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Taking into consideration the results of the written external feedback of 24 respondents Additional file 1 , we refined the principles. The key issues that came to light during the group discussions were passed on to all authors and agreement was sought on necessary changes to the manuscript. This paper reports on the key principles that emerged from this month iterative process to provide guidance on multimorbidity management for family physicians in their context-specific clinical decision making.

Stott and Davis described a widely used framework aimed at helping family physicians to broaden the consultation beyond the presenting complaint with the four following elements: i management of the presenting problems, ii management of continuing problems, iii modification of help-seeking behaviors, and iv opportunistic health promotion [ 16 ]. Patients with multimorbidity will also require attention to ongoing management of their other problems, including a check on progress, adherence to treatment, and any mention of secondary prevention.

This will compete for time during the consultation, and require careful prioritization. In our case example, Mr. It is important to avoid an excessively high treatment burden of patients that interferes with their daily life and results in adherence problems with treatments and appointments, both for presenting problems and ongoing diseases. For example, Mr. P is highly motivated and adheres to his treatment plan. However, at T3 he was unable to cope with either the treatment plan or ambulatory appointments.

Preventive activities should include appropriate age- and sex-specific prevention, but the presence of multimorbidity may overload patients and physicians. For instance, for Mr. P, at least seven primary prevention measures are recommended including a screening for colon cancer, osteoporosis and kidney disease, and visual and hearing impairment, as well as a fall assessment and a comprehensive eye examination [ 22 ].

Often, it is not feasible nor desirable to work-up all elements of a consultation within one appointment. Our principles are not limited to one consultation, but are expected to be applied continuously while emphasizing certain aspects in each consultation. Central to the process is the sharing of realistic treatment goals by physician and patient.

They result from a thorough interaction assessment of conditions and treatments — a necessary starting point for both presenting and continuing problems — and a prioritization of health problems that takes into account patient preferences. Individualized management realizes the best available options of care diagnostics and treatment, but also in primary and secondary prevention to achieve the goals.

Goal attainment is followed-up in accordance with a re-assessment during planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context of the patient may provoke the re- start of the process. The main forces driving the care of patients with multimorbidity are interacting conditions and treatments , as opposed to patients with a single disease even if complicated.

Life-time medical history of Mr. T1 to T3: Visits with patient at three different times see text. P is a year-old, married and highly educated man living at home with his wife. The course of his medical history is depicted in Figure 1. We selected three periods of Mr. P is 52 years old and the main focus of his medical care lies on his diabetes and hypertension.

He measures his blood glucose level and blood pressure on a daily basis. He takes oral hypoglycemics and antihypertensives, and follows dietary restrictions. For asthma control he uses inhalers. His benign prostatic hyperplasia is only mildly symptomatic. At T2 , Mr. P is a year-old pensioner who has been admitted to hospital with angina pectoris. A two-vessel coronary artery disease CAD is diagnosed, and Mr. P is discharged after a percutaneous coronary intervention that included stent implantation Stent-PCI at one vessel.

Ten months later, he is re-admitted with angina pectoris. Since T1, a primary Parkinson syndrome and a peripheral neuropathy have been newly diagnosed. The number of prescriptions has risen from 5 oral drugs to At T3 , Mr. P is 75 years old. He presents with a cough, problems swallowing and hypersalivation, increased stiffness, severe back pain, fluctuating blood pressure, and low mood.

He needs help with most activities of daily living and finds it increasingly difficult to follow his treatment plan encompassing 14 oral drugs, and two inhalers with seven times daily dosing. The administration of amantadine resulted in urinary retention, requiring the insertion of a transitory indwelling urine catheter. After drug withdrawal, the catheter could be removed. To date, he has no cognitive deficits and conducts all instrumental activities of daily living with reduced speed but without external support.

He practices physical exercise daily and is well integrated socially. In contrast to patients with single diseases, in patients with multimorbidity a broad variety of potential interactions between diseases and treatments may occur which may worsen the course of the disease s , cause avoidable symptoms, and complicate diagnostic work-up as well as treatment and prevention [ 24 ]. Therefore, relevant mechanisms which have to be checked separately are drug-drug, drug-disease, and disease-disease interactions.

Apart from possible adverse drug effects, which are more likely in multiple medications [ 25 ], complex medication regimens should trigger awareness of the increased risk of reduced adherence or under-treatment that are both typical risks of polypharmacy [ 26 ],[ 27 ]. It is important to keep a list of all individual diagnoses and to assess their severity and impact on quality of life and functioning.

Symptoms such as pain, fatigue, shortness of breath, or dizziness have a great impact on quality of life and life satisfaction and thus — likely — on patient preferences [ 28 ]. An active monitoring for signs and symptoms of psychological problems, mental disorders, and cognitive dysfunction is essential, as is the identification of social circumstances that may influence care seeking, patient health, and the need for assistance in activities of daily living [ 30 ],[ 31 ].

In patients with multiple diseases, the balance between resources and burden may be disrupted by diseases, such as depression, anxiety, or by contextual circumstances living conditions, level of social support, loneliness, or financial constraints [ 1 ],[ 9 ],[ 32 ]. Health literacy is challenged when complex health regimens are put in place. If the interactions of planned treatment result in more harm than good, or treatment goals compete with one another, or the total treatment burden is inacceptable, then priorities must be set.

Family physicians should be aware of their own potentially differing preferences [ 11 ] that may be the result of extrinsic factors, such as the fear of financial or legal threats. Family physicians may assess preferences on the basis of a discussion and rank the outcomes accordingly [ 33 ]. Patients may prioritize desired outcomes, such as symptom relief, preservation of physical, mental, and social functioning, or disease prevention, but also the avoidance of adverse outcomes, such as nausea, drowsiness, dizziness, lethargy, or confusion [ 34 ].

Family physicians should enquire about these preferences but also assess the acceptance of several treatments and the ability of the patient to manage them [ 9 ],[ 32 ]. Although, patients may want more or less responsibility for their health decision [ 35 ],[ 36 ], a neglected preference can be harmful [ 37 ].

The treatment goals should ideally be defined in terms of time, that is, at what point in time this goal should be reached or a benefit obtained. Such clarifications may support monitoring and re-discussing priorities when goals are not attained or not at the expected time. In particular, in typically long-lasting family physician-patient relationships [ 19 ], preferences, priorities, and treatment goals have to be re-assessed regularly, as they may change, or even be reversed when, for example, new diseases develop or contextual changes occur [ 38 ].

After the prioritization of problems, a care plan which sets out monitoring, treatment, prevention, and self- management advice should be developed to meet shared and realistic treatment goals. A central issue is whether the expected benefits of an intervention diagnostic, therapeutic, or preventive outweigh the likely downsides and harms to the individual patient.

Hence, benefits are more likely to outweigh harms; whereas low risk patients may expect less benefit but are exposed to the same potential harms [ 39 ]. A general model for treatment decisions. For example, for a patient with both rheumatoid arthritis and heart failure, any benefit of non-steroidal anti-inflammatory drugs needs to be weighed against the higher risk of fluid retention and its effects on heart failure [ 41 ].

The simple model may be complicated with multimorbidity by drug-drug, drug-disease, and disease-disease interactions, and further complicated by the paucity of data about their extent. The first consequence is that we should generally be more conservative when introducing additional treatments while at the same time remaining aware of the risk of under-treatment.

Secondly, we have to anticipate unintended consequences of any new treatment that is to check for potential interactions ex ante and ex post follow-up. The identification of interactions can be facilitated through collaboration with community pharmacists and the optimal use of technology.

User-friendly applications, such as optimized support systems alerting for potentially inappropriate medication or interactions, are useful, but are incomplete without a judgment of their clinical relevance. Thirdly, complex medication regimens are challenging for patients to comply with.

Sometimes simple solutions exist, such as altering preparations to modified release formulations or using simple prompts or reminders e. The careful coordination of care — the often necessary involvement of different health care professionals at different levels and settings of care — is an important component of individualized care and should ensure continuity [ 19 ]. Appointments should be prioritized by applying a minimally disruptive approach [ 9 ] to meeting agreed treatment goals.

Care plans for patients with multimorbidity are not static, but subject to continuous adaptation depending on changes in the prioritization of problems, goal attainment, or as a result of co-occurring events or altering contexts. It is also important that the patient has a family physician in charge of his overall health process [ 19 ].

P to slow down the progression of his coronary artery disease. This benefit outweighed potential harms of worsening his asthma. P agreed and his physician provided instructions for safety netting and regular follow-ups. However, the ambulatory intensification of drug therapy led to new problems. P agreed to admission to specialized care. Although complicated by an adverse drug event due to a drug-disease interaction amantadine and benign prostatic hyperplasia , his situation finally improved.

Over his life-course, treatment goals shifted from disease-specific e. P still has a strong preference for survival at good quality , and is willing and capable of coping with his diseases and treatment burden.

In accordance with this and his general prognosis, prioritization has not led to a de-intensification of his treatment but to a critical selection of further preventive activities. We have formulated a comprehensive longitudinal approach to the goal-oriented management of patients with multimorbidity in primary care, i. For the heterogeneous group of patients with multimorbidity, there are no easy solutions that apply to all patients.

Therefore, we have developed a set of principles that can be used to structure and enrich the approach to consultations as suggested by Stott and Davis and to improve patient outcomes using tailor-made approaches. This may be the case with treatments which may have beneficial effects to one disease and the potential to cause harm in another at the same time.

Although, physician and patient share the decision for this option, this does not necessarily prevent negative consequences. In other circumstances, patient and physician may share a decision against an effective therapy in order to reduce the treatment burden. This decision may well result in a preventable major event.

Only little is known about patients and caregivers coping with the negative consequences of such actions [ 34 ],[ 43 ]. Prioritization is a process of assigning priorities to problems or tasks but does not necessarily mean a reduction. Furthermore, our principles support a critical approach to guidelines in a patient with multimorbidity, as we have currently little to replace them [ 44 ]. The application of guidelines may be safe and effective when potential interactions are checked for, shared treatment goals are met, and the effects are closely followed-up on.

This may also have consequences for guideline-based processes such as disease management programs and financial incentives in health care systems. We do not pretend to have a final solution to the complex problem of managing patients with multimorbidity in primary care for several reasons. Firstly, although we received feedback from GPs and primary care researchers, the application of the proposed key principles has not yet been tested and the development process did not involve the patient.

Secondly, multimorbidity in itself is not a homogeneous condition. Not only the number and severity of conditions, but also other factors such as social issues or mental illness may determine multimorbidity [ 49 ],[ 50 ]. Thirdly, the implementation of these principles is rendered more complex by our current modest evidence-base and limited theory. The interaction assessment may be disappointing due to the shortcomings in the evidence about interactions and their clinical relevance.

High-quality and integrating information technology systems could help, but further work is needed to optimize the benefit of this modality [ 51 ],[ 52 ]. Furthermore, the gap of knowledge and development of proper theoretical models on the prioritization hamper this process.

In addition, evidence is sparse on the methods and impact of individualized management. Outcomes studied are often disease-specific and less meaningful for decision making in patients with multiple diseases [ 54 ]. Our principles may encourage physicians to actively consider multimorbidity when making medical decisions.

However, the principles need further critical reviewing, followed by empirical testing using case vignettes, case conferences, role plays, and directly observed consultations, involving GPs and patients. In addition, further work on prioritization is necessary to gain a better understanding of determinants and decision-making processes, and to provide appropriate tools supporting interaction assessment and a communication process that results in physician and patient sharing realistic treatment goals.

We have developed the Ariadne principles to be adopted by family physicians in daily practice. These principles may also be incorporated into educational programs on the care of patients with multimorbidity in both medical education and vocational training. The further refinement and elaboration of these principles should be based on experiences gained from their practical application.

Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Ann Fam Med. Br J Gen Pract. A review of literature. The promise is growing. What God spoke to you is developing. You may not see anything improving, but if you…. Drain The Swamp There is nothing so difficult than to bring about a new order of things - Machiavelli I Accept Privacy Policy. The International Speakers Bureau.

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