Background

Drug-related problems have been consistently identified as a cause of hospital admissions world-wide.1 Reducing preventable drug-related morbidity (PDRM) could potentially improve both the safety and the quality of health-care for patients, while reducing costs. Building on a feasibility study,2 this paper describes how the application of a series of PDRM indicators in primary care was used to facilitate improvements in medicines management.

Method

Following local research ethical committee approval, 29 indicators for PDRM3,4 were applied in eight diverse general practices from three English Primary Care Trusts (PCTs). Each indicator takes the form of an adverse therapeutic outcome (the PDRM event), resulting from an associated process of patient care. The number of potential PDRM events (as defined by the indicators) was assessed retrospectively in each practice by searching the electronic patient record (EPR) of all adult patients over a 2 year 3 month time-frame. The results were fed back at individual practice level via an audio-taped multidisciplinary discussion forum facilitated by a research pharmacist (CJM or RLH). Although the practices determined staff representation at this forum, we suggested that it included the GPs, at least one representative from the nursing staff, the practice / PCT pharmacist and the practice manager. These meetings used the indicator data to generate discussion about the possible practice systems that may be contributing to potential PDRM events and explore possible solutions to these problems. Practices will be subsequently contacted at intervals of one, three and six months to gauge progress made.

Results

Preliminary analysis suggests that one issue was perceived to be of importance to all of the practices, albeit to varying degrees (lack of monitoring of potassium and creatinine levels in patients prescribed angiotensin converting enzyme inhibitors). Some issues were regarded as highly important to some of the practices, but of no consequence to others (for example – (i) the additional recording of international normalised ratio results on the EPR for patients prescribed warfarin; (ii) ensuring patients prescribed high dose inhaled steroids are issued with a spacer device. A high level of importance was placed on one issue by a single practice alone (ensuring the blood results of patients prescribed carbamazepine are monitored). Although falls and fractures associated with the prescription of hypnotic-anxiolytics was often considered important, the practical problems associated with withdrawing benzodiazepines were raised.

Discussion

Data generated from application of the indicators can be used to facilitate discussion within general practices. A multidisciplinary forum provided practice staff with the opportunity to review processes of care for specific groups of patients and explore possible solutions in an open way. Different practices clearly placed different priority levels on the issues that they wished to take forward. Individual practice "ownership" of these will hopefully ultimately prove to be a driver to instituting change.

References

1. Winterstein AG, Sauer BC, Hepler CD, Poole C. Preventable drug-related hospital admissions. Ann Pharmacother 2002; 36:1238-1248
2. Morris CJ, Cantrill JA, Bate JR. How the use of preventable drug-related morbidity indicators can improve medicines management in primary care. Pharm J 2003; 271: 682-686
3. Morris CJ, Cantrill JA, Hepler CD, Noyce PR. Preventing drug-related morbidity - determining valid indicators. Int J Qual Health Care 2002; 14:183-198.
4. Morris CJ, Cantrill JA. Preventing drug-related morbidity - the development of quality indicators. J Clin Pharm Ther 2003; 28:295-305.