Improving primary care prescribing safety: DQIP and beyond
Prescribed medicines have many benefits but are also a major source of healthcare-associated harm. Adverse effects of community prescribing case ~6.5% of emergency hospital admissions, of which half are preventable. The aim of the Data-Driven Quality Improvement in Primary Care (DQIP) study was to develop and evaluate an informatics based complex intervention to improve primary care prescribing safety.
DQIP was a complex collaboration between academics and the NHS. The DQIP intervention had three components: an educational outreach visit, financial incentives for general practices to review patients with high-risk prescribing, and an informatics tool to identify patients and support review which was developed by the NHS and a commercial vendor. The intervention was evaluated in a cluster-randomised, stepped-wedge trial which required repeated measurement of the outcomes in all participating practices over several years, and HIC provided essential data extraction and linkage to allow outcome measurement in the secure Safe Haven environment. A key strength of the study was the ability to analyse linked emergency hospital admission to see if observed changes in high-risk prescribing were associated with clinical benefit.
The DQIP intervention was associated with a one-third reduction in the targeted high-risk prescribing (nine measures of high-risk non-steroidal inflammatory drug and antiplatelet drug prescribing), and significant reductions in associated emergency hospital admissions with gastrointestinal bleeding and heart failure. Full details of the study are available in the main trial paper which was published in the New England Journal of Medicine in 2016.
DQIP and our other work in this field have had significant influence on NHS Scotland policy and practice. Six related indicators were included in NHS Scotland National Therapeutic Indicators and informatics tools used by Health Boards (PRISMS) and general practices (the Scottish Therapeutic Utility) to manage prescribing. Several health boards have implemented interventions in all their practices and have shown large reductions in high-risk prescribing as a result. We are currently working with HIC on DQIP2 to develop and implement an informatics tool in the Scottish Therapeutics Utility (STU) to support medicines optimisation in people with polypharmacy. The impact of the tool will be evaluated as part of a system-wide implementation in NHS Tayside and if effective can then be used across NHS Scotland since all general practices have STU installed.
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