MediQuit - an electronic deprescribing tool: a pilot study in German primary care; GPs' and patients' perspectives.

BACKGROUND: General practitioners (GPs) are the central coordinators for patients with multimorbidity and polypharmacy in most health care systems. They are entrusted with the challenging task of deprescribing when inappropriate polypharmacy is present. MediQuit (MQu) is a newly developed electronic tool that guides through a deprescribing consultation. It facilitates the identification of a medicine to be discontinued (stage 1), a shared decision-making process weighing the pros and cons (stage 2), and equips patients with take-home instructions on how to discontinue the drug and monitor its impact (stage 3). We here aim to evaluate utility and acceptance of MQu from GPs' and patients' perspectives. METHODS: Uncontrolled feasibility study, in which 16 GPs from two regions in Germany were invited to use MQu in consultations with their multimorbid patients. We collected quantitative data on demography, utility and acceptance of MQu and performed descriptive statistical analyses. RESULTS: Ten GPs performed 41 consultations using MQu. Identification (step 1) and implementation elements (Step 3) were perceived most helpful by GPs. Whereas, shared-decision making elements (step 2) revealed room for improvement. Patients appreciated the use of MQu. They were broadly satisfied with the deprescribing consultation (85%) and with their decision made regarding their medication (90%). CONCLUSIONS: Implementation of MQu in general practice generally seems possible. Patients welcome consultations targeting medication optimization. GPs were satisfied with the support of MQu and likewise gave important hints for future development.

Inductive foraging: patients taking the lead in diagnosis, a mixed-methods study.

BACKGROUND: Patient involvement in treatment decisions is widely accepted. Making a diagnosis, however, is still seen as a technical task mainly driven by physicians. Patients in this respect are perceived as passive providers of data. But, recent patient-centred concepts highlight the value of an active patient involvement in diagnosis. OBJECTIVE: We aim to reach a deeper understanding of how patients themselves contribute to the diagnostic process. METHODS: This is an observational study of patient consultations with their General Practitioner (GP) in 12 German practices. We performed a mixed-method qualitative and quantitative analysis of 134 primary care consultations. RESULTS: At the beginning of most consultations lies a phase where patients were invited to freely unfold their reason for encounter: This was named "inductive foraging" (IF). While patients actively present their complaints, GPs mainly listen and follow the presentation. This episode was found with every GP participating in this study. Ninety-one percent of consultations with diagnostic episodes were opened by IF. IF had a major contribution to the number of cues (diagnostic information) yielded in the diagnostic process. We illustrate a variety of tactics GPs make use of to invite, support, and terminate their patients in IF. CONCLUSION: IF was found to be a highly relevant strategy in the diagnostic process. Patient involvement through IF offered a major contribution of diagnostic cues. We hypothesize that a patient-centred approach improves diagnosis.

Making a diagnosis is a central part in medicine. Before advising treatments, physicians need to understand patients' complaints and ideally the reason for their symptoms. Generating an accurate diagnosis is often attributed to clinicians asking many specific questions and performing an array of tests. The patients' task in turn is passively answering "yes" or "no," or donating blood. In this study, we shed a different light on the phenomenon of diagnosis. We observed and recorded 295 primary care consultations. After each consultation, GPs were asked to reflect on their diagnostic thinking during the encounter. At the beginning of consultations, we witnessed a phase where patients were invited to freely report their complains and unfold their reason for encounter. Here, physicians mainly listened to their patients and motivated for further elaboration. We termed this phase "inductive foraging." GPs received the majority of diagnostic information (cues) during this phase. We therefore belief that an active patient involvement may improve diagnosis.

MediQuit, an Electronic Deprescribing Tool for Patients on Polypharmacy: Results of a Feasibility Study in German General Practice.

BACKGROUND: Deprescribing is an important task for general practitioners (GPs) in the face of risky polypharmacy. The electronic tool "MediQuit" was developed to guide GPs and patients through a deprescribing consultation that entails a drug-selection phase, shared decision making, and advice on safe implementation. OBJECTIVES: A pilot study was conducted to determine the target group of patients that is selected for consultation and to assess the impact, patient involvement, and feasibility of the tool. METHODS: This was an uncontrolled pilot study. GPs from two German regions were invited to use MediQuit in consultations with a view to deprescribing one drug, if appropriate. They selected patients on the basis of broad inclusion criteria. Collected data entailed participants' characteristics, patients' medication lists, deprescribed drugs, and feasibility assessments. Patients were contacted shortly after the consultation and again after 4 weeks. RESULTS: In total, 16 GPs agreed to participate, of whom ten actually performed deprescribing consultations. They selected 41 predominately older patients on excessive polypharmacy. Deprescribing was achieved in 70% of consultations in agreement with patients. Drugs deprescribed were symptom-lowering and preventive drugs (mainly anatomical therapeutic chemical classes A and C). GPs found MediQuit useful in initiating communication on this issue and enhancing deliberations for a deprescribing decision. The median consultation length was 15 min (interquartile range 10-20). At follow-up, GPs and patients infrequently disagreed on which drug(s) was discontinued, and GPs rated patient involvement higher than did patients themselves. DISCUSSION: MediQuit assists in identifying concrete deprescribing opportunities, patient involvement, and shared decision making. The three-step deprescribing procedure is well-accepted once initial organizational efforts are overcome. After revision, further studies are needed to enhance the quality of evidence on acceptance and effectiveness.

Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing - a qualitative study.

BACKGROUND: Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs', community pharmacists' and specialist providers' role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches. METHOD: Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework. RESULTS: Twenty-six GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains 'Social/professional role and identity' (1), 'Social influences' (2), 'Reinforcement' (3) and ´Environmental context and resources' (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients' trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs' role and deprescribing attempts. Reinforcements (3) negatively affected GPs' and pharmacists' effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized. CONCLUSION: Understanding stakeholders' role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.

Generic instruments for drug discontinuation in primary care: A systematic review.

AIMS: The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting. METHODS: We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified. RESULTS: We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web-applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision-making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines. CONCLUSION: Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user-friendly tools that support physicians in communicational aspects, visualise trade-offs and also enhance patient involvement.

Beyond accuracy: hidden motives in diagnostic testing.

Background: Diagnostic decision-making is usually disease-focussed and intended to examine the patient's medical condition accurately. But diagnostic interventions may serve further purposes that are not yet fully understood. Objective: To explore GPs' diagnostic behaviour not related to confirming or refuting a specific disease. Methods: We recorded 295 primary care consultations in 12 practices. One hundred thirty-four consultations comprised at least one diagnostic episode. GPs were asked to reflect on their own diagnostic thinking in interviews for every single case. Qualitative and quantitative analyses were applied with focus on the GPs' cognitive processes during diagnostic decision-making. Results: Primary care physicians clearly stated that they requested some tests for other reasons than diagnosing disease. A feeling of uncertainty stimulated diagnostic procedures aiming to regulate the anticipation of regret. We identified patients' reassurance, patients' requests and strategic issues as further motives for diagnostic actions. Conclusion: Besides focussing on disease in the diagnostic process, emotional and strategic goals are hidden motives that play a critical role in clinical decision-making. They might even represent an initial factor in a cascade of interventions leading to overdiagnosis. How GPs might control these influences provides an important aspect for further research, practice and teaching.

Individual utilisation thresholds and exploring how GPs' knowledge of their patients affects diagnosis: a qualitative study in primary care.

BACKGROUND: One of the tenets of general practice is that continuity of care has a beneficial effect on patient care. However, little is known about how continuity can have an impact on the diagnostic reasoning of GPs. AIM: To explore GPs' diagnostic strategies by examining GPs' reflections on their patients' individual thresholds for seeking medical attention, how they arrive at their estimations, and which conclusions they draw. DESIGN AND SETTING: Qualitative study with 12 GPs in urban and rural practices in Germany. METHOD: After each patient consultation GPs were asked to reflect on their diagnostic reasoning for that particular case. Qualitative and quantitative analyses of consultations and interview content were undertaken. RESULTS: A total of 295 primary care consultations were recorded, 134 of which contained at least one diagnostic episode. When elaborating on known patients, GPs frequently commented on how 'early' or 'late' in an illness progression a patient tended to consult. The probability of serious disease was accordingly regarded as high or low. This influenced GPs' behaviour regarding further investigations or referrals, as well as reassurance and watchful waiting. GPs' explanations for a patient's utilisation threshold comprised medical history, the patient's characteristics, family background, the media, and external circumstances. CONCLUSION: The concept of an individual threshold for the utilisation of primary care would explain how GPs use their knowledge of individual patients and their previous help-seeking behaviour for their diagnostic decision making. Whether the assumption behind this concept is valid, and whether its use improves diagnostic accuracy, remains to be investigated.

TGF-beta signaling is dynamically regulated during the alveolarization of rodent and human lungs.

Although transforming growth factor-beta (TGF-beta) signaling negatively regulates branching morphogenesis in early lung development, few studies to date have addressed the role of this family of growth factors during late lung development. We describe here that the expression, tissue localization, and activity of components of the TGF-beta signaling machinery are dynamically regulated during late lung development in the mouse and human. Pronounced changes in the expression and localization of the TGF-beta receptors Acvrl1, Tgfbr1, Tgfbr2, Tgfbr3, and endoglin, and the intracellular messengers Smad2, Smad3, Smad4, Smad6, and Smad7 were noted as mouse and human lungs progressed through the canalicular, saccular, and alveolar stages of development. TGF-beta signaling, assessed by phosphorylation of Smad2, was detected in the vascular and airway smooth muscle, as well as the alveolar and airway epithelium throughout late lung development. These data suggest that active TGF-beta signaling is required for normal late lung development.