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Category Archives: Qualitative research

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



By Carol Sinnott


Using clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications. Our research group has just published a qualitative study exploring how GPs make decisions when prescribing for complicated multimorbid patients, with a view to informing intervention design in this field [1].
In qualitative interviews with GPs, we used case-specific information to reveal how GPs make compromises between patient centred and evidence based care in multimorbidity.
In the management of these cases, GPs integrated information from multiple sources including the patient, specialists and evidence based medicine. Difficulties arose if the recommendations or preferences conflicted with each other. GPs responded to this scenario by ‘satisficing’: accepting care that they deemed satisfactory and sufficient for a particular patient. In multimorbid patients perceived as stable, GPs’ preferred to ‘maintain the status quo’ rather than rationalize medications. This approach was due to GPs’ perceptions of the potential negative repercussions associated with changing medications. 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.
These new understandings will help to inform the design of behavioural interventions to assist medication management and patient centred care in multimorbidity.

The complete article can be accessed at: http://bjgp.org/content/65/632/e184

1: Sinnott C, Hugh SM, Boyce MB, Bradley CP. What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care. Br J Gen Pract. 2015 Mar;65(632):e184-91. doi: 10.3399/bjgp15X684001. PubMed PMID: 25733440.

How can eHealth technology address challenges related to multimorbidity?



By Donna Zulman

Patients with multiple chronic conditions (MCCs) face substantial self-management challenges related to having multiple health issues. For example, patients with MCCs frequently face unwieldy medication regimens and daily self-care routines that may reduce adherence to recommended treatment plans. They also often need to track and coordinate health information from different health care providers and monitor and distinguish between symptoms from different diseases. As a result, there is a great need for effective tools to support the self-care activities associated with multimorbidity. Patient-facing “eHealth” technology may provide opportunities to address these patients’ needs.

We conducted a qualitative study [1] (published in the Journal of General Internal Medicine) with patients with MCCs to explore their self-management and health care navigation challenges, and to identify opportunities to support these patients through new and enhanced eHealth technology. Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; and (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.

The abstract of the article can be found at http://www.ncbi.nlm.nih.gov/pubmed/25691239

1) Zulman DM, Jenchura EC, Cohen DM, Lewis ET, Houston TK, Asch SM. How can eHealth technology address challenges related to multimorbidity? Perspectives from patients with multiple chronic conditions. J Gen Intern Med. 2015 [Epub ahead of print]).

Challenges of self-management when living with multiple chronic conditions



By Clare Liddy

In our systematic review of the qualitative literature examining the patient’s perspectives of living with multiple chronic conditions published in Canadian Family Physician [1], we found that patients were able to clearly identify challenges associated with self-management and develop strategies to address these factors. The barriers to self-management are many and yet common between people with many different diseases. However, while most studies were disease-specific, we found that discussion among patients that related to specific medical conditions and disease-specific symptoms was strikingly absent. People did not complain about lack of skill to manage medical tasks such as injecting insulin or blood pressure monitoring; rather, they reported difficulties in dealing with physical and emotional symptoms, with depression, pain and fatigue being prominent. In addition, issues related to knowledge about self-management of conditions commonly arose because of confusing and often contradictory information provided by multiple health care providers. The use of cognitive strategies including reframing, prioritizing, and changing beliefs was reported to improve people’s ability to self-manage their multiple chronic conditions.
This study provides a unique view into the patients’ perspectives of living with multiple chronic conditions which are clearly linked to common functional challenges as opposed to specific diseases. Future policy and programming in self-management support should be better aligned with the patient’s perspectives of living with multiple chronic conditions and this may be achieved by ensuring a more patient-centered approach is adopted by providers and health service organizations.

1. Liddy, C., Blazkho, V. & Mill, K. (2014). “Challenges of self-management when living with multiple chronic conditions. Systematic review of the qualitative literature.” Canadian Family Physician, 60, 1123-1133.

The experience of adults with multimorbidity: a qualitative study



By Cynthia Duguay

Some studies indicate that the many challenges associated with multiple chronic diseases represent more than just the sum of each individual’s diseases. People with multimorbidity perceive their state of health as a series of medical and emotional crises that inevitably lead to physical loss and limitations, and can also create difficult social relationships. The literature does not provide sufficient evidence for us to determine whether the experiences of adults with multimorbidity are similar to those of the older population, despite multimorbidity also being common in younger adults whose social and family situations differ from those of their elders.
We conducted a qualitative study to have a deeper understanding of patients’ experiences from their own perspective (1). The purpose of this phenomenological study was to describe the fundamental structure of adults’ experience with multimorbidity.
The results of the study showed that at the core of the multimorbidity experience are the impression of aging prematurely, difficulties with self-care management, and issues with access to the healthcare system, which contribute to the problem’s complexity. Despite these issues, participants with multimorbidity report attempting to take control of their situation and adjusting to daily living. The whole article about this study is available at the website of the Journal of Comorbidity.

Reference
(1) Cynthia Duguay, Frances Gallagher, Martin Fortin. The unique experience of adults with multimorbidity: a qualitative study. Journal of Comorbidity 2014;4(1):11–21.

The care delivery experience of hospitalized patients with complex chronic disease

By Kerry Kuluski

What is important to individuals with complex chronic conditions when receiving care in a hospital setting? We recently published a paper in the journal Health Expectations [1] on the care delivery experiences of 116 inpatients at a complex continuing care/rehabilitation hospital in Toronto, Canada. Patients had an average of 5 morbidities and several illness symptoms including activity of daily living impairments, physical pain and depressive symptoms. Patients reported what kind of care they wanted delivered as well as how they wanted their care delivered. The findings speak to the importance of having a comprehensive assessment with less redundancy, support for transitions into and out of the hospital as well as greater attention to mental health during the hospital stay. On the staffing side, quicker response times, ongoing patient–provider communication and consistency between providers and across care units were highlighted. The patients noted the importance of feeling like a person, not a “knee replacement,” shedding light on the relational aspect of every care transaction. The study has generated a body of evidence on the important components of care delivery from the perspectives of a diverse group of chronically ill individuals who have spent a considerable amount of time in the health-care system. Moving forward, exploration around the appropriate funding models, skill mix and in-hospital processes (e.g., admission and discharge) are needed to move the evidence into changed practice. The findings can serve as a framework for designing patient centered hospital care for complex patient populations.

[1] Kuluski K, Hoang SN, Schaink AK, et al. The care delivery experience of hospitalized patients with complex chronic disease. Health Expectations. May 27 2013.

A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers

By Kerry Kuluski

  Do patients, their family physicians and informal caregivers agree on care goals? In short, rarely. We conducted interviews with 28 older persons with multi-morbidities, their informal caregivers and family physicians to assess and compare patient care goals. Maintaining functional independence was a common goal across all groups when looking at the data at the aggregate level. When comparing findings across patient-caregiver-family physician triads a different picture emerged. Very little alignment was found, particularly when patients were medically unstable and during transition points (e.g., when the patient required care in an alternate setting). While divergence in care goals may reflect the different roles and responsibilities of each of the players involved, these perspectives should be illuminated when building care plans to ensure that trade-offs are explored, the needs of the patient are supported and that quality of care is enhanced. This highly accessed paper was recently published in BMC Family Practice.