Is Australian primary care practice equipped to provide multimorbidity care?

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Background: Australia’s population health profile is characterized by rapidly growing numbers of people living with multiple chronic conditions. The challenges of delivering multimorbidity care are particularly salient for primary care as this is where the majority of chronic disease care is provided. Primary care practice tools that promote consistent evidence-based and patient-centred approaches to patient care are one component of the system-wide change needed to address this complex health systems challenge. Tools such as clinical practice guidelines, care plans and patient decision aids exist to support the management of single chronic diseases but their relevance and usefulness in the management of multiple conditions is unclear. Objectives: The overall aim of this thesis is to examine whether primary care practice tools developed to support the management of chronic disease in Australian primary care practice are transferable to the management of multiple chronic conditions. In answering this question the thesis considered: • What is known about living with multiple chronic conditions? • What is known about managing multimorbidity in primary care? • What primary care practice tools are currently in use to support chronic disease management? • What are the strengths and limitations of these primary care practice tools for supporting core components of multimorbidity care? • What are the implications of these findings for policy and practice? Design: Key elements of multimorbidity care in primary care practice were identified from the literature. The primary care practice tools themselves were identified through the published literature and in consultation with expert stakeholders to validate the selection of tools for analysis. Three tools identified as currently used or available to general practitioners in Australia were included for detailed review: clinical practice guidelines; care plans; and patient decision aids. Comprehensive searches of published and non-published sources were undertaken to identify existing tools relevant to multimorbidity care in each of these categories. Document analysis, directed by the framework approach, was used to systematically and rigorously assess the tools and to identify their strengths and shortcomings in relation to multimorbidity care. The Appraisal of Guidelines, Research and Evaluation (AGREE II) instrument was also used to assess the quality of clinical practice guidelines. Results: The analysis revealed strengths and limitations with each of the identified tools in relation to the management of multiple conditions. Of the thirteen clinical practice guidelines reviewed, twelve included at least one core patient-preference recommendation, but more explicit acknowledgement of these recommendations is required. Although ten guidelines used consumer engagement processes during guideline development, these processes were generally limited. More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Care plan templates also demonstrated limitations in their ability to support multimorbidity care. None of the sixteen included care plan templates addressed all of the criteria identified as necessary for care planning in a multimorbidity context, but most addressed one or more to at least some extent. Patient preferences, was the most commonly addressed criterion. Substantially less emphasis was placed on priority setting and the review of individual management goals. None of the care plan templates identified conflicts and synergies. The analysis also revealed the majority of templates are pre-filled and are formatted to consider conditions individually, potentially limiting their ability to contribute to genuine care planning and patient-centred care. Twenty-one patient decision aids were identified and reviewed. Key methods used by patient decision aids to acknowledge multiple conditions included flagging potential complications, prompting discussion between the patient and clinician and identifying how further illness could be prevented. All of the patient decision aids reviewed contributed to shared decision-making processes, but scope exists for more systematic presentation. Conclusion: Each of the three tools reviewed captures some elements of what is required to provide multimorbidity care but none was found to comprehensively incorporate the key components identified as integral to effective multimorbidity care. Adaptations are needed to improve the ability of each to contribute to patient-centred multimorbidity care. Furthermore, the thesis proposes how these primary care practice tools could be integrated to enhance shared decision-making and the incorporation of patient preferences.