‘Potentially inappropriate or specifically appropriate?’ Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people

Background: Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients.

Method: Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted.

Results: Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population.

Conclusions: Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP.

Complete framework for efficient characterisation of non-Markovian processes

A non-Markovian process is one that retains `memory' of its past. A systematic understanding of these processes is necessary to fully describe and harness a vast range of complex phenomena; however, no such general characterisation currently exists. This long-standing problem has hindered advances in understanding physical, chemical and biological processes, where often dubious theoretical assumptions are made to render a dynamical description tractable. Moreover, the methods currently available to treat non-Markovian quantum dynamics are plagued with unphysical results, like non-positive dynamics. Here we develop an operational framework to characterise arbitrary non-Markovian quantum processes. We demonstrate the universality of our framework and how the characterisation can be rendered efficient, before formulating a necessary and sufficient condition for quantum Markov processes. Finally, we stress how our framework enables the actual systematic analysis of non-Markovian processes, the understanding of their typicality, and the development of new master equations for the effective description of memory-bearing open-system evolution.