Development of an intervention to support medication management in patients with multimorbidity in primary care

The overarching aim of this thesis was to develop an intervention to support patient-centred prescribing in the context of multimorbidity in primary care. Methods A range of research methods were used to address different components of the Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in health care. The existing evidence on GPs’ perceptions of the management of multimorbidity was systematically reviewed. In qualitative interviews, chart-stimulated recall was used to explore the challenges experienced by GPs when prescribing for multimorbid patients. In a cross-sectional study, the psychosocial issues that complicate the management of multimorbidity were examined. To develop the complex intervention, the Behaviour Change Wheel (BCW) was used to integrate behavioural theory with the findings of these three studies. A feasibility study of the new intervention was then conducted with GPs. Results The systematic review revealed four domains of clinical practice where GPs experienced difficulties in multimorbidity. The qualitative interview study showed that GPs responded to these difficulties by ‘satisficing’. In multimorbid patients perceived as stable, GPs preferred to ‘maintain the status quo’ rather than actively change medications. In the cross-sectional study, the significant association between multimorbidity and negative psychosocial factors was shown. These findings informed the development of the ‘Multimorbidity Collaborative Medication Review and Decision-making’ (MY COMRADE) intervention. The intervention involves peer support: two GPs review the medications prescribed to a complex multimorbid patient together. In the feasibility study, GPs reported that the intervention was appropriate for the context of general practice; was widely applicable to their patients with multimorbidity; and recommendations for optimising medications arose from all collaborative reviews. Conclusion Applying theory to empirical data has led to an intervention that is implementable in clinical practice, and has the potential to positively change GPs’ behaviour in the management of medications for patients with multimorbidity.

Effect of road quality in structural health monitoring under operational conditions

The effect of unevenness in a bridge deck for the purpose of Structural Health Monitoring (SHM) under operational conditions is studied in this paper. The moving vehicle is modelled as a single degree of freedom system traversing the damaged beam at a constant speed. The bridge is modelled as an Euler-Bernoulli beam with a breathing crack, simply supported at both ends. The breathing crack is treated as a nonlinear system with bilinear stiffness characteristics related to the opening and closing of crack. The unevenness in the bridge deck considered is modelled using road classification according to ISO 8606:1995(E). Numerical simulations are conducted considering the effects of changing road surface classes from class A - very good to class E - very poor. Cumulant based statistical parameters, based on a new algorithm are computed on stochastic responses of the damaged beam due to passages of the load in order to calibrate the damage. Possibilities of damage detection and calibration under benchmarked and non-benchmarked cases are considered. The findings of this paper are important for establishing the expectations from different types of road roughness on a bridge for damage detection purposes using bridge-vehicle interaction where the bridge does not need to be closed for monitoring.