title: Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel.
abstract: BACKGROUND
  Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions.
  
  
  METHODS
  Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change.
  
  
  RESULTS
  We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs' capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives.
  
  
  CONCLUSIONS
  This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.
authors.affiliation: Department of General Practice, University College Cork, Cork, Ireland. csinnott@ucc.ie.
authors.forename: Carol
authors.initials: C
authors.lastname: Sinnott
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK. Stewart.Mercer@glasgow.ac.uk.
authors.forename: Stewart W
authors.initials: SW
authors.lastname: Mercer
authors.affiliation: Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Cambridge, UK. rap55@medschl.cam.ac.uk.
authors.forename: Rupert A
authors.initials: RA
authors.lastname: Payne
authors.affiliation: Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK. martin@theduerdens.co.uk.
authors.forename: Martin
authors.initials: M
authors.lastname: Duerden
authors.affiliation: Department of General Practice, University College Cork, Cork, Ireland. C.Bradley@ucc.ie.
authors.forename: Colin P
authors.initials: CP
authors.lastname: Bradley
authors.affiliation: Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland. molly.byrne@nuigalway.ie.
authors.forename: Molly
authors.initials: M
authors.lastname: Byrne
mesh_terms: D002908:Chronic Disease / Q000188:drug therapy*; D003142:Communication; D015897:Comorbidity; D003299:Cooperative Behavior; D003657:Decision Making; D004777:Environment; D058005:General Practitioners / Q000523:psychology*; D006801:Humans; D007318:Inservice Training; D054539:Medication Therapy Management / Q000458:organization & administration*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011582:Psychological Theory; D036301:Qualitative Research