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Author Archives: Susan Smith

Potential notice about Collaborative Doctoral Award in Multimorbidity

By Susan Smith
We think this is a world first – a nationally funded Structured Doctoral Training Programme in Multimorbidity, for a cohort of clinical and non-clinical researchers in primary care in Ireland. The programme is supported by a consortium of international, experienced inter-disciplinary multimorbidity researchers and PhD educators, including Prof Martin Fortin, Prof Cynthia Boyd, Prof Frances Mair, Prof Pete Bower, Prof Mogens Vestergaard and Prof Olov Rolandsson.
Patients with complex multimorbidity experience treatment burden and challenges around adhering to treatment advice, managing medicines, coordination of health and social care and patient related costs of care. The proposed PhD projects will address these interlinked but distinct areas within multimorbidity research. Cross project working will ensure exposure to a wide range of methodologies and disciplines. We will synthesise evidence from all projects at a programmatic level. The programme is supported by a specially convened Patient and Public Participation Panel and the consortium will provide an appropriate blend of research methodology skills, supervision and peer support and an opportunity for national and international PhD placements.
This doctoral programme will generate a national cohort of skilled post-doctoral students who can make a significant future international impact across a range of settings having developed expertise in the generation of research evidence to support cost-effective and patient-centred management of complex multimorbidity.

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.
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.

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.

Interventions for people with multimorbidity

By Susan Smith

The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions [1]. We have just published a paper in the Journal of Comorbidity presenting a consensus view from a group of international researchers working to guide future studies of interventions to improve outcomes for people with multimorbidity [2]. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems.
I would welcome any contact from research teams conducting evaluations of interventions for multimorbidity as these could potentially be included in the next update of the Cochrane Review of such interventions.

[1] Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev (2):CD003638. 2012;4:CD006560.
[2] Smith SM, Bayliss EA, Mercer SW, et al. How to design and evaluate interventions to improve outcomes for patients with multimorbidity. Journal of Comorbidity. 2013;3:10-17.

Review of Interventions for improving outcomes in patients with multimorbidity

By Susan Smith

We have finally published our Cochrane systematic review of Interventions for improving outcomes in patients with multimorbidity in primary care and community settings (1). This is now available on the Cochrane Library with related podcasts in English, French and Spanish.

The review aimed to determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings.

 We searched a range of international databases in April 2011. We included randomised controlled trials, controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS). Participants included any patients identified as having multimorbidity, i.e., two or more chronic conditions but we excluded studies where multimorbidity was not explicitly defined and reported. Outcomes included any validated measure of physical or mental health, psychosocial status including quality of life and measures of disability or functional status. We also included measures of patient and provider behaviour including medication adherence, utilisation of services and costs. Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible due to the variation in study participants and in interventions so we carried out a narrative synthesis of the results from the included studies. 

 We identified ten studies examining a range of complex interventions for patients with multimorbidity. All were randomised controlled trials with a low risk of bias. Two of the ten studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team-work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings. 

 The review highlights the paucity of research into interventions to improve outcomes for people with multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. There is a need for further studies with clear definitions of participants, consideration of appropriate outcomes, and interventions targeted at specific patient difficulties.

 1-  Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD006560. DOI: 10.1002/14651858.CD006560.pub2.

Training clinicians in the management of multimorbidity

By Susan Smith

In considering designing appropriate interventions to improve outcomes for patients with multimorbidity, we are beginning to look at ways of training clinicians in the management of these patients. Our specific intervention is being directed towards GPs or family practitioners. Is anyone aware of any training materials that have been or are being developed for training clinicians? We may focus it around improved medicines management but could also look at case based learning. I would really welcome any comments from others working in the field.