Patient centred care in an evidence based world? A meta-ethnography of multimorbidity interventions

Problem

Multimorbidity is a major challenge to global healthcare systems. Multimorbidity is socially patterned: it is more prevalent and begins up to 15 years earlier in communities experiencing socioeconomic deprivation. In recent years there has been an increase in multimorbidity interventions but there is a dearth of evidence on how best to improve outcomes and quality of life.

Treatment burden (the work done by patients to manage conditions) increases in the context of both multimorbidity and socioeconomic deprivation. In addition, factors known to impact on patients’ capacity (eg. low health literacy, environment) to manage multimorbidity cluster in communities experiencing socioeconomic deprivation. When an individual’s treatment burden exceeds their capacity to carry out that work it results in poorer adherence, access, and outcomes.

Despite recognition that treatment burden, patient capacity and social context significantly impact the experience of multimorbidity, the extent to which (if at all) current multimorbidity interventions consider treatment burden, patient capacity or social context remains unknown. This meta-ethnography aims to address this gap and explore experience of primary care multimorbidity interventions.

Approach

A search of Medline, Embase, CINAHL, AMED and Cochrane databases identified 3806 qualitative papers exploring experience of primary care multimorbidity interventions that have been evaluated by a randomised trial. Screening of potential articles was carried out by two reviewers, disagreements resolved by a third independent reviewer.

COREQ used to quality appraise. An analysis drawing on principles of meta-ethnography explores participant experience, and eMERGe reporting guidelines followed. We have assessed whether existing interventions address:

• Treatment burden: analysing whether interventions increase or decrease patient workload; the nature of identified work will be categorised using Normalisation Process Theory.

• Patient capacity: analysing whether the interventions enhance or diminish patient capacity; capacity will be categorised using Burden of Treatment Theory.

• Self-management: analysing the role of self-management in interventions; self-management will be categorised according to the PRISMS taxonomy.

• Social context: analysing whether interventions consider, explicitly target, or support, patient’s social context; contexts will be narratively described.

Findings

17 articles included for full-text screening. Analysis is ongoing; interim analysis of patient experience suggests patients’ value:

• Good practitioner-patient relationship

• Patient rather than practitioner driven interventions

• Building and encouraging patient capacity and autonomy

Interventions perceived as holistic were highly valued, however, patients and practitioners articulated intangible benefits, which are potentially hard to measure. Ongoing analysis will examine how the important components of treatment burden, patient capacity and social context were considered.

Consequences

Patient experience of multimorbidity interventions is important. Interventions that fail to adequately account for the impact of treatment burden, capacity and social context are less likely to offer tangible solutions. Our findings will inform the design of future patient-centred multimorbidity interventions that enhance patient experience and quality of life, improving outcomes in this critical area.