In the ever-evolving landscape of primary healthcare, managing patients with multiple chronic conditions—known as multimorbidity—has become a significant challenge for care providers. The Article published on May 6, 2019, in CMAJ (Canadian Medical Association Journal) by Susan M. Smith et al., titled “Managing multimorbidity in primary care,” addresses this very issue, emphasizing the necessity of a coordinated approach to improve patient outcomes and optimize healthcare resources. (DOI: 10.1503/cmaj.190406)
The article references a pragmatic randomized controlled trial (RCT) by Dolovich, L, Oliver, D, Lamarche, L, et al., which combined volunteers and primary care teamwork to support the health goals and needs of older adults (CMAJ 2019;191:E491–500, PMC6509034). This trial illuminates the effectiveness of an integrated model where the community and healthcare professionals work collaboratively in managing multimorbidity among the elderly in primary care settings.
As the global population ages, multimorbidity becomes a more pervasive and daunting reality. It poses unique complexities due to the interaction of various chronic diseases and their treatments, which can lead to increased hospitalizations, higher healthcare costs, and a diminished quality of life for affected individuals. An estimated one in four adults is suffering from multimorbidity, and this number is disproportionately higher among the elderly and socio-economically disadvantaged populations.
Given the multifaceted nature of multimorbidity, a single-disease approach often falls short in primary care practice. Smith commends efforts like the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform, which tailors healthcare to patient-reported needs and preferences. She also discusses the implementation of the ‘3D approach’ – a patient-centred care model validated by a pragmatic cluster-randomized trial, which is proactive, holistic, and includes a multidimensional assessment incorporating patient’s goals and priorities.
A central point in managing multimorbidity is the necessity of a paradigm shift from disease-focused care to patient-centred care. Smith highlights the critical role of healthcare personnel’s attitudes and preparedness in addressing patients’ complexities. Additionally, she emphasizes the importance of setting realistic health goals, patient education, self-management support, and the use of non-pharmacological interventions. This approach not only humanizes the care process but also aligns with the evolving goals of healthcare reform, such as enhancing patient satisfaction and reducing unnecessary healthcare usage.
Moreover, the interventional review by Smith SM, Wallace E, O’Dowd T, et al., published in the Cochrane Database of Systematic Reviews, provides evidence on interventions that can improve outcomes for patients with multimorbidity in primary care and community settings (Cochrane Database Syst Rev 2016;3:CD006560, PMC6703144).
With the recognition of multimorbidity as a growing public health concern, a call to action for research to inform effective strategies and interventions is urgent. Cottrell E and Yardley S’s work on the lived experiences of multimorbidity offers a narrative lens to understand the perspectives and challenges of patients, GPs, and trainees (Chronic Illn 2015;11:279–303).
Contemporary primary care must incorporate comprehensive care models, such as the one elucidated in the Salisbury, C. study, where a patient-centered approach was studied in a cluster-randomized trial of the 3D model (Lancet 2018;392:41–50, PMC6041724). Understandably, as Dowrick C’s commentary suggests, patient-centered care must be an end in itself, especially in the complex domain of multimorbidity (Lancet 2018;392:4–5).
Finally, the article underscores the need for a stronger emphasis on preventive measures and community-based interventions, as highlighted by Wallace E, Smith SM, Fahey T, et al. in reducing emergency admissions (BMJ 2016;352:h6817). The study of Murphy CA, Cupples ME, Percy A, et al., on peer-mentoring for first-time mothers from socio-economically disadvantaged backgrounds, also serves as a testament to the potential benefits of community involvement (BMC Health Serv Res 2008;8:46, PMC2291460).
In conclusion, managing multimorbidity in primary care is a complex challenge requiring an innovative, person-focused approach. Drawing on collective insights from various studies and trials, it is evident that no singular method suffices. The integration of patient goals, inter-professional collaboration, community engagement, and evidence-based models can pave the way for more effective multimorbidity management. Healthcare systems worldwide must adapt and evolve strategies focused on individualized care, preventive measures, and resource optimization to ensure that patients with complex health needs receive the care and support they require.
References
1. Dolovich L, Oliver D, Lamarche L, et al. Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial. CMAJ 2019;191:E491–500. DOI:10.1503/cmaj.190406, PMC6509034.
2. Smith SM, Wallace E, O’Dowd T, et al. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2016;3:CD006560. DOI: 10.1503/cmaj.190406, PMC6703144.
3. Cottrell E, Yardley S. Lived experiences of multimorbidity: an interpretative meta-synthesis of patients’, general practitioners’ and trainees’ perceptions. Chronic Illn 2015;11:279–303. DOI: 10.1177/1742395315574760.
4. Salisbury C, Man MS, Bower P, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet 2018;392:41–50. DOI: 10.1016/S0140-6736(18)31308-4, PMC6041724.
5. Murphy CA, Cupples ME, Percy A, et al. Peer-mentoring for first-time mothers from areas of socio-economic disadvantage: a qualitative study within a randomised controlled trial. BMC Health Serv Res 2008;8:46. DOI: 10.1186/1472-6963-8-46, PMC2291460.
Keywords
1. Multimorbidity Management
2. Primary Care Innovation
3. Patient-Centered Healthcare
4. Chronic Disease Care
5. Integrated Health Models