The care plus study - a whole system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation

Stewart W. Mercer, Bridie Fitzpatrick, Bruce Guthrie, Elisabeth Fenwick, Eleanor Grieve, Kenny Lawson, Nicki Boyer, Alex McConnachie, Suzanne M. Lloyd, Rosaleen O'Brien, Graham CM Watt, Sally Wyke

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Multimorbidity is common in deprived communities and reduces quality of life quality. Our aim was to evaluate a whole system primary care-based complex intervention to improve quality of life in multimorbid patients living in areas of very high deprivation.Methods: Phase 2 exploratory cluster randomised controlled trial with 8 general practices in Glasgow in very deprived areas involving multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and wellbeing (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible; outcome measurement and analysis were masked. Analyses were by intention to treat.Results: Of 76 eligible practices contacted, 12 accepted, and 8 were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68%) participated and 67/76 (88%) in each arm completed 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative wellbeing); effect size 0·33 (95% CI 0·11 to 0·55) at 12 months (p=0·0036). Positive wellbeing, energy, and general wellbeing (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve (AUC) over the 12 months was higher in the CARE Plus group (p=0.002). The incremental cost in the CARE Plus group was £929 (95% CIs: £86, £1788) per participant with a gain in quality adjusted life years of 0·076 (95% CI: 0·028, 0·124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per QALY gained. Modelling suggested that cost-effectiveness would continue.Conclusions: It is feasible to conduct a high quality cluster RCT of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life multimorbid patients in deprived areas.Trial Registration: Trial registration: ISRCTN 34092919, assigned 14/1/2013.
Original languageEnglish
Pages (from-to)1-10
Number of pages10
JournalBMC Medicine
Volume14
DOIs
Publication statusPublished - 22 Jun 2016

Keywords

  • Multimorbidity
  • Primary care
  • Deprivation
  • Socioeconomic
  • General practice
  • Longer consultations
  • Care plan
  • Mindfulness
  • Empathy
  • Complex intervention

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