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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.

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