LAUSR

4 www.thelancet.com Vol 392 July 7, 2018 Multimorbidity, which is defined as living with two or more chronic health problems, is a major and growing problem, especially in societies with ageing populations and substantial socioeconomic disparities. It is associated with reduced quality of life, impaired functional status, poor physical and mental health, and increased mortality. There is a broad international consensus that multi morbidity is best addressed in primary care set­ tings by a patient­centred approach, including reg­ ular appointments for comprehensive problem review and management options tailored to individual patient preferences. This care should be provided by a multi­ disciplinary team with a named lead clinician, and should be based on effective clinical information systems. But there remains the essential question of whether patient­centred interventions actually improve out comes for patients living with multimorbidity and the health systems that care for them. The results of a recent Cochrane review of 18 randomised controlled trials were equivocal, reporting little or no difference in clinical outcomes or in health service use, while suggesting that health outcomes could be improved if interventions are targeted at specific risk factors or functional difficulties. Chris Salisbury and colleagues help answer this question using findings from their cluster­randomised trial of the 3D approach (three dimensional approach based on dimensions of health, depression, and drugs), presented in The Lancet. Their UK­based, multisite trial is the largest study to my knowledge of patient­centred care for multimorbidity. Despite implementing all of the recommended elements of patient­centred care, the authors found no evidence of a significant effect on quality of life (the difference in mean EQ­5D­5L scores was 0·00, 95% CI –0·02 to 0·02; p=0·93), or on various measures of illness or treat ment burden. The authors did, however, find that participants randomly assigned to the intervention group reported significantly improved patient­centred care, including discussing problems most important to them (42% in the intervention group vs 26% in the usual care group; odds ratio 1·85, 95% CI 1·44 to 2·38; p<0·0001) and satisfaction with care received (56% vs 39%; 1·57, 1·19 to 2·08; p=0·0014). Patient-centred care for multimorbidity: an end in itself? The treatment of severe metabolic acidaemia in critically ill patients remains a challenging problem. Further assessment of the potential roles of sodium bicarbonate, other bases, and dialysis is needed, primarily evaluated with randomised controlled studies, such as the one reported here. Also, the effect of inhibition of an activated NHE1 (sodium/hydrogen exchanger 1) and catecholamine­induced stimulation of Na­K­ATPase as well as aerobic glycolysis, which have all been shown to improve haemodynamics and clinical outcome in experimental studies, deserves exploration.