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Randomized Controlled Trial
. 2018 Jul 7;392(10141):41-50.
doi: 10.1016/S0140-6736(18)31308-4. Epub 2018 Jun 29.

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

Chris Salisbury  1 , Mei-See Man  2 , Peter Bower  3 , Bruce Guthrie  4 , Katherine Chaplin  2 , Daisy M Gaunt  5 , Sara Brookes  5 , Bridie Fitzpatrick  6 , Caroline Gardner  3 , Sandra Hollinghurst  2 , Victoria Lee  3 , John McLeod  6 , Cindy Mann  2 , Keith R Moffat  6 , Stewart W Mercer  6
Affiliations
Randomized Controlled Trial

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

Chris Salisbury et al. Lancet. .

Abstract

Background: The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention.

Methods: We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months' follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958.

Findings: Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI -0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention.

Interpretation: To 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.

Funding: National Institute for Health Research.

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Figures

Figure 1
Figure 1
Overview of 3D intervention
Figure 2
Figure 2
Trial profile
See this image and copyright information in PMC

Comment in

References

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    1. US Department of Health and Human Services . US Department of Health and Human Services; Washington, DC: 2010. Multiple chronic conditions—a strategic framework: optimum health and quality of life for individuals with multiple chronic conditions.
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