Title: Improving the management of patients with multimorbidity in general practice
Funder: Department of Health (England)

Abstract: This is a pragmatic cluster RCT with nested process and economic evaluation of an intervention in general practice designed to improve the management of patients with multimorbidity. We hypothesise that this intervention will improve patients’ health related quality of life and experience of patient-centred care and will be more cost-effective than conventional service models.After initial optimisation & piloting in 4 practices we will recruit 32 general practices and randomise them to the intervention or usual care. Participants will be adults aged 18+ with multimorbidity defined as 3 or more long term conditions (LTCs).The intervention addresses the problems of illness burden (poor quality of life depression) treatment burden (multiple unco-ordinated appointments polypharmacy poor primary/secondary care co-ordination) and lack of patient-centred care (low continuity disregard of patients’ priorities) experienced by patients with multimorbidity. These patients will be prioritised to receive enhanced continuity of care and longer appointments. They will be invited to a comprehensive ‘3D’ assessment every 6 months. This focuses on (i) Dimensions of health (patient’s priorities for improving quality of life e.g. mobility pain before addressing disease markers e.g. BP) (ii) Depression (identified and treated as a priority) (iii) Drugs (addressing polypharmacy & poor medication adherence). The nurse will complete a bespoke computerised template to address these 3D elements collecting relevant data and arranging tests. The GP will review all the information thoroughly review medication and agree a written care plan for the patient to take away. To improve primary/secondary care integration each practice will have a designated hospital ‘general physician’ to discuss patients with complex needs.To ensure the intervention is effectively implemented it will be incentivised as if it were an Enhanced Service. Practices will train in local collaboratives to share ideas. We will allow local adaptation appoint a practice champion provide training and monthly feedback on perfomance.Control practices continue usual care. This usually involves patients being recalled to clinics to see different nurses to review each of their LTCs with a focus on QOF targets rather than quality of life or patients’ priorities.Outcomes will be measured at baseline 6 and 12 months and include measures of health related quality of life (EQ-5D-5L: primary outcome); depression; disease control; patient experience; use of primary and secondary care resources (including admission rates).A parallel mixed methods process evaluation combining quantitative and qualitative methods will provide understanding of trial delivery intervention implementation and responses of targeted participants.An economic evaluation will be undertaken from the perspectives of (a) NHS and personal social services and (b) patients providing a cost-consequences analysis and a cost-effectiveness analysis.Sample size: 1383 patients from 32 general practices. With 80% follow-up at 12 months and ICC at practice level of 0.03 the study will have about 90% power to detect an effect size of 0.274 SDs in the EQ-5D.Benefits and potential impacts: This intervention could improve the quality of life of patients and their experience of care and reduce NHS and patient costs. Working with the RCGP we will ensure that the intervention (if effective) can be implemented rapidly.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE