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