Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

1. Royal College of Surgeons in IrelandColáiste 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

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

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

9. 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 • 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

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)

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

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. 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. 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/