GPs’ management of polypharmacy and therapeutic dilemma in patients with multimorbidity: a cross-sectional survey of GPs in France

Carrier, Hélène; Zaytseva, Anna; Bocquier, Aurélie; Villani, Patrick; Verdoux, Hélène; Fortin, Martin; Verger, Pierre

doi:10.3399/bjgp19x701801

Cited by 20 publications

(41 citation statements)

References 27 publications

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“…While this study fits in with other research focusing on barriers and facilitators to deprescribing preventive medication (13,15,16,29,30,33,34,(36)(37)(38)(39)(40)(41), it focuses on gaps in GPs' in-practice knowledge and practice related to deprescribing antihypertensives, drawing on thinking around mindlines. Within the interview study, the use of chart-stimulated recall can add to the specificity of interview data and facilitate deeper reflection in participants (50).…”

Section: Strengths and Limitationsmentioning

confidence: 66%

“…With little information on the safety and efficacy of medication reduction, increased interest in deprescribing for older patients (16,(28)(29)(30)(31)(32)(33)(34) has had minimal impact on clinical practice (30,32,35,36). To date, studies have focused on barriers and facilitators to deprescribing preventive medication (13,15,16,29,30,34,(36)(37)(38)(39)(40)(41). What has received far less attention is: what shapes the decision-making of GPs at the sharp end in managing hypertension in frail older patients; how frameworks of knowledge are, individually and collectively, being created and maintained in response to increased attention towards polypharmacy concerns; and how GPs might learn from these in developing their own decision-making in this area.…”

Section: Introductionmentioning

confidence: 99%

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GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

et al. 2020

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Background: Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines – tacit, internalised guidelines developed over time from multiple sources – may be of particular importance in such situations. Aim: To explore GPs’ decision-making on deprescribing antihypertensives in multimorbid patients over 80 years old, drawing on the concept of mindlines. Design: Qualitative interview study. Setting: English general practice. Methods: Thematic analysis of face-to-face interviews with a sample of 15 GPs from 7 practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older multimorbid patients with hypertension. Results: GPs are typically confident making decisions to deprescribe antihypertensive medication in older multimorbid patients when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. Conclusion: In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practice-based experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing, and may be strengthened through reflective practice.

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Section: Strengths and Limitationsmentioning

confidence: 66%

Section: Introductionmentioning

confidence: 99%

GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

et al. 2020

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“…A total of 2 165 abstracts and 362 full‐text articles were assessed. Thirty‐two papers 14‐45 (25 qualitative, 5 quantitative, and 2 mixed‐methods) met the inclusion criteria (see Figure 1 for the flow diagram).…”

Section: Resultsmentioning

confidence: 99%

“…Generally, GPs treasure the availability of guidelines because they provide guidance to medical decision‐making, but at the same time, they express a feeling of restraint 30,33,37 . They are aware that their strict application in the case of multimorbidity is not only difficult but even potentially counterproductive or dangerous for the patient 18,25,26,29,30,33,40 . Indeed, single disease guidelines can be conflicting, which impedes using several guidelines for a given patient 25 .…”

Section: Resultsmentioning

confidence: 99%

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

et al. 2021

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Background Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow‐up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. Methods A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed‐methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. Results A total of 2 165 abstracts and 362 full‐text articles were assessed. Thirty‐two studies met the inclusion criteria. Results showcased that GPs’ clinical reasoning during the long‐term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients’ constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. Conclusions Although the challenges GPs are facing in the long‐term follow‐up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs’ clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

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“…We conducted a cross-sectional survey about the management of patients with multimorbidity and polypharmacy, nested in a panel of GPs in private practice in France. The panel design has been described in previous publications [17,18]. In brief, we randomly selected GPs from the exhaustive French database of health professionals (Répertoire Partagé des Professionnels de Santé) between December 2013 and March 2014.…”

Section: Design and Populationmentioning

confidence: 99%

General Practitioners' Propensity to Cooperate With Other Health Professionals in the Management of Patients With Multimorbidity and Polypharmacy: A Cross-sectional Study.

Carrier¹,

Zaytseva²,

Bocquier³

et al. 2020

Preprint

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Abstract Background. Cooperation between general practitioners (GPs) and other health professionals appears to help reduce the risk of adverse events linked to polypharmacy for patients with multimorbidity. We investigated the existence of different GP profiles according to their opinions and behaviors about such cooperation and studied the association between these profiles and the GPs’ characteristics and deprescribing behaviors.Methods. Between May and July 2016, we performed a cross-sectional survey in a panel of French GPsabout their management of patients with multimorbidity and polypharmacy, focusing specifically on their opinions of healthcare professionals’ roles and interprofessional cooperation. We used an agglomerative hierarchical cluster analysis to identify GP profiles and then multivariable logistic regression models to study their associations with these doctors' characteristics and deprescribing behaviors.Results. We identified four profiles of GPs according to their cooperation propensities: GPs from the “intensive” profile (14%) were favorable to cooperating with various health professionals, including delegating some prescribing tasks to pharmacists; GPs from the "moderate" profile (47%) had favorable opinions about health professionals’ roles, except for this specific task delegation; GPs from the "selective" profile (27%) tended to work only with physicians; GPs from the "low cooperation" profile (12%) didn’t appeared interested in cooperation. These profiles were associated with different professional characteristics.Conclusions. Current health policies encourage interprofessional cooperation for the management of patients with multimorbidity. Our study provides information for understanding disparities among GPs regarding working with other professionals who deal with their patients and suggests possible ways to improve cooperation.

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GPs’ management of polypharmacy and therapeutic dilemma in patients with multimorbidity: a cross-sectional survey of GPs in France

Cited by 20 publications

References 27 publications

GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

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

General Practitioners' Propensity to Cooperate With Other Health Professionals in the Management of Patients With Multimorbidity and Polypharmacy: A Cross-sectional Study.

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