Digital Support in Family Practices for Older Patients with Multiple Conditions

Multimorbidity means that a person suffers from multiple chronic conditions at the same time, which is particularly common among older adults. For some chronic conditions, patients have the option of enrolling in disease management programs (DMPs). These are structured treatment programs offered by primary care practices that primarily involve regular follow-up visits, patient counseling, and documentation of treatment outcomes. Despite these programs, treating patients with multiple chronic conditions is challenging, as different medications can interact with one another and varying treatment goals must be balanced. The S3 guideline on multimorbidity from the German Society for General Practice and Family Medicine (DEGAM) provides general practitioners with evidence-based recommendations for caring for these patients; however, fully implementing these recommendations remains a challenge. In response to this issue, the digital application gp-multitool.de was developed, which is based on the DEGAM’s S3 guideline on multimorbidity and is designed to facilitate its implementation. The web application enables primary care physicians to send questionnaires digitally to patients, who can complete them at home or in the office on an internet-enabled device. Among other things, the questionnaires assess personal treatment goals, social support, difficulties in managing prescribed medications, and health-related complaints such as pain or emotional distress. The results are then discussed together during the consultation, and at least one medication review is conducted to assess all medications taken for potential interactions and necessity.

The aim of this study is to investigate whether the web application gp-multitool.de can improve the quality of care for patients. Patients are recruited for the study through their primary care practices. Interviews with patients and their primary care physicians are conducted by telephone. After the initial survey, the primary care practices are randomly assigned to two groups (cluster-randomized). The practices in the study arm use the digital application for twelve months, and the practice staff receive additional training and support regarding questions about the web application. The practices in the control arm will continue to provide care as usual. The random assignment of the primary care practices is carried out by an independent statistician who does not receive any information about the enrolled patients. The primary objective is to determine whether the use of the digital tool reduces the need for hospital stays. Additional outcomes being measured include health-related quality of life, satisfaction with care, and the frequency of doctor visits.

Eligible participants are women and men aged 65 and older who are enrolled in a disease management program for a chronic condition (e.g., breast cancer, diabetes, heart and lung diseases, obesity, chronic back pain, depression, osteoporosis, or rheumatoid arthritis) and have at least two additional comorbidities.