Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions

New horizons in clinical practice guidelines for use with older people

Globally, more people are living into advanced old age, with age-associated frailty, disability and multimorbidity. Achieving equity for all ages necessitates adapting healthcare systems. Clinical practice guidelines (CPGs) have an important place in adapting evidence-based medicine and clinical care to reflect these changing needs. CPGs can facilitate better and more systematic care for older people. But they can also present a challenge to patient-centred care and shared decision-making when clinical and/or socioeconomic heterogeneity or personal priorities are not reflected in recommendations or in their application. Indeed, evidence is often lacking to enable this variability to be reflected in guidance. Evidence is more likely to be lacking about some sections of the population. Many older adults are at the intersection of many factors associated with exclusion from traditional clinical evidence sources with higher incidence of multimorbidity and disability compounded by poorer healthcare access and ultimately worse outcomes. We describe these challenges and illustrate how they can adversely affect CPG scope, the evidence available and its summation, the content of CPG recommendations and their patient-centred implementation. In all of this, we take older adults as our focus, but much of what we say will be applicable to other marginalised groups. Then, using the established process of formulating a CPG as a framework, we consider how these challenges can be mitigated, with particular attention to applicability and implementation. We consider why CPG recommendations on the same clinical areas may be inconsistent and describe approaches to ensuring that CPGs remain up to date.

Implementation considerations of deprescribing interventions: A scoping review

Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.

Identifying multimorbidity clusters among Brazilian older adults using network analysis: Findings and perspectives

In aging populations, multimorbidity (MM) is a significant challenge for health systems, however there are scarce evidence available in Low- and Middle-Income Countries, particularly in Brazil. A national cross-sectional study was conducted with 11,177 Brazilian older adults to evaluate the occurrence of MM and related clusters in Brazilians aged ≥ 60 years old. MM was assessed by a list of 16 physical and mental morbidities and it was defined considering ≥ 2 morbidities. The frequencies of MM and its associated factors were analyzed. After this initial approach, a network analysis was performed to verify the occurrence of clusters of MM and the network of interactions between coexisting morbidities. The occurrence of MM was 58.6% (95% confidence interval [CI]: 57.0–60.2). Hypertension (50.6%) was the most frequent morbidity and it was present all combinations of morbidities. Network analysis has demonstrated 4 MM clusters: 1) cardiometabolic; 2) respiratory + cancer; 3) musculoskeletal; and 4) a mixed mental illness + other diseases. Depression was the most central morbidity in the model according to nodes’ centrality measures (strength, closeness, and betweenness) followed by heart disease, and low back pain. Similarity in male and female networks was observed with a conformation of four clusters of MM and cancer as an isolated morbidity. The prevalence of MM in the older Brazilians was high, especially in female sex and persons living in the South region of Brazil. Use of network analysis could be an important tool for identifying MM clusters and address the appropriate health care, research, and medical education for older adults in Brazil.

Multimorbidity matters in low and middle-income countries

Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

Potentially inappropriate prescribing in older hospitalized Dutch patients according to the STOPP/START criteria v2: a longitudinal study

Purpose

To investigate prevalence, independent associations, and variation over time of potentially inappropriate prescriptions in a population of older hospitalized patients.

Methods

A longitudinal study using a large dataset of hospital admissions of older patients (≥ 70 years) based on an electronic health records cohort including data from 2015 to 2019. Potentially inappropriate medication (PIM) and potential prescribing omission (PPO) prevalence during hospital stay were identified based on the Dutch STOPP/START criteria v2. Univariate and multivariate logistic regression were used for analyzing associations and trends over time.

Results

The data included 16,687 admissions. Of all admissions, 56% had ≥ 1 PIM and 58% had ≥ 1 PPO. Gender, age, number of medications, number of diagnoses, Charlson score, and length of stay were independently associated with both PIMs and PPOs. Additionally, number of departments and number of prescribing specialties were independently associated with PIMs. Over the years, the PIM prevalence did not change (OR = 1.00, p = .95), whereas PPO prevalence increased (OR = 1.08, p < .001). However, when corrected for changes in patient characteristics such as number of diagnoses, the PIM (aOR = 0.91, p < .001) and PPO prevalence (aOR = 0.94, p < .001) decreased over the years.

Conclusion

We found potentially inappropriate prescriptions in the majority of admissions of older patients. Prescribing relatively improved over time when considering complexity of the admissions. Nevertheless, the high prevalence shows a clear need to better address this issue in clinical practice. Studies seeking effective (re)prescribing interventions are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-020-03052-2.

General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research

Background

General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care.

Methods

Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies.

Results

Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk.

Conclusions

GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient’s unique circumstances, and useable knowledge of each individual’s capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.

Development and Implementation of a Nurse-Led Model of Care Coordination to Provide Health-Sector Continuity of Care for People With Multimorbidity: Protocol for a Mixed Methods Study

Background

Innovative strategies are required to reduce care fragmentation for people with multimorbidity. Coordinated models of health care delivery need to be adopted to deliver consumer-centered continuity of care. Nurse-led services have emerged over the past 20 years as evidence-based structured models of care delivery, providing a range of positive and coordinated health care outcomes. Although nurse-led services are effective in a range of clinical settings, strategies to improve continuity of care across the secondary and primary health care sectors for people with multimorbidity have not been examined.

Objective

To implement a nurse-led model of care coordination from a multidisciplinary outpatient setting and provide continuity of care between the secondary and primary health care sectors for people with multimorbidity.

Methods

This action research mixed methods study will have two phases. Phase 1 includes a systematic review, stakeholder forums, and validation workshop to collaboratively develop a model of care for a nurse-led care coordination service. Phase 2, through a series of iterative action research cycles, will implement a nurse-led model of care coordination in a multidisciplinary outpatient setting. Three to five iterative action research cycles will allow the model to be refined and further developed with multiple data collection points throughout.

Results

Pilot implementation of the model of care coordination commenced in October 2018. Formal study recruitment commenced in May 2019 and the intervention and follow-up phases are ongoing. The results of the data analysis are expected to be available by March 2020.

Conclusions

Nursing, clinician, and patient outcomes and experiences with the nurse-led model of care coordination will provide a template to improve continuity of care between the secondary and primary health care systems. The model template may provide a future pathway for implementation of nurse-led services both nationally and internationally.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15006

Chronic disease management and dementia: a qualitative study of knowledge and needs of staff

Effective self-management is the cornerstone of chronic disease self-management. However, self-management of chronic disease in patients with comorbid dementia is particularly challenging. It is vital that clinicians, patients and carers work collaboratively to tailor self-management programs to each patient with dementia. This study aimed to identify barriers and facilitators of successful self-management in the context of cognitive impairment in order to optimise the capacity for self-management for persons with dementia (PWD). A qualitative study based on semistructured interviews was conducted in Victoria, Australia. Interviews were conducted with 12 people (employed in the ambulatory and dementia care sectors), representing six health services. Participants identified a healthcare system that is complex, not dementia friendly and not accommodating the needs of PWD who have comorbidities. Individual and systemic barriers contributed to ineffective self-management. Chronic disease support programs do not routinely undertake cognitive assessment or have guidelines for modified management approaches for those with cognitive impairment. Support needs to be long-term and requires a specialised skillset that recognises not only chronic disease management, but also the effect of cognition on self-management. Although formal guidelines are needed, care also needs to be tailored to individual cognitive abilities and deficits.

Undiagnosing to prevent overprescribing

Health care focuses on controlling symptoms and managing risk factors to improve survival by avoiding future complications. Diagnoses describe a group of signs and symptoms, often implying specific aetiologies and underlying pathophysiological disease processes. The diagnosis provides a tool for the health professional to conceptualise and classify a presentation, and thus manage the condition, and can provide the patient with an explanation or validation of their experience. Not every diagnosis holds significant clinical implications. There are diagnosed conditions that do not require treatment and, moreover, where treatment has the potential for harm without the potential for benefit. Promoting investigations and diagnoses can lead to overdiagnosis related to vested interests in increased services, use of devices or therapeutics. Multiple factors drive this issue, including broadening disease definitions and cultural factors that encourage tests and treatments, as well as medicolegal factors. While the traditional medicine review process typically involved cross-referencing medicines used with current diagnoses, a more sophisticated version of this process critically reviews the medicines and associated diagnosis, giving less emphasis to diagnoses that are no longer relevant. Known as undiagnosis, this process facilitates the withdrawal of corresponding medicines used to manage those conditions. Systematically reviewing diagnoses regularly and the associated medicine management strategies could reduce prescribing. The novel ERASE process can help clinicians Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines.

Anesthesia in children with comorbid pathology - clinical assessment of the most common pathological conditions in the practice of anesthesiologist

Currently, there is an increase in the number of children who have multiple connected or “independent” pathological conditions, hospitalized to General hospitals with severe pain. It significantly worsens the disease course and complicates differential diagnosis in these patients, requires a deeper treatment approach. Thus, it requires attention and discussion and is urgent to cover the concept of comorbidity, combined with pain syndrome in Pediatrics. In this article is carried out the analysis of comorbid pathology in surgery from the point of view of the children’s anaesthetist. There were allocated comorbidities that are commonly encountered in daily practice and are of danger in surgical practice. We have analyzed analgesia for obesity, blood diseases, congenital heart defects, concomitant respiratory diseases – during surgery and in the postoperative period. To improve the efficiency of medical care for these patients it is important to develop an algorithm of physician's actions in the most common comorbid conditions. It is concluded that there is a need for additional studies for further clarifying the optimal management of pain and the effect of pain in case of comorbidities.

Tools for Assessment of the Appropriateness of Prescribing and Association with Patient-Related Outcomes: A Systematic Review

BACKGROUND

There are tools and criteria in the literature aimed at distinguishing between appropriate and inappropriate medicines use. However, many have not been externally validated with regard to patient-related outcomes, potentially limiting their use in clinical practice.

OBJECTIVES

The aim of the study was to conduct a systematic review to summarise (1) available prescribing appropriateness assessment tools and criteria, and (2) their associations with patient-related outcomes (external validity).

METHODS

A systematic review was conducted using MEDLINE, EMBASE and Informit (Health Collection) databases to screen for articles in English that examined (1) tools to assess the appropriateness of prescribing and (2) associations of tools with patient-related outcomes, published between 2000 and 2016, without any limits placed on the study design, participant age or setting.

RESULTS

After screening 1710 articles, removing duplicates and shortlisting relevant articles, 42 prescribing assessment tools were identified. Out of the 42 tools, 78.6% (n = 33) provided guidance around stopping inappropriate medications, 28.6% (n = 12) around starting appropriate medications, 61.9% (n = 26) were explicit (criteria based) and 31.0% (n = 13) had been externally validated, with hospitalisation being the most commonly used patient-related outcome (n = 9, 21.4%).

CONCLUSION

The results of this systematic review highlight the need for evidence-based and externally validated tools, which combine the different aspects of medication management to optimise patient-related outcomes. PROSPERO registration number: CRD42017067233.

Guidance on guidelines: Understanding the evidence on the uptake of health care guidelines

RATIONALE

Regardless of health issue, health sector, patient condition, or treatment modality, the chances are that provision is supported by "a guideline" making professionally endorsed recommendations on best practice. Against this background, research has proliferated seeking to evaluate how effectively such guidance is followed. These investigations paint a gloomy picture with many a guideline prompting lip service, inattention, and even opposition. This predicament has prompted a further literature on how to improve the uptake of guidelines, and this paper considers how to draw together lessons from these inquiries.

METHODS

This huge body of material presents a considerable challenge for research synthesis, and this paper produces a critical, methodological comparison of 2 types of review attempting to meet that task. Firstly, it provides an overview of the current orthodoxy, namely, "thematic reviews," which aggregate and enumerate the "barriers and facilitators" to guideline implementation. It then outlines a "realist synthesis," focussing on testing the "programme theories" that practitioners have devised to improve guideline uptake.

RESULTS

Thematic reviews aim to provide a definitive, comprehensive catalogue of the facilitators and barriers to guideline implementation. As such, they present a restatement of the underlying problems rather than an improvement strategy. The realist approach assumes that the incorporation of any guideline into current practice will produce unintended system strains as different stakeholders wrestle over responsibilities. These distortions will prompt supplementary revisions to guidelines, which in turn beget further strains. Realist reviews follow this dynamic understanding of organisational change.

CONCLUSIONS

Health care decision makers operate in systems that are awash with guidelines. But guidelines only have paper authority. Managers do not need a checklist of their pros and cons, because the fate of guidelines depends on their reception rather than their production. They do need decision support on how to engineer and reengineer guidelines so they dovetail with evolving systems of health care delivery.

Prevalence and overlap of Disease Management Program diseases in older hospitalized patients

Many countries, like Denmark, have tailored Disease Management Programs (DMPs) based on patients having single chronic diseases [defined institutionally as "program diseases" (PDs)], which can complicate treatment for those with multiple chronic diseases. The aims of this study were (a) to assess the prevalence and overlap among acutely hospitalized older medical patients of PDs defined by the DMPs, and (b) to examine transitions between different departments during hospitalization and mortality and readmission within two time intervals among patients with the different PDs. We conducted a registry study of 4649 acutely hospitalized medical patients ≥65 years admitted to Copenhagen University Hospital, Hvidovre, Denmark, in 2012, and divided patients into six PD groups (type 2 diabetes, chronic obstructive pulmonary disease, cardiovascular disease, musculoskeletal disease, dementia and cancer), each defined by several ICD-10 codes predefined in the DMPs. Of these patients, 904 (19.4%) had 2 + PDs, and there were 47 different combinations of the six different PDs. The most prevalent pair of PDs was type 2 diabetes with cardiovascular disease in 203 (22.5%) patients, of whom 40.4% had an additional PD. The range of the cumulative incidence of being readmitted within 90 days was between 28.8% for patients without a PD and 46.6% for patients with more than one PD. PDs overlapped in many combinations, and all patients had a high probability of being readmitted. Hence, developing strategies to create a new generation of DMPs applicable to older patients with comorbidities could help clinicians organize treatment across DMPs.

The Challenges of Treating Sciatica Pain in Older Adults

Sciatica is a debilitating condition affecting approximately 25 % of the population. Typically, the patient will complain of lower limb pain that is more severe than pain in the lower back, usually accompanied by numbness and motor weakness. Most international guidelines recommend pharmacological management for the pain relief of sciatica, including paracetamol, non-steroidal anti-inflammatory drugs, opioid analgesics, anticonvulsants, and corticosteroids, among others. However, the evidence for most of these pharmacological options is scarce, and the majority of clinical trials exclude older patients. There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients with sciatica. This review presents a critical appraisal of the existing evidence for the pharmacological treatment of sciatica, with a special focus on the older adult. The age-related changes in the health of older patients, as well as their impact on the response to pharmacological treatment, including polypharmacy, drug interactions, and drug-disease interactions, is also discussed.

Management of vertebral compression fracture in general practice: BEACH program

Importance

The pain associated with vertebral compression fractures can cause significant loss of function and quality of life for older adults. Despite this, there is little consensus on how best to manage this condition.

Objective

To describe usual care provided by general practitioners (GPs) in Australia for the management of vertebral compression fractures.

Design, setting and participants

Data from the Bettering the Evaluation And Care of Health (BEACH) program collected between April 2005 and March 2015 was used for this study. Each year, a random sample of approximately 1,000 GPs each recorded information on 100 consecutive encounters. We selected those encounters at which vertebral compression fracture was managed. Analyses of management options were limited to encounters with patients aged 50 years or over.

Main outcome(s) and measure(s)

i) patient demographics; ii) diagnoses/problems managed; iii) the management provided for vertebral compression fracture during the encounter. Robust 95% confidence intervals, adjusted for the cluster survey design, were used to assess significant differences between group means.

Results

Vertebral compression fractures were managed in 211 (0.022%; 95% CI: 0.018–0.025) of the 977,300 BEACH encounters recorded April 2005– March 2015. That provides a national annual estimate of 26,000 (95% CI: 22,000–29,000) encounters at which vertebral fractures were managed. At encounters with patients aged 50 years or over (those at higher risk of primary osteoporosis), prescription of analgesics was the most common management action, particularly opioids analgesics (47.1 per 100 vertebral fractures; 95% CI: 38.4–55.7). Prescriptions of paracetamol (8.2; 95% CI: 4–12.4) or non-steroidal anti-inflammatory drugs (4.1; 95% CI: 1.1–7.1) were less frequent. Non-pharmacological treatment was provided at a rate of 22.4 per 100 vertebral fractures (95% CI: 14.6–30.1). At least one referral (to hospital, specialist, allied health care or other) was given for 12.3 per 100 vertebral fractures (95% CI: 7.8–16.8).

Conclusions and relevance

The prescription of oral opioid analgesics remains the common general practice approach for vertebral compression fractures management, despite the lack of evidence to support this. Clinical trials addressing management of these fractures are urgently needed to improve the quality of care patients receive.

Better guidelines for better care: accounting for multimorbidity in clinical guidelines – structured examination of exemplar guidelines and health economic modelling

Background

Multimorbidity is common but most clinical guidelines focus on single diseases.

Aim

To test the feasibility of new approaches to developing single-disease guidelines to better account for multimorbidity.

Design

Literature-based and economic modelling project focused on areas where multimorbidity makes guideline application problematic.

Methods

(1) Examination of accounting for multimorbidity in three exemplar National Institute for Health and Care Excellence guidelines (type 2 diabetes, depression, heart failure); (2) examination of the applicability of evidence in multimorbidity for the exemplar conditions; (3) exploration of methods for comparing absolute benefit of treatment; (4) incorporation of treatment pay-off time and competing risk of death in an exemplar economic model for long-term preventative treatments with slowly accruing benefit; and (5) development of a discrete event simulation model-based cost-effectiveness analysis for people with both depression and coronary heart disease.

Results

(1) Comorbidity was rarely accounted for in the clinical research questions that framed the development of the exemplar guidelines, and was rarely accounted for in treatment recommendations. Drug–disease interactions were common only for comorbid chronic kidney disease, but potentially serious drug–drug interactions between recommended drugs were common and rarely accounted for in guidelines. (2) For all three conditions, the trials underpinning treatment recommendations largely excluded older, more comorbid and more coprescribed patients. The implications of low applicability varied by condition, with type 2 diabetes having large differences in comorbidity, whereas potentially serious drug–drug interactions were more important for depression. (3) Comparing absolute benefit of treatments for different conditions was shown to be technically feasible, but only if guideline developers are willing to make a number of significant assumptions. (4) The lifetime absolute benefit of statins for primary prevention is highly sensitive to the presence of both the direct treatment disutility of taking a daily tablet and competing risk of death. (5) It was feasible to use a discrete event simulation-based model to represent the relevant care pathways to estimate the relative cost-effectiveness of pharmacological treatments of major depressive disorder in primary care for patients who are also likely to go on and receive treatment for coronary heart disease but the analysis was reliant on eliciting some parameter values from experts, which increases the inherent uncertainty in the results. The key limitation was that real-life use in guideline development was not examined.

Conclusions

Guideline developers could feasibly (1) use epidemiological data characterising the guideline population to inform consideration of applicability and interactions; (2) systematically compare the absolute benefit of long-term preventative treatments to inform decision-making in people with multimorbidity and high treatment burden; and (3) modify the output from economic models used in guideline development to examine time to benefit in terms of the pay-off time and varying competing risk of death from other conditions.

Future work

Further research is needed to optimise presentation of comparative absolute benefit information to clinicians and patients, to evaluate the use of epidemiological and time-to-benefit data in guideline development, to better quantify direct treatment disutility and to better quantify benefit and harm in people with multimorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

General Practitioners' Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

BACKGROUND

Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older.

METHOD

25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.

RESULTS

Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.

CONCLUSION

Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

Influence of medication risks and benefits on treatment preferences in older patients with multimorbidity

Multimorbidity is associated with use of multiple medicines, increased risk of adverse events and treatment conflicts. This study aimed to examine how older patients with multimorbidity and clinicians balance the benefits and harms associated with a medication and in the presence of competing health outcomes. Interviews were conducted with 15 participants aged ≥65 years with 2 or more chronic conditions. Three clinical scenarios were presented to understand patient preference to take a medicine according to i) degree of benefit, ii) type of adverse event and impact on daily living and iii) influence of comorbid conditions as competing health outcomes. Semi-structured interviews were also conducted with participants (n=15) and clinicians (n=5) to understand patient preferences and treatment decisions, in the setting of multimorbidity. The median age of participants was 79 years, 55% had 5 or more conditions and 47% took 8 or more medicines daily. When the level of benefit of the medicine ranged from 14% to 70%, 80% of participants chose to take the medicine, but when adverse effects were present, this was reduced to 0-33% depending upon impact on daily activities. In the presence of competing health outcomes, 13%-26% of patients chose to take the medicine. Two-thirds of patients reported that their doctor respects and considers their preferences and discussed medication benefits and harms. Interviews with clinicians showed that their overall approach to treatment decision-making for older individuals with multimorbidity was based upon 2 main factors, the patients' prognosis and their preferences. The degree of benefit gained was not the driver of patients' preference to take a medicine; rather, this decision was influenced by type and severity of adverse effects. Inclusion of patient preferences in the setting of risks and benefits of medicines with consideration and prioritization of competing health outcomes may result in improved health outcomes for people with multimorbidity.

Non-Communicable Disease Clinical Practice Guidelines in Brazil: A Systematic Assessment of Methodological Quality and Transparency

BACKGROUND

Annually, non-communicable diseases (NCDs) kill 38 million people worldwide, with low and middle-income countries accounting for three-quarters of these deaths. High-quality clinical practice guidelines (CPGs) are fundamental to improving NCD management. The present study evaluated the methodological rigor and transparency of Brazilian CPGs that recommend pharmacological treatment for the most prevalent NCDs.

METHODS

We conducted a systematic search for CPGs of the following NCDs: asthma, atrial fibrillation, benign prostatic hyperplasia, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and/or stable angina, dementia, depression, diabetes, gastroesophageal reflux disease, hypercholesterolemia, hypertension, osteoarthritis, and osteoporosis. CPGs comprising pharmacological treatment recommendations were included. No language or year restrictions were applied. CPGs were excluded if they were merely for local use and referred to NCDs not listed above. CPG quality was independently assessed by two reviewers using the Appraisal of Guidelines Research and Evaluation instrument, version II (AGREE II).

MAIN FINDINGS

"Scope and purpose" and "clarity and presentation" domains received the highest scores. Sixteen of 26 CPGs were classified as low quality, and none were classified as high overall quality. No CPG was recommended without modification (77% were not recommended at all). After 2009, 2 domain scores ("rigor of development" and "clarity and presentation") increased (61% and 73%, respectively). However, "rigor of development" was still rated < 30%.

CONCLUSION

Brazilian healthcare professionals should be concerned with CPG quality for the treatment of selected NCDs. Features that undermined AGREE II scores included the lack of a multidisciplinary team for the development group, no consideration of patients' preferences, insufficient information regarding literature searches, lack of selection criteria, formulating recommendations, authors' conflict of interest disclosures, and funding body influence.

Improving the applicability of guidelines on nonmelanoma skin cancer in frail older adults: a multidisciplinary expert consensus and systematic review of current guidelines

BACKGROUND

Balancing treatment decisions in frail older adults with nonmelanoma skin cancer (NMSC) can be challenging. Clinical practice guidelines (CPGs) could provide assistance.

OBJECTIVES

To collect and prioritize items related to frail older adults with NMSC for integration into CPGs and to assess the current extent of this integration.

METHODS

Items were collected and prioritized by a multidisciplinary working group (29 members) using a modified Delphi procedure and a five-point Likert scale. To assess current integration of these items in CPGs, a systematic review was subsequently performed by two independent reviewers using five medical databases (PubMed, Embase, Cochrane Library, SUMsearch and Trip Database), websites of guideline developers/databases, and (inter)national dermatological societies.

RESULTS

Prioritization of a final 13-item list showed that 'limited life expectancy' (4·5 ± 0·9) and 'treatment goals other than cure' (4·4 ± 0·7) were most desired to be integrated into CPGs; both were included in six (46%) of the CPGs found (n = 13). Attention to 'tumour characteristics' and 'comorbidities' were included in CPGs most often (100% and 77%, respectively).

CONCLUSIONS

More attention to items related to frail older adults in NMSC CPGs is broadly desired, but CPG integration of these items is currently limited. More integration might stimulate more holistic, personalized and patient-centred care in frail older adults.

Demand management for planned care: a realist synthesis

Background

The task of matching fluctuating demand with available capacity is one of the basic challenges in all large-scale service industries. It is a particularly pressing concern in modern health-care systems, as increasing demand (ageing populations, availability of new treatments, increased patient knowledge, etc.) meets stagnating supply (capacity and funding restrictions on staff and services, etc.). As a consequence, a very large portfolio of demand management strategies has developed based on quite different assumptions about the source of the problem and about the means of its resolution.

Methods

This report presents a substantial review of the effectiveness of main strategies designed to alleviate demand pressures in the area of planned care. The study commences with an overview of the key ideas about the genesis of demand and capacity problems for health services. Many different diagnoses were uncovered: fluctuating demand meeting stationary capacity; turf protection between different providers; social rather than clinical pressures on referral decisions; self-propelling diagnostic cascades; supplier-induced demand; demographic pressures on treatment; and the informed patient and demand inflation. We then conducted a review of the key ideas (programme theories) underlying interventions designed to address demand imbalance. We discovered that there was no close alignment between purported problems and advocated solutions. Demand management interventions take their starting point in seeking reforms at the levels of strategic decision-making, organisational re-engineering, procedural modifications and behavioural change. In mapping the ideas for reform, we also noted a tendency for programme theories to become ‘whole-system’ models; over time policy-makers have advocated the need for concerted action on all of these fronts.

Findings

The remainder and core of the report contains a realist synthesis of the empirical evidence on the effectiveness on a spanning subset of four major demand management interventions: referral management centres (RMCs); using general practitioners with special interests (GPwSIs) at the interface between primary and secondary care; general practitioner (GP) direct access to clinical tests; and referral guidelines. In all cases we encountered a chequered pattern of success and failure. The primary literature is replete with accounts of unanticipated problems and unintended effects. These programmes ‘work’ only in highly circumscribed conditions. To give brief examples, we found that the success of RMCs depends crucially on the balance of control in their governance structures; GPwSIs influence demand only after close negotiations on an agreed and intermediate case mix; significant efficiencies are created by direct GP access to tests mainly when there is low diagnostic yield and high ‘rule-out’ rates; and referral guidelines are more likely to work when implemented by staff with responsibility for their creation.

Conclusions

The report concludes that there is no ‘preferred intervention’ that has the capacity to outperform all others. Instead, the review found many, diverse, hard-won, local and adaptive solutions. Whatever the starting point, success in demand management depends on synchronising a complex array of strategic, organisational, procedural and motivational changes. The final chapter offers practitioners some guidance on how they might ‘think through’ all of the interdependencies, which bring demand and capacity into equilibrium. A close analysis of the implementation of different configurations of demand management interventions in different local contexts using mixed methods would be valuable to understand the processes through which such interventions are tailored to local circumstances. There is also scope for further evidence synthesis. The substitution theory is ubiquitous in health and social care and a realist synthesis to compare the fortunes of different practitioners placed at different professional boundaries (e.g. nurses/doctors, dentists/dental care practitioners, radiologists/radiographers and so on) would be valuable to identify the contexts and mechanisms through which substitution, support or short-circuit occurs.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Incorporating patient preferences in the management of multiple long-term conditions: is this a role for clinical practice guidelines?

BACKGROUND

Clinical practice guidelines provide an evidence-based approach to managing single chronic conditions, but their applicability to multiple conditions has been actively debated. Incorporating patient-preference recommendations and involving consumers in guideline development may enhance their applicability, but further understanding is needed.

OBJECTIVES

To assess guidelines that include recommendations for comorbid conditions to determine the extent to which they incorporate patient-preference recommendations; use consumer-engagement processes during development, and, if so, whether these processes produce more patient-preference recommendations; and meet standard quality criteria, particularly in relation to stakeholder involvement.

DESIGN

A review of Australian guidelines published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Document analysis of guidelines examined the presence of patient-preference recommendations and the consumer-engagement processes used. The Appraisal of Guidelines for Research and Evaluation instrument was used to assess guideline quality.

RESULTS

Thirteen guidelines were reviewed. Twelve included at least one core patient-preference recommendation. Ten used consumer-engagement processes, including participation in development groups (seven guidelines) and reviewing drafts (ten guidelines). More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Overall quality of guidelines was mixed, particularly in relation to stakeholder involvement.

CONCLUSIONS

Guidelines do incorporate some patient-preference recommendations, but more explicit acknowledgement is required. Consumer-engagement processes used during guideline development have the potential to assist in identifying patient preferences, but further research is needed. Clarification of the consumer role and investment in consumer training may strengthen these processes.

Exploring the factors that influence medication rating Web sites value to older adults: A cross-sectional study

In this cross-sectional study, we evaluated factors that affected the perceived value of medication rating Web sites to 284 people aged ≥ 60 years who were taking prescription medications. The Patient Reviews of Medication Experience (PROMEX) questionnaire score, which assessed participant opinions about the value of online reviews of medications, was positively associated with preference to share health care decision making with the health care provider and negatively associated with the Physical Component Summary (PCS-12) and Mental Component Summary scores of the Short Form 12 health survey. The Primary Care Assessment Survey Communication score, which measured participant satisfaction with the communication from the health care provider, was positively associated with PCS-12 and health literacy. In summary, older adults who had poor physical and mental health-related quality of life were more likely to believe that medication rating Web sites were useful and helpful in facilitating communication with health care providers.

Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults

BACKGROUND

Clinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature.

METHODS

We searched: 1) two systematic reviews on CPGs for CVD prevention and 2) the National CPG Clearinghouse, G-I-N International CPG Library and Trip databases for CPGs for CVD prevention, hypertension and cholesterol. We conducted our search between April and December 2013. We excluded CPGs for diabetes, chronic kidney disease, HIV, lifestyle, general screening/prevention, and pregnant or pediatric populations. Three authors independently screened citations for inclusion and extracted data. The primary outcomes were presence and extent of recommendations for older people including discussion of: (1) available evidence, (2) barriers to implementation of the CPG, and (3) tailoring management for this group.

RESULTS

We found 47 eligible CPGs. There was no mention of older people in 4 (9 %) of the CPGs. Benefits were discussed more frequently than harms. Twenty-three CPGs (49 %) discussed evidence about potential benefits and 18 (38 %) discussed potential harms of CVD prevention in older people. Most CPGs addressed one or more barriers to implementation, often as a short statement. Although 27 CPGs (58 %) mentioned tailoring management to the older patient context (e.g. comorbidities), concrete guidance was rare.

CONCLUSION

Although most CVD prevention CPGs mention the older population to some extent, the information provided is vague and very limited. Older adults represent a growing proportion of the population. Guideline developers must ensure they consider older patients' needs and provide appropriate advice to clinicians in order to support high quality care for this group. CPGs should at a minimum address the available evidence about CVD prevention for older people, and acknowledge the importance of patient involvement.

Quality of dementia clinical guidelines and relevance to the care of older people with comorbidity: evidence from the literature

PURPOSE

The aim of this paper was to explore the applicability of dementia clinical guidelines (CGs) to older patients, to patients with one or several comorbidities, and to both targets in order to evaluate if an association between the applicability and quality of the CGs exists.

MATERIALS AND METHODS

A systematic search strategy conducted on electronic databases identified CGs on diagnosis and treatment of dementia published from 2000 to 2013. In addition, websites of organizations devoted to the treatment and awareness of dementia were searched. The quality of evidence was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Two investigators independently scored the relevance of the CGs by means of a specific tool. Descriptive and inferential analyses were performed (Mann-Whitney test, 0.05 α-level).

RESULTS

Twenty-two CGs met our inclusion criteria. On average, the quality of the CGs was higher than 70% in three of six domains measured by the AGREE tool. The domains with lower mean scores (less than 50%) were "Applicability" and "Editorial independence". Considering applicability to older patients, 20 CGs (91%) addressed issues of treatment for older patients, five of them (23%) classified older patients by age, and 13 CGs (60%) addressed issues of comorbidity. Only seven (32%) discussed the quality of evidence for patients with multiple comorbid conditions. Thirteen CGs (60%) reported recommendations for patients with at least one comorbid condition, while seven of them (32%) reported on several comorbid conditions. No statistically significant association between CG quality and relevance to care of older people with or without comorbidity was found (P>0.05).

CONCLUSION

This study showed that dementia CGs poorly address treatment for older patients with comorbidities, regardless of their quality. Therefore, they scarcely satisfy the need of modern clinical practice.

Rationalizing prescribing for older patients with multimorbidity: considering time to benefit

Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.

[Development of clinical practice guidelines for patients with comorbidity and multiple diseases]

La atención a pacientes con comorbilidad y pluripatología supone un reto para cualquier sistema sanitario. Las guías de práctica clínica (GPC) presentan limitaciones cuando se aplican a esta población. El objetivo de este trabajo es realizar una propuesta terminológica y metodológica sobre el abordaje de la comorbilidad y la pluripatología en las GPC. De acuerdo a la revisión bibliográfica efectuada, se sugieren algunas propuestas para su abordaje en las diferentes fases de elaboración de las GPC, con especial atención a la inclusión de los clusters de comorbilidad en las preguntas clínicas iniciales, la incorporación de la evidencia indirecta, el peso de la carga de gestionar la enfermedad para el paciente y su entorno en la formulación de recomendaciones, así como las estrategias de difusión e implementación. Estas propuestas deben desarrollarse en mayor profundidad con la participación de más agentes para disponer de herramientas válidas y útiles en esta población.

Development of clinical practice guidelines for patients with comorbidity and multiple diseases

The management of patients with comorbidity and polypathology represents a challenge for all healthcare systems. Clinical practice guidelines (CPGs) have limitations when applied to this population. The aim of this study is to propose the terminology and methodology for optimally approach comorbidity and polypathology in the CPGs. Based on a literature review, we suggest a number of proposals for the approach in different phases of CPG preparation, with special attention to the inclusion of clusters of comorbidity in the initial questions the implementation of indirect evidence, the burden of disease management for patients and their environment, when establishing recommendations, as well as the strategies of dissemination and implementation. These proposals should be developed in greater depth with the implication of more agents in order to have valid and useful tools for this population.

Guideline compliance in chronic heart failure patients with multiple comorbid diseases: evaluation of an individualised multidisciplinary model of care

OBJECTIVE

To assess the impact of individualised, reconciled evidence-based recommendations (IRERs) and multidisciplinary care in patients with chronic heart failure (CHF) on clinical guideline compliance for CHF and common comorbid conditions.

DESIGN AND SETTING

A retrospective hospital clinical audit conducted between 1st July 2006 and February 2011.

PARTICIPANTS

A total of 255 patients with a diagnosis of CHF who attended the Multidisciplinary Ambulatory Consulting Services (MACS) clinics, at the Royal Adelaide Hospital, were included.

MAIN OUTCOME MEASURES

Compliance with Australian clinical guideline recommendations for CHF, atrial fibrillation, diabetes mellitus and ischaemic heart disease.

RESULTS

Study participants had a median of eight medical conditions (IQR 6-10) and were on an average of 10 (±4) unique medications. Compliance with clinical guideline recommendations for pharmacological therapy for CHF, comorbid atrial fibrillation, diabetes or ischaemic heart disease was high, ranging from 86% for lipid lowering therapy to 98% anti-platelet agents. For all conditions, compliance with lifestyle recommendations was lower than pharmacological therapy, ranging from no podiatry reviews for CHF patients with comorbid diabetes to 75% for heart failure education. Concordance with many guideline recommendations was significantly associated if the patient had IRERs determined, a greater number of recommendations, more clinic visits or if patients participated in a heart failure program.

CONCLUSIONS

Despite the high number of comorbid conditions and resulting complexity of the management, high compliance to clinical guideline recommendations was associated with IRER determination in older patients with CHF. Importantly these recommendations need to be communicated to the patient's general practitioner, regularly monitored and adjusted at clinic visits.

[Care as a cross-cutting element in the health care of complex chronic patients]

The care of people who live with chronic diseases is currently a priority on the roadmaps of all health care services. Within these strategies, there needs to be a specific approach required for a population group that is defined by having multiple diseases and the associated comorbidity. This group is especially vulnerable, fragile, and require very complex care, which uses up a high quantity of social health resources. The estimated prevalence in Spain is 1.4% in the general population, and approximately 5% in people over 64 years. The social and healthcare of this population requires a person-centered approach, as a paradigm of caring for the patients and not of the diseases. The models must leap from the segmented approach to diseases to a holistic and integrated vision, taking into account the social and psycho-affective situation, the experience of the patient, the family context, and the approach of human experience/response that these processes produce. The health professionals need support tools that can guide them and help in making clinical decisions in this population group. The clinical practice guidelines for the approach of patients with co-morbidity and multiple diseases have numerous limitations. Expert recommendations in this sense, lead us to a multidisciplinary approach, with self-care and self-health management as a cross-cutting element of healthcare.

Current and emerging treatment options for the elderly patient with chronic kidney disease

The objective of this article is to review the current and emerging treatments of CKD prior to dialysis in the elderly. Worldwide, there are increasing numbers of people who are aged over 65 years. In parallel, there are increasing numbers of elderly patients presenting with chronic kidney disease (CKD), particularly in the more advanced stages. The elderly have quite different health care needs related to their associated comorbidity, frailty, social isolation, poor functional status, and cognitive decline. Clinical trials assessing treatments for CKD have usually excluded patients older than 70–75 years; therefore, it is difficult to translate current therapies recommended for younger patients with CKD across to the elderly. Many elderly people with CKD progress to end-stage kidney disease and face the dilemma of whether to undertake dialysis or accept a conservative approach supported by palliative care. This places pressure on the patient, their family, and on health care resources. The clinical trajectory of elderly CKD patients has in the past been unclear, but recent evidence suggests that many patients over 75 years of age with multiple comorbidities have greatly reduced life expectancies and quality of life, even if they choose dialysis treatment. Offering a conservative pathway supported by palliative care is a reasonable option for some patients under these circumstances. The elderly person who chooses to have dialysis will frequently have different requirements than younger patients. Kidney transplantation can still result in improved life expectancy and quality of life in the elderly, in carefully selected people. There is a genuine need for the inclusion of the elderly in CKD clinical trials in the future so we can produce evidence-based therapies for this group. In addition, new therapies to treat and slow CKD progression are needed for all age groups.

Managing older patients with coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges

Asthma and chronic obstructive pulmonary disease (COPD) are common obstructive airway diseases, especially among older people. These conditions are associated with a significant and increasing disease burden. The diagnosis and management of asthma and COPD in older populations are complex, and consequently clinicians are faced with many therapeutic and diagnostic challenges. Both aging and obstructive airway diseases are associated with complex co-morbidities and these coexisting illnesses confound management. Moreover, the age-related physiological changes that occur in the lungs may lead to airflow limitation, and this may be difficult to distinguish from an active disease state. In practice, management of asthma and COPD is informed by disease-specific clinical practice guidelines; however, most older people with these conditions are excluded from clinical trials that are designed to inform practice, creating major evidence gaps. Furthermore, seldom do clinical practice guidelines consider the complexities of management in older populations. The problems experienced by older people are complex and multifactorial and our approach to management must reflect these challenges. Opportunities exist to improve the management and outcomes for older people with obstructive airway disease and there is an urgent need for clinical trials to test management approaches in this population; current research must consider the challenges and evidence gaps that exist.

The willingness of informal caregivers to assist their care-recipient to use Home Medicines Review

Objectives

Informal caregivers experience daily hassles – a form of persistent stress, as a consequence of caregiving. This study aimed to develop and test a new theoretical model of health information‐seeking behaviour, the Knowledge Hassles Information Seeking Model (KHISM). KHISM hypothesized that the knowledge hassles of caregivers – daily stressors experienced while dealing with tasks which require knowledge about the safety and effectiveness of the care‐recipients' medicines – would influence caregivers' willingness to assist their care‐recipient to use an Australian medication management service, Home Medicines Review (HMR).

Methods

A cross‐sectional postal survey was conducted among 2350 members of Carers (NSW, Australia). Respondents were included in the study if they were involved in medication‐related tasks for their care‐recipient and were not paid as caregivers. Also, their care‐recipient needed to be taking more than five medicines daily or more than 12 doses daily and had not yet experienced HMR. Structural equation modelling was used to test the model.

Results

A total of 324 useable surveys were returned yielding a response rate of 14%. Respondents were quite willing to assist their care‐recipient to use HMR (willingness). The model predicted 51% of the variation in willingness. Knowledge hassles increased positive outcome expectancy (β = 0.40, P < 0.05) and indirectly increased willingness.

Conclusions

The more caregivers experience hassles with medication knowledge, the more they perceive HMR to be a helpful information source and the more willing they are to use it. Targeted marketing centred on HMR as an information source may increase caregivers' demand for HMR. Further exploration of the phenomenon of knowledge hassles is warranted.

An evaluation of web-based clinical practice guidelines for managing problems associated with cannabis use

BACKGROUND

Cannabis is the most widely used illicit substance, and multiple treatment options and avenues exist for managing its use. There has been an increase in the development of clinical practice guidelines (CPGs) to improve standards of care in this area, many of which are disseminated online. However, little is known about the quality and accessibility of these online CPGs.

OBJECTIVE

The purpose of study 1 was to determine the extent to which cannabis-related CPGs disseminated online adhere to established methodological standards. The purpose of study 2 was to determine if treatment providers are familiar with these guidelines and to assess their perceived quality of these guidelines.

METHODS

Study 1 involved a systematic search using the Google Scholar search engine and the National Drugs Sector Information Service (NDSIS) website of the Alcohol and Other Drugs Council of Australia (ADCA) to identify CPGs disseminated online. To be included in the current study, CPGs needed to be free of charge and provide guidance on psychological interventions for reducing cannabis use. Four trained reviewers independently assessed the quality of the 7 identified guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Study 2 assessed 166 Australian cannabis-use treatment providers' (mean age = 45.47 years, SD 12.14) familiarity with and opinions of these 7 guidelines using an online survey. Treatment providers were recruited using online advertisements that directed volunteers to a link to complete the survey, which was posted online for 6 months (January to June 2012). Primary study outcomes included quality scores and rates of guideline familiarity, guideline use, and discovery methods.

RESULTS

Based on the AGREE II, the quality of CPGs varied considerably. Across different reporting domains, adherence to methodological standards ranged from 0% to 92%. Quality was lowest in the domains of rigor of development (50%), applicability (46%), and editorial independence (30%). Although examination of AGREE II domain scores demonstrated that the quality of the 7 guidelines could be divided into 3 categories (high quality, acceptable to low quality, and very low quality), review of treatment providers' quality perceptions indicated all guidelines fell into 1 category (acceptable quality). Based on treatment providers' familiarity with and usage rates of the CPGs, a combination of peer/colleagues, senior professionals, workshops, and Internet dissemination was deemed to be most effective for promoting cannabis use CPGs. Lack of time, guideline length, conflicts with theoretical orientation, and prior content knowledge were identified as barriers to guideline uptake.

CONCLUSIONS

Developers of CPGs should improve their reporting of development processes, conflicts of interest, and CPGs' applicability to practice, while remaining cognizant that long guidelines may deter implementation. Treatment providers need to be aware that the quality of cannabis-related CPGs varies substantially.

A scoping review and thematic classification of patient complexity: offering a unifying framework

The path to improving healthcare quality for individuals with complex health conditions is complicated by a lack of common understanding of complexity. Modern medicine, together with social and environmental factors, has extended life, leading to a growing population of patients with chronic conditions. In many cases, there are social and psychological factors that impact treatment, health outcomes, and quality of life. This is the face of complexity. Care challenges, burden, and cost have positioned complexity as an important health issue. Complex chronic conditions are now being discussed by clinicians, researchers, and policy-makers around such issues as quantification, payment schemes, transitions, management models, clinical practice, and improved patient experience. We conducted a scoping review of the literature for definitions and descriptions of complexity. We provide an overview of complex chronic conditions, and what is known about complexity, and describe variations in how it is understood. We developed a Complexity Framework from these findings to guide our approach to understanding patient complexity. It is critical to use common vernacular and conceptualization of complexity to improve service and outcomes for patients with complex chronic conditions. Many questions still persist about how to develop this work with a health and social care lens; our framework offers a foundation to structure thinking about complex patients. Further insight into patient complexity can inform treatment models and goals of care, and identify required services and barriers to the management of complexity. Journal of Comorbidity 2012;2:1-9.

Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method

OBJECTIVE

To further develop and validate previously published national prescribing appropriateness criteria to assist in identifying drug-related problems (DRPs) for commonly occurring medications and medical conditions in older (≥65 years old) Australians.

DESIGN

RAND/UCLA appropriateness method.

PARTICIPANTS

A panel of medication management experts were identified consisting of geriatricians/pharmacologists, clinical pharmacists and disease management advisors to organisations that produce Australian evidence-based therapeutic publications. This resulted in a round-one panel of 15 members, and a round-two panel of 12 members.

MAIN OUTCOME MEASURE

Agreement on all criteria.

RESULTS

Forty-eight prescribing criteria were rated. In the first rating round via email, there was disagreement regarding 17 of the criteria according to median panel ratings. During a face-to-face second round meeting, discussion resulted in retention of 25 criteria after amendments, agreement for 14 criteria with no changes required and deletion of 9 criteria. Two new criteria were added, resulting in a final validated list of 41 prescribing appropriateness criteria. Agreement after round two was reached for all 41 criteria, measured by median panel ratings and the amount of dispersion of panel ratings, based on the interpercentile range.

CONCLUSIONS

A set of 41 Australian prescribing appropriateness criteria were validated by an expert panel. Use of these criteria, together with clinical judgement and other medication review processes such as patient interview, is intended to assist in improving patient care by efficiently detecting potential DRPs related to commonly occurring medicines and medical conditions in older Australians. These criteria may also contribute to the medication management education of healthcare professionals.

Exploring patients' motivation to participate in Australia's Home Medicines Review program

BACKGROUND

Patients at risk of experiencing medicine-related problems do not always appear willing to participate in collaborative medication management services. Little is known about the psycho-social factors which motivate patients to participate in these services. The theory of motivated information management (TMIM) suggests that patients' willingness to participate may be motivated by their uncertainty and worry about their medicines.

OBJECTIVE

The objective of this study was to investigate factors which may motivate patients to participate in a collaborative medication management program.

SETTING

Fourteen semi-structured focus group interviews held throughout Australia provided the data for the study. Eighty participants were recruited by community pharmacists. Participants were recruited into the study if they had experienced Australia's Home Medicines Review (HMR) program or would be eligible to participate in the program because they were at risk of experiencing medicine-related problems. Methods An interview guide was developed which was informed by TMIM. Focus group data were audio-recorded, transcribed and where necessary, translated into English.

MAIN OUTCOME MEASURE

Qualitative data were thematically analysed to identify participants' expectations about the outcomes of HMR and the factors which may influence these expectations.

RESULTS

Participants' most salient outcome expectancies of HMR were that it was a medication-information source which would assist them to manage their medicines. Recipients of the program held overall positive outcome expectancies, whereas nonrecipients' expectancies varied widely. Consistent with theory, participants who expressed some worry about their medicines, generally held positive outcome expectancies and were willing to participate in HMR. Compared with younger participants, older participants (those aged >74 years) tended to engage less in their thoughts about being at risk, and consequently did not experience worry.

CONCLUSION

Worry about medicines is a key factor in motivating participants to engage in medicines information-seeking. Older persons who rely heavily on heuristics appeared less likely to worry about their medicines and willing to participate in medication management services. Age-related reduction in the motivation to participate may have important implications for medication safety. Further examination of this effect is warranted because older persons are at greatest risk of medicine related problems.

Ageing well: improving the management of patients with multiple chronic health problems

AIM

To identify and evaluate the management and care of older people with multiple chronic health problems (MCHP).

METHODS

Administrative health data from the Department of Veterans' Affairs and bio-social data from the Australian Longitudinal Study of Ageing are used to determine prevalence of MCHP, treatment patterns and patient outcomes. Focus groups and semistructured interviews are used to gain patient and health practitioner perspectives.

RESULTS

The prevalence of MCHP in older people is high (65%) and is associated with increased use of health services, mortality and poorer self-rated health. Australian disease-specific guidelines fail to address MCHP, and treatment conflicts with the potential to cause harm, were common.

CONCLUSION

Improvements in the care and management of older people with MCHP requires: a multifaceted approach, across the health-care system; better coordination of holistic, patient-centred multidisciplinary care; and effective communication and education of all stakeholders. The Health reform agenda in Australia provides an opportunity for change.