Patient centred care in an evidence based world? A meta-ethnography of multimorbidity interventions

Context: Burden of Treatment Theory proposes outcomes are poorer when the work associated with managing illness (treatment burden) outweighs an individual’s capacity to do it. Despite recognition that treatment burden, patient capacity and social context significantly impact experience of multimorbidity, the extent (if at all) that multimorbidity interventions consider these elements in their design or implementation is unknown.

Objective: To explore participant experience of primary care multimorbidity interventions and whether treatment burden, capacity or social context are considered in intervention development

Study Design: Meta-ethnography

Setting: Medline/Embase/CINAHL/AMED/Cochrane databases identified 3806 potential papers: 12 articles included, COREQ used to quality appraise.

Population: Qualitative studies of participant experience of primary care-based multimorbidity randomised trials

Intervention: Analysis drawing on principles of meta-ethnography explored participant experience, eMERGe guidelines followed.

Results: Qualitative exploration of participant experience of multimorbidity interventions mostly focused on practitioner experience/intervention implementation. Key themes: Patient Centred Care? Patient centred care lacked standard definition, often defined by practitioners. Right person/Right time: When recruited from the patient’s community, lay roles, providing flexible social support based on patient need were effective. Flexibility vs Structure: Tension between evidence-based intervention (inflexible) and what patients identified as important(highly contextual). Interventions with (often inadvertent) flexible components appeared more successful. One size doesn’t fit all: Characteristics influencing patient engagement appear related to personality; other personal/social capacity factors may be important but were not explored.

Conclusions: Despite the need for, and investment in, high quality multimorbidity interventions there is little qualitative evidence on participant experience, with a focus on practitioner perspectives of implementation. Further work to understand what “patient-centred” means to patients is crucial. Exploring what are key capacity, social and personality factors that determine response to interventions, and designing flexible components to allow for these are an important future target. Interventions that integrate flexibility, while permitting fidelity to the evidence base are likely to be most effective.