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Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Maoz Z, Huet I, Sudres JL, Bouchard JP. Clinical condition, Resuscitation and Medical-Psychological Care of Severe COVID-19 patients (part 2). ANNALES MEDICO-PSYCHOLOGIQUES 2022; 180:276-281. [PMID: 35039685 PMCID: PMC8755421 DOI: 10.1016/j.amp.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Respiratory rehabilitation is the penultimate step in the medical management of patients with severe COPD-19. It is an essential step before patients’ returning home, and is usually carried out in specialised Follow-up and Rehabilitation Clinics. When discharged from hospital, patients with post-severe COVID-19 usually progress in their medical condition. However, they may remain frail and have a constant fear of possible deterioration leading to (re)hospitalisation and a return to baseline. Psychological support in this phase can reduce patients’ anxiety and increase their motivation to carry out daily rehabilitation activities. This support provides a stable and consistent basis for patients to focus on their progress, leaving the difficulties behind. Being aware of the improvements in their physical condition allows them to maintain their motivation to continue to be physically active. Psychological support during respiratory rehabilitation aims at preparing patients to return to the normal life they had before the disease. It is usually based on brief psychotherapies that focus on strengthening the patient's abilities through behavioural changes and through reducing risk behaviours. Only after this phase is it sometimes possible to deal with complex issues and to cope with personality mechanisms and maladaptive behaviour patterns.
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Affiliation(s)
- Zeev Maoz
- Clinique Cardio Vasculaire et Pulmonaire de Saint-Orens, 12, avenue de Revel, 31650 Saint-Orens-de-Gameville, France
- Centre d'Etude et de Recherche en Psychopathologie et Psychologie de la Santé (CERPPS, EA 7411), Université Toulouse 2 Jean Jaurès, Maison de la recherche, 5, allées Antonio-Machado, 31058 Toulouse cedex 9, France
| | - Isabelle Huet
- Clinique Cardio Vasculaire et Pulmonaire de Saint-Orens, 12, avenue de Revel, 31650 Saint-Orens-de-Gameville, France
| | - Jean-Luc Sudres
- Centre d'Etude et de Recherche en Psychopathologie et Psychologie de la Santé (CERPPS, EA 7411), Université Toulouse 2 Jean Jaurès, Maison de la recherche, 5, allées Antonio-Machado, 31058 Toulouse cedex 9, France
| | - Jean-Pierre Bouchard
- Institut Psycho-Judiciaire et de Psychopathologie (IPJP), Institute of Forensic Psychology and Psychopathology, centre hospitalier de Cadillac, 89, rue Cazeaux-Cazalet, 33410 Cadillac, France
- Unité pour Malades Difficiles (UMD), pôle de psychiatrie médico-légale (PPML), centre hospitalier de Cadillac, 10, avenue Joseph-Caussil, 33410 Cadillac, France
- Statistics and Population Studies Department, Faculty of Natural Sciences, University of the Western Cape, Robert-Sobukwe road, Bellville, 7535 Cape-Town, South Africa
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Favarato MH, Germani ACCG, Martins MDA. Glimpsing the raging seas that stop swans: A qualitative look at living with multimorbidity and pain in patients from a tertiary care service. JOURNAL OF COMORBIDITY 2021; 11:2633556521999509. [PMID: 33796473 PMCID: PMC7968021 DOI: 10.1177/2633556521999509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 11/15/2022]
Abstract
Multimorbidity requires complex and ongoing care. Understanding the subjective illness experience is critical to effective care. Literature isn't clear about illness perception in patients with multimorbidity followed in services of high complexity. This study aims to investigate the illness experience based on narratives about daily living and symptoms of patients with multimorbidity and pain in a tertiary health care service. Methods Qualitative narrative inquiry design with framework analysis from semi-structured interviews at a tertiary internal medicine outpatient clinic. Patients with Elixhauser comorbidity index ≧3 or and pain during the last week were included. Framework analysis was performed using 3 main patterns of illness experience from a previous study: "Gliding swan" (Resilience); "Stormy Seas" (Vulnerability); and "Stuck adrift" (Disruption); and identifying subthemes. One case study was selected from each main category. 43 patients, 14 classified as "gliding swan," 12 as "stormy seas" and 17 as "stuck adrift." Within the "gliding swan" group, positive examples of how to navigate through physical and emotional factors to sustain their wellbeing based on comprehension; In the "stormy seas" group, themes revolved around vulnerability, burden and ambiguity in relation to the health team. In the "stuck adrift" group the main content was about overwhelmed feelings and limitations. Conclusions Narratives brought the content about lacking personalized understanding of diseases, with great emotional repercussion. Some meaningful anchors were highlighted. This study reinforces multimorbidity and pain interact and that healthcare professional should be aware of the turbulences that can disturb navigation in the raging seas of long-term multimorbid conditions.
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Affiliation(s)
- Maria Helena Favarato
- Departamento de Medicina Interna, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Maria Helena Favarato, Serviço de Clínica Geral e Propedêutica, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Av Dr Eneas de Carvalho Aguiar, 155, 4o andar. Emails: ;
| | | | - Milton de Arruda Martins
- Departamento de Medicina Interna, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Reeve J. Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice. Br J Clin Pharmacol 2020; 87:76-83. [PMID: 32840868 DOI: 10.1111/bcp.14531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/05/2020] [Accepted: 08/16/2020] [Indexed: 01/21/2023] Open
Abstract
Problematic polypharmacy is a growing challenge. Medication that is intended to improve patients' health and wellbeing is instead becoming part of the problem. The way we practice medicine has become a driver for the problem. Dealing with the challenge will need us to think differently about how we do clinical care. A 2013 Kings Fund report stated that tackling problematic polypharmacy requires us to actively build a principle of compromise into the way we use medicines. There are implications for how we consult and make decisions with patients, in how we design health practice and systems to support that decision making, and, in our understanding of the process of research, how we generate the knowledge that informs practice. This review considers the current state of play in all 3 areas and identifies some of the work we still need to do in order to generate the practice-based evidence needed to tackle this most challenging problem. Finding a way to redesign practice to address problematic polypharmacy could offer a template for tackling other related complex issues facing medical practice such as multimorbidity, chronic pain and complex mental health.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, UK
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Reeve J. Primary care redesign for person-centred care: delivering an international generalist revolution. Aust J Prim Health 2018; 24:PY18019. [PMID: 30099981 DOI: 10.1071/py18019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/31/2018] [Indexed: 02/28/2024]
Abstract
Person-centred primary care is a priority for patients, healthcare practitioners and health policy. Despite this, data suggest person-centred care is still not consistently achieved - and indeed, that in some areas, care may be worsening. Whole-person care is the expertise of the medical generalist - an area of clinical practice that has been neglected by health policy for some time. It is internationally recognised that there is a need to rebalance specialist and generalist primary care. Drawing on 15 years of scholarship within the science of medical generalism (the expertise of whole-person medical care), this discussion paper outlines a three-tiered approach to primary care redesign; describing changes needed at the level of the consultation, practice set up and strategic planning. The changing needs of patients living with complex chronic illness has already started a revolution in our understanding of healthcare systems. This paper outlines work to support that paradigm shift from disease-focused to person-focused primary healthcare.
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Plouvier AOA, Olde Hartman TC, van Litsenburg A, Bloem BR, van Weel C, Lagro-Janssen ALM. Being in control of Parkinson's disease: A qualitative study of community-dwelling patients' coping with changes in care. Eur J Gen Pract 2018; 24:138-145. [PMID: 29569501 PMCID: PMC5917327 DOI: 10.1080/13814788.2018.1447561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Chronically ill patients have to cope with transfers in the level or setting of care. Patients with prevalent disorders such as diabetes mellitus can be supported by their general practitioner (GP) when experiencing such care changes, as the GP already offers them disease-specific care. For community-dwelling patients with low-prevalent diseases such as Parkinson’s disease (PD) – for which disease-specific care is provided by medical specialists – tailoring support to handle care changes requires more insight into patients’ coping. Objectives: To explore PD patients’ coping with care changes. Methods: A qualitative interview study was performed in 2013–2015 with a purposive sample of 16 community-dwelling PD patients in the Netherlands. A research assistant visited patients every month to explore if they had experienced a care change. If so, patients were interviewed face-to-face. An inductive approach to comparative content analysis was used. Results: Patients encountered a variety of care changes such as changes in the level of unpaid care, the purchase of tools, modification of pharmacotherapy or admission to hospital. Being able to anticipate, initiate and independently handle care changes contributes to patients’ sense of control and acceptance of the post-change situation. Patients, who commenced care changes themselves, had more realistic expectations of it. Conclusion: Community-dwelling PD patients seem to be able to cope with the care changes they face. Offering education to facilitate their anticipation and initiation of changes in care and their ability to act independently, can contribute to patients’ wellbeing. GPs can play a role in this.
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Affiliation(s)
- Annette O A Plouvier
- a Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Tim C Olde Hartman
- a Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Anne van Litsenburg
- a Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Bastiaan R Bloem
- b Department of Neurology and Parkinson Centre Nijmegen, Donders Institute for Brain, Cognition and Behaviour , Radboud University Medical Center , Nijmegen , The Netherlands
| | - Chris van Weel
- a Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands.,c Department Health Services Research and Quality , Australian National University , Canberra , Australia
| | - Antoine L M Lagro-Janssen
- a Department of Primary and Community Care , Radboud University Medical Center , Nijmegen , The Netherlands
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Reeve J, Britten N, Byng R, Fleming J, Heaton J, Krska J. Identifying enablers and barriers to individually tailored prescribing: a survey of healthcare professionals in the UK. BMC FAMILY PRACTICE 2018; 19:17. [PMID: 29334913 PMCID: PMC5769369 DOI: 10.1186/s12875-017-0705-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 12/26/2017] [Indexed: 12/05/2022]
Abstract
Background Many people now take multiple medications on a long-term basis to manage health conditions. Optimising the benefit of such polypharmacy requires tailoring of medicines use to the needs and circumstances of individuals. However, professionals report barriers to achieving this in practice. In this study, we examined health professionals’ perceptions of enablers and barriers to delivering individually tailored prescribing. Methods Normalisation Process Theory (NPT) informed an on-line survey of health professionals’ views of enablers and barriers to implementation of Individually Tailored Prescribing (ITP) of medicines. Links to the survey were sent out through known professional networks using a convenience/snowball sampling approach. Survey questions sought to identify perceptions of supports/barriers for ITP within the four domains of work described by NPT: sense making, engagement, action and monitoring. Analysis followed the framework approach developed in our previous work. Results Four hundred and nineteen responses were included in the final analysis (67.3% female, 32.7% male; 52.7% nurse prescribers, 19.8% pharmacists and 21.8% GPs). Almost half (44.9%) were experienced practitioners (16+ years in practice); around one third reported already routinely offering ITP to their patients. GPs were the group least likely to recognise this as consistent usual practice. Findings revealed general support for the principles of ITP but significant variation and inconsistency in understanding and implementation in practice. Our findings reveal four key implications for practice: the need to raise understanding of ITP as a legitimate part of professional practice; to prioritise the work of ITP within the range of individual professional activity; to improve the consistency of training and support for interpretive practice; and to review the impact of formal and informal monitoring processes on practice. Conclusion The findings will inform the ongoing development of our new complex intervention (PRIME Prescribing) to support the individual tailoring of medicines needed to address problematic polypharmacy. Electronic supplementary material The online version of this article (10.1186/s12875-017-0705-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanne Reeve
- Hull York Medical School, Hull University, Cottingham Road, HU67RX, Hull, England.
| | - Nicky Britten
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, EX1 2LU, Exeter, England
| | - Richard Byng
- Clinical Trials and Health Research, Peninsula Schools of Medicine and Dentistry, ITTC, Drake Circus, PL4 8AA, Plymouth, England
| | - Jo Fleming
- Warwick Primary Care, Warwick Medical School, University of Warwick, CV4 7AL, Coventry, England
| | - Janet Heaton
- Division of Health Research, University of the Highlands and Islands, 10 Inverness Campus, IV2 5NA, Inverness, Scotland
| | - Janet Krska
- Medway School of Pharmacy, The Universities of Greenwich and Kent at Medway, Anson Building, Central Avenue, Chatham Maritime, Chatham Kent, ME4 4TB, Canada
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Realising the full potential of primary care: uniting the 'two faces' of generalism. Br J Gen Pract 2017; 67:292-293. [PMID: 28663412 DOI: 10.3399/bjgp17x691589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Dowrick C, Heath I, Hjörleifsson S, Misselbrook D, May C, Reeve J, Swinglehurst D, Toon P. Recovering the self: a manifesto for primary care. Br J Gen Pract 2016; 66:582-583. [PMID: 27789507 PMCID: PMC5072912 DOI: 10.3399/bjgp16x687901] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool
| | | | - Stefan Hjörleifsson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Carl May
- University of Southampton, Southampton
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Reeve J, Cooper L, Harrington S, Rosbottom P, Watkins J. Developing, delivering and evaluating primary mental health care: the co-production of a new complex intervention. BMC Health Serv Res 2016; 16:470. [PMID: 27600512 PMCID: PMC5012043 DOI: 10.1186/s12913-016-1726-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 08/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health services face the challenges created by complex problems, and so need complex intervention solutions. However they also experience ongoing difficulties in translating findings from research in this area in to quality improvement changes on the ground. BounceBack was a service development innovation project which sought to examine this issue through the implementation and evaluation in a primary care setting of a novel complex intervention. METHODS The project was a collaboration between a local mental health charity, an academic unit, and GP practices. The aim was to translate the charity's model of care into practice-based evidence describing delivery and impact. Normalisation Process Theory (NPT) was used to support the implementation of the new model of primary mental health care into six GP practices. An integrated process evaluation evaluated the process and impact of care. RESULTS Implementation quickly stalled as we identified problems with the described model of care when applied in a changing and variable primary care context. The team therefore switched to using the NPT framework to support the systematic identification and modification of the components of the complex intervention: including the core components that made it distinct (the consultation approach) and the variable components (organisational issues) that made it work in practice. The extra work significantly reduced the time available for outcome evaluation. However findings demonstrated moderately successful implementation of the model and a suggestion of hypothesised changes in outcomes. CONCLUSIONS The BounceBack project demonstrates the development of a complex intervention from practice. It highlights the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention; and describes the use of the research process in the generation of practice-based evidence. Implications for future translational complex intervention research supporting practice change through scholarship are discussed.
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Affiliation(s)
- Joanne Reeve
- Warwick Medical School, Warwick University, Coventry, CV4 7AL UK
- Division of Health Sciences Research, Liverpool University, Liverpool, L69 3GL UK
- http://www2.warwick.ac.uk/fac/med/staff/jreeve
| | - Lucy Cooper
- Division of Health Sciences Research, Liverpool University, Liverpool, L69 3GL UK
| | - Sean Harrington
- AiW Health, 38-44 Woodside Business Park, Birkenhead, Wirral CH41 1EL UK
| | - Peter Rosbottom
- AiW Health, 38-44 Woodside Business Park, Birkenhead, Wirral CH41 1EL UK
| | - Jane Watkins
- AiW Health, 38-44 Woodside Business Park, Birkenhead, Wirral CH41 1EL UK
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