1. Division of Population Health Sciences Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn How research participation enhances patient care Tom Fahey HRB Centre for Primary Care Research & RCSI Medical School

2. Division of Population Health Sciences Outline of talk Importance of research & teaching Quality of care- observational epidemiology Quality of care- proposed solutions

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5. (1) Importance of research & teaching Self evident Enables critical thought, reflection & review of clinical practice

6. Division of Population Health Sciences General practice “Sign of a coherent discipline is one that does its own research and teaching” Iona Health, President RCGP

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8. (2) Quality of care- observational epidemiology Potentially inappropriate prescribing (PIP) Between practice variation Prescribing at the primary/secondary care interface

9. Division of Population Health Sciences Background Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) –64 clinically significant criteria –Drug-drug and drug-disease interactions –Doses and duration STOPP A.Cardiovascular System 1.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).

10. Division of Population Health Sciences Results-PIP prevalence rates RoI (n=338,801) STOPP%n ONE PIP25%83,959 TWO PIP8%27,392 > THREE PIP3%10,103 OVERALL PIP36%121,454 Cahir et al. Brit J Clin Pharm 2010:69;543-552

11. Division of Population Health Sciences Association between the number of different drug classes (polypharmacy) and PIP (STOPP) in 2007 (95% CI)-RoI * Linear and quadratic trend p<0.0001

12. Five highest prevalence rates -RoI(n=338,801) STOPP DESCRIPTIONPREV %OR GENDER (F vs M) OR AGE (>75 vs 70-74) GastrointestinalPPI > 8 weeks full therapeutic dose (dose reduction, discontinuation) 16.69%0.80 (0.78-0.81) 1.05 (1.02-1.07) MusculoskeletalNSAID >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) DuplicatesNSAIDs, SSRIs, Antidep, ACE, Loop diuretics, opioids (optimisation of monotherapy) 4.78%1.19 (1.15-1.23) 0.74 (0.71-0.76) CardiovascularBeta-blocker with COPD (risk of increased bronchospasm) 2.34%0.53 (0.51-0.56) 0.84 (0.80-0.89)

13. Division of Population Health Sciences 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

14. Division of Population Health Sciences (2) Quality of care- observational epidemiology Potentially inappropriate prescribing (PIP) Between practice variation Prescribing at the primary/secondary care interface

15. Division of Population Health Sciences Antibiotics 2-nd line (J01)Statins (C10) CV: 27.6% SCV: 5.80 ***CV: 15.5% SCV: 0.95 *** Between-practice variation- Ireland PCRS data

16. Division of Population Health Sciences Practice variation- alternative drug classes

17. Division of Population Health Sciences (2) Quality of care- observational epidemiology Potentially inappropriate prescribing (PIP) Between practice variation Prescribing at the primary/secondary care interface

18. Division of Population Health Sciences 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

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20. Medicines management- primary/secondary interface Poor transcription Indication unclear and not linked to medication Appropriateness unclear Poor communication- no formal summary record Polypharmacy

21. Division of Population Health Sciences (3) Quality of care- proposed solutions Clinical Decision Support Irish Primary Care Research Network (IPCRN) Engage in Professional Competence requirements

22. Division of Population Health Sciences 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

23. Division of Population Health Sciences Implementation of research evidence

24. 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

25. Division of Population Health Sciences CDSS- level of functionality

26. 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

27. Division of Population Health Sciences 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

28. Division of Population Health Sciences Decision support- prescribing recommendations

29. Division of Population Health Sciences Decision support- comparative data

30. Division of Population Health Sciences (3) Quality of care- proposed solutions Clinical Decision Support Irish Primary Care Research Network (IPCRN) Engage in Professional Competence requirements

31. Division of Population Health Sciences Structure and ICT framework of Irish Primary Care Research Network

32. Division of Population Health Sciences The TRANSFoRm Project

33. Division of Population Health Sciences Define study eligibility criteria – electronic primary care research network (Epcrn)

34. Division of Population Health Sciences Gather study data - case report forms -ePCRN

35. Division of Population Health Sciences Generation of comparative clinical data

36. Division of Population Health Sciences 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

37. Division of Population Health Sciences 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

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