What influences prescribing decisions in a multimorbidity and
polypharmacy context on the acute medical unit? An interprofessional,
qualitative study
Abstract
ABSTRACT Rationale, aims and objectives The primary aim of the study was
to understand the mindset of doctors and pharmacists, as they embark
upon prescribing in a polypharmacy and multi-morbidity context during
routine practice at a hospital acute admissions unit. The study also
aimed to evaluate to what extent attitudes, embedded within real-life
decision-making scenarios, relate to existing theory and models of
prescribing decisions. Methods Anonymised case studies were identified
from the medical notes of patients aged 65 and over with conditions
likely to be associated with multi-morbidity, medication issues and
polypharmacy: namely: fall, urinary tract infection, confusion or lower
respiratory tract infection. A total of 39 doctors based on the acute
medical admissions unit and 9 pharmacists were recruited to one of three
focus groups. Patient case-studies provided the context for discussion
from which verbatim transcripts were thematically analysed using an
interpretative, qualitative approach. Sub-themes were matched to Murshid
and Mohaidin’s proposed model of physician prescribing decisions.
Results Seven principal themes were identified that were associated with
prescribing decisions on the acute medical unit, namely, ‘patient
characteristics’, ‘drug characteristics’, ‘pharmacist factors’,
‘trustworthiness’, ’reliability of medication history, ‘competing
pressures and priorities’ and ‘responsibilities of prescribers’.
Conclusion Prescribing decisions on the acute medical admissions unit
were influenced by a variety of factors, some of which have already been
acknowledged within existing theories and models. The findings
provisionally offer new insights, which, subject to confirmation by
further research, bring to light three attitudinal characteristics that
may impact negatively upon the quality of prescribing decisions. These
include, first, how perceived poor reliability of medication history may
result in information gaps that compromise prescribing decisions;
second, how competing pressures and priorities restrict doctors’
aptitude to conduct a review of medication and finally, how doctors may
rationalise the assignment of medication review to the GP.