Negotiating evidence-based and patient-centred approaches to the management of multimorbidity across the adult life span: the Australian general practitioner experience

Author: Raechel Damarell

Damarell, Raechel, 2021 Negotiating evidence-based and patient-centred approaches to the management of multimorbidity across the adult life span: the Australian general practitioner experience, Flinders University, College of Nursing and Health Sciences

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People with multimorbidity comprise an unprecedently large proportion of general practice patients. Increasingly, many will be of advanced age with life-limiting conditions requiring end-oflife care. Healthcare systems, policymakers, and patients themselves expect general practitioners to provide care that is both patient-centred and aligned with the tenets of evidence-based medicine. However, general practitioners may find this work challenging if constrained by system structures and research evidence oriented to single condition care. International studies suggest general practitioners are confronted with high levels of clinical uncertainty due to the complex nature of multimorbidity and needing to reconcile multiple drug risk/benefit ratios for each individual patient. There is currently little research describing Australian general practitioner

perspectives on multimorbidity and their patient management experiences. Healthcare reformers require this knowledge if it reveals challenges jeopardising the safety of patients or the sustainability of general practice.

This research is the first to explore the Australian general practitioner experience of managing patients with multimorbidity across the chronic management and end-of-life phases of care. Furthermore, it is unique in examining the implications of multimorbidity for the normative evidence-based and patient-centred expectations on general practitioner decision-making. The research program used a mixed methods exploratory sequential design of three interdependent phases and four studies to examine the general practitioner experience. The studies comprised a systematic review of qualitative studies of general practitioner perspectives, a content analysis of Australian chronic disease guidelines, in-depth interviews, and a quantitative cross-sectional survey of Australian general practitioners.

Most Australian general practitioner participants considered research evidence to have limited generalisability to their patients with multimorbidity. However, they differed in the ways they acted on guideline recommendations. Some adhered closely to evidence in formulating care plans, despite concern for patient safety. More, however, said they relied on fostered knowledge of individual patients to inform their care deliberations. Concerningly, general practitioners perceived the fragmented sectoral structure of the Australian healthcare system and its fee-forservice model of payment as incompatible with a patient-centred approach to care. Fee-forservice appears to penalise them financially from taking the time required to provide adequate care to complex patients. It also discourages residential aged care work and home visitations. Almost a third of general practitioners refer patients to other general practitioners or specialist palliative care at the end of life, not considering this as part of their role. The majority believed multimorbidity care became simpler at the end of life. However, multimorbidity could challenge prognostication and the timing of conversations around changing care goals.

General practice is at the frontline of multimorbidity care within the Australian healthcare system, yet it appears to be facing some significant resourcing and evidence challenges. According to general practitioners, these difficulties threaten the quality of the care they provide, their work satisfaction, and ultimately the sustainability of general practice. As Australia faces the reality of an ageing population with expanding needs for complex and costly care, the Australian Federal Government needs to attend to the concerns of those practitioners in its vanguard and invest in strengthening general practice. Guideline developers and research producers might also explore innovative ways to support clinical decision-making for patients with multimorbidity.

Keywords: Australia, General practice, multimorbidity, end-of-life care, palliative care, evidence-based medicine, patient-centred care, mixed methods

Subject: Health Service Management thesis

Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Nursing and Health Sciences
Supervisor: Professor Jennifer Tieman