Entete 3

Category Archives: Intervention

Improving care for patients with multimorbidity

By Chris Salisbury

Although there is a fairly clear sense of direction about how care needs to change for patients with multimorbidity, there have been few rigorous studies of new approaches.
Researchers from the Universities of Bristol, Glasgow, Manchester, Dundee, in partnership with the NHS and the Royal College of General Practitioners, have obtained funding for the ‘3D’ study to improve whole person care. This is an ambitious multi-centre cluster randomised trial of a new approach to improve the management of patients with multimorbidity in general practice, led by Professor Chris Salisbury. Funding of £1.78 million study has been obtained from the National Institute of Health Research (NIHR) through its Health Services and Delivery Research (HS&DR) Programme.

Following a pilot and optimisation study in 4 general practices, 32 practices will be recruited to the main trial and randomised to receive the new intervention or continue usual care. The intervention is designed to address the problems of illness burden (poor quality of life, depression) treatment burden (multiple unco-ordinated appointments, polypharmacy, poor primary/secondary care co-ordination) and lack of patient-centred care (low continuity, disregard of patients’ priorities) experienced by patients with multimorbidity.
Patients with multimorbidity will be identified and offered longer appointments with the same GP and nurse whenever possible, to maximise continuity of care. Instead of separate reviews of each of their long term conditions, patients will be invited for a comprehensive ‘3D’ health review every 6 months designed to cover all of their health issues. This will focus on identifying their main concerns and priorities to improve their quality of life, as well as seeking to improve disease control (Dimensions of health). The patients’ Drug regime will be reviewed and simplified, seeking to improve medication adherence.  The clinician will check for and treat Depression. In order to improve integration of care, the practice will have a linked ‘general physician’ at the local hospital.
The aim is to recruit 1382 multimorbid patients into the trial and follow them up for 12 months. The primary outcome is the patient’s quality of life, with secondary outcomes including measures of disease control, the burden of illness and treatment, and measures of patient centred care. A parallel process evaluation using mixed methods will explore how the intervention is implemented and achieves its effects and how it could be improved. Through an economic evaluation we will compare the costs and benefits of the intervention from different perspectives and determine whether it is cost-effective. Further information is available from the study website at http://www.bristol.ac.uk/3d-study.

The integration of physician-patient-nurse collaboration for patients with multimorbidity seen in a Family Medicine Group setting: A pilot study

By Tarek Bouhali

A Family medicine group (FMG) is a group of family physicians who work in close cooperation with nurses to offer health care services to registered individuals. On average, a FMG serves 15,000 people, and involves 10 doctors and two nurses [1]. This new form of group practice based on patient-centered approaches leads to interprofessional collaboration.

Interprofessional collaboration usually involves two disciplines or professionals, who interact continuously in a joint effort to solve or explore common issues. This approach involves active patient participation, gives priority to his/her goals and values, and establishes mechanisms for continuous communication among health care providers. Working within such a structure requires a redefinition of the physician-nurse partnership. Evidence-based interprofessional collaboration should involve intra-disciplinary and interdisciplinary participation in clinical decision making, and encourages the contribution of all professionals [2]. A number of studies has highlighted the need to redefine inter-professional collaboration to include the patient as participant as his/her perspective has been missing so far [2-4].

In this regard, the present pilot study aims to:

1) clarify the expectations of physicians, patients, and nurses involved in a collaborative approach;

2) identify the elements of collaboration that are prioritized by the participating professionals;

3) document the experience of collaboration among physicians, nurses and patients;

4) assess the feasibility of using generic outcome measures;

5) collect preliminary data on the variability of results and their sensitivity to changes in patients with multimorbidity.

Patients included in this study are adults (40 to 65 years) with at least two chronic diseases from two FMGs in the Saguenay-Lac-St-Jean region (Quebec, Canada). Two family physicians and two nurses from each FMG will form four physician-nurse teams. Ten patients will be recruited among each of the participating physician’s practice, for a total of 40 patients.

Physicians and nurses will take part in a training session on physician-patient-nurse collaboration. They will then participate in individual interviews to express their expectations (T0), and discuss strategies and tools used to make collaboration more relevant and responsive to patients with multiple chronic conditions at two other times (T1 and T2).

Two evaluations are planned for patients: before the first visit (T0), and 24 weeks later (T2). Before starting the collaborative process (T0), patients will be invited to participate in a focus group to clarify their expectations. Patients met at T0 will be asked to participate in a second focus group at T2 to discuss elements of satisfaction or dissatisfaction regarding physician-patient-nurse collaboration. At T0 and T2, they will be asked to complete a self-administered questionnaire on quality of life, self-efficacy, functional level, process of care and the achievement of personal goals.

Interprofessional collaboration in patient care has the potential to lead to positive impacts on the process of patient empowerment and self-efficacy. It can also contribute to an improvement in patients’ quality of life and a decrease in their level of psychological distress. Their perception of health care quality should improve as well. This pilot study will allow us to define the form that may take the intervention and methodological elements of a subsequent larger demonstration project.

1.         Commissaire à la santé et au bien-être. Rapport d’appréciation de la performance du système de santé et de services sociaux 2009: État de situation portant sur le système de santé et de services sociaux sur sa première ligne de soins. Québec; 2009.
2.         Juanita Barrett, Vernon Curran, Lindsay Glynn. Canadian Health Services Research Foundation (CHSRF) Synthesis: Interprofessional Collaboration and Quality Primary Healthcare, December 2007. http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/SynthesisReport_E_rev4_FINAL.pdf)
3.         Beaulieu M-D, Denis JL, D’ Amour D, et al. L’implantation des Groupes de médecine de famille : un défi de la réorganisation de la pratique et de la collaboration interprofessionnelle. Montréal: Canadian Health Services Research Foundation (CHSRF); 2006. (http://www.chsrf.ca/migrated/pdf/pastprograms/beaulieu_final.pdf )
4.         Ivy Oandasan, G.Ross Baker, et al. Teamwork in Healthcare: Promoting effective teamwork in healthcare in Canada. Canadian Health Services Research Foundation (CHSRF). Ottawa: FCRSS; 2006. (http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/teamwork-synthesis-report_e.pdf )

Adaptation, implementation and evaluation of an intervention involving the integration of chronic disease rehabilitation services into primary care

(Funded by: Pfizer-FRSQ-MSSS Chronic Disease Fund)

 By Martin Fortin and Maud-Christine Chouinard


Aging is associated with an increasing number of chronic diseases (CD) which represents a challenge for the healthcare system [1-2]. While traditional health care funding and management are mainly designed to address acute health conditions, the bulk of health funds is allocated to patients with CD [3]. The Chronic Care Model (CCM) suggested a multi-component remodeling of CD services to improve patient outcomes [4]. To meet the complex and ongoing needs of patients with CD, rehabilitation has been advocated as a key feature of primary care [5]. Moreover, patients with multimorbidity represent a greater challenge to primary healthcare as they are associated with high healthcare costs and poor compliance to treatment and recommendations [6-7]. In the presence of multimorbidity, health care providers acting in primary care face difficulties in applying guidelines and in maintaining continuity of care. To prevent potential health care system gaps in quality, efficiency, and effectiveness, primary care physicians have to play a gatekeeping role in the management of multimorbid patients and should be assisted in CCM integration and application. Consequently, decision makers and physicians have to look to evidence-based practice guidelines to improve the quality of care and to manage the allocation of resources as efficiently as possible[8].

In this regard, we aim to establish a clinical intervention that will adapt and permanently integrate rehabilitation services into primary care settings and to develop objective tools to assess the adaptation and implementation of this intervention in eight primary care practices in the Saguenay region (Quebec, Canada), in order to ensure the sustainability of interventions beyond the rehabilitation period. More specifically, the intervention will aim to clinically operationalize the mechanisms and tools necessary for the delivery of integrated CD services, promoting continuity of care in response to the needs expressed by stakeholders and to deploy rehabilitation services adapted to the realities of various primary care settings.

The evaluation of the implementation will be conducted using descriptive qualitative methods, while the evaluation of the effects will be based on a combination of experimental designs: randomized trial using a delayed intervention arm (n=326), a before and after design with repeated measures (n=163), and a quasi-experimental design using a comparative cohort (n=326). The qualitative evaluation will be based on focus groups and individual interviews before, during and after the implementation with various stakeholders (decision makers, primary care professionals, rehabilitation professionals and patients). Assessment of effects on patients will use self-administered questionnaires measuring chronic disease self-efficacy, health education impacts, health behaviors, quality of life, and psychological well-being.

Patients included in this study will be referred by their primary care provider and have to present at least one of the conditions for which rehabilitation is currently available (or their risk factors): diabetes, cardiovascular diseases, COPD, asthma. Total disease burden will be assessed for each patient. Data collected from participants will be analyzed in three steps according to a qualitative content analysis procedure to identify emerging themes and trends: coding, sorting of text content and analysis. In addition, the analysis will focus on shedding light on: (1) the interaction between the implementation context and the intervention on the effects obtained; (2) contextual determinants of the changes that occurred from various perspectives on organizational change, including political, structural, psychological and organizational models.

In the short-term, we are expecting improved patient self-efficacy, empowerment and self-management. In the long-term, this should result in a reduction of their risk factors, with an improvement in quality of life and psychological distress. At the organization level, the project should lead to a coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration.

Multimorbidity represents a crucial step in the process of adaptation of evidence-based medicine to the primary care reality. Among patients with CD, those presenting multimorbidity show high levels of health care utilization. It is important to increase our understanding of primary care needs in rehabilitation services and the characteristics of conceptual models of interventional approaches designed for patients followed up by family physicians. In conclusion, the integration of specialized rehabilitation services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated.

1. Fried, L.P., Epidemiology of aging. Epidemiol Rev, 2000. 22(1): p. 95-106.
2. WHO, Chronic disease risk factors. 2003.
3. Mirolla, M., The cost of chronic disease in Canada The Chronic Disease Prevention Alliance of Canada, 2008.
4. Wagner, E.H., et al., Improving chronic illness care: translating evidence into action. Health Aff (Millwood), 2001. 20(6): p. 64-78.
5. McColl, M.A., Structural determinants of access to health services for people with disabilities. Disability and social policy in Canada. 2nd ed.. Toronto: Captus Pr;, 2006: p. 293–313.
6. DiMatteo, M.R., et al., Patient adherence and medical treatment outcomes: a meta-analysis. Med Care, 2002. 40(9): p. 794-811.
7. Hughes, C.M., Medication non-adherence in the elderly: how big is the problem? Drugs Aging, 2004. 21(12): p. 793-811.
8. Wagner, E.H., B.T. Austin, and M. Von Korff, Organizing care for patients with chronic illness. Milbank Q, 1996. 74(4): p. 511-44.

Training clinicians in the management of multimorbidity

By Susan Smith

In considering designing appropriate interventions to improve outcomes for patients with multimorbidity, we are beginning to look at ways of training clinicians in the management of these patients. Our specific intervention is being directed towards GPs or family practitioners. Is anyone aware of any training materials that have been or are being developed for training clinicians? We may focus it around improved medicines management but could also look at case based learning. I would really welcome any comments from others working in the field.