The Ariadne principles: how to handle multimorbidity in primary care consultations

Abstract

Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient's conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient's preferences - his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.Please see related article: http://www.biomedcentral.com/1741-7015/12/222.

Figure 1

Life-time medical history of Mr. P. T1 to T3: Visits with patient at three different times (see text). AoI, Aortic insufficiency; B, Benign prostatic hyperplasia; CAD, Coronary artery disease; CCl4 Intox., Accidental intoxication with carbon tetrachloride; ChE, Cholecystectomy; D, Diabetes mellitus; H, Hypertension; P, Parkinson disease; Pn, Peripheral neuropathia. Mr. P is a 77-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’s history (T1, T2, and T3): At T1, 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 71-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. Another Stent-PCI is conducted and a beta-blocker is prescribed due to the CAD progression. 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 11. 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). At a special care unit for Parkinson’s, his medication has been changed completely. 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. He has physical therapy and is discharged with reduced symptoms of Parkinson’s (reduced stiffness, coughing, and back pain; no problems with hypersalivation and swallowing), increased functionality and mood, a treatment plan consisting of 12 drugs, six times a day, and no ongoing problems of urinary retention or fluctuations in blood pressure. 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.

Figure 2

Ariadne principles.

Figure 3

A general model for treatment decisions. (a) A net benefit only occurs when the individual patient’s risk or disease severity is sufficiently high to be to the right of the treatment threshold, where the benefit and harm lines cross. (b) In most cases, there is no clear cut-off between recommended and not recommended treatments. 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]. (c) Some chronic diseases, in particular renal and liver failure, narrow the therapeutic window of many drugs and hence increase the likelihood of harm. (d) Chronic diseases can attenuate the relative benefit of treatment such as statin therapy in patients with chronic kidney disease receiving dialysis [42].