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Author Archives: Chris Salisbury

Improving patient-centred care for multimorbidity

By Chris Salisbury, University of Bristol, on behalf of the 3D trial team.
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Full report of the 3D study helps us interpret the findings
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The 3D approach was designed to improve care for patients with multimorbidity. Based on a patient-centred care approach, it promotes continuity of care, offers a comprehensive holistic review which focuses on problems that most matter to the patient, and seeks to reduce inappropriate polypharmacy. The reviews involve a six-monthly multi-disciplinary review from a nurse, pharmacist and GP, leading to a health plan with specific goals agreed between the patient and GP. The 3D model incorporates most of the strategies recommended in international guidelines on multimorbidity.
We conducted a large cluster randomised controlled trial comparing the 3D approach and usual care, and the main trial results were published in the Lancet in July 2018 [1]. We found that the 3D intervention was effective at improving patient centred care, but did not result in improvements in patient’s quality of life, health outcomes or polypharmacy.
How should we make sense of these counter-intuitive results? Are the current international guidelines misconceived?  Perhaps the 3D approach was the wrong intervention, perhaps it was not effectively implemented or not provided for the long enough to make a difference. Or maybe we chose the wrong outcome measures. Interestingly, the conclusion that the 3D approaches improves patient-centred care but not quality of life is consisent with most previous trials of interventions for multimorbidity.
The Lancet paper has generally been interpreted as reporting a negative trial. The full report of the 3D study has now been published [2], and provides a more rounded perspective on the findings. It includes a process evaluation based on interviews with patients and staff, along with direct observation in case-study practices to help us understand how the 3D approach was implemented and how it might be improved. The full report also includes an economic evaluation of cost-effectiveness.
Through the process evaluation we found that practices were strongly supportive of the principles underlying the 3D approach, but they found implementing it logistically difficult. Many patients in the trial did not receive the full ‘dose’ of the intervention. Only half of the patients received two 3D reviews over 15 months as intended, while three-quarters received at least one review. This incomplete implementation was related to the pressures that general practices in the UK currently face, which made introducing any kind of change very difficult. Trying to do so within the context of a trial made it even more difficult. Introducing a new way of working for a limited period for a sub-set of patients, within practices which had well-established systems for offering single-disease care designed to meet the requirements of the Quality and Outcomes Framework, meant that not everything worked as planned. For example, some practices offered 3D reviews as well as, rather than instead of, single-disease reviews. However, practices did identify ways in which the 3D model might be improved, for example by more selectively targeting patients with the most complex problems, more training for staff and tailoring the frequency of reviews according to patients’ needs.
The economic evaluation showed that the 3D intervention was associated with small improvements in quality-adjusted life years (QALYs) along with small increases in NHS costs. The cost per QALY was £18,499, just below the threshold of £20,000 commonly used to justify new interventions in the NHS. Therefore the economic case for introducing 3D is arguable, and could be justified given that it provided care in a way that patient’s preferred and which they felt met their needs.
In summary, the report describes the advantages and limitations of the 3D approach, and ways in which it might be improved. There doesn’t appear to be a simple magic bullet to improve care for multimorbidity and no model of care has yet been convincingly shown to be effective in randomised trials. Paradoxically, one key finding from the report is that the 3D approach would probably need to become normal practice and offered over several years before the benefits became apparent, but testing this hypothesis in an affordable randomised trial would almost certainly be impossible.
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This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 12/130/15). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.
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Redesigning primary care for the people who use it: unveiling the results of the 3D trial for patients with multimorbidity in general practice

By Chris Salisbury, Peter Bower, Stewart Mercer and Bruce Guthrie
There is good agreement about the sort of care that people with multimorbidity need. But can it be delivered in the busy setting of general practice, and does it improve outcomes? In this blog we discuss the results of the 3D trial, the largest study of an intervention for multimorbidity published to date.
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Managing multimorbidity is a litmus test for modern health care systems. Patients with many long-term conditions face major challenges in managing their conditions and need significant support, which means that these patients are often associated with high costs.
Despite the complexity of caring for these patients, there is also significant agreement about what sort of care they need. Many authors have highlighted that patient-centred care is crucial, with a significant focus on core skills such as understanding patient needs, sharing decision-making, and supporting self-management. These well-known patient-centred skills need augmenting when managing patients with multiple conditions, to help patients to prioritise conditions and goals and manage depression. It is also important to provide continuity of care and co-ordination to help patients and carers navigate the health care system.
Despite this consensus about what should be done, two core questions remain. First, can general practice be supported to provide this sort of care, given the pressures of limited time, high demand and competing clinical responsibilities? The barriers to implementation are significant.
Secondly, will these kinds of changes to general practice care lead to demonstrable benefits in patient health, quality of life and cost-effectiveness?
The 3D trial (published today in the Lancet) was an ambitious attempt to answer these questions. We took the current consensus about optimal care for multimorbidity, and translated that into a practical intervention (called 3D). In brief, this is a patient-centred model that seeks to improve continuity, co-ordination and efficiency of care by replacing disease-focused reviews of single conditions with more comprehensive and integrated six monthly reviews.
We then supported practices to deliver 3D in the busy world of everyday clinical care, to test whether it enhanced care and improved outcomes.
The trial is fully detailed in the paper, but in summary we tested 3D in over 33 practices in a randomised trial in Bristol, Greater Manchester and Ayrshire. We then measured the outcomes of over 1500 patients after 15 months in the study.
We posed two questions earlier. The first question was: can we implement current ‘best practice’ for multimorbidity in general practice? The answer to this was clearly ‘Yes’. Despite the well-known pressures on primary care, practices undertook training, introduced new systems, and worked with patients to introduce this new model of care (although some practices implemented it more successfully than others).
We know that practices changed the care they provided, because we have good data showing that the 3D model was introduced. More importantly, patients clearly reported that their experience of care was improved, with a whole host of measures of patient-centred care showing improvements over usual care. Patients reported better empathy, that their care felt more ‘joined up’, and that care was better aligned to their priorities.
Our second question was: does the introduction of current ‘best practice’ care for multimorbidity lead to demonstrable benefits in patient quality of life? The answer was an equally clear ‘No’. Despite strong evidence that 3D was implemented and that the changes were appreciated by patients, we found no evidence of changes in quality of life (our pre-defined primary outcome).
Although the 3D trial faced the usual challenges of research in general practice, we are confident that the design is rigorous. The questions we now face are about how we interpret the results.
There are many possible reasons why the changes in patient-centred care did not translate to better quality of life. The changes in patient centred care were significant, but they may not have been large enough to translate to other outcomes. The 3D model may need modification, and practices may need more time and support to truly embed changes. Patients may need more experience of the 3D model before changes in the process of care impact on their quality of life. Some of the comparison general practices were beginning to implement some similar ideas to those in 3D, making it harder to detect benefit from 3D. It is possible that current measures of quality of life are not sensitive to the care of patients with multimorbidity.
In fact, our findings are not so different to the wider literature, where previous trials of a range of different ideas to improve care for patients with long-term conditions have also failed to demonstrate improvements in quality of life. Indeed it has long been recognised that health is mainly determined by factors other than health care, so perhaps it is not surprising that improved care for multimorbidity does not necessarily lead to better overall health.
There is an important debate as to whether the benefits we have seen from introducing the 3D model are of sufficient value. Care for patients with long-term conditions is supposed to target the ‘Triple Aim’, which includes improving patient experience alongside better health outcomes and reduced costs. General practice prides itself on its ability to provide patient-centred care, but changes in the delivery of care and high demand have placed limits on the ability of practice teams to do this. Patients in the 3D trial reported gaps in their experience of care at the start of the trial, and 3D successfully overcome some of those gaps and improved quality of care for a group of patients whose experience of the health care system is often less than optimal.
In the absence of better ways of organising care, there may be an argument that the benefits reported by patients through adoption of 3D are worthwhile, because improving the quality of their care is itself a good thing, even if we cannot yet help patients improve the quality of their lives.
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• 3D was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 12/130/15). The views and opinions expressed in this report are those of the authors and do not necessarily reflect those of the NIHR, the NHS or the Department of Health.

Improving care for patients with multimorbidity



By Chris Salisbury

Although there is a fairly clear sense of direction about how care needs to change for patients with multimorbidity, there have been few rigorous studies of new approaches.
Researchers from the Universities of Bristol, Glasgow, Manchester, Dundee, in partnership with the NHS and the Royal College of General Practitioners, have obtained funding for the ‘3D’ study to improve whole person care. This is an ambitious multi-centre cluster randomised trial of a new approach to improve the management of patients with multimorbidity in general practice, led by Professor Chris Salisbury. Funding of £1.78 million study has been obtained from the National Institute of Health Research (NIHR) through its Health Services and Delivery Research (HS&DR) Programme.

Following a pilot and optimisation study in 4 general practices, 32 practices will be recruited to the main trial and randomised to receive the new intervention or continue usual care. The intervention is designed to address the problems of illness burden (poor quality of life, depression) treatment burden (multiple unco-ordinated appointments, polypharmacy, poor primary/secondary care co-ordination) and lack of patient-centred care (low continuity, disregard of patients’ priorities) experienced by patients with multimorbidity.
Patients with multimorbidity will be identified and offered longer appointments with the same GP and nurse whenever possible, to maximise continuity of care. Instead of separate reviews of each of their long term conditions, patients will be invited for a comprehensive ‘3D’ health review every 6 months designed to cover all of their health issues. This will focus on identifying their main concerns and priorities to improve their quality of life, as well as seeking to improve disease control (Dimensions of health). The patients’ Drug regime will be reviewed and simplified, seeking to improve medication adherence.  The clinician will check for and treat Depression. In order to improve integration of care, the practice will have a linked ‘general physician’ at the local hospital.
The aim is to recruit 1382 multimorbid patients into the trial and follow them up for 12 months. The primary outcome is the patient’s quality of life, with secondary outcomes including measures of disease control, the burden of illness and treatment, and measures of patient centred care. A parallel process evaluation using mixed methods will explore how the intervention is implemented and achieves its effects and how it could be improved. Through an economic evaluation we will compare the costs and benefits of the intervention from different perspectives and determine whether it is cost-effective. Further information is available from the study website at http://www.bristol.ac.uk/3d-study.