Safer medicines in primary care.

Significant research has been conducted by the CPCR during the initial five years of funding that relates to safe and cost-effective medicines management in vulnerable patient groups. In the second phase of funding, this programme of activity will be continued but with a greater emphasis on the implementation of interventions that aim to improve medicines management in primary care. We plan to do this through further development and evaluation of Information and Communication Technology (ICT) interventions in the form of computer-based clinical decisions support systems (CDSSs) that enhance medicine management for acute and chronic illness. Evaluation will be conducted by means of a randomised controlled trial (RCT) with particular focus on integrated CDSS. Identification and follow up of patients will be through Health Intelligence Unit (HIU) information systems and the Irish Primary Care Research Network (IPCRN). The following is an overview of the activity in WP1:

1. Medicines reconciliation at the primary/secondary care interface
2. Observational epidemiology of safe prescribing
 2.1 The Irish Longitudinal Study of Ageing and the CPCR cohort
 2.2 The Primary Care Reimbursement Scheme and the Enhanced Prescribing database
3. Implementing safe and cost effective medicines through the implementation of a cluster RCT

Decision support in primary care

This work package builds on the work that we completed relating to Clinical Prediction Rules (CPRs) in primary care. To this end, we will evaluate the impact of implementing CPRs at point-of-care utilising the Electronic Patient Record (EHR). We will integrate the CPR register with ongoing European TRANSFoRm work while continuing observational research into the incidence and aetiology of error in primary care and development of interventions that combat common diagnostic error. To give context, CPRs are clinical tools that quantify the contribution of the history, physical examination and diagnostic tests and stratify patients according to the probability of having a target disorder. The outcome of interest can be diverse and range across the diagnostic, prognostic and therapeutic spectrum. Furthermore, CPRs have been developed, validated and used across the primary, secondary and tertiary care settings. Developing and validating a CPR is a particular form of observational epidemiological research that requires reference to specific methodological standards.
Conventionally CPRs go through three distinct stages prior to full implementation in a clinical setting:
1) development of the CPR - establishing the independent and combined effect of explanatory variables that can include symptoms, signs or diagnostic tests;
2) narrow and broad validation- where the explanatory variables or clinical predictors in the derivation CPR set are assessed in separate populations; and lastly
3) impact analysis of the CPR- assessed by means of an RCT where the impact of applying the CPR in a clinical setting is measured either by patient outcome, health professional behaviour, resource use or any combination of these outcomes.The following is a summary of the proposed work in WP2:

1. Dissemination and integration of international register of clinical prediction rules
 1.1 Dissemination and update of the international register of Clinical Prediction Rules in primary care
 1.2 Integration of CPR register with European TRANSFoRm collaborators

2. Implementation of computer based clinical decision support through integration with the EHR
 2.1 ComputeriseD dECisIon support for poorly-controlleD TypE 2 Diabetes (DECIDE)
 2.2 Rational use of antibiotics in primary care

3. Diagnostic and therapeutic error: patients and health professional perspectives
 3.1 Patients and health professionals’ perspectives of diagnostic and therapeutic error in primary care
 3.2 Epidemiology of diagnostic and therapeutic error in primary care
 3.3 Design and evaluation of a CDSS intervention to reduce diagnostic and prescribing error in primary care

Effective Care Delivery

Robust evidence shows that patient care delivered by a health system that has a strong primary care orientation is associated with more effective, equitable and efficient care. Subsumed within this overarching theme are concerns around effective management of long term conditions. This workpackage will focus on two aspects of effective care delivery that are of international relevance and importance, the management of multimorbidity and unwarranted medical practice variation. In this WP, we aim to undertake research that will build on our previous observational work on predicting outcomes in patients with multimorbidity and exploring variation in prescribing in chronic conditions. We also aim to undertake two experimental studies on interventions to target multimorbidity and target variation in treatment of poorly controlled type 2 diabetes as an exemplar chronic condition.The following is an overview of activity in WP3:

Multimorbidity, prediction of poor outcome and effective management
Addressing variation in treatment and effective care delivery