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Table of Contents
SPECIAL REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 26-29

Comorbidities and clinical decision support: Report of a virtual workshop led by junior doctors


1 Professional Support Unit, Health Education England London and KSS; Research Department of Medical Education, University College London, London, UK
2 Department of Trauma and Orthopaedics, Frimley Health NHS Trust, Frimley, UK
3 Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
4 Foundation Programme, University Hospitals Bristol and Weston, Bristol, UK
5 Department of Emergency, Salisbury NHS Foundation Trust, Salisbury, UK
6 King's College London, Guy's and St Thomas' NHS Foundation Trust, London, UK
7 Department of Emergency, Barking Havering and Redbridge NHS Trust, London, UK
8 Clinical Director, BMJ Knowledge Centre, BMJ, London, UK

Date of Submission11-Sep-2020
Date of Acceptance02-Dec-2020
Date of Web Publication7-May-2021

Correspondence Address:
Dr. Kieran Walsh
BMA House, Tavistock Square, London WC1H 9JR
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ehp.ehp_33_20

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  Abstract 


Clinical decision support tools should have a role in the management of patients with comorbidities. But until now, these tools have offered minimal support for managing such patients. BMJ Best Practice has recently launched a new resource – the comorbidities tool from BMJ Best Practice. This article describes and contextualizes the themes discussed at a workshop with junior doctors on clinical decision support for health-care professionals on comorbidities. Comorbidities were vitally important to the clinical practice of all the doctors in the workshop, but most perceived a lack of specific teaching and support on the subject of comorbidities. Most of the doctors found it a challenge to manage patients with comorbidities and were enthusiastic about a tool that would help them overcome these challenges and improve their clinical decision-making. We found that a workshop led by junior doctors provided deep insights into the issue of clinical decision support for patients with comorbidities.

Keywords: Clinical decision support, comorbidities, junior doctors


How to cite this article:
Adesalu O, Curwen O, Maheswaran Y, Mok J, Osinibi M, Penfold R, Wickramarachch C, Walsh K. Comorbidities and clinical decision support: Report of a virtual workshop led by junior doctors. Educ Health Prof 2021;4:26-9

How to cite this URL:
Adesalu O, Curwen O, Maheswaran Y, Mok J, Osinibi M, Penfold R, Wickramarachch C, Walsh K. Comorbidities and clinical decision support: Report of a virtual workshop led by junior doctors. Educ Health Prof [serial online] 2021 [cited 2021 Jun 13];4:26-9. Available from: https://www.ehpjournal.com/text.asp?2021/4/1/26/315623




  Introduction Top


One in three adults in the UK is living with two or more medical conditions.[1] One in three adults admitted to hospital in the UK has five or more conditions.[1] People living with multiple comorbidities have poorer functional status, quality of life, and health outcomes, and use ambulatory and inpatient health-care services more frequently than those without. People with multiple comorbidities also have higher in-hospital mortality rates.[2] This poses a problem for patients, health-care professionals, and health systems. When comorbidities are not taken into account, patients are at risk of receiving suboptimal care which leads to worse clinical outcomes. Patients with multiple comorbidities also tend to have longer lengths of stay. All of these factors put a strain on hospitals and health services. The current health-care system needs to change so that it can provide a better service for patients with multiple comorbidities. This is also true of medical education. According to Whitty et al., “training from medical school onwards, clinical teams, and clinical guidelines, however, all tend to be organised along single disease or single organ lines.”[3] Similarly, Barnett et al. state that “existing approaches focusing on patients with only one disease dominate most medical education.”[4]

There is evidence that newly qualified junior doctors feel unprepared for clinical practice generally and for the management of patients with comorbidities specifically. The General Medical Council commissioned report “How Prepared are UK Medical Graduates for Practice?” showed that Foundation Year 1 doctors “felt unprepared for complex cases (e.g., confused patients, comorbidity), often feeling uncertain. Some participants reported feeling better prepared for making diagnoses than patient management.”[5] Participants in this study “talked a lot about the growing issue of clinical complexity in terms of comorbidity and the need for Foundation year 1 doctors to avoid thinking in silos.”[5] Thus, there is a clear need to support junior doctors, particularly newly qualified doctors, in this area.

Clinical decision support can be described as “any electronic system designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient-specific assessments or recommendations that are then presented to clinicians for consideration.”[6] Clinical decision support has a clear role in the management of patients with multiple comorbidities. But until now, clinical decision support tools have offered minimal support for managing patients with multiple comorbidities. Instead, support tools generally focus on managing single conditions only.

BMJ Best Practice is a clinical decision support resource for use at the point of care. It provides evidence-based, continually updated, and practical knowledge to help health-care professionals make better decisions. In light of the lack of support for the management of patients with comorbidities, BMJ Best Practice recently launched a new resource – the comorbidities tool from BMJ Best Practice. This tool enables doctors to add a patient's comorbidities to an existing management plan, generating a more tailored plan instantly. It supports doctors in treating the whole patient when managing acute presentations. BMJ has developed this new tool with users. However, we want to ensure that the tool is fit for purpose and can help junior doctors better manage patients with multiple conditions. Junior doctors provide a significant proportion of frontline care delivery that is delivered in hospitals –so it is vital that their views are heard if we are to drive improvements in patient care.

This article describes and contextualizes the themes discussed at a workshop on education and clinical decision support for health-care professionals on the subject of comorbidities. It was led by junior doctors –the doctors who provide care on the frontline and who are therefore also responsible for the implementation of guidelines.


  The Workshop Top


The online workshop was held over two sessions on July 7 and 14, 2020. The purpose of the workshop was to seek the views of Foundation Programme doctors and Core Trainees on clinical decision support, evidence-based medicine, and comorbidities. The workshop comprised seven doctors with an interest in this subject. All of the doctors were working in frontline clinical roles in hospitals in England. They were working in different specialties including those of general internal medicine, critical care medicine, emergency medicine, and surgery. All workshop participants are the authors of this paper. Four of the doctors were male, and three were female. Five of the doctors were Foundation Programme doctors and two were core trainees in internal medicine and emergency medicine. The doctors took part in a semi-structured discussion at the workshop. The last author was the moderator or facilitator of the workshop.


  Themes Top


Detailed notes were taken during the workshop – these were subsequently analyzed to allow concepts and themes to emerge. Notes were analyzed using thematic analysis.[7] This was used to allow new concepts and themes to emerge from the data.

Five key themes emerged from the analysis of the notes.

Theme one: The significance of comorbidities in clinical practice

Comorbidities were important to the clinical practice of all the doctors in the workshops. They said that many of their patients had comorbidities. The number of comorbidities that patients might have depended on the context, but the doctors reported that it was quite common for patients to have between three and five comorbidities. Comorbidities had a strong influence on the decisions that the doctors took in their clinical practice, including important decisions on whether to admit or discharge and on what treatments to start or stop. The doctors reported that most of the comorbidities that patients had were chronic, noncommunicable diseases that especially affected older people, such as diabetes, chronic kidney disease, and cardiorespiratory diseases. The workshop was held in the midst of the COVID-19 pandemic. Most of the doctors felt that the pandemic had made comorbidities more important to their practice, as it was patients with specific comorbidities such as diabetes and hypertension who were most likely to have a severe infection. Some of the doctors mentioned the importance of comorbidities in making decisions about admission thresholds and treatment escalation plans. That is, patients who had multiple comorbidities and resultant severe frailty were less likely to benefit from the highest escalation of care, such as admission to intensive care units [Table 1].
Table 1: The importance of comorbidities in clinical practice

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Theme two: A lack of teaching and clinical support on the subject of comorbidities

The doctors felt that there was a lack of teaching and support on the subject of comorbidities. They stated that most of their teaching was disease-specific and conceptually siloed, rarely being about the patient as a whole. They did, however, receive some teaching about the management of complexity in health care. Most of the doctors stated that they learned about comorbidities from clinical practice and from the cases that they saw on the wards or in the emergency department. Sometimes, they learned from meetings where patients with comorbidities were discussed, such as morbidity and mortality meetings. Although limited, they received some support from hospital guidelines. These would often simply advise discussion with a senior doctor from the relevant team if the patient had a comorbidity. The support they were able to access was about tangible subjects, such as how to adjust drug doses in patients with specific comorbidities, such as renal disease. Usually, they would access drug databases to find answers to these questions rather than clinical guidelines or evidence-based medicine resources [Table 2].
Table 2: A lack of teaching and support on the subject of comorbidities

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Theme three: The challenge of managing patients with comorbidities

Most of the doctors found it a challenge to manage patients with comorbidities. They worried that they would miss an important component of care in both diagnosis and management of patients with multiple comorbidities. Many of the doctors had experience of working in busy clinical environments such as emergency departments. They did not have time to look up treatment options for all conditions for all patients, so prioritized concentrating on the main problems that the patients presented with. This prioritization was vital to be able to manage patients in a practical way. However, the doctors reported having concerns that an underlying comorbidity may be causing ongoing problems for the patient in the acute setting. They reported that, as they needed answers within seconds or minutes, it was impossible to read all the relevant clinical guidelines for patients with multiple comorbidities. Speed was vital in finding answers to the problems of patients with comorbidities and closely related to this was the ease of access. The doctors reported that they expected to be able to access content on their mobile devices, ideally without having to go through complex registration and log-in procedures [Table 3].
Table 3: The challenge of managing patients with comorbidities

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Theme four: Tools that could enable better management of patients with comorbidities

The doctors were enthusiastic about tools that would enable them to better manage patients with comorbidities, even though they realized the challenges of creating and using such tools. All of the doctors had looked at comorbidities from BMJ Best Practice or had the experience of using other resources such as the British National Formulary or the renal drug handbook, and some had used these in clinical practice. They had certain criteria that they expected all point of care tools to satisfy. These included speed of access, availability online and offline, practicality of content, and brevity of recommendations. Many used tools that their seniors had recommended or that they had started using when they were medical students and that they were used to. The doctors would sometimes use tools at the point of care and sometimes shortly after the event, for example, after their shift or immediately posttake. They found this useful to reflect on their clinical encounters and to learn from their experiences [Table 4].
Table 4: Tools that could enable better manage patients with comorbidities

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Theme five: Comorbidities and shared decision-making

The doctors were keen to practice shared decision-making when possible. They realized that this was the gold standard but stated that, while shared decision-making made sense in theory, it was actually very difficult to put into practice when they had patients with multiple comorbidities. They felt that it was important to ask the patient about their priorities such as which illnesses they were most worried about or what goals they wished to achieve. Most of the doctors worked in acute settings and had experience in managing acutely unwell patients. They reported that this made practicing shared decision-making even more challenging. Some spoke about the importance of involving relatives in this setting or of discussing management options with the multidisciplinary team. Some mentioned the importance of assessing the patient's baseline function before they became unwell and using this as a guide to decision-making. In the context of comorbidities in the acute setting, many thought that shared decision-making should be about decisions on treatment escalation plans, although all recognized that such conversations were difficult, and required the input from senior clinicians [Table 5].
Table 5: Comorbidities and shared decision-making

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  Conclusions Top


Comorbidities were vitally important to the clinical practice of all the doctors in the workshop, but most perceived a lack of specific teaching and support on the subject of comorbidities. Most of the doctors found it a challenge to manage patients with comorbidities and were enthusiastic about tools that would help them overcome these challenges and improve their clinical decision-making. The ultimate goal was better decision-making and also better shared decision-making, although all realized that the presence of comorbidities made this a significant challenge.

There are limitations to this report. All of the doctors worked in acute settings and so the conclusions should only be applied to this setting. Similarly, all of the doctors were Foundation and Core Trainees and so it is difficult to determine t he applicability of findings to higher specialty trainees. The number of participants was low – and yet it was a homogenous group. The workshop focused on the clinical decision support BMJ Best Practice. Some of the doctors had used BMJ Best Practice before and some had not. Those who had used the resource before may have been more willing and able to use an additional tool, such as BMJ Best Practice Comorbidities.

Nonetheless, we found that a workshop led by junior doctors provided deep insights into the issue of clinical decision support for patients with comorbidities. We feel that activities such as this workshop lead to much greater understanding when done with junior doctors as opposed to other methods of uncovering the views of doctors which are done to junior doctors. We also feel that the discourse around advances in clinical decision support should be led by the health-care professionals who will be putting such advances into practice.

We plan to use the insights drawn from this workshop to continue to improve the Comorbidities tool from BMJ Best Practice. We are planning to evaluate how the tool is used in real life and how it impacts on clinical care. The ultimate goal is to create a tool that will help overcome an enormous challenge to all health-care systems: how best to provide holistic care to the one in three adults living with comorbidities.

Financial support and sponsorship

Nil.

Conflicts of interest

KW works for BMJ Best Practice which is the clinical decision support tool of BMJ.



 
  References Top

1.
Stafford M, Steventon A, Thorlby R, Fisher R, Turton C, Deeny S. Briefing: Understanding the Health Care Needs of People with Multiple Health Conditions. London: The Health Foundation; 2018.  Back to cited text no. 1
    
2.
Zador Z, Landry A, Cusimano MD, Geifman N. Multimorbidity states associated with higher mortality rates in organ dysfunction and sepsis: A data-driven analysis in critical care. Crit Care 2019;23:247.  Back to cited text no. 2
    
3.
Whitty CJ, MacEwen C, Goddard A, Alderson D, Marshall M, Calderwood C, et al. Rising to the challenge of multimorbidity. BMJ 2020;368:l6964.  Back to cited text no. 3
    
4.
Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet 2012;380:37-43.  Back to cited text no. 4
    
5.
How Prepared are UK Medical Graduates for Practice? University of Exeter; 2014. Available from: https://www.gmc-uk.org/-/media/gmc-site-images/about/how-prepared-are-uk-medical-graduatesfor-practice.pdf?la=en&hash=1D87E30FB8A260AB20D662629D0F654FB64695FA. [Last accessed on 2020 Sep 08].  Back to cited text no. 5
    
6.
Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. BMJ 2005;330:765.  Back to cited text no. 6
    
7.
Joffe H, Yardley L. Content and thematic analysis. In: Marks DF, Yardley L, editors. Research Methods for Clinical and Health Psychology. London: Sage Publications; 2004. p. 56-68.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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