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

Royal College of Surgeons in Ireland
Coláiste Ríoga na Máinleá in Éirinn
Enhancing rational and safe prescribing in primary care
Tom Fahey
Professor of General Practice, RCSI Medical School & Principal Investigator, HRB Centre for Primary Care
Research
Division of Population Health Sciences
Overview
• Background
– Potentially inappropriate prescribing (PIP)
• OPTI-SCRIPT
– Development of intervention
– Results
• Summary
Division of Population Health Sciences
Overview
• Background
– Potentially inappropriate prescribing (PIP)
• OPTI-SCRIPT
– Development of intervention
– Results
• Summary
Division of Population Health Sciences
Background
• Prescribing is a challenging and complex process
• Appropriate prescribing
• Potentially inappropriate prescribing (PIP)
• Overprescribing, underprescribing and misprescribing
• Factors that contribute to PIP
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An overview of prescribing
indicators
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Overview cont’d
• Following a ‘systematic literature search’, identified 46
different tools
– English and German publications only
• 36 named older people as target patients
– 10 did not specify target age group
– Various settings
• Consensus methods used in development of 19 tools
• Over-, under- and mis-prescribing
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No perfect set of indicators
• The ideal set of indicators– Cover all aspects of appropriateness
– Be developed using evidence-based methods
– Show significant correlation between degree of
appropriateness and clinical outcomes
– Be applicable not only in research but in daily health
care practice
Kaufmann et al, 2013
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What contributes to PIP?
• Multimorbidity
• “Presence of two or more long-term conditions”
• 64.9% of people aged 65-84years [1]
• 30.4% of people aged 45-64 years [1]
• Polypharmacy
• “the ingestion of four or more medications”
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Prevalence of PIP
• PIP is prevalent in the older population (> 70 years)
• Republic of Ireland 36%
• Northern Ireland 34%
• United Kingdom 29%
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The prevalence of the most common STOPP/START PIP
indicators across three regions
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Overview
• Background
– Potentially inappropriate prescribing (PIP)
• OPTI-SCRIPT
– Development of intervention
– Results
• Summary
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OPTI-SCRIPT study development
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Study design & methodology –
cluster RCT
• GPs inclusion criteria:
• Based in greater Dublin area
• 80+ patients aged over 70
• Patients inclusion criteria:
• Aged 70+
• Had PIP as per study list
• Recruited and baseline data collection prior to
minimisation
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Study overview
Minimisation
Intervention
- Academic detailing
with a pharmacist
- Medicines review with
web-based treatment
algorithms
- Patient information
leaflets
Control
- Letter with recruited
patients and identified
PIP
- Continue to provide
usual care
PCRS – National
Contemporaneous
Control
- Observational
comparison to national
prescribing data
(376,858 patients,
2,000+ practices)
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OPTI-SCRIPT website
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OPTI-SCRIPT RCT results
• Participants
• 21 GP practices (32% cluster response rate)
• 196 patients (37% response rate)
• Minimisation
Intervention
Control
11 practices
99 patients
10 practices
97 patients
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Study design & methodology –
cluster RCT
• Primary outcome measure:
• Proportion of patients with no PIP
• Mean PIP per group
• Data collection baseline & immediate post intervention
• Between group differences:
• Random effects logistic regression
• Cluster mean
• Random effects poisson regression
• Process evaluation
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Outcome – Proportion with no PIP
Group
N
Intervention
99
Control
97
Number of
patients with no
PIP
47
% of patients
with no PIP
22
47.5
22.7
Adjusted odds ratio = 3.06 (95% CI 1.4,6.5; P=0.004)*
*adjusted for gender, age, baseline PIP, number repeat
medications, GP practice size
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National contemporaneous
control – PCRS
• Intervention period, Sep 2012 – August 2013
prevalence of 38%
• Odds of having no PIP in OPTI-SCRIPT intervention
compared to odds of having no PIP in the national
PCRS cohort
Odds Ratio
95% CI
2.49
1.68, 3.69
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Process evaluation – main findings
• Participants positive about study
– Barriers identified: GP time, communication, reimbursement
• Revealed intervention not delivered as expected:
–
–
–
–
Patient information leaflets not used at all
1 intervention practice did not complete reviews
2 Intervention practices conducted reviews without patients
2 control practices did alter patient medication
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Future work
• National trial of OPTI-SCRIPT
• Lessons learned?
– Computerise PIP identification
– Focus on top 10 PIP
– Embedded in practice software
– Practice incentives – reimbursement
– Economic evaluation
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Overview
• Background
– Potentially inappropriate prescribing (PIP)
• OPTI-SCRIPT
– Development of intervention
– Results
• Summary
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Summary
• Prevalence of PIP high in Ireland & UK
• Developed web-based intervention to target PIP in
primary care
• Process evaluation gave insight into intervention
delivery and barriers
• Further implementation of decision support to
improve quality & safety are planned
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Acknowledgements
This research is funded by the HRB Centre for Primary Care Research and the HRB PhD
Scholars programme in Health Service Research
Barbara Clyne, Susan Smith, Marie Bradley, Carmel Hughes, Janine Cooper, Fiona Boland, Ronan
McDonnell, David Williams, Nicola Motterlini, Marie-Claire Kennedy, Daniel Clear, Frank Moriarty,
Caitriona Cahir
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Baseline characteristics
Characteristic
Male
Intervention
Control
N
%
N
%
55
55.6
50
51.5
Mean age
77.1
76.4
Marital status
Married
Widowed
56
26
56.6
26.3
51
32
53.1
33.3
GMS card
88
88.9
95
97.9
Mean number
of repeat
medications
10.2
9.5
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Percentage (%)
PIP at baseline
80.0
75.0
70.0
65.0
60.0
55.0
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
1
2
3
4
PIP Number
Intervention
Control
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PPI
• 60% of participants had a PPI
• 53% of intervention, 65% of control at baseline
• At follow-up the odds of not having a PPI at maximum
therapeutic dose were 3 times higher in intervention
than control
(OR = 3.41, P = 0.006, 95% CI 1.43, 8.14)
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