A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT
2019
Background People with multimorbidity experience impaired quality of life, poor health
and a burden from treatment. Their care is often disease-focused rather than
patient-centred and tailored to their individual needs. Objective To implement and evaluate a patient-centred intervention to improve the
management of patients with multimorbidity in general practice. Design Pragmatic, cluster randomised controlled trial with parallel process and
economic evaluations. Practices were centrally randomised by a statistician
blind to practice identifiers, using a computer-generated algorithm. Setting Thirty-three general practices in three areas of England and Scotland. Participants Practices had at least 4500 patients and two general practitioners (GPs) and
used the EMIS (Egton Medical Information Systems) computer system. Patients
were aged ≥ 18 years with three or more long-term
conditions. Interventions The 3D (Dimensions of health, Depression and Drugs) intervention was designed
to offer patients continuity of care with a named GP, replacing separate
reviews of each long-term condition with comprehensive reviews every 6
months. These focused on individualising care to address patients’
main problems, attention to quality of life, depression and polypharmacy and
on disease control and agreeing treatment plans. Control practices provided
usual care. Outcome measures Primary outcome – health-related quality of life (assessed using the
EuroQol-5 Dimensions, five-level version) after 15 months. Secondary
outcomes – measures of illness burden, treatment burden and
patient-centred care. We assessed cost-effectiveness from a NHS and a social
care perspective. Results Thirty-three practices (1546 patients) were randomised from May to December
2015 [16 practices (797 patients) to the 3D intervention, 17 practices (749
patients) to usual care]. All participants were included in the primary
outcome analysis by imputing missing data. There was no evidence of
difference between trial arms in health-related quality of life {adjusted
difference in means 0.00 [95% confidence interval (CI) –0.02 to
0.02]; p = 0.93}, illness burden or treatment
burden. However, patients reported significant benefits from the 3D
intervention in all measures of patient-centred care. Qualitative data
suggested that both patients and staff welcomed having more time, continuity
of care and the patient-centred approach. The economic analysis found no
meaningful differences between the intervention and usual care in either
quality-adjusted life-years [(QALYs) adjusted mean QALY difference 0.007,
95% CI –0.009 to 0.023] or costs (adjusted mean difference £126,
95% CI –£739 to £991), with wide uncertainty around point
estimates. The cost-effectiveness acceptability curve suggested that the
intervention was unlikely to be either more or less cost-effective than
usual care. Seventy-eight patients died (46 in the intervention arm and 32
in the usual-care arm), with no evidence of difference between trial arms;
no deaths appeared to be associated with the intervention. Limitations In this pragmatic trial, the implementation of the intervention was
incomplete: 49% of patients received two 3D reviews over 15 months, whereas
75% received at least one review. Conclusions The 3D approach reflected international consensus about how to improve care
for multimorbidity. Although it achieved the aim of providing more
patient-centred care, this was not associated with benefits in quality of
life, illness burden or treatment burden. The intervention was no more or
less cost-effective than usual care. Modifications to the 3D approach might
improve its effectiveness. Evaluation is needed based on whole-system change
over a longer period of time. Trial registration Current Controlled Trials ISRCTN06180958. Funding This project was funded by the National Institute for Health Research (NIHR)
Health Services and Delivery Research programme and will be published in
full in Health Services and Delivery Research; Vol. 7, No.
5. See the NIHR Journals Library website for further project
information.
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