General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research

Abstract

Background: General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care. Methods: Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies. Results: Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk.

Multi-Morbidity and Polypharmacy in Older People: Challenges and Opportunities for Clinical Practice

“…Given the heterogeneity of disease trajectories in older people as well as symptoms and individual patient preferences, goals of care will vary between individuals. GPs are in an ideal position to make shared decisions with patients and families to prescribe, deprescribe, rationalise, and optimise medications but need funded time and space to nurture long-lasting, trustful therapeutic partnerships [ 53 , 63 , 64 ]. It is also clear that the impact of multi-morbidity, frailty, and polypharmacy spans both primary and secondary care.…”

Health Communication and Inter-professional Care in Context of Multimorbidity Management: Assessment of Health Professional Curricular Focus in India

“…Moreover, this is achieved even better when health professionals not only learn to effectively communicate with each other, but also with patients, their families, and the community in a collaborative and responsible way. A recent systematic review that discusses challenges faced by general physicians (GP) in ensuring quality patient care in case of multimorbidity management, highlighted concerns around poor communication with patients and with healthcare professionals (Damarell et al, 2020). This led to limitations in GP's sharing of care for multimorbidity patients with health professionals from outside primary care, resulting in a sense of "professional isolation" among them.…”

Identification of the multimorbidity training needs of primary care professionals: Protocol of a survey

“…Another complaint is that current consultation times in PC are insufficient to allow comprehensive management of multiple conditions and a lack of interprofessional coordination acts as a source of iatrogenesis and added uncertainty, in addition to negatively influencing the patient’s perception of their healthcare. 57 , 66 , 67 However, PC professionals recognize that longitudinality and continuity in the relationship with patients is a useful tool that can help address the challenge of MM and facilitate the adaptation of diagnostic and therapeutic plans and shared decision-making processes. PC workers have also proposed a range of improvements, including better working links with pharmacists to improve medication revision and the need for more training and education in the management of MM and its consequences.…”