Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing

Cathal A Cadogan, Cristín Ryan, Jill J Francis, Gerard J Gormley, Peter Passmore, Ngaire Kerse, Carmel M Hughes, Cathal A Cadogan, Cristín Ryan, Jill J Francis, Gerard J Gormley, Peter Passmore, Ngaire Kerse, Carmel M Hughes

Abstract

Background: The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.

Methods: Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs' perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.

Results: Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: 'Skills', 'Beliefs about capabilities', 'Beliefs about consequences', 'Environmental context and resources', 'Memory, attention and decision processes', 'Social/professional role and identity', 'Social influences' and 'Behavioural regulation'. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: 'Action planning', 'Prompts/cues', 'Modelling or demonstrating of behaviour' and 'Salience of consequences'. An additional BCT ('Social support or encouragement') was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.

Conclusions: Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.

References

    1. Sumukadas D, McMurdo MET, Mangoni AA, Guthrie B. Temporal trends in anticholinergic medication prescription in older people: repeated crosssectional analysis of population prescribing data. Age Ageing. 2014;43(4):515–21. doi: 10.1093/ageing/aft199.
    1. Hovstadius B, Hovstadius K, Astrand B, Petersson G. Increasing polypharmacy—an individual-based study of the Swedish population 2005–2008. BMC Clin Pharmacol. 2010;10:16. doi: 10.1186/1472-6904-10-16.
    1. Hughes C, Cooper JA, Ryan C. Going beyond the numbers—a call to redefine polypharmacy. Br J Clin Pharmacol. 2014;77(6):915–6. doi: 10.1111/bcp.12284.
    1. Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol. 2010;69(5):543–52. doi: 10.1111/j.1365-2125.2010.03628.x.
    1. Bradley MC, Fahey T, Cahir C, Bennett K, O’Reilly D, Parsons C, Hughes CM. Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database. Eur J Clin Pharmacol. 2012;68(10):1425–33. doi: 10.1007/s00228-012-1249-y.
    1. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57–65. doi: 10.1517/14740338.2013.827660.
    1. Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3(2):383–9.
    1. Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol. 2014;77(6):1073–82. doi: 10.1111/bcp.12292.
    1. Appleton SC, Abel GA, Payne RA. Cardiovascular polypharmacy is not associated with unplanned hospitalisation: evidence from a retrospective cohort study. BMC Fam Pract. 2014;15:58. doi: 10.1186/1471-2296-15-58.
    1. The King’s Fund . Polypharmacy and medicines optimisation: making it safe and sound. London: The King’s Fund; 2013.
    1. Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014;10:CD008165.
    1. Medical Research Council . Developing and evaluating complex interventions: new guidance. London: Medical Research Council; 2008.
    1. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26–33. doi: 10.1136/qshc.2004.011155.
    1. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles M, Cane J, Wood C. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81–95. doi: 10.1007/s12160-013-9486-6.
    1. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;57(4):660–80. doi: 10.1111/j.1464-0597.2008.00341.x.
    1. Cane J, Richardson M, Johnston M, Ladha R, Michie S. From lists of behaviour change techniques (BCTs) to structured hierarchies: comparison of two methods of developing a hierarchy of BCTs. Br J Health Psychol. 2015;20(1):130–50. doi: 10.1111/bjhp.12102.
    1. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37. doi: 10.1186/1748-5908-7-37.
    1. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, Buchbinder R, Schattner P, Spike N, Grimshaw JM. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012;7:38. doi: 10.1186/1748-5908-7-38.
    1. Murphy K, O’Connor DA, Browning CJ, French SD, Michie S, Francis JJ, Russell GM, Workman B, Flicker L, Eccles MP, Green SE. Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework. Implement Sci. 2014;9:31. doi: 10.1186/1748-5908-9-31.
    1. Bussieres AE, Patey AM, Francis JJ, Sales AE, Grimshaw JM. Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework. Implement Sci. 2012;7:82. doi: 10.1186/1748-5908-7-82.
    1. Hughes LD, McMurdo MET, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing. 2013;42(1):62–9. doi: 10.1093/ageing/afs100.
    1. Duncan EM, Francis JJ, Johnston M, Davey P, Maxwell S, McKay GA, McLay J, Ross S, Ryan C, Webb DJ, Bond C, Study Group P. Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. Implement Sci. 2012;7:86. doi: 10.1186/1748-5908-7-86.
    1. Huijg JM, Gebhardt WA, Crone MR, Dusseldorp E, Presseau J. Discriminant content validity of a theoretical domains framework questionnaire for use in implementation research. Implement Sci. 2014;9:11. doi: 10.1186/1748-5908-9-11.
    1. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Analyzing qualitative data. London;Routledge, 1994.
    1. Francis JJ, Stockton C, Eccles MP, Johnston M, Cuthbertson BH, Grimshaw JM, Hyde C, Tinmouth A, Stanworth SJ. Evidence-based selection of theories for designing behaviour change interventions: using methods based on theoretical construct domains to understand clinicians’ blood transfusion behaviour. Br J Health Psychol. 2009;14(Pt 4):625–46. doi: 10.1348/135910708X397025.
    1. Denzin N. The research act: a theoretical introduction to sociological methods. 3. New York: Transaction Publishers: McGraw-Hill; 1989.
    1. Francis JJ, O’Connor D, Curran J. Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implement Sci. 2012;7:35. doi: 10.1186/1748-5908-7-35.
    1. Hrisos S, Eccles M, Johnston M, Francis J, Kaner EFS, Steen N, Grimshaw J. Developing the content of two behavioural interventions: using theory-based interventions to promote GP management of upper respiratory tract infection without prescribing antibiotics #1. BMC Health Serv Res. 2008;8:11. doi: 10.1186/1472-6963-8-11.
    1. Squires JE, Sullivan K, Eccles MP, Worswick J, Grimshaw JM. Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews. Implement Sci. 2014;9:152. doi: 10.1186/s13012-014-0152-6.
    1. Cuthbertson BH, Campbell MK, MacLennan G, Duncan EM, Marshall AP, Wells EC, Prior ME, Todd L, Rose L, Seppelt IM, Bellingan G, Francis JJ. Clinical stakeholders’ opinions on the use of selective decontamination of the digestive tract in critically ill patients in intensive care units: an international Delphi study. Crit Care. 2013;17(6):R266. doi: 10.1186/cc13096.
    1. Huijg JM, Gebhardt W a, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJC, Crone MR. Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework. Implement Sci. 2014;9:33. doi: 10.1186/1748-5908-9-33.
    1. Phillips CJ, Marshall AP, Chaves NJ, Jankelowitz SK, Lin IB, Loy CT, Rees G, Sakzewski L, Thomas S, To TP, Wilkinson SA, Michie S. Experiences of using the Theoretical Domains Framework across diverse clinical environments: a qualitative study. J Multidiscip Healthc. 2015;8:139–46.
    1. Cullinan S, Fleming A, O’Mahony D, Ryan C, O’Sullivan D, Gallagher P, Byrne S. Doctors’ perspectives on the barriers to appropriate prescribing in older hospitalized patients: a qualitative study. Br J Clin Pharmacol. 2015;79(5):860–9. doi: 10.1111/bcp.12555.
    1. Mazza D, Petrovic K, Grech C, Harris N. HPV vaccination in women aged 27 to 45 years: what do general practitioners think? BMC Womens Health. 2014;14:91. doi: 10.1186/1472-6874-14-91.
    1. Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ Qual Saf. 2015;24:228–38. doi: 10.1136/bmjqs-2014-003627.
    1. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4:e006544. doi: 10.1136/bmjopen-2014-006544.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner