Volume 47, Issue 6, June 2018

Shared decision making in multimorbidity

Harini Sathanapally    Kamlesh Khunti    Umesh Kadam    Sam Seidu   
doi: 10.31128/AJGP-01-18-4469   |    Download article
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Multimorbidity: The scale of the problem

The prevalence of multimorbidity is on the rise,1,2 and it has become apparent that management of multimorbidity is among the most significant challenges faced by primary care clinicians today.3 Patients with multimorbidity have been shown to have a poorer health-related quality of life4 and poorer functional status,5 and multimorbidity is associated with an increase in healthcare use across both primary and secondary care settings.6 It has been shown in the UK that 78% of primary care consultations were with patients with multimorbidity.7 In Australia, 47.4% of general practice consultations were with patients with multiple conditions, and 27.4% of general practice consultations were with patients with ‘complex multimorbidity’.8

Managing patients with multiple morbidities is a difficult task. The guidelines set up to advise clinicians in clinical decision making are often focused on single diseases; these guidelines, when applied to patients with multiple chronic conditions, can lead to contradictory advice.9 Polypharmacy is frequently seen in patients with multimorbidity and has been considered to be a consequence of applying multiple disease-specific guidelines for this patient group.10 The risk of adverse drug events is also increased in patients with multimorbidity,11 and all of these factors contribute to the increased challenge of clinical decision making in this patient group.

Why is shared decision making important?

It has been suggested that individualised care, in which each patient’s case is considered on a holistic and personal basis, is important in tackling this complexity.12 Involving patients in the clinical decision-making process is integral to providing individualised care and is promoted as a hallmark of good clinical practice.13,14 It is also important from an ethical perspective for patients’ autonomy to be respected and for patients to be informed of the benefits and risks of decisions relating to their healthcare.15,16 This is especially important in the context of multimorbidity, when the benefits and risks may be less clear-cut and more complicated by the interplay of different chronic health conditions and treatment regimens. Eliciting the patient's health outcome priorities and preferences is key to this process of shared decision making. It can help to provide clarity for both the clinician and the patient in navigating through this decision-making process and potentially reduce the treatment burden by focusing on the patient’s priorities.

Challenges to shared decision making in multimorbidity

It has been shown previously that doctors find it difficult to incorporate the process of eliciting the patient’s priorities into their consultations and sometimes omit doing so altogether.17,18 The time constraints of general practice appointments may be one factor responsible for this omission. Patients may also find it difficult to express their feelings, given the constraints of a consultation, and may require time to consider what their priorities and preferences are. It has been suggested that doctors are at risk of making a ‘preference misdiagnosis’,19 in which they make an incorrect assumption regarding the priorities and preferences of their patients. Indeed, it was shown that doctors significantly overestimated the extent to which patients with breast cancer prioritised retaining their breast.20 Another study showed that doctors significantly overestimated the extent to which older patients prioritised continuation of life in the context of advanced dementia resulting in severe cognitive decline.21

While these were small studies carried out in the context of specific diseases, few studies have investigated whether primary care clinicians could be making a ‘preference misdiagnosis’ in the context of multimorbidity. Investigating this is important, as evidence of a significant mismatch between doctors’ perceptions of their patients’ preferences and the actual preferences of their patients would highlight a possible barrier to the process of shared decision making. It is equally important to investigate whether the treatment priorities of primary care physicians differ from the treatment priorities of patients with multimorbidity, as this could help to shed some light on why ‘preference misdiagnoses’ may be occurring and highlight another possible barrier to the process of shared decision making. The need to reconcile the differences in order to arrive at a mutually agreeable management plan in consultations with patients with multimorbidity would also become apparent.

Facilitating shared decision making in multimorbidity

Finding ways to help primary care clinicians elicit the treatment priorities and preferences of their patients, within the time constraints of a primary care consultation, may be one way of facilitating the process of shared decision making (Figure 1). A tool for assessing the health outcome priorities of patients with multimorbidity has already been developed in the form of a short questionnaire.22


Figure 1.
Possible facilitators to shared decision making in multimorbidity

Such questionnaires could be given to patients to complete either ahead of or during their consultations, so that primary care clinicians are aware of the health outcome priorities of their patients and can incorporate these priorities into the provision of individualised care. The priorities of patients may also change over time;23 therefore, it would also be important to revisit this process periodically or at different clinical encounters. The challenge would be to develop a tool that is concise enough to be completed in a time-efficient fashion yet comprehensive enough to capture the patient’s views.
Competing interests: KK has acted as a consultant and speaker for Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme. He has received grants in support of investigator and investigator-initiated trials from Novartis, Novo Nordisk, Sanofi-Aventis, Lilly, Pfizer, Boehringer Ingelheim and Merck Sharp & Dohme. KK has received funds for research, honoraria for speaking at meetings and has served on advisory boards for Lilly, Sanofi-Aventis, Merck Sharp & Dohme and Novo Nordisk.
Provenance and peer review: Not commissioned, externally peer reviewed.
The authors acknowledge support from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care – East Midlands (NIHR CLAHRC – EM), and the NIHR Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit, which is a partnership between University Hospitals of Leicester NHS Trust, Loughborough University and the University of Leicester. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
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  1. Fortin M, Hudon C, Haggerty J, van den Akker M, Almirall J. Prevalence estimates of multimorbidity: A comparative study of two sources. BMC Health Services Research 2010;10(1):111. Search PubMed
  2. van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: Prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol 1998;51(5):367–75. Search PubMed
  3. Mangin D, Jamoulle M. Beyond diagnosis: Rising to the multimorbidity challenge. BMJ 2012;344. Search PubMed
  4. Fortin M, Bravo G, Hudon C, et al. Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res 2006;15(1):83–91. Search PubMed
  5. Marengoni A, Angleman S, Melis R, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev 2011;10(4):430–39. Search PubMed
  6. Palladino R, Tayu Lee J, Ashworth M, Triassi M, Millett C. Associations between multimorbidity, healthcare utilisation and health status: Evidence from 16 European countries. Age Ageing 2016;45(3):431–35. Search PubMed
  7. Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: A retrospective cohort study. Br J Gen Pract 2011;61(582):e12–21. Search PubMed
  8. Harrison C, Henderson J, Miller G, Britt H. The prevalence of complex multimorbidity in Australia. Aust N Z J Public Health 2016;40(3):239–44. Search PubMed
  9. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004;351(27):2870–74. Search PubMed
  10. Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: The challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing 2013;42(1):62–69. Search PubMed
  11. Calderon-Larranaga A, Poblador-Plou B, Gonzalez-Rubio F, Gimeno-Feliu LA, Abad-Diez JM, Prados-Torres A. Multimorbidity, polypharmacy, referrals, and adverse drug events: Are we doing things well? Br J Gen Pract 2012;62(605):e821–26. Search PubMed
  12. Bower P. Better management of multimorbidity: A critical look at the ‘Ariadne principles’. BMC Medicine 2014;12:222. Search PubMed
  13. Chisholm A, Cairncross L, Askham J. Setting standards: The views of members of the public and doctors on the standards of care and practice they expect of doctors. Oxford, UK: Picker Institute Europe, 2006. Search PubMed
  14. General Medical Council (GMC). Good medical practice. Manchester, UK: GMC, 2014. Available at [Accessed 24 November 2017]. Search PubMed
  15. Ashcroft R, Hope T, Parker M. Ethical issues and evidence-based patient choice. In: Edwards A, Elwyn G, editors. Evidence-based patient choice: Inevitable or impossible? Oxford, UK: Oxford University Press, 2001:53–65. Search PubMed
  16. Schneider C. The practice of autonomy: Patients, doctors, and medical decisions. Oxford, UK: Oxford University Press on Demand, 1998. Search PubMed
  17. Mc Namara KP, Breken BD, Alzubaidi HT, et al. Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia. Age Ageing 2017;46(2):291–99. Search PubMed
  18. Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs’ perspectives on the management of patients with multimorbidity: Systematic review and synthesis of qualitative research. BMJ Open 2013;3(9):e003610-2013-003610. Search PubMed
  19. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: Patients’ preferences matter. BMJ 2012;345:e6572. Search PubMed
  20. Lee CN, Hultman CS, Sepucha K. Do patients and providers agree about the most important facts and goals for breast reconstruction decisions? Ann Plast Surg 2010;64(5):563–66. Search PubMed
  21. Volandes AE, Paasche-Orlow MK, Barry MJ, et al. Video decision support tool for advance care planning in dementia: Randomised controlled trial. BMJ 2009;338:b2159. Search PubMed
  22. Fried TR, Tinetti ME, Iannone L, O’Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med 2011;171(20):1856–58. Search PubMed
  23. Morris RL, Sanders C, Kennedy AP, Rogers A. Shifting priorities in multimorbidity: A longitudinal qualitative study of patient’s prioritization of multiple conditions. Chronic Illn 2011;7(2):147–61. Search PubMed

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