Abstract
BackgroundHigh-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents accounts for a significant proportion of hospital admissions due to preventable adverse drug events. The recently completed PINCER trial has demonstrated that a one-off pharmacist-led information technology (IT)-based intervention can significantly reduce high-risk prescribing in primary care, but there is evidence that effects decrease over time and employing additional pharmacists to facilitate change may not be sustainable.Methods/designWe will conduct a cluster randomised controlled with a stepped wedge design in 40 volunteer general practices in two Scottish health boards. Eligible practices are those that are using the INPS Vision clinical IT system, and have agreed to have relevant medication-related data to be automatically extracted from their electronic medical records. All practices (clusters) that agree to take part will receive the data-driven quality improvement in primary care (DQIP) intervention, but will be randomised to one of 10 start dates. The DQIP intervention has three components: a web-based informatics tool that provides weekly updated feedback of targeted prescribing at practice level, prompts the review of individual patients affected, and summarises each patient's relevant risk factors and prescribing; an outreach visit providing education on targeted prescribing and training in the use of the informatics tool; and a fixed payment of 350 GBP (560 USD; 403 EUR) up front and a small payment of 15 GBP (24 USD; 17 EUR) for each patient reviewed in the 12 months of the intervention. We hypothesise that the DQIP intervention will reduce a composite of nine previously validated measures of high-risk prescribing. Due to the nature of the intervention, it is not possible to blind practices, the core research team, or the data analyst. However, outcome assessment is entirely objective and automated. There will additionally be a process and economic evaluation alongside the main trial.DiscussionThe DQIP intervention is an example of a potentially sustainable safety improvement intervention that builds on the existing National Health Service IT-infrastructure to facilitate systematic management of high-risk prescribing by existing practice staff. Although the focus in this trial is on Non-steroidal anti-inflammatory drugs and antiplatelets, we anticipate that the tested intervention would be generalisable to other types of prescribing if shown to be effective.Trial registrationClinicalTrials.gov, dossier number: NCT01425502
Highlights
High-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents accounts for a significant proportion of hospital admissions due to preventable adverse drug events
A number of systematic reviews, including large scale studies conducted in the UK, have demonstrated deficits in the safety and quality of medication use to a degree, which constitutes a public health threat: 3% to 4% of all unplanned hospital admissions are caused by preventable adverse drug events [1,2]
We have shown that this prescribing is both common and highly variable between practices, which generally indicates scope for improvement [6]
Summary
IT-based interventions that identify and target patients with high-risk prescribing for review have previously shown to be potentially effective, there is a need for approaches that are more economically sustainable and produce longer-term effects. The DQIP intervention aims to support reach by timely and continuous identification of patients affected by high-risk prescribing, by email -reminders to practices to review their data, and by offering payment of 15 GBP (24 USD; 17 EUR) per patient reviewed. It is possible that some practices will change their prescribing behaviour as a consequence of being alerted to high-risk NSAIDs and antiplatelet prescribing during recruitment We expect such effects to be mild in comparison to the DQIP intervention because meaningful and sustained reductions in the targeted high-risk prescribing will require systematic and prolonged effort that is unlikely to occur before the DQIP tool is implemented [16].
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