Entete 3

The CARE Plus study

By Stewart Mercer

Scotland’s wide inequalities in health are well known, and despite having ‘universal coverage’ of healthcare through the NHS, the inverse care law remains an important issue (see work from our group published last year http://bjgp.org/keyword/inverse-care-law)
Our previous research also demonstrated how the inverse care law operates at the level of GPs. Routine consultations in poor areas of Scotland -despite higher levels of patient illness and thus need – are shorter, leave patients with complex needs feeling less enabled, and are associated with greater GP stress when compared with consultations in richer areas.
More recently, in a large prospective study of videoed-consultations, we demonstrated that due to the continuing existence of the inverse care law, GPs in deprived areas have less time to be patient-centred and patients have worse outcomes from the consultations.
In our new paper, the CARE Plus study, which was recently published in BMC Medicine https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0634-2 we tested the feasibility of carrying out a cluster RCT of a whole system intervention to improve quality of life of primary care patients with multimorbidity living in areas of high socioeconomic deprivation and measured indications of effectiveness and cost-effectiveness.
As Principal Investigator, I led the study with fellow academics at the Universities of Glasgow and Dundee, funded by the Scottish Government Chief Scientist Office. This was a programme of research called ‘Living Well with Multimorbidty’. The CARE Plus study focused on patients with multiple complex problems (multimorbidity), since these patients have the highest needs.
In usual consultations, GPs, nurses and patients all struggle to adequately manage the problems of multimorbidity in the context of high deprivation.
We initially co-developed and optimised the intervention over a period of 2-3 years (http://chi.sagepub.com/content/early/2016/04/22/1742395316644304) and then randomised 8 general practices serving patients in areas of very high socioeconomic deprivation to either the CARE Plus intervention or to ‘usual care’. The intervention was a complex one, and took a ‘whole-system approach’ which involved substantially longer consultations with the GPs; training and support for the practitioners; and additional ‘self-management’ support for the patients. GPs identified patients with multimorbidity who they felt would benefit more time for an empathic, holistic approach and to agree a plan of action, with follow-up and continuity of care.
On average, patients were in their early 50s with around five chronic conditions each. Compared with the control group, patients in the CARE Plus group had significantly better outcomes for some aspects of well-being and quality of life at 6 and 12 months. Importantly, the intervention was highly cost-effective.
The study demonstrated that it is possible to conduct a high quality cluster RCT in very deprived areas; all of the practices who agreed to take part stayed in the study, and we achieved follow-up rates on the patients in both arms of the trial of 88% at 12 months. However, it should be noted that this was an exploratory trial of 152 patients in 8 practices; a definitive trial is now warranted.

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