Moira Stewart1, Martin Fortin2, Judith Belle Brown1, Bridget L Ryan1, Pauline Pariser3, Jocelyn Charles3, Thuy-Nga Pham3, Pauline Boeckxstaens4, Sonja M Reichert1, G Y Zou5, Onil Bhattacharya3, Alan Katz6, Helena Piccinini-Vallis7, Tara Sampalli8, Sabrina T Wong9, Merrick Zwarenstein1. 1. Department of Family Medicine. 2. Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Canada. 3. Department of Family and Community Medicine, University of Toronto, Toronto, Canada. 4. Department of Family Medicine and Primary Healthcare, Ghent University, Ghent, Belgium. 5. Department of Epidemiology and Biostatistics, Western University, London, Canada. 6. Department of Community Health Sciences and Department of Family Medicine, University of Manitoba, Winnipeg, Canada. 7. Department of Family Medicine, Dalhousie University, Halifax, Canada. 8. Research and Innovation, Nova Scotia Health, Halifax, Canada. 9. School of Nursing and Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada.
Abstract
BACKGROUND: Patient-centred interventions to help patients with multimorbidity have had mixed results. AIM: 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. DESIGN AND SETTING: Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada. METHOD: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. RESULTS: 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, P = 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. CONCLUSION: 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.
RCT Entities:
BACKGROUND:Patient-centred interventions to help patients with multimorbidity have had mixed results. AIM: 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. DESIGN AND SETTING: Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada. METHOD: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. RESULTS: 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, P = 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. CONCLUSION: 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.
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