title: Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.
abstract: BACKGROUND
  Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery.
  
  
  METHODS
  Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method.
  
  
  RESULTS
  Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface.
  
  
  CONCLUSIONS
  These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.
authors.affiliation: Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand. tim.stokes@otago.ac.nz.
authors.forename: Tim
authors.identifier: http://orcid.org/0000-0002-1127-1952
authors.initials: T
authors.lastname: Stokes
authors.affiliation: Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
authors.forename: Emma
authors.initials: E
authors.lastname: Tumilty
authors.affiliation: Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
authors.forename: Fiona
authors.initials: F
authors.lastname: Doolan-Noble
authors.affiliation: Otago Business School, University of Otago, Dunedin, New Zealand.
authors.forename: Robin
authors.initials: R
authors.lastname: Gauld
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D000066491:Clinical Decision-Making; D003695:Delivery of Health Care / Q000379:methods*; D005260:Female; D058005:General Practitioners / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D000076322:Multimorbidity / Q000639:trends*; D009520:New Zealand; D010818:Practice Patterns, Physicians' / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research
keywords: Decision making; General practice; Health services; Multimorbidity; Primary care