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

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      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.

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      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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      Most cited references 54

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      Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.

      Long-term disorders are the main challenge facing health-care systems worldwide, but health systems are largely configured for individual diseases rather than multimorbidity. We examined the distribution of multimorbidity, and of comorbidity of physical and mental health disorders, in relation to age and socioeconomic deprivation. In a cross-sectional study we extracted data on 40 morbidities from a database of 1,751,841 people registered with 314 medical practices in Scotland as of March, 2007. We analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. We defined multimorbidity as the presence of two or more disorders. 42·2% (95% CI 42·1-42·3) of all patients had one or more morbidities, and 23·2% (23·08-23·21) were multimorbid. Although the prevalence of multimorbidity increased substantially with age and was present in most people aged 65 years and older, the absolute number of people with multimorbidity was higher in those younger than 65 years (210,500 vs 194,996). Onset of multimorbidity occurred 10-15 years earlier in people living in the most deprived areas compared with the most affluent, with socioeconomic deprivation particularly associated with multimorbidity that included mental health disorders (prevalence of both physical and mental health disorder 11·0%, 95% CI 10·9-11·2% in most deprived area vs 5·9%, 5·8%-6·0% in least deprived). The presence of a mental health disorder increased as the number of physical morbidities increased (adjusted odds ratio 6·74, 95% CI 6·59-6·90 for five or more disorders vs 1·95, 1·93-1·98 for one disorder), and was much greater in more deprived than in less deprived people (2·28, 2·21-2·32 vs 1·08, 1·05-1·11). Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas. Scottish Government Chief Scientist Office. Copyright © 2012 Elsevier Ltd. All rights reserved.
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            Author and article information

            Affiliations
            [ ]Institute of General Practice, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
            [ ]School CAPHRI, Department of Family Medicine, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
            [ ]Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33, blok J, 3000 Leuven, Belgium
            [ ]Department of Public Health and Primary Care, Leiden University Medical Center, Postbus 9600, 2300 RC Leiden, The Netherlands
            [ ]Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG UK
            [ ]Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Im Neuenheimer Feld 305, D‐69120 Heidelberg, Germany
            [ ]Netherlands Institute for Health Services Research (NIVEL), Postbus 1568, 3500BN Utrecht, The Netherlands
            [ ]Department of General Practice and Elderly care medicine/EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
            [ ]Department of Family Medicine, Preventive and Rehabilitative Medicine, Philipps University of Marburg, Karl-von-Frisch-Str. 4, D-35043 Marburg, Germany
            [ ]Department of General Practice and Family Medicine, University Hospital, Friedrich Schiller University, Bachstraße 18, D-07740 Jena, Germany
            [ ]Department of Primary Care Health Sciences, University of Oxford, 23-38 Hythe Bridge Street, Oxford, OX1 2ET UK
            [ ]EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute, IIS Aragón, Paseo Isabel La Católica 1-3, 50009 Zaragoza, Spain
            [ ]Department of Primary Medical Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
            [ ]Department of Medical Informatics, Biometry and Epidemiology, Ruhr University of Bochum, Overbergstr. 17, 44801 Bochum, Germany
            [ ]Department of Geriatrics, Marienhospital Herne, Clinical Centre of the Ruhr University, Widumer Str. 8, 44627 Herne, Germany
            [ ]The Centre for Research in Evidence-Based Practice (CREBP), Bond University, Gold Coast, Robina QLD 4226 Australia
            Contributors
            muth@allgemeinmedizin.uni-frankfurt.de
            marjan.vandenakker@maastrichtuniversity.nl
            j.w.blom@lumc.nl
            c.d.mallen@keele.ac.uk
            rochon@imbi.uni-heidelberg.de
            f.schellevis@nivel.nl
            annette.becker@Staff.Uni-Marburg.DE
            beyer@allgemeinmedizin.uni-frankfurt.de
            jochen.gensichen@med.uni-jena.de
            forschung@hanna-kirchner.de
            rafael.perera@phc.ox.ac.uk
            sprados.iacs@aragon.es
            m.scherer@uke.de
            ulrich.thiem@rub.de
            bussche@uke.de
            paul_glasziou@bond.edu.au
            Journal
            BMC Med
            BMC Med
            BMC Medicine
            BioMed Central (London )
            1741-7015
            8 December 2014
            8 December 2014
            2014
            : 12
            : 1
            25484244
            4259090
            223
            10.1186/s12916-014-0223-1
            © Muth et al.; 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.

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            © The Author(s) 2014

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