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Monthly Archives: February 2022

Challenges in multimorbidity research: lessons learned from the most recent randomized controlled trials in primary care


By Martin Fortin, Moira Stewart, José Almirall, and Priscilla Beaupré

Patients with multimorbidity need a new kind of health care. Numerous rigorous studies using randomized controlled designs (RCTs) have been conducted to demonstrate effectiveness of interventions aimed at improving outcomes for patient with multimorbidity in primary care, but most of them have reported neutral effects or mixed results. Nevertheless, these studies offer a valuable source of information to learn from in order to pave the way for future research in this area in primary care.
We conducted a scoping review [1] to include current up-to-date state-of-the-art studies in primary care published from 2019 until 2021 in order to synthesize and analyze the most recent RCTs and to identify the factors that may have contributed to the success or lack of success. Special attention was given to four elements of the intervention: 1) its description and content; 2) the context in which it was deployed; 3) the evaluation design chosen to test the effectiveness, and 4) the intervention’s implementation.
Nine articles reporting on six RCTs studies were included in the review. The findings were mixed, with primary outcomes showing no differences between intervention and control groups in four of the six but differences in secondary outcomes in all six. All studies involved family practice patients but interventions took place at different sites, and the time between the beginning of the intervention and the time of evaluation of outcomes varied across studies. Authors reported issues regarding the need for training of care teams, the roles and composition of the teams, the selection of patients and implementation barriers of the complex interventions in trying contexts with not enough time for the changes required.
This scoping review identified several lessons on planning for future intervention studies on multimorbidity in primary care. Interdisciplinary teams as the basis for most interventions, while recommended, may need more support by policy and practice leadership to be successfully deployed and evaluated. The randomized controlled design may not be the best evaluation design given the complexity of the interventions; alternative designs should be considered in which qualitative components are included. Special attention should be given to outcome measures ensuring that they are better aligned to patient goals. Selection of patients was prone to bias toward the less needy and this may hamper the ability to document effectiveness and raises questions about equity in research. Implementation of the interventions needs special attention and enough time to gel.

1-Fortin M, Stewart M, Almirall J and Beaupré P (2022) Challenges in Multimorbidity Research: Lessons Learned From the Most Recent Randomized Controlled Trials in Primary Care. Front. Med. 9:815783. doi: 10.3389/fmed.2022.815783

One-year follow-up and exploratory analysis of a patient-centered interdisciplinary care intervention for multimorbidity


By Martin Fortin

Different attempts have been made to create effective interventions in primary care for people with multimorbidity, being the predominant intervention element a change to the organization of care delivery. However, these interventions have obtained mixed results. We recently reported the results of a trial assessing the effectiveness of a multifaceted intervention based on a change in care delivery for patients with three or more chronic conditions [1]. After four months, the intervention showed a neutral effect on the primary outcomes and substantial improvement in two health behaviors as secondary outcomes. However, the effect of the intervention after a longer period of time was not known. We have now reported the one-year outcomes after exposure to the intervention, combining all participants in one single group that received the intervention, to document its long-term association with measures of self-care, quality of life and health-related behaviors [2]. Changes in these measures were also analyzed across age-, number of chronic conditions-, income-, and gender-based subgroups to explore factors potentially associated with variation in response to the intervention and help guide the development of more targeted interventions in the future.

We observed that one year after the intervention, the domain of emotional wellbeing of the Health Education Questionnaire (heiQ), improved significantly. However, we also observed deterioration in the domain of health services navigation of the heiQ. Improvement was also observed for the measures of the VR-12 (Veteran RAND-12 Health Survey) physical component, VR-12 mental component, in moderate to severe psychological distress measured with the Kessler six item Psychological Stress Scale (K6), and healthy eating.

Subgroup analyses in this exploratory study suggest that younger patients, those with lower number of chronic conditions or higher incomes may respond better in relation to self-management, health status and health behaviors. This suggests that future interventions should be tailored to patients’ characteristics including age, sex, income and number of conditions.

1.           Fortin M, Stewart M, Ngangue P, Almirall J, Belanger M, Brown JB, et al. Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial. Ann Fam Med (2021) 19(2):126-34. doi: 10.1370/afm.2650.

2.           Fortin M, Stewart M, Almirall J, Berbiche D, Belanger M, Katz A, et al. One year follow-up and exploratory analysis of a patient-centered interdisciplinary care intervention for multimorbidity. J Comorb (2021) 11:26335565211039780. doi: 10.1177/26335565211039780.