Entete 3

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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Publications on multimorbidity September – December 2018

By Martin Fortin
Our search for papers on multimorbidity that were published during the period September – December 2018 has been completed. As in previous searches, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases” in PubMed (https://www.ncbi.nlm.nih.gov/pubmed), but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

Articles from a special edition of the Journal of Internal Medicine

By Martin Roland
Following an international symposium on multimorbidity held in Stockholm in 2018, the following papers have been published this month in a special edition of the Journal of Internal Medicine. They’re excellent reviews and worth a read.
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Calderón‐Larrañaga A & L. Fratiglioni L  Multimorbidity research at the crossroads: developing the scientific evidence for clinical practice and health policy  https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12872
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Calderón‐Larrañaga A et al Multimorbidity and functional impairment–bidirectional interplay, synergistic effects and common pathways  https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12843
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Muth C et al. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus  https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12842
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Valderas JM et al Quality of care assessment for people with multimorbidity  https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12881

Joint workshop on multimorbidity in the UK and in low-and middle-income countries

By Martin Fortin
On 20 and 21 June 2018, the Academy of Medical Sciences (UK) organized a two-day workshop together with the Medical Research Council, the National Institute for Health Research, and Wellcome.
The primary objective of the workshop was to provide a platform to discuss key priorities for multimorbidity research, with the aim of identifying:
• Areas where research can have the most impact in addressing multimorbidity.
• Current barriers to performing and funding research, and ways in which they can be overcome.
• The methodological approaches needed to better enable multimorbidity research.
• The best mechanisms with which research funders can support research activity in this area.
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The report of this workshop is now available to download, along with the agenda and copies of the presentations at:

Publications on multimorbidity May – August 2018

By Martin Fortin
Our search for papers on multimorbidity that were published during the period May – Agust 2018 has been completed. As in previous searches, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases” in PubMed (https://www.ncbi.nlm.nih.gov/pubmed), but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

Potential notice about Collaborative Doctoral Award in Multimorbidity

By Susan Smith
We think this is a world first – a nationally funded Structured Doctoral Training Programme in Multimorbidity, for a cohort of clinical and non-clinical researchers in primary care in Ireland. The programme is supported by a consortium of international, experienced inter-disciplinary multimorbidity researchers and PhD educators, including Prof Martin Fortin, Prof Cynthia Boyd, Prof Frances Mair, Prof Pete Bower, Prof Mogens Vestergaard and Prof Olov Rolandsson.
Patients with complex multimorbidity experience treatment burden and challenges around adhering to treatment advice, managing medicines, coordination of health and social care and patient related costs of care. The proposed PhD projects will address these interlinked but distinct areas within multimorbidity research. Cross project working will ensure exposure to a wide range of methodologies and disciplines. We will synthesise evidence from all projects at a programmatic level. The programme is supported by a specially convened Patient and Public Participation Panel and the consortium will provide an appropriate blend of research methodology skills, supervision and peer support and an opportunity for national and international PhD placements.
This doctoral programme will generate a national cohort of skilled post-doctoral students who can make a significant future international impact across a range of settings having developed expertise in the generation of research evidence to support cost-effective and patient-centred management of complex multimorbidity.

Publications on multimorbidity January-April 2018

By Martin Fortin
Our search for papers on multimorbidity that were published during the period January – April 2018 has been completed. As in previous searches, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases” in PubMed (https://www.ncbi.nlm.nih.gov/pubmed), but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

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.

Frailty : Not just a problem for older people

By Peter Hanlon and Frances Mair
It is often said that many of the challenges faced in healthcare are due to ‘ageing populations’. It is clear, however, that health (and the need for health services) is not simply related to how old a person is. There are many other factors more closely linked to an individual’s need for care, many of which are related to age. These include multimorbidity – having two or more long-term health conditions – and frailty. Frailty is closely linked to multimorbidity, but the terms are not interchangeable.
Frailty describes a reduction in the body’s in-built reserves which is generally due to the cumulative effect of a range of individual deficits. People with frailty are therefore more at risk of developing significant illness, sometimes in response to relatively minor events or ‘stressors’. To provide high quality healthcare to people with frailty involves a holistic approach, considering the whole person and their wider context, rather than purely focusing on individual diseases in isolation. Managing frailty also takes considerable resource, as people may require additional support or services, and are more likely to require hospital admission.
Both frailty and multimorbidity are more common with increasing age, and therefore most research and interventions to improve care has focused on elderly people. It is also true, however, that the majority of people with multimorbidity are aged under 65 years. This is particularly true in areas of high socioeconomic deprivation. Despite this, the prevalence and effects of frailty at younger ages and in multimorbidity has not been investigated. Most studies, as well as most health services, that seek to target frailty have tended to exclude people aged less than 65 years, even though many people in this age group are affected by multimorbidity and may benefit from an approach to healthcare that reflects this.
Our recent study [1], published in The Lancet Public Health, seeks to address this research gap. It suggests that frailty affects ‘middle-aged’ as well as older people. We found that frailty, while strongly associated with multimorbidity, identifies middle aged people at increased risk of death, over-and-above known risk factors and number of long-term health conditions.
This study analyses frailty in a younger population than most previous research. We used data from the UK Biobank cohort – a large study of around 500,000 volunteers aged between 37 and 73 years. Participants in the study were considered ‘frail’ if they met three or more of the following criteria: weight loss, slow walking pace, low hand grip strength, low physical activity, and exhaustion. People with one or two of these features were considered ‘pre-frail’.
While frailty does get more common with increasing age, we found that people of all ages had the potential to be ‘frail’ using this definition. While only a small proportion of ‘middle-aged’ people were identified as frail by this definition – 3% overall – frailty was much more common in people with multimorbidity.  Of people with 2 or more long-term conditions, 7% were frail. This increased to 18% among people with 4 or more long-term conditions. Frailty was also closely linked with socioeconomic deprivation and obesity.
Frailty was associated with more than double the risk of death in men of all ages included (37 to 73 years) and in females above the age of 45 years. This was after accounting for deprivation, lifestyle factors such as smoking, obesity and alcohol, and the number of long-term conditions. Frailty, therefore, appears to carry additional risk of premature death in younger people, over-and-above the recognised risk factors such as smoking and multimorbidity. People with ‘pre-frailty’ also had an increased risk of death in all of these age groups.
These findings highlight the challenges faced by primary care teams caring for patients with complex problems and multimorbidity, many of whom may be too young to be eligible for existing services focusing on frailty in the elderly. This is particularly true in areas of high socioeconomic deprivation, where both multimorbidity and frailty among younger people is much more common.
This study shows that frailty may be identifiable at an earlier stage than is traditionally understood. This may, therefore, represent an opportunity to explore ways of intervening earlier. If this is to happen, researchers and healthcare professions will need to broaden their focus on frailty to include a wider age range. Importantly, it also highlights the need for a move away from disease focused to more person centred care that provides a more holistic approach to patient care that is tailored to meet an individual’s specific requirements.
Identifying frailty in those with multimorbidity may have positive implications for care, planning interventions and a patient’s prognosis.  We suggest integration of an assessment of frailty into the routine assessment of people with multimorbidity might help identification of those at greater risk and ensure more accurate targeting of the multidimensional, patient-centred reorganisation of care required to address complex multimorbidity.
There is a pressing need to understand frailty in younger people much more fully. When trying to provide services and care for people with frailty and multimorbidity it will be crucial to consider the needs of younger people (particularly those in areas of high socioeconomic deprivation). Our work demonstrates that frailty, like multimorbidity, is not just a problem that affects older people.
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[1] Peter Hanlon, Barbara I Nicholl, Bhautesh Dinesh Jani, Duncan Lee, Ross McQueenie, Frances S Mair. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health 2018. Published Online June 13, 2018. http://dx.doi.org/10.1016/S2468-2667(18)30091-4.

The Primary Care Outcomes Questionnaire: a new generic instrument for measuring outcomes in primary care

By Mairead Murphy and Chris Salisbury
The majority of primary care consultations are by patients with multiple long-term conditions [1]. With ninety percent of all patient interaction with health services in the UK going through primary care, it’s not surprising that primary care clinicians and researchers try to figure out ways to improve services for their patients. Interventions are many and varied, and result in important questions about their effectiveness. Do electronic consultations offer a good service to patients? If GPs introduce advice on healthy lifestyles into the consultation, does it make patients healthier? What about increasing the duration of GP appointments to ten minutes – does this improve outcomes for patients? Or ensuring that patients always see the same named doctor? Or painting the waiting room green?
Questions like these are normally answered by administration of a generic patient-reported questionnaire. By comparing the responses of groups of patients (say those with eight-minute consultations and those with ten-minute consultations), researchers can see which group has the highest scores, and therefore whether one method of delivering care is better than the other.
Although this might sound a simple process, in practice it is not so easy. The problem is that primary care delivers a range of outcomes, some of which are more directly health-related than others. The recent blog on this site by Susan Smith (Identifying key outcomes for multimorbidity research April 19th) found that 17 core outcomes were important to measure in people with long-term conditions. These included outcomes related to mortality, health-related quality of life, patient behaviours, shared decision making and quality of health services. When we explored this issue in 2015, we similarly found that primary care patients, both those with and without long term conditions want broad range of outcomes [2]. Some of these, such as reduction in pain or depression, are captured on most generic patient-reported questionnaires. But others, such as reduction in concern, a sense of confidence in health plan, or an understanding of illnesses/problems and an ability to manage symptoms, are less well-captured.
This is why we have designed a new questionnaire, called the Primary Care Outcomes Questionnaire, or the PCOQ. The PCOQ was designed in consultation with patients [3] specifically to measure outcomes which many primary care patients seek, and which GPs seek to deliver. It contains 24 questions in four areas: health and well-being; health knowledge and understanding; confidence in health plan; and confidence in health provision. We quantitatively tested the PCOQ in a sample of primary care patients and found that it was easy for patients to complete, had construct validity, and able to show change in each of the four areas. We published these findings in March in the BJGP [4]. We have made the PCOQ available free of charge for non-commercial use and hope that researchers will find it useful for assessing the effectiveness of interventions in primary care. In the future, we plan to test the PCOQ for use in routine clinical practice.
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1. Salisbury, C., et al., Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. British Journal of General Practice, 2011. 61(582): p. e12-21.
2. Murphy M, Hollinghurst S, Turner K, Salisbury C. Patient and practitioners’ views on the most important outcomes arising from primary care consultations: a qualitative study. BMC Fam Practice 2015;16:108. Doi: 10.1186/s12875-015-0323-9
3. Murphy M, Hollinghurst S, Salisbury C. Qualitative assessment of the primary care outcomes questionnaire: a cognitive interview study, BMC Health Services Research 2018 10.1186/s12913-018-2867-6
4. Murphy M, Hollinghurst S, Cowlishaw S, Salisbury C. Psychometric Testing of the Primary Care Outcomes Questionnaire, British Journal of General Practice, 26th March 2018,10.3399/bjgp18X695765