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How research participation enhances patient care

How research participation enhances patient care

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  • 1. 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. Outline of talk
    • Importance of research & teaching
    • Quality of care- observational epidemiology
    • Quality of care- proposed solutions
  • 3.  
  • 4.  
  • 5. (1) Importance of research & teaching
    • Self evident
    • Enables critical thought, reflection & review of clinical practice
  • 6. General practice
    • “ Sign of a coherent discipline is one that does its own research and teaching”
    • Iona Health, President RCGP
  • 7.  
  • 8. (2) Quality of care- observational epidemiology
    • Potentially inappropriate prescribing (PIP)
    • Between practice variation
    • Prescribing at the primary/secondary care interface
  • 9. Background
    • S creening T ool of O lder P erson’s potentially inappropriate P rescriptions (STOPP)
      • 64 clinically significant criteria
      • Drug-drug and drug-disease interactions
      • Doses and duration
      • STOPP
      • Cardiovascular System
      • 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. Results-PIP prevalence rates RoI (n=338,801) Cahir et al . Brit J Clin Pharm 2010:69;543-552 STOPP % n ONE PIP 25% 83,959 TWO PIP 8% 27,392 > THREE PIP 3% 10,103 OVERALL PIP 36% 121,454
  • 11. 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 DESCRIPTION PREV % OR GENDER (F vs M) OR AGE (>75 vs 70-74) Gastrointestinal PPI > 8 weeks full 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)
  • 13. 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. (2) Quality of care- observational epidemiology
    • Potentially inappropriate prescribing (PIP)
    • Between practice variation
    • Prescribing at the primary/secondary care interface
  • 15. Between-practice variation- Ireland PCRS data Antibiotics 2-nd line (J01) Statins (C10) CV: 27.6% SCV: 5.80 *** CV: 15.5% SCV: 0.95 ***
  • 16. Practice variation- alternative drug classes
  • 17. (2) Quality of care- observational epidemiology
    • Potentially inappropriate prescribing (PIP)
    • Between practice variation
    • Prescribing at the primary/secondary care interface
  • 18. 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
  • 19.  
  • 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. (3) Quality of care- proposed solutions
    • Clinical Decision Support
    • Irish Primary Care Research Network (IPCRN)
    • Engage in Professional Competence requirements
  • 22. 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. Implementation of research evidence
  • 24. 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. CDSS- level of functionality
  • 26. 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. Opti mizing Pre scri bing for Older P eople in Primary Care: a cluster randomized controlled t rial- 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. Decision support- prescribing recommendations
  • 29. Decision support- comparative data
  • 30. (3) Quality of care- proposed solutions
    • Clinical Decision Support
    • Irish Primary Care Research Network (IPCRN)
    • Engage in Professional Competence requirements
  • 31. Structure and ICT framework of Irish Primary Care Research Network
  • 32. The TRANSFoRm Project
  • 33. Define study eligibility criteria – electronic primary care research network (Epcrn)
  • 34. Gather study data - case report forms -ePCRN
  • 35. Generation of comparative clinical data
  • 36. 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. 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.
    • http://www.hrbcentreprimarycare.ie/