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

被引:91
作者
Damarell, Raechel A. [1 ]
Morgan, Deidre D. [1 ]
Tieman, Jennifer J. [1 ]
机构
[1] Flinders Univ S Australia, Coll Nursing & Hlth Sci, Res Ctr Palliat Care Death & Dying, GPO Box 2100, Adelaide, SA 5001, Australia
关键词
Multimorbidity; General practice; Patient-centred care; Evidence-based practice; Qualitative; Meta-synthesis; CLINICAL-PRACTICE GUIDELINES; MULTIPLE CHRONIC CONDITIONS; PRIMARY-CARE; OLDER-PEOPLE; HEALTH-CARE; DECISION-MAKING; CHRONIC DISEASES; OF-LIFE; CONTINUITY; CONSULTATIONS;
D O I
10.1186/s12875-020-01197-8
中图分类号
R1 [预防医学、卫生学];
学科分类号
1004 ; 120402 ;
摘要
BackgroundGeneral 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.MethodsSystematic 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.ResultsThirty-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.ConclusionsGPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient's unique circumstances, and useable knowledge of each individual's capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.
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