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Multimorbidity, the coexistence of multiple chronic conditions within an individual, is a growing global health challenge affecting a significant portion of the population. Patients with multimorbidity often face complex healthcare needs, leading to increased unplanned healthcare utilization. In an effort to address this issue, community-based interventions have emerged as potential solutions for providing continued care outside of traditional hospital settings. Our systematic review published in the Journal of the Royal Society of Medicine aims to summarize the impact of these interventions on unplanned healthcare use in patients with multimorbidity.

The Burden of Multimorbidity

With the prevalence of multimorbidity increasing, affecting approximately one-third of the global population, it is crucial to find effective strategies to manage this complex condition. The challenges posed by multimorbidity often result in frequent emergency department visits and hospital admissions, placing a significant strain on healthcare resources.

Community-Based Interventions

Community-based interventions offer a promising approach to address the needs of multimorbid patients. These interventions focus on delivering care in community settings, with an emphasis on education, self-monitoring of symptoms, and regular follow-ups. Additionally, some interventions aim to improve care coordination, advance care planning, and provide palliative care for patients with severe conditions. By implementing these interventions, healthcare providers seek to enhance patient self-management, reduce the burden on emergency departments, and improve overall health outcomes.

Findings from the Systematic Review

Thirteen studies, involving a total of 6148 participants, were included in this systematic review. Notably, all the studies were conducted in high-income settings and primarily focused on elderly people. The primary outcome assessed across all studies was emergency department attendance. The risk of bias was generally low across the included studies.

The results revealed that all 13 studies reported a decrease in emergency department visits following the implementation of community-based interventions. The risk reduction ranged from 0 (95% confidence interval [CI]: –0.37 to 0.37) to 0.735 (95% CI: 0.688–0.785). This suggests that these interventions have the potential to effectively reduce unplanned healthcare usage among patients with multimorbidity.

Challenges and Future Directions

Identifying specific successful components of community interventions proved challenging due to the overlaps between different interventions. However, the overall findings strongly support the integration of community-based approaches into existing healthcare structures. Policymakers should recognize the importance of these interventions and work towards their implementation to alleviate the burden on emergency departments and improve patient outcomes.

Future research must explore the impact of community interventions on a broader range of participants. This will allow for a better understanding of the effectiveness of these interventions in diverse populations and settings. By expanding the scope of research, we can gain deeper insights into the potential benefits of community-based interventions for patients with multimorbidity.

Conclusion

Community-based interventions have shown promise in reducing emergency department visits among patients with multimorbidity. These interventions empower patients to manage their conditions, promote education, and improve care coordination. Policymakers and healthcare providers should recognize the value of these interventions and work towards integrating them into existing healthcare structures. By doing so, we can enhance patient care, reduce healthcare costs, and alleviate the burden on emergency departments. As we move forward, further research is needed to explore the broader impact of community interventions and their potential to improve outcomes for patients with multimorbidity in various contexts.

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The Quality and Outcomes Framework (QOF) was introduced in 2004 as part of a new NHS GP contract with the aim of financially rewarding general practices for delivering evidence-based standards of care. While initially unique internationally, the QOF in the UK is now facing uncertainty, with calls to cut it back or abolish it due to various challenges faced by the NHS. In an article published in the journal BJJP Open, Mariam Molokhia and I discuss the role of the QOF in England’s NHS and argue for its importance in improving health outcomes and addressing public health challenges.

The Importance of Comprehensive Health Services

Primary care plays a vital role in providing comprehensive health services, covering both acute and long-term conditions. Beyond immediate patient needs, the focus should be on prevention, early diagnosis, and management of chronic diseases that contribute significantly to ill health, reduced quality of life, and increased NHS workload. Amid the COVID-19 pandemic, urgent care rightfully took precedence, but it is now crucial to restore high-quality care for long-term conditions.

The Role of QOF in Addressing Public Health Challenges

Public health challenges have underscored the importance of the QOF, especially in areas focused on secondary prevention and long-term condition management. Meeting QOF targets for conditions like type 2 diabetes leads to lower mortality rates, reduced emergency hospital admissions, and improved health outcomes. By using the QOF effectively, the NHS can alleviate pressures on other healthcare sectors and improve patient well-being.

Data Measurement and Research 

The QOF also facilitates data collection and measurement of healthcare quality, essential for planning health services, addressing health inequalities, and ensuring efficient use of public investments. The structured data entry required for QOF enables its use for clinical research, as shown during the COVID-19 pandemic. Abolishing or significantly cutting back the QOF would have far-reaching negative consequences, undermining these benefits.

Supporting Primary Care Teams and Addressing Challenges

Rather than discarding the QOF, it is crucial to support primary care teams in delivering structured care while addressing urgent patient needs. Adequate funding, including a review of funding allocation mechanisms, is necessary. Additionally, workforce issues should be addressed, promoting staff retention and expanding recruitment into new primary care roles. Integration of pharmacy and general practice services can also enhance primary care capabilities. Leveraging information technology and the wider primary care team can enable the delivery of QOF elements at scale, streamlining care processes and improving the efficiency of QOF.

Retaining Essential Elements of QOF

While criticisms exist regarding the QOF’s reporting domains and its evaluation of important dimensions of care quality, it is essential to retain its best elements. This includes focusing on early detection and management of long-term conditions while improving support through information technology and the wider primary care team. Recent research from Scotland demonstrates that the elimination of financial incentives can lead to reductions in recorded quality of care, emphasizing the importance of maintaining an effective QOF program.

Conclusion

The Quality and Outcomes Framework (QOF) remains an integral part of England’s NHS. Despite challenges faced by the healthcare system, the QOF’s role in improving health outcomes, addressing public health challenges, and promoting comprehensive care cannot be overlooked. By adequately supporting primary care teams, addressing workforce issues, and using technology and the wider primary care team, the QOF can continue to play a crucial role in reducing health inequalities and improving health outcomes in England.

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Our ability to engage in self-care practices plays a crucial role in promoting overall well-being and preventing and managing non-communicable diseases. To support individuals in assessing their self-care capabilities, many measurement tools have been developed. However, a comprehensive review specifically focusing on non-mono-disease specific self-care measurement tools for adults has been lacking. Our  scoping review in the journal BMC Public Health aims to identify and characterise such tools, including their content, structure, and psychometric properties.

Shifting Emphasis and Methodology

The review encompassed a thorough search of Embase, PubMed, PsycINFO, and CINAHL databases, covering a wide range of MeSH terms and keywords from January 1950 to November 2022. The inclusion criteria involved tools that assess health literacy, capability, and performance of general health self-care practices, targeting adults. Tools exclusive to disease management or specific medical settings were excluded. A total of 38 relevant tools, described in 42 primary reference studies, were identified from a pool of 26,304 reports.

A key observation from the descriptive analysis was the temporal shift in emphasis among the identified tools. Initially, there was a stronger focus on rehabilitation-oriented tools, while more recent tools have shown a shift towards prevention-oriented approaches. This reflects a growing recognition of the importance of proactive self-care practices to maintain optimal health and prevent the onset or progression of diseases.

Additionally, the method of administering these tools has evolved over time. Traditional observe-and-interview style methods have given way to self-reporting tools, which empower individuals to actively participate in assessing their own self-care capabilities. This shift in methods recognizes the value of self-awareness and self-reflection as integral components of self-care.

Content Assessment and Limitations

To provide a qualitative assessment of each tool, the review utilized the Seven Pillars of Self-Care framework. This framework encompasses seven domains of self-care: health literacy, self-awareness of physical and mental well-being, self-management of health conditions, physical activity, healthy eating, risk avoidance or mitigation, and good hygiene practices. Surprisingly, only five out of the identified tools incorporated questions that covered all seven pillars of self-care. This finding highlights the need for the development of a comprehensive, validated, and easily accessible tool capable of assessing a wide range of self-care practices.

While this review makes significant strides in identifying and characterizing non-mono-disease specific self-care measurement tools, it does have limitations. For example, the search was limited to specific databases and only included English-language studies. Therefore, some relevant tools and studies in other languages may have been overlooked.

Implications and Future Directions

The findings of this review underscore the importance of enhancing our understanding and assessment of self-care capabilities. By incorporating the Seven Pillars of Self-Care, a comprehensive tool can provide a holistic assessment, allowing for targeted health and social care interventions. Such interventions can empower individuals to improve their self-care practices, thereby promoting better health outcomes and reducing the burden of chronic diseases.

Moving forwards, future research should focus on developing a comprehensive, validated tool that encompasses a broader range of self-care practices. Additionally, efforts should be made to ensure the accessibility and usability of such a tool, considering diverse populations and their unique needs. Collaborative efforts between researchers, healthcare professionals, and technology experts can facilitate the creation of an effective and widely applicable self-care measurement tool.

Conclusion

Self-care is a fundamental aspect of promoting health and well-being across diverse populations. While several disease specific self-care measurement tools exist, this review highlights the need for a comprehensive, validated, and easily accessible tool that assesses a wide range of self-care practices. By embracing the Seven Pillars of Self-Care framework, we can effectively evaluate individual self-care capabilities, inform targeted interventions, and empower individuals to take an active role in their health and well-being. With continued research and collaboration, we can develop tools that facilitate and support the practice of self-care, ultimately leading to improved health outcomes for individuals and communities alike.

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