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      Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

      systematic-review

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          Abstract

          Background

          Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co‐exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity.

          Objectives

          To determine the effectiveness of health‐service or patient‐oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.

          Search methods

          We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies.

          Selection criteria

          Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non‐randomised clinical trials (NRCTs), controlled before‐after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre‐specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting.

          Data collection and analysis

          Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta‐analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types.

          Main results

          We identified 18 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid 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. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) −2.23, 95% confidence interval (CI) −2.52 to −1.95). There was probably a small improvement in patient‐reported outcomes (moderate certainty evidence) although 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 (Int 6%, Con 13%, absolute difference 7%). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient‐related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited.

          Authors' conclusions

          This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well‐organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.

          Improving outcomes for people with multiple chronic conditions

          Background

          The World Health Organization defines chronic conditions as "health problems that require ongoing management over a period of years or decades". Many people with a chronic health problem or condition, have more than one chronic health condition, which is referred to as multimorbidity. This generally means that people could have any possible combination of health conditions but in some studies the combinations of conditions are pre‐specified to target common combinations such as diabetes and heart disease. We refer to these types of studies as comorbidity studies. Little is known about the effectiveness of interventions to improve outcomes for people with multimorbidity. This is an update of a previously published review.

          Review question

          This review aimed to identify and summarise the existing evidence on the effectiveness of interventions to improve clinical and mental health outcomes and patient‐reported outcomes including health‐related quality of life for people with multimorbidity in primary care and community settings.

          Description of study characteristics

          We searched the literature up to September 2015 and identified 18 generally well‐designed randomised controlled trials meeting the eligibility criteria. Nine of these studies focused on specific combinations of health conditions (comorbidity studies), for example diabetes and heart disease. The other nine studies included people with a broad range of conditions (multimorbidity studies) although they tended to focus on elderly people. The majority of studies examined interventions that involved changes to the organisation of care delivery although some studies had more patient‐focused interventions. All studies had governmental or charitable sources of funding.

          Key results

          Overall the results regarding the effectiveness of interventions were mixed. There were no clear positive improvements in clinical outcomes, health service use, medication adherence, patient‐related health behaviours, health professional behaviours or costs. There were modest improvements in mental health outcomes from seven studies that targeted people with depression, and in functional outcomes from two studies targeting functional difficulties in participants. Overall the results indicate that it is difficult to improve outcomes for people with multiple conditions. The review suggests that interventions that are designed to target specific risk factors (for example treatment for depression) or interventions that focus on difficulties that people experience with daily functioning (for example, physiotherapy treatment to improve capacity for physical activity) may be more effective. There is a need for further studies on this topic, particularly involving people with multimorbidity in general across the age ranges.

          Quality/certainty of the evidence

          All of the included studies were randomised controlled trials. The overall quality of these studies was good though many studies did not fully report on all potential sources of bias. As definitions of multimorbidity vary among studies, the potential to reasonably combine study results and draw overall conclusions is limited. Overall, we judged that the certainty or confidence we can have in the results from this review is moderate but due to small numbers of studies and mixed results we acknowledge the uncertainty remaining and the potential that future studies could change our conclusions.

          Related collections

          Most cited references108

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          Adverse drug events in ambulatory care.

          Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies. We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two. Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28 percent) were ameliorable, and 20 (11 percent) were preventable. Of the 51 ameliorable events, 32 (63 percent) were attributed to the physician's failure to respond to medication-related symptoms and 19 (37 percent) to the patient's failure to inform the physician of the symptoms. The medication classes most frequently involved in adverse drug events were selective serotonin-reuptake inhibitors (10 percent), beta-blockers (9 percent), angiotensin-converting-enzyme inhibitors (8 percent), and nonsteroidal antiinflammatory agents (8 percent). On multivariate analysis, only the number of medications taken was significantly associated with adverse events. Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs. Copyright 2003 Massachusetts Medical Society
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                Author and article information

                Contributors
                susansmith@rcsi.ie , susmarsmith@gmail.com
                Journal
                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                14651858
                10.1002/14651858
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                1469-493X
                15 March 2016
                March 2016
                07 September 2017
                : 2016
                : 3
                Affiliations
                RCSI Medical School deptHRB Centre for Primary Care Research, Department of General Practice 123 St Stephens Green Dublin 2 Ireland
                Trinity College Centre for Health Sciences deptDepartment of Public Health and Primary Care Adelaide and Meath Hosptials, Incorporating the National Children's HospitalTallaght Dublin Ireland 24
                University of Sherbrooke deptDepartment of Family Medicine Unite de Medicine de famille de Chicoutimi305, St‐Vallier Chicoutimi Quebec Canada G7H 5H6
                Author notes

                Editorial Group: Cochrane Effective Practice and Organisation of Care Group.

                Article
                PMC6703144 PMC6703144 6703144 CD006560 CD006560.pub3
                10.1002/14651858.CD006560.pub3
                6703144
                26976529
                71db0e5b-7fa2-48e7-8f06-8c894a6d23d7
                Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
                Categories
                Medicine General & Introductory Medical Sciences

                Treatment Outcome,Risk Factors,Randomized Controlled Trials as Topic,Patient‐Centered Care/methods,Patient‐Centered Care,Disease Management,Comorbidity,Community Health Services,Chronic Disease/therapy,Chronic Disease,Age Factors,Primary Health Care,Humans

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