Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review

INTRODUCTION

Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention.

OBJECTIVES

To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions.

DESIGN

We performed a scoping review as defined by the Joanna Briggs Institute.

SETTING

The focus was on primary care settings.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024.

ELIGIBILITY CRITERIA

We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded.

EXTRACTION AND ANALYSIS

We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions.

RESULTS

In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention.

CONCLUSIONS

Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.

Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment

BACKGROUND

Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms.

AIM

This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting.

METHOD

This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome.

RESULTS

Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP.

CONCLUSION

GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).

Protocol for a cluster randomised trial of a goal-oriented care approach for multimorbidity patients supported by a digital platform

INTRODUCTION

Health information systems represent an opportunity to improve the care provided to people with multimorbidity. There is a pressing need to assess their impact on clinical outcomes to validate this intervention. Our study will determine whether using a digital platform (Multimorbidity Management Health Information System, METHIS) to manage multimorbidity improves health-related quality of life (HR-QoL).

METHODS AND ANALYSIS

A superiority, cluster randomised trial will be conducted at primary healthcare practices (1:1 allocation ratio). All public practices in the Lisbon and Tagus Valley (LVT) Region, Portugal, not involved in a previous pilot trial, will be eligible. At the participant level, eligible patients will be people with complex multimorbidity, aged 50 years or older, with access to an internet connection and a communication technology device. Participants who cannot sign/read/write and who do not have access to an email account will not be included in the study. The intervention combines a training programme and a customised information system (METHIS). Both are designed to help clinicians adopt a goal-oriented care model approach and to encourage patients and carers to play a more active role in autonomous healthcare. The primary outcome is HR-QoL, measured at 12 months with the physical component scale of the 12-item Short Form questionnaire (SF-12). Secondary outcomes will also be measured at 12 months and include mental health (mental component Scale SF-12, Hospital Anxiety and Depression Scale). We will also assess serious adverse events during the trial, including hospitalisation and emergency services. Finally, at 18 months, we will ask the general practitioners for any potentially missed diagnoses.

ETHICS AND DISSEMINATION

The Research and Ethics Committee (LVT Region) approved the trial protocol. Clinicians and patients will sign an informed consent. A data management officer will handle all data, and the publication of several scientific papers and presentations at relevant conferences/workshops is envisaged.

TRIAL REGISTRATION NUMBER

NCT05593835.

The challenge of clinical reasoning in chronic multimorbidity: time and interactions in the Health Issues Network model

The increasing prevalence of multimorbidity requires new theoretical models and educational approaches to develop physicians' ability to manage multimorbidity patients. The Health Issues Network (HIN) is an educational approach based on a graphical depiction of the evolutions over time of the concurrent health issues of a patient and of their interactions. From a theoretical point of view, the HIN approach is rooted in Prigogine's vision of the "becoming" of the events and in the concept of knowledge organization, intended as the process of storing and structuring of information in a learner's mind. The HIN approach allows to design clinical exercises to foster learners' ability to detect evolutionary paths and interactions among health issues. Recent findings of neuroscience support the expectation that interpreting, completing, and creating diagrams depicting complex clinical cases improves the "sense of time", as a fundamental competence in the management of multimorbidity. The application of the HIN approach is expected to decrease the risk of errors in the management of multimorbidity patients. The approach is still under validation, both for undergraduate students and for the continuous professional development of physicians.

Interventions and management on multimorbidity: An overview of systematic reviews

BACKGROUND

Multimorbidity poses an immense burden on the healthcare systems globally, whereas the management strategies and guidelines for multimorbidity are poorly established. We aim to synthesize current evidence on interventions and management of multimorbidity.

METHODS

We searched four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews). Systematic reviews (SRs) on interventions or management of multimorbidity were included and evaluated. The methodological quality of each SR was assessed by the AMSTAR-2 tool, and the quality of evidence on the effectiveness of interventions was assessed by the grading of recommendations assessment, development and evaluation (GRADE) system.

RESULTS

A total of 30 SRs (464 unique underlying studies) were included, including 20 SRs of interventions and 10 SRs summarizing evidence on management of multimorbidity. Four categories of interventions were identified: patient-level interventions, provider-level interventions, organization-level interventions, and combined interventions (combining the aforementioned two or three- level components). The outcomes were categorized into six types: physical conditions/outcomes, mental conditions/outcomes, psychosocial outcomes/general health, healthcare utilization and costs, patients' behaviors, and care process outcomes. Combined interventions (with patient-level and provider-level components) were more effective in promoting physical conditions/outcomes, while patient-level interventions were more effective in promoting mental conditions/outcomes and psychosocial outcomes/general health. As for healthcare utilization and care process outcomes, organization-level and combined interventions (with organization-level components) were more effective. The challenges in the management of multimorbidity at the patient, provider and organizational levels were also summarized.

CONCLUSION

Combined interventions for multimorbidity at different levels would be favored to promote different types of health outcomes. Challenges exist in the management at the patient, provider, and organization levels. Therefore, a holistic and integrated approach of patient-, provider- and organization- level interventions is required to address the challenges and optimize care of patients with multimorbidity.

A GP's clinical reasoning in the context of multimorbidity: beyond the perception of an intuitive approach

INTRODUCTION

GP's clinical reasoning processes in the context of patients suffering from multimorbidity are often a process which remains implicit. Therefore, the goal of this case study analysis is to gain a better understanding of the processes at play in the management of patients suffering from multimorbidity.

METHODS

A case study analysis, using a qualitative thematic analysis was conducted. This case follows a 54-year-old woman who has been under the care of her GP for almost 10 years and suffers from a number of chronic conditions. The clinical reasoning of an experienced GP who can explicitly unfold his processes was chosen for this case analysis.

RESULTS

Four main themes emerged from this case analysis: The different roles that GPs have to manage; the GP's cognitive flexibility and continual adaptation of their clinical reasoning processes, the patient's empowerment, and the challenges related to the collaboration with specialists and healthcare professionals.

CONCLUSION

This could help GPs gain a clearer understanding of their clinical reasoning processes and motivate them to communicate their findings with others during clinical supervision or teaching. Furthermore, this may emphasize the importance of valuing the role of the primary care physician in the management of multimorbid patients.

Prevalence and pattern of acute and chronic multimorbidity across all body systems and age groups in primary health care

Multimorbidity is more than just the addition of individual illnesses, and its diagnosis and treatment poses special problems. General practitioners play an important role in looking after multimorbid patients. The aim of this study is to assess the prevalence and pattern of acute and chronic multimorbidity in primary care patients, regardless of body system and age group. A convenience sample of 2099 patients treated by 40 general practitioners was assessed using the Burvill scale. This measure of multimorbidity differentiates according to organ system and covers both acute and chronic illnesses. It also allows severity ratings to be assessed for both acute and chronic conditions, and thus patients’ actual need for general practice care. Patients reported an average of 3.5 (SD = 2.0) acute and/or chronically affected body systems. Overall, 12.7% of patients reported only one health problem, 83.0% at least two, 65.8% at least three, 46.1% at least four, and 29.7% five or more. The most frequent problems were musculoskeletal (62.5%) and psychological (56.6%). Some morbidities were interrelated, while others co-occurred despite being medically independent. In primary care, multimorbidity is the rule rather than the exception. Acute and chronic morbidity both contribute to the burden of illness. Body systems reflect treatment needs. Instead of specialist treatment for individual illnesses, an integrative treatment approach is needed. This is the specialty of general practitioners.

Multimorbidity and clinical reasoning through the eyes of GPs: a qualitative study

Objectives

Despite the high prevalence of patients suffering from multimorbidity, the clinical reasoning processes involved during the longitudinal management are still sparse.

This study aimed to investigate what are the different characteristics of the clinical reasoning process clinicians use with patients suffering from multimorbidity, and to what extent this clinical reasoning differs from diagnostic reasoning.

Design

Given the exploratory nature of this study and the difficulty general practitioners (GPs) have in expressing their reasoning, a qualitative methodology was therefore, chosen. The Clinical reasoning Model described by Charlin et al was used as a framework to describe the multifaceted processes of the clinical reasoning.

Setting

Semistructured interviews were conducted with nine GPs working in an ambulatory setting in June to September 2018, in Geneva, Switzerland.

Participants

Participants were GPs who came from public hospital or private practice. The interviews were transcribed verbatim and a thematic analysis was conducted.

Results

The results highlighted how some cognitive processes seem to be more specific to the management reasoning.

Thus, the main goal is not to reach a diagnosis, but rather to consider several possibilities in order to maintain a balance between the evidence-based care options, patient’s priorities and maintaining quality of life. The initial representation of the current problem seems to be more related to the importance of establishing links between the different pre-existing diseases, identifying opportunities for actions and trying to integrate the new elements from the patient’s context, rather than identifying the signs and symptoms that can lead to generating new clinical hypotheses. The multiplicity of options to resolve problems is often perceived as difficult by GPs. Furthermore, longitudinal management does not allow them to achieve a final resolution of problems and that requires continuous review and an ongoing prioritisation process.

Conclusion

This study contributes to a better understanding of the clinical reasoning processes of GPs in the longitudinal management of patients suffering from multimorbidity. Through a practical and accessible model, this qualitative study offers new perspectives for identifying the components of management reasoning. These results open the path to new research projects.