A new model for clinical decision making in patients with multimorbidity

8 Mar 2019 04:15 PM

Blog posted by: Professor Neal Maskrey, Dr Edmund Jack, Professor Richard Byng in the Lancet, 08 March 2019.

Many people in the UK are living with long-term health problems. These may be mental health problems - such as depression or anxiety; or physical conditions such as high blood pressure, diabetes, heart disease or arthritis. Healthcare professionals diagnose 'multimorbidity' when people are living with more than 1 of type of health problem.

It is known that multimorbidity patients have limited understanding about their treatment options and prognosis and data on how to improve multimorbidity care is lacking.  The patient’s contributions in such cases are very important. Clinician’s need to understand their motivation, personal strengths, physical or cognitive capacity, and individual desire for active or passive participation in decision making. They all matter.

Hippocrates (460-370BC) said “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” A couple of millennia on, and the scientific evidence may tell us how to treat a disease, but doesn’t tell us whether an individual wants or will accept that treatment, only the patient can tell us that.

The Sharing Evidence Routine for a Person-Centred Plan for Action (SHERPA) model we have developed proposes three simple steps: share, link and plan.

SHERPA supports the translation of evidence-based medicine and complex consultation models into simpler, natural conversations about care, appropriate for individual patients with multimorbidity.

Step 1, share - the practitioner and patient discuss the problems and issues from their perspectives. The aim is to create a shared view about the relative importance of the issues.

Step 2, link - the clinician and patient work together to agree on how the issues link together, sketching these out on paper if helpful. This creates a shared understanding of the individual as a whole, which would inform decisions.

Step 3, plan - rather than basing management purely on the evidence about specific diseases, the patient and practitioner also incorporate evidence about what they believe is likely to work to create an individualised plan.

Convincing educators, policy makers, and practitioners to move from a disease-based approach to the SHERPA model will require a broad evaluation programme to show whether it works. We’re starting that now.

For more information we recently published a paper in the Lancet describing SHERPA – a new model for clinical decision making in patients with multimorbidity.

From left to right the authors: Neal Maskrey, Visiting Professor of Evidence-informed decision making, Keele University; Dr Edmund Jack, GP Partner Yealm Medical Centre, Clinical Champion - Making Sense of Evidence, PenCLAHRC; Richard Byng, GP and Professor in Primary Care Research, Plymouth University.