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Pollock KG, Dickerson C, Kainth M, Lawton S, Hurst M, Sugrue DM, Arden C, Davies DW, Martin AC, Sandler B, Gordon J, Farooqui U, Clifton D, Mallen C, Rogers J, Hill NR, Camm AJ, Cohen AT. Undertaking multi-centre randomised controlled trials in primary care: learnings and recommendations from the PULsE-AI trial researchers. BMC PRIMARY CARE 2024; 25:7. [PMID: 38166641 PMCID: PMC10759575 DOI: 10.1186/s12875-023-02246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Conducting effective and translational research can be challenging and few trials undertake formal reflection exercises and disseminate learnings from them. Following completion of our multicentre randomised controlled trial, which was impacted by the COVID-19 pandemic, we sought to reflect on our experiences and share our thoughts on challenges, lessons learned, and recommendations for researchers undertaking or considering research in primary care. METHODS Researchers involved in the Prediction of Undiagnosed atriaL fibrillation using a machinE learning AlgorIthm (PULsE-AI) trial, conducted in England from June 2019 to February 2021 were invited to participate in a qualitative reflection exercise. Members of the Trial Steering Committee (TSC) were invited to attend a semi-structured focus group session, Principal Investigators and their research teams at practices involved in the trial were invited to participate in a semi-structured interview. Following transcription, reflexive thematic analysis was undertaken based on pre-specified themes of recruitment, challenges, lessons learned, and recommendations that formed the structure of the focus group/interview sessions, whilst also allowing the exploration of new themes that emerged from the data. RESULTS Eight of 14 members of the TSC, and one of six practices involved in the trial participated in the reflection exercise. Recruitment was highlighted as a major challenge encountered by trial researchers, even prior to disruption due to the COVID-19 pandemic. Researchers also commented on themes such as the need to consider incentivisation, and challenges associated with using technology in trials, especially in older age groups. CONCLUSIONS Undertaking a formal reflection exercise following the completion of the PULsE-AI trial enabled us to review experiences encountered whilst undertaking a prospective randomised trial in primary care. In sharing our learnings, we hope to support other clinicians undertaking research in primary care to ensure that future trials are of optimal value for furthering knowledge, streamlining pathways, and benefitting patients.
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Affiliation(s)
| | | | | | - Sarah Lawton
- School of Medicine, Keele University, Staffordshire, UK
| | - Michael Hurst
- Bristol Myers Squibb Pharmaceutical Ltd, Uxbridge, UK
| | | | - Chris Arden
- University Hospital Southampton, Southampton, UK
| | | | - Anne-Céline Martin
- Service de Cardiologie, Université de Paris, Innovative Therapies in Haemostasis, INSERM, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris, France
| | | | - Jason Gordon
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | | | - David Clifton
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | | | | | - Nathan R Hill
- Bristol Myers Squibb Pharmaceutical Ltd, Uxbridge, UK
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK
| | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas' NHS Foundation Trust, King's College London, London, UK
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Eto F, Samuel M, Henkin R, Mahesh M, Ahmad T, Angdembe A, Hamish McAllister-Williams R, Missier P, J. Reynolds N, R. Barnes M, Hull S, Finer S, Mathur R. Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink. PLoS Med 2023; 20:e1004300. [PMID: 37889900 PMCID: PMC10610074 DOI: 10.1371/journal.pmed.1004300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 09/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. METHODS AND FINDINGS Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. CONCLUSIONS These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.
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Affiliation(s)
- Fabiola Eto
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Miriam Samuel
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Rafael Henkin
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Meera Mahesh
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Tahania Ahmad
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Alisha Angdembe
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - R. Hamish McAllister-Williams
- Translational and Clinical Research Institute, Newcastle University, Newcastle, United Kingdom
- Northern Centre for Mood Disorders, Newcastle University, Newcastle, United Kingdom
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle, United Kingdom
| | | | | | - Michael R. Barnes
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Sally Hull
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Sarah Finer
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Rohini Mathur
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
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Hu XJ, Wang HHX, Li YT, Wu XY, Wang Y, Chen JH, Wang JJ, Wong SYS, Mercer SW. Healthcare needs, experiences and treatment burden in primary care patients with multimorbidity: An evaluation of process of care from patients' perspectives. Health Expect 2021; 25:203-213. [PMID: 34585465 PMCID: PMC8849236 DOI: 10.1111/hex.13363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/15/2021] [Accepted: 09/06/2021] [Indexed: 01/06/2023] Open
Abstract
Background Patients with multimorbidity often experience treatment burden as a result of fragmented, specialist‐driven healthcare. The ‘family doctor team' is an emerging service model in China to address the increasing need for high‐quality routine primary care. Objective This study aimed to explore the extent to which treatment burden was associated with healthcare needs and patients' experiences. Methods Multisite surveys were conducted in primary care facilities in Guangdong province, southern China. Interviewer‐administered questionnaires were used to collect data from patients (N = 2160) who had ≥2 clinically diagnosed long‐term conditions (multimorbidity) and had ≥1 clinical encounter in the past 12 months since enrolment registration with the family doctor team. Patients' experiences and treatment burden were measured using a previously validated Chinese version of the Primary Care Assessment Tool (PCAT) and the Treatment Burden Questionnaire, respectively. Results The mean age of the patients was 61.4 years, and slightly over half were females. Patients who had a family doctor team as the primary source of care reported significantly higher PCAT scores (mean difference 7.2 points, p < .001) and lower treatment burden scores (mean difference −6.4 points, p < .001) when compared to those who often bypassed primary care. Greater healthcare needs were significantly correlated with increased treatment burden (β‐coefficient 1.965, p < .001), whilst better patients' experiences were associated with lower treatment burden (β‐coefficient −0.252, p < .001) after adjusting for confounders. Conclusion The inverse association between patients' experiences and treatment burden supports the importance of primary care in managing patients with multimorbidity. Patient Contribution Primary care service users were involved in the instrument development and data collection.
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Affiliation(s)
- Xiu-Jing Hu
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Harry H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China.,JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Yu-Ting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Ya Wu
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Yi Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jia-Heng Chen
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jia-Ji Wang
- Guangdong-provincial Primary Healthcare Association, Guangdong, China.,School of Public Health, Guangzhou Medical University, Guangzhou, China
| | - Samuel Y S Wong
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Stewart W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Scotland, UK
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Eyowas FA, Schneider M, Alemu S, Getahun FA. Multimorbidity of chronic non-communicable diseases: burden, care provision and outcomes over time among patients attending chronic outpatient medical care in Bahir Dar, Ethiopia-a mixed methods study protocol. BMJ Open 2021; 11:e051107. [PMID: 34497085 PMCID: PMC8438962 DOI: 10.1136/bmjopen-2021-051107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Multimorbidity refers to the presence of two or more chronic non-communicable diseases (NCDs) in a given individual. It is associated with premature mortality, lower quality of life (QoL) and greater use of healthcare resources. The burden of multimorbidity could be huge in the low and middle-income countries (LMICs), including Ethiopia. However, there is limited evidence on the magnitude of multimorbidity, associated risk factors and its effect on QoL and functionality. In addition, the evidence base on the way health systems are organised to manage patients with multimorbidity is sparse. The knowledge gleaned from this study could have a timely and significant impact on the prevention, management and survival of patients with NCD multimorbidity in Ethiopia and in LMICs at large. METHODS AND ANALYSIS This study has three phases: (1) a cross-sectional quantitative study to determine the magnitude of NCD multimorbidity and its effect on QoL and functionality, (2) a qualitative study to explore organisation of care for patients with multimorbidity, and (3) a longitudinal quantitative study to investigate disease progression and patient outcomes over time. A total of 1440 patients (≥40 years) on chronic care follow-up will be enrolled from different facilities for the quantitative studies. The quantitative data will be collected from multiple sources using the KoBo Toolbox software and analysed by STATA V.16. Multiple case study designs will be employed to collect the qualitative data. The qualitative data will be coded and analysed by Open Code software thematically. ETHICS AND DISSEMINATION Ethical clearance has been obtained from the College of Medicine and Health Sciences, Bahir Dar University (protocol number 003/2021). Subjects who provide written consent will be recruited in the study. Confidentiality of data will be strictly maintained. Findings will be disseminated through publications in peer-reviewed journals and conference presentations.
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Affiliation(s)
- Fantu Abebe Eyowas
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- Health Systems Strengthening (HWIP), Jhpiego-Ethiopia, Bahir Dar, Ethiopia
| | | | - Shitaye Alemu
- College of Medicine and Health Sciences, School of Medicine, Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Fentie Ambaw Getahun
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Dennett EJ, Janjua S, Stovold E, Harrison SL, McDonnell MJ, Holland AE. Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review. Cochrane Database Syst Rev 2021; 7:CD013384. [PMID: 34309831 PMCID: PMC8407330 DOI: 10.1002/14651858.cd013384.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality. OBJECTIVES To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data). SEARCH METHODS We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021. SELECTION CRITERIA Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations. MAIN RESULTS Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall. AUTHORS' CONCLUSIONS Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.
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Affiliation(s)
- Emma J Dennett
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Elizabeth Stovold
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | | | - Melissa J McDonnell
- Department of Respiratory Medicine, Galway University Hospital, Galway, Ireland
| | - Anne E Holland
- Physiotherapy, Alfred Health, Melbourne, Australia
- Discipline of Physiotherapy, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
- Institute for Breathing and Sleep, Melbourne, Australia
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Jungo KT, Meier R, Valeri F, Schwab N, Schneider C, Reeve E, Spruit M, Schwenkglenks M, Rodondi N, Streit S. Baseline characteristics and comparability of older multimorbid patients with polypharmacy and general practitioners participating in a randomized controlled primary care trial. BMC FAMILY PRACTICE 2021; 22:123. [PMID: 34157981 PMCID: PMC8220761 DOI: 10.1186/s12875-021-01488-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Abstract
Objectives Recruiting general practitioners (GPs) and their multimorbid older patients for trials is challenging for multiple reasons (e.g., high workload, limited mobility). The comparability of study participants is important for interpreting study findings. This manuscript describes the baseline characteristics of GPs and patients participating in the ‘Optimizing PharmacoTherapy in older multimorbid adults In primary CAre’ (OPTICA) trial, a study of optimization of pharmacotherapy for multimorbid older adults. The overall aim of this study was to determine if the GPs and patients participating in the OPTICA trial are comparable to the real-world population in Swiss primary care. Design Analysis of baseline data from GPs and patients in the OPTICA trial and a reference cohort from the FIRE (‘Family medicine ICPC Research using Electronic medical records’) project. Setting Primary care, Switzerland. Participants Three hundred twenty-three multimorbid (≥ 3 chronic conditions) patients with polypharmacy (≥ 5 regular medications) aged ≥ 65 years and 43 GPs recruited for the OPTICA trial were compared to 22,907 older multimorbid patients with polypharmacy and 227 GPs from the FIRE database. Methods We compared the characteristics of GPs and patients participating in the OPTICA trial with other GPs and other older multimorbid adults with polypharmacy in the FIRE database. We described the baseline willingness to have medications deprescribed of the patients participating in the OPTICA trial using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire. Results The GPs in the FIRE project and OPTICA were similar in terms of sociodemographic characteristics and their work as a GP (e.g. aged in their fifties, ≥ 10 years of experience, ≥ 60% are self-employed, ≥ 80% work in a group practice). The median age of patients in the OPTICA trial was 77 years and 45% of trial participants were women. Patients participating in the OPTICA trial and patients in the FIRE database were comparable in terms of age, certain clinical characteristics (e.g. systolic blood pressure, body mass index) and health services use (e.g. selected lab and vital data measurements). More than 80% of older multimorbid patients reported to be willing to stop ≥ 1 of their medications if their doctor said that this would be possible. Conclusion The characteristics of patients and GPs recruited into the OPTICA trial are relatively comparable to characteristics of a real-world Swiss population, which indicates that recruiting a generalizable patient sample is possible in the primary care setting. Multimorbid patients in the OPTICA trial reported a high willingness to have medications deprescribed. Trial registration Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013) Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01488-8.
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Affiliation(s)
- Katharina Tabea Jungo
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Rahel Meier
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Fabio Valeri
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Nathalie Schwab
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudio Schneider
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Marco Spruit
- Department of Information and Computing Sciences, Utrecht University, Utrecht, The Netherlands.,Public Health & Primary Care, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland.,Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
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Lautamatti E, Sumanen M, Raivio R, Mattila KJ. Continuity of care is associated with satisfaction with local health care services. BMC FAMILY PRACTICE 2020; 21:181. [PMID: 32887566 PMCID: PMC7487808 DOI: 10.1186/s12875-020-01251-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/25/2020] [Indexed: 11/29/2022]
Abstract
Background Satisfaction is a major element in assessing quality of care. It has decreased in Finland in recent decades as well as continuity of care. We investigated which demographic, health-related, and local health care service factors, especially continuity of care, are associated with the population’s satisfaction with local health care services. Methods The data are part of the Health and Social Support (HeSSup) study’s follow-up questionnaire in 2012. The study is based on a random Finnish population sample. Satisfaction was studied based on the question “How satisfied are you with your local health care services?” Demographic factors, obesity, self-assessed health status, depressive mood (BDI-12 questionnaire), New York Heart Association class, and chronic diseases were asked in the questionnaire. Questions describing local health care services were also presented. We assessed the association of an assigned and named GP and the respondents’ proactivity in contacting the same doctor with satisfaction. We used crosstabulation and binary logistic regression in the analyses. Results The Health and Social Support study was answered in 2012 by 15,993 participants (45.4%) and majority (61.3%) was satisfied with their local health care services. An assigned and named GP (OR 1.79; 95% CI 1.67–1.92) and the respondent’s proactivity in contacting the same doctor (OR 1.23; 95% CI 1.15–1.32) were associated with satisfaction in the adjusted multivariate analysis. BDI score < 19 had the strongest association with satisfaction (OR 1.91; 95% CI 1.65–2.23). Older participants, males, and those in a relationship were more likely to be satisfied. Conclusions A named GP in primary care proved to have a positive correlation with patient satisfaction. Depression was associated with decreased satisfaction. A named GP indicates continuity of care, and it should be seriously considered when planning treatment for patients with chronic conditions.
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Affiliation(s)
- E Lautamatti
- Faculty of Medicine and Health Technology, Tampere University, Tampere and Centre for General Practice of the Pirkanmaa Hospital District, Tampere, Finland.
| | - M Sumanen
- Faculty of Medicine and Health Technology, Tampere University, Tampere and Centre for General Practice of the Pirkanmaa Hospital District, Tampere, Finland
| | - R Raivio
- Päijät-Häme Joint Authority for Health and Wellbeing, Primary Health Care, Lahti, Finland
| | - K J Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere and Centre for General Practice of the Pirkanmaa Hospital District, Tampere, Finland
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Dou L, Huang J, Duncan P, Guo L. Translation, cultural adaptation and validation of the Chinese Multimorbidity Treatment Burden Questionnaire(C-MTBQ): a study of older hospital patients. Health Qual Life Outcomes 2020; 18:194. [PMID: 32571343 PMCID: PMC7310246 DOI: 10.1186/s12955-020-01395-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 05/07/2020] [Indexed: 12/23/2022] Open
Abstract
Background Due to an ageing population, multimorbidity is becoming more common. Treatment burden (the effort required of patients to look after their health and the impact this has on their wellbeing) is prevalent in patients with multimorbidity. The Multimorbidity Treatment Burden Questionnaire (MTBQ) is a patient-reported outcome measure of treatment burden that has been validated amongst patients with multimorbidity in the UK. The aim of this study was to translate and culturally adapt the MTBQ into Chinese and to assess its reliability and validity in elderly patients with multimorbidity in hospital. Methods The original English version of the MTBQ was translated into Chinese using Brislin’s model of cross-culture translation. The C-MTBQ was piloted on a sample of 30 elderly patients with multimorbidity prior to being completed by 156 Chinese elderly patients with multimorbidity recruited from a hospital in Zhengzhou, China. We examined the proportion of missing data, the distribution of responses and floor and ceiling effects for each question. Factor analysis, Cronbach’s alpha, intraclass coefficient and Spearman’s rank correlations assessed dimensional structure, internal consistency reliability, test-retest reliability and criterion validity, respectively. Results The average age of the respondents was 73.5 years (range 60–99 years). The median C-MTBQ global score was 20.8 (interquartile range 12.5–29.2). Significant floor effects were seen for all items. Factor analysis supported a three-factor structure. The C-MTBQ had high internal consistency (Cronbach’s alpha coefficient, 0.76) and test-retest reliability (the intraclass correlation coefficient, 0.944), the correlations between every item and global scores scored > 0.4. The scale content validity index(S-CVI) was 0.89, and the item level content validity index(I-CVI)was 0.83 ~ 1.00. The criterion validity was 0.875. Conclusion The Chinese version of MTBQ showed satisfactory reliability and validity in elderly patients with multimorbidity, and could be used as a tool to measure treatment burden of elderly patients with multimorbidity in hospital.
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Affiliation(s)
- Liyuan Dou
- School of Nursing and Health, Zhengzhou University, No.101, Kexue Road, Zhengzhou, Henan Province, 450000, People's Republic of China
| | - Juan Huang
- Party Secretary Office, People's Hospital of Zhengzhou, Zhengzhou, Henan Province, 450000, People's Republic of China. .,Centre for Academic Primary Care, University of Bristol, Bristol, BS6 6HL, UK.
| | - Polly Duncan
- Centre for Academic Primary Care, University of Bristol, Bristol, BS6 6HL, UK
| | - Lixiang Guo
- School of Nursing and Health, Zhengzhou University, No.101, Kexue Road, Zhengzhou, Henan Province, 450000, People's Republic of China
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9
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Zhu Y, Edwards D, Mant J, Payne RA, Kiddle S. Characteristics, service use and mortality of clusters of multimorbid patients in England: a population-based study. BMC Med 2020; 18:78. [PMID: 32272927 PMCID: PMC7147068 DOI: 10.1186/s12916-020-01543-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/26/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Multimorbidity is associated with mortality and service use, with specific types of multimorbidity having differential effects. Additionally, multimorbidity is often negatively associated with participation in research cohorts. Therefore, we set out to identify clusters of multimorbidity patients and how they are differentially associated with mortality and service use across age groups in a population-representative sample. METHODS Linked primary and secondary care electronic health records contributed by 382 general practices in England to the Clinical Practice Research Datalink (CPRD) were used. The study included a representative set of multimorbid adults (18 years old or more, N = 113,211) with two or more long-term conditions (a total of 38 conditions were included). A random set of 80% of the multimorbid patients (N = 90,571) were stratified by age groups and clustered using latent class analysis. Consistency between obtained multimorbidity phenotypes, classification quality and associations with demographic characteristics and primary outcomes (GP consultations, hospitalisations, regular medications and mortality) was validated in the remaining 20% of multimorbid patients (N = 22,640). RESULTS We identified 20 patient clusters across four age strata. The clusters with the highest mortality comprised psychoactive substance and alcohol misuse (aged 18-64); coronary heart disease, depression and pain (aged 65-84); and coronary heart disease, heart failure and atrial fibrillation (aged 85+). The clusters with the highest service use coincided with those with the highest mortality for people aged over 65. For people aged 18-64, the cluster with the highest service use comprised depression, anxiety and pain. The majority of 85+-year-old multimorbid patients belonged to the cluster with the lowest service use and mortality for that age range. Pain featured in 13 clusters. CONCLUSIONS This work has highlighted patterns of multimorbidity that have implications for health services. These include the importance of psychoactive substance and alcohol misuse in people under the age of 65, of co-morbid depression and coronary heart disease in people aged 65-84 and of cardiovascular disease in people aged 85+.
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Affiliation(s)
- Yajing Zhu
- MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK.
| | - Duncan Edwards
- Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Worts' Causeway, Cambridge, CB1 8RN, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Steven Kiddle
- MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK
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10
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Mann C, Shaw ARG, Guthrie B, Wye L, Man MS, Chaplin K, Salisbury C. Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed-methods process evaluation. BMJ Open 2019; 9:e031438. [PMID: 31699734 PMCID: PMC6858134 DOI: 10.1136/bmjopen-2019-031438] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions. DESIGN Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients. SETTING Thirty-three UK general practices in three areas. PARTICIPANTS The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview. RESULTS Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from 'tick-box' to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns. CONCLUSIONS Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention. TRIAL REGISTRATION NUMBER ISRCTN06180958.
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Affiliation(s)
- Cindy Mann
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Ali R G Shaw
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Division of Population Health Sciences, University of Dundee, Dundee, UK
| | - Lesley Wye
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Mei-See Man
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
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11
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Eyowas FA, Schneider M, Yirdaw BA, Getahun FA. Multimorbidity of chronic non-communicable diseases and its models of care in low- and middle-income countries: a scoping review protocol. BMJ Open 2019; 9:e033320. [PMID: 31619434 PMCID: PMC6797258 DOI: 10.1136/bmjopen-2019-033320] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/13/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Multimorbidity is the coexistence of two or more chronic non-communicable diseases (NCDs) in a given individual. Multimorbidity is increasing in low- and middle-income countries (LMICs) and challenging health systems. Individuals with multimorbidity are facing the risk of premature mortality, lower quality of life and greater use of healthcare services. However, despite the huge challenge multimorbidity brings in LMICs, gaps remain in mapping and synthesising the available knowledge on the issue. The focus of this scoping review will be to synthesise the extent, range and nature of studies on the epidemiology and models of multimorbidity care in LMICs. METHODS PubMed (MEDLINE) will be the main database to be searched. For articles that are not indexed in the PubMed, Scopus, PsycINFO and Cochrane databases will be searched. Grey literature databases will also be explored. There will be no restrictions on study setting or year of publication. Articles will be searched using key terms, including comorbidity, co-morbidity, multimorbidity, multiple chronic conditions and model of care. Relevant articles will be screened by two independent reviewers and data will be charted accordingly. The result of this scoping review will be presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist and reporting guideline. ETHICS AND DISSEMINATION This scoping review does not require ethical approval. Findings will be published in peer-reviewed journal and presented at scientific conferences.
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Affiliation(s)
- Fantu Abebe Eyowas
- Department of Public Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Marguerite Schneider
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Biksegn Asrat Yirdaw
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Fentie Ambaw Getahun
- Department of Public Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- Department of Public Health, School of Medicine, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
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12
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Rahtz E, Child S, Knight S, Warber SL, Dieppe P. Clients of UK healers: A mixed methods survey of their demography, health problems, and experiences of healing. Complement Ther Clin Pract 2019; 35:72-77. [PMID: 31003689 DOI: 10.1016/j.ctcp.2019.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/11/2019] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Healing has not been well researched, and very little is known about who goes to healers, and what they experience. METHODS A survey of UK-based healers was undertaken with the help of The Confederation of Healing Organisations, asking healers to report on up to 20 consultations. Forms asked about the demography of healer and client, reasons for the consultation, type of healing, and outcomes. Both quantitative and qualitative data were analysed. RESULTS 278 returned forms from 39 healers (average age 58) were analysed. Healing was described as Spiritual (69%), Reiki (15%) or Energy (10%). The clients had an average age of 57, and 76% were women. The most common reasons for consulting were mental health problems and pain. 93% of the clients reported experiencing immediate benefits. Relaxation, improved wellbeing and relief of pain were often reported. In addition, 76 (27%) had some unusual sensory experiences during the session, such as feelings of warmth, seeing coloured lights, or tingling sensations. The majority of general comments about the experience were positive, and 68% made another appointment. CONCLUSIONS Older people, particularly older women, are the main recipients of healing in the UK, and they go for help with many problems, particularly mental health issues and pain. The majority have a positive experience, and come back for more. In addition to relief of symptoms, many have sensory experiences which could indicate that some special type of interaction was taking place between healer and healee.
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Affiliation(s)
| | - Sue Child
- The University of Exeter Medical School, UK
| | - Sue Knight
- The Confederation of Healing Organisations, UK
| | - Sara L Warber
- The University of Exeter Medical School, UK; The University of Michigan Department of Family Medicine, USA
| | - Paul Dieppe
- The University of Exeter Medical School, UK.
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13
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Salisbury C, Man MS, Bower P, Guthrie B, Chaplin K, Gaunt DM, Brookes S, Fitzpatrick B, Gardner C, Hollinghurst S, Lee V, McLeod J, Mann C, Moffat KR, Mercer SW. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet 2018; 392:41-50. [PMID: 29961638 PMCID: PMC6041724 DOI: 10.1016/s0140-6736(18)31308-4] [Citation(s) in RCA: 234] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/09/2018] [Accepted: 05/15/2018] [Indexed: 12/14/2022]
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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Affiliation(s)
- Chris Salisbury
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Mei-See Man
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Bruce Guthrie
- Population Health Sciences Division, School of Medicine, University of Dundee, Dundee, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daisy M Gaunt
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sara Brookes
- Bristol Randomised Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, UK
| | - John McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cindy Mann
- Centre for Academic Primary Care, NIHR School for Primary Care Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Keith R Moffat
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stewart W Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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