Informing intervention design in multimorbidity: An exploration of difficult decision making using chart stimulated recall

Published in European Journal of General Practice Vol.20 - Abstracts for the EGPRN

Background: To date, research on improving the management of multimorbidity in primary care has concentrated on organisational and patient-orientated interventions. Few studies have examined the role of professional-orientated interventions.

Research Question: To explore how GPs currently deal with challenges in managing multimorbidity, for identifying targets suitable in professional-orientated interventions.

Method: Design: In-depth qualitative interviews incorporating chart stimulated recall, a clinical assessment tool that uses a medical chart to stimulate a physician's recall of a case and its management. Setting: Primary care in the Republic of Ireland. Participants: GPs purposively sampled from continuing professional development groups, using sampling criteria of: length of time qualified; location (rural/ urban); and practice size (single/ group practices). Analysis: Interviews were coded using the grounded theory method of constant comparison and theory was developed iteratively.

Results: Twenty interviews were conducted. The data demonstrates how decision making in multimorbidity requires integration of information from multiple sources, including the patient, specialists, evidence based medicine, and the expertise of GP themselves. These factors vary in importance on a case-by-case basis, and their relative contributions are integrated and ‘balanced’ by the GP to make the most appropriate decision for that patient. Difficulties arise when a factor contributes too much or too little, unbalancing the decision making process. GPs respond to this using strategies such as ‘broadening the loop’ to include other professionals, ‘maintaining the status quo’ or acting as a ‘final arbitrator.’ Imbalances most commonly arose when GPs were isolated from the support of other generalists (GPs/ specialists), or had difficulties in the doctor-patient relationship.

Conclusion: This study identified potential weaknesses in decision making in multimorbidity, such as GPs’ ability to access professional support and communication with patients. These findings will inform the development of a professional-orientated intervention, to assist the provision of multimorbidity care.