German general practitioners' self-reported management of patients with chronic depression

Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research

BACKGROUND

Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term.

METHODS

A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient.

CONCLUSIONS

Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

Persistence with selective serotonin (norepinephrine) reuptake inhibitors in Germany-A retrospective database analysis

INTRODUCTION

Selective serotonin (norepinephrine) reuptake inhibitors (SS(N)RIs) are used in the treatment of depression. The aim of this study was to assess the persistence with SS(N)RIs in outpatients treated by general practitioners (GP) or psychiatrists (PSY) in Germany, and to investigate the association between persistence and the following factors: age, gender, specialty of the physician initiating treatment, initial molecule, and prior antidepressant prescription.

METHODOLOGY

A longitudinal pharmacy database (IMS LRx®) was used to identify patients (>18 years old) who had received an initial prescription (Rx) of an SS(N)RI between January 2014 and December 2016 (index date) from a GP or a PSY. Patients were only included if they had at least one year of pre-index observation time. The primary outcome was the rate of patients without SS(N)RI treatment discontinuation in the 12 months following the index date. Persistence was assessed using the Kaplan-Meier method. Cox regression was used to determine the impact of covariates on persistence.

RESULTS

A total of 1,213,344 patients were eligible to be included (mean age: 55.9 years, 67% women). Twelve months after initiation of SS(N)RI therapy, 28.3% of patients were persistent. Higher age was significantly associated with a lower discontinuation risk. In addition, female gender, treatment initiation by a PSY, and treatment with other antidepressants at the index date were associated with a slightly higher persistence. There were significant associations for the different molecules; however, the absolute differences were small (below 5%).

CONCLUSION

The results show that the proportion of patients receiving long-term SS(N)RI therapy (at least 12 months) was low. Discontinuation depended mainly on age and, to a lesser degree, on gender, the specialty of the physician initiating treatment, other antidepressant prescription at the index date, and initial molecule.