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

Salisbury, Chris, Man, Mei-See ORCID: https://orcid.org/0000-0003-4948-5670, Bower, Peter, Guthrie, Bruce, Chaplin, Katherine, Gaunt, Daisy M., Brookes, Sara, Fitzpatrick, Bridie, Gardner, Caroline, Hollinghurst, Sandra, Lee, Victoria, McLeod, John, Mann, Cindy, Moffat, Keith R. and Mercer, Stewart W. (2018) Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. The Lancet, 392. pp. 41-50. ISSN 0140-6736

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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.

Item Type:	Article
Faculty \ School:	Faculty of Medicine and Health Sciences > Norwich Medical School
UEA Research Groups:	Faculty of Medicine and Health Sciences > Research Centres > Population Health
Depositing User:	LivePure Connector
Date Deposited:	28 Jan 2020 03:53
Last Modified:	24 Sep 2024 12:54
URI:	https://ueaeprints.uea.ac.uk/id/eprint/73828
DOI:	10.1016/S0140-6736(18)31308-4

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