What to give the patient who has everything? Development of an intervention to improve prescribing in multimorbidity.

The problem

In General Practice (GP), patients with multi-morbidity prescribed multiple long-term medications are increasingly the norm. Interventions are required to guide general practitioners' (GPs) prescribing for these complicated patients. However, many interventions targeted at healthcare professionals fail or have limited practical value because they lack a sound theoretical basis. Our aim was to design a theoretically based intervention to improve prescribing behaviour in multimorbid patients in primary care.

The approach

The steps set out in the Medical Research Council (MRC) guide to developing complex interventions were used as the overarching framework. The relevant existing evidence on GPs' prescribing challenges in multimorbidity was compiled in a systematic review (presented at SAPC 2013). An additional primary qualitative study with GPs on the issue was performed (presented at SAPC 2014). The aggregated empirical data were qualitatively re-analysed using the theoretically based Behavioural Change Wheel (BCW). The BCW facilitates a comprehensive understanding of current behaviour and then links this understanding with the intervention strategies, and behavioural change techniques (BCTs), that are most likely to achieve the desired behaviour. A panel of experts with expertise in the field of prescribing, multimorbidity and intervention design was convened to refine the emerging intervention and develop an implementation strategy.

Findings

The empirical evidence revealed a range of potential GP behavioural targets to improve medication management for multimorbid patients. From these, we chose to address the behaviour of purposeful medication review. Interpretation of the data using the BCW revealed the reasons of capability; opportunity; and motivation for why this behaviour (medication review) was not happening routinely in general practice. Further analysis highlighted that GP enablement; GP incentivisation; and environmental re-structuring (relating to the GPs' clinic) were the broad intervention strategies most likely to affect behavioural change. The specific BCTs chosen to deliver these strategies were practical social support (two GPs to conduct review), restructuring the social environment (allocating time for review), uses of prompts/cues (prescribing tool), and incentivisation (professional development points). The consensus opinion of the expert panel determined the prescribing tool to use, the instructions to be delivered to GPs, and the outcomes to follow.

Consequences

This paper describes the explicit, systematic development of a behavioural change intervention tailored to GPs' prescribing behaviour for multimorbid patients. The robust theoretical approach used to design the intervention will facilitate a thorough evaluation of effectiveness in the next phase of this work.

Credits

• Carol Sinnott, National Univeristy of Ireland, Galway, Ireland
• Molly Byrne, South East GP Training Scheme, Waterford, Ireland
• Rupert Payne, University of Glasgow, Glasgow, UK
• Stewart Mercer
• Colin Bradley, National Univeristy of Ireland, Galway, Ireland