The Data-driven Quality Improvement in Primary Care (DQIP) trial evaluated education, informatics to support patient identification, and financial incentives for patient review.12 There was a 41% reduction in the odds of the composite measure of targeted high-risk prescribing at 1 year, sustained in the following year. The lower-intensity Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) intervention had a 14% reduction in the odds of six measures of high-risk NSAID and antipsychotic prescribing after five rounds of quarterly feedback.13 However, whether these improvements can be replicated in everyday practice is uncertain. The UK Medical Research Council recommends phase IV evaluation to ‘determine whether others can reliably replicate your intervention and results in uncontrolled settings over the long term’10 as:
‘... effects are likely to be smaller and more variable once the intervention becomes implemented more widely, and … long-term follow-up may be needed to determine whether short-term changes persist’.14
How this fits in
There is good evidence from phase III cluster randomised trials that a number of interventions reduce high-risk prescribing in primary care, but whether similar improvements can be realised in the real-world setting is less clear. A system-wide quality-improvement intervention combining education, feedback, support to identify patients to review, and small financial incentives resulted in large reductions in the high-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) of a similar magnitude to those seen in phase III trials. The effect on high-risk NSAID prescribing waned somewhat in the year after the intervention ended, highlighting the need for healthcare improvement to monitor impact over a longer term and consider interventions to sustain benefit. The same intervention had no effect on the high-risk prescribing of antipsychotics, highlighting that interventions may have differential effectiveness, depending on the wider context of prescribing.
The aim of this phase IV study, therefore, was to evaluate the impact of a complex, whole-system, real-world intervention to improve prescribing safety implemented in all practices in a Scottish health board region with a population about 300 000, including whether impact was sustained post intervention.