Department of Family Medicine.
Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Canada.
Br J Gen Pract. 2021 Mar 26;71(705):e320-e330. doi: 10.3399/bjgp21X714293. Print 2021 Apr.
Patient-centred interventions to help patients with multimorbidity have had mixed results.
To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.
Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.
Patients aged 18-80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients' experiences of the intervention.
A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.
Overall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference's recommendations.
以患者为中心的干预措施，以帮助患有多种疾病的患者，结果喜忧参半。
评估一种由提供者创建的、以患者为中心的、多提供者病例会议，并进行后续随访，了解其在何种情况下有效，以及在何种情况下无效。
采用混合方法设计，包括一项实用随机试验和一项定性研究，涉及加拿大安大略省的 9 个城市初级保健点。
年龄在 18-80 岁之间、患有≥3 种慢性疾病的患者被转诊至远程医疗 IMPACT Plus 干预措施；护士和患者共同规划多提供者病例会议，在此期间可以制定护理计划。患者被随机分配到干预组或对照组。进行了两项亚组分析和一项保真度评估，主要结局为 4 个月时的自我管理和自我效能。次要结局为心理健康和身体状况、生活质量和健康行为。主题分析探讨了患者对干预措施的体验。
干预组 86 例患者和对照组 77 例患者之间没有差异，但在年收入≥50000 加元的亚组中，干预措施改善了心理健康状况（β系数为 11.003， = 0.006）。更多的提供者和随访时间与较差的结果相关。定性研究中确定了五个主题：团队受到重视、患者感到支持、收到随访计划、获得治疗方案的新内容和帮助、体验到积极的结果。
总体而言，该干预措施仅对年收入≥50000 加元的患者有效，这意味着需要解决干预措施中不受现有卫生政策覆盖的部分的费用问题。研究结果表明，需要根据患者的偏好优化团队组成，修改提供者的数量和类型，增加护士随访时间，以更好地支持患者实施病例会议的建议。
