Prof. Tom fahey

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How research participation enhances patient care

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Prof. Tom fahey

  1. 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. 2. Outline of talk <ul><li>Importance of research & teaching </li></ul><ul><li>Quality of care- observational epidemiology </li></ul><ul><li>Quality of care- proposed solutions </li></ul>
  3. 5. (1) Importance of research & teaching <ul><li>Self evident </li></ul><ul><li>Enables critical thought, reflection & review of clinical practice </li></ul>
  4. 6. General practice <ul><li>“ Sign of a coherent discipline is one that does its own research and teaching” </li></ul><ul><li>Iona Health, President RCGP </li></ul>
  5. 8. (2) Quality of care- observational epidemiology <ul><li>Potentially inappropriate prescribing (PIP) </li></ul><ul><li>Between practice variation </li></ul><ul><li>Prescribing at the primary/secondary care interface </li></ul>
  6. 9. Background <ul><li>S creening T ool of O lder P erson’s potentially inappropriate P rescriptions (STOPP) </li></ul><ul><ul><li>64 clinically significant criteria </li></ul></ul><ul><ul><li>Drug-drug and drug-disease interactions </li></ul></ul><ul><ul><li>Doses and duration </li></ul></ul><ul><ul><li>STOPP </li></ul></ul><ul><ul><li>Cardiovascular System </li></ul></ul><ul><ul><li>Digoxin at a long-term dose > 125μg/day with impaired renal function∗ (increased risk of toxicity). </li></ul></ul><ul><ul><li>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). </li></ul></ul>
  7. 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
  8. 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
  9. 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)
  10. 13. Cost of PIP-RoI <ul><li>Gross cost of PIP for one year (2007) €38,664,640 </li></ul><ul><li>Total expenditure (gross cost, VAT,+pharmacist dispensing fee) €45,631,319 </li></ul><ul><li>Total expenditure accounted for 9% of overall expenditure on pharmaceuticals in those aged ≥ 70 years in 2007 </li></ul>
  11. 14. (2) Quality of care- observational epidemiology <ul><li>Potentially inappropriate prescribing (PIP) </li></ul><ul><li>Between practice variation </li></ul><ul><li>Prescribing at the primary/secondary care interface </li></ul>
  12. 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 ***
  13. 16. Practice variation- alternative drug classes
  14. 17. (2) Quality of care- observational epidemiology <ul><li>Potentially inappropriate prescribing (PIP) </li></ul><ul><li>Between practice variation </li></ul><ul><li>Prescribing at the primary/secondary care interface </li></ul>
  15. 18. General practice <ul><li>“ In general practice the people stay and the diseases come and go. In hospital the diseases stay and the people come and go” </li></ul><ul><li>Iona Health, President RCGP </li></ul>
  16. 20. Medicines management- primary/secondary interface <ul><li>Poor transcription </li></ul><ul><li>Indication unclear and not linked to medication </li></ul><ul><li>Appropriateness unclear </li></ul><ul><li>Poor communication- no formal summary record </li></ul><ul><li>Polypharmacy </li></ul>
  17. 21. (3) Quality of care- proposed solutions <ul><li>Clinical Decision Support </li></ul><ul><li>Irish Primary Care Research Network (IPCRN) </li></ul><ul><li>Engage in Professional Competence requirements </li></ul>
  18. 22. Health informatics- levels of functionality <ul><li>1 Record keeping </li></ul><ul><ul><li>Medical records </li></ul></ul><ul><ul><li>Patient scheduling </li></ul></ul><ul><ul><li>Appointments </li></ul></ul><ul><li>2 Coding & prescribing </li></ul><ul><ul><li>Morbidity coding </li></ul></ul><ul><ul><li>Drug prescribing </li></ul></ul><ul><ul><li>Drug interaction </li></ul></ul><ul><li>3 Communication </li></ul><ul><ul><li>Laboratory </li></ul></ul><ul><ul><li>Health professional & patient </li></ul></ul><ul><li>4 Clinical knowledge </li></ul><ul><ul><li>CDSS </li></ul></ul><ul><ul><li>Decision aids </li></ul></ul><ul><ul><li>Comparative clinical data </li></ul></ul>
  19. 23. Implementation of research evidence
  20. 24. Computerized clinical decision support systems (CDSSs) <ul><li>Information systems designed to improve clinical decision making </li></ul><ul><li>Key elements: </li></ul><ul><ul><li>Integration EPR </li></ul></ul><ul><ul><li>Computerized knowledge base </li></ul></ul><ul><ul><li>Provide patient-specific information </li></ul></ul><ul><ul><li>Software algorithm </li></ul></ul>
  21. 25. CDSS- level of functionality
  22. 26. CDSS prescribing primary/secondary interface <ul><li>Prescribing error </li></ul><ul><ul><li>Indication, ordering, interactions, allergies </li></ul></ul><ul><ul><li>Transcription </li></ul></ul><ul><ul><li>Dispensing </li></ul></ul><ul><ul><li>Co-ordination & monitoring </li></ul></ul><ul><li>Evidence-based </li></ul><ul><ul><li>Clinical & prescribing knowledge base </li></ul></ul><ul><li>Patient focussed </li></ul><ul><ul><li>Patient information leaflet </li></ul></ul><ul><li>Comparative clinical data </li></ul><ul><ul><li>Quality improvement & monitoring </li></ul></ul>
  23. 27. Opti mizing Pre scri bing for Older P eople in Primary Care: a cluster randomized controlled t rial- OPTI-SCRIPT <ul><li>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 </li></ul>
  24. 28. Decision support- prescribing recommendations
  25. 29. Decision support- comparative data
  26. 30. (3) Quality of care- proposed solutions <ul><li>Clinical Decision Support </li></ul><ul><li>Irish Primary Care Research Network (IPCRN) </li></ul><ul><li>Engage in Professional Competence requirements </li></ul>
  27. 31. Structure and ICT framework of Irish Primary Care Research Network
  28. 32. The TRANSFoRm Project
  29. 33. Define study eligibility criteria – electronic primary care research network (Epcrn)
  30. 34. Gather study data - case report forms -ePCRN
  31. 35. Generation of comparative clinical data
  32. 36. Conclusions <ul><li>Engagement with research & teaching is an important marker of professional engagement </li></ul><ul><li>Enables critical thought, reflection & review of clinical practice </li></ul><ul><li>Opportunities at a local, national and international level </li></ul>
  33. 37. Acknowledgments <ul><li>Caitriona Cahir </li></ul><ul><li>Kathleen Bennett </li></ul><ul><li>Derek Corrigan </li></ul><ul><li>Brian Cleary </li></ul><ul><li>Deirdre Murphy </li></ul><ul><li>Marie Bradley </li></ul><ul><li>Sean Higgins </li></ul><ul><li>Ronan McDonnell </li></ul><ul><li>Borislav Dimitrov </li></ul><ul><li>Claire Keogh </li></ul><ul><li>Emma Wallace </li></ul><ul><li>Udo Reulbach </li></ul>
  34. 38. <ul><li>http://www.hrbcentreprimarycare.ie/ </li></ul>

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