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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. Journal Club CUMG – 16.12.2005. 1. Introduction. Drug-related problems (DRPs) in older persons

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Journal Club CUMG – 16.12.2005

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  1. 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 Journal Club CUMG – 16.12.2005

  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. 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. Qualitative research in health care  quantitative • Approach: • often exploratory work: “how” and “why”  how many? • hypothesis generating  testing • Sample • small and purposive  large, random • Methods • interviews, observation, documents  survey, RCT • Analysis: qualitative  quantitative

  5. HCPs • Doctors (5) • Pharmacists (3) • Nurses (4) • 1/1 interviews (semi-structured) • Patients (17) • Group interviews (focus groups) • Geriatric wards (2) • Observation (participant) 3.1. Study design and sampling strategy Sample (purposive) Method

  6. Geriatric wards (2) Observation • HCPs • Doctors (5) • Pharmacists (3) • Nurses (4) • 1/1 interviews (semi-structured) • Patients (17) • Group interviews (focus groups) 3.1. Study design and sampling strategy Sample (purposive) Method 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

  7. 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

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

  9. 4. Results

  10. 4. Results

  11. 4. Results

  12. 4. Results

  13. 4. Results

  14. 4. Results

  15. 4. Results

  16. Multidisciplinary team • Identification of drug-related problems by team members (nurse, physiotherapist,…)  communication to the prescriber • Input of geriatricians •  « one size fits all » 4. Results • Factors leading to a BETTER use of medicines

  17. 5. Conclusion

  18. 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)

  19. 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

  20. 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)

  21. 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…

  22. 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

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