TY - JOUR
T1 - Management of multimorbidity using a patient-centred care model
T2 - a pragmatic cluster-randomised trial of the 3D approach
AU - Salisbury, Chris
AU - Man, Mei-See
AU - Bower, Peter
AU - Guthrie, Bruce
AU - Chaplin, Katherine
AU - Gaunt, Daisy M.
AU - Brookes, Sara
AU - Fitzpatrick, Bridie
AU - Gardner, Caroline
AU - Hollinghurst, Sandra
AU - Lee, Victoria
AU - McLeod, John
AU - Mann, Cindy
AU - Moffat, Keith R.
AU - Mercer, Stewart W.
N1 - This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 12/130/15). This study was designed and conducted in collaboration with the Bristol Randomised Trials Collaboration (BRTC), a UKCRC Registered clinical trials unit (CTU) in receipt of National Institute for Health Research CTU support funding. CS is partly supported by The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West. (NIHR CLAHRC West)
PY - 2018/7/7
Y1 - 2018/7/7
N2 - 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.
AB - 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.
KW - Aged
KW - Chronic Disease/psychology
KW - England
KW - Female
KW - Follow-Up Studies
KW - Humans
KW - Interdisciplinary Communication
KW - Intersectoral Collaboration
KW - Male
KW - Middle Aged
KW - Multimorbidity
KW - Patient Care Team
KW - Patient-Centered Care
KW - Quality of Life/psychology
KW - Scotland
KW - Self Care/psychology
UR - http://www.scopus.com/inward/record.url?scp=85049349646&partnerID=8YFLogxK
U2 - 10.1016/S0140-6736(18)31308-4
DO - 10.1016/S0140-6736(18)31308-4
M3 - Article
C2 - 29961638
SN - 0140-6736
VL - 392
SP - 41
EP - 50
JO - Lancet
JF - Lancet
IS - 10141
ER -