Patient-centred care for multimorbidity: an end in itself?
Authors: Christopher Dowrick
Journal: The Lancet (2018)

Multimorbidity, which is defined as living with two or more chronic health problems, is a major and growing problem, especially in societies with ageing populations and substantial socioeconomic disparities.1Pathirana TI Jackson CA Socioeconomic status and multimorbidity: a systematic review and meta-analysis.Aust N Z J Public Health. 2018; 42: 186-194Crossref PubMed Scopus (133) Google Scholar It is associated with reduced quality of life, impaired functional status, poor physical and mental health, and increased mortality.2Barnett K Mercer SW Norbury M Watt G Wyke S Guthrie B Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.Lancet. 2012; 380: 37-43Summary Full Text Full Text PDF PubMed Scopus (3701) Google Scholar There is a broad international consensus3US Department of Health and Human ServicesMultiple chronic conditions—a strategic framework: optimum health and quality of life for individuals with multiple chronic conditions. US Department of Health and Human Services, Washington, DC2010Google Scholar, 4NICEMultimorbidity: clinical assessment and management. National Institute for Health and Care Excellence, London2016Google Scholar that multimorbidity is best addressed in primary care settings by a patient-centred approach, including regular appointments for comprehensive problem review and management options tailored to individual patient preferences. This care should be provided by a multidisciplinary team with a named lead clinician, and should be based on effective clinical information systems. But there remains the essential question of whether patient-centred interventions actually improve outcomes for patients living with multimorbidity and the health systems that care for them. The results of a recent Cochrane review5Smith SM Wallace E O'Dowd T Fortin M Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.Cochrane Database Syst Rev. 2016; 3 (CD006560.)Google Scholar of 18 randomised controlled trials were equivocal, reporting little or no difference in clinical outcomes or in health service use, while suggesting that health outcomes could be improved if interventions are targeted at specific risk factors or functional difficulties. Chris Salisbury and colleagues6Salisbury C Man M-S Bower P et al.Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach.Lancet. 2018; (published online June 28.)http://dx.doi.org/10.1016/S0140-6736(18)31308-4Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar help answer this question using findings from their cluster-randomised trial of the 3D approach (three dimensional approach based on dimensions of health, depression, and drugs), presented in The Lancet. Their UK-based, multisite trial is the largest study to my knowledge of patient-centred care for multimorbidity. Despite implementing all of the recommended elements of patient-centred care, the authors found no evidence of a significant effect on quality of life (the difference in mean EQ-5D-5L scores was 0·00, 95% CI −0·02 to 0·02; p=0·93), or on various measures of illness or treatment burden.6Salisbury C Man M-S Bower P et al.Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach.Lancet. 2018; (published online June 28.)http://dx.doi.org/10.1016/S0140-6736(18)31308-4Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar The authors did, however, find that participants randomly assigned to the intervention group reported significantly improved patient-centred care, including discussing problems most important to them (42% in the intervention group vs 26% in the usual care group; odds ratio 1·85, 95% CI 1·44 to 2·38; p<0·0001) and satisfaction with care received (56% vs 39%; 1·57, 1·19 to 2·08; p=0·0014).6Salisbury C Man M-S Bower P et al.Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach.Lancet. 2018; (published online June 28.)http://dx.doi.org/10.1016/S0140-6736(18)31308-4Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar The 3D approach was based on the best available evidence from international clinical guidelines. Built around two 6-monthly appointments with a nurse and a physician, and medication review by a pharmacist, it was crafted and designed to be pragmatic and achievable. The findings should therefore be assumed to be robust and generalisable across the National Health Service. The findings are also likely to be of relevance in other health-care systems based on well established primary care teams with a commitment to reducing the burden of chronic disease. Although the findings of Salisbury and colleagues might encourage people committed to single disease management approaches, it would be premature to consign patient-centred multimorbidity care to the dustbin of medical history. The core components of the intervention could have been insufficient to treat deep-rooted health problems, especially since only 49% of the intervention participants attended both appointments. Despite specific pharmacist review, there was no difference in rates of prescription of potentially inappropriate medications. Trials of longer-term interventions, involving greater intensity of contact between patients and health-care professionals, are therefore indicated. It is implausible to assume that the organisation and delivery of even the highest quality primary care is sufficient in itself to address the complexity of multimorbidity, the underlying causes of which are often rooted in socioeconomic deprivation.7Lund J N Pedersen HS Vestergaard M Mercer SW Glümer C Prior A The impact of socioeconomic status and multimorbidity on mortality: a population-based cohort study.Clin Epidemiol. 2017; 9: 279-289Crossref PubMed Google Scholar It would therefore be advisable to develop multmodal approaches, linking patient-centred primary care with public health policy level interventions addressing behavioural, environmental, and occupational determinants of long-term illness and inequity.8Newton JN Briggs AD Murray CJ et al.Changes in health in England, with analysis by English regions and areas of deprivation,1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2015; 386: 2257-2274Summary Full Text Full Text PDF PubMed Scopus (240) Google Scholar As the authors note, the study results call into question the assumed causal link between patient-centred care and improved quality of life and health outcomes. Although such a link has been a standard assumption in primary care for many years, and is commonly seen as the underlying reason for holistic approaches to health care,9Toop L Primary care: core values. Patient centred primary care.BMJ. 1998; 316: 1882-1883Crossref PubMed Scopus (54) Google Scholar, 10Dowrick C Person-centred primary care: searching for the self. Routledge, Abingdon2018Google Scholar it is important to acknowledge that this assumption needs to be challenged and tested. This raises a further question, whether patient-centred care for patients with multimorbidity is a means to an end, or an end in itself. In the study by Salisbury and colleagues, quality of life and disease management outcomes were no worse than those for standard care, so there is no evidence of the trial intervention doing harm. I await the results of the health economics analyses from this study, which will be published separately. Assuming comparability, it will be reasonable to conclude that, given competing models of service delivery providing equivalent health care, modes of delivery that are rated more highly by patients11Little P Everitt H Williamson I et al.Preferences of patients for patient centred approach to consultation in primary care: observational study.BMJ. 2001; 322: 468-472Crossref PubMed Google Scholar are intrinsically preferable. I have collaborated with some of the authors of the Article being discussed here on other projects and publications. I declare no other competing interests. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approachTo 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. Full-Text PDF Open Access