Table 2

Translations between studies with third order interpretation and line of argument formation

First authorDisorganisation and fragmentation of healthcareThe inadequacy of guidelines and evidence-based medicineChallenges in patient-centred careChallenges in shared decision-making
Smith et al23lines 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 medicationsa 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 al24adaptation of existing practice systems, particularly appointment length, relationship continuity and referral systems for resources outside primary care, may improve services from the perspectives of professionalsneed .. to demonstrate that we are interested in (patients) as a person, not someone who has heart failurewanted to develop relationships with patients because she thought that greater understanding of their circumstances would help her get to the root of (medical) problemsthere 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 doinga 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 al26fragmentation 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 manageI 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 guidelinesMany 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 al28The coordination of the medication regime of different disciplines is a tough jobpreventive aims are often minimal considering their age and polypathology, which is in contrast with guidelines talking about one specific diseaseAs a GP you have a broader view of your patient. You look at him/her from his own lifeThey 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 al29clash 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 al31poor 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 usedconflict arose in the actions of GPs trying to deliver personalised care to individuals and trying to delivering guideline orientated careuncertainty 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 al32in 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 diseasesA 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 interpretationsThe 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 roleGPs 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 themPatient-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 medicineWhile 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.