Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery

Abstract

BackgroundPeople are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked ‘what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?’MethodsThis realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.ResultsThe final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.ConclusionsThis study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.Trial registrationPROSPERO International prospective register of systematic reviews CRD42013003862Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0234-9) contains supplementary material, which is available to authorized users.

The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review

“…14 Our objective was to perform, for the first time, a meta-analytic review of RCTs to investigate the application and efficacy of MBIs in primary care patients. We had several initial hypotheses 14 : (1) the number of welldesigned studies in primary care is greater than that in other levels of care, because most patients receive long-term assistance here; (2) the clinical impact of MBIs in primary care patients is greater than that at other levels of the health system, because such patients adhere more to mindfulness programs; (3) the range of health conditions addressed by MBIs is larger in primary care (including health promotion in at-risk population and application in patients with multimorbidity), 15 owing to unrestricted access to such care; and (4) as MBIs are complex interventions in primary care, their program contents are systematically adapted to patients' local needs, services, culture, and epidemiology.…”

Managing diabetes in people with dementia: a realist review

“…The results of the RCT 103 and accompanying process evaluation 104 and qualitative study 60 suggest that SM support did not fit with a biomedically focused ethos and, as a result, practices did not give it the priority needed to embed it in the day-to-day work of primary care. A qualitative study conducted in the USA also found that an overemphasis on biometrics and medicalisation by HCPs was a Several studies 70,98,134 suggested that there is 'goal divergence' between patients, carers and HCPs, particularly when there is medical uncertainty, as is generally the case with the dynamic nature of living with multiple conditions. In a realist synthesis, Yardley et al 134 suggested that, to reconcile discrepancies between the goals of patients, carers and HCPs, there is a need for less emphasis on a 'diagnostic-cure model'.…”

“…A qualitative study conducted in the USA also found that an overemphasis on biometrics and medicalisation by HCPs was a Several studies 70,98,134 suggested that there is 'goal divergence' between patients, carers and HCPs, particularly when there is medical uncertainty, as is generally the case with the dynamic nature of living with multiple conditions. In a realist synthesis, Yardley et al 134 suggested that, to reconcile discrepancies between the goals of patients, carers and HCPs, there is a need for less emphasis on a 'diagnostic-cure model'. Patient-centred communication and collaboration between HCPs and patients/families appear to be key to achieving individualised care 70,98,134 (see also Context-mechanism-outcome 2: person-centred approaches to care planning).…”

“…In a realist synthesis, Yardley et al 134 suggested that, to reconcile discrepancies between the goals of patients, carers and HCPs, there is a need for less emphasis on a 'diagnostic-cure model'. Patient-centred communication and collaboration between HCPs and patients/families appear to be key to achieving individualised care 70,98,134 (see also Context-mechanism-outcome 2: person-centred approaches to care planning).…”

“…Twenty-two of the 79 research papers were reviews. Of those, 15 were systematic reviews, 79,80,82,84,89,90,93,101,[125][126][127]131,132,137,143 one was a realist review 134 and six were non-systematic reviews. 25,37,45,66,73,105 The rest of the research papers (n = 57) related to primary research.…”