1. 1 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

2. 2 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

3. 3 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

4. 4 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

5. 5 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)

6. 6 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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8. 8 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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10. 10 4. Results 3 main categories of factors underlying inappropriate use of medicines Several factors that promoted a better use of medicines

11. 11 4. Results

12. 12 4. Results

13. 13 4. Results

14. 14 4. Results

15. 15 4. Results

16. 16 4. Results

17. 17 4. Results

18. 18 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

19. 19 5. Conclusion

20. 20 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)

21. 21 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

22. 22 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)

23. 23 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…

24. 24 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