SPIDER-NET, A Structured Process Informed by Data, Evidence and Research-Network: An approach to support primary care practices in optimizing the management of patients with complex needs

Chercheurs principaux : Michelle Greiver, Patricia A. O’Brien, Margo Twohig, Frederick I. Burge, Simone Dahrouge, Neil A. Drummond, Noah M. Ivers, Marie-Thérèse Lussier, Donna P. Manca, Alexander G. Singer

Health care costs are increasing quickly. About half is spent on a small number of people with complex health problems. We need to address this. Built on a successful model for improving care by working together, the Structured Process Informed by Data, Evidence and Research (SPIDER) contains 3 parts: 1) Build teams with family physicians, nurses, pharmacists, medical staff and patients. These teams will learn together, from each other and from experts about improving quality in practice; 2) Use information from Electronic Medical Records (EMRs) to discover what the issues in each practice are, and decide together what could be done; and 3) Start making the practice changes that were agreed to with the help of coaches. Repeatedly test, measure and improve care. We will test SPIDER to see if it helps older patients taking many medications (polypharmacy), some of which may not be necessary or may even be harmful. More drugs often mean more side effects and this is even worse as people age. The risks of side effects like confusion, dizziness and falls increases in elders. Older patients taking ten or more medications are especially complex and high risk; we can do better for them. We expect SPIDER to help family doctors and their teams deliver better care by reviewing and reducing riskier drugs for these patients. We will test SPIDER in seven centres, in five provinces. We expect that it will improve patients’ quality of life and their heath; it may also save money by reducing the number of times people are admitted to hospital. Our team is made up of experts and leaders in quality improvement, audit and feedback, pharmacists, physicians, patients and researchers. All of us have experience in the parts that make up SPIDER, so we are able to do this; we will now work together to improve care for elders in our communities by reducing and improving medications, to support their health and help them reach their goals for quality of life.

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