Entete 3

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:
.
[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.

Comorbidity and progression of late onset Alzheimer’s Disease: A systematic review

By Miriam L. Haaksma
and Lara R. Vilela, Alessandra Marengoni, Amaia Calderón-Larrañaga, Jeannie-Marie S. Leoutsakos, Marcel G.M. Olde Rikkert, René J.F. Melis.
.
Alzheimer’s disease is a neurodegenerative syndrome characterized by multiple dimensions including cognitive decline, decreased daily functioning and psychiatric symptoms. This systematic review [1] aimed to investigate the relation between somatic comorbidity burden and progression in late-onset Alzheimer’s disease (LOAD). We searched four databases for observational studies that examined cross-sectional or longitudinal associations of cognitive or functional or neuropsychiatric outcomes with comorbidity in individuals with LOAD. From the 7966 articles identified originally, 11 studies were included in this review. Nine studies indicated that comorbidity burden was associated with deterioration in at least one of the three dimensions of LOAD examined. Seven out of ten studies investigating cognition found comorbidities to be related to decreased cognitive performance. Five out of the seven studies investigating daily functioning showed an association between comorbidity burden and decreased daily functioning. Neuropsychiatric symptoms (NPS) increased with increasing comorbidity burden in two out of three studies investigating NPS. Associations were predominantly found in studies analyzing the association cross-sectionally, in a time-varying manner or across short follow-up (≤2 years). Rarely baseline comorbidity burden appeared to be associated with outcomes in studies analyzing progression over longer follow-up periods (>2 years). This review provides evidence of an association between somatic comorbidities and multifaceted LOAD progression. Given that time-varying comorbidity burden, but much less so baseline comorbidity burden, was associated with the three dimensions prospectively, this relationship cannot be reduced to a simple cause-effect relation and is more likely to be dynamic. Therefore, both future studies and clinical practice may benefit from regarding comorbidity as a modifiable factor with a possibly fluctuating influence on LOAD.
.

Is it possible to improve drug prescription in primary care patients with multimorbidity and polypharmacy by implementing the Ariadne principles in clinical practice?

By Alexandra Prados Torres
This is the question that Multi-PAP is trying to answer.
Multi-PAP is a coordinated multicentre project aimed at designing and measuring the effectiveness of a complex intervention in primary care for improving drug prescription in multimorbid patients compared to usual care. The intervention is based on the Ariadne principles designed by Muth et al. in 2014, and consists of two components: training of General Practitioners (GP) and GP-patient interviews.
Training of physicians has been conceived as a 4-weeks massive online open course (MOOC) designed by a multidisciplinary team with emphasis in multimorbidity, polypharmacy, medication appropriateness and adherence, and the Ariadne principles and tools for their implementation in clinical practice. During GP-patient interviews that will be conducted over a month, physicians are expected to put into practice the knowledge acquired during the training.
To measure the effectiveness of this intervention, Multi-PAP is conducting a pragmatic cluster randomized clinical trial (RCT) in primary care health centres in three regions in Spain (Aragon, Madrid and Andalusia). The unit of randomization is the family physician (N=80), and the unit of analysis is the patient. The study population is conformed by 400 patients (200 per study arm) aged 65–74 years with multimorbidity (defined as presence of 3 or more chronic diseases) and polypharmacy (defined as 5 or more drugs prescribed in ≥3 months). The intervention is based on the implementation of the Ariadne principles (GP training and GP-patient interviews) and it is compared to usual care. The main outcomes, to be measured at months 6 and 12, are: MAI score, health services use, quality of life, pharmacotherapy and adherence to treatment, and clinical and socio-demographic variables.
This project is justified by the need to provide evidence concerning interventions on primary care patients with polypharmacy and multimorbidity, conducted in the context of routine clinical practice, and involving young-old patients with significant potential for preventing negative health outcomes.
This RCT is registered in Clinicaltrials.gov (NCT02866799). Accessible at:
The full-text protocol of Multi-PAP RCT is accessible at: http://rdcu.be/rErC

Book: Aging, Place, and Health: A Global Perspective

By: William A. Satariano, and Marlon Maus
This book represents a collaboration of experts in the field of aging and public health. The present book builds on the first edition of the book (Epidemiology of Aging:  An Ecological Approach. Satariano, 2006).
Various international researchers and practitioners were asked to join the project based on their expertise in particular areas of aging research, practice, and policy. This has resulted in a book that presents each topic, e.g., cognitive function, as an outcome in epidemiological research.  In addition, each chapter considers conceptual and measurement issues, implications for practice and policy, and future directions for research.  The book stresses a global perspective identifying work from countries throughout the world, not just the U.S.
This edition of the book is intended to target a wide audience which includes not only other experts in the field and academics, but also students, practitioners and interested researchers from other disciplines. The book is intended to help inspire further progress in the global effort towards what the World Health Organization has described as a “state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity” of our older population.
Chapter 8, Disease, Comorbidity, and Multimorbidity, by Martin Fortin, Aline Ramond, Cynthia Boyd, and Jose Almirall focuses on multimorbidity (MM). The authors explore how the several coexisting health conditions in a single individual negatively affect an individuals’ health-related outcomes (functional status, social participation, quality of life, life expectancy) and is also responsible for numerous impacts on society (healthcare utilization, direct and indirect costs). The importance of MM is now acknowledged as a research priority in health care, and in-depth understanding of its main determinants is required as a first step in this direction. This chapter helps distinguish MM-related essential definitions and concepts and successively addresses the role of sociodemographics, socioeconomic factors, social networks, social capital, genetics, lifestyle, psychological and psychosocial factors, and polypharmacy as potential risk factors for MM, following an ecological model of health. Finally, the chapter highlights current gaps in the literature as well as specific challenges, and suggests future directions for MM epidemiology research.

Multimorbidity as a complex systems phenomenon: a series exploring this perspective from the Journal of Evaluation in Clinical Practice

By René Melis
Multimorbidity is one of public health and healthcare’s top priorities. Yet despite this, healthcare continues to struggle to provide solutions to deal with multimorbidity in healthcare that work. It is recognized that our healthcare systems – due to their focus on the acute phase of single diseases – are not well positioned to deal with multimorbidity. Unfortunately, our dealings with changing the system do not easily translate into successes: there are so many stakeholders involved and multimorbidity is interconnected with a huge number of aspects of life and society. Where to begin? Our multimorbidity challenge has all the characteristics of a “wicked problem”: a societal problem that is so complex that is seems difficult or even impossible to solve. In the most recent Complexity Forum of the Journal of Evaluation in Clinical Practice a series of articles explore multimorbidity and how we should shape our healthcare from the perspective of complex systems thinking (http://onlinelibrary.wiley.com/doi/10.1111/jep.12723/full). Rather than a stable, albeit complicated, arrangement of individual elements with predictable results following from inputs in a linear way, a complex system is a dynamic, ecological system in which outcomes seem to emerge quite unpredictably out of the interaction of the starting conditioning. For the reasons mentioned above, this “complexity” approach might fit very well to the multimorbidity challenge.
The series starts with an introductory paper of Dr Joachim Sturmberg and colleagues. Sturmberg, who is a general practitioner as well as a longstanding expert on complexity in health (care systems), together with his colleagues explore how taking multimorbidity as a complexity phenomenon might shape integrated, personalized care differently. Following, this work is commented on by several authors from different perspectives. Being a “wicked problem” neither of these works provide a miracle potion to solve our multimorbidity issue, however, the richness of the perspectives included does shed new light. The famous Cynefin framework (https://hbr.org/2007/11/a-leaders-framework-for-decision-making) for management problems tells us that managing complex problems – and multimorbidity sure is! – has to begin with uncovering the “unknown unknowns” and we need to “probe first, then sense, and then respond”. The latter is what this series hopefully has to offer to the multimorbidity community.