Many people with chronic disease have more than one illness, which is referred to as multimorbidity. Susan Smith from the Department of General Practice at the Royal College of Surgeons in Ireland describes an updated, March 2016, Cochrane Review which sought out evidence on interventions that might help.
David: Many people with chronic disease have more than one illness, which is referred to as multimorbidity. Susan Smith from the Department of General Practice at the Royal College of Surgeons in Ireland describes an updated, March 2016, Cochrane Review which sought out evidence on interventions that might help.
Susan: In primary care settings, approximately 30% of people aged 50 have multimorbidity, rising to 70% by age 70. People with multimorbidity are more likely to die prematurely, be admitted to hospital and have longer hospital stays. They have poorer quality of life, loss of physical functioning, are more likely to suffer from depression, and are probably receiving multiple medications with consequent difficulties with adherence. Despite this, there is limited evidence on ways to improve outcomes in patients with multimorbidity. Their clinical care is complex and the evidence base for managing chronic conditions is based largely on trials of interventions for single illnesses, which too often exclude patients with multiple conditions.
We wanted to get beyond this, to try to determine the effectiveness of interventions that had been specifically designed to improve outcomes in patients with multimorbidity in primary care and community settings.
A variety of study designs were eligible for the review, including non-randomized trials and interrupted time series analyses, as well as the more usual, randomized trials. In fact, all 18 of the studies we found were randomized trials. While most studies were from the USA, seven of the 18 studies were from other countries – namely the UK, Australia and Canada.
We were particularly interested in the effects on clinical outcomes, mental health outcomes, patient reported outcomes measures including quality of life, and disability or functional status. We also sought data on measures of patient and provider behaviour including medication adherence, prescribing, utilisation of services and costs.
The 18 studies examined a range of complex interventions, with multiple elements in each of the interventions. Nine studies focused on defined combinations of conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 12 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. The wide variety of interventions, participants and outcomes meant that meta-analysis was only possible for a small number of outcomes.
Overall, there was little or no difference in clinical outcomes but there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression. There was probably a small improvement in patient-reported outcomes and two studies that specifically targeted functional difficulties in participants had positive effects on functional outcomes with one of these studies also reporting a reduction in mortality at four year follow-up. The interventions had little or no effect on health service use, slightly improved medication adherence, patient related health behaviours and provider behaviour in terms of prescribing and quality of care delivery. Cost data were limited.
Our review gathers together the growing evidence base on interventions to improve outcomes for people with multimorbidity. There is still a clear need for further evidence to inform policy and practice for patients and for those of us working in primary care. Tackling the remaining uncertainty requires further studies with clear definitions of participants, appropriate outcomes, and interventions targeted at specific patient difficulties.”
David: If you would like to read more about each of the studies in Susan’s review, you can find the meta-analyses and narrative synthesis she mentioned within the full review at The Cochrane Library dot com.