Update: In September 2018, Dr. Michelle Greiver was named the new Gordon F. Cheesbrough Research Chair in Family and Community Medicine at North York General Hospital and Director of the University of Toronto Practice-Based Research Network (UTOPIAN). Learn more.
Dr. Michelle Greiver is a practicing Family Physician and Research Scientist at North York General Hospital (NYGH). She and her research team were recently awarded a $2.6 million highly competitive operating grant. Of this amount, $1 million is funded by the Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research Primary and Integrated Health Care Innovations Network (SPOR-PIHCIN), and $1.6 million matched funds are committed by contributing partners. The grant will fund a research project proposing a SPIDER (Structured Process Informed by Data, Evidence and Research) approach supporting primary care practices in optimizing care for patients with complex needs.
Canadian health care expenses are increasing and about half of health care costs are incurred by the most complex patients, representing 5% of the population. Many of these complex patients are elders living with multiple chronic conditions and taking many medications: about a quarter of elders have received prescriptions for ten or more different medications in a single year.
Taking a significant number of medications has been called “polypharmacy”— and some medications could and should be stopped. Decreasing polypharmacy could lead to improvements in patients' overall care and health and, as a result, a greater workplace satisfaction for physicians and others involved in the care of complex patients. In addition, prescribing fewer medications could also lead to a decrease in costs for the health care system. Choosing Wisely Canada and the Canadian Deprescribing Network have identified medications that may be less likely to benefit patients. Conversations between patients and clinicians about thoughtful medication choices could decrease polypharmacy and improve care for elders.
“Reducing medications that may be less helpful in elders could help reduce side effects like dizziness and confusion,” says Dr. Greiver. “This could lead to a decrease in falls and an improvement in patients' ability to manage at home. Consequently, this could impact some areas of NYGH such as the emergency department (fewer visits due to falls and fractures) and the geriatric inpatient unit (fewer admissions).”
The $2,600,000 grant will support Dr. Greiver's SPIDER research project to address these critical issues. The main goal of the project is to evaluate the SPIDER model in helping primary care practices to optimize care for older patients living with polypharmacy.
“Patients have been highly involved in our grant application and told us that they want to see this project through,” she says. “They feel that better quality of care and outcomes and better patient experiences are important for our complex elders.”
Collaborative activities to improve patient care
Transforming patient care in effective and efficient ways requires collaboration and team efforts. SPIDER leverages existing quality improvement (QI) capacity and available electronic medical record (EMR) data. The project involves patients, family physicians and other health professionals, health planners and QI coaches who will form a Learning Collaborative. As part of the Learning Collaborative, members work together to test methods to improve care in ways that are practical, useful and sustainable in daily family practice.
“QI and Research are both about improving patient care and health, but the two programs do not always work together,” says Dr. Greiver. “Collaborative activities could synergize efforts towards better outcomes.”
The Quality & Innovations Program at the Department of Family and Community Medicine (DFCM), University of Toronto, brings expertise in QI methodologies and experience in practice coaching and Learning Collaboratives. Trish O'Brien, Quality & Innovations Program Manager at DFCM and Principal Knowledge User of SPIDER, will lead the design, development and coaching focus of the Learning Collaborative. “Working with and benefiting from the expertise of our colleagues at the Quality & Innovations Program at DFCM makes so much sense,” says Dr. Greiver.
SPIDER will be rolled out in five provinces across Canada, comprising seven Practice Based Research Networks (PBRNs) that are alliances between primary care clinicians and researchers aiming to improve quality in participating practices. The feasibility of the combined QI – research – EMR data approach will first be tested and improved in Toronto and Edmonton. QI programs and coaches will help clinicians with practice changes to improve care for complex elders living with polypharmacy. PBRNs and their research teams will work on measuring overall changes and will also interview patients and practices to find out what worked and what did not.
EMR data will be used to identify elders with polypharmacy for the practices looking after these patients; the data will also be used to measure changes in the types and number of drugs prescribed. This will be done while preserving the privacy and confidentiality of the information. The approach will then be assessed as part of a randomized controlled trial in five other PBRNs (Halifax, Montreal, Ottawa, Winnipeg and Calgary). The trial will randomly assign practices to participation in SPIDER or to continuing with usual care, and the changes will be compared.
NYGH transforming care through applied research and innovation
The project led by Dr. Michelle Greiver has a team of more than 50 investigators; as a key site, North York General is well represented in this application. The lead Patient Partner, Margo Twohig, is the Co-Chair of NYGH's Patient and Family Advisory Council. The Knowledge Translation team will be led by Monika Kastner, PhD, Research Chair in Knowledge Translation and Implementation at NYGH. Dr. Braden O'Neil, a Family Physician and a Clinician Researcher at NYGH, is a Co-Investigator. North York Family Health Team's Executive Director, Susan Griffis and Medical Director, Dr. Maria Muraca are participating in the project as Policy Maker and Expert Clinician Collaborator, respectively.
“This grant application has been a very enriching experience as it provided opportunities for North York General researchers to work with different experts across Canada,” says Dr. Greiver. “Notably, Senior Investigator Dr. Simone Dahrouge of the University of Ottawa, has provided extensive advice on key elements of the grant, including highly relevant work on patient engagement. Our SPIDER team of more than 50 experts and leaders with diverse professional backgrounds, aims to provide new insights to improve patient care and the patient experience.”
Finally, this study on polypharmacy enlightens the SPIDER project's potential to address a variety of quality issues in primary care with the possibility of applying this model to other priority areas.
Dr. Greiver's project is a recent example of how North York General Hospital is transforming care through applied research and innovation. Visit the Canadian Institutes of Health Research website to get more information on this research grant.
Dr. Greiver was also involved in the Health Databank Collaborative – Powered by North York General Hospital. Read more about this project.