1. Division of Population Health Sciences Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Enhancing drug safety with Information & Communication Technology (ICT) Tom Fahey HRB Centre for Primary Care Research

2. Division of Population Health Sciences Outline of talk Epidemiology of prescribing Quality of prescribing Primary care and prescribing Solutions

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4. (1) Descriptive epidemiology of prescribing in Ireland Primary Care Reimbursement Scheme (PCRS) –Expenditure €2,489,000,000 –Expenditure increase 17% PA –Population coverage 2.47 million –Generic prescribing 18% –Private prescription

5. Division of Population Health Sciences Growth in Community Drug Schemes

6. Division of Population Health Sciences Most costly drugs Lipid modifying agents - €160m Acid Related Disorders - €127m Renin-Angiotensin system - €75m Drugs for Obstructive Airways Disease - €110m Clinical Nutritional Products - €52m Psycholeptics and Psychoanaleptics - €149m

7. Division of Population Health Sciences (2) Quality of prescribing Misuse- medication error Underuse- of proven medicines Overuse- in inappropriate medicines

8. Division of Population Health Sciences Clinical example 22 year old asylum seeker Prescribed oral tetracycline (minocycline) for acne Attends 8/40 pregnant Example of FDA classification “D”- positive evidence of fetal risk (teeth staining, dental hypoplasia)

9. Division of Population Health Sciences Pregnant women Quality standard for prescribing in pregnancy- FDA risk classification –“A”- possibility of fetal harm remote –“B”- controlled studies fail to demonstrate a risk –“C”- animal studies show risk –“D”- positive evidence of risk but benefits may be acceptable –“X”- definite risk that outweighs benefit

10. Division of Population Health Sciences Medication exposure- 61,252,women Coombe Women & Infants University Hospital 2000-7 Category D- evidence of fetal risk, benefits may outweigh harm Category X- evidence of fetal risk, any possible benefit outweighed by risk 1,532 (2.5%) 1,987 (3.2%)

11. Division of Population Health Sciences FDA category D/X drug exposure

12. Division of Population Health Sciences Factors associated with FDA category D/X drug exposure Booking <12/40 Being unemployed Unplanned pregnancy* (OR 1.63, 95% CI 1.47, 1.81) Single marital status* (OR 2.22, 95% CI 2.00, 2.46) Multiple pregnancy* (OR 1.56, 95% CI 1.13, 2.13) Smoking in pregnancy* (OR 3.31, 95% CI 2.98, 3.67) Publicly funded patient* (OR 1.49, 95% CI 1.32, 1.68) *odds ratio relative to not having characteristic

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14. (2) Quality of prescribing Misuse- medication error Underuse- of proven medicines Overuse- in inappropriate medicines

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16. (2) Quality of prescribing Misuse- medication error Underuse- of proven medicines Overuse- in inappropriate medicines

17. Division of Population Health Sciences Potentially inappropriate prescribing (PIP) Drugs to be avoided in older patients –Beers criteria –STOPP criteria –Consensus guideline of drugs that are problematic in older patients –Process measure in relation to prescribing

18. Division of Population Health Sciences Potentially Inappropriate Prescribing (PIP) BeersSTOPP ONE PIP25.31% TWO PIP6.39%8.40% THREE PIP1.27%2.39% OVERALL PIP33.22%36.84%

19. Division of Population Health Sciences PIP is three times more likely in those prescribed > 5 medications per month per Beers criteria PIP is five times more likely in those prescribed > 5 medications per month per STOPP criteria PIP and polypharmacy

20. Division of Population Health Sciences Overall Costs Beers maximum costs –Net ingredient cost €10,712,129 –Total expenditure€15,478,526 STOPP maximum costs –Net ingredient cost€38,995,584 –Total expenditure€46,034,507

21. Division of Population Health Sciences Antibiotic prescribing rates in children 2004-2008

22. Division of Population Health Sciences Cost antibiotic prescribing YearNet ingredient cost (€)Approx cost to State (€ +25%) 20042, 318 8592, 898 574 20052, 263 5522, 829 440 20062, 629 6203, 287 025 20072, 847 4253, 559 294 20082, 864 2263, 580 283

23. Division of Population Health Sciences Comparison to EU rates StudyCountryAge groupPrevalence Rate GMS data (2008)Ireland0-15578/1000 Lusini (2009)Italy0-19512/1000 Lusini (2009)Denmark0-19328/1000 de Jong (2008)Netherlands0-17178/1000 Ekins-Daukes (2002)Scotland0-16142/1000 GMS data (2008)Ireland0-4751/1000 Schindler (2003)Germany0-6429/1000

24. Division of Population Health Sciences Comparison to EU: Italy and the Netherlands Ireland (2008) Prescriptions % Italy (2003) Prescriptions % Netherlands (1998) Prescriptions % Amoxicillin28.625.848.4 Co-amoxiclav34.638.79.8 Cefaclor11.718.0- Clarithromycin5.220.56.7 Phenoxymethylpenicillin5.2-7.3

25. Division of Population Health Sciences Pyschostimulant prescribing ADHD Methylphenidate improves core symptoms Dexamfetamine and atomoxetine may be also beneficial Atomoxetine may cause rare but serious liver injury Clonidine and modafinil may improve symptoms, but are associated with an increased risk of adverse effects Effectiveness of buproprion is unknown Long-term effectiveness of all psychostimulants is unknown 25

26. Division of Population Health Sciences Prevalence of psychostimulant prescriptions in Ireland (2002-2008) Age: 0-4 yearsAge: 5-11 yearsAge: 12-15 years Patient-based rateRate (95% CI) Rate (95% CI) Rate (95% CI) Methylphendiate ATC N06BA04 0.341 (0.295-0.392) 8.105 (7.910-8.304) 9.218 (8.936-9.506) Dexamfetamine ATC N06BA02 0.031 (0.018-0.049) 0.196 (0.167-0.229) 0.089 (0.063-0.121) Modafinil ATC N06BA07 0.0017 (0.00004-0.0096) 0.004 (0.001-0.011) 0.023 (0.011-0.0419) Atomoxetine ATC N06BA09 0.0017 (0.00004-0.0096) 0.484 (0.437-0.534) 0.610 (0.539-0.688) 26

27. Division of Population Health Sciences Time trend of psychostimulant prescriptions in Ireland (2002- 2008)

28. Division of Population Health Sciences Psychostimulant prescribing Methylphenidate is the main substance prescribed for ADHD children in Ireland The prevalence of psychostimulant prescriptions is increasing Further research required with respect to –Male-dominated prescription patterns –Co-medications –Practice variation 28

29. Division of Population Health Sciences Quality of prescribing Misuse- medication error Underuse- of proven medicines Overuse- in inappropriate medicines

30. Division of Population Health Sciences (3) Primary care and prescribing Core function of primary care Clinical case

31. Division of Population Health Sciences Core functions of primary care Gate-keeping role to the upper levels of the healthcare system First contact provision of care Continuity of care Coordination of care Comprehensiveness of care (including prevention and chronic disease management)

32. Division of Population Health Sciences Medicines management in elderly patient Dynamic process –Reconciliation –Appropriateness –Safety –Interactions –Monitoring

33. Division of Population Health Sciences (4) Solutions Policy Clinical practice

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35. ICT and Patient Safety “Fit for purpose Information and Communication Technology (ICT), are essential to underpin a modern health system”

36. Division of Population Health Sciences HIQA recommendations- drug safety National framework for information sharing enabled through ICT Unique patient identifier facilitates safe and secure linkage of information Development of national standards for health information A feasibility study on the introduction of a national electronic prescribing system Comprehensive information system to support the monitoring of the quality of healthcare delivery

37. Division of Population Health Sciences (4) Solutions Policy Clinical practice

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39. 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

40. Division of Population Health Sciences GP computer usage- Ireland 1992- 27% 2005- 89%

41. Division of Population Health Sciences Implementation of research evidence

42. Division of Population Health Sciences 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

43. Division of Population Health Sciences 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

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46. Generation of comparative clinical data

47. Division of Population Health Sciences Integrated CDSS

48. Division of Population Health Sciences Conclusions Quality & safety of prescribing is a national challenge Solution requires co-ordination –Health policy –Clinical practice –Multi-disciplinary

49. Division of Population Health Sciences Acknowledgments Caitriona Cahir Kathleen Bennett John Feely Conor Teljeur Brian Cleary Deirdre Murphy Tamasine Grimes Borislav Dimitrov Claire Keogh Emma Wallace Brenda Courtney Udo Reulbach

50. Division of Population Health Sciences http://www.hrbcentreprimarycare.ie/