The discomfort of an evidence-based prescribing decision

Appropriateness of Telemedicine Versus In-Person Care: A Qualitative Exploration of Psychiatrists' Decision Making

OBJECTIVE

With widespread adoption of telemedicine in response to the COVID-19 pandemic, psychiatrists must determine which visits are best conducted via telemedicine versus in person. Although some telepsychiatry guidelines and best practices have been developed, the literature has not described how psychiatrists make decisions about offering different care modalities. The authors explored how psychiatrists decide whether telemedicine is appropriate for a given patient.

METHODS

From June 25 to August 4, 2021, the authors conducted semistructured interviews with 20 outpatient psychiatrists. The authors used a critical incident technique and clinical vignettes to identify conscious and unconscious factors that influence psychiatrists' decision to offer telemedicine. Using inductive thematic analysis, the authors analyzed interview data.

RESULTS

Psychiatrists perceived that most patients are good candidates for telemedicine visits in the context of hybrid care models. Patient preference and situational factors, such as access to private spaces, rather than any particular diagnosis or patient demographic characteristic, drove telemedicine versus in-person care. Psychiatrists described numerous factors affecting their decision to offer telemedicine, and they were driven to try telemedicine and adjust as needed to "meet patients where they are" and to improve engagement in care. Psychiatrists reported using telemedicine as a bargaining chip in negotiations with patients, leveraging the offer of telemedicine to improve treatment attendance and adherence.

CONCLUSIONS

This detailed assessment of how psychiatrists choose different care modalities can inform clinical practice guidelines and reimbursement policies that often mandate in-person visits. The results show that psychiatrists did not perceive intermittent in-person visits as essential for high-quality care.

Factors determining the adherence to antimicrobial guidelines and the adoption of computerised decision support systems by physicians: A qualitative study in three European hospitals

BACKGROUND AND OBJECTIVES

Antimicrobial stewardship (AMS) programs aim to optimize antibiotic use and reduce inappropriate prescriptions through a panel of interventions. The implementation of clinical guidelines is a core strategy of AMS programs. Nevertheless, their dissemination and application remain low. Computerised decision support systems (CDSSs) offer new opportunities for semi-automated dissemination of guidelines. This qualitative study aimed at gaining an in-depth understanding of the determinants of adherence to antimicrobial prescribing guidelines and CDSSs adoption and is part of a larger project, the COMPASS trial, which aims to assess a CDSS for antimicrobial prescription. The final objective of this qualitative study is to 1) provide insights from end-users to assist in the design of the COMPASS CDSS, and to 2) help with the interpretation of the quantitative findings of the randomised controlled trial assessing the COMPASS CDSS, once data will be analysed.

METHODS

We conducted semi-structured individual interviews among in-hospital physicians in two hospitals in Switzerland and one hospital in France. Physicians were recruited by convenience sampling and snowballing until data saturation was achieved.

RESULTS

Twenty-nine physicians were interviewed. We identified three themes related to the potential barriers to guideline adherence: 1) insufficient clarity, accessibility and applicability of guidelines, 2) need of critical thinking skills to adhere to guidelines and 3) impact of the team prescribing process and peers on physicians in training. As to the perception of CDSSs, we identified four themes that could affect their adoption: 1) CDSSs are perceived as time-consuming, 2) CDSSs could reduce physicians' critical thinking and professional autonomy and raise new medico-legal issues, 3) effective CDSSs would require specific features, such as ease of use and speed, which affect usability and 4) CDSSs could improve physicians' adherence to guidelines and patient care.

DISCUSSION

CDSSs have the potential to overcome several barriers for adherence to guidelines by improving accessibility and providing individualised recommendations backed by patient data. When designing CDSSs, mixed clinical and information technology teams should focus on user-friendliness, ergonomics, workflow integration and transparency of the decision-making process.

Foundation year one and year two doctors' prescribing errors: a comparison of their causes

OBJECTIVE

Junior doctors have the highest rates of prescribing errors, yet no study has set out to understand the differences between completely novice prescribers (Foundation year one (FY1) doctors) and those who have gained some experience (Foundation year two (FY2) doctors). The objective of this study was to uncover the causes of prescribing errors made by FY2 doctors and compare them with previously collected data of the causes of errors made by FY1 doctors.

DESIGN

Qualitative interviews, using the critical incident technique, conducted with 19 FY2 doctors on the causes of their prescribing errors and compared with interviews previously conducted with 30 FY1 doctors. Data were analysed using a constant comparison approach after categorisation of the data using Reason's model of accident causation and the London protocol.

RESULTS

Common contributory factors in both FY1 and FY2 doctors' prescribing errors included working on call, tiredness and complex patients. Yet, important differences were revealed in terms of application of prescribing knowledge, with FY1 doctors lacking knowledge and FY2 misplacing their knowledge. Due to the rotation of foundation doctors, both groups are faced with novel prescribing contexts, yet the previous experience that FY2 doctors gained led to misplaced confidence when caution would have been expedient.

CONCLUSIONS

Differences in the contributory factors of prescribing errors should be taken into account when designing interventions to improve the prescribing of foundation doctors. Furthermore, careful consideration should be taken when inferring expertise in FY2 doctors, who are likely to prescribe in contexts in which their experience is little different to an FY1 doctor.

What makes decision-making difficult for oncologists faced with critical situations? The socio-affective side of the physician-patient relationship

The aim of this qualitative study based on a Social Representations approach was to explore experienced oncologists' representations of difficult decision-making situations. In total, 22 semi-structured interviews with oncologists were conducted and analysed by performing a thematic content analysis. The thematic content analysis brought to light the main medical problem involved such as uncertainty, the lethal nature of cancer and physicians' specialties, as well as the psychosocial ones, such as patients' non-medical characteristics and the patient-physician relationships. This analysis also showed the painful tensions experienced by specialists in the context of decision-making situations when the medical arguments conflict with the psychosocial ones. These findings suggest that in order to understand more clearly the complex processes involved in difficult medical decision-making situations, studies on physicians' expertise should include the socio-affective climate involved in each patient-physician relationship.

Patient-centred professionalism in pharmacy: values and behaviours

PURPOSE

Research on patient-centred professionalism in pharmacy is scarce compared with other health professions and in particular with pharmacists early in their careers. The purpose of this paper is to explore patient-centred professionalism in early career pharmacists and to describe reported behaviours. DESIGN/METHODOLOGY/APPROACH - This study explored patient-centred professional values and reported behaviours, taking a qualitative approach. In all, 53 early-career pharmacists, pharmacy tutors and pharmacy support staff, practising in community and hospital pharmacy in England took part; the concept of patient-centred professionalism was explored through focus group interviews and the critical incident technique was used to elicit real-life examples of professionalism in practice.

FINDINGS

Triangulation of the data revealed three constructs of pharmacy patient-centred professionalism: being professionally competent, having ethical values and being a good communicator.

RESEARCH LIMITATIONS/IMPLICATIONS

It is not known whether our participants' perspectives reflect those of all pharmacists in the early stages of their careers. The data provide meaning for the concept of patient-centred professionalism. The work could be extended by developing a framework for wider application. Patient-centred professionalism in pharmacy needs further investigation from the patient perspective.

PRACTICAL IMPLICATIONS

The findings have implications for pharmacy practice and education, particularly around increased interaction with patients.

SOCIAL IMPLICATIONS

The data contribute to a topic of importance to patients and in relation to UK health policy, which allocates more directly clinical roles to pharmacists, which go beyond the dispensing and supply of medicines.

ORIGINALITY/VALUE

The methods included a novel application of the critical incident technique, which generated empirical evidence on a previously under-researched topic.

Deprescribing benzodiazepines and Z-drugs in community-dwelling adults: a scoping review

BACKGROUND

Long-term sedative use is prevalent and associated with significant morbidity, including adverse events such as falls, cognitive impairment, and sedation. The development of dependence can pose significant challenges when discontinuation is attempted as withdrawal symptoms often develop. We conducted a scoping review to map and characterize the literature and determine opportunities for future research regarding deprescribing strategies for long-term benzodiazepine and Z-drug (zopiclone, zolpidem, and zaleplon) use in community-dwelling adults.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, CINAHL, TRIP, and JBI Ovid databases and conducted a grey literature search. Articles discussing methods for deprescribing benzodiazepines or Z-drugs in community-dwelling adults were selected.

RESULTS

Following removal of duplicates, 2797 articles were reviewed for eligibility. Of these, 367 were retrieved for full-text assessment and 139 were subsequently included for review. Seventy-four (53%) articles were original research, predominantly randomized controlled trials (n = 52 [37%]), whereas 58 (42%) were narrative reviews and seven (5%) were guidelines. Amongst original studies, pharmacologic strategies were the most commonly studied intervention (n = 42 [57%]). Additional deprescribing strategies included psychological therapies (n = 10 [14%]), mixed interventions (n = 12 [16%]), and others (n = 10 [14%]). Behaviour change interventions were commonly combined and included enablement (n = 56 [76%]), education (n = 36 [47%]), and training (n = 29 [39%]). Gradual dose reduction was frequently a component of studies, reviews, and guidelines, but methods varied widely.

CONCLUSIONS

Approaches proposed for deprescribing benzodiazepines and Z-drugs are numerous and heterogeneous. Current research in this area using methods such as randomized trials and meta-analyses may too narrowly encompass potential strategies available to target this phenomenon. Realist synthesis methods would be well suited to understand the mechanisms by which deprescribing interventions work and why they fail.

Therapeutic inferences for individual patients

RATIONALE, AIMS AND OBJECTIVES

Increased awareness of the gap between controlled research and medical practice has raised concerns over whether the special attention of doctors to probability estimates from clinical trials really improves the care of individuals. Evidence-based medicine has acknowledged that research results are not applicable to all kinds of patients, and consequently, has attempted to overcome this limitation by introducing improvements in the design and analysis of clinical trials.

METHODS

A clinical case is used to highlight the premises required to support reasonable extrapolations from controlled research to individuals. Then, the prospects of two key methodological improvements - pragmatic randomized controlled trials and subgroup analysis - are critically appraised.

RESULTS

A principle to guide therapeutic inferences is suggested. According to this principle, the probabilities of interest for purposes of therapeutic decision making are those of the set defined by everything that is relevant to the patient and the outcome of interest at the time of the decision. It is argued that the conditions necessary to authorize automatic extrapolations of research results to specific patients are highly demanding. Furthermore, these requirements are rarely accomplished in real practice, even in the event that probability estimates come from samples generally taken as representative and are derived from specific subsets of patients.

CONCLUSIONS

Clinicians should generally avoid unreflective extrapolations from research and address, as explicitly as possible, the challenge of estimating probabilities for individual patients. A key element of this task is the integration of data from research and non-research sources.

Why do GPs continue inappropriate hospital prescriptions of proton pump inhibitors? A qualitative study

BACKGROUND

Inappropriate prescriptions of Proton pump inhibitors (PPIs) initiated in hospitals are frequently continued in primary care. No research has explored why general practitioners (GPs) continue or discontinue inappropriate drug therapy.

OBJECTIVES

This study aims to describe factors and motives associated with the continuation of inappropriate prescriptions of PPIs in primary care.

METHODS

Semi-structured qualitative interviews on basis of a purposive sampling of five GPs who often continued inappropriate prescriptions and five GPs who frequently discontinued inappropriate drug therapy with PPIs (10 GPs total, of which four were female and six male).

RESULTS

Although all GPs enrolled in the study were enthusiastic about the effectiveness of PPIs, differences between the continuing and discontinuing GPs exists in three areas: The two groups varied ( 1 ) in awareness of indications and general attitudes towards prescribing ( 2 ) in perception of the hospital physicians' competence in prescribing and ( 3 ) appreciation of general prescribing conditions in hospitals.

CONCLUSION

Differences between the continuing and discontinuing GPs were found in their level of knowledge and their perceptions of the hospital physicians' competence and the threshold to prescribing in hospitals. Financial pressure and possible adverse effects demand a more balanced and evidence-based prescribing of PPIs. Attempts to change behaviour should focus on the GPs' awareness of indications for PPIs, NSAID risks, and prescribing approaches in hospitals. Default prescribing in hospital demands critical examination.

The discomfort caused by patient pressure on the prescribing decisions of hospital prescribers

BACKGROUND

The influence of patient expectations and demands on the decisions of prescribers in general practice has been associated with irrational prescribing and lack of evidence-based practice. However, to our knowledge, no one has investigated patient pressure to prescribe in secondary care.

OBJECTIVES

To investigate the influences on hospital prescribers' decisions by exploring what they found uncomfortable when prescribing.

METHODS

Qualitative interviews with 48 prescribers of varying seniority from 4 hospitals were conducted. Interviews were based on the critical incident technique, and prescribers were asked, before an interview, to remember any uncomfortable prescribing decisions that they had made; these were then discussed in detail during an interview. This approach allowed the interviewer to explore the more general influences on the decision to prescribe. Interviews were tape recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

RESULTS

Prescribers discussed various factors that could provoke feelings of discomfort when prescribing. Pressure on the prescribing decision from patients, relatives, or carers was a major theme, and more than half of interviewees discussed discomfort caused by such perceived pressure on the prescribing decision. How prescribers dealt with this pressure varied with seniority and the type of relationship that they had fostered with the patient. Nearly half of all incidents of patient pressure resulted in the patient being prescribed the medication they requested. Yet, many of these requests were deemed inappropriate by the prescriber. Their reasons for capitulation varied but included maintaining a good prescriber-patient relationship and avoiding conflict in the wider health care team.

CONCLUSIONS

Pressure from patients, relatives, or carers was an uncomfortable influence on these hospital prescribers' prescribing decisions. Increasingly consumer-driven health care will intensify these issues in the future. We advocate further research, focusing on managing patient demands and improving prescribers' coping strategies.

Uncomfortable prescribing decisions in hospitals: the impact of teamwork

OBJECTIVES

Prescribing is not always driven by therapeutic motives alone; social and intrinsic factors also play a part in the decision. However, most research into prescribing influences has been conducted in general practice, with very little conducted within hospitals. One potential influence is the hospital multidisciplinary team, yet little attention has been paid to how interactions between teams and team members may influence prescribing. This study investigated the effect that team interaction and structure had upon UK hospital doctors' prescribing decisions, particularly their discomfort felt prescribing.

DESIGN AND SETTING

The study used the critical incident technique and in-depth interviews. Prior to an in-depth interview, 48 doctors of varying grades from four hospitals were asked to remember any uncomfortable prescribing decisions that they had recently made. These 'incidents' were discussed in depth. All interviews were tape-recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

RESULTS

There were 193 critical incidents described in the interviews. Over one-third were related to the difficulties of prescribing within a team environment. Discomfort frequently arose because of factors relating to the hierarchical structure; in particular, junior doctors described their discomfort when they were uncertain of seniors' prescribing decisions. Prescribers also adhered to rules of prescribing etiquette, including the maintenance of other doctors'/teams' prescribing decisions and adherence to prescribing norms. Discomfort also arose from a perceived pressure to prescribe from the nursing team. Doctors admitted to prescribing to maintain overall team relationships, sometimes ignoring hospital regulations and best practice to do so.

CONCLUSION

Overall, this study demonstrated that hospital doctors' prescribing decisions were strongly influenced by relationships with other team members, particularly nurses and senior doctors. Ways of reducing this discomfort should be explored and further research is advocated in this area.