Simplifying Care for Complex Patients

It is heartening to see the evidence base around multimorbidity developing so rapidly, given the gap between the impact of multimorbidity and our knowledge about how to manage it succesfully. The papers discussed in this issue of the Annals provide important directions for research and practice.

Previous work has highlighted the barriers to effective management in patients with multiple conditions (1,2) and initial findings suggested that achieving benefits across a range of outcomes in patients with co- morbidity was problematic (3,4). The latest papers provide a more positive picture. Morris et al report that the benefits of antidepressants are not moderated by comorbid conditions and that patients with multimorbidity stand to benefit as much as those with single conditions (5). This is in line with our previous findings that, despite the poorest baseline health, patients with co-morbid physical and mental health conditions may have the greatest capacity to gain from self-management interventions (6). Caution is required in secondary analyses from individual trials, and we would encourage further preplanned secondary analyses of this kind on published trials in the care of long-term conditions, using agreed measures of multimorbidity, to allow us to develop the evidence base rapidly. These findings do highlight that a key aim may be to overcome barriers in access to care in patients with multimorbidity, rather than an exclusive focus on enhancing effectiveness.

This issue of the journal also reports two trials using integrated care managers, and showing benefits on mental health and physical health outcomes (7,8).

A key challenge is to distill the aspects of care from these succesful interventions that enable patients to effectively manage multiple conditions. Lin et al highlight improvements in the process of care (9), but detailed analysis of interactions between care managers and patients may be required to highlight the communicative, motivational and decision-making processes that enable patients to overcome the known barriers to effective care, including confusion about the links between conditions, and competing priorities (10).

In the United Kingdom, key barriers to the deployment of integrated care managers are the competing priorities that many primary care staff (such as nurses) report in delivering the disease specific care required for our pay for performance scheme (the Quality and Outcomes Framework). This puts significant limits on the dissemination of integrated care models, limits which are further exacerbated in these times of economic uncertainty. We are currently exploring the potential of a new cadre of mental health providers to deliver the benefits of integrated care to patients with comorbid depression and vascular disorders. These professionals have the advantage of an existing knowledge base around the delivery of evidence-based brief psychological treatments. Our challenge is to provide them skills to deliver these treatments in partnership with primary care staff in patients with chronic disease, and to overcome some of the complex interactions between mental and physical health that can stand in the way of change (11).

Finally, we would concur with Bayliss that work is needed to identify optimal outcomes in patients with multimorbidity (12). With growing consensus on the limits of a single disease focus in service delivery, it would be ironic if research studies continued to apply such a paradigm to outcome measurement. Measures that capture and place value on the process and outcome of integrated care are required to ensure that our trials are sensitive to the needs of this group.

Peter Bower, NIHR School for Primary Care Research, Health Sciences Research Group, University of Manchester, United Kingdom

Linda Gask, NIHR CLAHRC for Greater Manchester, Health Sciences Research Group, University of Manchester, United Kingdom

Peter Coventry, NIHR CLAHRC for Greater Manchester, Health Sciences Research Group, University of Manchester, United Kingdom

Reference List

1. Bayliss E, Steiner J, Fernald D, Crane L, Main D. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med 2003;1:15-21.

2. Lin E, Katon W, Rutter C, et al. Effects of enhanced depression treatment on diabetes self-care. Ann Fam Med 2006;4:46-53.

3. Harkness E, MacDonald W, Valderas J, Coventry P, Gask L, Bower P. Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: systematic review and meta regression. Diabet Care 2010;33:926-930.

4. Katon W, Von Korff M, Lin E, et al. The Pathways study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004;61:1042-1049.

5. Morris D, Budhwar N, Husain M, et al. Depression treatment in patients with general medical conditions: results from the CO-MED trial. Ann Fam Med 2012;10:23-33.

6. Harrison M, Reeves D, Harkness E, et al. What is the moderating effect of depression and multimorbidity on the effectiveness of a chronic disease self-management programme? Secondary analysis of a randomised controlled trial. Pat Educ Couns 2011;(in press)

7. Katon W, Lin E, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363:2611-2620.

8. Bogner H, Morales K, de Vries H, Cappola A. Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial. Ann Fam Med 2012;10:15-22.

9. Lin E, Von Korff M, Ciechanowski P, et al. Treatment adjustment and medication adherence for complex patients with diabetes, heart disease and depression: a randomized controlled trial. Ann Fam Med 2012;10:6-14.

10. Morris R, Sanders C, Kennedy A, Rogers A. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient's prioritization of multiple conditions. Chronic Illness 2011;7:147-161.

11. Detweiler-Bedell J, Friedman M, Leventhal H, Miller I, Leventhal E. Integrating co-morbid depression and chronic physical disease management: Identifying and resolving failures in self-regulation. Clin Psychol Rev 2008;28:1426-1446.

12. Bayliss E. Simplifying care for complex patients. Ann Fam Med 2012;10:3-5.

Competing interests:   None declared

In this welcome and well argued editorial, Bayliss sets out questions around models of care for patients with multiple chronic medical conditions which incorporate interventions on a number of levels. For approaches which are based in primary care, it makes sense to have a flexible, generic approach to support and care for such patients and to have a chance of a sustainable impact, any approaches need to integrate interventions or change at three levels: the patient, the clinician and the health system.(Kennedy, Rogers, & Bower 2007) One issue raised is that of considering what outcomes matter to patients. The three papers referred to all focus on adherence to bio-medical interventions and it is hard to maintain a patient-centred approach when the patients' day-to-day life and circumstances are not taken into account. What matters to patients varies depending on a number of external factors and the way in which people's priorities shift.(Morris et al. 2011) We have developed a tool to help health professionals assess patient's needs in relation to the support they need to self-manage their long-term condition(s).(Protheroe et al. 2010) We are currently assessing the implementation of a whole systems approach (which we have termed WISE - Whole Systems Informing Self-management Engagement) within a large health system serving a deprived population. The training has been received well by primary care professionals.(Kennedy et al. 2010) It remains to be seen whether the primary outcomes we have decided on: shared decision-making with primary care health professionals; self-efficacy; and generic health-related quality of life can be improved through applying a whole systems model of care.(Bower et al. 2012). Finally, outside the narrow confines of the consultation there is emerging evidence that far more attention needs to be paid to the social networks that people have access to which enables individuals to mobilize resources and assets to take advantage of interventions designed to promote support for multiple conditions.(Vassilev et al. 2011) References

Bower, P., Kennedy, A., Reeves, D., Rogers, A., Blakeman, T., Chew- Graham, C., Bowen, R., Eden, M., Hann, M., Lee, V., Morris, R., Protheroe, J., Richardson, G., Sanders, C., Swallow, A., & Thompson, D. A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol. Implementation Science in press. 2012.

Kennedy, A., Chew-Graham, C., Blakeman, T., Bowen, A., Gardner, C., Protheroe, J., Rogers, A., & Gask, L. 2010, "Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation", Implementation Science, vol. 5, no. 1, p. 7. Kennedy, A., Rogers, A., & Bower, P. 2007, "Support for self care for patients with chronic disease", BMJ, vol. 335, no. 7627, pp. 968-970. Morris, R. L., Sanders, C., Kennedy, A. P., & Rogers, A. 2011, "Shifting priorities in multimorbidity: a longitudinal qualitative study of patient's prioritization of multiple conditions", Chronic Illness, vol. 7, no. 2. Protheroe, J., Blakeman, T., Bower, P., Chew-Graham, C., & Kennedy, A. 2010, "An intervention to promote patient participation and self- management in long term conditions: development and feasibility testing", BMC Health Services Research, vol. 10, no. 1, p. 206. Vassilev, I., Rogers, A., Sanders, C., Kennedy, A., Blickem, C., Protheroe, J., Bower, P., Kirk, S., Chew-Graham, C., & Morris, R. 2011, "Social networks, social capital and chronic illness self- management: a realist review", Chronic Illness, vol. 7, no. 1.

Competing interests:   None declared

While offering congratulations on the three publications in the first issue of 2012 in Annuals of Family Medicine, and appraising the accompanying editorial commentary from Dr. Bayliss (Bayliss 2012), I give more thoughts on what other messages we, the clinicians who take care of complex patients daily, may need to take home from the findings.

As someone who conducts research, teaches, and practices in Medicine and psychiatry combined, I believe strongly that many common mental illnesses, especially when they are mild to moderate in severity, can be successfully managed in primary care and other non-traditional psychiatric settings provided by health care professionals who can deliver integrated care effective and efficiently.

Effective mental health care delivery in these settings requires a multi-disciplinary infrastructure (Katon 2010). It is imperative that mental health care is not simply providing antidepressants for depression or other psychotropics for other mental illnesses. Depression may represent multiple abnormalities of an individual. For example, depression may reflect a psychological adjustment to life stress interfacing with developmental experiences and their social environment. Alternatively, it may reflect the underlying process of other mental or physical illnesses or an endogenous melancholic depression, etc. Differential diagnosis is a critical process throughout the management of depression or any other mental illness. Co-morbid mild to moderate depression in many medical illnesses may not require or respond to antidepressants (O’Connor 2011, Jiang 2011). Psycho-behavioral therapeutic modalities are significant components of mental health and psychiatric interventions and may be more cost effective in many instances (Wang 2011). Therefore, medicating every patient who has depressive symptoms should not be the first line of depression care for patients with complex co-morbidities. Analogies are found in many medical or physical conditions, such as fever, cough, or high blood pressure. If we cannot simply treat every fever with acetaminophen as the only measure, we cannot simply give antidepressant to every individual presenting depression.

To best deliver a patient-centered care service, mental health education and training needs to be significantly improved in medical schools and residency programs. For trainees who become primary care or family physicians and pediatricians, 6-months of tailored mental health training should be integrated to the current traditional specialty training curriculum. Such training will yield skillful integrated health providers who can lead a multi-disciplinary team that effectively and efficiently utilizes resources from mental health expertise.

Mental health is part of human health. As such, it is surprising that it has been minimized in the educational and training systems and segregated from the general health care service. The integration of mental health services with general practice will better serve our patients and reduce health care costs in the future.

Bayliss EA. Simplifying Care for Complex Patients. Ann Fam Med 2012;10:3-5.

Katon W, Unützer J, Wells K, Jones L. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry. 2010;32:456-64.

Jiang W, Krishnan R, Kuchibhatla M, Cuffe MS, Martsberger C, Arias RM, O’Connor CM for the SADHART-CHF Investigators. Characteristics of Depression Remission and Its Relation With Cardiovascular Outcome Among Patients With Chronic Heart Failure (from the SADHART-CHF Study). Am J Cardiol. 2011;107:545-51.

O’Connor CM, Jiang W, Kuchibhatla M, Silva SG, Cuffe MS, Callwood DD, Zakhary B, Henke E, Arias RM, Krishnan R for the SADHART-CHF Investigators. Safety and Efficacy of Sertraline for Depression in Patients With Heart Failure: Results of the SADHART-CHF Trial. JACC 2010; 56:692-699.

Wang JT, Hoffman B, Blumenthal JA. Management of depression in patients with coronary heart disease: association, mechanisms, and treatment implications for depressed cardiac patients. Expert Opin Pharmacother. 2011;12:85-98.

Competing interests:   None declared