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A complex intervention for multimorbidity in primary care: A feasibility study.

ABSTRACT: Aim:To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics. Methods:Inclusion criteria were age ?18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurse care manager support in general practice and intensified cross-sectorial collaboration. Elements included a structured care plan based on patients' care goals, coordination of services, and, if appropriate, shifting outpatient clinic visits to general practice, medication review, referral to rehabilitation, and home care. The acceptability dimension of feasibility was assessed with validated questionnaires, observations, and focus groups. Results:Forty-eight patients were included (mean age 72.2 (standard deviation (SD) 9.5, range 52-89); 23 (48%) were men. Thirty-seven patients had two diseases; most commonly COPD and cardiovascular disease (46%), followed by diabetes and cardiovascular disease (23%), and COPD and diabetes (15%). Eleven (23%) patients had all three conditions. Focus group interviews with patients with multimorbidity identified three main themes: (1) lack of care coordination existed across health-care sectors before the CIM, (2) extended consultations provided better care coordination, and (3) patients want to be involved in planning their treatment and care. In focus groups, health-care professionals discussed two main themes: (1) patient-centered care and (2) culture and organizational change. Completion rates for questionnaires were 98% (47/48). Conclusions:Patients and health-care professionals found the CIM acceptable.

SUBMITTER: Birke H

PROVIDER: S-EPMC7418232 | biostudies-literature | 2020 Jan-Dec

REPOSITORIES: biostudies-literature

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A complex intervention for multimorbidity in primary care: A feasibility study.

Birke Hanne H Jacobsen Ramune R Jønsson Alexandra Br AB Guassora Ann Dorrit Kristiane ADK Walther Marie M Saxild Thomas T Laursen Jannie T JT Vall-Lamora Maria Helena Dominquez MHD Frølich Anne A

Journal of comorbidity 20200101

<h4>Aim</h4>To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics.<h4>Methods</h4>Inclusion criteria were age ≥18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurs ...[more]

PMID: 32844099

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Project description:Objectives(A) To measure the extent to which different candidate outcome measures identified high-risk prescribing that is potentially changeable by the data-driven quality improvement in primary care (DQIP) intervention.(B) To explore the value of reviewing identified high-risk prescribing to clinicians.(C) To optimise the components of the DQIP intervention.DesignMixed method study.SettingGeneral practices in two Scottish Health boards.Participants4 purposively sampled general practices of varying size and socioeconomic deprivation.Outcome measuresPrescribing measures targeting (1) high-risk use of the non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelets; (2) 'Asthma control' and (3) 'Antithrombotics in atrial fibrillation (AF)'.InterventionThe prescribing measures were used to identify patients for review by general practices. The ability of the measures to identify potentially changeable high-risk prescribing was measured as the proportion of patients reviewed where practices identified a need for action. Field notes were recorded from meetings between researchers and staff and key staff participated in semistructured interviews exploring their experience of the piloted intervention processes.ResultsPractices identified a need for action in 68%, 25% and 18% of patients reviewed for prescribing measures (1), (2) and (3), respectively. General practitioners valued being prompted to review patients, and perceived that (1) 'NSAID and antiplatelet' and (2) 'antithrombotics in AF' were the most important to act on. Barriers to initial and ongoing engagement and to sustaining improvements in prescribing were identified.Conclusions'NSAIDs and antiplatelets' measures were selected as the most suitable outcome measures for the DQIP trial, based on evidence of this prescribing being more easily changeable. In response to the barriers identified, the intervention was designed to include a financial incentive, additional ongoing feedback on progress and reprompting review of patients, whose high-risk prescribing was restarted after a decision to stop.Trial registration numberClinicaltrials.gov NCT01425502.

Project description:IntroductionOlder Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches.Methods and analysisNine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation.Ethics and disseminationThis study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners.Trial registration numberNCT03442426;Pre-results.

Project description:Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice.Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation.72 general practices in Hesse, Germany.505 randomly sampled, cognitively intact patients (?60 years, ?3?chronic conditions under pharmacological treatment, ?5?long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study.Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care.The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9?months' follow-up: quality of life, functioning, medication adherence, and so on.At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence).The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement.ISRCTN99526053. NCT01171339; Results.

Project description:IntroductionGoal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice.ObjectiveTo assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial.Design and settingCluster-randomised controlled feasibility trial of goal-setting compared with control in six general practices.ParticipantsAdults with two or more long term health conditions and at risk of unplanned hospital admission.InterventionsGeneral practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation 6 months later. The control group received usual care planning.Outcome measuresHealth-related quality of life (EQ-5D-5L), capability (ICEpop CAPability measure for Older people), Patient Assessment of Chronic Illness Care and healthcare use. All consultations were video-recorded or audio-recorded, and focus groups were held with participating GPs and patients.ResultsFifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years, 54% were female and the median number of prescribed medications was 13, compared with 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 min in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting and felt it delivered more patient-centred care, and they highlighted the importance of training.ConclusionsThis goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness.Trial registration numberISRCTN13248305; Post-results.

Project description:BackgroundA general practitioner (GP)-targeted intervention aimed at improving the prescribing of appropriate polypharmacy for older people was previously developed using a systematic, theory-based approach based on the UK Medical Research Council's complex intervention framework. The primary intervention component comprised a video demonstration of a GP prescribing appropriate polypharmacy during a consultation with an older patient. The video was delivered to GPs online and included feedback emphasising the positive outcomes of performing the behaviour. As a complementary intervention component, patients were invited to scheduled medication review consultations with GPs. This study aimed to test the feasibility of the intervention and study procedures (recruitment, data collection).MethodsGPs from two general practices were given access to the video, and reception staff scheduled consultations with older patients receiving polypharmacy (≥4 medicines). Primary feasibility study outcomes were the usability and acceptability of the intervention to GPs. Feedback was collected from GP and patient participants using structured questionnaires. Clinical data were also extracted from recruited patients' medical records (baseline and 1 month post-consultation). The feasibility of applying validated assessment of prescribing appropriateness (STOPP/START criteria, Medication Appropriateness Index) and medication regimen complexity (Medication Regimen Complexity Index) to these data was investigated. Data analysis was descriptive, providing an overview of participants' feedback and clinical assessment findings.ResultsFour GPs and ten patients were recruited across two practices. The intervention was considered usable and acceptable by GPs. Some reservations were expressed by GPs as to whether the video truly reflected resource and time pressures encountered in the general practice working environment. Patient feedback on the scheduled consultations was positive. Patients welcomed the opportunity to have their medications reviewed. Due to the short time to follow-up and a lack of detailed clinical information in patient records, it was not feasible to detect any prescribing changes or to apply the assessment tools to patients' clinical data.ConclusionThe findings will help to further refine the intervention and study procedures (including time to follow-up) which will be tested in a randomised pilot study that will inform the design of a definitive trial to evaluate the intervention's effectiveness.Trial registrationISRCTN18176245.

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A complex intervention for multimorbidity in primary care: A feasibility study.

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A complex intervention for multimorbidity in primary care: A feasibility study.

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