Although a similar strategy for polypharmacy was described, there was variation between GPs in the actual performance. There was variation in the (number of) treatment goals formulated for the patient, and the number of proposed primary goals; there was a focus on addressing several goals simultaneously versus a ‘step-by-step’ approach. Further, there was variation as regards focusing on optimising clinical values by referring to targets described in CPGs, or focusing on the reason for an encounter. As a result, the proposed adjustments in the cases’ prescribed medications varied (Figures 1–4). In Box 1 noteworthy findings per vignette are given, accompanied by statements made from GPs. The GPs expressed that work experience facilitates the decision-making process. Nevertheless, they seemed indecisive about the best approach; they repeatedly declared that they needed to search for information (for example, reference values, medication dosages, potential side effects), and were interested in the approach of other GPs. Besides, several prescribing options seemed possible according to the GPs. Yet, consulting a pharmacist or medical specialist was rarely considered, as they wanted to optimise the patient’s condition themselves first. Only if the patient’s condition did not improve, would they be likely to deliberate with a medical specialist.
Box 1. Findings per case vignette, accompanied by statements given from the participating GPs
For case 1 (Appendix 1), it can be seen that all GPs focused on lowering blood pressure in this patient, which resulted in adding an ACE inhibitor. The variation in changes could be due to the fact that some GPs had more primary goals, whereas others had a more ‘step-by-step’ approach: ‘I have changed a series of prescribed medications. I am not sure if I will change everything at once, but this would be my purpose’ (GP8) and ‘[about the fact that this GP reported far less adjustments in the medication list] Yes, I did not want to adjust everything at the same time. I have recorded the medications which I would like to change at first place … After that you will see the patient again, and then you could focus on remaining goals … It is not very inspiring for the relationship of trust if you would say “Now we will do everything differently” after 8 years of treatment.’ (GP9)
With respect to case 2 (Appendix 2), nearly all GPs stated that naproxen should be stopped immediately, but not all GPs suggested alternatives to treating the patient’s pain. Moreover, only some GPs mentioned pain management as a treatment goal. Furthermore, all GPs suggested focusing on lowering blood pressure, but some GPs preferred to await the effect of stopping naproxen before increasing the dosage of enalapril.
GPs considered case 3 (Appendix 3) a typical ‘general practice patient’ because their approach would be to make one or two changes, wait a few days, and then determine the effect of the changes. For this patient, there was no apparent primary treatment goal: 10 different treatment goals were reported, and most GPs focused on three or four goals. This could be due to ambiguity about some symptoms or complaints. A GP stated, ‘That dizziness, we don’t know the type of dizziness. I am curious about the woman’s type of dizziness, I really want to know that. It hinders me.’ (GP1)
As regards case 4 (Appendix 4), nearly all GPs said that they would wish to stop hydrochlorothiazide because of the patient’s gout attack, despite the fact that this is no longer recommended in the Dutch guidelines. Treatment goals mainly focused on pain management and lowering the blood pressure.
