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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.

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