International multimorbidity

The PhD programme, led by Professor Susan Smith, is funded by a Health Research Board (HRB) Collaborative Doctoral Award in Patient-focused Research. Dr Annalisa Montesanti of the HRB opened the event before the audience was introduced to Michael, who collaborated with the PhD students as a Public and Patient Involvement (PPI) contributor throughout the research. Michael described his experiences living with multiple conditions, highlighting the high number of regular medicines, the financial costs of travelling to multiple appointments, and how symptoms and treatments for multiple conditions co-exist. Michael called for more personalised and connected healthcare to meet the needs of people who live with multiple ongoing conditions every day. This set the scene very well for the remainder of the morning, as Aisling Croke, James Larkin, Bridget Kiely and I (Louise Foley) presented key findings and recommendations from our research which aimed to understand and address these challenges.

Managing multiple medicines

The first session, titled “Managing Medicines”, was chaired by Professor Carmel Hughes. I first presented my research on the topic of medication adherence (1–4). The key findings suggested that medication non-adherence is common but varies considerably in the literature, that multiple medicines and conditions extend the work associated with chronic condition self-management, and that beliefs about medicines prescribed for multimorbidity can be complex in how they relate to medication taking behaviours. Based on this research, I recommended that involvement in decisions about medicines is individualised, that discussions about medication adherence are integrated into routine practice, and that a variety of strategies are used together to support people experiencing different types of barriers to taking multiple medicines. This was followed by Ms Aisling Croke, who presented her PhD research on the role of general practice-based pharmacists in medication optimisation interventions (5–7). The key findings suggested that pharmacists can reduce potentially inappropriate prescribing and number of medications, that costs reduce alongside reductions in potentially inappropriate prescribing, and that pharmacists are generally accepted in the general practice setting. Drawing on this research, Aisling recommended that patients are empowered to make decisions related to medicines through patient-centred review structures, that greater uniformity of reporting outcomes is needed to establish a strong evidence base, and that there is potential for integrating pharmacists in the general practice setting, which should be examined further in a definitive trial. The session concluded with a panel discussion featuring myself and Aisling, alongside our respective PhD supervisors Professor Gerry Molloy and Dr Frank Moriarty. The discussion was largely focused on real-world implementation considerations. Practical barriers to implementing general practice-based pharmacist roles were discussed, including space, time and prescribing limits. Questions also arose around how to engage those who are likely to benefit most from medication reviews and adherence discussions, and how to incorporate such exchanges in a time-limited context.

Treatment burden

The second session, titled “Treatment Burden”, was chaired by Dr Frank Moriarty. Dr James Larkin presented his research on the experience of financial burden among people living with multimorbidity (8–11). Findings highlighted the high healthcare costs associated with multimorbidity, that these high healthcare costs can have unintended consequences such as non-adherence and non-attendance, and that healthcare entitlements can reduce financial burden significantly. Based on this PhD research, James recommended that cost-of-care conversations are implemented by healthcare workers, that user charges and health-related travel expenses are reduced, and that a healthcare system designed for multimorbidity is realised. This was followed by Dr Bridget Kiely, who presented her PhD research on social prescribing for people living with multiple long-term conditions (12–15). Key findings from a systematic review highlighted limited evidence for the cost-effectiveness of link worker interventions, a randomised trial suggested potential for general practice-based link worker interventions to be cost-effective, and a process evaluation found that patients welcomed the presence of link workers in the general practice setting. Based on these findings, Bridget recommended stronger embedding of social prescribing in general practice, that several issues with evaluation need to be overcome to strengthen the evidence base, and that it may be too soon for widespread rollout of link worker interventions in the absence of robust evaluations accounting for opportunity cost. The session concluded with a panel discussion involving James and Bridget, PPI contributor Michael, Professor Frances Mair and James’ PhD supervisor Dr Barbara Clyne. The discussion highlighted the importance of care that addresses both health and social needs, and comparisons were made with the UK healthcare system where social prescribing has been implemented in primary care. The overarching theme of the panel discussion echoed the point originally made by Michael, who highlighted the need for personalised and connected healthcare to reduce burden.

Reflecting on the process and impacts

The afternoon session provided opportunities for reflecting on the PhD programme. This included a conversation between James and PPI contributor Declan Keely, who chatted about their personal experiences of working collaboratively across the PhD projects and the impacts of the collaboration on the research and individuals involved. Declan reflected on the progress the PhD students made over the years, particularly in relation to communicating clearly and effectively with the public. An international perspective was then offered by Professor Frances Mair, who directs the Multimorbidity PhD Programme for Health Professionals in Scotland, funded by the Wellcome Trust. Several of the fellows visited Dublin with Frances to attend the dissemination event and to network with the Irish PhD cohort, which is reflected upon further in this blog by Dr Benedict Warner. The day concluded with a panel discussion on policy and practice implications, chaired by Professor Andrew Murphy, and featuring Professor Peter Bower, Professor Sara Burke, PPI Contributor Michael, Professor Frances Mair, and Dr Ciara Kirke. The central role of evidence was emphasised throughout the panel discussion. The session and day concluded with a reflection on the importance of approaching research incrementally and building on what we learn is working well in practice, with the aim of establishing a strong evidence base to guide meaningful investment in patient-oriented care. 

 

 

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First published: 11 March 2024