How can we make care for people at risk of multimorbidity more inclusive?: Findings from the SYMPHONI study.

Problem

People with inflammatory rheumatological disorders (IRDs) are at high risk of developing multimorbidity, specifically cardiovascular disease and mood problems. UK guidelines advocate annual reviews for people with Rheumatoid Arthritis (RA), although not other IRDs. Current reviews in primary care are often condition-specific, focusing on existing morbidities rather than identification and management of future risk, and may not include advice to support behaviour change. A 2021 review of NHS HealthChecks highlight that some vulnerable groups do not access them and there should be a focus on risk prevention.

Approach

The SYMPHONI study aimed to explore perspectives on reviews to identify and manage risk of multimorbidity. People with IRDs completed individual semi-structured interviews by telephone or online platform. HCPs (including primary and secondary care clinicians) participated in online focus groups. Data were transcribed verbatim and analysed using inductive thematic analysis. Ethical approval was obtained.

Findings

15 people with IRDs were interviewed. 3 focus groups were conducted. Four themes were identified regarding reviews: content, preparation, delivering a holistic review and intended outcomes.

Content: People described current reviews as a ‘tick-box’ exercise, with challenges aligning agendas: HCPs reported targets from Quality Outcomes Framework left little time for patient agenda to be addressed and created challenges in providing a holistic review. Variable attitudes to considering future risks were identified, ranging from whether people wanted all, some or no knowledge of their risk for other conditions influenced by whether these could be prevented.

Preparation: Pre-review preparation was important to maximise effectiveness. Written information was important to understand the review aims, align agendas and for the HCP to understand the patient context, saving time and ensuring person-centred care. Participants recognized the challenge of ensuring materials are inclusive of under-served patient groups who may face difficulties accessing preparation materials.

Delivery: People with IRDs preferred face-to-face appointments over digital, highlighting the perceived need for physical assessment but the importance of patient preference/choice was highlighted. Group consultations were perceived as potentially useful for information sharing and social support, many people reported reluctance to discuss topics such as mental health in a group setting.

Outcomes: It was considered important that outcomes from a review (including actions for a patient or HCP) should be clearly understood for a review to be perceived as beneficial, and follow-up essential in ensuring actions were addressed.

Consequences

Moving reviews beyond a “tick-box” requires preparation by both patient and practitioner to ensure they are person-centered to maximise utility and perceived value whilst ensuring they are targeted at those patient groups most likely to benefit.