Interventions for Improving Outcomes in Patients With Multimorbidity in Primary Care and Community Setting: A Systematic Review

Abstract

BackgroundMultimorbidity, defined as the co-existence of two or more chronic conditions, presents significant challenges to patients, healthcare providers and health systems. Despite this, there is ongoing uncertainty about the most effective ways to manage patients with multimorbidity. This review aimed to determine the effectiveness of interventions designed to improve outcomes in people with multimorbidity in primary care and community settings, compared to usual care.MethodsWe searched eight databases and two trials registers up to 9th September 2019. Two review authors independently screened and selected studies, extracted data, evaluated study quality and judged the certainty of the evidence (GRADE). Interventions were grouped by their predominant focus into care-coordination/self-management support, self-management support and medicines management. Main outcomes were health related quality of life (HRQoL) and mental health. Meta-analyses were conducted, where possible, but the synthesis was predominantly narrative.ResultsWe included 16 RCTs with 4,753 participants, the majority being older adults with at least three conditions. There were eight care-coordination/self-management support studies, four self-management support studies and four medicines management studies. There was little or no evidence of an effect on primary outcomes of HRQoL (MD 0.03, 95% CI -0.01 to 0.07, I2 = 39%) and mental health or on secondary outcomes with a small number of studies reporting that care coordination may improve patient experience of care and self-management support may improve patient health behaviours. Overall the certainty of the evidence was graded as low due to significant variation in study participants and interventions. Conclusions There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity, despite the growing number of RCTs conducted in this area. Our findings suggest that future research should consider patient experience of care, optimising medicines management and targeted patient health behaviours such as exercise.

Comorbidity: From a Confounder in Longitudinal Clinical Research to the Main Issue in Population Management

“…The term "multimorbidity" -which at times has been used interchangeably with comorbidity -has been defined by many different criteria -most commonly as two or more conditions [18], but also as one of 40 chronic diseases [19], one of 918 ICD-10 disease groups grouped Psychother Psychosom 2022;91:145-151 DOI: 10.1159/000521952 into 60 categories [20], two of 28 diseases [21], treatment with multiple medications [17], impaired quality of life or function [22] and/or physical and mental disorders [19]. The lack of a standard definition vastly complicates the interpretation and use of multimorbidity [18,[23][24][25].…”

Using self‐determination theory in research and evaluation in primary care

“…[1][2][3][4]6,7 The evidence base for how best to treat patients with multimorbidity is very limited, and most interventions to date have not been evaluated or demonstrated effectiveness or cost-effectiveness. 8 It is widely accepted that interventions in multimorbidity are likely to be complex, 9 and expert guidelines exist on the development and evaluation of complex interventions. 9,10 A recent Delphi study funded by the MRC-NIHR Methodology Research Panel also reached a consensus that theory is a crucial part of developing complex interventions and concluded that a theory-driven approach to intervention development and evaluation is more likely to be effective than a purely pragmatic or empirical approach.…”

“…The evidence base for how best to treat patients with multimorbidity is very limited, and most interventions to date have not been evaluated or demonstrated effectiveness or cost‐effectiveness 8 . It is widely accepted that interventions in multimorbidity are likely to be complex, 9 and expert guidelines exist on the development and evaluation of complex interventions 9,10 .…”

Multicomponent, high-intensity, and patient-centered care intervention for complex patients in transitional care: SPICA program

“…It has been observed in studies with Spanish patients that those who use primary care the most are multimorbid people (3,4). This supposes significant challenges for health systems (8,9). It has been considered to increase mortality, decrease quality of life (10,11), and increase costs and negative consequences for patients (12,13).…”