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