The CARE Plus study

By Stewart Mercer

Scotland’s wide inequalities in health are well known, and despite having ‘universal coverage’ of healthcare through the NHS, the inverse care law remains an important issue (see work from our group published last year
Our previous research also demonstrated how the inverse care law operates at the level of GPs. Routine consultations in poor areas of Scotland -despite higher levels of patient illness and thus need – are shorter, leave patients with complex needs feeling less enabled, and are associated with greater GP stress when compared with consultations in richer areas.
More recently, in a large prospective study of videoed-consultations, we demonstrated that due to the continuing existence of the inverse care law, GPs in deprived areas have less time to be patient-centred and patients have worse outcomes from the consultations.
In our new paper, the CARE Plus study, which was recently published in BMC Medicine we tested the feasibility of carrying out a cluster RCT of a whole system intervention to improve quality of life of primary care patients with multimorbidity living in areas of high socioeconomic deprivation and measured indications of effectiveness and cost-effectiveness.
As Principal Investigator, I led the study with fellow academics at the Universities of Glasgow and Dundee, funded by the Scottish Government Chief Scientist Office. This was a programme of research called ‘Living Well with Multimorbidty’. The CARE Plus study focused on patients with multiple complex problems (multimorbidity), since these patients have the highest needs.
In usual consultations, GPs, nurses and patients all struggle to adequately manage the problems of multimorbidity in the context of high deprivation.
We initially co-developed and optimised the intervention over a period of 2-3 years ( and then randomised 8 general practices serving patients in areas of very high socioeconomic deprivation to either the CARE Plus intervention or to ‘usual care’. The intervention was a complex one, and took a ‘whole-system approach’ which involved substantially longer consultations with the GPs; training and support for the practitioners; and additional ‘self-management’ support for the patients. GPs identified patients with multimorbidity who they felt would benefit more time for an empathic, holistic approach and to agree a plan of action, with follow-up and continuity of care.
On average, patients were in their early 50s with around five chronic conditions each. Compared with the control group, patients in the CARE Plus group had significantly better outcomes for some aspects of well-being and quality of life at 6 and 12 months. Importantly, the intervention was highly cost-effective.
The study demonstrated that it is possible to conduct a high quality cluster RCT in very deprived areas; all of the practices who agreed to take part stayed in the study, and we achieved follow-up rates on the patients in both arms of the trial of 88% at 12 months. However, it should be noted that this was an exploratory trial of 152 patients in 8 practices; a definitive trial is now warranted.

Prevalence of multimorbidity in the general population and in primary care practices

By Martin Fortin
It is known that settings affect estimation of the prevalence of multimorbidity. In a recently published paper  [1], we have compared estimates of the prevalence of multimorbidity in the general population and in primary care clinical practices.
The new aspect of this recent study was that prevalence in both settings was measured simultaneously, in the same region, and with the same methods. This way, we eliminated methodological limitations found in previous studies that prevented to conclude definitively the extent to which prevalence estimates differ in these two study populations [2].
Also, we explored the effect of using different operational definitions of multimorbidity on the differences of prevalence observed between the two sampled populations.
We concluded that there is a difference of about 10% in prevalence estimates of multimorbidity between samples from the general population and primary care clinical practices, with a higher prevalence in the latter setting. The difference of the prevalence between the two settings was not affected by the use of different operational definitions of multimorbidity.
1.- Mokraoui NM, Haggerty J, Almirall J, Fortin M. Prevalence of self-reported multimorbidity in the general population and in primary care practices: a cross-sectional study. BMC Res Notes. 2016;9:314.
2.- Fortin M, Hudon C, Haggerty J, van den Akker M, Almirall J. Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Services Research. 2010;10:111.

Multimorbidity in adults from a southern Brazilian city

By Bruno P. Nunes
We are very satisfied to disseminate another recent paper about multimorbidity from Brazil in International Research Community on Multimorbidity (IRCMo) site. In this paper, we explore the occurrence and patterns (through Factorial Analysis) in Brazilian adults [1]. The manuscript used data from a population-based study carried out in 2012 in the individuals (20 or more years) households living in Pelotas, southern Brazil. Multimorbidity was evaluated by a list of 11 morbidities (based on medical diagnosis; Patient Health Questionnaire 9 for depression; and Anatomical Therapeutic Chemical index). The sample was made up of 2927 adults. Multimorbidity reached 29.1 % (95 % CI: 27.1; 31.1) for ≥2, and 14.3 % (95 % CI: 12.8; 15.8) for ≥3 morbidities. Two patterns of morbidities (cardio-metabolic and joint problems; and respiratory diseases) were observed. The high frequency and the observed patterns increase the need to address multimorbidity in Brazilian health policies and diseases guidelines.
To access the manuscript, please click in the following link:
Furthermore, we reinforce our invite to researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others). Contact e-mail for further information:
1) Nunes BP, Camargo-Figuera FA, Guttier M, de Oliveira PD, Munhoz TN, Matijasevich A, Bertoldi AD, Wehrmeister FC, Silveira MP, Thumé E, Facchini LA. Multimorbidity in adults from a southern Brazilian city: occurrence and patterns. Int J Public Health. 2016 Apr 22. [Epub ahead of print]

Updated Cochrane Review: Interventions for improving outcomes in patients with multimorbidity in primary care and community settings

By Susan M Smith, Emma Wallace, Tom O’Dowd, Martin Fortin
This Cochrane systematic review aimed to identify and summarise the existing evidence on the effectiveness of interventions to improve clinical and mental health outcomes and patient-reported outcomes including health-related quality of life for people with multimorbidity in primary care and community settings.
The Cochrane library have just published an update of the original 2012 review and for this update the literature was searched up to September 2015. In total, we identified 18 generally well-designed randomised controlled trials meeting the eligibility criteria, 8 of which were identified in the updated searches. Nine of the 18 studies focused on specific combinations of health conditions (comorbidity studies), for example diabetes and heart disease. The other nine studies included people with a broad range of conditions (multimorbidity studies) although they tended to focus on elderly people. The majority of studies examined interventions that involved changes to the organisation of care delivery although some studies had more patient-focused interventions.
Key results
Overall the results regarding the effectiveness of interventions were mixed. There were no clear positive improvements in clinical outcomes, health service use, medication adherence, patient-related health behaviours, health professional behaviours or costs. There were modest improvements in mental health outcomes from seven studies that targeted people with depression, and in functional outcomes from two studies targeting functional difficulties in participants. Overall the results indicate that it is difficult to improve outcomes for people with multiple conditions. The review suggests that interventions that are designed to target specific risk factors (for example treatment for depression) or interventions that focus on difficulties that people experience with daily functioning (for example, physiotherapy treatment to improve capacity for physical activity) may be more effective.
Authors’ conclusions:
This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. However, several large ongoing studies were identified that will add to the slowly emerging evidence base. The current evidence from this review suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.
Citation: Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD006560. DOI: 10.1002/14651858.CD006560.pub3.

Risk factors and symptoms in the definition of multimorbidity

By Tora Grauers Willadsen and Niels de Fine Olivarius
We want to share our new paper”The role of diseases, risk factors and symptoms in the definition of multimorbidity – a systematic review” (Scandinavian Journal of Primary Health Care 2016 March 8, : 1-10) here on the International Research Community on Multimorbidity’s (IRCMo) site.
Our objective was to explore how multimorbidity is defined in the scientific literature, with a focus on the role of diseases, risk factors, and symptoms in the definitions. We used systematic review as design. We searched MEDLINE (PubMed), Embase, and The Cochrane Library for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Our main outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diseases, risk factors, and symptoms.
We had the following results: In 61 (37 %) articles, out of the 163 articles we included, the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions. As earlier found diabetes was the most frequent disease. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways.
This review demonstrated, as shown previously, a heterogeneous definition of multimorbidity. Furthermore, it shows that risk factors are more often included than symptoms and that severity of conditions is seldom included in the definition. The fundamental role of risk factors in the definition of multimorbidity is one reason for the high prevalence of multimorbidity. Symptoms and severity are included less often and this contributes to making the existing definitions more usable for epidemiologists than for clinicians and patients. We believe this review adds to the discussion about more comprehensive and clinically relevant multimorbidity definitions.
To access the full manuscript, please click the following link:
At The research Unit for General Practice and Department of General Practice at The University of Copenhagen we are working on several projects about multimorbidity, both quantitative register-based studies including the whole Danish population, and qualitative studies. You are very welcome to contact us for more information. E-mail:

Publications on multimorbidity September 2015 – January 2016

By Martin Fortin
Our search for papers on multimorbidity that were published during the period September 2015 – January 2016 has been completed. As in previous searches, we found many new papers and the list is too long for this venue. Therefore, 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”, 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.

What is the future of general practice academics interested in research on multimorbidity?

By Aline Ramond-Roquin and Martin Fortin
In a recent provocative blogpost [1] hosted by the Canadian Medical Association Journal, the associate editor Domhnall MacAuley initiated an interesting discussion on the challenges general practice research currently faces. We would like to extend the reflection and to discuss some issues relevant for multimorbidity research.
First, we somewhat disagree on the fact that academic general practitioners have “become less and less embedded in daily patient care”. Many of them still deliver “personal, primary and continuing care”. The traditional model of single-handed practitioners offering “twenty four hour access to patients” is quite obsolete, but this reflects the evolution of general practice rather than a specific characteristic of academics.
Indeed, general practitioners can no longer single-handedly fill the increasingly complex needs of their patients. Patients living with multimorbidity, who are now considered the rule in primary care, need interdisciplinary care. The current evolution towards increasing interdisciplinary work has generated specific research questions which require lowering some traditional barriers in the academic setting and developing interdisciplinary research, to appropriately address them. In this regard, having non-doctor primary care researchers in academic departments of general practice should neither be reduced to a question of “cost-effectiveness”, nor be considered as a threat for general practice research, as suggested in the CMAJ blogpost. Rather, collaborations within interdisciplinary teams are definitely an advantage to undertake research in complex fields such as multimorbidity. In these teams, general practitioners with significant clinical activity have a crucial and irreplaceable role.
Finally, meaningful research for people living with multimorbidity is often based on complex designs, such as multi-level epidemiological studies or pragmatic trials. We therefore strongly argue for scientific journals not neglecting research grounded in the real world of practice. They should not only focus on “sample size” and “international generalizability”, but should also be concerned by clinical relevance and potential for implementation and transferability in different contexts. Producing and publishing practice-based evidence is required to practice evidence-based medicine relevant to the context, with the potential to eventually improve the life of our patients.

Multimorbidity in Brazil

By Bruno P. Nunes, Elaine Thumé, and Luiz A. Facchini
We are very satisfied to disseminate our recent paper in International Research Community on Multimorbidity (IRCMo) site. This community was and continues to be very important for our studies related to this topic in Brazil.
Despite worldwide importance of multimorbidity and the specific Brazilian context (more than 200 million inhabitants, rapid epidemiologic and demographic transitions, and relatively new universal health system), populational information about occurrence of multiple health problems is scarce in the country. Thus, data from a population-based survey that we conducted in 2008 were used to provide information and start works about multimorbidity in Brazilian context. The sample was comprised by 1593 elderly (≥60 years old) who lived in Bagé, a medium-sized city in Southern Brazil. The individuals were interviewed in their households through face-to-face interviews. In total, 17 morbidities were used and we measured multimorbidity according to two cutoff points: ≥2 and ≥3 morbidities. Descriptive analysis, and dyads and triads of diseases were calculated. We found that 94% of the sample presented, at least, one morbidity. High blood pressure – HBP – (55.3%) and spinal column disease (37.4%) were the diseases most frequent. Multimorbidity reached 81.3% (95 % CI: 79.3; 83.3) and 64.0 % (95% CI: 61.5; 66.4) of the individuals for ≥2 and ≥3 morbidities, respectively. As found in others studies, most vulnerable elderly presented higher occurrence of multiple diseases. For example, 87.1% of the elderly without schooling presented 2 or more diseases (22.3 percentage points higher than elderly which studied 8 years or more).  Another challenge to public health system was demonstrated by higher frequency of multimorbidity between individuals without health private plan and those who are living in Family Health Strategy (organizational axis of primary health care) catchment areas.
These results about multimorbidity in older adults from Brazil may provide initial information to address multiple diseases in clinical protocols and contribute to subsidize actions in health services to management of multimorbidity.
To access the full manuscript, please click in the following link:
Furthermore, we are drafting others papers about multimorbidity in Brazil, including evaluation of national-based studies. Therefore, we would like to invite researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others) to contact us. Contact e-mail for further information:
  • Reference: Nunes BP, Thumé E, Facchini LA: Multimorbidity in older adults: magnitude and challenges for the Brazilian health system. BMC Public Health 2015, 15(1):1172

IMPORTANT ANNOUNCEMENT. Indexing in MEDLINE: Journal of Comorbidity needs your help

By Martin Fortin, Jane Gunn, Stewart W. Mercer, Susan Smith, Marjan van den Akker
At the Journal of Comorbidity, we recognize the importance of publishing high-quality work in a timely manner, and publishing work that can be discovered by the wider community in bibliographic databases. One of the premier databases that many authors and readers turn to is MEDLINE®, the National Library of Medicine’s (NLM) database containing over 20 million citations of biomedical literature. Indexing in MEDLINE is therefore key to helping any journal seeking the widest dissemination of their published content.
Although the Journal of Comorbidity is indexed in many databases, it currently does not meet the minimum requirements for MEDLINE indexing. The journal is therefore increasing its efforts to achieve this as soon as possible – but first, we need your help.
In order to be considered for MEDLINE indexing, we have to meet a set of minimum requirements, particularly with regard to the quantity of published articles. And this is where we ask for your help. We are inviting all researchers, clinicians and other healthcare professionals with an interest in comorbidity/multimorbidity to submit their work to the Journal of Comorbidity. (refer to the online author guidelines for preparing your article: We are currently seeking publications – original research papers, but also critical reviews and study protocols – to meet our target. We believe that indexing in MEDLINE will help to increase our visibility, increase access to our content, and will encourage more authors at all levels of experience and expertise to publish their work in the journal.
With your help, we can make the Journal of Comorbidity grow, and enhance its impact in this niche field and beyond.
We would like to thank all members of our editorial board, reviewers, readers, and our contributors, who together have shaped the journal into its current form and who have provided articles of great interest.
We look forward to a continued collaboration in further developing this journal into an authoritative resource on comorbidity/multimorbidity.
About the Journal of Comorbidity
The Journal of Comorbidity is an international, open-access, peer-reviewed journal with a focus on comorbidity and multimorbidity – the only journal of its kind. Established in Switzerland in 2011, the journal has attracted important and well-cited research worldwide. The Journal of Comorbidity is overseen by five co-Editors-in-Chief and by over 40 editors from across the globe. The journal publishes original clinical and experimental research articles, guidelines, policies, editorials, commentaries, protocols, and critical review papers. The journal provides a forum for scientists, researchers and healthcare professionals to share their research, experience and insight into diverse aspects of medicine in order to optimize the management of patients with comorbidity/multimorbidity.
Further information can be found online:, or contact one of our editors today:

Conceptualising multiple conditions in Australia

By Christine Walker

Since the 1970s greater numbers of people are now living with several serious long term illnesses. These include rarer genetic conditions and ‘lifestyle conditions’ as well as those of an idiopathic nature. A recently published article [1] examines the growing need for new terms and concepts that reflect the changes in the lives of people living with long-term serious illnesses.

The Chronic Illness Alliance conducted a workshop with its members who had multiple conditions to scope the problems they faced in receiving health care. A literature review using the principles of meta-synthesis which aims to systematise qualitative concepts provided the means to identify whether the concerns raised by consumers were recognised in the literature. The risks identified by consumers were used both as search terms and analytical terms. While the consumer perspective appeared absent in the literature, many authors showed similar concern about the tardiness of health systems to acknowledge the impact of multi-morbidities for consumers and the associated risks. More importantly the literature review demonstrated that problems associated with concepts, definitions and data collection impact on health care and service delivery. This in turn dictates how consumers receive their health care services and ultimately influences the safety and quality of their health care. The article argues that the adoption of better concepts is a first step to achieving systemic change on behalf of people with multiple conditions.

[1] Walker C. Conceptualising multiple conditions in Australia: First steps to systemic change to meet the needs of people with serious long-term illnesses. Patient Experience Journal, Volume 2, Issue 2 -Fall 2015, pp. 69-76.