Evaluating the effectiveness of PINCER when widely implemented
Research type
Research Study
Full title
Evaluating the effectiveness, and cost-effectiveness, of a pharmacist-led IT-based intervention (PINCER) when widely implemented in general practices to reduce the prevalence of patient exposure to hazardous prescribing, and the incidence of serious harm
IRAS ID
243026
Contact name
Anthony J Avery
Contact email
Sponsor organisation
University of Nottingham
Duration of Study in the UK
2 years, 2 months, 0 days
Research summary
Standard care:
We have previously demonstrated that an IT-based pharmacist-led intervention (PINCER) is effective at reducing hazardous prescribing in general practices. PINCER searches computer records to find patients who have already received medicines which might harm them. The PINCER study, published in the Lancet, showed that the number of patients at risk of harm is reduced when GPs use this approach, along with the support of a pharmacist to correct any problems found.It is a new model of care and has been incorporated into national guidelines to support medicines optimisation by both NICE and NHS England. The PINCER tool is made available to general practices via CHART and CHART Online software owned by PRIMIS. PRIMIS are a Crown Commercial Service Supplier and a business unit of the University of Nottingham. PRIMIS is the leading organisation in extracting knowledge and value from primary care data
Research study: This project will evaluate the effectiveness, and cost-effectiveness, of a pharmacist-led IT-based intervention (PINCER) when widely implemented in general practices.
Given that one in 25 hospital admissions relate to hazardous prescribing at an annual cost of around £650 million, and that our prescribing safety indicators focus on those medicines that contribute most often to serious adverse drug events causing hospitalisation, we wish to evaluate whether PINCER:
• Reduces the prevalence of patient exposure to hazardous prescribing
• Reduces the incidence of serious harm in patients at risk of hazardous prescribing
• Provides value for money for the NHSThis study involves medical record data collection of the PINCER indicators from primary care general practices and linkage by NHS Digital to Hospital Episode Statistics (HES) and mortality data. Confidentiality Advisory Group (CAG) support will be sought to access medical records without consent under Section 251.
Lay summary of study results: Background Previous studies have demonstrated the effectiveness and cost-effectiveness of a pharmacist-led information technology intervention (PINCER). A study in the East Midlands of England demonstrate that PINCER was effective in reducing hazardous prescribing when rolled out at scale in general practices. This new study focused on these same East Midlands practices but with complete data to validate our previous findings, to investigate whether this reduction was sustained up to 24 months, and to estimate real-world costs and cost per hazardous prescribing event prevented.
Methods and findings
We extracted data from 115 practices who received the PINCER intervention between February 2013 and August 2019. We used a multiple interrupted time series design whereby successive groups of general practices received the intervention. We used 11 prescribing safety indicators to identify potentially hazardous prescribing and collected data over a maximum of 27 quarterly time periods. The primary outcome was a composite of all the indicators; a composite for indicators associated with gastrointestinal bleeding was also reported, along with 11 individual indicators of hazardous prescribing. Data were analysed using logistic mixed models for the quarterly event numbers with the appropriate denominator, and calendar time, practice clustering and seasonality included as covariates.
For the composite outcome, the PINCER intervention was associated with a decrease in the odds of hazardous prescribing of 18% at 6 months and 23% at 12 months and 22% at 24 months post-intervention. The unadjusted rate of hazardous prescribing reduced from 50.0 patients per 1000 patients at risk pre-intervention (130067 patients in the denominator) to 41.4 at 6 months, 39.1 at 12 months and 39.5 at 24 months.
For the gastrointestinal composite indicator, the PINCER intervention was associated with a decrease in the odds of hazardous prescribing of 26% at 6 months, 31% 29% 24 months post intervention. The unadjusted rate of hazardous prescribing reduced from 158.2 per 1000 patients at risk pre implementation to 121.9 per 1000 patients at 6 months, 115.2per 1000 patients at 12 months and 117.1per 1000 patients 24 months post intervention.
We adjusted for calendar time, practice and seasonality, but since this was an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to the PINCER intervention.
We calculated costs of PINCER using resource-use estimates elicited from staff with hands-on responsibility for the rollout, combined with standard unit costs. We compared this cost with expected reduction in hazardous prescribing events. PINCER cost £1,373 (95% CI £1,006 to £1,830) per practice to implement; at 6- 12- and 24-months post-intervention, this equates to £163, £127 and £146, respectively, per hazardous prescribing event prevented.
Conclusions
Reductions in hazardous prescribing of 18%, 23% and 22% were found in this new study at 6- 12- and 24-months post-intervention, respectively. The greatest reductions in hazardous prescribing were for indicators associated with risk of gastrointestinal bleeding. Real-world costs of PINCER were very similar to those estimated in the RCT. Future research should project long-term costs and consequences associated with preventing hazardous prescribing events, to enable comprehensive evaluation of the interventionREC name
East Midlands - Leicester Central Research Ethics Committee
REC reference
19/EM/0283
Date of REC Opinion
2 Dec 2019
REC opinion
Further Information Favourable Opinion