Entete 3

Identifying key outcomes for multimorbidity research

By Susan M Smith, Emma Wallace, Chris Salisbury, Maxime Sasseville, Elizabeth Bayliss, Martin Fortin
A new study has identified the most appropriate outcomes to assess in studies examining interventions for patients who suffer from multiple chronic medical conditions (multimorbidity). It has been conducted by researchers from RCSI (Royal College of Surgeons in Ireland). The study was carried out by the Health Research Board (HRB) Centre for Primary Care Research at RCSI’s Department of General Practice in collaboration with researchers from the University of Bristol, in the United Kingdom, the University of Sherbrooke in Canada and the University of Colorado din the USA . The study was published in the leading US primary care journal, the Annals of Family Medicine [1].
Multimorbidity is present in a patient when the individual has two or more chronic medical conditions. These patients are more likely to experience decreased quality of life, functional decline and increased need for healthcare. They often need to take several medications (polypharmacy) and can experience fragmented care due to involvement with multiple healthcare providers. There is growing interest in trying to identify effective interventions that can improve outcomes for patients with multimorbidity. We conducted a study to identify which outcomes should be prioritised in these studies. We used a Delphi consensus process involving 26 researchers, clinicians and patients from 13 countries.
This panel of international experts agreed that clinical trials of multimorbidity should measure and report, at minimum, quality of life, mortality, and mental health outcomes. The panel reached consensus on 17 core outcomes for multimorbidity research in total. The highest ranked outcomes were health-related quality of life, mental health outcomes and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); outcomes related to the medical visit (communication, shared decision-making, prioritization); and health systems outcomes (healthcare utilization, costs, quality of healthcare). The authors suggest that, when designing studies to capture important domains in multimorbidity, researchers consider the full range of outcomes based on study aims and interventions.
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1. Smith SM, Wallace E, Salisbury C, et al. A Core Outcome Set for Multimorbidity Research (COSmm). Ann Fam Med 2018;16(2):132-38.

A general practice street health service

By Tom Brett
This qualitative study [1] explores patient and allied health staff perspectives of a street-based, primary health service with the aim of identifying factors that influence patient access and management.
It is a useful companion paper to our recent 10-year retrospective cohort study [2] of multimorbidity among marginalised patients attending the Freo Street Doctor service.
Key themes emerging from the research included better doctor-patient empathy, better understanding of patient circumstances, fostering of social capital and facilitating referral pathways to health and social services.
The researchers noted that the provision of services for homeless and marginalised patients can be challenging for mainstream general practices.
Our findings show that patients attending the Freo Street Doctor service appreciate the open access nature of the clinic, the focus on psycho-social as well as medical needs and the empathy and understanding shown by the GPs, nurses and outreach services who deliver the service. The preparedness of the street health service providers to meet the altered needs of marginalised patients in their own backyard is a key factor in engagement.
Mainstream primary health care services would do well to recognise and adopt strategies that recognise the special needs and social circumstances of these patients.
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1.       Strange C,   Fisher C, Chan She Ping-Delfos W, Arnold-Reed D, Brett T.  A general practice street health service – patient and allied service provider perspectives. AJGP. 2018. 47 (1-2): 44-48.
2.       Arnold-Reed D, Troeung L, Brett T,  Chan She Ping-Delfos W, Geelhoed E, Fisher C, Preen D. Increasing multimorbidity in an Australian street health service – a 10-year retrospective cohort study,. AJGP. 2018; 47 (4): 181-189.

Multimorbidity in an Australian street health service

By Tom Brett
The Freo Street Doctor service is a free, primary care–based, mobile health clinic that has been operating in Fremantle, Western Australia since 2005. It operates from various locations in and around Fremantle, offering homeless and disadvantaged patients access to an accredited general practice service. It is serviced by a number of general practitioners, nurses, social workers and Aboriginal health workers as well as collaborating with numerous ancillary services to improve the health and circumstances of marginalised patients in this population group.
We report on a total of 4285 patients who attended the service over a 10 year period [1]. We found multimorbidity to be associated with increasing age, male sex and Aboriginality. An important finding from our study is the high Aboriginal attendance, comprising 31.5% of the total cohort (with 50.8% female). This attendance ratio is in sharp contrast with the <2% Aboriginal patients attending mainstream GP clinics Australia-wide.
Our research shows that multimorbidity is increasing over the past decade and presents as chronic physical and mental health problems in these marginalised, street health patients. These patients are at increased risk of ongoing neglect unless provided with a no-cost, multidisciplinary approach capable of delivering health and social services in a non-judgemental, comfortable and secure environment.
The progressive increase in attendance by young, especially Aboriginal, patients over the past decade, and the positive feedback from patients and allied services attending the Freo Street Doctor, make compelling arguments that this accredited, general practice–based service is addressing important health and social needs in an environment where they are clearly needed.
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1. Arnold-Reed D, Troeung L,  Brett T, Chan She Ping-Delfos W, Strange C, Geelhoed E, Fischer C,  Preen D. Increasing multimorbidity in an Australian street health service – a 10 year retrospective cohort study. AJGP. 2018; 47 (4): 181-189.

Publications on multimorbidity September- December 2017

By Martin Fortin
Our search for papers on multimorbidity that were published during the period September – December 2017 has been completed. As in previous searches, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases” in PubMed (https://www.ncbi.nlm.nih.gov/pubmed), but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

The EpiChron Cohort Study of Chronic Diseases and Multimorbidity

By Alexandra Prados Torres
I would like to share with you the profile of the EpiChron Cohort recently published in the International Journal of Epidemiology, a large-scale population-based study aimed at understanding how multimorbidity and the main chronic conditions appears and evolve in the population, and impact on health services and health outcomes. Created in 2010, it will gather information of the 1.3 M inhabitants of the Spanish region of Aragon until 2020. It has been developed by the EpiChron Research Group on Chronic Diseases from Aragon Health Sciences Institute (IACS) and IIS Aragón. This Cohort aims to study the problems associated to multimorbidity and chronicity (e.g., polypharmacy, low adherence to medical plan, increased risk of mortality, frailty, inappropriate health services use) and to identify risk factors (e.g., clinical, social, demographical) of negative health related outcomes. We also aim to study the evolution of trajectories of multimorbidity patterns over time and their impact on health outcomes with the final goal of developing predictive modeling tools. One key point of the project is to scaling up the knowledge in the area of chronicity and multimorbidity and to foster collaborations with other European and international research groups working in this area to conduct cross-national studies.
Besides the main characteristics of the EpiChron Cohort, this paper describes the data quality control process followed to ensure an adequate level of accuracy, reliability and appropriateness of data for research in multimorbidity.  Moreover, the main findings obtained to date are detailed in the paper.
The publication can be found in the following link: Prados-Torres et al 2018

Multimorbidity has become a Medical Subject Heading (MeSH) in 2018

By Martin Fortin
Medical Subject Headings (MeSH®) is the National Library of Medicine (NLM)’s controlled vocabulary thesaurus. It consists of sets of terms naming descriptors in a hierarchical structure that permits searching at various levels of specificity.
The MeSH thesaurus is used by NLM for indexing articles from the world’s leading biomedical journals for the MEDLINE®/PubMED® database.
Until the end of 2017, the term multimorbidity was not a MeSH. The term was a subheading under the term comorbidity. As a consequence, a search for the term multimorbidity in PubMED yielded thousands of publications that included those using the term multimorbidity and/or comorbidity.
Starting in January 2018, multimorbidity is now a MeSH heading:
This will facilitate the indexing and search of articles on this subject.
We believe that the ever increasing number of publications on multimorbidity, which includes articles from those participating in this community, has led to the recognition of the importance of the term, and deserves a congratulation to all those who have contributed to making the term achieve this important recognition.

A portrayal of the patient-reported outcomes used in multimorbidity intervention research

By Maxime Sasseville
Heterogeneity in outcome measures used in multimorbidity intervention research currently leads to a lack of consistent evidence to support clinical implementation. Understanding the current state of patient-reported outcome assessment is an important endeavor for multimorbidity research and policy-making, as its use contributes to a patient-centered approach.
This scoping review [1] aimed to describe patient-reported outcomes in the context of chronic disease management interventions for people with multimorbidity. Specifically, the objectives of the review were 1) to portray the current use of patient-reported outcomes in multimorbidity interventions; and 2) to propose a descriptive classification system according to the different types of outcomes identified.
Twenty-two studies were identified from which 56 outcomes measures were reported. The measures were grouped into 18 categories and six emergent domains of outcomes: General health, Psychosocial, Disease management, Health-related behaviours, Functional and Health services. Quality of life, health-related behaviors and self-efficacy were the most reported outcome categories, while patient satisfaction, communication with providers and adverse outcomes were rarely reported.
The organization proposed in this paper could contribute to improving outcome selection for research, clinical care and policy and lead to the creation of adapted patient-related outcome measures. Consistent design of outcome assessment between multimorbidity intervention study could lead to a more coherent body of evidence for clinical implementation.
The article can be freely accessed until December 15 2017 by following this link:
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[1] Sasseville, M., Chouinard, M. C., & Fortin, M. (2017). Patient-reported outcomes in multimorbidity intervention research: A scoping review. International Journal of Nursing Studies. 77 145-153

The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity

By Jonathan Stokes

There is a lack of evidence on effective intervention for managing patients with multimorbidity. A major barrier to progress in this area is the lack of consensus over how best to describe models of care for multimorbidity. If evidence is to drive clinical innovation, we need to build the evidence base through ongoing evaluation and review. That process is hampered, however, by incomplete descriptions of models in publications. Without accurate descriptions, researchers cannot replicate studies or identify ‘active ingredients’. There have been many examples in recent years of reporting frameworks that have improved the utility of health services research (http://www.equator-network.org/). In this paper [1], we describe a framework as a starting point for addressing this need in the high-profile area of multimorbidity.

Our framework describes each model in terms of the foundations:
• its theoretical basis (i.e. the clear and explicit aims, values and assumptions of what it is trying to achieve)
• the target population (‘multimorbidity’ is a somewhat vague term, so there is the need to define the group carefully, e.g. a patient with diabetes and hypertension might have very different care needs than a patient with dementia and depression)
• the elements of care implemented to deliver the model

We categorised elements of care into 3 types: (1) clinical focus (e.g. a focus on mental health), (2) organisation of care (e.g. offering extended appointment times for those who have multimorbidity), (3) support for model delivery (e.g. changing the IT system to better share electronic records between primary and secondary care).

Using the framework to look at current approaches to care for multimorbid patients, we found:

• The theoretical basis of most current models is the Chronic Care Model (CCM). This was initially designed for single disease-management programmes, and arguably not sensitive to the needs of multimorbidity.
• That current models mostly focus on a select group, usually elderly or high risk/cost. It is important to remember that in absolute terms, there are more people with multimorbidity aged under 65 years. Similarly, high risk patients are an obvious target, but there may be too few of them to make a significant impact on overall system costs. It is important that models incorporate the needs of younger and (currently) lower risk/cost patients (potentially with most scope for effects of preventing future deterioration).
• There is a need for increased attention for low-income populations (where multimorbidity is known to be more common), and for a focus on mental health (multimorbid patients with a mental health issue are at increased risk for detrimental outcomes).
• The literature suggests that the large emphasis in current models of care on self-management may not always be appropriate for multimorbid patients who frequently have barriers to self-managing their diseases. The emphasis on case management (intensive individual management of high-risk patients) should take into account the evidence that while patient satisfaction can be improved, cost and self-assessed health are not significantly affected.

We also looked at how approaches have changed over time, comparing newer to older models. Newer models tend to favour expansion of primary care services in a single location (e.g. increased co-location of social care services and extended chronic disease appointments), rather than coordination across multiple providers or at home (e.g. decreased care planning and integration with other social and community care services, decreased home care).

Health systems have only recently begun to implement new models of care for multimorbidity, with
limited evidence of success. Careful design, implementation, and reporting can assist in the development of the evidence base in this important area. We hope our framework can encourage more standardised reporting and research on the theoretical basis and target population for interventions, as well as the contribution of different elements (including interactions between them) needed to provide cost-effective care and support redesign of health systems for those who use them most.

This free to read article can be found at the following link:
http://www.annfammed.org/content/15/6/570.full

[1] Stokes J, Man M-S, Guthrie B, Mercer SW, Salisbury C, Bower P. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. The Annals of Family Medicine. 2017;15(6):570-7.

An International Perspective on Chronic Multimorbidity: Approaching the Elephant in the Room

By Davide L Vetrano and Amaia Calderón-Larrañaga
Multimorbidity is a common and burdensome condition that may affect quality of life, increase medical needs and make people live more years of life with disability. Negative outcomes related to multimorbidity occur beyond what we would expect from the summed effect of single conditions, as chronic diseases interact with each other, mutually enhancing their negative effects, and eventually leading to new clinical phenotypes. Moreover, multimorbidity mirrors an accelerated global susceptibility and a loss of resilience, which are both hallmarks of aging. Due to the complexity of its assessment and definition, and the lack of clear evidence steering its management, multimorbidity represents one of the main current challenges for clinicians, researchers and policymakers.
Together with an international group of researchers, we reflected on these issues during two twin international symposia at the 2016 European Union Geriatric Medicine Society (EUGMS) meeting in Lisbon, Portugal, and the 2016 Gerontological Society of America (GSA) meeting in New Orleans, USA. The results of this discussion have been reported in an article [1] that we recently published in the Journal of Gerontology: Medical Sciences. In this work we summarize the most relevant aspects related to multimorbidity, with the ultimate goal to identify knowledge gaps and suggest future directions to approach this condition.
This open access article can be found in the following link:
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[1] Vetrano DL, Calderón-Larrañaga A, Marengoni A, Onder G, Bauer JM, Cesari M, Ferrucci L, Fratiglioni L. An international perspective on chronic multimorbidity: approaching the elephant in the room. J Gerontol A Biol Sci Med Sci. 2017 Sep 16. doi: 10.1093/gerona/glx178.