Joanne Reeve

Solutions to problematic polypharmacy: learning from the expertise of patients

A lively debate in the final plenary at last year’s Royal College of General Practitioners (RCGP) Annual Primary Care Conference considered the provocation: ‘My Doctor Makes Me Sick — what can we do about it?’. The event was run by the Heseltine Institute for Public Policy & Practice at Liverpool University, in conjunction with Mersey Faculty and the RCGP. It followed on from a public debate ‘My doctor makes me sick’ held in Liverpool at the opening of the conference. The audience were invited to propose solutions to current concerns about overmedicalisation, treatment burden, and over- and under-diagnosis. Two of the final eight proposals related to reducing prescribing. GPs called for incentives not to use medicines and for deprescribing; both seen as necessary to support the individually-tailored care that GPs and patients1 seek. But GPs have described needing help in tailoring prescribing to individual needs, particularly when individual needs may appear to be at odds with the ‘ideal’ described by guidelines for best practice.2 So how can we help professionals and patients tackle a problem of perceived overprescribing and problematic polypharmacy?

Generalist solutions to complex problems: generating practice-based evidence - the example of managing multi-morbidity.

BackgroundA growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare?DiscussionStrengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem.We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem.SummaryAnswers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

Revisiting depression in palliative care settings: the need to focus on clinical utility over validity.

Objective: To review the literature on depression in palliative care patients to identify implications for development of clinical practice and individual patient care. Method: A qualitative review of depression prevalence studies in palliative care settings. We explore the utility of existing prevalence studies for clinical practice through testing two hypotheses: that high prevalence rates are associated with increased risk factors in study samples, and that poor methodological quality of the studies artefactually inflate prevalence estimates. Eighteen studies were identified in the search and included in this review. Results: Risk factors may contribute to depression prevalence but through a complex interaction of factors making individual risk levels hard to determine. Measurement artefact cannot, alone, account for elevated levels of depression in this population but may contribute to imprecision. The importance of organic decline as a potential confounding variable is highlighted. Conclusion: Future research into the causes and prevalence of depression should adopt longitudinal approaches using large samples, and consider the impact of organic disorder as an important confounding factor. Clinical practice and care of individual patients may be better supported by development of a prognostic index considering the predictive power of depressive symptoms and risk factors on well-being.

Protecting generalism: moving on from evidence-based medicine?

Quality of decision making in modern health care is defined with reference to evidence-based medicine. There are concerns that this approach is insufficient for, and may thus threaten the future of, generalist primary care. We urgently need to extend our account of quality of knowledge use and decision making in order to protect and develop the discipline. Interpretive medicine describes an alternative framework for use in generalist care. Priorities for clinical practice and research are identified.

Evaluating the evaluation: Understanding the utility and limitations of evaluation as a tool for organizational learning

Objective Organizational learning, underpinned by evidence-based health care, and greater user involvement in planning and delivery were key objectives of the NHS Plan. Evaluation, and specifically participatory evaluation, offers the potential to address these elements of the NHS modernization agenda. We discuss the strengths and limitations of evaluation in delivering the modernization agenda through use of a case study — the evaluation of a Healthy Living Centre project, catchon2us! Setting A Healthy Living Centre project in Merseyside. Results There was evidence that collaborative research can promote opportunities which foster significant learning and change, thus making the effort and time involved worthwhile. However, the two-way flow of information necessary for development of shared goals and learning at strategic, as well as provider, levels is not easily achieved. Barriers include the rigidity of organizational structures within large agencies such as the NHS, with priorities imposed from national levels overriding local priorities. Conclusions The inherent contradictions in current strategic drivers in the NHS need to be addressed if services can ever deliver the goal of true organizational learning.

Age‐related changes in muscle calcium content in dystrophin‐deficient mdx mice

Duchenne muscular dystrophy (DMD) is caused bya lack of muscle dystrophin,9and characterized byprogressive degeneration and fibrofatty replacementof muscle fibers.20An elevated total muscle calciumcontent in muscle biopsies from DMD patients hasbeen widely reported.1,10,12Similar findings in pre-necrotic fetal DMD muscle2and muscle from femalecarriers of the genetic defect15suggest that calciumelevation is an early event in the dystrophic process.Progressive muscle degeneration in DMD pa-tients leads to the presence of a mixed population ofnormal fibers and fibers at different stages of thedegenerative and regenerative process. Investiga-tions of biochemical changes within these musclesare thus confounded by the presence of nonviablefibers and nonmuscle tissue. Muscle from the mdxmouse3also lacks dystrophin,9and has been used asa model for investigating the pathogenesis of DMD.Skeletal muscle in the mdx mouse shows a multi-staged disease progression. Postnatal muscle appearsessentially histologically normal. An acute onset ofnecrosis is seen at 14–21 days old, rapidly followed bythe onset of regeneration, which apparently com-pensates for the degenerative phase.4Regenerationappears essentially complete by 3 months old.5Incontrast, the diaphragm muscle of the mdx mouseexhibits a pattern of progressive degeneration andfibrosis more comparable with that seen in DMDlimb muscles, although the mouse shows no overtsigns of respiratory impairment.18Measurements ofboth total and free calcium content in mdx micemuscle fibers have been contradictory, with bothnormal and increased levels recorded.14This mayreflect the different ages of the mice studied.The mdx mouse model of DMD provides an op-portunity to examine the pattern of change ofmuscle calcium levels during the progression of thedystrophic process. The apparent normality of skel-etal muscle in dystrophin-deficient mdx mice of lessthan 14 days old allowed us to investigate whetherloss of calcium homeostasis occurs as a primary eventprior to the onset of degeneration, or as a nonspe-cific event, secondary to the onset of muscle degen-eration.The study also examined the possibility that thedelayed onset of muscle degeneration in young mdxmice was related to the mitochondrial sequestrationof an increased cell calcium content.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions.

Objectives Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. Design Qualitative study in General Practice. Setting UK primary care. Main outcome measures A qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. Design and setting Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. Participants UK based GPs (interview and surveys); European GP trainees (focus groups). Results Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. Conclusions We describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

Dismantling Lord Moran's ladder: the primary care expert generalist

> ‘It’s not a choice for me to be a generalist. I would have liked to have done something more.’ (Early career doctor)1 It is over 50 years since Lord Moran suggested that GPs were doctors who have fallen off the specialist ladder.2 Then, two-thirds of early career GPs would have preferred to have been specialists.2 Today Lord Moran’s ladder lives on. General practice is still not a first career choice for many graduates, certainly not enough to sustain the workforce we need.3 Our conversations with early career medics reveal that they value the opportunities for flexible working within general practice. But also that they want ‘something more’ than the GP role: notably, opportunities to develop ‘special interests’. We suggest this represents a failure to recognise, or value, the specific expertise of the GP role itself; and in particular a misunderstanding of the primary care expert generalist approach. We start by considering what we understand by the expert generalist. The role is defined by two elements. First, a principle of personalised decision making which recognises health as a resource for …

Measuring medicine-related experiences from the patient perspective: a systematic review

Background There is an increasing drive to measure and so improve patients’ experiences and outcomes of health care. This also applies to medicines, given their ubiquity as health care interventions. Patients’ experiences of using medicines vary, and instruments which measure these are seen as an essential component to improve care. We aimed to identify generic measures of patients’ experiences of using prescription medicines and to examine their properties and suitability for use in research or practice. Methods Multiple electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycARTICLES, CINHAL Plus, PROQOLID®, and Google Scholar. We identified, critically appraised, and summarized generic questionnaires assessing one or more aspects of the medicine use experience among adult patients using prescription medicines for chronic conditions, and the process of questionnaire development, degree of patient involvement, and/or validation processes. Results Fifteen questionnaires were included. Of these, nine measures were multidimensional, covering various aspects of medicine use. Six instruments covered only a single domain, assessing a specific facet of using medicines. Domains covered were the following: effectiveness; convenience, practicalities, and/or managing medicines; information, knowledge, and/or understanding; side effects; relationships and/or communication with health professionals; impact on daily living and/or social life; general satisfaction; attitudes; beliefs, concerns, and/or perceptions; medical follow-up and/or adherence-related issues; treatment- and/or medicine-related burden, perceived control, or autonomy; self-confidence about medicine use; availability and accessibility; and medicine-related quality of life. None of the identified questionnaires covered all domains. Instruments varied in the extent of patient involvement in both their development and validation. Conclusion There is a scarcity of psychometrically sound, comprehensive, and generic measures of experiences of using prescription medicines among adult patients living with chronic illnesses. There is a need for further development and/or validation of existing instruments suitable for use in this population.

Can generalism help revive the primary healthcare vision

It is more than 30 years since the World Health Organization (WHO) called for a paradigm-shift to a model of primary healthcare: a vision of creating ‘Health for All’ through ‘putting people at the centre of health care’.1 Since then, we have seen significant advances in health and healthcare. People are ‘healthier, wealthier and liver longer today than 30 years ago’.2 Economic growth, increased resources, and rapid expansion of scientific knowledge and technological advancement have all contributed.2 But we see growing concerns that the primary healthcare vision is being lost, with a worrying impact on our current systems of healthcare.2 The burden of care on individual patients is increasing.3 An excessive focus on disease, fragmentation of care and unregulated commercialization2 has been linked to inefficiency, ineffectiveness and inequity.4 All against a background of changing health needs, notably a rise in the burden of chronic, complex illness.2,5 WHO calls for a revival and strengthening of the primary healthcare vision to meet modern needs, refocusing health services around people.2 Generalism describes an approach to care which is person-, not disease-focused; continuous, not episodic; integrates biotechnical and biographical understanding of illness; and promotes health as a resource for living, and not an end in itself.6 So can generalism help revive the primary healthcare vision?