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

Salisbury, C. et al. (2018) Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet, 392(10141), pp. 41-50. (doi: 10.1016/S0140-6736(18)31308-4) (PMID:29961638) (PMCID:PMC6041724)

Abstract

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.

• Item Type: Articles
• Additional Information: This project was funded by the NIHR Health Services and Delivery Research Programme (project number 12/130/15).
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Mercer, Professor Stewart and Fitzpatrick, Dr Bridie and McLeod, Mr John and Moffat, Dr Keith
• Authors: Salisbury, C., Man, M.-S., Bower, P., Guthrie, B., Chaplin, K., Gaunt, D. M., Brookes, S., Fitzpatrick, B., Gardner, C., Hollinghurst, S., Lee, V., McLeod, J., Mann, C., Moffat, K. R., and Mercer, S. W.
• College/School: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > General Practice and Primary Care
• Journal Name: Lancet
• Publisher: The Lancet Publishing Group
• ISSN: 0140-6736
• ISSN (Online): 1474-547X
• Published Online: 29 June 2018
• Copyright Holders: Copyright © 2018 The Authors
• First Published: First published in Lancet 392(10141): 41-50
• Publisher Policy: Reproduced under a Creative Commons License