Multimorbidity or polypharmacy: two sides of the same coin?

Polypharmacy, broadly defined as the chronic co-prescription of several drugs [1], has long been recognized as problematic. The greater the number of medicines a patient takes, the greater the risk of adverse effects of any one medicine, and the greater the risk of drug–drug interactions. Thus, polypharmacy is an accepted risk for poor health outcomes, including hospitalizations and mortality [2]. The number of drugs per patient (or polypharmacy) has come to be used as a measure of potentially hazardous professional behaviour, and is sometimes used in conjunction with the term ‘inappropriate prescribing’. Nonetheless, the prevalence of polypharmacy is rising inexorably [3]. This rise is driven, principally, by the rising prevalence of multimorbidity, i.e. the co-occurrence of two or more chronic long-term diseases or conditions in one patient [4]. The issue is compounded by clinical guidelines that advocate the use of several medicines in the management of individual diseases and their associated risk factors [5]. The result is a dilemma for prescribers: on the one hand there is the need to keep the number of medicines to a minimum, while on the other ensuring that the patient receives what evidence-based guidelines advocate as being in their best interest [6]. Journal of Comorbidity 2015;5(1):29–3

Knowledge is power: general practitioners prescribing of new oral anticoagulants in Ireland

Objective: New oral anticoagulants (NOACs) aim to overcome warfarin’s shortcomings, however their pharmacokinetic characteristics make prescribing complex. Thus it is imperative that general practitioners (GPs) are aware of specific treatments so as to maximise their benefits and minimise their pitfalls. This study explores GPs attitudes and experiences with prescribing NOACs in Ireland where, despite clear national prescribing guidelines advocating warfarin as first line therapy, the number of patients being prescribed NOACs for the first time is growing. Results: Using primary data collected from GPs in Ireland the factors influencing the likelihood of a GP initiating a prescription for a NOAC are determined using a probit model. Results indicate 46% of the sample initiated NOAC prescriptions and GP practice size is a significant factor influencing this. Analysis revealed no difference regarding the sources of information considered important amongst GPs when prescribing new drugs. However, there were differences in which factors were considered important when prescribing anticoagulants between initiating and non-initiating NOAC prescribers. The results of this study suggest better utilisation of existing information and education tools for GPs prescribing NOACs and managing NOAC patients is imperative, to ensure the right anticoagulant is prescribed for the right patient at the right time

A scoping review of the potential for chart stimulated recall as a clinical research method.

Background: Chart-stimulated recall (CSR) is a case-based interviewing technique, which is used in the assessment of clinical decision-making in medical education and professional certification. Increasingly, clinical decision-making is a concern for clinical research in primary care. In this study, we review the prior application and utility of CSR as a technique for research interviews in primary care. Methods: Following Arksey & O'Malley's method for scoping reviews, we searched seven databases, grey literature, reference lists, and contacted experts in the field. We excluded studies on medical education or competence assessment. Retrieved citations were screened by one reviewer and full texts were ordered for all potentially relevant abstracts. Two researchers independently reviewed full texts and performed data extraction and quality appraisal if inclusion criteria were met. Data were collated and summarised using a published framework on the reporting of qualitative interview techniques, which was chosen a priori. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines informed the review report. Results: From an initial list of 789 citations, eight studies using CSR in research interviews were included in the review: six from North America, one from the Netherlands, and one from Ireland. The most common purpose of included studies was to examine the influence of guidelines on physicians' decisions. The number of interviewees ranged from seven to twenty nine, while the number of charts discussed per interview ranged from one to twelve. CSR gave insights into physicians' reasoning for actions taken or not taken; the unrecorded social and clinical influences on decisions; and discrepancies between physicians' real and perceived practice. Ethical concerns and the training and influence of the researcher were poorly discussed in most of the studies. Potential pitfalls included the risk of recall, selection and observation biases. Conclusions: Despite the proven validity, reliability and acceptability of CSR in assessment interviews in medical education, its use in clinical research is limited. Application of CSR in qualitative research brings interview data closer to the reality of practice. Although further development of the approach is required, we recommend a role for CSR in research interviews on decision-making in clinical practice

GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research

Objective To synthesise the existing published literature on the perceptions of general practitioners (GPs) or their equivalent on the clinical management of multimorbidity and determine targets for future research that aims to improve clinical care in multimorbidity. Design Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore GPs’ experiences of clinical management of multimorbidity or multiple chronic diseases. Data sources EMBASE, MEDLINE, CINAHL, PsycInfo, Academic Search Complete, SocIndex, Social Science Full Text and digital theses/online libraries (database inception to September 2012) to identify literature using qualitative methods (focus groups or interviews). Review methods The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data. Results Of 1805 articles identified, 37 were reviewed in detail and 10 were included, using a total of 275 GPs in 7 different countries. Four areas of difficulty specific to the management of multimorbidity emerged from these papers: disorganisation and fragmentation of healthcare; the inadequacy of guidelines and evidence-based medicine; challenges in delivering patient-centred care; and barriers to shared decision-making. A ‘line of argument’ was drawn which described GPs’ sense of isolation in decision-making for multimorbid patients. Conclusions This systematic review shows that the problem areas for GPs in the management of multimorbidity may be classified into four domains. There will be no ‘one size fits all’ intervention for multimorbidity but these domains may be useful targets to guide the development of interventions that will assist and improve the provision of care to multimorbid patients

Counselling in primary care - a general practitioner’s perspective

Introduction: Counselling in Primary care (CIPC) is a new service introduced by the HSE in 2013, providing short-term counselling for medical-card holders, suffering from mild to moderate mental health problems. Aims: To explore GP’s views on CIPC for the treatment of mild to moderate mental health disorders. Methods: Qualitative semi-structured interviews were conducted with GPs who had previously utilized the CIPC service in the Cork/ Kerry region. Forty GPs were identified and sent invitation letters. GPs were purposefully sampled based on criteria of location (urban/rural), gender, practice size (single handed/group) and length of time qualified. A total sample size was generated using the ‘ten plus three’ method. Interviews were carried out in person, transcribed verbatim and analyzed using the framework analysis method. Results: Nineteen GPs were interviewed. Core themes emerged and were analyzed. 1. GPs unanimously agreed that CIPC has been of benefit in treating mild to moderate mental health disorders. 2. Suggested improvements to the service were made, including allowing GP visit card holders to avail of the service (n=10) and adolescents aged between 16 and 18 (n=5). 3. A majority (n=12) of GPs interviewed expressed the opinion that a combination of talk therapy and medication was associated with the best outcomes in treating mild to moderate mental health disorders. Conclusion: CIPC seems to improve mental health services at a primary care level. While improvements can certainly be made to the service, GPs report positive patient outcomes and a reduction in psychiatric referrals for patients who can be suitably managed within the community

Approving a participatory research proposal: perspectives from a Research Ethics Committee Chair and a researcher in Ireland [Case 7.1]

This case concerns a participatory health research project that was submitted for approval to a Research Ethics Committee in Ireland. All researchers wishing to undertake research linked to general medical practice need to submit an application to the Ethics Committee outlining the aims, design and methods, including how people will give consent to participate, how anonymity will be dealt with, potential harm and risk minimised, etc. The case is in two parts. The first part was contributed by a medical academic, based on a time when he chaired the Irish College of General Practitioners Research Ethics Committee. He outlines the Committee's response to an application for approval for a participatory research project. The second part is a short reflection by a health care academic, who was part of the team that submitted the application

Self-care coping strategies in people with diabetes: a qualitative exploratory study

<p>Abstract</p> <p>Background</p> <p>The management of diabetes self-care is largely the responsibility of the patient. With more emphasis on the prevention of complications, adherence to diabetes self-care regimens can be difficult. Diabetes self-care requires the patient to make many dietary and lifestyle changes. This study will explore patient perceptions of diabetes self-care, with particular reference to the burden of self-care and coping strategies among patients.</p> <p>Methods</p> <p>A maximum variation sample of 17 patients was selected from GP practices and diabetes clinics in Ireland to include patients with types 1 and 2 diabetes, various self-care regimens, and a range of diabetes complications. Data were collected by in-depth interviews; which were tape-recorded and transcribed. The transcripts were analysed using open and axial coding procedures to identify main categories, and were reviewed by an independent corroborator. Discussion of the results is made in the theoretical context of the health belief, health value, self-efficacy, and locus of control frameworks.</p> <p>Results</p> <p>Patients' perceptions of their self-care varied on a spectrum, displaying differences in self-care responsibilities such as competence with dietary planning, testing blood sugar and regular exercise. Three patient types could be distinguished, which were labeled: "proactive manager," a patient who independently monitors blood glucose and adjusts his/her self-care regime to maintain metabolic control; "passive follower," a patient who follows his/her prescribed self-care regime, but does not react autonomously to changes in metabolic control; and "nonconformist," a patient who does not follow most of his/her prescribed self-care regimen.</p> <p>Conclusion</p> <p>Patients have different diabetes self-care coping strategies which are influenced by their self-care health value and consequently may affect their diet and exercise choices, frequency of blood glucose monitoring, and compliance with prescribed medication regimens. Particular attention should be paid to the patient's self-care coping strategy, and self-care protocols should be tailored to complement the different patient types.</p

'Working away in that Grey Area...' A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia

Background: general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives: to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs’ management decisions; and to identify strategies for overcoming these challenges. Design: qualitative study of GPs experiences of managing BPSD. Methods: semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results: three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs’ confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions: this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice

Does contact with a podiatrist prevent the occurrence of a lower extremity amputation in people with diabetes? A systematic review and meta-analysis

Objective To determine the effect of contact with a podiatrist on the occurrence of Lower Extremity Amputation (LEA) in people with diabetes.Design and data sources We conducted a systematic review of available literature on the effect of contact with a podiatrist on the risk of LEA in people with diabetes. Eligible studies, published in English, were identified through searches of PubMed, CINAHL, EMBASE and Cochrane databases. The key terms, ‘podiatry’, ‘amputation’ and ‘diabetes’, were searched as Medical Subject Heading terms. Reference lists of selected papers were hand-searched for additional articles. No date restrictions were imposed.Study selection Published randomised and analytical observational studies of the effect of contact with a podiatrist on the risk of LEA in people with diabetes were included. Cross-sectional studies, review articles, chart reviews and case series were excluded. Two reviewers independently assessed titles, abstracts and full articles to identify eligible studies and extracted data related to the study design, characteristics of participants, interventions, outcomes, control for confounding factors and risk estimates.Analysis Meta-analysis was performed separately for randomised and non-randomised studies. Relative risks (RRs) with 95% CIs were estimated with fixed and random effects models as appropriate.Results Six studies met the inclusion criteria and five provided data included in meta-analysis. The identified studies were heterogenous in design and included people with diabetes at both low and high risk of amputation. Contact with a podiatrist did not significantly affect the RR of LEA in a meta-analysis of available data from randomised controlled trials (RCTs); (1.41, 95% CI 0.20 to 9.78, 2 RCTs) or from cohort studies; (0.73, 95% CI 0.39 to 1.33, 3 Cohort studies with four substudies in one cohort). Conclusions There are very limited data available on the effect of contact with a podiatrist on the risk of LEA in people with diabetes