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Table 1 Characteristics of included studies

From: Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review

Study ID
Study participants
Duration and follow-up
Intervention aim, elements and comparison
TIDIER checklist
Why: Aim
What: procedures and materials
Where; When and how much
Who provided
Primary outcome
Care coordination or planning and support for self-management
Boult 2011 [35]
904 adults > 65, multimorbid and high service use, mean age 77 and mean 4.3 conditions
Intervention 18 months, follow-up at 6 and 18 months
Aim: to measure the effect of guided care teams on multimorbid older patients’ use of health services
Guided Care (GC): Enhanced multidisciplinary team providing self-management support
Home assessments and coordination of care by GC nurses with monthly monitoring over 18 months
Patient care plans and educational materials
Providers: Eight primary care systems, 14 GC nurses, 49 primary care physicians and managing 50‑60 patients, training of nurse managers
Comparison: Usual care
Health service use
Contant 2019 [27]
RCT (Fortin 2016)
(secondary analysis of multimorbidity sub-group)
281 patients 18 to 75 years of age with at least 3 of the following chronic conditions diabetes, cardiovascular disease, COPD, asthma, tobacco smoking, obesity and hyperlipidemia, mean age 53.4 and mean 5.4 conditions
Intervention 3 months, follow-up immediately post intervention
Aim: To analyse the effect of a multidisciplinary self-management intervention amongst patients with multimorbidity.
Initial nurse evaluation with design of individualised intervention plan in collaboration with the patient, based on their objectives; and adaptable over time.
Printed information and other educational material for patients
At least 3 individual encounters with trained chronic disease prevention and management (CDPM) professionals over 3 months
Providers: Four primary care clinics with doctors working together in group practices. Could include encounters with 1 or more CDPM professionals in the following disciplines: nursing, physical activity, nutrition, respiratory therapy and smoking cessation therapy
Comparison: Usual care
Self-management (Health Education Impact Questionnaire (heiQ))
Gonzalez Ortega 2017 [30]
161 adults with significant chronic disease in 3 or more organ systems; mean age 80.5, mean 3.9 conditions, mean 8.4 medications.
Intervention duration 6 months with immediate follow up at intervention completion
Aim: To evaluate the impact that adding a telephone coaching intervention by a family physician to usual care has on reducing resource consumption and improving health status, caregiver burden and quality of life amongst complex chronic patients compared with usual care.
Telephone coaching and support for self-management by an intervention primary care physician (PCP).
Patients had initial face-to-face meeting in their home or in the clinic and were then phoned twice a month over 6 months. Calls addressed symptoms, medications, social contexts and support for self-management.
The PCP also reviewed the patients’ record and added notes regarding the calls.
Providers: Three Primary Care teams. One independent intervention PCP.
Comparison: Usual are from own PCP
Emergency admissions
Hochhalter 2010 [31]
79 adults aged > 65, with ≥ two of seven chronic conditions;
Mean age 74 and mean 3.6 conditions
Intervention three months, follow-up 3 months after intervention
Aim: to test the efficacy of a patient engagement intervention for older adults with multiple chronic illnesses.
Patient engagement intervention
Led by ‘coaches’ with focus on making most of healthcare, supporting self-management.
Checklists and protocols for coaches to follow during the workshop and calls.
Two-hour workshop and two telephone calls a week before and a week after a medical appointment.
Intervention was designed to prepare patients for appointments, to communicate effectively during appointments and follow through on care plans.
Providers: Large Internal Medicine clinic. Coaches (professional qualifications and number coaches not reported)
Comparison: 1. Attention control: 2-h workshop on safety issues and calls before and after a naturally occurring medical encounter. 2. Usual care
Self-management (patient activation measure)
Mercer 2016 [38]
Cluster RCT (exploratory)
142 patients from 8 general practices in areas of deprivation, with ≥ two long term conditions; mean of 4.9 conditions, and mean age 52
Intervention duration 12 months with data collection at 6 months and at intervention completion
Aim: to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation.
CarePlus: Primary care-based whole-system intervention
Structured extended GP consultations and relationship continuity
Practitioner support and training
Patient self-management support with patient support materials
Providers: Eight general practices in the most deprived parts of Glasgow
Comparison: Usual GP care
Health-related quality of life (EQ-5D-5L) and well- being (W-BQ12)
Salisbury 2018 [40]
Cluster RCT
1546 patients from 35 practice aged 18 years or older, with ≥ 3 chronic condition, based on 17 chronic conditions in Quality and Outcomes Framework; mean age 71 years, mean 3 conditions
Intervention duration 15 months and outcomes measured at 9 and 15 months
Aim: The aim of this study was to implement and assess the effectiveness of a new approach to managing patients with multimorbidity in primary care.
3D intervention based on patient-centred care with focus on continuity, coordination, and efficiency of care with 6-monthly comprehensive multidisciplinary review (nurse, pharmacist and physician/GP) with extended appointments if requested.
IT support to facilitate identification of patients, recall and 3D templates
Printed care plans to support shared decision making
Practice training: 2 half-days
Practice supports: nominated practice 3D champion, automated monthly feedback compared to peers and financial incentives for completed reviews (GBP 30 per review).
Providers: 33 general practices with named GP, practice nurse and pharmacists (who may or may not have worked with the practice previously)
Comparison: Usual GP care
Health-related quality of life (EQ-5D-5L)
Schafer 2018 [41]
Cluster RCT
650 patients from 55 general practices with ≥ 3 conditions; mean age 73.5, mean 8.5 chronic conditions, mean 7 medications.
Intervention duration: 12 months with final data collection at intervention completion
Aim: To determine if patient-centred communication leads to a reduction in the number of medications taken without reducing health-related quality of life.
Multicare AGENDA: Patient-centred communication
GP Training: 3 sessions lasting 4 h on narrative based patient-doctor dialogues
Three 30 min ‘talks’ between GP and patients over 12 months:
1. Focus on patient priorities (including non-medical)
2. Medication review
3. Review previous goals and considered goal attainment at end of 12 months
Providers: 55 general practices
Comparison: Usual care with wait-list control
Number medications and Health-related quality of life (EQ-5D)
Sommers 2000 [42]
543 adults aged > 65 with at least two conditions; mean age 77.5, mean number conditions not reported
Intervention 18 months, follow-up 12 months after intervention
Aim: To examine the impact of an interdisciplinary, collaborative, practice intervention for community dwelling seniors with chronic illnesses
Senior Care Connections
Enhanced multidisciplinary teams with 2 months immersion in primary care practice for the nurses and social workers before intervention commenced
Initial home assessment by the nurse or social worker to gather data on patient concerns
Team then met and drafted risk reduction care plans and support for self-management to discuss with patients and family members
Nurse or social worker monitored patients every 6 weeks between primary care physicians (PCP visits) either in home, in clinic or by phone
Monthly team meetings to discuss patient progress with training and ongoing support for nurses and social workers.
Providers: 18 PCPs working in 9 teams with a full-time nurse with geriatrics training and half-time social worker per team
Comparison: Usual care
Health service use and self-rated health
Support for self-management
Eakin 2007 [28]
(multimorbidity sub-group data from authors)
175 adults with ≥ 2 conditions (of 14 conditions listed), mean age 50; mean conditions not reported
Intervention 16 weeks, follow-up 6 months after intervention
Aims: To address multiple risk factors in patients targeting low-income, largely Spanish speaking patients with multiple chronic conditions
Self-management support, diet, and exercise intervention based on chronic care model
Patient education materials with three tailored newsletters and linkage to local services
Two structured visits (home or clinic) lasting 60‑90 min and two follow up telephone contacts over 16 weeks
Providers: An experienced bilingual health educator working in a community health centre providing primary healthcare services to low-income and medically underserved individuals
Comparison: usual care plus a guide to local services and three newsletters
Dietary behaviour and physical activity
Garvey 2015 [29]
50 participants with ≥ 2 chronic conditions and 4 repeat medications, median age 66, median 4.5 conditions
Intervention duration: 6 weeks with 2-week post intervention follow-up
Aim: to address the challenges of living with multimorbidity in a primary care setting.
OPTIMAL, occupational therapy (OT) led self-management support course
Focus on goal setting and prioritisation
Peer support through group meetings
Weekly meetings in local health centre over 6 weeks, meeting duration 2.5 h
Providers: Three primary care centre. Primary care OTs in each centre led the programme with input from physiotherapist and pharmacist for one session each. Training and intervention manual for OT providers, provided by the research team.
Comparison: Wait-list control. Received usual care whilst waiting.
Activity participation (Frenchay Activities Index)
O’Toole 2020 [33]
149 patients aged over 18, ≥ 2 conditions and 4 regular medicines.
Mean age 65 years, mean number 4.5 conditions and mean 9 repeat medicines
Intervention duration: 6 weeks with immediate post intervention (primary outcomes only) and 6 months follow-up
Aim: To evaluate the effectiveness of a group based, 6-week, occupational therapy led self-management support programme (OPTIMAL) for patients with multimorbidity and test the sustainability of its effect over time.
OPTIMAL, occupational therapy (OT) led self-management support course
Focus on goal setting and prioritisation
Peer support through group meetings
Weekly meetings in local health centre over 6 weeks, meeting duration 2.5 h
Providers: Eight Primary care Centres. Primary care OTs led the programme with one session each from physiotherapist and pharmacist. Training and intervention manual for OTs, provided by the research team.
Comparison: Wait-list control. Received usual care whilst waiting.
Health-related quality of life (EQ5D) and Activity Participation (Frenchay Activities Index)
Reed 2018 [34]
254 adults aged over 60 years with ≥ 2 conditions and neutral or poor self-rated health;
mean age not reported, approx. 50% > 75 years, mean 4.5 conditions
Intervention duration: 6 months with immediate follow-up
Aim: To determine whether a clinician-led chronic disease self-management support (CDSMS) programme improves the overall self-rated health level of older Australians with multiple chronic health conditions.
Clinician-led CDSMS Programme which included goal setting and the development of individualised care plans, based on the Flinders CDSMS programme.
Delivered by nurses or psychologists in the patients’ home, 3 home visits with 4 follow up phone calls over 6 months, delivered independently of GP care. Mentoring of clinicians by trained accreditors.
Providers: Trained nurses and psychologists, mentor supervising them
Comparison: Attention control - same number of visits to the study clinicians but did not receive the CDSMS programme
Self-rated Health
Medicines management
Jager 2017 [36]
Cluster RCT
273 patients from 22 practices, aged >50 years, with at least 3 chronic diseases, more than 4 drugs, and at high risk for medication-related events; mean age 72.2, mean conditions 5.7
Intervention duration 9 months; follow-up at intervention completion
Aim: to assess the effect of a tailored programme to improve the implementation of three important processes of care for this patient group: (a) structured medication counselling including brown bag reviews, (b) the use of medication lists, and (c) structured medication reviews to reduce potentially inappropriate medication.
PomP: A tailored medicines management programme
Training and resources for general practitioners (GPs) and medical assistants: 4-h workshop
Patients: educational materials, electronic information tool and reminders for patients
Implementation action plans for each GP practice with focus on three priority actions for medicines management and consideration of patient preferences
Providers: 22 GPs from 18 practices of 66 GP Quality Circles, mean 4.6 medical assistants per practice
Comparison: Usual care plus GPs informed of prescribing targets and aware of which patients identified for the trial as high risk
Summary score of 10 prescribing indicators
Koberlein Neu 2016 [37]
cRCT (stepped wedge design)
162 adults age ≥ 65 years, with ≥ 3 chronic disorders affecting two different organ systems, at least one cardiovascular disease, at least one visit to the PCP in each of the preceding three-month intervals, five or more long-term medicines, mean age 76.8, mean number conditions 12.7, mean number medications 9.4
Intervention duration 15 months, variable intervention exposure based on stepped wedge design. Data extracted for first phase of 3 months when was intervention vs control and no variation in exposure
Aim: To evaluate the effectiveness of interprofessional medication management for elderly multimorbid patients
WESTGEM intervention: Comprehensive medication management
Medication management with primary care physicians (PCPs) who sent e-information to home care specialists Care provided by home-care specialists using case management, conducting a home visit and assessment and communicating this to a pharmacist who undertook a medicines review and made recommendations. PCPs then responsible for delivering recommendations
Providers: 12 PCPs and attached home care specialists, pharmacist (number not reported)
Comparison: Usual care with their PCP
Quality of medication therapy (MAI score)
Krska 2001 [32]
332 adults aged ≥ 65 with ≥ 2 conditions and on ≥ 4 medicines; mean age 75 and mean 3.9 conditions
Intervention three months, follow-up three months after drug review
Aim: To evaluate the effects of pharmacist-led medication reviews in elderly patients taking multiple medications
Clinical pharmacist conducted a home visit with patients and created a pharmaceutical patient care plan, which was then entered in to the patient’s record and implemented by practice team
Providers: Clinical pharmacist, General Practitioners (numbers not reported)
Comparison: Usual care and had review of drug therapy by pharmacist but no pharmaceutical care plan implemented
Pharmaceutical care issues
Muth 2018 [16]
Cluster RCT
505 cognitively intact patients from 20 general practices, ≥ 60 years, ≥ 3 chronic conditions, ≥ 5 long-term medicines, mean age 72, Charlson score 3.1; CIRS score 7.7
Intervention duration: Intervention delivered over two sessions (HCA and then GP) sessions, lasting 35‑45 min each, follow-up at 6 and 9 months
Aim: to improve the appropriateness of medication in older patients with multimorbidity in general practice.
PRIMUM: Prioritising Multimedication in Multimorbidity
Pre-intervention training of 90‑120 min for healthcare assistant (HCA) and GP.
HCA conducted a checklist-based interview with patients on medication-related problems and a brown bag review to reconcile their medications. HCA entered details into the computerised decision support system (CDSS)
GP undertook a review assisted by the CDSS and optimised medication, discussed it with patients and adjusted it accordingly.
Providers: 72 general practices and had to have HCA with access to internet
Comparison: Usual care but the control practice teams also received the GP guidelines for ambulatory geriatric care to harmonise usual care in both groups
Medication Appropriateness Index (MAI)