Pharmacist and Data Driven Quality Improvement in Primary Care

Overview

P-DQIP is an intervention to improve prescribing safety in primary care. The 'intervention' is a health board quality improvement programme that will be implemented across all practices in one National Health Service (NHS) board in Scotland (Tayside), and comprises the following components: i. Case finding of patients with drug therapy risks via the P-DQIP informatics tool ii. Decision support for clinicians when conducting medication reviews via the P-DQIP informatics tool iii. Support from practice pharmacists in reviewing and managing targeted patients iv. Ongoing performance feedback via the P-DQIP informatics tool v. Promotion of the P-DQIP tool and intervention among general practices. The P-DQIP intervention will be evaluated in all NHS Tayside practices who agree to share their data for monitoring and evaluation purposes.

Study Type

  • Study Type: Observational
  • Study Design
    • Time Perspective: Other
  • Study Primary Completion Date: May 31, 2021

Detailed Description

P-DQIP is an intervention to improve prescribing safety in primary care. The 'intervention' is a health board quality improvement programme that will be implemented across all practices in NHS Tayside. The study is therefore a service evaluation of an NHS Tayside-led initiative, which comprises the following components: i. Case finding. The P-DQIP informatics tool will be added to medicines management software (the Scottish Therapeutics Utility), which is already installed in all general practices in NHS Scotland. The P-DQIP tool can be accessed by General Practitioners (GPs) and other clinicians in the practice including Health Board employed primary care pharmacists 'attached' to practices. The core of the tool is a set of indicators of high-risk prescribing to identify patients at high risk of drug related harm. The indicators have been developed by The Scottish Government's Polypharmacy working group. ii. Decision support. The P-DQIP tool provides structured information on patients' medical and medication histories and highlights specific drug therapy risks for consideration by the reviewing clinician. All decision making remains at the discretion of the reviewing clinician. iii. Pharmacist support. Teams of practice pharmacists working in practices within the same locality will be invited to participate in a half-day workshop, in which they will be trained on the use of the P-DQIP informatics tool. A total of 8 to 12 workshops will be conducted. The workshop will be facilitated by the P-DQIP project team. As part of the workshop, locality pharmacist teams will be encouraged to plan the P-DQIP work and to agree targets. They will be instructed to introduce the P-DQIP pogramme in a stepwise fashion, targeting patients at risk of bleeding and hypoglycaemia first. iv. Ongoing performance feedback. Practices and locality pharmacists will be able to access reports on the number of reviews conducted and the numbers of patients with targeted high-risk prescribing via the P-DQIP informatics tool. v. Promotion of the P-DQIP tool and intervention among GP practices. GP clusters will be offered a visit by the lead pharmacist for the programme, who will provide background and rationale for the P-DQIP programme, demonstrate the functionalities of the P-DQIP informatics tool and encourage collaboration in reviewing and managing targeted drug therapy risks with pharmacists.

Interventions

  • Behavioral: P-DQIP
    • The ‘intervention’ is a health board quality improvement programme to be implemented across all practices in one Scottish NHS health board and comprises the following components: (i) Case finding via the P-DQIP informatics tool to identify patients with drug therapy risks for review; (ii) Decision support via the P-DQIP informatics tool to facilitate medication reviews; (iii) Practice pharmacists will be trained on the use of the P-DQIP informatics tool and instructed to target patients at risk of bleeding and hypoglycaemia first (iv) Ongoing performance feedback. Practices and locality pharmacists will be able to access reports on review activity and targeted prescribing; (v) promotion of the P-DQIP tool and intervention among GP practices. The P-DQIP intervention will be evaluated in all NHS Tayside practices who agree to share their data for monitoring and evaluation purposes.

Clinical Trial Outcome Measures

Primary Measures

  • Initially targeted drug therapy risks in patients aged 75 years or older
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P011; Numerator definition: No. of denominator patients meeting one or more numerator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P011

Secondary Measures

  • All targeted drug therapy risks in patients aged 75 years or older (patient count)
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P046; Numerator definition: No. of denominator patients meeting one or more numerator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P046
  • All targeted drug therapy risks in patients aged 75 years or older (indicator count)
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P046; Numerator definition: No. of indicators specified under ‘Other Pre-specified Outcomes’ P001 to P046 triggered by denominator patients
  • Initially targeted drug therapy risks in younger patients
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged <75 years meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P011; Numerator definition: No. of denominator patients meeting one or more numerator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P011;
  • All targeted drug therapy risks in younger patients (patient count)
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged <75 years meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P046; Numerator definition: No. of denominator patients meeting one or more numerator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P046
  • All targeted drug therapy risks in younger patients (indicator count)
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged <75 years meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P001 to P046; Numerator definition: No. of indicators specified under ‘Other Pre-specified Outcomes’ P001 to P046 triggered by denominator patients
  • ‘Ongoing’ versus ‘new’ drug therapy risks (‘Ongoing’)
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older meeting one or more denominator definitions specified under ‘Other Pre-specified Outcomes’ P001 to P011, who have met one or more numerator definitions specified under ‘Other Pre-specified Outcomes’ P001 to P011 in the previous 57 to 364 days; Numerator definition (Old): No. of denominator patients meeting one or more numerator definitions specified under ‘Other Pre-specified Outcomes’ P001 to P011
  • ‘Ongoing’ versus ‘new’ drug therapy risks (‘New’)
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older meeting one or more denominator definitions specified under ‘Other Pre-specified Outcomes’ P001 to P011, who have NOT met any numerator definitions specified under ‘Other Pre-specified Outcomes’ P001 to P011 in the previous 57 to 364 days; Numerator definition: No. of denominator patients meeting one or more numerator definitions specified under ‘Other Pre-specified Outcomes’ P001 to P011
  • Electrolyte disturbances
    • Time Frame: Measured at intervals of 8 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged <75 years meeting one or more denominator definitions as specified under ‘Other Pre-specified Outcomes’ P047 to P050; Numerator definition: No. of indicators specified under ‘Other Pre-specified Outcomes’ P047 to P050 triggered by denominator patients
  • Related unscheduled care events (1) – Bleeding
    • Time Frame: Measured at intervals of 12 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older; Numerator definition: No. of denominator patients who had an unscheduled care event with bleeding in the previous 84 days
  • Related unscheduled care events (2) – Hypoglycaemia, falls, fractures
    • Time Frame: Measured at intervals of 12 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older; Numerator definition: No. of denominator patients who had an unscheduled care event with hypoglycaemia, a fall or a fracture in the previous 84 days
  • Related unscheduled care events (3) – Any potentially drug related events
    • Time Frame: Measured at intervals of 12 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older; Numerator definition: No. of denominator patients who had an unscheduled care event in the previous 84 days with any of the following: Hypoglycaemia, fall, fracture, bleeding, heart failure, bradycardia, acute kidney injury, constipation, dehydration, hyperkalaemia, hyponatraemia, urinary retention, delirium) in the previous 84 days
  • Unrelated unscheduled care events
    • Time Frame: Measured at intervals of 12 weeks over a period of 18 months prior to and subsequent to the start date. The measurement on the start date will be excluded from analyses to account for the availability of a test version of the P-DQIP tool since Sept 2018
    • Denominator definition: No. of patients aged 75 years or older; Numerator definition: No. of denominator patients who had an unscheduled care event in the previous 84 days with an unrelated ambulatory care sensitive admission (Appendicitis, pancreatitis, cholecystitis, cancer, cellulitis)

Participating in This Clinical Trial

Inclusion Criteria

  • General practices in NHS Tayside, who use the Vision electronic medical record software and agree to the extraction of data from medical records for monitoring and evaluation purposes Exclusion Criteria:

  • General practices using electronic medical record software other than Vision

Gender Eligibility: All

Minimum Age: N/A

Maximum Age: N/A

Investigator Details

  • Lead Sponsor
    • University of Dundee
  • Collaborator
    • NHS Tayside
  • Provider of Information About this Clinical Study
    • Principal Investigator: Nicola Gray, Dr – University of Dundee
  • Overall Official(s)
    • Tobias Dreischulte, Principal Investigator, University of Dundee/NHS Tayside
  • Overall Contact(s)
    • Tobias Dreischulte, PhD, +447540736211, t.dreischulte@dundee.ac.uk

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