How to deal with the challenges of multimorbidity in general practice?
From its start, the case-based workshop during the EPCCS CV Summit was very interactive, as patient cases frequently encountered in general practice were discussed: situations not limited to one disease and one therapy.
While guidelines often focus on a single disease, GPs are well aware that many patients have multiple comorbidities. Oftentimes, guidelines do not give adequate guidance on how to manage patients with several conditions and therapies. The disease-specific guidelines lack integration, thus various guidelines need to be considered for good care of a single patient.
Most RCT evidence has limited applicability to patients with multimorbidity, because complex patients are often excluded from trials. Some evidence is available, however, based on subgroup analyses in large RCT’s, but these data do not get a lot of attention.
Not only physical conditions are relevant, but the GP should also consider psychosocial factors and mental problems or illness. The physical and psychological domains may not only affect each other, but also medications may interact, or confer risks to develop other conditions. In addition, patients not only have to manage their disease and their therapy, but they also have family (all with their own joys and issues), jobs, household and/or other activities and issues to take care of.
Appropriate consideration of all these factors is demanding for practitioners, and better evidence and approaches for management are welcomed. This may include a shift towards focus on more patient-centred goals, rather than disease-centred goals, and similarly, reimbursement systems should be based on quality of care. Medical decision-making should be based more on optimising benefit, minimizing harm and enhancing quality of life, and the treatment complexity and feasibility need to be assessed. All along, patient preferences should be incorporated. While evidence from published reports should be applied, it is also important to acknowledge the limitations of the available evidence base.
Other presentations during the EPCCS CV Summit also considered the challenges imposed by multimorbidity, and this topic will continue to receive attention during future EPCCS Summits.