GPs should write up individual care plans for patients with multimorbidity, says NICE

GPs should establish the 'treatment burden' of patients with multimorbidity and draw up a tailored approach to their care that takes their preferences and priorities into account, NICE guidelines on treating multiple conditions say.

GPs should identify medicines with the higher risk of unwanted side effects and stop treatment if appropriate to help cut down on polypharmacy, according to guidelines released on Thursday.

The draft guidance – NICE’s first on multimorbidity – begins by notifying GPs that the evidence for its regular guidelines for single conditions is ‘regularly drawn from people without multimorbidity’.

It advises GPs to think carefully about the risks and benefits of applying individual treatments recommended in other sets of its own guidance to patients with multimorbidity.

It says the multimorbidity guidance – unique in that it recommends when to stop treatment as well as start it – will help GPs ‘put patients at the heart of the decisions about their care’.

Patients with frailty or those prescribed multiple regular medicines are among the groups of patients who should be given a ‘tailored approach to care’ with an individualised management plan, the guidelines say.

Treating multimorbidity

This should detail their health needs, how their quality of life could be improved by reducing their treatment burden and how the person’s health conditions and treatments interact with each other.

GP should identify patients with multimorbidity who could benefit from tailored care opportunistically during routine care and proactively using electronic health records, NICE said.

It is recommended that any patient prescribed 15 or more regular medicines should be given a tailored plan, as they have the highest risk of experiencing adverse events from drug interactions.

GPs are also advised to consider the approach with patients who are prescribed 10 to 14 regular medicines or are prescribed fewer than 10 but are deemed to be at particular risk of adverse events.

Frailty should be identified using a walking gait speed test, self-reported health status, or by inferring gait speed informally – such as by assessing how long it takes a patient to walk to the waiting room or answer their door.

A patient’s preferences and priorities – such as extending life, playing an active role in family life, undertaking paid or voluntary work, or preventing specific outcomes – should be established and taken into account when considering stopping or changing a multimorbid patient’s treaments.

If a patient is unsure of any benefits a treatment they are taking is having, or if they are experiencing harm as a result, GPs should discuss reducing or stopping the treatment.

Tackling polypharmacy

A screening tool such as the STOPP/START tool could also be used to identify medicine-related safety concerns when reviewing medicines and other treatments.

GPs should keep in mind other medicines or non-pharmacological treatments that might be started as well as those that might be stopped.

Former GP Professor David Haslam, chairman of NICE, said: ‘When working with patients, healthcare professionals should use their judgement when deciding treatments or services appropriate to someone with more than one long-term health condition. It is important to balance the evidence for benefit with the potential harm of treatment for the individual, and take into account the preferences and wishes of the person themselves.’

Professor Bruce Guthrie, a professor of primary care who chaired the group developing the guideline, said: ‘General practice and other generalist services, like care of the elderly, have a crucial role in co-ordinating care through a person-centred rather than disease-focused perspective. The new draft guideline emphasises the importance of this perspective.’

NICE’s draft guidance on multimorbidity is open for consultation until 12 May. The finalised guidance is due for release this September.

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