Patient-centred care yields mixed results

AN emphasis on patient-centred care in dealing with multimorbidity in primary care yields mixed results, according to a new study.

Researchers from the National Institute for Health Research UK gathered data from 1,546 patients in England and Scotland and found that making health reviews more patient-centred improved patient satisfaction significantly, but measures of health-related quality of life (including mobility, self-care, pain/discomfort, and anxiety and depression) were unchanged.

One in four people in the UK and the US have two or more long-term health conditions, increasing to two-thirds for patients aged over 65. These include diabetes, heart disease and asthma, and mental health conditions, such as depression and dementia. Multimorbidity is associated with reduced quality of life, worse physical and mental health, and increased mortality.

The study tested a ‘3D’ approach to caring for people with multimorbidity, which encourages clinicians to think broadly about the different dimensions of health, simplify complex drug treatment and consider mental health (depression) as well as physical health. It is designed to treat the whole person rather than focusing on individual conditions in isolation.

In the trial involving 33 general medical practices, roughly half offered 3D intervention (797 patients) and the other half offered usual care (749 patients). The 3D intervention replaced disease-focused reviews of each health condition with one comprehensive 'patient-centred' review every six months with a nurse and doctor. These reviews focused on discussing the problems that bothered the patients most, how to improve their quality of life as well as management of their health conditions. A pharmacist reviewed the patient's medication.

A health care plan was then devised with each patient and reviewed six months later. All measures of patient experience showed benefits after 15 months, with patients widely reporting that they felt their care was more joined up and attentive to their needs. However, there was no difference between the two groups in their reported quality of life at the end of the study period.

Professor Chris Salisbury of the University of Bristol's Centre for Academic Primary Care and lead author of the study, which was published in the Lancet, said: "Existing treatment is based on guidelines for each separate condition meaning that patients often have to attend multiple appointments for each disease which can be repetitive, inconvenient and inefficient. They see different nurses and doctors who may give conflicting advice. Patients with multiple physical health problems frequently get depressed and they also sometimes complain that no-one treats them as a 'whole person' or takes their views into account.

"Internationally, there is broad consensus about the key components of an approach to improve care for people with multimorbidity but we found little evidence about their effectiveness. We incorporated these components in the 3D approach, including a regular review of patients' problems according to their individual circumstances. We were surprised to find no evidence of improved quality of life for patients as a result of the intervention but this was balanced by significant improvements in patients' experience of care.

"The question now is whether improved patient experience is sufficient justification for this approach. Given that improving patient experience is one of the triple arms of health care, alongside improving health and reducing costs, our view is that providing care that significantly improves patients' experience is justification in itself."

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