Translating ‘practice into evidence’: why polypharmacy research needs ethnography

Problem

Polypharmacy is an urgent research priority. An ageing population with complex multimorbidities, a cash-strapped NHS, and concerns that prescribing numerous medicines is costly, wasteful, and exposes patients to unwarranted risks lie behind efforts to grapple with the ‘polypharmacy problem’. Health systems and ‘best practice’ guidelines are typically configured around a ‘single disease’ model which drives polypharmacy. Although increasingly recognised as problematic, our capacity to reconfigure care to adapt to the complex realities of patients’ lives is limited by our poor understanding of ‘what matters’ to patients and clinicians. Patients experience a ‘burden of treatment’ but we lack evidence to support complex decision-making around not prescribing or stopping treatments.

Approximately half of medicines prescribed for long-term conditions are unused. Careful attention to ‘real world’ priorities and practices of patients around medicines-taking, alongside study of professional practices and institutional contexts that sustain (and challenge) polypharmacy may hold clues for ‘optimising’ prescribing. We aim to improve care by producing ‘practice-based evidence’ to inform medicines optimisation, ensuring that patients’ priorities for their care and professionals’ concerns for good practice are upheld.

Approach

In-depth ethnographic case study employing mixed qualitative methods:

• Longitudinal observation of 30 patients, aged 65+ and prescribed 10+ medications (‘high risk’ polypharmacy) over 2 years, following their medicines trajectory, interactions with health services, and medicines practices. Narrative interviews and ethnographic observations in the home and healthcare settings.

• Observation of healthcare professional practices (in GP and pharmacy settings) and key organisational routines. Shadowing, interviewing and video-recording of ‘medicines review’ consultations.

• Identifying professional concerns through video-elicited feedback with clinicians, individually and in action learning sets (video-reflexive ethnography)

Findings

Our work is ‘in-progress’. Ethnography has been under-exploited in healthcare research despite its potential to illuminate how and why things are done, how people make sense of their experiences, and to contribute to debates on quality and safety. Drawing on ‘practice theory’ we will bring together diverse datasets, ‘zooming in’ and ‘zooming out’ on narrative, interactional and ethnographic data and between data and relevant social theory. We will identify where there are opportunities to avoid unnecessary/unwanted treatments and where there are vulnerabilities to error, misunderstanding or waste. Findings will be integrated to develop professional e-learning materials and patient-engagement materials through a process of stakeholder workshops and participatory co-design involving professionals and patients.

Consequences

We are conceptualising practice as an accomplishment, worthy of detailed study in its own right: situated, creative, interpretive and inherently moral in nature. This turns the translational ‘gap’ on its head. The focus shifts away from ‘evidence-into-practice’ and instead focuses on translating ‘practice-into-evidence’ producing new forms of evidence which hold promise for improving practice in terms that make sense to those that matter: patients and practitioners.