Entete 3
Others

Interventions for people with multimorbidity

November 15, 2013 – 9:45 am



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.

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Qualitative research

The care delivery experience of hospitalized patients with complex chronic disease

November 8, 2013 – 9:21 am

By Kerry Kuluski

What is important to individuals with complex chronic conditions when receiving care in a hospital setting? We recently published a paper in the journal Health Expectations [1] on the care delivery experiences of 116 inpatients at a complex continuing care/rehabilitation hospital in Toronto, Canada. Patients had an average of 5 morbidities and several illness symptoms including activity of daily living impairments, physical pain and depressive symptoms. Patients reported what kind of care they wanted delivered as well as how they wanted their care delivered. The findings speak to the importance of having a comprehensive assessment with less redundancy, support for transitions into and out of the hospital as well as greater attention to mental health during the hospital stay. On the staffing side, quicker response times, ongoing patient–provider communication and consistency between providers and across care units were highlighted. The patients noted the importance of feeling like a person, not a “knee replacement,” shedding light on the relational aspect of every care transaction. The study has generated a body of evidence on the important components of care delivery from the perspectives of a diverse group of chronically ill individuals who have spent a considerable amount of time in the health-care system. Moving forward, exploration around the appropriate funding models, skill mix and in-hospital processes (e.g., admission and discharge) are needed to move the evidence into changed practice. The findings can serve as a framework for designing patient centered hospital care for complex patient populations.

[1] Kuluski K, Hoang SN, Schaink AK, et al. The care delivery experience of hospitalized patients with complex chronic disease. Health Expectations. May 27 2013.

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Qualitative research

A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers

November 1, 2013 – 2:55 pm
By Kerry Kuluski

  Do patients, their family physicians and informal caregivers agree on care goals? In short, rarely. We conducted interviews with 28 older persons with multi-morbidities, their informal caregivers and family physicians to assess and compare patient care goals. Maintaining functional independence was a common goal across all groups when looking at the data at the aggregate level. When comparing findings across patient-caregiver-family physician triads a different picture emerged. Very little alignment was found, particularly when patients were medically unstable and during transition points (e.g., when the patient required care in an alternate setting). While divergence in care goals may reflect the different roles and responsibilities of each of the players involved, these perspectives should be illuminated when building care plans to ensure that trade-offs are explored, the needs of the patient are supported and that quality of care is enhanced. This highly accessed paper was recently published in BMC Family Practice.

 

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Others

Incorporating comorbidity interrelatedness into clinical practice, research, and policy

October 4, 2013 – 12:56 pm

By Donna Zulman

Multimorbidity is an increasingly recognized challenge to quality improvement and cost-containment efforts for healthcare systems. In order to optimize interventions and policies addressing multimorbidity, we must have a clear understanding of the relationship between multimorbidity and quality of care. In a recent article in the Journal of General Internal Medicine [1], we review the literature on multimorbidity and quality of care, the majority of which has focused on how clinical care is affected by a patient’s number of chronic conditions and specific characteristics of those conditions (e.g. symptom intensity, clinical dominance). We suggest that quality of care for patients with multiple chronic conditions is also likely influenced by comorbidity interrelatedness, or the degree to which conditions interact to affect clinical management.
 
 While comorbidity interrelatedness is a familiar concept to many clinicians, there is a need to more formally integrate this construct into research, clinical support tools, and quality metrics. In our article, we introduce a framework for multimorbidity that incorporates comorbidity interrelatedness, as well as traditional concepts of comorbidity count and characteristics. We describe how each of these constructs can generate clinical complexity and influence quality of care. Finally, we provide recommendations for operationalizing the concept of comorbidity interrelatedness, and incorporating this construct into clinical practice, research, guideline development, and performance metrics and reimbursement.
 
 
 
[1] Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of Care for Patients with Multiple Chronic Conditions: The Role of Comorbidity Interrelatedness. J Gen Intern Med. Oct 1 2013.
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Others

GPs’ perspectives on the management of patients with multimorbidity

September 27, 2013 – 7:43 am

By Carol Sinnott

Our research group has recently published a systematic review of the existing published literature on the perceptions of general practitioners (GPs) or their equivalent on the clinical management of multimorbidity [1].

Article focus:
• Patients with multiple morbidities present unique challenges to healthcare providers. An awareness of these challenges is needed to direct research efforts and intervention design in this field.
• Qualitative studies have explored GPs perceptions of the management of multimorbid patients, but to date these studies have not been systematically reviewed or synthesized.

Key messages:
• This systematic review shows that the problem areas for GPs in the management of multimorbidity may be classified into four domains: disorganization and fragmentation of health care; the inadequacy of guidelines and evidence based medicine; challenges in delivering patient centred care; and barriers to shared decision making.
• These domains may be useful targets to guide the development of interventions that will assist and improve the provision of care to multimorbid patients.

Strengths and limitations:
• The meta-ethnographic approach used in this review gave a broader understanding of the challenges of multimorbidity than any single study, while still preserving the context of included studies.
• We focused on the GPs’ perspective on multimorbidity – an understanding of the challenges experience by patients is also required to inform the development of effective interventions. 

The complete article can be accessed at:
http://bmjopen.bmj.com/cgi/content/full/bmjopen-2013-003610

 
[1] Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3(9):e003610.

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Epidemiology and outcomes research

Depression Screening and Multimorbidity

September 17, 2013 – 7:44 am

By Bhautesh Jani and Frances Mair

Our new paper published in Plos One examines the impact of routine depression screening, using the Hospital Anxiety and Depression Scale (HADS), and its relationship with multimorbidity and chronic disease management. In our study based on more than 125000 patients with chronic disease, the findings highlight the difficulties in implementing depression screening universally in primary care, despite incentivisation. Younger patients and those from deprived socio-economic background were more likely to have a positive result, when screened for depression symptoms. Importantly, depression screening did lead to an increase in the rate of anti-depressant prescribing in patients with chronic disease, which has significant resource implications.

In our study, depression screening was more often undertaken in patients with multimorbidity when compared to those with a single disease. Patients with multimorbidity had a greater chance of having a raised HADS score on depression screening, which resonates with the emerging evidence in this area. The crucial question will be to investigate the effect of depression screening in patients with chronic disease and multimorbidity on clinical outcomes, if any. The next phase of our project aims to address this question.

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Care model

ICARE4EU: Innovating care for people with multiple chronic conditions in Europe

July 31, 2013 – 9:56 am

By François Schellevis

A consortium, coordinated by NIVEL, the Netherlands Institute for Health Services Research, has obtained a 1.2 million Euros grant from the European Commission for the ICARE4EU project which started on March 1st, 2013. ICARE4EU will describe and analyse innovative approaches in multidisciplinary care for people with multiple chronic conditions currently existing in Europe. By disseminating knowledge about effective and innovative solutions, we hope to contribute to an improved design, a wider applicability and more effective implementation of patient-centred multidisciplinary care for people with multimorbidity. The ICARE4EU project is part of the Health Programme 2008-2013 of the European Commission.

Project activities

Expert organizations will be approached in the 28 EU Member States, Iceland and Norway. These organizations will provide information about the characteristics of care programmes aimed at patients with multimorbidity that have been initiated in their country. This will include information about for instance the target group of the programmes, the disciplines involved, the care pathway or procedures, the way patients and informal carers are actively involved, and their evidence or results. More detailed information will be gathered about the following subjects: patient-centeredness, use of e-health technology, management practices & professional competencies and financing systems. Additionally, country level information about the health care system and its characteristics will be gathered. Best practices will be identified for each of the four afore mentioned subjects. Based on this information key characteristics for successful management and implementation strategies will be identified. A plan for future monitoring of the developments in multimorbidity chronic illness care will also be developed.

The consortium

Project partners include the Technische Universität Berlin (Germany), the University of Eastern Finland, the Italian National Institute of Health and Science on Aging, the University of Warwick, the AGE Platform Europe and Eurocarers, the European association working for carers, and we collaborate with the European Observatory on health systems and policies. NIVEL, the Netherlands Institute for Health Services Research, coordinates the ICARE4EU project.

The research team

NIVEL: François Schellevis, Mieke Rijken, Daphne Jansen, Sanne Snoeijs
Technical University Berlin: Reinhard Busse, Ewout van Ginneken, Verena Struckmann
Italian National Institute of Health and Science on Aging: Maria Gabriella Melchiorre, Roberta Papa
University of Eastern Finland: Sari Rissannen, Anneli Hujala
University of Warwick: Aileen Clarke, Mariana Dyakova

Further information

www.icare4eu.org

Contact

icare4eu@nivel.nl

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Care model

PACE in multimorbidity. Patient-Centred Innovations for Persons with Multimorbidity

July 18, 2013 – 12:27 pm

By Moira Stewart and Martin Fortin

A Canadian research group led by Drs. Moira Stewart and Martin Fortin recently received funding in the amount of 2.5 million dollars over five years to improve the delivery of primary health care for people with multimorbidity. Awarded by the Canadian Institutes of Health Research (CIHR), this important grant is part of a government initiative to support research on community-based primary health care (CBPHC) across Canada.

Based on a partnership between the respective research teams of Dr. Fortin (Université de Sherbrooke, Québec) and Dr. Moira Stewart (Western University, Ontario), as well as partners from three other Canadian provinces and collaborators from five countries, this group will use a programmatic research approach and timeline to develop, implement and compare innovative models of integrated chronic disease prevention and management (CDPM). The research Team competed with 95 teams from across Canada to obtain this funding. The Team is called “PACE in multimorbidity” for “Patient-Centred Innovations for Persons with Multimorbidity”.

The Team proposes innovations in CDPM that will: reorient care from a single disease focus to a multimorbidity focus; centre on not only disease but also the patient in context; and realign the health care system from separate silos to coordinated collaborations in care. The proposed multifaceted innovations will be grounded in the current realities of CDPM (i.e. chronic care models including self-management programs) that are linked to primary care reform efforts. The Team will build on this firm foundation, will design and test promising innovations and will achieve transformation by creating structures to sustain relationships among researchers, health professionals, patients and decision-makers. The Team will conduct cross-jurisdictional comparisons and is mainly a Quebec – Ontario collaboration with participation from three other provinces: British Columbia, Manitoba and Nova Scotia.

The program will identify factors responsible for the success or failure of current CDPM initiatives linked to the primary care reform, by conducting a realist synthesis of their quantitative and qualitative evaluations and transform consenting CDPM initiatives by aligning them to promising innovations on patient-centred care for multimorbidity patients. The Team will test these new innovations in at least two jurisdictions and compare among jurisdictions. In addition, the program aims to foster the scaling up of innovations and to conduct research on different approaches to scaling up.

The Team’s objectives are based on the concerns expressed by decision-makers and will create new capacity for CBPHC research in Canada by building sustainable networks of interdisciplinary researchers and policy makers, including mentoring junior Team members to build future capacity. The Team is confident that some of the innovations studied over the five years will improve patient self-rated health outcomes while at the same time reduce costs to the system.

Research Team:

Moira A. Stewart, Martin Fortin, Martine Couture, Paul Huras, Onil Bhattacharyya, Antoine Boivin, Judith Brown, Maud-Christine Chouinard, Frances Gallagher, Richard Glazier, William Hogg, Catherine Hudon, Alan Katz, Christine Loignon, Jonathan Sussman, Amardeep Thind, Walter Wodchis, Sabrina Wong, Merrick Zwarenstein, Roxane Borgès Da Silva, Rick Glazier, Fred Burge.

International Advisory Committee

Stewart Mercer (UK), Marjan van den Akker (The Netherlands), John Furler (Australia), Paul Little (UK), Elizabeth A. Bayliss (USA).

Other national collaborators: decision-makers, researchers, collaborators for capacity building and patient advisory committee.

For further information, please do not hesitate to contact Team coordinators: Louisa Bestard Denomme (lbestar@uwo.ca) and Tarek Bouhali (tarek.bouhali@usherbrooke.ca).

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Others

Publications on multimorbidity January – April 2013

June 4, 2013 – 7:58 am

By Martin Fortin

Our search for papers on multimorbidity that were published during the first quarter of this year 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 papers 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.

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Epidemiology and outcomes research Theory, concept and measure

Comparisons of multi-morbidity in family practice – issues and biases

May 16, 2013 – 8:11 am

By Moira Stewart, Martin Fortin, Helena Britt, Christopher Harrison, and Heather Maddocks


A recent study published in Family Practice “Comparisons of multi-morbidity in family practice – issues and biases” [1] compared the methods and results of three separate prevalence studies of multi-morbidity from; i) the Saguenay region of Quebec [2]; ii) a sub-study of the Bettering Evaluation and Care of Health (BEACH) program in Australia [3,4]; and iii) the Deliver Primary Health Care Information (DELPHI) project in South-western Ontario [5,6].

A re-estimate of the prevalence rates using identical age-sex groups found multi-morbidity prevalence to vary by as much as 61%, where reported prevalence was 95% among females aged 45–64 in the Saguenay study, 46% in the BEACH sub-study and 34% in the DELPHI study.

Several aspects of the methods and study designs were identified as differing among the studies, including the sampling of frequent attenders, sampling period, source of data, and both the definition and count of chronic conditions.

The paper offers a guide for authors reporting the methods used in multi-morbidity prevalence research, recommending detailed descriptions of the type of sampling, completeness and accuracy of the source of data, and the definition of chronic conditions.

Further comparisons among multi-morbidity data using agreed upon standards for the definition of chronic conditions and the way to count multi-morbidity are recommended to assess the impact of these methodological variations.

References:

1 Stewart M, Fortin M, Britt H, Harrison C, Maddocks H.  Comparisons of multi-morbidity in family practice – issues and biases.  Family Practice. May 2013.  doi: 10.1093/fampra/cmt012.

2 Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005; 3: 223–8.

3 Britt HC, Harrison CM, Miller GC, Knox SA. Prevalence and patterns of multimorbidity in Australia. Med J Aust 2008; 189: 72–7.

4 Knox SA, Harrison CM, Britt HC, Henderson JV. Estimating prevalence of common chronic morbidities in Australia. Med J Aust 2008; 189: 66–70.

5 Stewart M, Thind A, Terry AL, et al. Multimorbidity in primary care: a study using electronic medical record (EMR) data. In: Thirty-Seventh Annual Meeting of North American Primary Care Research Group, Quebec, Canada, 14–18 November, 2009.

6 Stewart M, Thind A, Terry A, Chevendra V, Marshall JN. Implementing and maintaining a researchable database from electronic medical records—a perspective from an academic family medicine department. Healthc Policy 2009; 5: 26–39.

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