Improving wellbeing and quality of life in individuals with multiple health conditions and common mental health problems

Background

As the population ages, the number of adults living with multimorbidity- defined as having two or more chronic conditions-is increasing. The current healthcare system often focuses on treating one disease at a time, can fail to meet these individuals ' needs with risk of on the one hand unmet care needs and on the other risk of more visits to more healthcare providers and medications than benefits the individual. To better serve older individuals with multimorbidity, the healthcare system, particularly primary care, needs to adapt and evolve. This involves adopting a more person-centred and holistic approach to care, considering the individual' wants and needs, all health conditions, and overall well-being, rather than treating each disease separately. By doing so, the healthcare system can provide coordinated, person-centred care that effectively meets the complex needs of these individuals.

Aim

The aim of this thesis was to develop and pilot a complex intervention to improve wellbeing and quality of life in individuals with multiple health conditions and common mental health problems in Swedish primary care.

Methods

This thesis involves four studies involving quantitative, qualitative and mixed methods methodologies. Study 1 is a systematic literature review and qualitative synthesis of collaborative care interventions for individuals with multimorbidity and common mental health problems in primary care and community settings and a map of intervention components. Study 2 is a total population-based cohort study investigating the association between having multimorbidity with an increasing number of chronic diseases and potentially inappropriate prescribing of benzodiazepines in the total adult population in Stockholm, Sweden in two cohorts, one before and one during COVID-19. Study 3 is a qualitative study exploring GP's experiences of managing individuals with multimorbidity and common mental health problems in primary care in Stockholm, Sweden using reflexive thematic analysis. From the findings of study 1 and 3 the intervention Health and Life in Balance was developed for improving patient capacity for older people with multimorbidity. The intervention includes the collaborative care components of relational continuity, a shared care plan, and teamwork identified in study 1. Moreover, it uses a person-centred approach to care, minimally disruptive medicine, to assess patient capacity and workload in individuals with multimorbidity. This approach was identified in the literature sharing similarities with the findings from study 3. Study 4 is a pragmatic convergent mixed methods non- randomised pilot study. The study aimed to assess the acceptance, feasibility and further need of development of Health and Life in Balance.

Results

In study 1, 12 Randomised controlled studies were included. Eleven studies with medium to high quality showed positive results in reducing depressive symptoms in individuals with multimorbidity involving depression and one chronic disease. The last study had medium to low quality and investigated the effect on anxiety and depressive symptoms. There was a lack of medium to high quality studies addressing collaborative care for individuals with multimorbidity and anxiety, and for individuals with more than two health conditions. The qualitative synthesis identified a map of shared content in the 11 studies of collaborative care models with medium to high quality. In study 2, an association between an increasing number of chronic conditions and potentially inappropriate prescribing of benzodiazepines was identified in both cohorts, before and during COVID-19. The logistic regression model was adjusted for age and socioeconomic status and stratified for sex. The association remained although decreased when adjusting for each of the clinical confounders: number of healthcare visits, polypharmacy, and having a psychiatric diagnosis. In study 3 two themes were generated: Unmet patient needs and fragmented care send patients and physicians off balance and Dancing with the patient individually and together with others leads to confident and satisfied patients and physicians. General practitioners found it hard to address common mental health problems in individuals with multimorbidity, limited by disease-specific guidelines and fragmentation. They highlighted that aspects of person-centred care, involving relational continuity, flexibility and teamwork, would help them better address these individuals. In study 4, Health and Life in Balance was acceptable and feasible regarding to have relational continuity to a district nurse addressing non-disease-specific issues for individuals in need of it. However, the intervention needs further development. The intervention needs to be targeted for individuals with the greatest care needs including aspects of frailty, deprived psychosocial situation and many healthcare providers. Further, it needs to be further developed to provide person-centred care in a busy primary care setting, including raising priority for individuals with multimorbidity involving non- disease-specific needs, addressing how to provide and implement a person- centred care, and addressing how to provide teamwork and cooperation with others.

Conclusions

This thesis identifies individuals with multiple health conditions to be at risk of potentially inappropriate prescribing of benzodiazepines and poorly addressed non-disease-specific issues in today's fragmented healthcare system and shows person-centred care as a potential solution to address these issues. Furthermore, it describes the development and piloting of Health and Life in Balance, a person-centred intervention aiming to address these risks. The findings from the pilot study identified the intervention to be acceptable and feasible when at-need individuals had relational continuity to a district nurse who could address non-disease-specific needs. Yet, the intervention needs further development to identify and target individuals with the greatest care needs, make these individuals a priority in primary care, and to ensure teamwork and delivery and implementation of person-centred care. The results from this thesis and included studies can inform policy makers and other stakeholders of the need of prioritising a shift from fragmented care to person- centred and holistic care for vulnerable individuals and a need of further intervention development to address these individuals' needs. Furthermore, the findings can be used in further intervention development. However, in future intervention development it is important to involve individuals with multimorbidity and other stakeholders in both the research group and in different phases of the intervention development.

List of scientific papers

I. Specific content of collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care. C Kappelin, A Carlsson, C Wachtler Fam Pract 2021 Sep 21;39(4):725-734. https://doi.org/10.1093/fampra/cmab079

II. The association between number of chronic diseases and potentially inappropriate benzodiazepine prescribing: A total population-based cohort study in Region Stockholm, Sweden. Caroline Kappelin, Caroline Wachtler, Gunnar Ljunggren, Axel Carlsson. [Submitted]

III. Dancing with the patient: a qualitative study of general practitioners' experiences of managing patients with multimorbidity and common mental health problems. Kappelin C, Sandlund C, Westman J, Wachtler C. BMC Prim Care. 2023 Apr 20;24:104. https://doi.org/10.1186/s12875-023-02056-y

IV. Health and Life in Balance an intervention to improve patient capacity for older people with multimorbidity: A pragmatic mixed methods non-randomised pilot study. Caroline Kappelin, Klas Ytterbrink Nordenskiöld, Elisabeth Bos Sparén, Annica Lagerin, Caroline Wachtler. [Submitted]