Entete 3

Monthly Archives: September 2014

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.

Multimorbidity in a marginalised, street-health Australian population

By Tom Brett

A recent publication from The University of Notre Dame Australia, Fremantle in BMJ Open (1) deals with patterns, prevalence and disease severity of multimorbid chronic conditions among a street-based vulnerable and marginalized population.
Our research brings new information on a disadvantaged cohort of patients who access an innovative, accredited, mobile outreach primary care medical service.
We have again used the Cumulative Illness Rating Scale among the 2587 patients seen over a six year period in the Fremantle area of Western Australia.
Disease patterns and severity were compared with 4583 mainstream patients from a similar geographical area.
A key finding from our research is that this population develops chronic conditions at a much earlier age especially when compared with earlier research worldwide from mainstream practices.
A positive outcome from our research was the willingness of Aboriginal patients to engage with the mobile, outreach primary care medical service. This compares very favourably with the traditional low attendance patterns of Aboriginal patients with mainstream practices.

(1) Brett T, Arnold-Reed DE, Troeung L, Bulsara MK, Williams A, Moorhead RG. Multimorbidity in a marginalised, street-health Australian population: a retrospective cohort study. BMJ Open. 2014 Aug 19;4(8):e005461. doi: 10.1136/bmjopen-2014-005461.