The Ariadne principles: how to handle multimorbidity in primary care consultations

Abstract

Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.Please see related article: http://www.biomedcentral.com/1741-7015/12/222.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0223-1) contains supplementary material, which is available to authorized users.

Discordance Between Drug Adherence as Reported by Patients and Drug Importance as Assessed by Physicians

“…A first way to reconcile viewpoints could be to encourage better patient-physician collaboration in drug treatment. In the current context of managing multimorbidity in primary care, 27,28 patient-centered care with shared decision making seems to be a key to managing patient complexity 25,28,29 and to achieving minimally disruptive medicine. 30 Physicians have to reach an optimal patientphysician relationship, which requires good communication and may result in better health outcomes, 31 especially for medication adherence.…”

Is Australian primary care practice equipped to provide multimorbidity care?

“…In some instances, one option may far outweigh the others, while others might be preferencesensitive (244,246). Preference-sensitive decisions, are those for which there is limited evidence informing the options; the benefits and harms of the provided options are similar; or the evidence does not favour one option over another (141,(247)(248)(249)(250)(251)(252). In these situations the preferences and priorities of the patient need to be considered, as the value placed on the expected benefits, harms and/or outcomes may differ across clinicians and patients, across patients faced with the same decision, and within patients over time (244,246,251,253).…”

“…Subsequent authors (141,247,248,255) have identified similar components or steps, but central to all of these works is the focus on engaging and involving patients in decision-making processes. Of note is the emphasis on sharing information in order to achieve shared decision-making.…”

“…A recent Cochrane review of 15 randomised trials examining personalised care planning for adults with chronic conditions, found no studies that explicitly examined whether care plans led to improved physical, psychological, or subjective health, or improved capabilities for self-management for patients with multiple conditions (335). Acknowledging the limited evidence informing multimorbidity care (16,62), researchers have increasingly argued in favour of approaches that move beyond a focus on disease (12,141,248,250,309). These arguments are grounded within a patient-centred approach, but also stem from empirical work identifying the impractical and potentially hazardous outcomes that can arise when disease-centric interventions that target single conditions (such as clinical practice guidelines) are applied across multiple conditions (62,303).…”

“…These arguments are grounded within a patient-centred approach, but also stem from empirical work identifying the impractical and potentially hazardous outcomes that can arise when disease-centric interventions that target single conditions (such as clinical practice guidelines) are applied across multiple conditions (62,303). Care plans have been emphasised as a mechanism for enhancing the provision of multimorbidity care by supporting patient-centred care (12,21,62,141,248,335), although in practice patients report diverse experiences and different levels of engagement in care planning processes (275,321,390,391). To achieve greater consistency in care planning and the resultant care plan broader system level interventions are required (136,392).…”