# Integrated care for people with multimorbidity into elective surgical pathways: mixed-methods co-design study

## TL;DR

This study co-designed a model to better integrate care for people with multiple long-term conditions into elective surgery pathways, aiming to improve health outcomes.

## Contribution

A co-designed model for integrating MLTC care into surgical pathways, focusing on early identification and optimization.

## Key findings

- Current UK pathways for elective surgery lack structured integration of MLTC care.
- A pragmatic intervention was developed with five components to address diabetes, hypertension, weight management, and smoking cessation.
- Only 10% of hospitals had MLTC-specific care pathways for elective surgical patients.

## Abstract

People with multiple long-term conditions (MLTC) commonly undergo elective surgery, yet current pathways remain poorly equipped to meet their complex needs. These pathways present a unique, time-sensitive opportunity to act. The aim of this study was to co-design a feasible intervention that integrates MLTC care into surgical pathways.

This was a theory-informed mixed-methods co-design study (informed by the National Institute for Health and Care Research (NIHR)/Medical Research Council (MRC) complex intervention framework). Phase 1 involved contextual analysis of current UK pathways (pathway mapping, policy/guideline scan, and national survey) and phase 2 involved multidisciplinary stakeholder workshops to develop a Theory of Change.

In phase 1, pathway mapping identified variation and delayed preassessment, resulting in a limited window to optimize chronic diseases. The scoping review found no UK guidance integrating MLTC into surgical pathways. In the survey (73 responses, 51 National Health Service (NHS) Trusts), few services screened at listing and structured pathways were uncommon. Only one-in-ten hospitals had an MLTC-specific care pathway for elective surgical patients, primarily focusing on diabetes or anaemia management. In phase 2, 21 stakeholders agreed upon a pragmatic intervention prioritized on four domains (diabetes, hypertension, weight management, and smoking cessation), with five intervention components: surgeon-led checklist-based early identification at listing; automated referral to primary care/specialist services; patient-activation materials; optimization during waiting time; and structured discharge communication.

This study presents a co-designed model that shifts MLTC care upstream to the point of listing, offering the potential to improve short- and long-term health.

This study presents a co-designed model that shifts multiple long-term condition (MLTC) care upstream to the point of listing. Although this model offers the potential to improve short- and long-term health, closing the knowledge gap on its clinical effectiveness is required before broader implementation into the National Health Service (NHS).