Entete 3

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:
[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:

[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:
[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.

Publications on multimorbidity May – August 2017

By Martin Fortin
Our search for papers on multimorbidity that were published during the period May – October 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.

Appreciation of Dr. Martin Fortin’s work on multimorbidity

Dr. Martin Fortin is one of the 5 founders the International Research Community on Multimorbidity. He is still a dedicated and active member of the community and its online blog. In the last few weeks, Dr. Fortin’s contribution in advancing knowledge on multimorbidity in primary care deserved the attention from two sources:
Canadian Academy of Health Sciences
The Canadian Academy of Health Sciences (CAHS) Induction Ceremony was held in Ottawa on September 14, 2017. This year, the Academy welcomed 52 new members. Among this group, Dr. Martin Fortin received this honour for his career as a family physician, teacher and researcher. Induction into CAHS is considered one of the highest and prestigious honours for members of the health sciences community in Canada.
Canadian Family Physician
Dr. Martin Fortin’s work was the subject of the cover story of the Canadian Family Physician’s journal. The article, written by Sarah de Leeuw, is titled: Courage, relationships, and applicability – Big research from small places. The article describes Dr. Fortin’s journey and research on the topic of multimorbidity in a regional context. Dr. Fortin is the Research Chair on Chronic Diseases in Primary Care.
To read the article: www.cfp.ca
Congratulations Dr. Fortin!

Paper – Multimorbidity in Brazil

By Bruno P Nunes and Sandro R Rodrigues Batista
In this paper, we evaluate the magnitude of multimorbidity in 60202 Brazilian adults, including the assessment of individual and contextual (state level) variables. The Brazilian national-based study was carried out in 2013. Multimorbidity was evaluated by a list of 22 physical and mental morbidities. Factor analysis and multilevel models were used to analyze the data. Multimorbidity frequency was 22.2% for ≥2 morbidities and 10.2% for ≥3 morbidities. For the whole Brazilian population, at least 41 and 19 million adults had multimorbidity, according ≥2 and ≥3 morbidities, respectively. The occurrence was different among states, being higher in southern Brazil (see below the Supplementary_figure_1). Contextual and individual social inequalities were observed.
To access the manuscript, please click in the following link:
Reference: Nunes BP, Chiavegatto Filho ADP, Pati S, Cruz Teixeira DS, Flores TR, Camargo-Figuera FA, Munhoz TN, Thumé E, Facchini LA, Rodrigues Batista SR. Contextual and individual inequalities of multimorbidity in Brazilian adults: a cross-sectional national-based study BMJ Open 2017;7:e015885. doi: 10.1136/bmjopen-2017-015885

Publications on multimorbidity January – April 2017

By Martin Fortin
Our search for papers on multimorbidity that were published during the period January – April 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.