1
|
Tsang JY, Sperrin M, Blakeman T, Payne RA, Ashcroft D. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. BMJ Open 2024; 14:e081698. [PMID: 38803265 PMCID: PMC11129052 DOI: 10.1136/bmjopen-2023-081698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 05/11/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention. OBJECTIVES To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions. DESIGN We performed a scoping review as defined by the Joanna Briggs Institute. SETTING The focus was on primary care settings. DATA SOURCES Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024. ELIGIBILITY CRITERIA We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded. EXTRACTION AND ANALYSIS We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions. RESULTS In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention. CONCLUSIONS Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.
Collapse
Affiliation(s)
- Jung Yin Tsang
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester Division of Population Health Health Services Research and Primary Care, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Matthew Sperrin
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester Division of Population Health Health Services Research and Primary Care, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Rupert A Payne
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | - Darren Ashcroft
- NIHR Greater Manchester Patient Safety Research Collaboration (GMPSRC), Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences Centre (MAHSC), The University of Manchester, Manchester, UK
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| |
Collapse
|
2
|
Health complaints in individual visiting primary health care: population-based national electronic health records of Iran. BMC Health Serv Res 2022; 22:502. [PMID: 35421968 PMCID: PMC9008379 DOI: 10.1186/s12913-022-07880-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background The mission of medical schools is a sustainable commitment to orient education, research, and services based on the priorities and expectations of society. The most common complaints of patients from comprehensive health service centers (CHSCs) based on the data from electronic health records were assessed in order to determine primary health care (PHC) priorities for the educational planning of medical students in Iran. Methods A population-based national study was designed to assess clinical complaints of patients in all age groups who were referred to CHSCs at least once to be visited by physicians. All the data in the census were extracted from electronic health records in PHC system during 2015–2020, classified by the International Classification of Primary Care 2nd edition (ICPC-2e-English), and statistically analyzed. The total number of complaints that were recorded in the system was 17,430,139. Results 59% of the referring patients were women. The highest number of referrals was related to the age group of 18–59 years (56.9%), while the lowest belonged to the elderly people (13.3%). In all age and sex groups, the first ten complaints of patients with three top priorities in each category included process (follow-up, consultation, and results exam), digestive (toothache and gum complaint, abdominal pain, and diarrhea), respiratory (cough, sore throat, and runny nose), general (fever, pain, and weakness and fatigue), musculoskeletal (back pain, leg complaint, and knee injuries), endocrine and nutritional (weight gain, Feeding problem, and weight loss), cardiovascular (hypertension, palpitations, and Postural hypotension), neurological (headache, dizziness, and paralysis), sexual dysfunction (vaginal complaint, discharge, and irregular menstruation), and dermatological (pruritus, rash, and inflammation) problems. Conclusion High priorities in referring to PHC had a key role in assessing the country's health needs. Since this study was in line with the national pattern of complaints and patients' profile, the present findings can be helpful to amend policy-making, educational planning and curricula development in medical schools. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07880-z.
Collapse
|
3
|
Rachamin Y, Jäger L, Meier R, Grischott T, Senn O, Burgstaller JM, Markun S. Prescription Rates, Polypharmacy and Prescriber Variability in Swiss General Practice—A Cross-Sectional Database Study. Front Pharmacol 2022; 13:832994. [PMID: 35237170 PMCID: PMC8884695 DOI: 10.3389/fphar.2022.832994] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose: The frequency of medication prescribing and polypharmacy has increased in recent years in different settings, including Swiss general practice. We aimed to describe patient age- and sex-specific rates of polypharmacy and of prescriptions of the most frequent medication classes, and to explore practitioner variability in prescribing. Methods: Retrospective cross-sectional study based on anonymized electronic medical records data of 111 811 adult patients presenting to 116 Swiss general practitioners in 2019. We used mixed-effects regression analyses to assess the association of patient age and sex with polypharmacy (≥5 medications) and with the prescription of specific medication classes (second level of the Anatomical Therapeutic Chemical Classification System). Practitioner variability was quantified in terms of the random effects distributions. Results: The prevalence of polypharmacy increased with age from 6.4% among patients aged 18–40 years to 19.7% (41–64 years), 45.3% (65–80 years), and 64.6% (81–92 years), and was higher in women than in men, particularly at younger ages. The most frequently prescribed medication classes were antiinflammatory and antirheumatic products (21.6% of patients), agents acting on the renin-angiotensin system (19.9%), analgesics (18.7%), and drugs for acid related disorders (18.3%). Men were more often prescribed agents targeting the cardiovascular system, whereas most other medications were more often prescribed to women. The highest practitioner variabilities were observed for vitamins, for antiinflammatory and antirheumatic products, and for mineral supplements. Conclusion: Based on practitioner variability, prevalence, and risk potential, antiinflammatory drugs and polypharmacy in older patients appear to be the most pressing issues in current drug prescribing routines.
Collapse
|
4
|
Hardman R, Begg S, Spelten E. Exploring the ability of self-report measures to identify risk of high treatment burden in chronic disease patients: a cross-sectional study. BMC Public Health 2022; 22:163. [PMID: 35073896 PMCID: PMC8785389 DOI: 10.1186/s12889-022-12579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/13/2022] [Indexed: 09/03/2023] Open
Abstract
Background Effective self-management of chronic health conditions is key to avoiding disease escalation and poor health outcomes, but self-management abilities vary. Adequate patient capacity, in terms of abilities and resources, is needed to effectively manage the treatment burden associated with chronic health conditions. The ability to measure different elements of capacity, as well as treatment burden, may assist to identify those at risk of poor self-management. Our aims were to: 1. Investigate correlations between established self-report tools measuring aspects of patient capacity, and treatment burden; and 2. Explore whether individual questions from the self-report tools will correlate to perceived treatment burden without loss of explanation. This may assist in the development of a clinical screening tool to identify people at risk of high treatment burden. Methods A cross-sectional survey in both a postal and online format. Patients reporting one or more chronic diseases completed validated self-report scales assessing social, financial, physical and emotional capacity; quality of life; and perceived treatment burden. Logistic regression analysis was used to explore relationships between different capacity variables, and perceived high treatment burden. Results Respondents (n = 183) were mostly female (78%) with a mean age of 60 years. Most participants were multimorbid (94%), with 45% reporting more than five conditions. 51% reported a high treatment burden. Following logistic regression analyses, high perceived treatment burden was correlated with younger age, material deprivation, low self-efficacy and usual activity limitation. These factors accounted for 50.7% of the variance in high perceived treatment burden. Neither disease burden nor specific diagnosis was correlated with treatment burden. Conclusions This study supports previous observations that psychosocial factors may be more influential than specific diagnoses for multimorbid patients in managing their treatment workload. A simple capacity measure may be useful to identify those who are likely to struggle with healthcare demands. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12579-1.
Collapse
|
5
|
Multimorbidity and its effect on perceived burden, capacity and the ability to self-manage in a low-income rural primary care population: A qualitative study. PLoS One 2021; 16:e0255802. [PMID: 34370758 PMCID: PMC8351969 DOI: 10.1371/journal.pone.0255802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/25/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Multimorbidity is increasing in prevalence, especially in low-income settings. Despite this, chronic conditions are often managed in isolation, potentially leading to burden-capacity imbalance and reduced treatment adherence. We aimed to explore, in a low-income population with common comorbidities, how the specific demands of multimorbidity affect burden and capacity as defined by the Cumulative Complexity Model. Materials and methods Qualitative interviews with thirteen rural community health centre patients in Victoria, Australia. Participants were aged between 47–72 years and reported 3–10 chronic conditions. We asked about perceived capacity and burden in managing health. The Theory of Patient Capacity was used to analyse capacity and Normalisation Process Theory to analyse burden. All data specifically associated with the experience of multimorbidity was extracted from each burden and capacity domain. Results The capacity domains of biography, resource mobilisation and work realisation were important in relation to multimorbidity. Conditions causing functional impairment (e.g. chronic pain, depression) interacted with physical, psychological and financial capacity, leading to biographical disruption and an inability to realise treatment and life work. Despite this, few people had a treatment plan for these conditions. Participants reported that multimorbidity affected all burden domains. Coherence and appraisal were especially challenging due to condition interactions, with clinicians providing little guidance. Discussion The capacity and burden deficits highlighted by participants were not associated with any specific diagnosis, but were due to condition interactions, coupled with the lack of health provider support to navigate interactions. Physical, psychological and financial capacities were inseparable, but rarely addressed or understood holistically. Understanding and managing condition and treatment interactions was a key burden task for patients but was often difficult, isolating and overwhelming. This suggests that clinicians should become more aware of linkages between conditions, and include generic, synergistic or cross-disciplinary approaches, to build capacity, reduce burden and encourage integrated chronic condition management.
Collapse
|
6
|
Zechmann S, Senn O, Valeri F, Essig S, Merlo C, Rosemann T, Neuner-Jehle S. Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial. BMC Geriatr 2020; 20:471. [PMID: 33198634 PMCID: PMC7670707 DOI: 10.1186/s12877-020-01870-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022] Open
Abstract
Background Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients. Methods This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures. Results Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures. Conclusion Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success. Trial registration Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014. The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01870-8.
Collapse
Affiliation(s)
- Stefan Zechmann
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Stefan Essig
- Institute of Primary and Community Care, Lucerne, Switzerland
| | - Christoph Merlo
- Institute of Primary and Community Care, Lucerne, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| |
Collapse
|
7
|
Sidorkiewicz S, Malmartel A, Prevost L, Partouche H, Pinot J, Grangé-Cabane A, du Vaure CB, Gilberg S. Patient-Physician Agreement in Reporting and Prioritizing Existing Chronic Conditions. Ann Fam Med 2019; 17:396-402. [PMID: 31501200 PMCID: PMC7032904 DOI: 10.1370/afm.2444] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 02/15/2019] [Accepted: 03/28/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE In this study, we aimed to assess (1) the agreement between patient self-reports and general practitioner (GP) reports of the chronic conditions affecting the patients and (2) the agreement between patients and GPs on health priorities in a primary care setting. METHOD Patients were recruited in the Parisian area of France by a convenience sample of GPs; eligibility criteria required that the GP was the patient's listed primary care provider for at least 12 months. Participants were asked to report all the patient's current chronic conditions by using a previously developed list of 124 chronic conditions and write a list of up to 3 priority conditions. RESULTS From April to May 2017, 233 patients were recruited from 16 GP practices. Agreement between the number of conditions reported by patients and by GPs was moderate (intraclass correlation coefficient 0.59, 95% CI, 0.50 to 0.69). Agreement between patient self-reports and GP reports of each chronic condition ranged from very good (eg, κ = 0.85 for hypothyroidism) to poor (eg, κ = 0.12 for chronic anxiety disorder). Among the 153 patient-GP pairs for which both the patient and GP wrote a priority list, 45 (29.4%) of patients' first priorities did not appear anywhere on the corresponding GPs' lists, and 19 (12.4%) pairs had no matching priority condition. CONCLUSIONS Agreement between patients and their GPs varied widely depending on the diseases reported. Low agreement on health priorities suggests a need for improvement to ensure better alignment between patient and physician perspectives.
Collapse
Affiliation(s)
- Stéphanie Sidorkiewicz
- Department of General Medicine, Paris Descartes University, Paris, France .,METHODS Team, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), INSERM, UMR 1153, Paris, France
| | - Alexandre Malmartel
- Department of General Medicine, Paris Descartes University, Paris, France.,METHODS Team, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), INSERM, UMR 1153, Paris, France
| | - Lea Prevost
- Department of General Medicine, Paris Descartes University, Paris, France
| | - Henri Partouche
- Department of General Medicine, Paris Descartes University, Paris, France
| | - Juliette Pinot
- Department of General Medicine, Paris Descartes University, Paris, France
| | | | - Céline Buffel du Vaure
- Department of General Medicine, Paris Descartes University, Paris, France.,METHODS Team, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), INSERM, UMR 1153, Paris, France
| | - Serge Gilberg
- Department of General Medicine, Paris Descartes University, Paris, France
| |
Collapse
|
8
|
Herzig L, Zeller A, Pasquier J, Streit S, Neuner-Jehle S, Excoffier S, Haller DM. Factors associated with patients' and GPs' assessment of the burden of treatment in multimorbid patients: a cross-sectional study in primary care. BMC FAMILY PRACTICE 2019; 20:88. [PMID: 31253097 PMCID: PMC6598361 DOI: 10.1186/s12875-019-0974-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/05/2019] [Indexed: 11/11/2022]
Abstract
Background Multimorbid patients may experience a high burden of treatment. This has a negative impact on treatment adherence, health outcomes and health care costs. The objective of our study was to identify factors associated with the self-perceived burden of treatment of multimorbid patients in primary care and to compare them with factors associated with GPs assessment of this burden. Method A cross sectional study in general practices, 100 GPs in Switzerland and up to 10 multimorbid patients per GP. Patients reported their self-perceived burden of treatment using the Treatment Burden Questionnaire (TBQ, possible score 0–150), whereas GPs evaluated the burden of treatment on a Visual Analog Scale (VAS) from 1 to 9. The study explored medical, social and psychological factors associated with burden of treatment, such as number and type of chronic conditions and drugs, severity of chronic conditions (CIRS score), age, quality of life, deprivation, health literacy. Results The GPs included 888 multimorbid patients. The overall median TBQ was 20 and the median VAS was 4. Both patients’ and GPs’ assessment of the burden of treatment were inversely associated with patients’ age and quality of life. In addition, patients’ assessment of their burden of treatment was associated with a higher deprivation score and lower health literacy, and with having diabetes or atrial fibrillation, whereas GPs’ assessment of this burden was associated with the patient having a greater number of chronic conditions and drugs, and a higher CIRS score. Conclusion Both from patients’ and GPs’ perspectives TB appears to be higher in younger patients. Whereas for patients the burden of treatment is associated with socio-economic and psychological factors, GPs’ assessments of this burden are associated with medical factors. Including socio-economic and psychological factors on patients’ self-perception is likely to improve GPs’ assessments of their patients’ burden of treatment thus favoring patient-centered care. Electronic supplementary material The online version of this article (10.1186/s12875-019-0974-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lilli Herzig
- Department of Family Medicine, General Medicine and Public Health Centre, University of Lausanne, Bugnon 44, 1011, Lausanne, Switzerland. .,, Croisettes 14, 1066, Epalinges, Switzerland.
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Jérôme Pasquier
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Sophie Excoffier
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dagmar M Haller
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| |
Collapse
|
9
|
Barriers and enablers for deprescribing among older, multimorbid patients with polypharmacy: an explorative study from Switzerland. BMC FAMILY PRACTICE 2019; 20:64. [PMID: 31088397 PMCID: PMC6518702 DOI: 10.1186/s12875-019-0953-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/29/2019] [Indexed: 02/03/2023]
Abstract
Background Polypharmacy is an increasing problem, leading to increased morbidity and mortality, especially in older, multimorbid patients. Consequently, there is a need for reduction of polypharmacy. The aim of this study was to explore attitudes, beliefs, and concerns towards deprescribing among older, multimorbid patients with polypharmacy who chose not to pursue at least one of their GP’s offers to deprescribe. Methods Exploratory study using telephone interviews among patients of a cluster-randomized study in Northern Switzerland. The interview included a qualitative part consisting of questions in five pre-defined key areas of attitudes, beliefs, and concerns about deprescribing and an open explorative question. The quantitative part consisted of a rating of pre-defined statements in these areas. Results Twenty-two of 87 older, multimorbid patients with polypharmacy, to whom their GP offered a drug change, did not pursue all offers. Nineteen of these 22 were interviewed by telephone. The 19 patients were on average 76.9 (SD 10.0) years old, 74% female, and took 8.9 (SD 2.6) drugs per day. Drugs for acid-related disorders, analgesics and anti-inflammatory drugs were the three most common drug groups where patient involvement and the shared-decision-making (SDM) process led to the joint decision to not pursue the GPs offer. Eighteen of 19 patients fully trusted their GP, 17 of 19 participated in SDM even before this study and 8 of 19 perceived polypharmacy as a substantial burden. Conservatism/inertia and fragmented medical care were the main barriers towards deprescribing. No patient felt devalued as a consequence of the deprescribing offer. Our exploratory findings were supported by patients’ ratings of predefined statements. Conclusion We identified patient involvement in deprescribing and coordination of care as key issues for deprescribing among older multimorbid patients with polypharmacy. GPs concerns regarding patients’ devaluation should not prevent them from actively discussing the reduction of drugs. Trial registration ISRCTN16560559. Electronic supplementary material The online version of this article (10.1186/s12875-019-0953-4) contains supplementary material, which is available to authorized users.
Collapse
|
10
|
Family practitioners' top medical priorities when managing patients with multimorbidity: a cross-sectional study. BJGP Open 2019; 3:bjgpopen18X101622. [PMID: 31049405 PMCID: PMC6480857 DOI: 10.3399/bjgpopen18x101622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/16/2018] [Indexed: 11/09/2022] Open
Abstract
Background Managing multiple chronic and acute conditions in patients with multimorbidity requires setting medical priorities. How family practitioners (FPs) rank medical priorities between highly, moderately, or rarely prevalent chronic conditions (CCs) has never been described. The authors hypothesised that there was no relationship between the prevalence of CCs and their medical priority ranking in individual patients with multimorbidity. Aim To describe FPs’ medical priority ranking of conditions relative to their prevalence in patients with multimorbidity. Design & setting This cross-sectional study of 100 FPs in Switzerland included patients with ≥3 CCs on a predefined list of 75 items from the International Classification of Primary Care 2 (ICPC-2); other conditions could be added. FPs ranked all conditions by their medical priority. Method Priority ranking and distribution were calculated for each condition separately and for the top three priorities together. Results The sample contained 888 patients aged 28–98 years (mean 73), of which 48.2% were male. Included patients had 3–19 conditions (median 7; interquantile range [IQR] 6–9). FPs used 74/75 CCs from the predefined list, of which 27 were highly prevalent (>5%). In total, 336 different conditions were recorded. Highly prevalent CCs were only the top medical priority in 66%, and the first three priorities in 33%, of cases. No correlation was found between prevalence and the ranking of medical priorities. Conclusion FPs faced a great diversity of different conditions in their patients with multimorbidity, with nearly every condition being found at nearly every rank of medical priority, depending on the patient. Medical priority ranking was independent of the prevalence of CCs.
Collapse
|
11
|
Déruaz-Luyet A, N'Goran AA, Pasquier J, Burnand B, Bodenmann P, Zechmann S, Neuner-Jehle S, Senn N, Widmer D, Streit S, Zeller A, Haller DM, Herzig L. Multimorbidity: can general practitioners identify the health conditions most important to their patients? Results from a national cross-sectional study in Switzerland. BMC FAMILY PRACTICE 2018; 19:66. [PMID: 29776442 PMCID: PMC5960174 DOI: 10.1186/s12875-018-0757-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 05/01/2018] [Indexed: 11/22/2022]
Abstract
Background Faced with patients suffering from more than one chronic condition, or multimorbidity, general practitioners (GPs) must establish diagnostic and treatment priorities. Patients also set their own priorities to handle the everyday burdens associated with their multimorbidity and these may be different from the priorities established by their GP. A shared patient–GP agenda, driven by knowledge of each other’s priorities, would seem central to managing patients with multimorbidity. We evaluated GPs’ ability to identify the health condition most important to their patients. Methods Data on 888 patients were collected as part of a cross-sectional Swiss study on multimorbidity in family medicine. For the main analyses on patients-GP agreement, data from 572 of these patients could be included. GPs were asked to identify the two conditions which their patient considered most important, and we tested whether either of them agreed with the condition mentioned as most important by the patient. In the main analysis, we studied the agreement rate between GPs and patients by grouping items medically-related into 46 groups of conditions. Socio-demographic and clinical variables were fitted into univariate and multivariate models. Results In 54.9% of cases, GPs were able to identify the health condition most important to the patient. In the multivariate model, the only variable significantly associated with patient–GP agreement was the number of chronic conditions: the higher the number of conditions, the less likely the agreement. Conclusion GPs were able to correctly identify the health condition most important to their patients in half of the cases. It therefore seems important that GPs learn how to better adapt treatment targets and priorities by taking patients’ perspectives into account. Electronic supplementary material The online version of this article (10.1186/s12875-018-0757-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anouk Déruaz-Luyet
- Institute of Family Medicine, University of Lausanne, 44 rue du Bugnon, 1011, Lausanne, Switzerland
| | - Alexandra A N'Goran
- Institute of Family Medicine, University of Lausanne, 44 rue du Bugnon, 1011, Lausanne, Switzerland
| | - Jérôme Pasquier
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrick Bodenmann
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefan Zechmann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | | | - Nicolas Senn
- Institute of Family Medicine, University of Lausanne, 44 rue du Bugnon, 1011, Lausanne, Switzerland
| | - Daniel Widmer
- Institute of Family Medicine, University of Lausanne, 44 rue du Bugnon, 1011, Lausanne, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Berne, Berne, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Dagmar M Haller
- Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lilli Herzig
- Institute of Family Medicine, University of Lausanne, 44 rue du Bugnon, 1011, Lausanne, Switzerland.
| |
Collapse
|