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Monthly Archives: June 2018

Intervention

Redesigning primary care for the people who use it: unveiling the results of the 3D trial for patients with multimorbidity in general practice

June 29, 2018 – 7:50 am

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.
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Epidemiology and outcomes research

Frailty : Not just a problem for older people

June 14, 2018 – 9:04 am

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.
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