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Category Archives: Intervention

One-year follow-up and exploratory analysis of a patient-centered interdisciplinary care intervention for multimorbidity


By Martin Fortin

Different attempts have been made to create effective interventions in primary care for people with multimorbidity, being the predominant intervention element a change to the organization of care delivery. However, these interventions have obtained mixed results. We recently reported the results of a trial assessing the effectiveness of a multifaceted intervention based on a change in care delivery for patients with three or more chronic conditions [1]. After four months, the intervention showed a neutral effect on the primary outcomes and substantial improvement in two health behaviors as secondary outcomes. However, the effect of the intervention after a longer period of time was not known. We have now reported the one-year outcomes after exposure to the intervention, combining all participants in one single group that received the intervention, to document its long-term association with measures of self-care, quality of life and health-related behaviors [2]. Changes in these measures were also analyzed across age-, number of chronic conditions-, income-, and gender-based subgroups to explore factors potentially associated with variation in response to the intervention and help guide the development of more targeted interventions in the future.

We observed that one year after the intervention, the domain of emotional wellbeing of the Health Education Questionnaire (heiQ), improved significantly. However, we also observed deterioration in the domain of health services navigation of the heiQ. Improvement was also observed for the measures of the VR-12 (Veteran RAND-12 Health Survey) physical component, VR-12 mental component, in moderate to severe psychological distress measured with the Kessler six item Psychological Stress Scale (K6), and healthy eating.

Subgroup analyses in this exploratory study suggest that younger patients, those with lower number of chronic conditions or higher incomes may respond better in relation to self-management, health status and health behaviors. This suggests that future interventions should be tailored to patients’ characteristics including age, sex, income and number of conditions.

1.           Fortin M, Stewart M, Ngangue P, Almirall J, Belanger M, Brown JB, et al. Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial. Ann Fam Med (2021) 19(2):126-34. doi: 10.1370/afm.2650.

2.           Fortin M, Stewart M, Almirall J, Berbiche D, Belanger M, Katz A, et al. One year follow-up and exploratory analysis of a patient-centered interdisciplinary care intervention for multimorbidity. J Comorb (2021) 11:26335565211039780. doi: 10.1177/26335565211039780.

Patient-centered innovation for multimorbidity care: the Ontario trial

By Moira Stewart

As part of the research program entitled Patient-Centered Innovations for Persons with Multimorbidity (PACE in MM), research trials were conducted simultaneously in the Canadian provinces of Quebec and Ontario. The aim of the trials was to assess the effectiveness of a patient-centered, multi-provider intervention for patients with multimorbidity, and understand under what circumstances it worked, and did not work. The report about the Quebec trial was recently published [1], and it is our pleasure to announce that the report of the trial in Ontario is now published too [2].

Both trials used mixed-methods design with a pragmatic randomized trial and qualitative study, involving primary care sites. Outcome measures were the same: two primary outcome measures representing patient education, empowerment, and agency (the Health Education Impact Questionnaire (heiQ); and the Self-Efficacy for Managing Chronic Disease scale), and four secondary outcome measures (VR12 Health Status; EQ-5D quality of life; Kessler Psychological Distress Scale; and Health Behaviour Survey). Outcomes were assessed at baseline and at 4 months after the intervention, a period considered long enough for follow-up to the trial.

A total of 86 patients in the intervention group and 77 in the control group participated in the Ontario trial. The intervention had a neutral effect on the primary outcomes, although one subgroup (those with an income of ≥C$50 000) significantly benefitted in terms of the mental health outcome. Qualitative and fidelity findings revealed aspects of the intervention that could be improved. For example, the qualitative study found patients’ enthusiasm for a coalesced action plan, but their frustration in its absence.

As a consequence of these findings, policymakers and clinicians are encouraged to seek ways to enhance care for patients with annual incomes of <C$50 000, to optimize team composition based on an individual patient’s preferences and abilities, and to enhance and tailor follow-up care by ensuring the creation of a coherent plan with actionable steps.

  1. Fortin M, Stewart M, Ngangue P, et al. Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial. Ann Fam Med 2021;19:126-34. doi: https://doi.org/10.1370/afm.2650
  2. Stewart M, Fortin M, Brown JB, et al. Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients’ experience. Br J Gen Pract 2021;71(705):e320-e30. doi: 10.3399/bjgp21X714293

Patient-centered interdisciplinary care for multi-morbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial in primary care

By Martin Fortin

The Patient-Centered Innovations for Persons with Multimorbidity research program, funded by the Canadian Institutes of Health Research, had an overall goal to build on existing structures and initiatives to evaluate patient-centered innovations relevant to multimorbidity in primary care. As part of this program, trials were conducted in 2 Canadian provinces, Quebec and Ontario. We reported the Quebec trial where the research team collaborated with a regional health care organization to implement an integrated chronic disease prevention and management program into family medicine groups (FMG), the most prevalent type of primary care practice in Quebec [1].

We conducted a concurrent triangulation mixed methods study, with convergent quantitative and qualitative components. The first component was a pragmatic randomized controlled trial with a delayed intervention in the control group to evaluate the effect of the intervention on patient’s self-management and self-efficacy for managing chronic diseases. The second concurrent component used a descriptive qualitative approach.

Primary outcomes were the Health Education Impact Questionnaire (heiQ) and Self-Efficacy for Managing Chronic Diseases. Secondary outcomes included health status measured by the Veterans RAND 12 Item Health Survey (VR-12), quality of life measured with the EuroQol 5-dimensions questionnaire, psychological distress, measured with the Kessler 6-item Psychological Distress Scale Questionnaire (K6), and health behaviors (tobacco smoking, physical activity, healthy eating, and high risk alcohol consumption) assessed with specific questions from the Enquête de santé du Saguenay–Lac-Saint Jean 2007 and the Behavioral Risk Factor Surveillance System.

The trial randomized 284 patients (144 in intervention group, 140 in control group). After 4 months, the intervention showed a neutral effect for the primary outcomes, but there was significant improvement in 2 health behaviors (healthy eating, and physical activity).

The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results. Qualitatively, the intervention was evaluated as positive.

The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.

  1. Fortin M, Stewart M, Ngangue P, et al. Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial. Ann Fam Med 2021; 19: 126-134. DOI: https://doi.org/10.1370/afm.2650.

A multidisciplinary self-management intervention among patients with multimorbidity: Impact of socioeconomic factors

By Martin Fortin
The objective of this study was to analyze the effect of a multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on the results.
Participants of this study were multimorbid patients from of a pragmatic randomized trial evaluating an intervention that included patients (18 to 75 yrs.) from eight primary care practices in Quebec, Canada. The intervention included self-management support and patient-centered motivational approaches.
Self-management was evaluated using the Health Education Impact Questionnaire (heiQ) which measures eight different domains.
The effect of the intervention on the likelihood of an improvement in self-management was significant in six heiQ domains in the univariate analysis: Health-directed behavior, Emotional well-being, Self-monitoring and insight, Constructive attitudes and approaches, Skill and technique acquisition, and Health services navigation. After controlling for age and gender the results remained essentially the same.
After additional adjustments for family income, education and self-perceived financial status, the likelihood of an improvement was no longer significant in the domains Emotional well-being and Self-monitoring and insight.
It was concluded that the intervention produced significant improvements in multimorbid patients for most domains of self-management but socioeconomic factors had a minor impact on the results.
The complete article can be accessed at the following link:

Improving patient-centred care for multimorbidity

By Chris Salisbury, University of Bristol, on behalf of the 3D trial team.
Full report of the 3D study helps us interpret the findings
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.
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.

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.
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.
• 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.

Is it possible to improve drug prescription in primary care patients with multimorbidity and polypharmacy by implementing the Ariadne principles in clinical practice?

By Alexandra Prados Torres
This is the question that Multi-PAP is trying to answer.
Multi-PAP is a coordinated multicentre project aimed at designing and measuring the effectiveness of a complex intervention in primary care for improving drug prescription in multimorbid patients compared to usual care. The intervention is based on the Ariadne principles designed by Muth et al. in 2014, and consists of two components: training of General Practitioners (GP) and GP-patient interviews.
Training of physicians has been conceived as a 4-weeks massive online open course (MOOC) designed by a multidisciplinary team with emphasis in multimorbidity, polypharmacy, medication appropriateness and adherence, and the Ariadne principles and tools for their implementation in clinical practice. During GP-patient interviews that will be conducted over a month, physicians are expected to put into practice the knowledge acquired during the training.
To measure the effectiveness of this intervention, Multi-PAP is conducting a pragmatic cluster randomized clinical trial (RCT) in primary care health centres in three regions in Spain (Aragon, Madrid and Andalusia). The unit of randomization is the family physician (N=80), and the unit of analysis is the patient. The study population is conformed by 400 patients (200 per study arm) aged 65–74 years with multimorbidity (defined as presence of 3 or more chronic diseases) and polypharmacy (defined as 5 or more drugs prescribed in ≥3 months). The intervention is based on the implementation of the Ariadne principles (GP training and GP-patient interviews) and it is compared to usual care. The main outcomes, to be measured at months 6 and 12, are: MAI score, health services use, quality of life, pharmacotherapy and adherence to treatment, and clinical and socio-demographic variables.
This project is justified by the need to provide evidence concerning interventions on primary care patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes.
This RCT is registered in Clinicaltrials.gov (NCT02866799). Accessible at:
The full-text protocol of Multi-PAP RCT is accessible at: http://rdcu.be/rErC

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.

OPTIMAL, a promising intervention to improve outcomes for people with multimorbidity

By Jess Garvey, Deirdre Connolly and Susan Smith

We investigated the effectiveness of an occupational therapy led self-management support programme, OPTIMAL, designed to address the challenges of living with multiple chronic conditions or multimorbidity in a primary care setting. We conducted a pragmatic feasibility randomised controlled trial including fifty participants with multimorbidity recruited from family practice and primary care settings in Dublin in Ireland. OPTIMAL is a six-week community-based programme, led by occupational therapy facilitators and focuses on problems associated with managing multimorbidity. The primary outcome was frequency of activity participation. Secondary outcomes included self-perception of, satisfaction with and ability to perform daily activities, independence in activities of daily living, anxiety and depression, self-efficacy, health-related quality of life, self-management support, healthcare utilisation and individualised goal attainment. Outcomes were collected within two weeks of intervention completion.
At immediate post intervention follow-up we found significant improvements in frequency of activity participation, measured using the Frenchay Activities Index, for the intervention group compared to the control group (Adjusted Mean Difference at follow up 4.22. 95% Confidence Interval 1.59-6.85). There were also significant improvements in perceptions of activity performance and satisfaction, self-efficacy, independence in daily activities and quality of life. Additionally, the intervention group demonstrated significantly higher levels of goal achievement, following the intervention. No significant differences were found between the two groups in anxiety, depression, self-management scores or healthcare utilisation.
OPTIMAL significantly improved frequency of activity participation, self-efficacy and quality of life for patients with multimorbidity. Further work is required to test the sustainability of these effects over time but this study indicates that it is a promising intervention that can be delivered in primary care and community settings.
Full details of this article can be found at http://www.biomedcentral.com/1471-2296/16/59/abstract
We would welcome contact and collaboration with other researchers looking to test the feasibility and effectiveness of the OPTIMAL programme in other healthcare settings.

Take a stand on complexity and gain a better understanding of the roles of professionals in care coordination!

By Anne Doessing

We recently published a scoping study addressing two issues: what are the conditions of care coordination for patients with multimorbidity; and which factors promote or inhibit care coordination in provider organizations and among healthcare professionals [1].
The central theme emerging was complexity: The specific medical conditions of patients with multimorbidity are highly complex as is the organization of care delivery.
What are the implications for care coordination then? One approach is to reduce complexity and the other is to embrace complexity. Either way, future research in care coordination interventions in multimorbidity must take a more explicit stand on complexity.
In the included studies there was a significant lack of clarity regarding the role of different professionals in care coordination. It is unclear what role the various health professions play in care coordination, what coordination tasks different professions perform and whether some professions are more suited for care coordination than others. Also, it is unclear how different organizations and sectors affect the coordination carried out by different professions.
The research on care coordination interventions for patients with multimorbidity seems to focus on organizing healthcare without paying much attention to the role of professions in frontline care coordination. However, this ought to be a prerequisite for the development of care coordination interventions.
Therefore there is a need for more research to uncover the role of different professions in care coordination. This must comprehend both their actions and the health professionals’ own understanding of their role in care coordination.
Perhaps some of the failures of existing care coordination interventions can be explained by the fact that the specific delegation of coordination is at odds with the health professionals’ own understanding of their professional domain?

The complete article can be accessed at: http://www.jcomorbidity.com/index.php/test/article/view/39

1: Doessing A, Burau V. Care coordination of multimorbidity: a scoping study. J Comorbidity 2015;5:15-28