A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study

Introduction Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them. Methods Qualitative focus groups and semi-structured interviews took place between 2022–2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis. Results Two key themes limiting the effectiveness of SMRs in clinical practice were identified: ‘Medication Reviews in Practice’ and ‘Medication-related Challenges’. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication. Conclusion SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems

A positive deviance approach to understanding key features to improving diabetes care in the medical home

Contains fulltext : 118403.pdf (publisher's version ) (Open Access)PURPOSE The medical home has gained national attention as a model to reorganize primary care to improve health outcomes. Pennsylvania has undertaken one of the largest state-based, multipayer medical home pilot projects. We used a positive deviance approach to identify and compare factors driving the care models of practices showing the greatest and least improvement in diabetes care in a sample of 25 primary care practices in southeast Pennsylvania. METHODS We ranked practices into improvement quintiles on the basis of the average absolute percentage point improvement from baseline to 18 months in 3 registry-based measures of performance related to diabetes care: glycated hemoglobin concentration, blood pressure, and low-density lipoprotein cholesterol level. We then conducted surveys and key informant interviews with leaders and staff in the 5 most and least improved practices, and compared their responses. RESULTS The most improved/higher-performing practices tended to have greater structural capabilities (eg, electronic health records) than the least improved/lower-performing practices at baseline. Interviews revealed striking differences between the groups in terms of leadership styles and shared vision; sense, use, and development of teams; processes for monitoring progress and obtaining feedback; and presence of technologic and financial distractions. CONCLUSIONS Positive deviance analysis suggests that primary care practices' baseline structural capabilities and abilities to buffer the stresses of change may be key facilitators of performance improvement in medical home transformations. Attention to the practices' structural capabilities and factors shaping successful change, especially early in the process, will be necessary to improve the likelihood of successful medical home transformation and better care

A formal calculus for informal equality with binding

Abstract. In informal mathematical usage we often reason using languages with binding. We usually find ourselves placing capture-avoidance constraints on where variables can and cannot occur free. We describe a logical derivation system which allows a direct formalisation of such assertions, along with a direct formalisation of their constraints. We base our logic on equality, probably the simplest available judgement form. In spite of this, we can axiomatise systems of logic and computation such as first-order logic or the lambda-calculus in a very direct and natural way. We investigate the theory of derivations, prove a suitable semantics sound and complete, and discuss existing and future research.

Hierarchical Decision Making by Autonomous Agents

Often, decision making involves autonomous agents that are structured in a complex hierarchy, representing e.g. authority. Typically the agents share the same body of knowledge, but each may have its own, possibly conflicting, preferences on the available information

On Programs with Linearly Ordered Multiple Preferences

The extended answer set semantics for logic programs allows for the defeat of rules to resolve contradictions. We propose a refinement of these semantics based on a preference relation on extended literals. This relation, a strict partial order, induces a partial order on extended answer sets. The preferred answer sets, i.e. those that are minimal w.r.t. the induced order, represent the solutions that best comply with the stated preference on extended literals. In a further extension, we propose linearly ordered programs that are equipped with a linear hierarchy of preference relations. The resulting formalism is rather expressive and essentially covers the polynomial hierarchy. E.g. the membership problem for a program with a hierarchy of height n is # n+1 -complete. We illustrate an application of the approach by showing how it can easily express hierarchically structured weak constraints, i.e. a layering of "desirable" constraints, such that one tries to minimize the set of violated constraints on lower levels, regardless of the violation of constraints on higher levels