Translations between studies with third order interpretation and line of argument formation
| First author | Disorganisation and fragmentation of healthcare | The inadequacy of guidelines and evidence-based medicine | Challenges in patient-centred care | Challenges in shared decision-making |
|---|---|---|---|---|
| Smith et al23 | lines of communication need time and nobody appears to have time collusion of anonymity, which is, you know, this is not my patient, not my patient | the paradox faced by conscientious GPs in attempting to balance the potentially competing demands of health promotion, evidence-based medicine and the use of multiple medications | a focus on function and quality of life was preferable to considering specific-disease outcome measures | ..decision making very difficult to achieve. decisions were linked to the theme of avoidance of complex issues which…can appear to become increasingly problematic and unsolvable |
| O'Brien et al24 | adaptation of existing practice systems, particularly appointment length, relationship continuity and referral systems for resources outside primary care, may improve services from the perspectives of professionals | need .. to demonstrate that we are interested in (patients) as a person, not someone who has heart failure | wanted to develop relationships with patients because she thought that greater understanding of their circumstances would help her get to the root of (medical) problems | there was a need to address ‘a bit of the patient's agenda and our agenda’ within consultations |
| Steinman et al25 | – | …those with multiple comorbid conditions were more likely to experience harm from aggressive guideline-based treatments guidelines represent a criterion standard of evidence-based care….regardless of patient age or comorbid burden | Each patient is a unique situation and is not going to be the same as another patient…. We have to go by the individual patient, by the patient's comfort, how is he feeling and how is he doing | a suggested approach to decision making for older adults that provides guidance on prioritising care, accounting for comorbid conditions and factoring in the role of estimated life expectancy |
| Fried et al26 | fragmentation of care for patients who receive care for their multiple conditions from many physicians. the limitations imposed by current reimbursement systems, which fail to acknowledge the complexities of caring for older persons with multiple conditions | If they cannot manage … I am not going to complicate it further by adding something to get to the goal range. other clinicians believed that guideline-directed care would produce the best outcomes | Tailoring their approach …from a consideration of such factors as patients’ cognition and availability of social support | …conflicts between what they wanted to do for the patient and what the patient wanted …patients’ and families’ inaccurate understanding of harms and benefits, and they described performing testing to help patients understand their risk |
| Solomon et al27 | - | there was a perception that real patients differ from those recruited to the trials that inform guidelines | Many GPs felt they needed to be able to interpret guidelines in the context of individual patients | to reach a compromise by following guidelines and accommodating patient factors, such as patient preferences or the patient's ability to tolerate medicines |
| Anthierens et al28 | The coordination of the medication regime of different disciplines is a tough job… | preventive aims are often minimal considering their age and polypathology, which is in contrast with guidelines talking about one specific disease | As a GP you have a broader view of your patient. You look at him/her from his own life | They have a holistic view of the patient because of the long-standing doctor–patient relationship.…. a very tough job for GPs with major implications for their workload |
| Bower et al29 | clash between services and the needs of patients was most salient in terms of logistics and inconvenience Difficulties in information sharing between professionals meant that patients often had to co-ordinate care | …ambivalence about the need to consistently change clinical practice to reflect multimorbidity …why should their asthma be treated any differently just because they've got asthma and heart disease and you know, osteoporosis or whatever | Weighing up what that patient can manage on the conditions they have, as to what it actually says to do. benefits of continuity of care in patients with multimorbidity | Dealing with multiple competing agendas in multimorbidity was important. limited impact of multimorbidity on clinical decision making |
| Schuling et al30 | …medication lists of the doctors involved are not exchanged and are consequently inconsistent. …several healthcare providers are involved in a patient's treatment and communication is sometimes poor | guidelines are kind of a hindrance. At the moment they do not cater for older patients. I have difficulty not following the guidelines if I don't have good reasons to do so | GPs report to support the concept of a patient-centred management as best practice take her quality of life into account and ask myself will she live long enough to benefit from this (preventive) drug? | the importance of exploring patient preferences about treatment goals, in practice GPs appear hesitant. … GPs tend to avoid discussing withdrawal of preventive medication with their elderly patients |
| Marx et al31 | poor communication from specialists and hospitals to the family physician highlights the need for professional discussion on the one hand and avoiding unnecessary medication by ‘multiple prescribers on the other hand | The desire of family doctors to deliver the best possible patient care quickly leads to polypharmacy, if guidelines are used | conflict arose in the actions of GPs trying to deliver personalised care to individuals and trying to delivering guideline orientated care | uncertainty could be counteracted by good communication between the doctor and patient. the patient and the doctor are in an interactive process, which necessitates careful negotiation |
| Luijks et al32 | in multimorbidity, fragmentation of care is a pitfall …. stimulated by disease-centred reimbursement systems impeding multimorbidity management … insufficient time and compensation | adhering to standard regimens or strict guidelines was unwanted, as it contradicts their integrated perception of a unique person with a specific combination of diseases | A personal patient–doctor relationship was considered a major facilitator in the management of multimorbidity patient-centredness can be regarded as ‘tool’ to counteract multimorbidity's potential pitfalls | GPs agreed that they want to involve their patients’ perspectives and preferences into the decision-making process |
| Third order interpretations | The involvement of multiple specialists each operating on a single disease paradigm without an overview of the ‘whole patient’ leads to fragmented care in patients with multimorbidity. Single disease care is antagonistic to the goals of GPs in primary care. This problem is compounded by poor co-ordination and communication within the health service, leaving GPs feeling excluded from their patients care and with a sense of uncertainty regarding their role | GPs have reservations about the outcomes and risk-benefit of guidelines in multimorbid patients. Although useful as a template, GPs feel that guidelines offer them less guidance or support for multimorbid patients and may in fact cause additional problems when they try to adhere to them | Patient-centred care is an over-riding principal for GPs in multimorbidty and incorporates the principles of individualisation and generalism. Trying to achieve this aim increases the complexity of care in some cases, and can lead the GP into additional conflict with specialist services or evidence based medicine | While GPs recognise the importance of involving patients in decision-making process, they have difficulties in doing so. Communicating risk and outcomes in way that will engage patients in the decision-making process is an area that GPs feel unskilled in, thereby limiting the patients influence as factor that would help the decision making process |
Italicised extracts represent first-order interpretations (views of participants in included studies). Non-italicised extracts represent second-order interpretations (views of authors of included studies).
GP, general practitioner.