"Multimorbidity will tie one arm behind your back” – The challenges of healthcare provision for people with rheumatoid arthritis/persistent musculoskeletal pain and multiple chronic conditions

Problem

The challenges faced by healthcare professionals (HCPs) in managing patients with either rheumatoid arthritis (RA) or persistent musculoskeletal (MSK) pain and multimorbidity - 2 or more long term conditions (LTCs)-remain unexplored. This study addresses this knowledge gap.

Approach

As part of the Multimorbidity in Arthritis and persistent musculoskeletal Pain (MAP) study we have undertaken interviews with a maximum variation sample of 40 HCPs (primary/secondary care) in two Health Boards in Scotland to explore the challenges faced in managing persistent MSK pain or RA in the context of multimorbidity. Our participants included: GPs, Rheumatology Consultants, Pain Consultants, Practice Nurses, Psychologists and Specialist Pain Nurses.

Interviews were transcribed and analysed using a conceptual framework underpinned by Burden of Treatment Theory (BOTT). BOTT has been used in patients to explore the balance between ‘work’ e.g. tasks of self-care or given to patients by HCPs, and ‘capacity’ e.g. ability to perform these tasks. It is particularly relevant in multimorbidity, where multiple conditions can create a mismatch between ‘work’ and ‘capacity.’

Here we present preliminary findings from this work. Interviews were coded independently to BOTT and reviewed as a group in coding clinics to check for coding discrepancies. Any discrepancies were resolved by discussion.

Findings

Key findings include:

• A multidisciplinary approach in secondary care improved the management of patients from a secondary care HCP viewpoint with multimorbidity and RA/persistent MSK pain, allowing frictionless intra-secondary care referrals and providing the network to obtain informal advice from colleagues

• Referral pathways were clear for primary care, but in acute situations GPs often relied on informal routes of communication to get specialist support e.g. phoning consultant secretaries, e-mail or personal connections

• Unlike the more integrated service in secondary care, GPs struggled to obtain timely support from physiotherapy and occupational therapy

• Medication options in primary and secondary care were limited by the presence of multimorbidity and polypharmacy, especially for those with persistent MSK pain and cardiovascular or renal disease, or in those with a history of substance abuse and mental health problems

• Multimorbidity increased complexity such that generic physiotherapy was unhelpful, and individualised, resource-intensive programmes were required

• Multimorbidity limited a patient’s ability to attend appointments (reduced patient capacity), reducing a HCP’s ability to deliver treatments that may otherwise have been of benefit e.g. psychological interventions.

Consequences

The work highlights how multiple interacting conditions and medications further restrict already limited treatment options, and how system design impacts HCP’s ability to manage these vulnerable patients. These findings will be combined with parallel work with patients to provide clear recommendations for research, practice and policy.