CARE Plus: improving quality of life for multimorbidity patients in socioeconomic deprivation

Today BMC Medicine publishes an article investigating a system intervention to improve the quality of life for patients with multiple complex problems in Scotland. This study, known as CARE Plus, also looks at the cost-effectiveness of the intervention and finds some promising results. Co-author Stewart Mercer explains more here.

I am a researcher and a doctor, working in primary care, and for almost 20 years now I have been interested in how the health service can better meet the needs of ‘under-served’ populations.

Scotland has very wide inequalities in health, despite having ‘universal coverage’ of healthcare, free at the point of care. However, the fact that the national health service (NHS) in the United Kingdom often fails to meet the needs of those who need them most was pointed out some 45 years ago by general practitioner (GP) and researcher, Dr Julian Tudor Hart, in what he described as the ‘inverse care law’.

Our previous research demonstrated how the inverse care law operates at the level of GPs. Routine consultations in poor areas of Scotland – despite higher levels of patient illness and thus need – are shorter, leave patients with complex needs feeling less enabled, and are associated with greater GP stress when compared with consultations in richer areas.

More recently, in a large prospective study of videoed-consultations, we demonstrated that due to the continuing existence of the inverse care law, GPs in deprived areas have less time to be patient-centred and patients have worse outcomes from the consultations.

Improving patient outcomes

Can it be shown that more time and support for GPs to be more patient-centred in areas of high need actually improves patient outcomes in a cost-effective way?

But the question is this – can it be shown that more time and support for GPs to be more patient-centred in areas of high need actually improves patient outcomes in a cost-effective way?

Our CARE Plus study – a whole system intervention to improve quality of life of primary care patients with multiple complex problems (multimorbidity) in areas of high socioeconomic deprivation – set out to test the feasibility of conducting a high quality randomized controlled trial (RCT) in high deprivation areas of Glasgow in Scotland, and to see if there was any indication of effectiveness and cost-effectiveness.

As Principal Investigator, I led the study with fellow academics at the Universities of Glasgow and Dundee, funded by the Scottish Government Chief Scientist Office. The CARE Plus study focused on patients with multimorbidity, since these patients have the highest needs.

In usual consultations, GPs, nurses and patients all struggle to adequately manage the problems of multimorbidity in the context of high deprivation.

So what did we do?

The intervention was a complex one, and took a ‘whole-system approach’ which involved substantially longer consultations with the GPs; training and support for the practitioners; and additional ‘self-management’ support for the patients.

Having carefully co-developed and optimized the intervention over a period of 2-3 years we randomized eight general practices serving patients in areas of very high socioeconomic deprivation to either the CARE Plus intervention or to ‘usual care’.

The intervention was a complex one, and took a ‘whole-system approach’ which involved substantially longer consultations with the GPs; training and support for the practitioners; and additional ‘self-management’ support for the patients.

GPs identified patients with multimorbidity who they felt would benefit more time to ‘get to the bottom’ of their problems by taking an empathic, holistic approach and to agree a plan of action, with follow-up and continuity of care.

What did we find?

On average, patients were in their early 50s with around five chronic conditions each. Compared with the control group, patients in the CARE Plus group had significantly better outcomes for some aspects of well-being and quality of life at 6 and 12 months. Importantly, the intervention was highly cost-effective.

The study demonstrated that it is possible to conduct a high quality cluster RCT in very deprived areas; all of the practices who agreed to take part stayed in the study, and we achieved follow-up rates on the patients in both arms of the trial of 88% at 12 months. However, it should be noted that this was an exploratory trial of 152 patients in eight practices, and needs to be replicated on a bigger sample.

It does support the benefits of additional clinical capacity and an integrated approach to care in general practice in deprived areas and experimentally demonstrates that reversal of the inverse care law leads to gain.

However, it does support the benefits of additional clinical capacity and an integrated approach to care in general practice in deprived areas and experimentally demonstrates that reversal of the inverse care law leads to gain.

The Scottish Government is committed to reducing health inequalities, and major policy changes are in process, including a new Scottish contract for GPs, and the funding of a range of pilot studies testing ways to improve primary care in the context of new statutory integration of health and social care.

Our study suggests that investing in general practice and primary care in deprived areas may help reduce health inequalities and improve the quality of life of patients with multimorbidity.

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