Does a patient centred approach improve outcomes for people with multimorbidity? Pragmatic cluster randomised controlled trial

Conference:

SAPC ASM 2018 - London

Talk Code:

Prize Plenary 2

Presenter:

Chris Salisbury

Co-authors:

Mei-See Man [1,2], Peter Bower [3], Bruce Guthrie [4], Katherine Chaplin [1], Daisy Gaunt [2], Sara Brookes [2], Bridie Fitzpatrick [5 ], Caroline Gardner [3], Sandra Hollinghurst [1], Victoria Lee [3], John McLeod [4], Cindy Mann [1], Keith Moffat [5], Stewart Mercer [5]

Author institutions:

[1]Centre for Academic Primary Care University of Bristol, [2]Bristol Randomised Trials Collaboration University of Bristol, [3]Centre for Primary Care University of Manchester, [4]Population Health Sciences Division University of Dundee, [5]Institute of Health and Wellbeing University of Glasgow

Problem

The growing number of people with multiple chronic conditions challenges health care systems which are designed to manage each condition in isolation. There is international consensus about the need for a more patient-centred approach to the management of multimorbidity, which is tailored to individuals’ priorities, considers quality of life alongside disease control, seeks to reduce treatment burden (particularly inappropriate polypharmacy) and promotes self-management towards goals agreed between patients and clinicians. However, there is little evidence about the effectiveness of this approach. The aim of this study was to implement at scale and evaluate the 3D approach to managing patients with multimorbidity, based on a patient-centred care model.

Approach

We conducted a pragmatic cluster-randomised trial amongst general practices in England and Scotland. Practices were randomly allocated to continue usual care or to provide the ‘3D’ approach which offered six-monthly comprehensive reviews based on a patient-centred care model and incorporated strategies reflecting the international consensus. Care was delivered by a multidisciplinary team supported by an interactive clinical information system. Adult patients with three of more chronic conditions were recruited. The primary outcome was quality of life after 15 months follow-up, measured using the EQ-5D-5L questionnaire. Secondary outcomes were measures of patient-centred care, illness burden, treatment burden, and improved care processes. In parallel with the trial we conducted a qualitative process evaluation and an economic evaluation of cost-effectiveness (reported separately).

Findings

We recruited 1546 patients from 33 practices. In intention-to-treat analysis, all measures of patient-centred care showed significant benefit from the 3D intervention, including the Patient Assessment of Care for Chronic Conditions (PACIC) measure (adjusted mean difference 0.29 [0.16 to 0.41], p<0.001). However, there was no evidence of difference between trial arms in the primary outcome of quality of life after 15 months follow-up (adjusted difference in mean EQ-5D-5L 0.00 (95% CI -0.02 to 0.02), p=0.825). There was also no difference in any measure of illness burden or treatment burden.

Consequences

This trial represents the largest and most rigorous test yet conducted of the international consensus about the optimal way to manage multimorbidity in primary care. The 3D intervention improved patient-centred care but was not associated with benefits in quality of life, illness burden or treatment burden. This raises questions about whether the assumption that improved patient-centred health care will lead to improved health and well-being is flawed. Alternatively it could be argued that providing care which respects patient’s wishes and priorities is itself sufficient justification for implementation.

Submitted by:

Chris Salisbury

Funding acknowledgement:

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 in this report are those of the authors and do not necessarily reflect those of the NIHR, the NHS or the Department of Health.