Redesigning the general practice consultation to improve care for patients with multimorbidity
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6202 (Published 17 September 2012) Cite this as: BMJ 2012;345:e6202
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There is evidence that spending more overall time per patient (or having less listed patients)is associated with better care for chronic patients and better scores in the patient questionnaire on service and care items. This knowledge also did not lead to a policy change in The Netherlands, because the costs are considerable. Yet it may save expensive care if patients could be handled by the GP, who has time to do things as decision sharing or Motivational interviewing.
Perfect paper hopefully opening the discussion again on more time for patients and/or less patients on the list. www.biomedcentral.com/1472-6963/9/118/abstract
Competing interests: No competing interests
This article illustrates how we are many years from developing any strategies to deal with multimorbidity and polypharmacy. Even if evidence arises for the support of longer consultation times and more cohesive multidisciplinary teams, what will be the financial costs and strain on resources?
Competing interests: No competing interests
BMJ has been publishing an interesting series on multimorbidity1,2, highlighting the paucity of evidence-based research on the treatment of patients with concomitant diseases3. In this context, we read with great interest your Editorial4 and the audacious proposal by Guthrie and colleagues5 of elaborating clinical guidelines to treat co-morbid patients. However, we think that a more specific discussion on how to deal with nursing home (NH) residents is still lacking in the BMJ multimorbidity series. NH residents constitute a particular population, with different care needs compared to community-dwelling older people. Multimorbidity and polypharmacy are not an exception in NHs. Our experience in an ongoing research among 175 NHs6 in France is striking: 79.2% of the 6275 NH participating residents had at least 2 chronic conditions (they took in average 8.4 ±3.5 drugs), and more than 12% had 5 or more diseases (9.8 ±3.5 drugs). Despite this, NH residents constitute a frequently “forgotten” population in the research field (NH admission is a frequent “reason” for withdrawal from studies), especially in controlled drug trials; that is why experts in geriatrics, on the behalf of the World Health Organization, recently recommended “That national drug approval agencies consider requiring drug trials that are age appropriate and inclusive of nursing home residents before they are approved”7.
Therefore, how to redesign general practice consultations in NH residents? One possible strategy is to develop multidisciplinary team works. We are currently testing this approach in a randomized controlled trial among 1428 NH residents. However, the concern exposed by Kadam in the Editoria4 with regards to time limitations of general practitioners is highly relevant, since GPs attendance is very low in our study: 4 GPs among the 133 participating health professionals. Paradoxically, GPs reported that they are interested by this approach, but time limitations constitute an important obstacle for participation. Therefore, the use of telehealth in the context of multidisciplinary team works could be a feasible and attractive option to deal with multimorbidity and polypharmacy.
References
1. Haggerty JL. Ordering the chaos for patients with multimorbidity. BMJ. 2012;345:e5915.
2. Mangin D, Heath I, Jamoulle M. Beyond diagnosis: rising to the multimorbidity challenge. BMJ. 2012;344:e3526.
3. Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345:e5205.
4. Kadam U. Redesigning the general practice consultation to improve care for patients with multimorbidity. BMJ. 2012;345:e6202.
5. Guthrie B, Payne K, Alderson P, McMurdo MET, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ. 2012;345:e6341.
6. Barreto PS, Lapeyre-Mestre M, Mathieu C, et al. A multicentric individually-tailored controlled trial of education and professional support to nursing home staff: research protocol and baseline data of the IQUARE study. J Nutr Health Aging, In Press.
7. Tolson D, Rolland Y, Andrieu S, Aquino J-P, Beard J, Benetos A, et al. International Association of Gerontology and Geriatrics: a global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc. 2011 mars;12(3):184-9
Competing interests: No competing interests
Re: Redesigning the general practice consultation to improve care for patients with multimorbidity
Kadam’s editorial and the excellent paper by Guthrie and colleagues in the same journal (1,2), accurately describe the challenges which physicians who regularly treat older patients must address.
Guthrie and colleagues rightly point out that a single disease focus; frequently deployed by secondary care physicians invariably does not do justice to the needs of such patients.
Problem lists are advocated both by the Royal College of Physicians and the British Geriatrics Society as beneficial in the assessment and management of older medical patients (3,4); however uptake in secondary care is very patchy.
In my own practice as a physician and orthogeriatrician; I find that the use of problem lists greatly assists the management of such patients; and in a recent audit we demonstrated that use of problem lists not only enhanced the care of such patients; but also improved the quality of communication with primary care.
We introduced problem list (PL)-based record keeping in our department by increasing awareness amongst medical staff at departmental meetings. PL were based on the method of Weed (5,6,7).
50 randomly selected case notes were reviewed post-discharge and PL made for each of them by independent senior clinician assessors. Notes were scrutinized for whether PL were made during admission; whether they were updated and accurate (>70% concordance with assessors), and for accuracy of discharge summary. We found that updated and accurate PL resulted in more accurate discharge summaries.
In an era when the medical care of inpatients is frequently discontinuous; the transfer of accurate information becomes ever more important, never more so than in the care the frail older patients with multimorbidity; who constitute nearly 65% of hospital inpatients (8). The completion of accurate; updated problem lists improve the transfer of accurate clinical information, the quality of communication with primary care; and therefore the quality of care.
1. BMJ 2012;345:e6202 (Published 17 September 2012)
2. BMJ 2012;345:e6341 (Published 4 October 2012)
3. Consultant Physicians Working with Patients RCP 2008
4. Comprehensive Assessment for the Older Frail Patient in Hospital. British Geriatrics Society 2005.
5. Hyatt R; Sen D et al. Problem lists in older in-patients: an old idea whose time has come? Submitted for publication 2012
6. Weed L et al, Archive Internal medicine, 1971, Vol. 127, Pg 101-105
7. Quality control and the medical record. Weed L et al, Arch. Int. Med. 1971, 127; 101-105
8. Hospitals on the Edge? Royal College of Physicians Sept 2012
Dr Ray Hyatt; consultant physician and orthogeriatrician; East Lancashire
Dr D Sen; SpR stroke medicine; Salford.
Competing interests: No competing interests