E-Newsletter – Multimorbidity #CLAHRC @OfficialNIHR @ClahrcP #CLAHRCImpact

Welcome to the community e-newsletter for the CLAHRCs, bringing you news from across the thirteen collaborations and the health service research community.

This newsletter looks at the work NIHR CLAHRCs are doing to address Multimorbidity

Find out more about the CLAHRC Partnership Programme at: www.clahrcprojects.co.uk/

NIHR CLAHRC Community e-newsletter – Multimorbidity Issue 60

CLAHRC East Midlands: Renal complications being reduced by ‘simple prompt’ in CLAHRC East Midlands study

CLAHRC East Midlands is helping to reduce cardiac and renal complications in people with Type 2 diabetes and microalbuminuria thanks to a new IT prompt.

GP surgeries across Leicester City and Leicestershire are using the simple software tool, which is incorporated into the medical records systems in general practice. This works as a ‘prompt’ and signals healthcare professionals caring for these individuals to use tighter treatment targets for known modifiable risk factors such as hyperglycaemia, hypertension and hypercholesterolemia.

Tighter targets in these patients, compared to standard diabetes care, results in greater reductions in the risk of cardiovascular disease and death, microvascular complications and improvements in kidney function.

Read more here.

CLAHRC East Midlands: CLAHRC East Midlands drive to improve cardiovascular disease outcomes

A study led by CLAHRC East Midlands is looking at ways to cut down the huge impact of heart disease.

The 3R Programme (Ready to Reduce Risk) has been launched in Northamptonshire to establish what motivates people into making lifestyle changes by using group education sessions, focused on improving health.

Dr Stephen Rogers, who has been a public health doctor in Northamptonshire for 10 years and is the Principal Investigator of the study said: “The study investigates the likely impact of an innovative group based approach to supporting and enabling people who have a high cardiovascular risk to understand what this means and what they can do to change things.”

Two trained educators have been delivering group education sessions at people who are deemed at high risk of cardiovascular disease CVD. The classes have covered the risks of heart disease and how to make lifestyle and medication changes to prevent its development.

The study findings could be rolled out on a national basis in the future.

More about this CLAHRC study here.

CLAHRC Greater Manchester:  Heywood, Middleton and Rochdale (HMR) Long Term Conditions NHS Test Bed: A Service Evaluation of Implementation and Impact.

Long-term health conditions (LTCs) are making increasing demands on health resources. Consequently, there is interest in developing effective interventions that can improve care and reduce cost.

NIHR CLAHRC Greater Manchester and colleagues from the University of Manchester are working together to independently evaluate the test-bed programme within NHS Heywood Middleton and Rochdale Clinical Commissioning Group (HMR CCG) as part of NHS England’s National Test Bed Programme. The programme, led by NHS HMR CCG in collaboration with two health technology companies, MSD and Verily, provides an innovative practice-level intervention targeted at improving the management of selected LTCs. The intervention comprises three elements:

  • Software to help primary care staff identify those with/at risk of the aforementioned LTCs.
  • A training programme which supports primary care staff in effective use of the software.
  • A home-based monitoring and support service for patients with heart failure/COPD (two of the selected LTCs).

Whilst each of these components in isolation has some evidence of effectiveness, it is possible that the combination will deliver a greater impact on health service utilisation than each component would individually.

The project draws on participants from frontline healthcare providers through to senior CCG members, and uses both qualitative and quantitative methods. The project aims to evaluate the implementation of this intervention and its impact on several health outcomes including unplanned LTC-related hospital admissions. Preliminary results are expected in autumn 2017.

More information is available here

CLAHRC Greater Manchester: Talking Therapies for Patients with Chronic Widespread Pain (CWP)

Talking therapies for patients with Chronic Widespread Pain (CWP) is a major public health problem, affecting between 11-13% of the population. Individuals with CWP frequently experience comorbidities such as irritable bowel syndrome, chronic fatigue syndrome, joint pain and headaches along with mental health disorders including depression and anxiety.  It is therefore vital that patients have access to timely and appropriate resources to help improve their health and wellbeing, including support for physical symptoms and also access to psychological support, should they require it.

Over the past 10 months, NIHR CLAHRC Greater Manchester has been working with Six Degrees social enterprise on a project, funded by NHS Salford Clinical Commissioning Group, which has seen 146 patients with CWP referred into the service through a dedicated ‘Pain Platform’. Referral into the service has been opened up to secondary care, including from muscular-skeletal physiotherapists, rheumatologists and pain specialists.

Patients referred into the service had direct access into a range of therapy options, based on clinical need and patient preference, including cognitive behavioural therapy (CBT) and mindfulness. Those requiring higher intensity psychological interventions may also be “stepped-up”. The project has also provided access to evidence based telephone delivered CBT (T-CBT), delivered by psychological wellbeing practitioners at Six Degrees with additional training in its delivery.

The final project report, due within the next month, will evaluate the implementation of the Pain Platform and the T-CBT.

For more information please contact Michael Spence, Programme Manager.
CLAHRC North Thames: Health inequalities and multimorbidity

Whilst the relationship between socioeconomic inequalities and life expectancy is well established, previous research has adopted a single disease approach, with limited investigation of these disparities in the context of multimorbidity. CLAHRC North Thames researchers  are investigating if the type and combinations of diseases play out differently across socioeconomic groups, resulting in the large, and persistent, rich-poor gap we observe in life expectancy at older ages.

In the first study to analyse ‘big’ data longitudinally, researchers are aiming to understand how inequalities in the age of disease onset and the subsequent accumulation of multiple diseases over the life course impact on mortality rates. They have selected 30 diseases, grouping them into 7 more manageable clinically defined major disease “clusters”. Early findings support the assertion that compared to advantaged groups, deprived populations experience earlier onset of multimorbidity, acquire multiple diseases more rapidly and consequently, have higher mortality rates.

Contact Dr Madhavi Bajekal m.bajekal@ucl.ac.uk

CLAHRC North West Coast: Title Accelerating Delivery Of Psychological Therapies after Stroke (ADOPTS)

Psychological problems, such as depression, are common after stroke and can have negative effects on stroke survivors and their carers. Although general psychological services exist (e.g. Improving Access to Psychological Therapies (IAPT) services), there is a lack of psychological support available for stroke survivors. Some IAPT services do provide psychological support for stroke survivors, but this is rare.

This may be because of the range of difficulties that stroke survivors might have, for example, problems with communication, which make it more challenging for IAPT services to provide effective support.

People who have a stroke also tend to be less well-off so they may have difficulty accessing general psychological services for themselves. This means stroke survivors do not always receive the psychological care they need and, as a consequence, may have a reduced quality of life.

This research aims to see if we can use services that already exist for general psychological support (IAPT services) and adapt them to be useful for stroke survivors. We will develop an Implementation Package (pathways and training) that healthcare staff can use to ensure that stroke survivors receive suitable psychological support. More

CLAHRC North West Coast: The PERMIT Project (Personalised Renal Monitoring via Information Technology)

There are clear guidelines for the treatment of heart failure, which include the use of diuretics at some point during the treatment pathway. However, these guidelines do not cover when and how frequently patients with heart failure should have their renal function monitored largely because there is no good evidence to indicate optimum frequency in given circumstances.

A study published in the BMJ in 2004 prospectively analysed 18,820 individuals admitted to hospital in a six month period. Overall, 6.5% presented with adverse drug reactions (ADR). Next to NSAIDs, diuretics were the second commonest cause of drug-induced hospital admissions, with most patients presenting with renal impairment.

These findings reflect a lack of guidance on when and how frequently renal function should be monitored. If evidence-based guidance on this was available, potentially this could be a method to prevent unnecessary diuretic-related hospital admissions. The aim of this project is to develop this guidance by using electronic health records and using novel analytical methodologies to define decision rules for individualised renal function monitoring.

CLAHRC NWC  aims to develop personalised kidney function monitoring guidelines based on the characteristics of individual patients (for example: severity of heart failure, drugs being taken and other diseases that they might have).

The availability of such monitoring protocols would change clinical care pathways, and potentially reduce hospital admissions, reduce cost and improve patient quality of life.

To generate this personalised guidance system, electronic health care databases will be used to identify heart failure patients on diuretics. Patient data will be examined to evaluate how often renal function monitoring was done over the course of their heart failure diagnosis and how many of the patients were reported to develop renal impairment. Along with personal characteristics (for example gender, age, ethnicity) these data will be collated and examined in detail to provide indicators of how often monitoring would need to be done based on individual patient characteristics.

Once a personalised guidance system has been developed, we aim to pilot the system out in primary care practices across the UK, using feedback from patients and clinicians in order to improve the design. This system is anticipated to set a precedent in machine learning based guidelines for the use of personalised medicine within the UK.

PenCLAHRC: Handling multiple-prescribed medicines

More medicines are available to clinicians and their patients, and more people live longer with multiple conditions. A result of this is that patients are prescribed a number of different medicines (polypharmacy), with the ongoing burden of managing their intake of those medicines. A study supported by PenCLAHRC, in partnership with CLAHRC West Midlands and CLAHRC North West Coast, is developing and testing a whole-practice approach to help doctors make tailored decisions about how medicines are used for their patients, tackling the issue of polypharmacy and helping patients to manage their prescriptions. More here.

PenCLAHRC: Mental health disorders and children with long-term chronic conditions

A long-term physical condition in children can also result in depression and anxiety, yet it has not been established which mental health support measures work best, or whether they work at all. A study supported by PenCLAHRC, in partnership with CLAHRC North Thames, is carrying out two systematic reviews looking at: cost and cost-effectiveness of mental health support measures; the effects of the measures on social and family function, and; the factors which help or hinder the effectiveness of the measures. More here.

PenCLAHRC: Patient-Centred Coordinated Care (PCCC)

A suite of projects under the PenCLAHRC umbrella are focused on Patient-Centred Coordinated Care (PCCC), the very ethos of which is, in part, designed to address the needs of patients with comorbidity. From reviews of literature to bottom-up service redesign and implementation, the evaluation of innovation and whole system, and the synthesis of evidence on how to practically deliver PCCC, work in this area is already making positive impact on the needs of patients with comorbidities in the South West and beyond. More here.

CLAHRC Oxford: Implementing evidence based depression care in the Oxford Cancer Centre (OCC)

Many people who have a physical illness also have a mental illness; this combination is called medical-psychiatric multimorbidity. Multimorbidity is important because it leads to poorer quality of life and worse outcomes for patients as well as greatly increasing the cost of medical care.

In patients with poor prognosis cancers, like lung cancer, depression and anxiety are both common, often go untreated, and can blight the time these people have left to live.

However, the quality of life of these patients can be significantly improved with a new, integrated approach to care, called ‘Depression Care for People with Cancer’ (DCPC), as revealed by NIHR CLAHRC Oxford part-funded research published in The Lancet.

In the study 142 lung cancer patients who received an integrated care programme – addressing both their physical and mental health needs – had a significantly greater improvement in depression symptoms compared with those receiving existing treatments, thereby enhancing their quality of life.

The treatment is delivered by a team of specialist cancer nurses and supervising psychiatrists, who work in collaboration with the patient’s oncology team and GP. Most sessions are delivered face-to-face.

Read more about this project here.

CLAHRC Oxford: Development of a PROM for long-term conditions

Living with long-term conditions – such as chronic back pain, diabetes, or multiple sclerosis (MS) – can seriously affect people’s enjoyment and quality of life.

According to NHS England, 15.4 million people in England have a long-term condition. An increasing number of whom have multiple conditions (multimorbidity).

The NHS Outcomes Framework lays out a range of indicators across five key ‘domains’ against which the performance of the NHS is assessed. One of these is ‘enhancing quality of life for people with long-term conditions’.

The EQ 5D questionnaire is often used to understand how people living with long-term conditions experience their health. However, the EQ 5D does not address many important aspects of living with long-term conditions, such as multimorbidity.

Working with patients who have long-term conditions, this project is developing and validating a new ‘Patient Reported outcome Measure’ (PROM), complimentary to the EQ 5D.

This will measure a broader range of important aspects of living with long-term conditions, including multimorbidity, to help improve the care of people with long-term conditions.

More accurate indicators of how NHS services are performing, that truly reflect patients own experiences with long-term conditions, should lead to patient-focused improvements in both quality of care and patient outcomes.

More here.

CLAHRC South London: Making better use of information that is regularly and routinely collected about stroke survivors

Every day, GPs and other healthcare professionals record information about patients and decisions about their care. Members of the CLAHRC South London stroke research team want to create a new electronic system that is capable of storing all this information in one place in order to ultimately help offer better care to stroke survivors who have a number of different health problems. The research team is developing a prototype of an advanced information system that can allow medical records and other information collected about stroke survivors to be used for research; to help plan services; and to inform healthcare professionals’ decisions. The prototype will use information about stroke survivors who live in Lambeth.

Read more.

CLAHRC West: Understanding the physical harm of taking more than one antipsychotic drug

Schizophrenia is a serious mental illness which affects about 1 per cent of people. The most common treatment for schizophrenia is a type of drug called an antipsychotic. Many patients are prescribed more than one at a time, even though experts recommend that only one should be taken at a time. There is also no clear evidence that taking more than one antipsychotic drug at a time is more effective.

People with schizophrenia die about 20 years earlier than those without a serious mental illness. This is partly because they are more likely to have serious health problems such as obesity, diabetes, high blood pressure and high cholesterol. All of these increase the risk of having a heart attack or stroke. People may be more likely to have these problems if they take more than one antipsychotic over a long time, although we don’t have firm evidence about this.

In this study, CLAHRC West researchers will look at information that’s routinely collected at GP surgeries for a large group of middle-aged people with schizophrenia, to find out how many antipsychotic drugs they are prescribed. They will then follow them for up to 15 years to find out whether they are diagnosed with one of these serious health problems. Find out more on the CLAHRC West website

CLAHRC Yorkshire and Humber: The Lifestyle Health and Wellbeing Cohort

The Lifestyle Health and Wellbeing Survey for people with severe mental ill health (SMI) is part of the NIHR CLAHRC Yorkshire and Humber Mental Health and Comorbidity theme which explores the interface between mental and physical ill-health.
People with SMI experience significantly poorer physical health and higher mortality compared to the general population, dying on average 15-20 years earlier than people without SMI. The main cause of these deaths is due to chronic physical conditions such as diabetes, cardiovascular, respiratory and infectious disease and hypertension. Preventable risk factors such as smoking, physical inactivity, poor diet, obesity, tobacco use and the side effects of psychiatric medication all contribute to this health inequality. Contact: emily.peckham@york.ac.uk


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