Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Multimorbidity decision burden for medicines not recognised
- Rebecca E Ryan, Sophie Hill (19 August 2009)
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Epidemic of good news
- Joan McClusky (20 August 2009)
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Telehealth as a practical way of enabling minimally disruptive medicine
- Brian Montgomery (20 August 2009)
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At last, some recognition of a growing problem.
- Shahid M Dadabhoy (20 August 2009)
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Too complex
- Anthony N Glaser (24 August 2009)
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Listening to the patient
- Judith H Harvey (26 August 2009)
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It is good to talk
- David R Warriner (27 August 2009)
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Treatment accessibility
- Peter Lapsley (29 August 2009)
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The social utility of research - a small example
- Keith Taylor (15 September 2009)
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Rebecca E Ryan, Research Fellow Centre for Health Communication and Participation, La Trobe University, Victoria 3086, Sophie Hill
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Dear Editor, We have read with interest the recent paper by May and colleagues [1] on the challenges that multiple co-occurring chronic diseases present for consumers, carers and health professionals. We agree with the authors’ argument that the co-occurrence of multiple conditions, or multimorbidity [2], creates a heavy burden. In such situations it may be difficult to manage medicines effectively and medicines-related adverse events can flourish. Ideally, interventions to promote safer, more effective medicines use could help to diminish many of these problems. We argue that while such interventions might focus in part on promoting treatment adherence they must also take a wider perspective on consumers’ medicines use. This could take many forms, such as interventions to promote understanding of medicines; to support people to take medicines safely and effectively; to improve self-care skills; or to minimise harms [3]. In reality, the state of the evidence on consumers’ use of medicines appears far from ideal. As part of a larger research project4, we selected systematic reviews of interventions directed to consumers and aiming to improve the use of medicines, and assessed the extent to which these reviews and their included studies considered multimorbidity. The dataset comprised relevant reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects from inception to September 2008 [4]. Of the 53 reviews, 45 (85%) did not explicitly consider multimorbidity, either at the review or included study level. In the remaining eight reviews, people with multimorbidity were not explicitly excluded, but were typically found in only a minority of the included studies. Furthermore, while inclusion of these people might imply interest in multimorbidity, there was little discussion of the impact of multimorbidity on medicines use in this smaller subset of reviews. There was one exception: polypharmacy in the elderly was addressed in some detail by a few reviews. However, there is almost no evidence to guide action on the issue of polypharmacy in other populations, despite rising chronic disease and multimorbidity rates across all age groups [5]. This gap has serious implications for decision making and self-care by people with multimorbidity. As May and colleagues point out, the evidence underpinning interventions to promote safe and effective medicines use does not apply to patients typically seen in clinical practice. Furthermore, the evidence fails to consider the interactions between diseases and the way this affects people’s lives. This creates a significant burden of decision making for consumers, their carers and health professionals. Given that multimorbidity is common [5] and is associated with conspicuously poor outcomes [2,6], this decisional burden has profound implications for evidence-based healthcare. Explicitly recognising the impact of multimorbidity and its effects on medicines use and other aspects of self-care will be essential if we are to improve outcomes in people with chronic illnesses. Yours sincerely Rebecca Ryan, Sophie Hill References 1 May C, Montori V, Mair FS. We need minimally disruptive medicine. BMJ 2009; 339:b2803. 2 Fortin M, Soubhi H, Hudon C et al. Multimorbidity's many challenges. BMJ 2007; 19;334(7602):1016-7. 3 Ryan R, Santesso N, Hill S et al. Consumer-oriented interventions for evidence-based prescribing and medicine use: an overview of Cochrane reviews (Protocol). Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007768. DOI: 10.1002/14651858.CD007768 4 See ‘Consumer’ under Rx for Change database, available at: http://www.cadth.ca/index.php/en/compus/optimal-ther- resources/interventions 5 Fortin M, Bravo G, Hudon C, et al. Prevalence of multimorbidity among adults seen in family practice. Annals of Family Medicine. 2005; 3(3):223-8. 6 Smith SM, Soubhi H, Fortin M, et al. Interventions to improve outcomes in patients with multimorbidity in primary care and community settings. (Protocol). Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD006560:DOI: 10.1002/14651858.CD006560. Competing interests: None declared |
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Joan McClusky, Medical writer 10003
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It might be helpful to recast how chronic illness is viewed, both for patients and healthcare providers. May et al note that "chronic disease is the great epidemic of our times" reflecting the "epidemiological shift from acute disease, where the emphasis was on cure." In fact, one might say that the emphasis shifted from dying of untreatable diseases to curing those, and living to a greater age with incurable but manageable disease. A primary reason for an "epidemic" of chronic disease is not because so many more are occurring, but because so many more are living with them rather than dying from something else. Thus, the "epidemic" is largely a lot of people who would, according to old expectations and treatments, be dead. Suppose that many of the women who formerly died in childbirth now often lived, but with some sort of ongoing problem? Would we note the success of preventing their deaths, or bemoan the fact that there were so many women with birth-related problems? I think it would help both patients and healthcare providers to start seeing chronic disease as the other side of not dying early. It is, in fact, the "price" of a longer life for many. Some may choose to "throw in the towel" once the burden becomes too great--not be treated, at least for some things, with the recognition that this might hasten their deaths. Others might be more than willing to do whatever is necessary to prolong life. But both require a dialogue between physician and patient about exactly what they are getting for the price of ongoing disease management and adherence to treatment. Competing interests: None declared |
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Brian Montgomery, Associate Medical Director NHS Lothian, Deaconess House, 148 Pleasance, Edinburgh, EH8 9RS
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Dear Editor, Lothian has a high incidence of COPD and as Associate Medical Director for NHS Lothian, I was heartened to read Professors May, Montori, and Mair’s article, ‘We need minimally disruptive medicine’, and would like to highlight telehealth as a practical way of enabling minimally disruptive medicine. I very much agree with their observation that patient involvement must play a central part in disentangling individual and collective treatment burdens. NHS Lothian is rolling out one of the largest telehealth programmes in the UK, working with Intel Corporation and Tunstall Healthcare Group. The project includes 400 patients with chronic conditions including COPD and heart failure. We have found telehealth helps improve patient awareness of their condition and self management, empowers our patients to take more control and to move to the centre of the treatment process. It has been adopted enthusiastically by patients and their carers and they report greater feelings of confidence and independence. Importantly it enables the healthcare team to cut through the over complex care environment that most of these patients exist within, allowing earlier treatment intervention to anticipate and manage exacerbations and thereby prevent the condition from worsening. This in turn can help to reduce the number of unplanned hospital admissions. Yours sincerely,
Competing interests: None declared |
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Shahid M Dadabhoy, General Practitioner The Microfaculty, 107/109 Chingford Mount Road, Chingford, London E4 8LT
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I was inspired by this article in this week's BMJ. I am a jobbing, nobody and hick GP in Chingford, North East London, an area where I am seeing the fallout of the Credit Crunch in the Consulting Room day in and day out. In addition, I have a sub-interest in rehabilitating people with chronic conditions back to work or sustaining them in the workplace. Recently, there has been a sustained effort by the Department of Work and Pensions in the UK to encourage those on long term disability back to the workplace. This is very welcome and I concur that work is good for health. This trend has been supported by an initiative from the Royal College of General Practitioners. Yet, hitherto, there has been virtually nothing on how difficult it is to manage a chronic condition and the fact that this represents almost a second career in itself requiring massive organisational skills on the part of the individual and frequently unbelievable logistical efforts by health services that frequently do not repay the patient's commitment or engagement. Interestingly, whilst there has been a lot of discussion of the role of Primary Care and its accesibility through, in the UK, the Darzi report, Secondary Care remains in patient contact for non Acute problems and especially Chronic Disease Management the same 9 to 5 Monday to Friday phenomenon that it always has been. I think this article strongly supports the view that every time we write a referral to a new service, request that they undertake a new investiigation (even as simple as a blood test) or ask them to attend another outpatients appointment, we need to think hard about the effort and resources that will entail our patients with chronic conditions have to go through. As a GP the Patient Experience element of my pay is increasing. As this trend, which is altogether fair I think, spreads, can we really afford not to take this aspect of delivering healthcare seriously? Dr Shahid Dadabhoy
Competing interests: None declared |
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Anthony N Glaser, Assistant Professor of Family Medicine Medical University of South Carolina, Charleston, SC 29483, USA
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May et al make some excellent points. I believe that medical care has advanced to the point that it is essentially too complex and sophisticated for patients to manage; certainly many doctors and health care systems cannot manage it well, so why on earth should we expect patients to be able to accomplish this feat? In my practice, anecdotal observation suggests that most doctors seeing any given patient, whether in the hospital or as an outpatient, do not know what medications the patient is normally taking - and clearly patients do not either. Here in the US, the financial barriers to filling prescriptions (often at different pharmacies for different drugs, either for cost reasons or because of insurance policies), the cost of treatment, the difficulty of getting to various appointments where there is little or no public transport, the incomprehensibility of medical bills and insurance policies, and the prevalent "rationing by inconvenience" by third-party payors, all add to the problem. Medical payment systems and the medicolegal context encourage excessive complexity, with over-testing, over-imaging, over-visiting of doctors, and when I try to save a patient a burdensome visit to me by emailing their response to a new medication I am voluntarily cutting my income and that of my employer. Only when the system incentivises rational care will we move towards improving the problem - as usual, anyone can make things complicated, but it takes genius to simplify things Competing interests: None declared |
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Judith H Harvey, retiring GP NW8 9QG
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More and more patients are burdened with complex, time consuming, sometimes expensive and all too often counterproductive management and treatment regimes. If we doctors establish relationships with our patients which give them confidence and time to talk, we can find out what they feel. Only then can we hope to simplify these routines to something that is safe, therapeutic and allows them some time off from being a patient. Competing interests: None declared |
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David R Warriner, ST2 Gastroenterology Barnsley Hospital, South Yorkshire, S70 2JW
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I agree absolutely. There is a saying "if you let the patient talk, they will tell you the diagnosis". It is very rare for my working diagnosis to be changed by the examination, rarer still by investigation. Yet we still insist on treating test results not what the patient is complaining of. Why? Because we interrupt, assume and confabulate, thinking we know best. We don't. Then we wonder why the patient doesn't accept, take or respond to out treatment. Talking might not win any Nobel prizes, but it will save unneccesary investigations, admissions and possibly lives. Competing interests: None declared |
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Peter Lapsley, Patient editor BMJ
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May, Montori and Mair have identified a growing problem for people with chronic conditions and a useful set of principles for helping resolve it. They have not, however, mentioned treatment accessibility and usability, a significant and increasing obstacle to adherence to treatment regimens that could quite easily be removed. All too often, the pharmaceutical industry seems oblivious to the need for patients to be able to access and manipulate treatments. Evidence of this is to be seen in the inexorable drive towards the provision of pills, tablets and capsules in blister packs, which runs contrary to patients’ interests. The problems posed by blister packs are often exacerbated by the use of pills too small easily to be seen or handled. Like increasing numbers of people, my step-mother is elderly, determinedly independent, and has macular degeneration and moderate arthritis in her fingers. She has been prescribed digoxin for arrhythmia, taking two tablets daily to make up the total dose. The tablets are less than 5mm in diameter. I watched recently when she insisted on accessing them herself, waiting for a full five minutes as she wrestled with the blister pack, becoming increasingly agitated and frustrated, and losing one pill on the floor before eventually I intervened. I myself have good eyesight and am reasonably dextrous. Even so, trying to extract (5mm diameter) coversyl 2mg tablets and 25mcg thyroxine tablets from blister packs is a frustrating chore. I have had capsules break apart when being pressed out of blister packs. And I encountered a pack recently on which the backing foil was so thick that it had to be cut on three sides of each capsule before the capsule could be released. Many less determinedly adherent patients would stop taking such treatments rather than continue to wrestle with tiny pills and nigh- impenetrable packaging. The Association of the British Pharmaceutical Industry says that blister packs facilitate the provision of patient information leaflets with all medication, that they meet the requirement that medications should be presented in as tamper-proof and as child-resistant a form as possible, and that they make counterfeiting more difficult. That is misleading. In reality, the regulations leading to the growth in the use of blister packs were introduced solely for the benefit of the industry. All of those objectives could as effectively be achieved with factory -sealed bottles or containers with tamper-proof caps. The re-introduction of such containers – and the bulking up of all pills to at least (say) 7.5mm in diameter - could significantly improve patients’ adherence to agreed treatment regimens. Competing interests: None declared |
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Keith Taylor, GP Scotland
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Dear Editor, As a working GP, occasional patient and occasional carer, this article struck a particular chord. In an era of increasing sub-specialism it was refreshing to hear the authors take a step back and question the complexity, industry and outcome of continually 'doing things to patients'. How though do we measure the impact or utility of such research? I left a copy of the article with someone who has no medical background but is caring for a relative with Alzheimers. She had an appointment with an old age psychiatrist later that week and was wearily anticipating another round of investigation, referral and potentially 'disruptive' treatment. Instead she was overjoyed to encounter an empathic, supportive and non-directive young doctor who recognised that both patient and carer were becoming overwhelmed and responded appropriately. Disruptive medicine often results from doctors misunderstanding patient expectation, the contribution of colleagues and the consequence of action. Perhaps the culture shift that the authors call for may come from a shared inter-professional understanding that, to quote John Donne "no man is an island entire of itself...because I am involved in mankind" Competing interests: None declared |
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