We need minimally disruptive medicine

Shifting priorities in multimorbidity: a longitudinal qualitative study of patient's prioritization of multiple conditions

OBJECTIVE

To examine what influences self-management priorities for individuals with multiple long-term conditions and how this changes over time.

METHODS

A longitudinal qualitative study using semi-structured interviews completed with 21 participants with more than one chronic condition.

RESULTS

The study demonstrates the impact of multiple conditions on many aspects of people's illness management. Narratives illuminated how individual's condition priorities changed at pivotal points and altered their engagement with self-management practices. This is influenced by contact with health professionals and how people framed illness and lifestyle changes. Medication management was a central point where individuals took control of their conditions. Additional conditions were more readily accommodated if people established a cognitive link between existing management practices. Thus, multiple conditions were not inevitably experienced as an increasing burden but subject to considerable flux and change.

DISCUSSION

Prioritizing one condition over another at a particular time together with a transfer and amalgamation of practices appears to facilitate accommodation of multiple conditions and ease the burden of everyday management. These findings have implications for how we understand the variable nature of multimorbidity experience and management for patients. Clinicians might usefully engage with patients' understanding to reduce complexity, and enhance engagement of condition management.

Integrating telecare for chronic disease management in the community: what needs to be done?

Background

Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community.

Methods

Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers.

Results

Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice.

Conclusion

Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care.

Close to the bench as well as at the bedside: involving service users in all phases of translational research

AIM

The paper aims to develop a model of translational research in which service user and other stakeholder involvement are central to each phase.

BACKGROUND

'Translational' is the current medical buzzword: translational research has been termed 'bench to bedside' research and promises to fast-track biomedical advances in the service of patient benefit. Models usually conceive of translational research as a 'pipeline' that is divided into phases: the early phase is characterized as the province of basic scientists and laboratory-based clinical researchers; the later phases focus on the implementation, dissemination and diffusion of health applications. If service user involvement is mentioned, it is usually restricted to these later phases.

METHODS

The paper critically reviews existing literature on translational research and medicine. The authors develop a theoretical argument that addresses why a reconceptualization of translational research is required on scientific, ethical and pragmatic grounds.

RESULTS

The authors reconceptualize the model of translational research as an interlocking loop rather than as a pipeline, one in which service user and other stakeholder involvement feed into each of its elements. The authors demonstrate that for the 'interlocking loop' model of translational research to be materialized in practice will require changes in how health research is structured and organized.

CONCLUSION

The authors demonstrate the scientific, ethical and pragmatic benefits of involving service users in every phase of translational research. The authors' reconceptualized model of translational research contributes to theoretical and policy debates regarding both translational research and service user involvement.

Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews

BACKGROUND

Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use.

OBJECTIVES

To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services.

METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews.

MAIN RESULTS

We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes.

AUTHORS' CONCLUSIONS

Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.

Understanding patients' experiences of treatment burden in chronic heart failure using normalization process theory

PURPOSE

Our goal was to assess the burden associated with treatment among patients living with chronic heart failure and to determine whether Normalization Process Theory (NPT) is a useful framework to help describe the components of treatment burden in these patients.

METHODS

We performed a secondary analysis of qualitative interview data, using framework analysis, informed by NPT, to determine the components of patient "work." Participants were 47 patients with chronic heart failure managed in primary care in the United Kingdom who had participated in an earlier qualitative study about living with this condition. We identified and examined data that fell outside of the coding frame to determine if important concepts or ideas were being missed by using the chosen theoretical framework.

RESULTS

We were able to identify and describe components of treatment burden as distinct from illness burden using the framework. Treatment burden in chronic heart failure includes the work of developing an understanding of treatments, interacting with others to organize care, attending appointments, taking medications, enacting lifestyle measures, and appraising treatments. Factors that patients reported as increasing treatment burden included too many medications and appointments, barriers to accessing services, fragmented and poorly organized care, lack of continuity, and inadequate communication between health professionals. Patient "work" that fell outside of the coding frame was exclusively emotional or spiritual in nature.

CONCLUSIONS

We identified core components of treatment burden as reported by patients with chronic heart failure. The findings suggest that NPT is a theoretical framework that facilitates understanding of experiences of health care work at the individual, as well as the organizational, level. Although further exploration and patient endorsement are necessary, our findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care.

Informing clinical practice guideline development and implementation: prevalence of coexisting conditions among adults with coronary heart disease

OBJECTIVES

To describe the prevalence of coexisting conditions that affect clinical decision-making in adults with coronary heart disease (CHD).

DESIGN

Cross-sectional.

SETTING

National Health and Nutrition Examination Survey, 1999 to 2004.

PARTICIPANTS

Eight thousand six hundred fifty-four people aged 45 and older; 1,259 with CHD.

MEASUREMENTS

Coexisting conditions relevant to clinical decision-making and implementing therapy for CHD across three domains: chronic diseases, self-reported and laboratory-based clinical measures, and health status factors of self-reported and observed function. Prevalence was estimated according to sex and age, mutually exclusive patterns were examined, and the odds ratios (OR) of having incurred repeated hospitalization in the last year of participants with CHD and each complexity pattern versus CHD alone were modeled.

RESULTS

The prevalence of comorbid chronic diseases in subjects with CHD was 56.7% for arthritis, 29.0% for congestive heart failure, 25.5% for chronic lower respiratory tract disease, 24.8% for diabetes mellitus, and 13.8% for stroke. Clinical factors adding to complexity of clinical decision-making for CHD were use of more than four medications (54.5%), urinary incontinence (48.6%), dizziness or falls (34.8%), low glomerular filtration rate (24.4%), anemia (10.1%), high alanine aminotransferase (5.9%), use of warfarin (10.2%), and health status factors were cognitive impairment (29.9%), mobility difficulty (40.4%), frequent mental distress (14.3%), visual impairment (16.7%), and hearing impairment (17.9%). Several comorbidity patterns were associated with high odds of hospitalization.

CONCLUSION

Coexisting conditions that may modify the effectiveness of or interact with CHD therapies, influence the feasibility of CHD therapies, or alter patients' priorities concerning their health care should be considered in the development of trials and guidelines to better inform real-world clinical decision-making.

Improving quality of life in depressed COPD patients: effectiveness of a minimal psychological intervention

Depression and anxiety are highly prevalent in elderly COPD patients. Since symptoms of depression and anxiety reduce quality of life in these patients, treatments aimed at improving mental health may improve their quality of life. This study evaluated the effectiveness of a nurse-led Minimal Psychological Intervention (MPI) in reducing depression and anxiety, and improving disease-specific quality of life in elderly COPD patients. In a randomized controlled trial an MPI was compared with usual care in COPD patients. COPD patients aged 60 years or over, and with minor or mild to moderate major depression were recruited in primary care (n = 187). The intervention was based on principles of cognitive behavioural therapy (CBT) and self-management. Outcomes were symptoms of depression, symptoms of anxiety, and disease-specific quality of life, assessed at baseline and at one week and three and nine months after the intervention. Results showed that patients receiving the MPI had significantly fewer depressive symptoms (mean BDI difference 2.92, p = 0.04) and fewer symptoms of anxiety (mean SCL difference 3.69, p = 0.003) at nine months than patients receiving usual care. Further, mean SGRQ scores were significantly more favourable in the intervention group than in the control group after nine months (mean SGRQ difference 7.94, p = 0.004). To conclude, our nurse-led MPI reduced symptoms of depression and anxiety and improved disease-specific quality of life in elderly COPD patients. The MPI appears to be a valuable addition to existing disease-management programmes for COPD patients.

Ambulatory oxygen: why do COPD patients not use their portable systems as prescribed? A qualitative study

Background

Patients with COPD on long term oxygen therapy frequently do not adhere to their prescription, and they frequently do not use their ambulatory oxygen systems as intended. Reasons for this lack of adherence are not known. The aim of this study was to obtain in-depth information about perceptions and use of prescribed ambulatory oxygen systems from patients with COPD to inform ambulatory oxygen design, prescription and management.

Methods

A qualitative design was used, involving semi-structured face-to-face interviews informed by a grounded theory approach. Twenty-seven UK community-dwelling COPD patients using NHS prescribed ambulatory systems were recruited. Ambulatory oxygen systems comprised cylinders weighing 3.4 kg, a shoulder bag and nasal cannulae.

Results

Participants reported that they: received no instruction on how to use ambulatory oxygen; were uncertain of the benefits; were afraid the system would run out while they were using it (due to lack of confidence in the cylinder gauge); were embarrassed at being seen with the system in public; and were unable to carry the system because of the cylinder weight. The essential role of carers was also highlighted, as participants with no immediate carers did not use ambulatory oxygen outside the house.

Conclusions

These participants highlighted previously unreported problems that prevented them from using ambulatory oxygen as prescribed. Our novel findings point to: concerns with the lack of specific information provision; the perceived unreliability of the oxygen system; important carer issues surrounding managing and using ambulatory oxygen equipment. All of these issues, as well as previously reported problems with system weight and patient embarrassment, should be addressed to improve adherence to ambulatory oxygen prescription and enhance the physical and social benefits of maintaining mobility in this patient group. Increased user involvement in both system development and service provision planning, could have avoided many of the difficulties highlighted by this study.

Medication compliance aids: a qualitative study of users' views

BACKGROUND

Despite the rapid rise in the use of multicompartmental compliance aids (MCAs), little is known about the role they play in self-management of medication.

AIM

To explore the perceived benefits of MCAs for people using them to manage their own or a relative's medication.

DESIGN OF STUDY

Qualitative study using in-depth interviews.

SETTING

West Northumberland.

METHOD

Recruitment was via posters and leaflets in general practices and community pharmacies. In-depth interviews were conducted using a topic guide.

RESULTS

Nineteen people were interviewed. Three overarching themes emerged in relation to medicine taking: disruption, organisation, and adherence, which impacted on control. The medication regime had caused disruption to their lives and this had led to the purchase of an MCA. The MCA enabled them to organise their medication, which they believed had improved the efficiency of medicine taking and saved time. Although the MCA did not prompt them to take their medication, they could see whether they had actually taken it or not, which alleviated their anxiety. To meet their individual needs and lifestyles, some had developed broader systems of medication management, incorporating the MCA. For a small cost--the initial outlay for the MCA and time spent loading it--they gained control over the management of their medication and their condition.

CONCLUSION

This group found the use of an MCA to be beneficial, but advice and support regarding how best to manage their medication and on the most appropriate design to suit their needs would be helpful.

Normalisation process theory: a framework for developing, evaluating and implementing complex interventions

BACKGROUND

The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).

DISCUSSION

In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.

SUMMARY

The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial.

An intervention to promote patient participation and self-management in long term conditions: development and feasibility testing

BACKGROUND

There is worldwide interest in managing the global burden of long-term conditions. Current health policy places emphasis on self-management and supporting patient participation as ways of improving patient outcomes and reducing costs. However, achieving genuine participation is difficult. This paper describes the development of an intervention designed to promote participation in the consultation and facilitate self-management in long-term conditions. In line with current guidance on the development of complex interventions, our aim was to develop and refine the initial intervention using qualitative methods, prior to more formal evaluation.

METHODS

We based the intervention on published evidence on effective ways of improving participation. The intervention was developed, piloted and evaluated using a range of qualitative methods. Firstly, focus groups with stakeholders (5 patients and 3 clinicians) were held to introduce the prototype and elucidate how it could be improved. Then individual 'think aloud' and qualitative interviews (n = 10) were used to explore how patients responded to and understood the form and provide further refinement.

RESULTS

The literature highlighted that effective methods of increasing participation include the use of patient reported outcome measures and values clarification exercises. The intervention (called PRISMS) integrated these processes, using a structured form which required patients to identify problems, rate their magnitude and identify their priority. PRISMS was well received by patients and professionals. In the individual qualitative interviews the main themes that emerged from the data related to (a) the content of the PRISMS (b) the process of completing PRISMS and how it could be operationalised in practice and (c) the outcomes of completing PRISMS for the patient. A number of different functions of PRISMS were identified by patients including its use as an aide-memoire, to provide a focus to consultations, to give permission to discuss certain issues, and to provide greater tailoring for the patient.

CONCLUSIONS

There was evidence that patients found the PRISMS form acceptable and potentially useful. The challenge encountered by patients in completing PRISMS may encourage exploration of these issues within the consultation, complementing the more 'task focussed' aspects of consultations resulting from introduction of clinical guidelines and financial incentives. Further research is required to provide a rigorous assessment of the ability of tools like PRISMS to achieve genuine change in the process and outcome of consultations.

Medicare and chronic disease management: integrated care as an exceptional circumstance?

Chronic disease represents a significant challenge to the design and reform of the Australian healthcare system. The Medicare Benefits Schedule (MBS) provides a framework of numerous chronic disease management programs; however, their use at the patient level is complex. This analysis of the MBS chronic disease framework uses a hypothetical case study of a diabetic patient (with disease-related complications and a complex psychosocial background) to illustrate the difficulties in delivering appropriate multidisciplinary chronic disease care under the MBS. The complexities at each step – from care planning, service provision, and monitoring and review – are described, as are the intricacies involved in providing patient care under different MBS programs as well as those in the broader health and community care system. As demonstrated by this case study, under certain circumstances the provision of truly integrated care to this hypothetical patient would constitute an ‘exceptional circumstance’ under the MBS. Although quality improvement efforts can improve functioning within the limitations of the current system, system-wide reforms are necessary to overcome complexity and fragmentation. What is known about the topic?Chronic disease management requires optimal health system design to provide appropriate patient care. In Australia, the Medicare Benefits Schedule (MBS) provides chronic disease-focussed programs, but the multitude of available programs and items are administratively complex, overlapping and subject to claiming incompatibilities. What does this paper add? This paper illustrates the complexity of the various MBS programs for chronic disease management using a case study of the potential service response to a single diabetic patient with disease-related complications and a complex psychosocial background. This analysis illustrates the manifold problematic interactions and incompatibilities that may arise in relation to this hypothetical patient. What are the implications for practitioners?Under the current MBS framework, providing patients with optimum chronic disease management requires both clinical and administrative skill on the part of GPs. Time spent on administrative requirements is time away from clinical care. Although quality improvement efforts may improve functioning within the existing system to a certain extent, broader system reforms are necessary to support optimal chronic disease management in Australia.