions in high-risk polypharmacy. We anticipate that improved systems for identifying and managing high-risk polypharmacy will substantially reduce preventable drug related adverse event.
For more information please contact:
Dr Madalina Toma,