Patients' evaluation of the appropriateness of their hypertension management--a qualitative study.

BACKGROUND: The existing appropriateness measures for prescribing used in the United States and the United Kingdom use clinical attributes. Treatment and care from a patient's perspective need to be evaluated in terms of whether they are more likely to lead to an outcome of a life worth living, in social, psychological, and physical terms. However, it is unclear whether patients specifically evaluate their prescribed medication and treatment. If so, do they use only clinical attributes or a combination of clinical and nonclinical attributes? OBJECTIVES: The aim of this study was to explore if patients evaluated their hypertension management, and if they did, investigate what attributes were involved in the evaluation. METHODS: Semistructured interviews, which focused on personal experiences of hypertension and its management were undertaken with patients (n=28). The aim of the interviews was to obtain, in a narrative format, the experiences, beliefs, and information that patients considered important when discussing the management of hypertension. Data analysis used a constant comparative method. RESULTS: All patients considered their hypertension management regimen appropriate, but were able to mention only 2 categories of attributes to justify their decision (the relationship with their General Practitioner and lowering of their blood pressure). Further series attributes were mentioned by the patient during the course of their interview; these attributes were considered to be involved in their evaluation. These implicit attributes were categorized as anxieties and concerns regarding treatment and diagnosis, explanation of the consequences of treatment, choice of antihypertensives, and the side effects experienced. CONCLUSIONS: Patient's evaluation of appropriateness was constructed from both explicit and implicit attributes. Implicit attributes, those not consciously known to the patient still, could be involved in the process of evaluating hypertension, its treatment, and care. Although the nonmedical attributes that are considered by patients can be categorized, it has to be remembered that it is the inherent meaning held by each individual patient involved when an evaluation is made.

Individual patient's preferences for hypertension management: a Q-methodological approach.

OBJECTIVE: To systematically explore and elicit individual patient's preferences in the management of their hypertension using Q-methodology. METHODS: Using Q-methodology, 120 patients ranking 42 statements according to their agreement or disagreement when considering appropriate hypertension management. The statements were derived from an earlier qualitative study. Factor analysis of the data was undertaken using PQMethod software to determine if any patterns were discernible. RESULTS: Ninety-two patients clustered to five factors, which all varied in the degree of involvement patients had, or wished to have, in their hypertension management. The 42 patients who loaded to factor 1 considered that appropriate antihypertensive treatment involved leaving medical decisions to their GPs and trusting their judgement in such matters. The patients (n = 31) who positively loaded to factor 2 suggested that an autonomous relationship with their healthcare professional(s) was an important issue when considering treatment. CONCLUSION: It is concluded that this study has successfully used Q-methodology to systematically investigate people's subjectivity and developed a novel approach to elicit the views of individual patients, as well as explore and differentiate between groups of patients. PRACTICE IMPLICATIONS: The formation of true partnerships between patients and healthcare professionals which will enhance individual patients' ability to self-manage chronic disease.

Identifying and establishing consensus on the most important safety features of GP computer systems: e-Delphi study.

Our objective was to identify and establish consensus on the most important safety features of GP computer systems, with a particular emphasis on medicines management. We used a two-round electronic Delphi survey, completed by a 21-member multidisciplinary expert panel, all from the UK. The main outcome measure was percentage agreement of the panel members on the importance of the presence of a number of different safety features (presented as clinical statements) on GP computer systems. We found 90% or greater agreement on the importance of 32 (58%) statements. These statements, indicating issues considered to be of considerable importance (rated as important or very important), related to: computerised alerts; the need to avoid spurious alerts; making it difficult to override critical alerts; having audit trails of such overrides; support for safe repeat prescribing; effective computer-user interface; importance of call and recall management; and the need to be able to run safety reports. The high level of agreement among the expert panel members indicates clear themes and priorities that need to be addressed in any further improvement of safety features in primary care computing systems.

Patients' and general practitioners' views of what constitutes appropriate hypertension management.

OBJECTIVES: To explore how patients and general practitioners (GPs) construct the concept of appropriateness in the context of hypertension management. METHOD: Q-methodology was used. The study involved 120 patients and 12 GPs ranking 42 statements according to their degree of agreement or disagreement when considering appropriate hypertension management. The statements, comprising both clinical and non-clinical attributes, were developed from a qualitative study. Factor analysis of the data, using PQMethod computer software, determined if any patterns were discernible. RESULTS: Patients (n = 92) and GPs (n = 10) exclusively clustered to six factors (factor loadings > or = 0.5, P <0.01), which accounted for 77% of the total variance. The findings indicated that patients and GPs consider appropriate hypertension management in different ways. The GPs indicated that they considered non-pharmacological measures highly important, whereas 72% of patients were ambivalent. The patients clustered to five appropriateness factors, which varied in the degree of involvement patients had, or wished to have, in their hypertension management. Of these five, two were chosen by 73 patients. CONCLUSION: GPs' views differ from those of patients and there is variation between patients, which has important implications for patient-centred care. Further application of Q-methodology to explore patients' views of appropriateness of other medical conditions would be valuable.

Safer medicines management in primary care.

Errors in the medicines management process represent an important source of iatrogenic harm in primary care. Most errors result from underlying systems-based problems that are amenable to intervention and potentially preventable. In this paper, we seek to identify the frequency of medication-related morbidity in primary care, understand the underlying systemic reasons that increase risk of medication-related errors and iatrogenic harm, and suggest strategies for improving the safety of medicines management.

Preventable drug-related morbidity indicators in the U.S. and U.K.

OBJECTIVE: To qualitatively describe differences between a series of preventable drug-related morbidity (PDRM) indicators in the United States (U.S.) and the United Kingdom (U.K.), after transfer from the U.S. to the U.K. health care setting. METHODS: A preliminary validation was undertaken of the U.S.-derived indicators within the University of Manchester School of Pharmacy, followed by a 2-round Delphi questionnaire of a sample of general practitioners (n=6) and primary care pharmacists (n=10). The main outcome measures were (1) relevance of the U.S. indicators to U.K. primary care prescribing as determined by preliminary validation and (2) the establishment of consensus among the Delphi participants that an indicator represented PDRM. RESULTS: After preliminary validation, 7 of the U.S. indicators and a part of 2 indicators were considered of insufficient relevance to take any further part in the validation process. A further 18 of the U.S.-derived indicators failed to achieve consensus as PDRMs by the U.K. Delphi panel. At the end of the validation process, 19 indicators remained. CONCLUSIONS: Many of the U.S.-derived indicators lacked relevance in the U.K. due to differences in transatlantic clinical practice. In addition, there may be differences in the philosophical viewpoints of health professionals practising in the U.S. and the U.K. In practice, it is therefore inappropriate to transfer quality indicators of this nature directly from the U.S. to the U.K. However, if some form of validation process is undertaken, indicators derived in one health care setting appear to provide a very useful starting point for those developed in another.