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Author Archives: Susan Smith

Updated Cochrane Review: Interventions for improving outcomes in patients with multimorbidity in primary care and community settings


By Susan M Smith, Emma Wallace, Tom O’Dowd, Martin Fortin
This Cochrane systematic review aimed to identify and summarise the existing evidence on the effectiveness of interventions to improve clinical and mental health outcomes and patient-reported outcomes including health-related quality of life for people with multimorbidity in primary care and community settings.
The Cochrane library have just published an update of the original 2012 review and for this update the literature was searched up to September 2015. In total, we identified 18 generally well-designed randomised controlled trials meeting the eligibility criteria, 8 of which were identified in the updated searches. Nine of the 18 studies focused on specific combinations of health conditions (comorbidity studies), for example diabetes and heart disease. The other nine studies included people with a broad range of conditions (multimorbidity studies) although they tended to focus on elderly people. The majority of studies examined interventions that involved changes to the organisation of care delivery although some studies had more patient-focused interventions.
Key results
Overall the results regarding the effectiveness of interventions were mixed. There were no clear positive improvements in clinical outcomes, health service use, medication adherence, patient-related health behaviours, health professional behaviours or costs. There were modest improvements in mental health outcomes from seven studies that targeted people with depression, and in functional outcomes from two studies targeting functional difficulties in participants. Overall the results indicate that it is difficult to improve outcomes for people with multiple conditions. The review suggests that interventions that are designed to target specific risk factors (for example treatment for depression) or interventions that focus on difficulties that people experience with daily functioning (for example, physiotherapy treatment to improve capacity for physical activity) may be more effective.
Authors’ conclusions:
This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. However, several large ongoing studies were identified that will add to the slowly emerging evidence base. The current evidence from this review suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.
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Citation: Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD006560. DOI: 10.1002/14651858.CD006560.pub3.

Interventions for people with multimorbidity



By Susan Smith

The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions [1]. We have just published a paper in the Journal of Comorbidity presenting a consensus view from a group of international researchers working to guide future studies of interventions to improve outcomes for people with multimorbidity [2]. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems.
I would welcome any contact from research teams conducting evaluations of interventions for multimorbidity as these could potentially be included in the next update of the Cochrane Review of such interventions.

[1] Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev (2):CD003638. 2012;4:CD006560.
[2] Smith SM, Bayliss EA, Mercer SW, et al. How to design and evaluate interventions to improve outcomes for patients with multimorbidity. Journal of Comorbidity. 2013;3:10-17.

Review of Interventions for improving outcomes in patients with multimorbidity

By Susan Smith

We have finally published our Cochrane systematic review of Interventions for improving outcomes in patients with multimorbidity in primary care and community settings (1). This is now available on the Cochrane Library with related podcasts in English, French and Spanish.

The review aimed to determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings.

 We searched a range of international databases in April 2011. We included randomised controlled trials, controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS). Participants included any patients identified as having multimorbidity, i.e., two or more chronic conditions but we excluded studies where multimorbidity was not explicitly defined and reported. Outcomes included any validated measure of physical or mental health, psychosocial status including quality of life and measures of disability or functional status. We also included measures of patient and provider behaviour including medication adherence, utilisation of services and costs. Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible due to the variation in study participants and in interventions so we carried out a narrative synthesis of the results from the included studies. 

 We identified ten studies examining a range of complex interventions for patients with multimorbidity. All were randomised controlled trials with a low risk of bias. Two of the ten studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team-work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings. 

 The review highlights the paucity of research into interventions to improve outcomes for people with multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. There is a need for further studies with clear definitions of participants, consideration of appropriate outcomes, and interventions targeted at specific patient difficulties.

 1-  Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD006560. DOI: 10.1002/14651858.CD006560.pub2.

Training clinicians in the management of multimorbidity

By Susan Smith

In considering designing appropriate interventions to improve outcomes for patients with multimorbidity, we are beginning to look at ways of training clinicians in the management of these patients. Our specific intervention is being directed towards GPs or family practitioners. Is anyone aware of any training materials that have been or are being developed for training clinicians? We may focus it around improved medicines management but could also look at case based learning. I would really welcome any comments from others working in the field.