Title: Improving GPs’ knowledge of benefits and harms of treatments to support decision making in multimorbidity: qualitative research and co-design of a novel electronic information resource.
Funder: Department of Health and Social Care

Abstract: Background Multimorbidity, the presence of two or more long term conditions (LTCs) in one person, is increasingly common. Most LTCs are managed in primary care, supported by single-condition guidelines, each of which suggests multiple drugs. The resulting polypharmacy can be harmful and wasteful, so some drugs are better omitted. The question is, which? To make such decisions (and to share decisions with patients), GPs need to know the absolute and relative benefits and harms of treatments. Yet research shows that they rarely do, and guidelines do not provide this information in an easily-accessible format. Aims and objectives Aims: To reduce polypharmacy in patients with multimorbidity by making evidence about benefits and harms of treatments easier for GPs to access and understand. Objectives: To co-design a novel electronic information resource for communicating evidence on benefits and harms of treatments in a way that GPs will find accessible and usable during consultations with patients with multi-morbidity. Research questions 1. What are GPs' needs and preferences for accessing evidence-based quantitative information on the benefits and harms of medications when managing patients with multimorbidity and polypharmacy? 2. How can we draw on design principles and clinician and patient input to co-design an interactive information resource to support informed conversations and shared decisionmaking? 3. To what extent will such a resource prove helpful in practice? Methods Work package 1 Semi-structured interviews with 10-15 GPs to build an understanding of how they reason with regard to reducing polypharmacy in patients with multi-morbidity. Use this information to supplement an existing literature review (from an NIHR-funded MSc in EBHC) by exploring additional themes that emerge from GP interviews. Work package 2 Co-design project with GPs (along with patient input) to develop the format and content of an internet-accessible information resource that can be used in real time to inform and guide GP-patient conversations about which medications to start and which to stop in the context of multimorbidity and polypharmacy. Six professionally-facilitated co-design workshops will be held and outputs fed into iterative technology design. Work package 3 A short pilot study of the new resource will involve 30 GPs providing brief online feedback, as well as more in-depth interviews with 6 GPs and data interrogation of the resource website. Patient and public involvement A patient participation group, already engaged on my related MSc research advised on this project. We will meet formally at key stages and they are keen to participate in some of the co-design workshops. Outputs/dissemination The main output will be the resource itself, as an open-access public resource potentially usable by both clinicians and patients. Academic papers, lay summaries and policy briefings will also be produced. Anticipated impact For patients: Better, tailored treatment plans and reduced harm from over-medication or underuse of beneficial treatments For GPs: Greater understanding and confidence about the value of treatments. For the NHS: Savings through the avoidance of waste and harm. For guideline developers: Findings from this research could be used to improve guideline usability and effectiveness

Lay abstract: Multimorbidity means a person has two or more long term conditions (such as high blood pressure, diabetes or asthma). 23% of all adults and 65% of over 65s in the UK have multimorbidity.Most long term conditions are treated by doctors using guidelines (recommendations derived from research evidence on a topic). Each guideline tends to look at a single illness, and typically suggests more than one drug. Patients with multimorbidity can end up taking a large number of medicines (polypharmacy). When doctors have to balance many different guidelines, the medications that are most effective may get overlooked. On the other hand, people can end up being prescribed multiple drugs in combination, which increases the chance of side effects as well increasing the treatment burden. Not all the drugs on offer will be the right thing for an individual person. The NICE guideline on multimorbidity recommends that doctors should: Review medicines and other treatments taking into account evidence of likely benefits and harms for the individual patient and outcomes important to the person. The idea is that instead of prescribing (say) ten drugs, the doctor would find out which (say) three or four drugs are likely to make the biggest difference, and then discuss with the patient a trade-off between the benefits and harms of treatments rather than following all the guidelines to the letter. Of course, for some patients, taking all the recommended treatments will be the right thing to do. Research has shown that doctors usually don't know the size of the benefits and harms of every treatment. Such information is mostly buried in the complex supporting documents that accompany the guidelines, so doctors don't have it at their fingertips in a format that they and their patients can use in a consultation. This project aims to produce a solution: a web resource aimed at GPs (but freely available to all) that provides evidence-based information on the benefits and harms of treatments, in a clear visual format that can be used to support conversations between patients and GPs about treatment options. It will initially focus on four long-term conditions and their treatments: long-term care after a heart attack, high cholesterol, high blood pressure and Type 2 diabetes. These were chosen as they are important, common conditions and between them share an evidence-base which presents a range of challenges in terms of how to summarise and present the evidence. In time, more long-term conditions can be added into the resource. There will be three phases, working with practising GPs recruited from across the UK recruited through Clinical Commissioning Group lists. Phase 1. I will interview GPs to find out firstly, what challenges they face around understanding the benefits and harms of treatments when making prescribing decisions. Secondly, what their needs and preferences are in terms of accessing information on the relevant clinical evidence. Findings from this will inform the next phase. Phase 2. Working with technology design experts over two years, I will conduct a series of co-design workshops with GPs and patients. We will design and build a new web-based electronic information resource to communicate information about benefits and harms of treatments. Patient members for this phase will be recruited from an existing Patient and Public Involvement group who have already had input into the project and will continue to do so through its development. Phase 3. I will recruit a group of 30 GPs to test the new resource in practice, and collect feedback to inform further development. My findings will be disseminated via academic papers, lay summaries and presentations to clinicians, policymakers and patients.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE