Primary care, multimorbidity Other Long-term health conditions, chronic conditions, cardiovascular disease, coronary heart disease, hypertension, heart failure, peripheral arterial disease, chronic kidney disease, stroke, transient ischaemic attack (TIA), atrial fibrillation, diabetes mellitus, chronic obstructive pulmonary disease (COPD), asthma, epilepsy, depression or severe mental health problems, schizophrenia or psychotic illness, dementia, learning disability, rheumatoid arthritis, frai
Conditions
Interventions
This is a study to implement and evaluate a computerised template for clinicians to conduct combined annual reviews with patients with multiple conditions. The study seeks to explore how best to imple
Sponsors
University of Bristol
Eligibility
Sex/Gender
All
Age
18 Years to 100 Years
Inclusion criteria
Inclusion criteria: Practices: 1. Use the EMIS practice computer system 2. Have a subscription to Ardens templates. This applies to most practices within the regions involved in this study. 3. List size of =5000 patients Staff: 1. Have used the intervention to conduct reviews with patients, or will soon be doing so 2. Have been involved in the implementation of the intervention within the practice Patients: 1. Registered with a practice that agrees to take part in the evaluation 2. Aged =18 years 3. Due to be invited by their practice for an annual review (face-to-face or remote) of their long-term conditions at the practice within the next 12 months 4. Fall under at least two of the following 11 groups of long-term health conditions, including at least one of the conditions asterisked: 4.1. Cardiovascular disease: Coronary heart disease*, hypertension*, heart failure*, peripheral arterial disease, or chronic kidney disease (stage 3 to 5) 4.2. Stroke/TIA* or Atrial fibrillation* 4.3. Diabetes* 4.4. Chronic Obstructive Pulmonary Disease* or Asthma* 4.5. Epilepsy 4.6. Depression or Severe mental health problems (schizophrenia or psychotic illness)* 4.7. Dementia* 4.8. Learning disability 4.9. Rheumatoid arthritis* 4.10. Frailty (severe) The chronic conditions listed above are included because they are common and they benefit from regular review in general practice. The conditions asterisked already lead to annual review consultations in most general practices, to meet the requirements of the QOF. Some conditions (e.g. the first group listed above) are grouped so that two or more diagnoses within the group just count as one for the purpose of defining multimorbidity. Frailty is included because although it is not a single diagnosis, patients with severe frailty are normally reviewed annually so it makes sense to do this as part of the annual multimorbidity review, rather than calling the patient back again.
Exclusion criteria
Exclusion criteria: Practices: 1. Not a subscriber to Ardens clinical templates 2. Does not use EMIS clinical software 3. <5000 registered patients Staff: 1. Not likely to be involved in the implementation or use of the intervention Patients: 1. On a palliative care register 2. Would be excluded from an annual review for individual reasons. For example, for some patients who are housebound or in a nursing home it may not be possible to conduct the same type of ‘template-based’ review away from the surgery. In many cases, community nurses undertake a review without a template, so these reviews would not be relevant to this study of implementation of a template. In some cases, practices offer ‘virtual’ reviews for these patients, and in such cases the practice will be encouraged to use the multimorbidity template. The usefulness of a virtual review will depend on the patient’s combination of conditions and this will be left to the discretion of the practice and clinician. 3. Have declined a review OR have been contacted multiple times unsuccessfully
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| There is no single primary outcome. The study will use a range of qualitative and quantitative measures to evaluate the implementation of the intervention. Primary quantitative outcome: 1. The number of people who have received a personalised care and support plan as a result of their annual review consultation measured using anonymous general practice and hospital data collected at a single timpoint | — |
Secondary
| Measure | Time frame |
|---|---|
| There are no secondary outcome measures | — |
Countries
England, United Kingdom
Outcome results
None listed