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      Better management of multimorbidity: a critical look at the ‘Ariadne principles’

      research-article
      BMC Medicine
      BioMed Central
      Assessment, Multimorbidity, Treatment burden, Treatment goals

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          Abstract

          Primary care clinicians and researchers are growing increasingly aware of the prevalence of multimorbidity among long-term conditions, and the impact on patient experience, health, and utilisation of care. The correspondence paper by Muth et al. entitled ‘ The Ariadne principles: how to handle multimorbidity in primary care consultations’ outlines new thinking on a better way to manage the challenges of decision-making in multimorbidity. The paper highlights the importance of shared treatment goals as a fundamental basis for more effective management. Although a welcome contribution to the literature, the principles raise a number of challenges: the complexities of achieving effective patient-centred assessment and goal-setting; how best to encourage implementation of new practices; and the current state of the evidence around multimorbidity and its management.

          Please see related article: http://www.biomedcentral.com/1741-7015/12/223.

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          Most cited references20

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          Multimorbidity: redesigning health care for people who use it.

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

            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. Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0223-1) contains supplementary material, which is available to authorized users.
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              An 'endless struggle': a qualitative study of general practitioners' and practice nurses' experiences of managing multimorbidity in socio-economically deprived areas of Scotland.

              To understand general practitioners' (GPs) and practice nurses' (PNs) experiences of managing multimorbidity in deprived areas and elicit views on what might help. Qualitative interviews with 19 GPs and PNs in four practices with a high percentage of patients living in the top 15% most deprived areas of Scotland. Data were analysed using constant comparison. Professionals' discussions of how they managed multimorbidity captured: (1) definitions of multimorbidity that included multiple social, psychological, and health problems associated with deprivation; (2) descriptions of the 'endless struggle' of patients trying to manage illnesses in the midst of chaotic lives with limited personal, social, and material resources; (3) accounts of the ongoing struggle of professionals trying to manage, with personal consequences for some; and (4) ideas on what might help, including 'whole person' approaches. Professionals' discussions of the difficulties that they face personally and attempt to help those most in need reflect both the continuing existence of the 'inverse care law' and the need for whole system changes to enhance the effectiveness of primary care for patients with multimorbidity in deprived areas.
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                Author and article information

                Contributors
                peter.bower@manchester.ac.uk
                Journal
                BMC Med
                BMC Med
                BMC Medicine
                BioMed Central (London )
                1741-7015
                8 December 2014
                8 December 2014
                2014
                : 12
                : 1
                : 222
                Affiliations
                NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
                Article
                222
                10.1186/s12916-014-0222-2
                4258943
                25484120
                4fcaa3ab-4556-4dd6-9b2a-e7d6a16a62ae
                © Bower; licensee BioMed Central Ltd. 2014

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 4 November 2014
                : 4 November 2014
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                © The Author(s) 2014

                Medicine
                assessment,multimorbidity,treatment burden,treatment goals
                Medicine
                assessment, multimorbidity, treatment burden, treatment goals

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