Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach

Background

The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention.

Methods

We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months’ follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958.

Findings

Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention.

Interpretation

To our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients’ quality of life.

Funding

National Institute for Health Research.
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Primary care estate

Reform has published A design diagnosis: reinvigorating the primary care estate.  This report looks at financing options for GPs who wish to upgrade their estate and finds private sector finance can upgrade the estate at value for money for the taxpayer.   It suggests GPs need to be well-informed on financing options and building design to ensure public-private partnerships deliver value for money and that STPs have a critical role in supporting GPs when they are interacting with estate developers.

Additional link: Reform blog

General practice case studies

NHS England has published the following case studies relating to general practice:

Improving general practice: case studies

NHS England has published the following case studies illustrating efficiency improvements in general practices:

The financial challenges facing general practice

Future-Focused Finance and the HFMA have worked together to produce this briefing on the current financial challenges facing general practice.

We asked general practitioners (GPs) and practice managers about the current financial challenges they are facing Their responses highlight a number of serious concerns about the issues facing general practice and in this briefing we make a number of recommendations to address some of the most pressing issues.

General practice is facing unprecedented pressures and, with GPs managing heavier and more complex workloads, uncertainty about a sustainable future in a rapidly changing landscape is understandable. In such a stretched environment general practice needs guidance and support to manage the status quo, let alone deliver the increasing expectations set out in Next steps on the NHS five year forward view.

Further information is available here.