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A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT

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A patient-centred intervention to improve the management of multimorbidity in general practice : the 3D RCT. / Salisbury, Chris; Man, Mei-See; Chaplin, Katherine; Mann, Cindy; Bower, Peter; Sara, Brookes; Duncan, Polly; Fitzpatrick, Bridie; Gardner, Caroline; Gaunt, Daisy; Guthrie, Bruce; Hollinghurst, Sandra; Kadir, Bryar; Lee, Victoria ; McLeod, John; Stewart, Mercer; Moffatt, H. Keith; Moody, Emma; Rafi, Imran; Robinson, Rebecca; Shaw, Alison R G; Thorn, Joanna.

In: Health Services and Delivery Research, Vol. 7, No. 5, 15.02.2019.

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Salisbury, C, Man, M-S, Chaplin, K, Mann, C, Bower, P, Sara, B, Duncan, P, Fitzpatrick, B, Gardner, C, Gaunt, D, Guthrie, B, Hollinghurst, S, Kadir, B, Lee, V, McLeod, J, Stewart, M, Moffatt, HK, Moody, E, Rafi, I, Robinson, R, Shaw, ARG & Thorn, J 2019, 'A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT', Health Services and Delivery Research, vol. 7, no. 5. https://doi.org/10.3310/hsdr07050

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Salisbury, Chris ; Man, Mei-See ; Chaplin, Katherine ; Mann, Cindy ; Bower, Peter ; Sara, Brookes ; Duncan, Polly ; Fitzpatrick, Bridie ; Gardner, Caroline ; Gaunt, Daisy ; Guthrie, Bruce ; Hollinghurst, Sandra ; Kadir, Bryar ; Lee, Victoria ; McLeod, John ; Stewart, Mercer ; Moffatt, H. Keith ; Moody, Emma ; Rafi, Imran ; Robinson, Rebecca ; Shaw, Alison R G ; Thorn, Joanna. / A patient-centred intervention to improve the management of multimorbidity in general practice : the 3D RCT. In: Health Services and Delivery Research. 2019 ; Vol. 7, No. 5.

Bibtex

@article{021304e1cc464154a466ac8493cf008f,
title = "A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT",
abstract = "BackgroundPeople 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.ObjectiveTo implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.DesignPragmatic, 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.SettingThirty-three general practices in three areas of England and Scotland.ParticipantsPractices 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.InterventionsThe 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 measuresPrimary 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.ResultsThirty-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.LimitationsIn 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.ConclusionsThe 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 registrationCurrent Controlled Trials ISRCTN06180958.FundingThis 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.",
author = "Chris Salisbury and Mei-See Man and Katherine Chaplin and Cindy Mann and Peter Bower and Brookes Sara and Polly Duncan and Bridie Fitzpatrick and Caroline Gardner and Daisy Gaunt and Bruce Guthrie and Sandra Hollinghurst and Bryar Kadir and Victoria Lee and John McLeod and Mercer Stewart and Moffatt, {H. Keith} and Emma Moody and Imran Rafi and Rebecca Robinson and Shaw, {Alison R G} and Joanna Thorn",
year = "2019",
month = "2",
day = "15",
doi = "10.3310/hsdr07050",
language = "English",
volume = "7",
journal = "Health Services and Delivery Research",
issn = "2050-4349",
publisher = "NIHR Journals Library",
number = "5",

}

RIS - suitable for import to EndNote

TY - JOUR

T1 - A patient-centred intervention to improve the management of multimorbidity in general practice

T2 - the 3D RCT

AU - Salisbury, Chris

AU - Man, Mei-See

AU - Chaplin, Katherine

AU - Mann, Cindy

AU - Bower, Peter

AU - Sara, Brookes

AU - Duncan, Polly

AU - Fitzpatrick, Bridie

AU - Gardner, Caroline

AU - Gaunt, Daisy

AU - Guthrie, Bruce

AU - Hollinghurst, Sandra

AU - Kadir, Bryar

AU - Lee, Victoria

AU - McLeod, John

AU - Stewart, Mercer

AU - Moffatt, H. Keith

AU - Moody, Emma

AU - Rafi, Imran

AU - Robinson, Rebecca

AU - Shaw, Alison R G

AU - Thorn, Joanna

PY - 2019/2/15

Y1 - 2019/2/15

N2 - BackgroundPeople 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.ObjectiveTo implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.DesignPragmatic, 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.SettingThirty-three general practices in three areas of England and Scotland.ParticipantsPractices 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.InterventionsThe 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 measuresPrimary 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.ResultsThirty-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.LimitationsIn 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.ConclusionsThe 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 registrationCurrent Controlled Trials ISRCTN06180958.FundingThis 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.

AB - BackgroundPeople 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.ObjectiveTo implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.DesignPragmatic, 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.SettingThirty-three general practices in three areas of England and Scotland.ParticipantsPractices 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.InterventionsThe 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 measuresPrimary 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.ResultsThirty-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.LimitationsIn 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.ConclusionsThe 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 registrationCurrent Controlled Trials ISRCTN06180958.FundingThis 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.

U2 - 10.3310/hsdr07050

DO - 10.3310/hsdr07050

M3 - Article

VL - 7

JO - Health Services and Delivery Research

JF - Health Services and Delivery Research

SN - 2050-4349

IS - 5

ER -