Coping with complexity: working beyond the guidelines for patients with multimorbidities

Received: Feb 9, 2015; Accepted: Feb 9, 2015; Published: Mar 4, 2015 Primary care physicians believe they are delivering evidence-based care, understanding that adherence to evidence-based clinical guidelines results in tangible benefits in the populations for which they were developed. Unfortunately, most clinical guidelines are based on trial populations which are very different to primary care populations [1], and do not reflect the reality of multimorbidity in general practice [2–6]. Since patients with multimorbidity account for around eight in every 10 primary care consultations [7], it is unsurprising that many primary care physicians find managing these patients challenging. Additionally, current clinical guidelines do not provide guidance on how best to prioritize recommendations for individuals with multimorbidity, and may therefore result in over-treatment and polypharmacy, and a risk of overlooking patient preferences [2,8]. To illustrate the point, allow me to present Mary, an 82-year-old, socially active woman living alone. Mary has been taking alendronate and calcium/vitamin C following a Colles fracture 5 years ago. She has difficulty walking as a result of osteoarthritis (for which she takes paracetamol and naproxen) and chronic obstructive pulmonary disease (for which she uses salbutamol for short-term symptom relief plus a salmeterol/fluticasone inhaler to prevent exacerbations). Mary is visiting her GP today to discuss her recently diagnosed stage 2 hypertension (ambulatory blood pressure 162/92 mmHg), her fasting total:HDL (high-density lipoprotein cholesterol) of 5.3, and her newly diagnosed chronic kidney disease (CKD) stage 3aA2. With strict adherence to all the current evidencebased guidelines for her conditions, Mary would be leaving her appointment today with a prescription containing all of the following: