Entete 3
Event

An International Perspective on Designing Interventions for Multimorbidity in Primary Care

May 7, 2013 – 7:58 am

By Martin Fortin, Elizabeth A. Bayliss, Susan M. Smith, Stewart W. Mercer, Mogens Vestergaard, Chris Salisbury

Under the sponsorship of the Agency for Healthcare Research and Quality Multiple Chronic Conditions (AHRQ MCC) Research Network, a panel of six members of the International Research Community on Multimorbidity (CIRMo) presented a webinar on interventions for patients with multimorbidity: “An International Perspective on Designing Interventions for Multimorbidity in Primary Care”. The webinar included three parts:

Context and background for interventions: Dr. Chris Salisbury, University of Bristol, UK, discussed the eligibility criteria in intervention studies for multimorbidity (Who should we include in studies of interventions for multimorbidity?). Dr. Elizabeth A. Bayliss, Kaiser Permanente Colorado, University of Colorado School of Medicine, USA, who acted as the moderator of the webinar, presented “Outcomes for Multimorbidity Interventions” followed by Dr. Susan M. Smith, HRB Centre for Primary Care Research, RCSI Medical School, Dublin, Ireland, who presented a brief summary of a systematic review: “Interventions for improving outcomes in patients with multimorbidity in primary care and community settings”.

Reports on specific research and operational interventions: Senior investigators described three intervention initiatives in three different contexts. Dr. Stewart W. Mercer from the Institute of Health & Wellbeing, University of Glasgow, Scotland, presented “Preliminary findings of an exploratory cluster RCT of a primary care-based complex intervention for multimorbid patients living in deprived areas”. Dr. Martin Fortin, Université de Sherbrooke, Québec, Canada, presented results of an ongoing pragmatic randomized controlled trial: “PR1MaC: Evaluating the integration of chronic disease prevention and management services into primary healthcare” and Dr. Mogens Vestergaard, Aarhus University, Denmark, described a very interesting Danish experience in managing patients with multimorbidity: “The multimorbidity clinic at silkeborg hospital”.

Questions & answers period: At the end of the presentation was a very interesting period of interactions between participants of the webinar and the panel of researchers.

The Webinar was coordinated by James R. Fraser and hosted by Jared Lyle from the AHRQ MCC Research Network.

You can access the webinar presentations and recording through the AHRQ MCC Research Network website:

https://ahrqplexnet.sharepointspace.com/Grantee%20Site%20Pages/Meetings%20and%20Webinars.aspx

Look for the last item under “Webinars & Workshops” entitled “An International Perspective on Designing Interventions for Multimorbidity in Primary Care.”

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Others

Publications on multimorbidity September – December 2012

February 22, 2013 – 9:06 am

By Martin Fortin

You are invited to have at look at the results of our latest literature search for published papers on multimorbidity. We used the search term “multimorbidity”, but also its variant “multi-morbidity” and the expression “multiple chronic diseases”.

As in our previous posting covering the May – August 2012 period, we found many new papers on multimorbidity published from September to December. As the number of publications in the list is too long for this venue, a PDF file can be accessed following this link.

All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

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Event

Multimorbidity: The need for a consistent and coherent approach

February 7, 2013 – 10:03 am

By the Chronic Disease Surveillance and Monitoring Division, Public Health Agency of Canada (CDSMD-PHAC)

The need for a consist and coherent approach to measure multimorbidity was the main message arising from a meeting hosted by the Chronic Disease Surveillance and Monitoring Division of the Public Health Agency of Canada on December 14, 2012 in Ottawa, ON.  The Agency convened several leaders working in the area of multimorbidity in Canada to discuss the conceptualization and definition of multimorbidity from a public health surveillance perspective.

Multimorbidity leaders agreed that while some efforts have been made to establish standardised tools and techniques to assess multimorbidity, there has been a lack of consensus and multimorbidity measures to date have been characterized by high heterogeneity.  Without consistent methodologies to measure multimorbidity, public health practitioners and clinicians may receive little or inconsistent information about the scope and burden of multimorbidity and what can be done to address the problem.

Leaders emphasized the need to define multimorbidity in a way that will resonate with both public health policy makers and clinicians and they encouraged continued attention toward the issues at the heart of multimorbidity in Canada, such as complexity of clinical care, cases of concurrent mental illness, and the common risk factors and determinants which precipitate development of multiple diseases.

The Chronic Disease Surveillance and Monitoring Division is looking forward to working with other multimorbidity leaders to help meet this challenge, and to advance the measurement and reporting of multimorbidity in Canada.

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Others

A survey on the definition of multimorbidity: WE NEED YOUR INPUT!

January 22, 2013 – 4:36 pm

By Martin Fortin and Marcello Tonelli

We have seen many different operational definitions of multimorbidity. In fact, the list of chronic conditions considered by different authors varies from less than 10 to all possible diagnoses. A team of Canadian researchers is submitting a research proposal to a funding agency and need your input in giving weight to the definition of multimorbidity that we propose future studies use. We are conducting a three-question survey that should take you about one minute to complete. The questions are:

1. Where are you from?
Choices: 1) Canada; 2) USA; 3) Europe; 4) Asia; 5) Australia/New Zealand; 6) South/Central America 7) Other

2. Many different definitions of multimorbidity have been used in previous studies. How important is it that future studies use definitions that are similar to those previously used, to allow comparisons with prior and future work?
Choices: 1) Very important; 2) Somewhat important; 3) Neither important nor unimportant; 4) Somewhat unimportant; 5) Not important

3. If asked to recommend an existing list of chronic conditions or diseases that should be more broadly used in future studies on the operational definition of multimorbidity in adult populations, which would you suggest?
Choices: 1) Barnett et al; 2) Bayliss et al; 3) O’Halloran et al; 4) Muggah et al; 5) Canadian Community Health Survey; 6) Other (please specify)

Blog subscribers will receive the link to complete the survey, by email. Those who are not subscribed to the blog, but would like to complete the survey, are invited to contact José Almirall at jose.almirall@usherbrooke.ca to receive the link by email. The deadline to participate in the survey is February 7, 2013.

Please consider completing the survey and helping us out. Your input is important. Many thanks for your help.

Click here to see the responses to the survey.

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Event

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

January 18, 2013 – 9:35 am

By Martin Fortin

As part of the 2012 Annual Meeting of the North American Primary Care Research Group (NAPCRG), participants from different disciplines and fields of expertise had the opportunity to take part in the “International collaborative research initiative to design interventions for patients with multimorbidity in primary health care” to discuss and share ideas and perspectives with each other.

This forum was initiated and organized by six researchers: Martin Fortin, MD, MSc; Elizabeth A. Bayliss, MD, MSPH; Stewart Mercer, MBChB, PhD; Susan Smith, MD, MSc; Jane Gunn, MBBS, FRACGP, PhD, DRANZCOG; Mogens Vestergaard, MD, PhD. The forum aimed to use a group process to identify a set of attributes relevant to interventions in multimorbidity, to share findings and to identify potentially important future directions for improving generalist patient-centered care of persons with multimorbidity in primary care settings.

Participants came from different organizations across the USA, Canada, Australia, Denmark, Ireland and the UK which fostered discussions enlightened by different perspectives and experiences. The forum’s organizers gave very short presentations on a number of topics (list presented below*) before handing the floor over to participants for very enthusiastic small group and plenary discussions.

The organizers would like to thank and congratulate each one of the participants for so generously sharing their wide-ranging perspectives and to inform them that the lead group is planning to write a paper based on the forum’s discussions and the work leading up to it.

*Presentation list (summary):
-Concepts and definitions for multimorbidity interventions (M Fortin)
-Systematic review of interventions to improve outcomes for patients with multimorbidity in primary care and community settings (S Smith)
-Outcomes for multimorbidity interventions (E Bayliss)
-Preliminary findings of an exploratory cluster RCT of a primary care-based complex intervention for multimorbid patients living in areas of high deprivation in Scotland: The CARe Plus Study (S Mercer)
-Co-designing an intervention for improving care for those with severe and enduring mental health problems (J Gunn)
-Integration of chronic disease prevention and management services into primary health care: The PR1MaC Study (M Fortin)
-Interventions for multimorbid patients in Denmark (M Vestergaard)

From left to right:
Chris Salisbury, Stewart Mercer, Susan Smith, Mogens Vestergaard,
Martin Fortin, Jane Gunn, Elizabeth A. Bayliss and Sally Wyke. 

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Epidemiology and outcomes research

The impact of Multiple Chronic Diseases on ambulatory care use

January 4, 2013 – 8:48 am

By Elizabeth Muggah

Our paper, The impact of Multiple Chronic Diseases on ambulatory care use; a population based study in Ontario, Canada, was recently published in BMC Health Services Research. This study is an important addition to what we know about the burden of multimorbidity on the primary care system as we focused specifically on ambulatory health care use and looked at the burden of disease on both the patient and on the health system more broadly.

This research was completed using health administrative data housed at the Institute of Clinical Evaluative Sciences (ICES) in Toronto, Canada. We used well validated methods to search administrative data in one large province of Canada to identify persons who had at least one of nine common chronic diseases (diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure).  We then identified the number of outpatient primary care and specialist visits over a 2 year period.

We found that multiple chronic diseases were common among the Ontario population, (in 2009, 26.3% of Ontarians had one chronic disease, 10.3% had two diseases, and 5.6% had three or more diseases). The annual number of primary health care visits per patient increased significantly with each additional chronic disease and patients with two or more diseases made more than twice as many visits each year to primary health care providers compared to specialists. At the extremes of age we saw an increase in the number of primary care visits across all groups while specialist care dropped off. Looking from a health system perspective we found the largest total number of visits were made by those with no or one chronic disease compared to those with multiple diseases.

This study reinforces what we know about the considerable burden of illness felt by persons with multiple chronic diseases and confirms that these patients seek care disproportionately from their primary care providers.  However from a health system perspective those with no or one chronic disease are responsible for the largest number of ambulatory health care visits.  In our view continued investment in primary health care is needed both to care for those with multiple diseases as well as to maintain a focus on preventing the accumulation of chronic diseases with advancing age.  It would be important to explore these trends over time to see if the pattern of health care use we found is changing given the predicted rise in the prevalence of multiple chronic diseases with the aging of our population.

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Others

Multiple conditions: exploring literature from the consumer perspective in Australia

December 21, 2012 – 9:10 am

By Christine Walker

The article “Multiple conditions: exploring literature from the consumer perspective in Australia”, published in Health Expectations October 2012 (doi:10.1111/hex.12015), arose from a workshop held by The Chronic Illness Alliance in Melbourne Australia. Participants were people who had more than one health condition. Some participants had co-morbidities, others had iatrogenic conditions, others had conditions arising from treatments while others simply had unrelated conditions. In all cases participants considered having more than one condition made them vulnerable in a health system that still focused on the care of single conditions.

Workshop participants wanted to argue for better recognition of their complex health needs and requested that a literature review be undertaken to identify if the needs of consumers with multiple conditions had been recognised in other countries.

The resulting literature review is based on the parameters set by the workshop participants who were concerned about the quality of care and the resultant quality of their lives. This meant that a qualitative analysis of literature, that is, a meta-synthesis was more appropriate than a systematic review of literature. Our review found that the consumer perspective was not explored in literature on multi-morbidities though many of the problems identified in health services research were clearly relevant to improving the quality of care for people with multiple conditions. Identified problems include issues of polypharmacy and adverse events, poor recognition of depression and problems of identifying which condition requires most attention. At the same time the meta-synthesis revealed there were problems with consistent definitions of co-morbidity and multi-morbidity which compounded the accurate collection of data relating to multi-morbidity. Many of these problems were reproduced and compounded in health policies. We argue that specific reform to health services and policies are required to better meet needs of people with more than one condition.

Christine Walker
Chronic Illness Alliance
587 Canterbury Rd
Surrey Hills VIC 3127

cwalker@chronicillness.org.au

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Epidemiology and outcomes research

Multimorbidity, polypharmacy, referrals, and adverse drug events

December 12, 2012 – 9:10 am

By Amaia Calderón and Alexandra Prados-Torres

A paper entitled “Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well?” was recently published in the British Journal of General Practice. The work was carried out by members of the EpiChron Research Group on Chronic Diseases of the Aragon Health Sciences Institute in Spain, and its objective was to shed light on the interrelations between multimorbidity, polypharmacy, multiple referrals to specialised care, and the occurrence of adverse drug events (ADEs), in the context of a national healthcare system.

Results of this observational study demonstrate that multimorbidity, polypharmacy and multiple referrals are strongly and independently associated to occurrence of ADEs, even after adjusting for potential confounders. As the clinical situation of the patient becomes more complex and requires the intervention of different specialists, the likelihood of a lack of coordination among professionals and potential interactions among prescribed medications could favour the occurrence of undesirable effects, such as ADEs.

As indicated by Starfield et al[1] a decade ago, it is necessary, now more than ever, to design strategies that focus on individual’s health problems in their totality, rather than examining each of the patient’s illnesses individually. This approach is important given the high frequency of multimorbidity in all stages of life, the proved risk of interactions between illnesses and medications or among medications, and the acknowledged impact of not doing so both for the healthcare system and the health of the patient.

This research, financed by the Spanish Institute of Health Carlos III, is framed within a wider project focused on the epidemiology of multimorbidity, utilization patterns and the response of healthcare systems to populations suffering from it.

[1] Starfield B, Lemke KW, Bernhardt T, et al. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med 2003; 1(1): 8–14.

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Event

Multimorbidity: a hidden epidemic that challenges European health services

November 26, 2012 – 9:05 am

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:

http://www.eupha.org/site/upcoming_conference.php

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Event

Evidence-Based Medicine Meets Multimorbidity: A Blind Date?

November 13, 2012 – 9:10 am

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:
http://www.allgemeinmedizin.uni-frankfurt.de/forschung2/ebm_symposium.html.

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.

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