Michelle Greiver Simone Dahrouge Patricia O Brien Donna Manca Marie-Thérèse Lussier

Transcription

1 Michelle Greiver Simone Dahrouge Patricia O Brien Donna Manca Marie-Thérèse Lussier University of Toronto Practice Based Research Network Ottawa Practice Enhancement Network Quality & Innovation Program, University of Toronto Northern Alberta Primary Care Research Network Primary Care Research Network of the Université de Montréal Family Medicine Forum November 16 th,

2 Faculty/Presenter Disclosure Faculty: Michelle Greiver, Simone Dahrouge, Patricia O Brien, Donna Manca and Marie-T Lussier Relationships with financial sponsors: Grants/Research Support: o Canadian Institutes of Health Research (CIHR) Speakers Bureau/Honoraria: None Consulting Fees: None Patents: None Other: None 2

3 Disclosure of Financial Support This program has received financial support from CIHR in the form of Operating Grant. This program has received in-kind/cash support from the following organizations Organization Support Organization Support North York General Hospital Cash/In-kind University of Toronto Practice Based Research Network (UTOPIAN) In-kind Quality & Innovation Program, Department of Family & Community In-kind Medicine, University of Toronto The College of Family Physicians of Canada In-kind Dept. of Family Medicine, Faculty of Medicine, University of Dept. of Family Medicine, Faculty of Medicine & Dentistry, Cash Ottawa University of Alberta In-kind Dept. of Family Medicine, Faculty of Medicine, University of Manitoba Primary Care Research Network, Department of Family In-kind Calgary Medicine, University of Manitoba In-kind Dept. of Family Medicine, Max Rady College of Medicine, University of Manitoba Cash Research Manitoba Cash Fonds de recherche du Québec Santé Cash Réseau-1 Québec, Université de Montréal Cash Nova Scotia Health Authority Cash/In-kind Dept. of Family Medicine, Dalhousie University Cash/In-kind Vice President Research Office, Dalhousie University Cash Dept. of Community Health & Epidemiology, Dalhousie University Undergraduate Medical Education, Faculty of Medicine, Dalhousie University Potential for conflict(s) of interest: None In-kind Dalhousie Medical Research Foundation Cash Doctors Nova Scotia Cash/In-kind Maritime SPOR SUPPORT Unit In-kind 3

4 Mitigating Potential Bias The research proposal has been reviewed and approved by the following institutions to ensure the scientific rigour and ethical soundness of the study Peer-review committee of CIHR Clinical Trials Ontario through North York General Hospital s Research Ethics Board 4

5 Outline Polypharmacy amongst complex older patients Applying QI methodologies for safer describing Measuring the practice changes using EMR data * group reflection, discussion and application 5

6 Learning Objectives Apply QI methods to introduce and test changes in practice to improve care for complex older patients Utilize practice data to source older patients with polypharmacy ( 10 unique medications) and measure the impact of changes Explore existing resources, programs and personnel to support the implementation, spread and sustainability of practice changes 6

7 Percentage of older Canadians claimants by # of medication classes Polypharmacy amongst Complex Older Patients CIHI: Drug use among seniors in Canada, 2016: o 26.5% of older Canadians were prescribed 10 + medication classes each year Canadian Institute for Health Information. Drug Use Among Seniors in Canada, Ottawa, ON: CIHI;

8 Polypharmacy amongst Complex Older Patients Data from UTOPIAN shows: o o o One in four older patients ( 65yrs) were prescribed 10 unique medications in their EMR in the past 12 months 75% had at least one medication that could be potentially problematic Each family physician looks after, on average, 24 older patients prescribed 10 or more unique medications in the past year 8

9 ADR-related hospitalization rate Polypharmacy amongst Complex Older Patients Polypharmacy is associated with elevated risks of: o Poor patient health o Reduced quality of life o Care provider frustration o High healthcare costs Rate of ADR-related hospitalizations increased dramatically among older patients using more medications Older patients using 10 + unique medication classes were accounted for 58.6% of ADR-related hospitalizations # of medications Canadian Institute for Health Information. Drug Use Among Seniors in Canada, Ottawa, ON: CIHI;

10 Group Reflection Reflecting on the patients in your practice: Do you have concerns about the older patients who may experience polypharmacy? What approach do you feel is feasible to address this challenge in caring for older patients? Could the use of a QI approach support improving care in a sustainable way? What might your first step be? 10

11 QI for Safer Prescribing Quality Improvement (QI) is defined as a method of continuously finding better ways to provide better patient care and services QI embodies the following principles: o Engaging the patient/family o Attention to continuous improvement of processes o Involvement of all team members o Employing data and knowledge to enable decision making 11

12 SPIDER: A Comprehensive QI approach for Safer Prescribing Structured Process Informed by Data, Evidence & Research o The Institute for Healthcare Improvement (IHI) Breakthrough Series Model A structure to enable inter-team networking, sharing, and QI knowledge and skill capacity building A process to facilitate learning between teams and from experts 12

13 SPIDER: A QI approach for Safer Prescribing Key Elements of SPIDER Approach QI Learning Collaboratives Involving interprofessional teams (physicians, nurses, pharmacists, admin) Engaging patient partners throughout the process All teach, all learn Support of Practice Coaches/Facilitators Adapt/guide QI approach for practices Build capacity for using improvement tools Address sustainability to ensure lasting positive change for practices and patients Facilitate inter-team communication and sharing Provision of validated and comparable EMR data for feedback and measurement Principle Embodiment Patient-focused Involvement of the team Learning together Continuous improvement Use of data for decision making & learning 13

14 The Model for Improvement Specify and set the aim Establish measures Change concepts & change ideas PDSA Cycles Langley, Nolan, Nolan, Norman, Provost; The Improvement Guide, 1996.

15 Quality Improvement Application Process To improve safer prescribing for elderly patients 65 + yrs prescribed 10 + unique medications by MM-YYYY Patient identification, engagement & deprescribing Reducing # of older patients prescribed 10+ unique medications who have a PIP* Patient/family perception of experience and safety Quarterly EMR data reports What are we trying to accomplish? What changes can we make that will result in improvement? How will we know that a change is an improvement? Project Set-Up Diagnostic Change Idea Generation PDSAs Testing & Implementation Spread/ Sustainability * Reduce # prescriptions/pt.

16 Process Map applied to Safer Prescribing Identify PIPs Confirm Prescription is inappropriate Identify opportunity to discuss deprescriptio n with patient & family Come to agreement on process of deprescription Start deprescribing process Monitor side effect of med change * At any point along this pathways, decision might be made that prescription is needed for clinical reasons or patient preference 16

17 Resources and Toolkits for Safer Prescribing Deprescribing Algorithms Patient Education Materials Deprescribing Toolkits Webinars PPI Antipsychotics Benzodiazepines Sulfonylurea Patient resource for Use of PPI Treating dementia with Antipsychotics Sleeping pills in older adults PPI patient decision aid Deprescribing information pamphlets Drowsy without feeling lowsy (deprescribing Benzo toolkit) Bye Bye PPI (deprescribing PPI toolkit) Deprescribing in Primary care (Choosing Wisely Canada) Shared decision making with pts (deprescribing.org) Change ideas: Choosing Wisely Canada, Canadian Deprescribing Network (CaDeN), Institute for Safe Medication Practices (ISMP) 17

18 Group Discussion Are you aware of QI-related programs or resources available where you work? o If no, Can you source programs or resources online perhaps? o If yes, What types of programs or resources exist? Can you access these programs or resources for support? 18

19 Measuring the Impact Using EMR data If you cannot measure it, you cannot improve it. - Lord Kelvin You cannot manage what you cannot measure and what gets measured gets done. - Bill Hewlett 19

20 Group Discussion Are there resources/tools available for you to access your EMR data? Have you used EMR data to solve problems relevant to your clinical work? 20

21 Measuring the Impact Using EMR data Use of EMR data to o Identify complex older patients in primary care o Identify PIPs o Identify areas that needs to be improved o Assess the effect on changes pertaining to safer prescribing o Assist planning and decision making Dahrouge S, Wodchis W. Identifying high users in Ontario - an algorithm for use in primary care practices. 2017; In press

22 Measuring the Impact Using EMR data Canadian Primary Care Sentinel Surveillance Network o Canada s first pan-canadian multi-disease EMR surveillance system 10 PBRNs 5 chronic & mental health conditions o De-identified, validated and comparable EMR data readily available for research 22

23 Measuring the Impact Using EMR data 23

24 Measuring the Impact Using EMR data 24

25 Application Exercise Form small groups (3-4 people per group) Review sample data report What questions do you have? What changes come to mind? Are there improvement opportunities? 25

26 Group Reflection Summary of your group s discussion o What questions have you identified? o What changes would you like to make? o How might you approach change? o What do you need? 26

27 Wrap Up Polypharmacy amongst older complex patients is common Quality Improvement has the potential to improve care and safer prescribing in a spreadable and sustainable way EMR data can be used for case identification and outcome measurement 27

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29 Please fill out your session evaluation now! Complete a session evaluation one of two ways: FMF app Fmf.cfpc.ca Session #: F167 Session Name: Using Data and Resources to Improve the Care of Elderly Patients with Polypharmacy YOUR FEEDBACK IS IMPORTANT TO US!