Health and treatment priorities in patients with multimorbidity: Report on a workshop from the European General Practice Network meeting ‘Research on multimorbidity in general practice’

Abstract

Setting health and treatment priorities is necessary when caring for multiple and complex patient issues. This is already done in the doctorpatient consultation—yet implicitly rather than explicitly. The aim of this European General Practice Network workshop was to advance a consultation approach that deals with shared priority setting. The workshop was divided into three parts: (1) how to gain a comprehensive health overview for patients with multiple problems as a basis for priority setting; (2) how to establish priorities considering patient and doctor perspectives; and (3) how to practice a communication style that achieves shared priority setting. The workshop participants preferred to gain information on patients’ health status using documentations from patient records rather than conducting systematic assessments. The group emphasized that medical as well as everyday life problems need to be considered when determining priorities, a procedure that requires time and resources not readily available in daily practice. Existing skills for person-centred communication with patients should be applied in order to agree on priorities. Overall it became apparent how challenging it is to arrange and prioritize an array of health problems in a consultation with patients. Existing concepts augmented by innovative systematic methods may be the way forward.

Keywords::

• Multimorbidity
• aged
• family practice
• attitude to health
• patient-centred care

Background

In general practice it is often necessary and in the best interest of the individual patient to determine health and treatment priorities. This is particularly true for older patients with multimorbidity. They contact their general practitioners (GPs) with several issues and a complex agenda. Doctors, however, are sometimes overwhelmed by the complexity that needs untangling. Disease management programmes and guidelines are meant to enhance the quality of practice, but they focus on single diseases and neglect their interaction as well as the patients’ perspective. Gain may turn into harm, when recommendations for care are simply added up. The accumulation of treatment regimens imposes medication risks as well as excessive demands on health behaviour and the daily lives of older people (1).

‘Research on multimorbidity in general practice’ was the topic of the last European General Practice Research Network meeting held in Dubrovnik on the 15–18 October 2009. This presented a good oppor-tunity to exchange ideas on the subject ‘How to determine health and treatment priorities in patients with multimorbidity’ in a preconference workshop.

The aim of this three-hour workshop was to advance an innovative consultation approach that deals with shared priority setting. In this newly structured consultation, patients will have the opportunity to express their perceptions on the importance of each of their health problems. Doctors, in turn, inform about their views on treatment and care priorities. Patients and doctors will then negotiate a common framework of care and treatment priorities (as well as posteriorities) based on their respective views on priorities.

Method

Fifteen GPs and researchers in primary care from seven European countries (BE, DE, DK, HR, IE, NL, RS) participated in the workshop. It was divided into three parts of approximately equal length. The first part dealt with the question of how to build a comprehensive health overview as a basis for priority setting. The participants were asked to form three groups in order to come up with solutions suitable in general practice. In the second part , we analysed the different views that patients and doctors have on health problems and their respective priorities. We first presented the results of our project ‘Prefcheck’ funded by the German Ministry of Education and Research (01GX0744) that provide insight into views on priorities by patients and their doctors (2). The workshop participants were then asked to reflect on their own practice on priority setting with older patients using a case study. In the final part , we presented findings from our patients’ and doctors’ interviews on patient involvement in decision making. Again three groups were formed to examine ways of engaging patients in a person-centred approach for priority setting.

Below we give a summary of each workshop part, divided into a short introduction into the topic, followed by a short presentation of study findings, and ending with the results of the workshop discussions. In the conclusion we reflect on all three parts of the workshop results.

Part I: How to gain an overview on health problems in patients with multimorbidity

Some European countries offer a geriatric assessment to older primary care patients. Generally, it is a standardized diagnostic procedure that covers specific health domains focussing on the particular needs of the elderly population. In fact, there are lots of different assessment instruments in use. The questions were whether GPs from European countries actually use the assessment, what experiences they have and whether it is actually necessary to gain a health overview in this way.

To encourage the discussion we presented the STEP-assessment, as it has been developed in a European Concerted Action and combines bio-psycho-social and functional aspects of health. In this assessment, nurses conduct a set of questionnaires and some standardized tests (3). Studies have shown that the procedure takes approximately 50 min and uncovers on average 13 health problems per patient; nearly 20% of these are not previously known to their GPs (4,5).

Most of the workshop participants reported that they did not apply a comprehensive geriatric assessment approach (CGA) in daily practice due to system, patient, and doctor related reasons. It was suggested that health care systems were not ready for CGAs. There were no allowances for the expenditure of time, no financial incentives and no possibilities externally to demonstrate improvements in the quality of care. In addition, the assessment could be tiring for the patient and might cause anxieties, raise high expectations, and even initiate unwarranted diagnostic and therapeutic procedures. Some participants questioned the validity, feasibility, and its benefit. They felt that CGA may duplicate already existing information, which has been collected in the patient records over time. The participants also voiced doubts on their responsibility for all health related social and financial problems of patients.

As a practicable solution, the participants preferred to gain information on patients’ health status falling back on patient records with their cumulated entries on encounters and diagnoses rather than building a systematic overview. In their view, only for specific health domains were standard questionnaires or tests acceptable.

Part II: Health and treatment priorities: Which problems are important for whom and why?

In order to deepen the understanding of priority setting with older patients, we presented the findings of our qualitative study on 34 patients and their 9 doctors (2). The patients had completed the STEP assessment and were then asked to rate their problems as important or unimportant as well as to explain the reasons for their ratings. The doctors independently rated the patient problems according to their own views and also gave their reasons. Doctors and patients often disagreed on the importance of health problems. Patients considered medical problems as well as issues of daily functioning and social participation important. Patients deemed conditions relevant, if they were associated with emotional strain or with a feeling of loneliness/uselessness, or if the conditions were age related and not accepted as part of normal ageing. Doctors’ priorities, however, were more determined by medical aspects of the disease. Doctors found health problems important, if the disease was severe, had a poor prognosis or needed lifestyle changes. If doctors did not perceive suitable actions or did not feel in charge of a specific problem, they rated it as unimportant. Health problems were important to both, patient and doctor, if loss of independent living was at threat.

The group then worked on a case study of a real patient, an 84-year old lady with 15 health problems. They reflected their own practice when consulting and treating this patient. It became apparent, that medical as well as everyday life aspects are both important in the elaboration of care and treatment plans with older patients. The participants stated that doctors should consider the patients’ perspective as well as their own. This, however, would be a complex process that needed time and resources not readily available in daily practice. The working group emphasized that doctors alone could not solve all problems. Delegation and teamwork were essential.

Part III: Communication and patient involvement on health and treatment priorities in consultations

In order to arrive at common care and treatment priorities, it is necessary that doctors and patients understand and communicate their individual per-spectives and motives. This requires patient involvement in all stages of the consultation (6).

In our interviews with 34 patients we had enquired about their willingness to be involved. The level of involvement depended on the nature of the problem. If it was a medical theme, patients preferred to follow the professional recommendation of their GP; however, if the theme had a direct impact on their daily lives (e.g. changes at home), the patients themselves wanted to make the decision. In general, patients expressed a need for undivided attention, understandable information, time, and a calm atmosphere in the consultation. Our interviews with nine doctors showed that although they maintained the position that patient involvement was important, some of the doctors provided deviant definitions of the concept. Patient-involvement was understood in four different ways:

1. Patients put into practice, what doctors say.

2. Doctors offer one option, patients accept it.

3. Doctors submit several options; patients do or do not accept them.

4. Doctors offer different options and discuss them together with the patients.

Doctors especially saw limitations in patient involvement in case of emergency, risk of harm or self-harm, patient’s refusal, and perceived lack of understanding (2).

We discussed these findings and asked the workshop participants how they would put a consultation with priority setting into practice. It was suggested that it would be sufficient to fall back on methods of good communication, such as open questioning, careful listening and applying the ICE (ideas, concerns, expectations) concept (7). The process of setting priorities may also be one that needs time for reflection. More than one contact may be necessary to establish common priorities. Patients may be sent home to do homework and rank their priorities. Overall it was found that basic operational conditions such as more time and specialised multimorbidity clinics were needed. The group suggested that software programmes may facilitate an overview of patients’ problems and priorities.

Discussion

Setting shared priorities becomes a challenging necessity when dealing with the multiple health problems of older patients. There is no established procedure on how to gain a health overview for patients with multimorbidity as a basis for priority setting. The workshop participants preferred to utilize already documented health problems of patient records; this however raises questions. Is it possible to filter those health problems that are still relevant today? Is it possible to retrieve all relevant problems by chart review? It remains to be proven that current documentation habits in patient records are suitable for a health overview that covers all ongoing problems of the patient.

Priorities are already set in consultations today, yet implicitly rather than explicitly. Doctors assume that patients’ priorities are the ones that they offer as reasons for encounter—a questionable conjecture. Doctors’ views on priorities are rather controlled by medical aspects of disease; and, admittedly, it is overwhelming to meet all patients’ prior needs as laid down in the WONCA tree with its holistic and comprehensive claim under given health care conditions (8). We need a professional debate on how to put the WONCA definition of family medicine into practice without it having to shed its leaves.

At present it is questionable whether treatment or care plans for older patients are truly shared. Existing concepts of person-centred communication as well as innovative systematic methods that arrange and prioritise an array of health problems, as tested in our ‘PrefCheck’ project, may be the way forward.

Acknowledgements

The authors thank all workshop participants for their dedicated collaboration: F. Buntinx (BE), L. Peremans (BE), E. Hauswaldt (DE), J. Hauswaldt (DE), C. Müller (DE), I. Voigt (DE), J. Wrede (DE), K. Larsen (DK), P. Jankovic (RS), N. O’Brien (IE), A. Murphy (IE), S. Aarts (NL), M. van den Akker (NL), H. Jellema (NL), H. Luijks (NL).

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.