What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care

Abstract

BackgroundUsing clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications. AimTo explore how GPs make decisions when prescribing for multimorbid patients, with a view to informing intervention design. Design and settingIn-depth qualitative interviews incorporating chart-stimulated recall with purposively sampled GPs in the Republic of Ireland. MethodGrounded theory analysis with iterative theory development. ResultsTwenty GPs were interviewed about 51 multimorbid cases. In these cases, GPs integrated information from multiple sources including the patient, specialists, and evidencebased medicine. Difficulties arose when recommendations or preferences conflicted, to which GPs responded by 'satisficing': accepting care that they deemed satisfactory and sufficient for a particular patient. Satisficing was manifest as relaxing targets for disease control, negotiating compromise with the patient, or making 'best guesses' about the most appropriate course of action to take. In multimorbid patients perceived as stable, GPs preferred to 'maintain the status quo' rather than rationalise medications, even in cases with significant polypharmacy. Proactive changes in medications were facilitated by continuity of care, sufficient consultation time, and open lines of communication with the patient, other healthcare professionals, and other GPs. ConclusionGPs respond to conflicts in the management of multimorbid patients by making compromises between patient-centred and evidence-based care. These findings will be used to inform interventions that aim to care in multimorbidity.

Medication management strategy for older people with polypharmacy in general practice: a qualitative study on prescribing behaviour in primary care

“…The themes were integrated into the clinical vignette survey, and concerned 'patient complexity' and 'treatment goals/strategy', as these concepts were both considered as influencing GPs' management. 12,18,22 Concerning decision support, no a priori themes were defined. After the first meeting, the audio-tape was transcribed verbatim.…”

“…Contrary to the methods chosen in previous studies, 11,12,17,18,22,29,30 this study incorporated the assessment of case vignettes based on fictitious patients into focus group sessions, which yielded information about variation in medication adjustments between GPs, as well as considerations for the choices made. This study therefore clearly showed that, for similar patients, GPs executed their medication management strategy quite differently.…”

Person-centred medicines optimisation policy in England: an agenda for research on polypharmacy

“…A recent study in Ireland of how general practitioners make compromises when prescribing for patients with multimorbidity is a helpful contribution to knowledge in this regard (Sinnott, Mc Hugh, Boyce and Bradley 2015).…”

Prescribing for patients with multimorbidity: aiming to tailor to patient-set goals

“…They describe this decision-making process as 'satisficing', where doctors accept care that is satisfactory and sufficient for particular patients. 12 The study opens the 'black box' on what is going on in the mechanism of prescribing decisions in complex situations, revealing the tacit processes. It is a substantial contribution to the body of evidence that promises to emerge to guide professionals and patients on how best to prescribe in multimorbidity.…”

“…Making such tacit ideas explicit is important in developing skills to care for patients with multimorbidity, for the education of professionals caring for them, and to be able to maintain accountability by more accurately documenting the rationale behind decisions made. 11 Sinnott et al's rigorously conducted qualitative study, which appears in this issue, 12 seeks to understand how GPs make prescribing decisions in patients with multimorbidities. They describe this decision-making process as 'satisficing', where doctors accept care that is satisfactory and sufficient for particular patients.…”