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Monthly Archives: March 2016

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.
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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: olivarius@sund.ku.dk

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.