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Factors Affecting Primary Care Physician Decision-Making for Patients with Complex Multimorbidity: A Qualitative Study


 Background

Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity
Methods

This was a qualitative study involving semi-structured telephone interviews with PCPs working ≥ 40% time in a team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA). Interviews were conducted from April to July, 2020. Content was analyzed with inductive thematic analysis.
Results

25 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA’s national clinic network. Seven major themes emerged for factors affecting decision-making for complex patients with multimorbidity. Physicians described collaborating on care plans with their care team; considering impacts from patient access and resources on care plans; the boundaries provided by organizational structures; tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; and impacts on decisions from their own emotions and relationship with patient.
Conclusions

PCPs described individual, relationship-based, and environmental factors affecting their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients, such as delegation of follow-up within care teams, optimizing visit time vs frequency, and deliberate investment in patient relationship building to gain buy-in to care plans.