Changes in health-related quality of life before and after a 12-month enhanced primary care model among chronically ill primary care patients in Australia

The exponential rise in chronic disease prevalence presents significant public health burden to health care systems worldwide and challenges the need to revisit strategies towards effective prevention and management [1, 2]. In Australia, chronic conditions have accounted for 87% of deaths and a collective 61% of fatal and non-fatal burden in 2015 [3, 4]. Moreover, there is an increasing trend of multimorbidity among the ageing population resulting in greater demand for integration of health services [5, 6]. The health and economic ramifications of chronic illness in terms of premature mortality [7], polypharmacy [8], complexity of care [9], and diminished health-related quality of life [10] are well documented. Additionally, the increased health service utilisation among chronic disease sufferers is especially of interest, given Australia’s current fragmented health care framework which lacks continuity of care and care coordination [11, 12]. On the contrary, there is increasing evidence of improved health-related quality of life (HRQoL) in patients receiving collaborative and patient-centred care [13, 14].

In recent decades, there has been a paradigm shift in the measure of health care evaluation from the traditional health indicators of mortality and morbidity towards a broader perspective of patient reported outcome measures (PROMS) including daily functioning, quality of life, symptoms, and other aspects of their health [15, 16]. HRQoL is a multi-dimensional concept that measures the impact and quality of health encompassing an individual’s physical, mental, and social functioning [17, 18]. Determining the HRQoL for patients with chronic illness in primary care setting is beneficial as it enables understanding of patient’s insights and perception on where care needs to be directed in relation to their condition [19, 20]. This in turn allows providers to improve self-management behaviours among patients to effectively manage their conditions and symptoms [21]. There is evidence showing strong association between patient-provider communication and improved HRQoL [22, 23].

Australia has a long-standing use of surveys to measure population health quality and status, including recent incorporation of health utility measures. Data from the South Australia’s annual Health Omnibus Survey (HOS) and New South Wales’ 45 and Up Study have been extensively used to study HRQoL in several wide-level population norms [24, 25]. For instance, trends in the HRQoL study by Atlantis et al. shows that HRQoL significantly worsened over a 10-year period (1998–2008) for individuals with comorbid conditions compared to those with a single chronic condition [26]. Despite recent work, current knowledge of the HRQoL among specific population groups, like primary care patients with one or more chronic conditions, remains largely unknown. Therefore, the aim of this study is to evaluate the HRQoL, before and one-year after enrolment into an enhanced primary care program, and to investigate predictors of change in the HRQoL among primary care patients presenting with one or more chronic conditions.

To our knowledge, WellNet study is the first study to evaluate the changes in HRQoL among patients with one or more chronic conditions in Australian primary care settings based on the principles of PCMH model. Findings of this study are consistent with the growing body of evidence showing strong association between patients’ HRQoL and several core elements of the PCMH such as involvement of a MDT [40, 41], continuity of care [42, 43], and shared decision making and patient-provider communication [22, 23]. Previous Australian studies by McCaffrey et al. [24] and others [44] have reported on health utilities and HRQoL on the general population norms using cross-sectional data. However, studies reporting on the disease-specific, high risk sub-group population using GP data are relatively less, which is of interest, as primary care is the forefront of care delivery in Australia with at least 85% of Australians consulting a GP every year [3]. In view of this, the WellNet study is novel as it closely examines the outcome of integrating care delivery on HRQoL at two different time points whilst determining predictors of change using GP data.

In this study, the use of EuroQol EQ-5D-5L over other instruments owes to its simplicity in accruing several aspects of an individual’s self-perceived health status in a relatively short duration through use of a short 5-item questionnaire [45]. Moreover, the EQ-5D-5L has also been reported as one of the sensitive instruments in terms of better discriminative power in effectively detecting changes in the HRQoL [46]. In addition, it is reported to have better known-group validity where subjective patient scores are shown to be in accordance with the objective investigator findings of changes in the HRQoL [47].

Findings of our study showed both statistical significance whilst also meeting the bare minimal threshold of clinical significance in EQ-5D index scores after adjusting for baseline covariates. However, considering that our sample is chronically ill with many patients having multiple diseases, MCID may not even be a significant indicator on population level. In this population, we would typically expect that many patients would have progressed in their disease, so even small change or no change in the EQ. 5D scale may be a positive outcome for the program. The effectiveness of PCMH model on improving patients’ HRQoL is consistent with studies by Schuttner et al. [13] and Hynes et al. [14].

Of the five dimensions of EQ-5D, WellNet patients reported substantial improvement particularly on two domains of pain/discomfort and usual activities in terms of a 33 and 28% increase, respectively, in the ‘no problem’ level at follow-up. This could be attributed to the primary objective of the WellNet program in improving self-management behaviour among patients to effectively manage symptoms associated with their chronic conditions [27]. Improved self-management behaviours are strongly associated with improved HRQoL [48, 49].

Findings of the multivariable regression model show that higher baseline index value and positive diagnosis of respiratory disease were significantly associated with EQ-5D index at 12 months. Higher baseline EQ-5D index value as significant predictor of increased follow-up index scores is consistent with other study findings by Van Eck et al. [39]. This could be because patients who already reported better HRQoL at baseline benefitted through further patient education and self-management from the WellNet care team. A positive history of respiratory disease was negatively associated with HRQoL at follow-up compared to those without prior respiratory disease. The poor HRQoL reported among patients with respiratory disease due to several reasons of duration and severity of the condition supplemented with or without harmful lifestyle behaviours is well documented [50, 51].

KOOS and HOOS assessments were recorded in parallel with EQ. 5D instrument in the WellNet study. Changes in the KOOS and HOOS scores were supplemented with the primary outcome of EQ. 5D changes. Besides statistical significance, the scores also met the MCID rendering them clinically relevant for changes in the patient management. The favourable changes in this study is consistent with findings of other studies of collaborative care [52, 53].

Our study has several strengths and limitations. This is the first study in Australia to evaluate the outcome of a PCMH model on HRQoL among patients in primary care setting. The study includes an effectively targeted sample with longitudinal measurements at two different time intervals enabling determining predictors of change in the HRQoL scores. This study also exhibited a good response rate of 68% which is high and satisfactory in this kind of survey [54]. This study also adds to the relatively less than adequate research conducted using GP-data. Although the aim of this study was to evaluate changes in HRQoL after the 12-month WellNet intervention, this study was not designed as an effectiveness study, but rather as a proof-of-concept study.

In regard to study limitations, although WellNet program comprises an effectively matched comparison group, the EuroQol EQ-5D-5L was recorded only among treatment group, thereby limiting to within-group analysis. The lack of control group means that the possibility of potential bias cannot be excluded, and we cannot be sure that improvement in EQ. 5D scores may have occurred anyway without the enhanced PCMH intervention. However, that seems unlikely based on research conducted with use of control groups reporting similar outcomes [55, 56]. Additionally, some key socio-economic variables such as annual income were unavailable due to privacy concerns, which may also have impacted prediction of the index scores over time. With exception of HOOS and KOOS surveys, we did not have other validated instruments to determine HRQoL in parallel with the EQ-5D-5L instrument, which could have further increased the reliability of the findings. Finally, consistent with other originally designed programs, reproducibility of findings is constrained by potential barriers in the form of uniqueness of data and by patient and provider-level determinants [27, 57].

Evaluating the HRQoL for patients with chronic illness enables understanding of patient’s insights and perception on where care needs to be directed in relation to their condition. The integration of GPs and trained CDM coordinators proves critical for provision of individualised care for patients presenting with multiple chronic conditions. This study demonstrates outcome of integrating care delivery on HRQoL at two different time points whilst determining predictors of change using GP data. Besides statistical significance, patients also met the MCID rendering them clinically relevant for change in patient management. Future research should seek to evaluate the sustained effects and cost-benefits of the WellNet program.