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Table 3 Empirical and model based studies specific to multimorbidity in primary care

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

Study Methods Key findngs
Loffler [12] ENI with model: grounded theory analysis of patient interviews producing a model of coping categories, strategies and outcomes for patients •Multifaceted coping strategies among patients (aged 65–85) with multimorbidity
•Patients distinguished between emotional coping (when it is believed nothing can be done to change the situation) and problem-solving focuses of coping which they used when they had expectation of change (social and practical coping)
•Patients keen to preserve their autonomy but described emotional oscillation between anxiety and strength
•Many of them were making reasoned choices about their use of medication, even when this conflicted with professional advice
Morris [13] ENI with model: longitudinal semi-structured interviews with patients •Theoretical model produced identifying four factors which influenced self-management
1.disruption by conditions (lack of engagement, confusion, being overwhelmed, uncertainty, separation of conditions)
2.accommodation of conditions (continuity from existing illness behaviour/integration with existing practices, control over conditions and symptoms, enough understanding of conditions, confidence)
3.factors influencing the shift from accommodation to disruption (exacerbations, confusion and contradictory information, events, loss of control, medication)
4.factors influencing shift from disruption to accommodation (taking control, links between existing knowledge and experiences, adapting information and practices into new routines, interaction with health care professionals)
•Patients sought to make new diagnoses minimally disruptive and may have benefited from discussion of their priorities with professionals and/or better information on which to prioritise
Barnett [2] ENI: cross-sectional epidemiological study •Demonstrated that over 40% of patients in large Scottish sample had one or more chronic disease and over 20% had multimorbidity, defined as two or more chronic conditions
•Multimorbidity increased with age (although the absolute number of people was higher under 65 years) and with social deprivation
•Mental health disorders were a significant feature
Bower [14] ENI: qualitative interviews with GPs and practice nurses •Identified tensions primary care professionals experience between delivering care to meet externally imposed targets and achieving patients’ personal agendas
•Amongst interviewees there was limited consideration of interactions or synergies between conditions and their management
Fortin [15] ENI: psychiatric symptom questionnaire study •Significant association with increased distress as severity of morbidities increased (although not with a simple count of number of conditions suggesting that functional impact may be relevant)
Luijks [16] ENI: Group interviews with GPs •Themes that were important in the practical experiences of GPs: managing multimorbidity in the face of limited scientific evidence, applying an integrated approach, medical considerations placed into perspective of patients, shared decision-making and responsibility
•Outworking of themes influenced by the personal relationship between doctor and patient, whether the patient had mental health problems, interacting conditions and practical problems such as shortage of time and polypharmacy
Moth [17] ENI: cross-sectional study •Over 30% of Danish GP consultations were with patients who had more than one chronic disease and a rise in time consumption and contact burden was associated with this
•Diagnoses of depression and dementia led to particularly complex consultations as did additional psychosocial problems
•Few contacts were considered appropriate to delegate to other members of the primary care team by the GPs
Frueh [18] ENI: focus groups with patients •Identified problems of poor levels of function, negative psychological reactions, negative effects on relationships and interference with work or leisure activities
•Polypharmacy a major concern
•Some patients described problematic interactions with professionals and health care systems
•Patients were willing to engage in self-management and the use of technology but did not want this to replace human contact
•Support from professionals other than doctors was considered acceptable if complementary rather than replacing doctor consultations
Noel [19] ENI: cross-sectional survey •Patients with multimorbidity were significantly more likely to express willingness to learn self-management techniques than those with a single chronic condition, and a higher percentage of those with multimorbidity were willing to see non-physician providers
O’Brien [20] ENI: qualitative study of GPs and practice nurses •Management of multimorbidity experienced as an ‘endless struggle’ of trying to manage illness in the context of chaotic lives with few resources, personal consequences for some professionals and a desire to pursue holistic approaches
•Authors conclude that data confirms the presence of an inverse care law in the context of multimorbidity
•Professionals were concerned that these patients lacked the self-efficacy to pursue self-management and thought there was a need for health care delivery systems to be redesigned
Schuling [21] ENI: qualitative focus groups with GPs •GPs were able to delineate differences between symptomatic and preventative medication but found the latter more difficult to deprescribe with concerns about patients feeling they had given up on, conversations about life expectancy versus quality, and contradicting guidelines
Smith [22] ENI: qualitative focus groups with GPs and pharmacists •Problems with health systems included: lack of time, inter-professional communication difficulties and fragmentation of care
•Personal issues for these clinicians with respect to roles, clinical uncertainty, avoidance, patient concerns and potential management solutions
Townsend [23] ENI: patient interviews using Bourdieu’s concepts for analysis •Broader cultural structures became part of individuals’ narratives of their illness with for example GPs perceived to be the dispenser of capital (e.g. legitimising the sick role)
•Patients experienced losses of previously taken for granted activities, disrupted family relationships, and awareness of a sense that they were not fulfilling societal expectations
•Many adopted strategies such as stoicism to try and regain control and avoid being judged as ‘failures’
AGS [24] LR with model •Model approach recommends first focusing on the each patient’s primary concern before either addressing a specific aspect of care in negotiation with the patient or reviewing the whole care plan
•Consideration of prognosis, interactions within and among conditions and treatments, benefit and harm and regular reassessment should all form part of the negotiation
•Model was not tested in practice.
Boyd [1] TO with model •Draws heavily on the ‘Chronic Care Model’ [25] with its emphasis on a patient-centred approach
Soubhi [26] TO with model •Theoretical model of care which draws on communities of practice theory to develop shared learning between patients, their families and professionals