Managing multimorbidity in primary care

• Many health systems are seeking ways to serve aging populations and an increasing prevalence of patients with multimorbidity.

• A new study adds to a growing evidence base for complex interventions to manage multimorbidity in older patients in primary care.

• While it can be difficult to understand how complex interventions achieve outcomes, it is becoming clearer that patient-centred and multidisciplinary approaches are promising.

In linked research, Dolovich and colleagues present the results of a pragmatic randomized controlled trial examining the Health TAPESTRY (Health Teams Advancing Patient Experience: Strengthening Quality) intervention.1 This intervention — described in detail in a published protocol2 — is an approach that integrates volunteers with professionals on primary care teams to improve outcomes for older patients living at home. The HEALTH Tapestry intervention is novel because it integrates multiple elements, which have been developed individually and evaluated previously. It draws together components that include use of community volunteers who provide peer and social support, identification of patient goals or priorities, and changes to the organization of care to allow enhanced team work. Volunteer health workers link with primary health care providers to ensure that patient goals are addressed. The linked study contributes to a growing evidence base for interventions presented in the Cochrane review of the effectiveness of interventions for patients with multimorbidity in primary care and community settings.3

The linked research addresses a clear challenge for health systems globally that are experiencing a rising prevalence of multimorbidity and aging populations.1 All health systems currently face the need to shift from single-condition care pathways to innovative approaches that can address multimorbidity. The study is also patient focused, as it aims to facilitate goal-setting for patients. A qualitative systematic review found that patients with multimorbidity prioritized the ability to decide on their own preferences for action.4 The Health TAPESTRY trial — like many studies in the aforementioned Cochrane systematic review3 — focuses on older adults, with about 30% of participants having 3 or more chronic conditions. It can be challenging to engage this group of patients in research; only 18% of eligible patients agreed to enrol in the linked study, which affects the generalizability of the findings.

Disappointingly, the study authors found no differences in the primary outcome of goal attainment between the intervention and comparison groups. They discuss comprehensively why this might have occurred. One reason may be that, in this study, the control group undertook the goal-setting exercise with researchers at baseline. This was done to allow collection of outcome data on goal ascertainment, yet the process of engaging in goal-setting itself likely had an effect. It is hard to see how this kind of challenge can be addressed in future studies, as collecting outcomes like goal ascertainment requires active engagement with all participants.

The study did, however, find some differences in use of health care resources and in attainment of goals regarding physical activity. The authors refer to one of the largest multimorbidity studies published to date, the 3D Study, which examined a complex multidimensional and patient-focused intervention in 1546 patients in 33 general practices in the United Kingdom and also reported disappointing results regarding its primary outcome of health-related quality of life.5 Importantly, the 3D Study did report substantial improvements in patients’ experience of care, and the accompanying editorial pointed out that this is an important outcome in itself.6

That hospital admissions decreased in the intervention group in the linked research is an interesting finding.1 It is not clear how these differences could have occurred. Admissions, particularly emergency admissions, have been a source of great interest as an outcome but are challenging to study.7 The authors suggest that the reduction in admissions may indicate a shift from reactive care to proactive and preventive care with the Health TAPESTRY intervention. Further research on this intervention would be needed to confirm this, and a shift in focus from admissions generally to ambulatory care–sensitive admission might help to clarify this effect further.

A key element of Health TAPESTRY is use of volunteers, but Dolovich and colleagues do not really explore this element or discuss the large literature on peer support in improving health outcomes. Peer support is another form of using volunteers to enhance delivery of health care. This literature highlights potential harms to peer supporters themselves, which may also apply to volunteers.8 Critical incidents were infrequent in this trial but highlight challenges faced by some of the volunteers, as well as the importance of clear support structures to address these challenges.

The study also provides information on the wide variety of goals identified by older patients with multimorbidity, with physical activity, productivity and social connectedness ranking just ahead of managing medical problems. The results of this study suggest that the Health TAPESTRY intervention may contribute to improvements in patient care for older, community-dwelling adults. Further exploration of this model of care is warranted given the challenge for all health systems in shifting from single-condition care pathways to approaches that seek to address multimorbidity.