Entete 3

Different multimorbidity measures affect estimated levels of physical quality of life

By Aline Ramond-Roquin
Health-related quality of life is adversely affected by the presence of multimorbidity in a way that an increasing number of concurrent chronic conditions is associated with lower scores of health-related quality of life. Studies aiming to quantify the impact of multimorbidity on the quality of life show wide heterogeneity in terms of the intensity of this association but these studies also present other important methodological differences such as population studied, measure of quality of life, measure of multimorbidity, etc.
Most operational definitions of multimorbidity have been based on a simple count of conditions which are screened as present or not in a given individual from a predetermined list of conditions. Many different lists of potential conditions have been proposed, with some being as short as six conditions and others as long as 40.
We investigated the influence of the list of conditions on the estimated level of the physical component of health-related quality of life in individuals with multimorbidity and found that the length of the list of candidate conditions considered has a great impact on the estimations of physical health-related quality of life.
This argues for careful methodological consideration when measuring multimorbidity and its association with different outcomes. We conclude that standardization of the measure of multimorbidity is needed to allow the comparison of the results across different studies on multimorbidity.
The article describing this study was published on line (1) and is freely accessible to those interested in this subject.
1) Ramond-Roquin A, Haggerty J, Lambert M, Almirall J, Fortin M: Different Multimorbidity Measures Result in Varying Estimated Levels of Physical Quality of Life in Individuals with Multimorbidity: A Cross-Sectional Study in the General Population. Biomed Res Int. 2016;2016:7845438.

Publications on multimorbidity July – September 2016

By Martin Fortin
Our search for papers on multimorbidity that were published during the period July – September 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.

Training doctors to manage patients with multimorbidity: a systematic review

By Cliona Lewis and Susan Smith

We have published a systematic review of the literature addressing training of doctors in the management of patients with multimorbidity [1]. Overall, 75,110 citations were screened, of which 68 full-text articles were then assessed for eligibility, and just two studies met the inclusion criteria for the review.
While much has been published about the challenges presented by patients with multimorbidity, the issue of educating doctors to manage these patients has been poorly addressed. The two studies presented in this review implemented and evaluated multimorbidity workshops, and provide a basis for further research. It remains to be determined whether there is a specific need for training of doctors to manage patients with multimorbidity, and if so, how that need can best be met. It also remains to be proven that improving knowledge, skills and confidence of doctors results in improved care of this patient group. We have identified existing literature that provides a platform for management of these patients, and for curriculum development in training doctors in the management of multimorbidity. Incorporation of emerging guidelines and research findings into multimorbidity training curricula for doctors is needed in order to optimise practice and enhance the competence and confidence of doctors in managing this challenging population of patients, with the ultimate aim of improving clinical outcomes.
1) Lewis C, Wallace E, Kyne L, Cullen W, Smith SM. Training doctors to manage patients with multimorbidity: a systematic review. Journal of Comorbidity 2016;6(2):85–94. DOI: 10.15256/joc.2016.6.87

‘Addressing the global challenge of multimorbidity’: Call for written evidence

The Academy of Medical Sciences has recently launched a new working group project on ‘Addressing the global challenge of multimorbidity’ and is seeking your views on multimorbidity as an international health challenge.

Throughout the world, as life expectancy increases, the population incidence of non-communicable diseases is also increasing. Further, communicable diseases, with both their short and long term sequelae, continue to affect millions of people every year. Together, all of these factors mean that multimorbidity has become, and will increasingly be, an international health challenge.

However, currently there is no commonly used framework for defining or more widely understanding multimorbidity. Further, most health related research is currently focused on the prevention and management of disorders in isolation. Consequently, it is difficult to compile a coherent body of research in this area or develop evidence-based strategies for use in healthcare systems. In order to address the challenge of multimorbidity, we must understand the problem better.

The questions outlined in the call for written evidence have therefore been developed to gather information on the definition(s) of multimorbidity, better understand the current knowledge base on multimorbidity as an international health challenge, and to gather opinions about future priorities and opportunities.

This call is part of our process of gathering external input into the project, and we would welcome responses from external stakeholders, including researchers, healthcare professionals, research institutions, funders, industry, patients and members of the public.

The deadline for submission is 30 November 2016.

For more information about the project and to submit a response, please visit the Academy’s website. If you have any questions, please contact Dr Rachel Brown (rachel.brown@acmedsci.ac.uk).

Publications on multimorbidity February – June 2016

By Martin Fortin
Our search for papers on multimorbidity that were published during the period February – June 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.

The CARE Plus study

By Stewart Mercer

Scotland’s wide inequalities in health are well known, and despite having ‘universal coverage’ of healthcare through the NHS, the inverse care law remains an important issue (see work from our group published last year http://bjgp.org/keyword/inverse-care-law)
Our previous research also demonstrated how the inverse care law operates at the level of GPs. Routine consultations in poor areas of Scotland -despite higher levels of patient illness and thus need – are shorter, leave patients with complex needs feeling less enabled, and are associated with greater GP stress when compared with consultations in richer areas.
More recently, in a large prospective study of videoed-consultations, we demonstrated that due to the continuing existence of the inverse care law, GPs in deprived areas have less time to be patient-centred and patients have worse outcomes from the consultations.
In our new paper, the CARE Plus study, which was recently published in BMC Medicine https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0634-2 we tested the feasibility of carrying out a cluster RCT of a whole system intervention to improve quality of life of primary care patients with multimorbidity living in areas of high socioeconomic deprivation and measured indications of effectiveness and cost-effectiveness.
As Principal Investigator, I led the study with fellow academics at the Universities of Glasgow and Dundee, funded by the Scottish Government Chief Scientist Office. This was a programme of research called ‘Living Well with Multimorbidty’. The CARE Plus study focused on patients with multiple complex problems (multimorbidity), since these patients have the highest needs.
In usual consultations, GPs, nurses and patients all struggle to adequately manage the problems of multimorbidity in the context of high deprivation.
We initially co-developed and optimised the intervention over a period of 2-3 years (http://chi.sagepub.com/content/early/2016/04/22/1742395316644304) and then randomised 8 general practices serving patients in areas of very high socioeconomic deprivation to either the CARE Plus intervention or to ‘usual care’. The intervention was a complex one, and took a ‘whole-system approach’ which involved substantially longer consultations with the GPs; training and support for the practitioners; and additional ‘self-management’ support for the patients. GPs identified patients with multimorbidity who they felt would benefit more time for an empathic, holistic approach and to agree a plan of action, with follow-up and continuity of care.
On average, patients were in their early 50s with around five chronic conditions each. Compared with the control group, patients in the CARE Plus group had significantly better outcomes for some aspects of well-being and quality of life at 6 and 12 months. Importantly, the intervention was highly cost-effective.
The study demonstrated that it is possible to conduct a high quality cluster RCT in very deprived areas; all of the practices who agreed to take part stayed in the study, and we achieved follow-up rates on the patients in both arms of the trial of 88% at 12 months. However, it should be noted that this was an exploratory trial of 152 patients in 8 practices; a definitive trial is now warranted.

Prevalence of multimorbidity in the general population and in primary care practices

By Martin Fortin
It is known that settings affect estimation of the prevalence of multimorbidity. In a recently published paper  [1], we have compared estimates of the prevalence of multimorbidity in the general population and in primary care clinical practices.
The new aspect of this recent study was that prevalence in both settings was measured simultaneously, in the same region, and with the same methods. This way, we eliminated methodological limitations found in previous studies that prevented to conclude definitively the extent to which prevalence estimates differ in these two study populations [2].
Also, we explored the effect of using different operational definitions of multimorbidity on the differences of prevalence observed between the two sampled populations.
We concluded that there is a difference of about 10% in prevalence estimates of multimorbidity between samples from the general population and primary care clinical practices, with a higher prevalence in the latter setting. The difference of the prevalence between the two settings was not affected by the use of different operational definitions of multimorbidity.
1.- Mokraoui NM, Haggerty J, Almirall J, Fortin M. Prevalence of self-reported multimorbidity in the general population and in primary care practices: a cross-sectional study. BMC Res Notes. 2016;9:314.
2.- Fortin M, Hudon C, Haggerty J, van den Akker M, Almirall J. Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Services Research. 2010;10:111.

Multimorbidity in adults from a southern Brazilian city

By Bruno P. Nunes
We are very satisfied to disseminate another recent paper about multimorbidity from Brazil in International Research Community on Multimorbidity (IRCMo) site. In this paper, we explore the occurrence and patterns (through Factorial Analysis) in Brazilian adults [1]. The manuscript used data from a population-based study carried out in 2012 in the individuals (20 or more years) households living in Pelotas, southern Brazil. Multimorbidity was evaluated by a list of 11 morbidities (based on medical diagnosis; Patient Health Questionnaire 9 for depression; and Anatomical Therapeutic Chemical index). The sample was made up of 2927 adults. Multimorbidity reached 29.1 % (95 % CI: 27.1; 31.1) for ≥2, and 14.3 % (95 % CI: 12.8; 15.8) for ≥3 morbidities. Two patterns of morbidities (cardio-metabolic and joint problems; and respiratory diseases) were observed. The high frequency and the observed patterns increase the need to address multimorbidity in Brazilian health policies and diseases guidelines.
To access the manuscript, please click in the following link:
Furthermore, we reinforce our invite to researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others). Contact e-mail for further information: nunesbp@gmail.com.
1) Nunes BP, Camargo-Figuera FA, Guttier M, de Oliveira PD, Munhoz TN, Matijasevich A, Bertoldi AD, Wehrmeister FC, Silveira MP, Thumé E, Facchini LA. Multimorbidity in adults from a southern Brazilian city: occurrence and patterns. Int J Public Health. 2016 Apr 22. [Epub ahead of print]

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.

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