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Journal Club CUMG – 16.12.2005

Qualité d’utilisation des médicaments en gériatrie:

Etude qualitative

Spinewine A, Swine C, Dhillon S, Dean Franklin B, Tulkens PM, Wilmotte L, Lorant V.

British Medical Journal 2005;331:935-8

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1. Introduction

• Drug-related problems (DRPs) in older persons– 5-17% of hospital admissions < preventable adverse drug reactions– Medicines are frequently overused/misused/underuse – 50% of older people may not be taking their medicines as intended– Poor 2-way communication between hospitals and primary care

• Reasons underlying inappropriate use of medicines in frail elderly patients???– CAUSES???

proposal for adequate optimisation strategies

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2. Objectives

• To explore the processes leading to (in)appropriate use of medicines for older patients admitted on geriatric wards

– Prescribing– Counseling– Information given to the general practitioner at discharge

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Qualitative research in health care

• Sample – small and purposive large, random

• Approach: – often exploratory work: “how” and “why” how many?– hypothesis generating testing

• Methods– interviews, observation, documents survey, RCT

• Analysis: qualitative quantitative

quantitative

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3.1. Study design and sampling strategy

Sample (purposive) Method

• HCPs– Doctors (5)– Pharmacists (3)– Nurses (4)

• 1/1 interviews

(semi-structured)

• Patients (17) • Group interviews (focus groups)

• Geriatric wards (2) • Observation (participant)

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3.1. Study design and sampling strategy

• Geriatric wards (2) • Observation

Sample (purposive) Method

• HCPs– Doctors (5)– Pharmacists (3)– Nurses (4)

• 1/1 interviews

(semi-structured)

• Patients (17) • Group interviews (focus groups)

Rationale:

- To overcome the discrepancy between what people say and what they actually do

- To uncover behaviors or routines of which the participants themselves may be unaware

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3.2. Data processing and analysis

1. Close and repeated reading of transcripts (2 researchers) development of coding framework

- open coding- axial coding- conceptual orientation

2. Themes validated by discussion among all authors after independent reading of a sample of transcripts

3. Coding all transcripts (1 person + check for reliability)

4. Analysis, interpretation (research team)

- intra-node, inter-node – node combinations patterns- data from interviews versus data from other sources- differences/similarities between categories of participants

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FREE CODING AXIAL CODING

Process for coding: Categories contributing to inappropriate drug use – from free coding to axial coding

- Knowledge gap- Lack of time- Lack of resources- …

Rather descriptive More analytical

-Anticipating inefficiency in searching drug information- Prospective attitude- Caring by conservatism/reflexivity- Agency- Patient resisting to change- Shared decision making- Patient’s willingness to know not elicited- Tailoring prescribing behavior to the elderly- Uneasy at working for unknown medications anchoring- …

- Anticipating inefficiency- Lack of systematic and proactive attitude- Gap in knowledge and geriatric skills- Patient reluctance versus poor concordance- Deviance from agreed treatment objectives for reasons unrelated to the patient

Not satisfactory because does not really explain the reason why quality of drug use is not optimal

Key words or topics identified:

-Pay attention to…- Systematic procedure…- Learning- Take time to…- Relation with other prescribers- Patient attached or reluctant- …

Validation: See next page

Further minor modifications

- Patient-related issues- Physician-related- Relation patient-physician

- Anchoring in acute care and short-term treatment- Passive attitude towards learning outcomes- Paternalistic decision-makingSeveral readings and

modifications in analytical codes

THEN axial coding

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4. Results

• 3 main categories of factors underlying inappropriate use of medicines

• Several factors that promoted a better use of medicines

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4. Results

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4. Results

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4. Results

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4. Results

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4. Results

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4. Results

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4. Results

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4. Results

• Multidisciplinary team• Identification of drug-related problems by team

members (nurse, physiotherapist,…) communication to the prescriber

• Input of geriatricians

« one size fits all »

• Factors leading to a BETTER use of medicines

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5. Conclusion

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6. Discussion

• Strengths of the study– Topical issue; not previously investigated – Triangulation

• Results– « New » and « already known » factors

• Weaknesses– Generalisability– Researcher-respondent interaction (Hawthorne

effect)

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6. Discussion

• Recommendations on strategies for improvement• Incentives for « chronic considerations » in acute care• Active learning in geriatrics by junior doctors• Systems for reliable transfer of information between

care settings patient involvement• Promote constructive communication between

prescribers• Encourage active multidisciplinary communication and

input of geriatricians• Collaboration with clinical pharmacists

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7. Reflective practice

• “Qualitative” does not mean “less rigorous”• Time-consuming!• Multidisciplinary research team

– crucial (especially for developing coding framework, and interpreting the results)

• N-Vivo enhances rigor in analysis (+ facilitates)

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7. Reflective practice: writing up

• Use of relevant literature– Background knowledge– Guidelines to conduct qualitative studies– Past issues of the journals (qualitative research), review

• Take time to reflect on your work – Before and after data collection– Before submission– When receiving comments by the reviewers…

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8. Acknowledgments

• All participants to interviews and observations

• D Paulus and JM Feron (UCL, CUMG)• F Smith (UK, London)• S Arman (UCL, observations)

• Fonds National de la Recherche Scientifique