Entete 3

Category Archives: Event

Multimorbidity: a hidden epidemic that challenges European health services

By Christiane Muth, Amaia Calderón-Larrañaga, Marjan van den Akker, Beatriz Poblador-Plou and Alexandra Prados-Torres (from left to right)

A workshop on multimorbidity was held in Malta the 9th November in the context of the 20th Annual European Public Health Conference (EUPHA).

This workshop was organized by researchers of the Aragon Institute of Health Sciences (IACS) in Spain and the CAPHRI School for Public Health and Primary Care in the Netherlands, and supported by the EUPHA Section on Chronic Diseases. The aim was to shed light on future research and action strategies for patients with multiple chronic conditions.

The analysis was performed from three complementary perspectives. During the first part of the workshop, coordinated by Alexandra Prados and Amaia Calderón from the EpiChron Research Group on Chronic Diseases of the IACS, results from epidemiological research were presented regarding the systematic association between diseases or medications into so-called multimorbidity and polypharmacy patterns. The role of adverse drug events on increased morbidity burden was discussed.

The second part, led by Marjan van den Akker from CAPHRI School at Maastricht University, focused on the role to be played by health services in face of this reality, and the need to reorient them to give a global response to patient’s health problems. Specific interventions involving the patient (e.g. shared decision making, patient centred care), but also at the level of the organization of care (e.g. case managers, reorganizing chains of care) were reviewed.

Finally, Christiane Muth from the Institute of General Practice at Frankfurt’s Goethe University suggested a methodological framework to systematically address multimorbidity in clinical practice guidelines. Taking chronic heart failure (CHF) as an example, the importance of identifying relevant interactions between CHF and its common comorbidities, as well as potential drug-disease and drug-drug interactions was highlighted, as a necessary precondition and a first step to optimize health care in patients with multiple conditions.

For further detail on the program and speakers, see:


Evidence-Based Medicine Meets Multimorbidity: A Blind Date?

By Marjan van den Akker and Christiane Muth

On Wednesday, October 17, 2012, an international symposium took place at the ´Deutsche Nationalbibliothek´ in Frankfurt am Main, Germany.

The focus of the symposium was on questions that keep family doctors and general practice researchers busy, such as: What should and can be done when my patient has several illnesses simultaneously? What are the problems of multimorbidity and polypharmacy that confront us today? What clinical decision-support does evidence-based medicine (EbM) currently provide, and how can EbM contribute in the future? Leading researchers representing both disciplines – EbM and multimorbidity research – discussed the dilemmas and challenges that multimorbidity entails, as well as strategies to overcome them.

The symposium garnered attention, both from Germany and abroad. There were over 130 registrations. For further detail on the program and speakers, see [link to the Institute of General Practice, Goethe-University, Frankfurt, Germany:

The Symposium was part of the Friedrich Merz Foundation’s 22nd visiting professorship, to which Professor Marjan van den Akker from Maastricht University was appointed this year.

Subsequent to the symposium a 2-day international workshop on ´How to handle patients with multimorbidity in primary care´ was conducted. Twenty participants from the UK, Canada, Australia, Germany, the Netherlands and Spain exchanged on this subject. Although there is a growing body of knowledge regarding multimorbidity, it seems to mainly focus on observational, epidemiological studies. There remains a lack of research studying and supporting every day clinical practice for patients with multimorbidity.

A collaborative report on the workshop will follow.

An International collaborative research initiative to design interventions for patients with multimorbidity in primary health care

By Martin Fortin

2012 North American Primary Care Research Group (NAPCRG) Annual Meeting Forum

Martin Fortin, MD, MSc, Université de Sherbrooke, Québec (Canada); Elizabeth A. Bayliss, MD, MSPH, University of Colorado School of Medicine, USA; Stewart W. Mercer, MBChB, PhD, University of Glasgow, UK; Susan M. Smith,  MD, MSc, Royal College of Surgeons, Ireland; Jane Gunn, MBBS, FRACGP, PhD, DRANZCOG, The University of Melbourne, Australia; Mogens Vestergaard, MD, PhD, Aarhus University, Denmark.

A recent Cochrane systematic review on the impact of interventions for patients with multimorbidity (MM) found that there was a paucity of studies and a need for the consideration of appropriate outcomes and further pragmatic studies based in primary care settings (S. Smith et al. see S. Smith posting in IRCMo Blog, April 9, 2012: http://crmcspl-blog.recherche.usherbrooke.ca/?author=10 ). During this NAPCRG annual meeting forum, we will expand on an ongoing dialogue within an existing international community of researchers, decision-makers and health care providers interested in MM (International Research Community on Multimorbidity – IRCMo) and follow-up on discussions initiated during the NAPCRG 2007 meeting, and continued during sessions in Frankfurt, 2011; Glasgow, 2011-2012; and Aarhus, 2012. We aim to accomplish the following tasks in order to lay the groundwork for interventions to improve outcomes for persons with MM:

1) Identify key elements for interventions aimed at improving outcomes for MM;

2) Create a list of patient-centered outcomes relevant to interventions in this population and based on patient input;

3) Propose suitable intervention research designs;

4) Discuss specific evaluation methods;

5) Solicit input on potential national and international collaborations including funding opportunities.

The forum will include short presentations to outline the current focus and direction of interventions in MM followed by group discussions, each of which will address one specific topic. Finally we will synthesize the discussions into a report that will subsequently be shared among forum participants and with members of the IRCMo.

We welcome members to take part in this forum scheduled on Wednesday, December 5 from 9:30 am. to 12:30 pm.

Please visit: http://www.napcrg.org/ for more information about the forum.

“The Impact of Primary Care Teams on Multimorbidity (IMPCT): Optimizing care for patients living with multiple chronic conditions” meeting

By Tarek Bouhali

On December 8-9, 2011, the first meeting of “The Impact of Primary Care Teams on Multimorbidity (IMPCT): Optimizing care for patients living with multiple chronic conditions” team was held at the INSPQ (Institut national de santé publique du Québec) offices in Montréal (Quebec, Canada). Over the two days, we have greatly benefited from the very animated discussions among our panel of speakers and discussants. We would therefore like to thank and congratulate each one of them for sharing their wide-ranging perspectives.

This gathering of 28 team members and collaborators from various disciplines including academic researchers, policy-makers, public health practitioners, program specialists and representatives from government agencies was convened to examine issues related to multimorbidity in various Canadian jurisdictions (Quebec, Ontario, Alberta) as well as in many other countries such as the USA, the UK, the Netherlands and Australia.

During the consultation process and workshops, we received input and recommendations on intervention strategies that will help the IMPCT team enhance its efforts focused on patients with or at highest risk for multimorbidity and complexity. Although IMPCT interventions will be patient-centered, the IMPCT Panel has paid attention to recommendations of policy-makers to expand the reach to organizational levels.

The team’s leads (Martin Fortin, Jean-Frédéric Levesque and Renée F. Lyons) take pride in having hosted this meeting. They hope that the presentations given and the discussions that followed during this meeting have generated a better appreciation of the nuances on key issues and objectives, as well as research questions and strategic decisions that will be included in the team grant application to the Canadian Institutes of Health Research (CIHR).

Thanks again to all the participants and international collaborators for taking the time to be a part of this important meeting. We value members’ expertise and appreciate their continued support and commitment to the upcoming team grant proposal. A special thank you is owed to Meghan McMahon from CIHR for taking the time to present the details of the Canadian Institutes of Health Research – Community-Based Primary Health Care (CIHR CBPHC) Team Grant Competition to the meeting participants. We would also like to thank our international collaborators (Grant Russell, Australia; Jane Gunn, Australia; Michel Wensing, The Netherlands; Stewart Mercer, UK; Stephen Peckham, UK) who shared their views and experiences via telephone conferences.

The IMPCT team is preparing a meeting summary report that will be made available to all participants by next week.

Top row left to right: Christine Loignon, Guillaume Ruel, William L. Miller, Erin Strumpf, Antoine Boivin, Frances Gallagher, Debbie Feldman, Cecile Bensimon, Maud-Christine Chouinard, Sylvie Provost, Mary Byrnes, William Hogg, Benjamin F. Crabtree, Maxime Ouellette. Front row, left to right: Martin Fortin, Jean-Frédéric Lévesque, Renee F. Lyons, Catherine Hudon, Moira Stewart, Denise Campbell-Scherer. Meeting participants missing from the picture: Jeannie Haggerty, Robert Salois, Marie-Dominique Beaulieu.

“I also want researchers to specialize in me!”

By Maud-Christine Chouinard


Greetings from the NAPCRG Conference in beautiful Banff! I am currently amongst a record assistance of more than 750 attendees who is gathered this week in a most enchanting and wintery site in the Rocky Mountains. As a nursing researcher, I am delighted to be able to present a poster and to get to choose among hundreds of presentations and 3 poster sessions on primary care research!

 For the last two days, I have had the opportunity to meet and greet with researchers and clinicians from various disciplines and to hear and see oral and poster presentations on a vast array of subjects such as evidence based medicine, translational research, chronic disease management, patient-centered care, self-management, etc. The captivating conferences were competing with the majestic peaks of the Rocky Mountains in the background.

 Garnering buzzing interest was the keynote presentation given by Professor Martin Fortin: Multimorbidity in primary care: Recognizing and dealing with the elephant in the room. Professor Martin Fortin presented in English in front of a captive audience including established and new researchers as well as members of the editorial committees of medical journals and representatives of funding agencies.

 Martin Fortin provided a clear message to draw the attention of the research community on the importance of prioritizing the thematic research area of multimorbidity and patient-centered care to continue transforming the healthcare system and thus better contend with the current and future boom in chronic diseases, especially in primary care. He also invited researchers of all disciplines to work together to develop interventions aiming to optimize care for people with multimorbidity. His presentation ended with a genuine plea in the defense of the interests of patients suffering from multiple chronic diseases.

 One line created a buzz on Twitter when Professor Fortin, paraphrasing a patient of Ian McWhinney said “I want a doctor who specializes in me”. However, his message really aims to go further with: “I also want researchers to specialize in me!”

 Finally, although we did not see any elephants in the room, Dr. Fortin convinced us of the importance of taking a real interest in the elephants in primary care with his infectious passion for the subject.

 For a copy of his presentation please contact José Almirall at: jose.almirall@usherbrooke.ca


60-second lecture at AHRQ Grantees conference (9/2011)

By Elizabeth A. Bayliss

In delivering patient-centered care to complex patients, success is measured by achieving health outcomes that matter to patients. 

Historically health outcomes have been disease-specific. These reflect appropriate treatment intensification by clinicians and appropriate adherence to recommendations by patients in order to achieve the best outcomes for a single condition. Goal attainment is facilitated by incentives and protocols that make it relatively easy for both groups to adhere to guidelines. For example, our current investigation suggests that attainment of cholesterol goals in cancer survivors—a protocol-driven outcome—is not associated with cancer stage, but is associated with overall morbidity.  

But which outcomes matter to patients? These often fall into the category of patient-reported outcomes and are increasingly recognized as equally important. Many clinicians are in favor of systematic collection of these outcomes as well. Thanks to extensive validation, we know which measures of patient-reported outcomes are valid, but do we know which outcomes matter? And to whom?

It may be worth pausing before we systematize the collection of patient-reported outcomes in order to check in with patients. We should ask them which health outcomes they consider meaningful, how they would like their clinicians to use this information, and how they would like to have it collected. At that point we will be better prepared to collect –and jointly use– health outcomes relevant to complex patients. 

International Workshop, Glasgow, April 18th, 2011

By Stewart Mercer

The challenge of multimorbidity – what can we learn from cohort studies? 

This one day meeting was organised by Professor Stewart Mercer, Professor of Primary Care Research at the University of Glasgow, who leads a national research programme on multimorbidity in Scotland with the Scottish School of Primary Care.

The morning seminar, which was the inaugural event of the newly established Institute of Health and Well-being at the University of Glasgow, and was chaired by Professor Sally Wyke, welcomed Professor Jane Gunn from Melbourne University, who is Visiting Professor with the Scottish School of Primary Care, who described her work over several years on the DIAMOND primary care cohort on depression and multimorbidity. Professor Martin Fortin from Sherbrooke University in Canada, then described the cohort studies he has recently been involved in setting up in primary care in Canada with Professor Jeannie Haggerty. This was followed by Professor Frances Mair, Head of the Academic Unit of General Practice and Primary Care at the University of Glasgow, who spoke of the treatment burden in multimorbidity, and the need for ‘minimally disruptive medicine.’ Finally, Professor Mercer described work to date on multimorbidity in Scotland, and work in progress in developing the MALT (Multiple and Long-Term conditions) cohort in Scotland.

 The afternoon consisted of a workshop to discuss multimorbidity cohort studies further, and the MALT Cohort development. Attendees included experts from Scotland, Ireland, England, as well as our morning speakers. The need for cohort studies on multimorbidity was agreed, based on simple models, and as far as possible based on collaboration between countries. The lack of evidence on multimorbid patients’ views and experiences of health and healthcare was a strong theme of the afternoon. It was agreed that those at the workshop would continue to debate these issues collaboratively.

 Overall, this was a very enjoyable and stimulating meeting and we look forward to seeing more guests in the future at our next ‘Glasgow Meeting’ on interventions in multimorbidity in March next year.

University of Glasgow

A Masterclass on Multimorbidity Research

By François Schellevis

On the occasion of the stay of prof. Martin Fortin in the Netherlands, we organised on April 27th, 2011 a Masterclass on Multimorbidity Research under the auspices of the Dutch Primary Care Research School “CaRe”. CaRe represents the cooperation between the departments of general practice of three Dutch universities and NIVEL, the Netherlands Institute for Health Services Research (www.researchschoolcare.nl). We used this opportunity to bring together researchers working on different multimorbidity issues. It was unique experience with a very fruitful exchange and discussions with prof. Fortin, the “Master”, and with colleagues.

The Masterclass started with a presentation of prof. Fortin about Multimorbidity research in Canada. Research is focused on three themes: conceptual issues (including how to measure multimorbidity), the epidemiology of multimorbidity, and interventions focusing on improving health and health care. After this, four researchers from each CaRe partner presented their work, followed by a discussion with the audience. Mrs. Ruth van Nispen (EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam) showed how multimorbidity affects the quality of life of severely impaired visually handicapped persons. Mrs. Sil Aarts (CAPHRI/MENS, University of Maastricht) discussed the issue of measuring the physical and mental aspects of quality of life in multimorbid patients in general practice. Mrs. Annemarie Uijen (Department of Primary Care, St Radboud University Medical Center Nijmegen) presented the development of a generic questionnaire to measure continuity of care among multimorbid patients in different care settings. Finally, Mrs. Nathalie Versnel (NIVEL, Utrecht and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam) presented the design of a randomized controlled trial to establish the effectiveness of case management in diabetes patients with comorbidity.

All participants were very positive about the Masterclass which provided many new insights into research issues regarding multimorbidity. They considered the setting of a Masterclass with an expert from abroad and discussions in a small group of colleagues working on comparable issues as very fruitful. We were very grateful to prof. Fortin for providing us with this opportunity.

International Workshop on Collaborative Strategies in Multimorbidity

By Dr. Med. Christiane Muth

Seventeen experts from five countries (Canada, Ireland, the UK, the Netherlands and Germany) participated in an interdisciplinary workshop that took place at the Institute for General Practice on February 4/5, 2011. Those that took part included research scientists from the fields of general practice, clinical pharmacology and gerontology, as well as a number of methodologists.

The focus of the meeting was on multimorbidity and particularly on the increasing use of multimedication resulting from the demographic ageing of the population. Intensive discussions took place on model creation, concept development, epidemiology, the development of interventions, and improving healthcare for multimorbid patients. Two trials currently being conducted in Maastricht (PIL: Polypharmacy Intervention Limburg [link]) and Frankfurt (PRIMUM: PRIorization of MUltimedication in Multimorbidity [link]) were of central importance for the optimization of multimedication therapies. Special attention was also paid to specific methodological aspects characterizing the development, evaluation and implementation of complex interventions. Ways in which the participants can continue to cooperate in the future were also discussed.

The workshop was supported by the Association of Patrons and Friends of the Johann Wolfgang Goethe University Frankfurt am Main e.V.