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Verdonck C, Van Daele E, Willems R, Borgermans L, Boeckxstaens P. Underlying motivations hampering Flemish primary care physicians from overcoming the barriers in osteoporosis care: an EMR-facilitated clinical reasoning study. BMC Health Serv Res 2023; 23:1428. [PMID: 38104093 PMCID: PMC10725585 DOI: 10.1186/s12913-023-10441-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/05/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Over half of the European population aged minimum 65 years presents with at least two chronic diseases. Attention towards these diseases exhibits disparities, with limited primary care physician (PCP) attention for osteoporosis. This was confirmed in a previous integrated osteoporosis care (IOC) project in which notable difficulties to enlist PCPs arose. Consequently, this study was initiated in Flemish PCPs for in-depth analysis of underlying mechanisms hampering PCPs to fully commit to osteoporosis care. METHODS A qualitative Electronic Medical Record (EMR)-facilitated clinical reasoning study was conducted. A semi-structured interview guide was employed to guide PCPs from reflections on their own patients to broader views regarding osteoporosis care. An inductive thematic analysis was performed using NVivo 12. RESULTS Thirteen PCPs were interviewed. They stated that osteoporosis patients often had complex (medical) profiles. PCPs emphasised the ongoing necessity for prioritisation within this context. This leads to a competition for PCP attention during consultations at three levels: i. between acute versus preventive care; ii. between primary fracture prevention and other preventive services and iii. between secondary fracture prevention and other preventive services; spanning eight areas of competition: disease significance, perceived impact, PCP awareness, the patient agenda, PCP competence, PCP support, perceived patient burden, and efficiency of care provision. Applicability of these areas of competition differed between levels. CONCLUSION The intricate context in which PCPs operate, creates a competition for PCP attention leading to a lack of attention for fracture prevention. To preserve efforts in fracture prevention, areas of competition should be systematically addressed. TRIAL REGISTRATION Approval for the study has been provided by the Ghent University Hospital Ethics Committee (BC-09797).
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Affiliation(s)
- Caroline Verdonck
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10 - Entrance 42 - 4thFloor, 9000, Ghent, Belgium.
| | - Ellis Van Daele
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10 - Entrance 42 - 4thFloor, 9000, Ghent, Belgium
| | - Ruben Willems
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10 - Entrance 42 - 4thFloor, 9000, Ghent, Belgium
| | - Liesbeth Borgermans
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10 - Entrance 42 - 4thFloor, 9000, Ghent, Belgium
| | - Pauline Boeckxstaens
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10 - Entrance 42 - 4thFloor, 9000, Ghent, Belgium
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Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, Patterson SM, Kerse N, Cardwell CR, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023; 10:CD008165. [PMID: 37818791 PMCID: PMC10565901 DOI: 10.1002/14651858.cd008165.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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Affiliation(s)
- Judith A Cole
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | | | | | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Schuttner L, Guo R, Wong E, Jimenez E, Klein M, Roy S, Rosland AM, Chang ET. High-Risk Patient Experiences Associated With an Intensive Primary Care Management Program in the Veterans Health Administration. J Ambul Care Manage 2023; 46:45-53. [PMID: 36036980 PMCID: PMC9691513 DOI: 10.1097/jac.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85).
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Affiliation(s)
- Linnaea Schuttner
- Health Systems Research & Development, VA Puget Sound Health Care System, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Rong Guo
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA
- University of California at Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
| | - Edwin Wong
- Health Systems Research & Development, VA Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA
| | - Elvira Jimenez
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA
- University of California at Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
| | - Melissa Klein
- VA Northeast Ohio Healthcare System, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sudip Roy
- Salisbury W.G. Hefner VA Medical Center, Salisbury, NC
| | - Ann-Marie Rosland
- VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Evelyn T. Chang
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA
- University of California at Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
- VA Greater Los Angeles Healthcare System, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
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Hughes LD. Understanding the processes behind the decisions – GPs and complex multimorbidity decision making. BMC PRIMARY CARE 2022; 23:162. [PMID: 35761167 PMCID: PMC9238096 DOI: 10.1186/s12875-022-01781-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022]
Abstract
AbstractComplex multimorbidity, defined either as three or more chronic conditions affecting three or more different body systems or by the patients General Practitioner (GPs), is associated with various adverse outcomes. Understanding how GPs reach decisions for this complex group of patients is currently under-researched, with potential implications for health systems and service delivery. Schuttner and colleagues, through a qualitative approach, reported that internal factors of individuals (decisions tailored to patients; Primary Care Physician (PCP) consultation style; care planning towards an agreed goal of care), external factors within the environment or context of encounter (patient access to healthcare; organizational structures acting as barriers), and relationship-based factors (collaborative care planning; decisions within a dynamic patient clinician relationship) all influence care planning decisions. There are other important findings which have broader relevance to the literature such as the ongoing separation of physical and mental health which persist even within integrated care systems, GPs continue to prioritize continuity of care and that organizational barriers are reported as factors in clinician decision-making for patients. More broadly, the work has proved valuable in extending previously reported findings surrounding care coordination, and limitation of current guidelines for patients with complex multimorbidity. Work-load in general practice is increasing due to an ageing population, increasing prevalence of multimorbidity and polypharmacy, and transfer of clinical activities from secondary to primary care. The future for GPs is more complexity in the clinic room, understanding how GPs make decisions and how this can be supported is crucial for the sustainability for general practice.
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Schuttner L, Lee JR, Hockett Sherlock S, Ralston JD, Rosland AM, Nelson K, Simons C, Sayre GG. Primary Care Physician Perspectives on the Influence of Patient Values, Health Priorities, and Preferences on Clinical Decision-Making for Complex Patients with Multimorbidity: A Qualitative Study. Risk Manag Healthc Policy 2022; 15:2135-2146. [PMID: 36415219 PMCID: PMC9675988 DOI: 10.2147/rmhp.s380021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The prevalence of patients with multimorbidity (ie, multiple chronic conditions) is increasing. Clinical decision-making guided by patients' values, health priorities and goals, and treatment preferences is particularly important in the context of interacting diseases and psychosocial needs. Physicians face challenges incorporating patient perspectives into care plans. We examined primary care physician (PCP) views on the influence of patients' values, health priorities and goals, and preferences on clinical decisions for patients with multimorbidity and increased psychosocial complexity. Methods We conducted semi-structured telephone interviews with 23 PCPs within patient-centered medical home teams in a nationally integrated health system in the United States between May and July 2020. Data were analyzed via thematic analysis with deductive and inductive coding. Results Three major themes emerged: 1. Patient personal values were rarely explicitly discussed in routine clinical encounters but informed more commonly discussed concepts of patient priorities, goals, and preferences; 2. Patient values, health priorities and goals, and preferences were sources of divergent views about care plans between healthcare teams, patients, and families; 3. Physicians used explicit strategies to communicate and negotiate about patient values, health priorities and goals, and preferences when developing care plans, including trust-building; devoting extra effort to individualizing care; connecting patient values to healthcare recommendations; deliberate elicitation and acknowledgement of patient concerns; providing "space" for patient perspectives; incorporating family into care planning; pairing physician to patient priorities; and collaborative teamwork. Conclusion Primary care physicians perceive patient values, health priorities and goals, and preferences as influential during clinical decision-making for complex patients with multimorbidity. Participants used concrete strategies to negotiate alignment of these aspects when physician-patient divergence occurred. While rarely discussed directly in clinical encounters, personal values affected patient health priorities, goals, and preferences during care planning, suggesting a clinical role for more deliberate elicitation and discussion of patient values for this population.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jenney R Lee
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Stacey Hockett Sherlock
- Comprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System, Iowa City, IA, USA
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Karin Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carol Simons
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
| | - George G Sayre
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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