Intended for healthcare professionals

Rapid response to:


Redesigning the general practice consultation to improve care for patients with multimorbidity

BMJ 2012; 345 doi: (Published 17 September 2012) Cite this as: BMJ 2012;345:e6202

Rapid Response:

Re: Redesigning the general practice consultation to improve care for patients with multimorbidity

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.

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

16 October 2012
Philipe S Barreto
Yves Rolland
Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse
37, Allées Jules Guesde. 31000 Toulouse, France.