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QOL of patients with multimorbidity is not improved with patient-centered care model
Clinical Question
Is the patient-centered care model more effective than usual care in improving the quality of life of patients with multiple chronic medial problems?
Bottom line
In this cluster randomized trial, a patient-centered care model was no better than usual care in improving quality of life or measures of illness or treatment burden among patients with multiple chronic medical conditions. 2b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Government
Setting: Outpatient (primary care)
Synopsis
Patient-centered care, especially among patients with multiple chronic conditions, is bit like mom, the flag, and apple pie: an important, foundational thing about which one should not speak poorly. However, the hypothesis that patient-centered care improves outcomes is largely untested. These researchers conducted a cluster randomized trial using 33 primary care practices in England and Scotland. The patients within those practices with at least 3 chronic major medical conditions (eg, diabetes, chronic obstructive pulmonary disease, cardiovascular disease, depression, dementia, and so forth) were randomized to receive usual care (17 practices, 749 patients) or to semi-annual visits that focused on health, depression, and medications. The intervention also included several approaches to enhance continuity of care: increased visit duration, team-based care, and financial incentives. Although the study participants and practice staff were not masked, the data analysts were masked to intervention assignment. Fifteen months after enrollment, the authors found no difference in quality of life between the 2 groups. Additionally, they found no difference in measures of illness burden or treatment burden despite significant increases in measures of patient-centered care. Five percent of the patients died during the study period; none of the deaths were judged by the treating physician as being related to patient management. It is unclear how the baseline unique aspects of primary care practices in England and Scotland limited the ability to observe measurable differences in the outcomes.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Not being one who typically 'gets on the band wagon' there are a lot of Holy Grails in Medicine which are adopted without anyone looking closely to see if there is any truth to what we are told to believe in.
the synopsis fails to describe any actual active care provided. It seems neither group benefited at all, or that neither approach did anything at all, except provide good livelihoods to quite a large number of people, perhaps more in the team approach. It is difficult to imagine how any patient care can be not patient-centered care, by definition.So the whole thing seems stupid to me. Probably look good on someone's c.v. though
I am perplexed by the review of this study. The "patient-centred" care intervention was semi-annual visits compared to usual care (which was not described). The outcome was assessed after 15 months of being assigned to one or the other. That means only time for two visits in the patient centred care group. Is there any reason to even suspect that these patients would have better outcomes after only two visits over 15 months? Makes no sense to me.
I suspect the value of patient centred care comes in relationship building over time, and 15 months of episodic visits will not show the value of that relationship.
This is very interesting as we have been focusing on increasing patient centred care and increasing our burden, when it may not be that helpful. We just may need more GP's to support these folks. This is a small study, but an interesting start.
PAtient-centrerd care- is there a definition which includes frequency of contact? I'm not certain that semi-annual visits would imply patient-centred care. Not surprised that there were no meaurable QOL differences from semi-annual visits.
This study seems like a poor attempt to undermine patient centered care by misrepresenting it in both definition and practice. Others have already noted omissions and inconsistencies with the study. If you want to sacrifice a sacred cow at least do a fair job of representing it. I think all this study does is give those drs who don’t take the time (or have it to begin with) to practice pt-centered care another excuse not to bother. Also, one of the most important aspects for the successful delivery of pt-centered care is the level of empathy and compassion modelled by the healthcare practitioner, which was not addressed at all in this study and is in short supply thanks to an epidemic of burnt out drs.
makes no sense
This is under powered by too many unknowns. What are the cost implications? How did they measure QOL? We're the measures thoroughly proven? Did the patients feel more secure with the regular visits or did it just waste their time? It is difficult to see how monitoring BP, for example, and sugar levels or obesity can have no impact.
Excellent
It is my impression that this may be unique to England and Scotland because of their heavy focus on a good primary care model and support; it is probably worst in the US and somewhere in-between in Canada, I would guess. This would be a good area to research and do a comparative study to show (my hypothesis) that good primary care and coordination can replace a patient-centred care model, but it is necessary in regions where primary care is weak or lacking.
Good poem
I am unsure from the study design if what was compared was patient centred care to usual care. It seems what is described a chronic disease framework with incentives and longer visits. I think patient centred care is more complex. It requires consideration for what does the patient and family actually want? What are the values? What are their goals. I do not think from the description that was actually included in the design?