Colin P Bradley

Using Reflexivity to Optimize Teamwork in Qualitative Research

Reflexivity is often described as an individual activity. The authors propose that reflexivity employed as a team activity, through the sharing of reflexive writing (accounts of personal agendas, hidden assumptions, and theoretical definitions) and group discussions about arising issues, can improve the productivity and functioning of qualitative teams and the rigor and quality of the research. The authors review the literature on teamwork, highlighting benefits and pitfalls, and define and discuss the role for reflexivity. They describe their own team and detail how they work together on a project investigating doctor-patient communication about prescribing. The authors present two reflexive tools they have used and show through examples how they have influenced the effectiveness of their team in terms of process, quality, and outcome.

Uncomfortable prescribing decisions: a critical incident study.

OBJECTIVE--To explore the discomfort experienced by general practitioners in relation to decisions about whether or not to prescribe. DESIGN--Focused interviews of general practitioners about prescribing decisions that made them uncomfortable. Analysis based on the critical incident technique. SETTING--One family practitioner committee area in the north of England. RESPONDENTS--69 principals and five trainee general practitioners. MAIN OUTCOME MEASURES--Drugs and clinical problems associated with prescribing discomfort. Reasons given by doctors for making the prescribing decisions they did and reasons for feeling uncomfortable. RESULTS--Antibiotics, tranquillisers, hypnotics, and symptomatic remedies were most often associated with discomfort, but any prescribable item could be associated with discomfort. Respiratory diseases, musculoskeletal problems, and anxiety were most often associated with discomfort, but again any condition could be associated. The main reasons given for the decisions made were patient expectation, clinical appropriateness, factors related to the doctor-patient relationship, and precedents. The main reasons given for feeling uncomfortable were concern about drug toxicity, failure to live up to the general practitioners own expectations, concern about the appropriateness of treatment, and ignorance or uncertainty. CONCLUSIONS--Many considerations, including medical, social, and logistic ones, influence the decision to prescribe in general practice. The final action taken depends on a complex interaction of these disparate influences.

Patients, society, and the increase in self medication

Self medication with over the counter medicines has long been a feature of the lay health system. With the reclassification of certain drugs, the public can buy preparations that were previously available only prescription. Sales of over the counter medicines are now equivalent to a third of the NHS drugs bill; governments throughout the world see self medication as a way of shifting some of the cost of health care onto consumers. The trend towards increased self care and with it the increasing empowerment of patients has many potential benefits; collaboration between doctors and pharmacists will be critical.

GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research

Objective To synthesise the existing published literature on the perceptions of general practitioners (GPs) or their equivalent on the clinical management of multimorbidity and determine targets for future research that aims to improve clinical care in multimorbidity. Design Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore GPs’ experiences of clinical management of multimorbidity or multiple chronic diseases. Data sources EMBASE, MEDLINE, CINAHL, PsycInfo, Academic Search Complete, SocIndex, Social Science Full Text and digital theses/online libraries (database inception to September 2012) to identify literature using qualitative methods (focus groups or interviews). Review methods The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data. Results Of 1805 articles identified, 37 were reviewed in detail and 10 were included, using a total of 275 GPs in 7 different countries. Four areas of difficulty specific to the management of multimorbidity emerged from these papers: disorganisation and fragmentation of healthcare; the inadequacy of guidelines and evidence-based medicine; challenges in delivering patient-centred care; and barriers to shared decision-making. A ‘line of argument’ was drawn which described GPs’ sense of isolation in decision-making for multimorbid patients. Conclusions This systematic review shows that the problem areas for GPs in the management of multimorbidity may be classified into four domains. There will be no ‘one size fits all’ intervention for multimorbidity but these domains may be useful targets to guide the development of interventions that will assist and improve the provision of care to multimorbid patients.

A review of self-medication in physicians and medical students

BACKGROUND There is a culture within medicine that doctors do not expect themselves or their colleagues to be sick. Thus, the associated complexities of self-diagnosis, self-referral and self-treatment among physicians are significant and may have repercussions for both their own health and, by implication, for the quality of care delivered to patients. AIMS To collate what is known about the self-treatment behaviour of physicians and medical students. METHODS The following databases were searched: PubMed, PsychInfo, EBSCO, Medline, BioMed central and Science Direct. Inclusion criteria specified research assessing self-treatment and self-medicating of prescription drugs among physicians and/or medical students. Only peer-reviewed English language empirical studies published between 1990 and 2009 were included. RESULTS Twenty-seven studies were identified that fitted the inclusion criteria. Self-treatment and self-medicating was found to be a significant issue for both physicians and medical students. In 76% of studies, reported self-treatment was >50% (range: 12-99%). Overall, only one of two respondents was registered with a general practitioner or primary care physician (mean = 56%, range = 21-96). Deeper analysis of studies revealed that physicians believed it was appropriate to self-treat both acute and chronic conditions and that informal care paths were common within the medical profession. CONCLUSIONS Self-treatment is strongly embedded within the culture of both physicians and medical students as an accepted way to enhance/buffer work performance. The authors believe that these complex self-directed care behaviours could be regarded as an occupational hazard for the medical profession.

Primary care—opportunities and threats: developing prescribing in primary care

Abstract The latest white papers on the NHS focus on stimulating innovation in the delivery of primary care and removing barriers to further development. Some of this innovation relates directly to prescribing in primary care, and in this article the authors speculate on what might happen if the prescribing initiatives referred to in the white papers were extended and disseminated more widely. The initiatives which might have the biggest impact are those encouraging closer collaboration between general practitioners and community pharmacists and those aiding extension of the current nurse prescribing scheme in primary care. Both offer considerable opportunities to improve primary care, but both bear some potential risks.

The effect of copayments for prescriptions on adherence to prescription medicines in publicly insured populations; a systematic review and meta-analysis.

Introduction Copayments are intended to decrease third party expenditure on pharmaceuticals, particularly those regarded as less essential. However, copayments are associated with decreased use of all medicines. Publicly insured populations encompass some vulnerable patient groups such as older individuals and low income groups, who may be especially susceptible to medication non-adherence when required to pay. Non-adherence has potential consequences of increased morbidity and costs elsewhere in the system. Objective To quantify the risk of non-adherence to prescribed medicines in publicly insured populations exposed to copayments. Methods The population of interest consisted of cohorts who received public health insurance. The intervention was the introduction of, or an increase, in copayment. The outcome was non-adherence to medications, evaluated using objective measures. Eight electronic databases and the grey literature were systematically searched for relevant articles, along with hand searches of references in review articles and the included studies. Studies were quality appraised using modified EPOC and EHPPH checklists. A random effects model was used to generate the meta-analysis in RevMan v5.1. Statistical heterogeneity was assessed using the I2 test; p>0.1 indicated a lack of heterogeneity. Results Seven out of 41 studies met the inclusion criteria. Five studies contributed more than 1 result to the meta-analysis. The meta-analysis included 199, 996 people overall; 74, 236 people in the copayment group and 125,760 people in the non-copayment group. Average age was 71.75years. In the copayment group, (verses the non-copayment group), the odds ratio for non-adherence was 1.11 (95% CI 1.09–1.14; P = <0.00001). An acceptable level of heterogeneity at I2 = 7%, (p = 0.37) was observed. Conclusion This meta-analysis showed an 11% increased odds of non-adherence to medicines in publicly insured populations where copayments for medicines are necessary. Policy-makers should be wary of potential negative clinical outcomes resulting from non-adherence, and also possible knock-on economic repercussions.

Trends in the incidence of lower extremity amputations in people with and without diabetes over a five-year period in the Republic of Ireland.

Aims To describe trends in the incidence of non-traumatic amputations among people with and without diabetes and estimate the relative risk of an individual with diabetes undergoing a lower extremity amputation compared to an individual without diabetes in the Republic of Ireland. Methods All adults who underwent a nontraumatic amputation during 2005 to 2009 were identified using HIPE (Hospital In-patient Enquiry) data. Participants were classified as having diabetes or not having diabetes. Incidence rates were calculated using the number of discharges for diabetes and non-diabetes related lower extremity amputations as the numerator and estimates of the resident population with and without diabetes as the denominator. Age-adjusted incidence rates were used for trend analysis. Results Total diabetes-related amputation rates increased non-significantly during the study period; 144.2 in 2005 to 175.7 in 2009 per 100,000 people with diabetes (p = 0.11). Total non-diabetes related amputation rates dropped non-significantly from 12.0 in 2005 to 9.2 in 2009 per 100,000 people without diabetes (p = 0.16). An individual with diabetes was 22.3 (95% CI 19.1–26.1) times more likely to undergo a nontraumatic amputation than an individual without diabetes in 2005 and this did not change significantly by 2009. Discussion This study provides the first national estimate of lower extremity amputation rates in the Republic of Ireland. Diabetes-related amputation rates have remained steady despite an increase in people with diabetes. These estimates provide a base-line and will allow follow-up over time.

Developing a measure for the appropriateness of prescribing in general practice

Objective: To explore the feasibility of using a broader definition of the appropriateness of prescribing in general practice by developing ways of measuring this broader definition and by identifying possible relationships between different aspects of appropriateness and patient outcomes. Design: A questionnaire study of patients and general practitioners before and after study consultations, supplemented by data collected from patients’ medical records and telephone interviews with patients 1 week later. Setting: General practices in the south of England. Participants: 24 general practitioners and 186 of their consulting patients. Main outcome measures: Unwanted, unnecessary, and pharmacologically inappropriate prescriptions; patients’ adherence. Results: Before the consultation 42% of patients said they wanted or expected a prescription for their main problem. Prescriptions were written in two thirds (65%) of study consultations, and 7% of these had not been wanted or expected beforehand. Doctors recorded that one in five prescriptions they wrote were not strictly indicated. Of the 92 independent assessments of these prescriptions, four were judged to be inappropriate and in 19 cases the assessors were uncertain. 41% of prescriptions written were wanted, necessary, and appropriate. Subsequently, 18% of patients for whom a prescription had been written were potentially non-adherent and 25% had worries or concerns about their medication. Conclusion: The attempt to measure appropriateness of prescribing along the three dimensions of patients’, prescribers’, and pharmacological perspectives is both feasible and likely to yield valuable insights into the nature of general practice prescribing and patients’ use of medicines.

Antibiotic prescribing in primary care, adherence to guidelines and unnecessary prescribing - an Irish perspective

BackgroundInformation about antibiotic prescribing practice in primary care is not available for Ireland, unlike other European countries. The study aimed to ascertain the types of antibiotics and the corresponding conditions seen in primary care and whether general practitioners (GPs) felt that an antibiotic was necessary at the time of consultation. This information will be vital to inform future initiatives in prudent antibiotic prescribing in primary care.MethodsParticipating GPs gathered data on all antibiotics prescribed by them in 100 consecutive patients’ consultations as well as data on the conditions being treated and whether they felt the antibiotic was necessary.Results171 GPs collected data on 16,899 consultations. An antibiotic was prescribed at 20.16% of these consultations. The majority were prescribed for symptoms or diagnoses associated with the respiratory system; the highest rate of prescribing in these consultations were for patients aged 15–64 years (62.23%). There is a high rate of 2nd and 3rd line agents being used for common ailments such as otitis media and tonsillitis. Amoxicillin, which is recommended as 1st line in most common infections, was twice as likely to be prescribed if the prescription was for deferred used or deemed unnecessary by the GP.ConclusionThe study demonstrates that potentially inappropriate prescribing is occurring in the adult population and the high rate of broad-spectrum antimicrobial agents is a major concern. This study also indicates that amoxicillin may be being used for its placebo effect rather than specifically for treatment of a definite bacterial infection.