The 3D Study: Improving the management of patients with multimorbidity in general practice. Initial observations from the pilot study

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The problem

The management of long term conditions is based on guidelines for each specific disease. However, there is an increasing prevalence of patients with multimorbidity. For these patients, the single condition model for treatment may be burdensome. They attend multiple clinics which can be inconvenient and inefficient. They frequently get depressed and sometimes complain that no-one treats them as a ‘whole person' or takes their views into account. Complex polypharmacy and treatment adherence can also be issues. An increasing body of literature describes the scale of this problem, with qualitative research disclosing the views of patients and health professionals, and editorials expounding what should be done, but few large scale randomised controlled trials examining what is clinically and cost effective. This study aims to develop, optimise and evaluate a new approach to improve the management of multimorbidity in general practice. Instead of focussing on each disease in isolation, the aim is to treat the whole patient in a joined-up manner in order to improve their overall quality of life.

The approach

The study is a pragmatic cluster randomised controlled trial with nested process evaluation and economic analysis of cost effectiveness. Instead of unco-ordinated reviews of each of their conditions, patients will have ‘3D' reviews focussing on ‘Dimensions of Health' (patients' priorities, quality of life, and disease control), ‘Depression' (assessment and treatment) and ‘Drugs' (pharmacist recommendations, strategies to simplify drug regimes and improve adherence). The primary outcome is quality of life (EQ5D-5L). Target sample size is 1383 (43 patients from each of 32 practices). Recruitment for the pilot phase, consisting of 3 practices (2 in Bristol and 1 in Manchester) is complete. Eligible participants were aged >=18 with multimorbidity, defined as 3 or more long term conditions from a predefined list of chronic conditions included in QOF. Invitations to complete questionnaires and allow access to medical records were sent to 280 randomly selected patients.


Prevalence of multimorbidity (3+ QOF conditions) was found to be 5% of patients aged 18 and over (mean age 76 years, 35-103). Within this group 54% were female and 46% were male. Almost all patients (92%) have cardiovascular disease and approximately half have chronic kidney disease or diabetes. Of the 280 patients invited to complete questionnaires 196 responded (70%). Written consent and a completed questionnaire was received from 98 (35%) patients. To date 13 patients have received a 3D review.


The pilot phase has shown that the 3D study is viable and can recruit the numbers needed. We hope that this study will inform new approaches to GP management of multimorbidity patients. If successful, this intervention could improve the quality of life of patients, their experience of care and reduce NHS and patient costs.


  • Katherine Chaplin, University of Manchester, Manchester, UK
  • Mei-See Man, University of Manchester, Manchester, UK
  • Pete Bower, University of Glasgow, Glasgow, UK
  • Sara Brookes, University of Manchester, Manchester, UK
  • Ali Heawood, University of Manchester, Manchester, UK
  • Sandra Hollinghurst, University of Manchester, Manchester, UK
  • Bruce Guthrie, Royal College of General Practitioners, London, UK
  • Cindy Mann, University of Manchester, Manchester, UK
  • Imran Rafi
  • Stewart Mercer, University of Dundee, Dundee, UK
  • Chris Salisbury, University of Manchester, Manchester, UK