Effective strategies to better involve patients with multimorbidity and limited health literacy in decision-making in general practice.

PROBLEM Two thirds of consultations in general practice involve patients with MULTIMORBIDITY (coexistence of at least 2 chronic conditions). In addition, 30% of the adult population has LIMITED HEALTH LITERACY (LHL). This number is substantially higher in patients with multimorbidity. Patients with multimorbidity and LHL are insufficiently involved in health decisions, contributing to health disparities and increasing the risk for over- and undertreatment. Shared decision making (SDM) has been developed as models for patients and care providers to jointly make decisions on what is best for the patient. However, most models are based on ‘cure’ situations in hospital settings, and fall short in the complex care situations often encountered in general practice. Also, in general practice, patients with multimorbidity and LHL have been underrepresented in the development and testing of interventions for SDM. For these patients it is especially important to first prioritize health problems and decisions that need to be most urgently addressed from the patient’s perspective. SDM should therefore start with carefully identifying the patient’s primary concerns and goals, and subsequently engaging in patient-centred goal setting. This is referred to as ‘goal talk’. So, the problem is that exploring goals and preferences is crucial but challenging for many patients with multimorbidity and LHL and the GPs who look after them. Most existing tools to support SDM have been developed and evaluated with highly motivated clinicians and higher educated patients. AIM The proposed research will generate the much-needed knowledge on how GPs can engage and support patients with multimorbidity and LHL in SDM. We will develop, test and implement new strategies, building on existing tools. To achieve this aim we first need to understand how to engage patients with multimorbidity and LHL in SDM with a focus on ‘goal talk’. Based on this understanding we will subsequently develop and evaluate strategies to support ‘goal talk’. Research questions: 1. How can GPs elicit goals and preferences in this group (more effective ‘goal talk’)? 2. Which tool/strategy can optimally support this process? 3. What do GPs and patients need to optimally benefit from implementing this tool/strategy? 4. What is the effect of the tool/strategy on the SDM process? PROJECT PLAN This mixed-methods action research study is guided by the UK MRC Framework for development of complex interventions and the Consolidated Framework Implementation Research model. Key stakeholders (GPs and patients) will be involved in all study phases, using the Co-creation Impact Compass. Levels of patient participation include control, partnership, advising, consulting, and informing. The 48-months study consists of four iterative phases: Phase 1: analysis of current practice (pretest) and of needs and barriers (months 1-20); Phase 2: co-creation of the intervention (months 12-26); Phase 3: pilot study to assess acceptability, appropriateness and feasibility (months 26-29); Phase 4: assess effect on SDM and patient outcomes (posttest) (months 30-40). PARTICIPANTS GPs and their practice nurses/assistants. We aim to include 20 GPs in each study phase, except for Phase 3 (8 GPs), by targeted recruitment in postal code areas with a low socioeconomic status (highest expected numbers of patients with LHL). We aim to have sufficient variation in GP characteristics (age, gender, years of experience, practice size). Patients. We aim to include 60 patients in both Phase 1 and 4. Eligible are patients with multimorbidity (at least 2 chronic conditions) who contact the GP with a new health issue and who have LHL (as identified by the GP based on e.g. low educational level, language barriers, difficulty expressing complaints and/or preferences, difficulty understanding advice or explanations and a general passive attitude in the consultation). DATA COLLECTION AND ANALYSIS Phase 1: quantitative and qualitative analysis of video-recorded consultations (pretest); goal-talk and SDM (objectified by Option-5 instrument) and patient measures (perceived level of patient centredness); qualitative interviews (GPs and patients). Phase 2: co-creation of the intervention using focus groups and methods such as Prototyping. Phase 3: pilot study of the intervention among 8 GPs and their patients. Phase 4: evaluation study (post-test) to assess effect on SDM and patient outcomes, as in Phase 1. Statistical differences between pre- and posttest findings will be assessed. DELIVERABLES This will result in an SDM tool/strategy that has the potential to improve outcomes for this vulnerable group of patients. The deliverables will be disseminated at three levels: 1) the academic research level, 2) the healthcare professional and patient level (symposium, disseminated to the curricula of under- and postgraduate medical students, and 3) the policy level. All relevant stakeholders being involved from scratch will contribute to implementation.