Results of the largest ever multimorbidity trial in primary care challenge current thinking

In the largest ever trial of an intervention to treat people with multiple long-term conditions (multimorbidity) in primary care, researchers at the Universities of Bristol, Manchester, Dundee and Glasgow found that the patient-centred approach taken improved patients’ experience of their care but did not improve their health-related quality of life. This is a challenge to current thinking on which UK and international guidelines are based.

In a study involving 1,546 patients from England and Scotland, they found that by making health reviews more patient-centred, such as involving patients in the planning and delivery of their care, overall patient satisfaction improved significantly. However, their health-related quality of life, which included measures of mobility, self-care, pain and discomfort, and anxiety and depression, did not.

The findings, published in The Lancet Thursday 28 June, provide the best evidence to date of the effectiveness of a person-centred approach for multimorbidity, for which there is international consensus but little evidence.

One in four people in the UK and the US have two or more long-term health conditions, increasing to two-thirds for patients aged over 65, placing a major strain on health services. Conditions include diabetes, heart disease and asthma, and can include mental health conditions such as depression and dementia. Multimorbidity is associated with reduced quality of life, worse physical and mental health, and increased mortality. Treatment for multimorbidity places an additional burden on patients, who may have to take large numbers of drugs, make lifestyle changes and attend numerous appointments for health care.

The study, funded by the National Institute for Health and Care Research (NIHR), tested a new approach to caring for people with three or more long-term conditions, which aimed to improve their health-related quality of life and experience of patient-centred care, and reduce their burden of illness and treatment compared with usual care. The ‘3D’ approach, which encourages clinicians to think broadly about the different dimensions of health, simplify complex drug treatment and consider mental health (depression) as well as physical health, was designed to treat the whole person and overcome the disadvantages of treating individual conditions in isolation.

Lead author of the study, Professor Chris Salisbury from the University of Bristol’s Centre for Academic Primary Care and NIHR CLAHRC West said:

“Existing treatment is based on guidelines for each separate condition meaning that patients often have to attend multiple appointments for each disease which can be repetitive, inconvenient and inefficient. They see different nurses and doctors who may give conflicting advice. Patients with multiple physical health problems frequently get depressed and they also sometimes complain that no-one treats them as a ‘whole person’ or takes their views into account.

“Internationally, there is broad consensus about the key components of an approach to improve care for people with multimorbidity but we found little evidence about their effectiveness. We incorporated these components in the 3D approach, including a regular review of patients’ problems according to their individual circumstances. We were surprised to find no evidence of improved quality of life for patients as a result of the intervention but this was balanced by significant improvements in patients’ experience of care.

“The question now is whether improved patient experience is sufficient justification for this approach. Given that improving patient experience is one of the triple arms of health care, alongside improving health and reducing costs, our view is that providing care that significantly improves patients’ experience is justification in itself.”

Patients from 33 primary care practices in Bristol, Greater Manchester and Ayrshire in Scotland took part in the study. Roughly half of the practices offered the 3D intervention (to 797 patients) and other half offered usual care (to 749 patients). Patients were aged 18 and older. The 3D intervention replaced disease-focused reviews of each health condition with one comprehensive ‘patient-centred’ review every 6 months with a nurse and doctor. These reviews focused on discussing the problems that bothered the patients most, how to improve their quality of life and how to improve management of their health conditions. A pharmacist reviewed the patient’s medication. A health care plan was then devised with each patient and reviewed six months later.

All measures of patient experience showed benefits after 15 months, with patients widely reporting that they felt their care was more joined up and attentive to their needs. However, there was no difference between the two groups in their reported quality of life at the end of the study period.