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Author Archives: Stewart Mercer

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.

ABC of multimorbidity

By Stewart Mercer, Chris Salisbury and Martin Fortin

The ABC of multimorbidity is a book (64 pages) recently published by WILEY Blackwell seeking to explore some important issues on the subject. Contributors to the book were Marjan van den Akker, Elizabeth A. Bayliss, Peter Bower, Sonny Cejic, Peter Coventry, Martin Fortin, Katie I. Gallacher, Linda Gask, Jane Gunn, Karen Kinder, Frances Mair, Carl May, Stewart W. Mercer, Victor Montori, Christiane Muth, Ignacio Ricci-Cabello, Martin Roland, Chris Salisbury, Efrat Shadmi, Moira Stewart, Amanda L. Terry, José M. Valderas, Concepción Violán, and Jonathan P. Weiner.
Divided in 12 chapters, the book addresses the prevalence of multimorbidity, its impact on patients, the relationship between physical and mental health problems, and how managing multiple health problems concurrently can create a heavy burden of treatment for patients. At the heart of the book is the authors’ shared conviction that health care should be person -centered.
Due to space limitations each chapter is rather short. We hope that experts on the subject do not judge us too severely for the limited amount of information we could provide, and that busy physicians looking for an informative and practical source of knowledge will find this book useful.

Can we exclude exclusion criteria?

By Graham Watt
I keep a cartoon in which a patient tells a flummoxed psychiatrist,

” I have neither illusions nor delusions, Doc. My problem is that I exist day after day in grim reality”.

In seeking to pigeon-hole the patient as a case, the doctor ignores her reality.
Does the same thing happen in multiple morbidity?
Shakespeare first noted, “When troubles come, they come not single spies but in batallions”

That seems true of multiple morbidity in socio-economically deprived areas, defined as the “number, severity and complexity of health and social problems within families”.

Operational definitions of multiple morbidity in research studies, based on counts of conditions, get nowhere near this, largely missing out on social and family aspects.

The problem is heterogenity, something that research tries to eliminate.
How can multiple morbidity research put heterogenity centre stage, so that results inform the majority of patients’ circumstances and not only those meeting case definitions?

Of course, asking the question is the easy part.

International Workshop, Glasgow, April 18th, 2011

By Stewart Mercer

The challenge of multimorbidity – what can we learn from cohort studies? 

This one day meeting was organised by Professor Stewart Mercer, Professor of Primary Care Research at the University of Glasgow, who leads a national research programme on multimorbidity in Scotland with the Scottish School of Primary Care.

The morning seminar, which was the inaugural event of the newly established Institute of Health and Well-being at the University of Glasgow, and was chaired by Professor Sally Wyke, welcomed Professor Jane Gunn from Melbourne University, who is Visiting Professor with the Scottish School of Primary Care, who described her work over several years on the DIAMOND primary care cohort on depression and multimorbidity. Professor Martin Fortin from Sherbrooke University in Canada, then described the cohort studies he has recently been involved in setting up in primary care in Canada with Professor Jeannie Haggerty. This was followed by Professor Frances Mair, Head of the Academic Unit of General Practice and Primary Care at the University of Glasgow, who spoke of the treatment burden in multimorbidity, and the need for ‘minimally disruptive medicine.’ Finally, Professor Mercer described work to date on multimorbidity in Scotland, and work in progress in developing the MALT (Multiple and Long-Term conditions) cohort in Scotland.

 The afternoon consisted of a workshop to discuss multimorbidity cohort studies further, and the MALT Cohort development. Attendees included experts from Scotland, Ireland, England, as well as our morning speakers. The need for cohort studies on multimorbidity was agreed, based on simple models, and as far as possible based on collaboration between countries. The lack of evidence on multimorbid patients’ views and experiences of health and healthcare was a strong theme of the afternoon. It was agreed that those at the workshop would continue to debate these issues collaboratively.

 Overall, this was a very enjoyable and stimulating meeting and we look forward to seeing more guests in the future at our next ‘Glasgow Meeting’ on interventions in multimorbidity in March next year.

University of Glasgow