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Author Archives: Martin Fortin

Multimorbidity publications October – December 2011

January 24, 2012 – 9:46 am

By Martin Fortin

Here are the results of a literature search that I would like to share with you presenting articles on multimorbidity published between October and December 2011, along with the links to the abstracts or full texts:

1-    Caughey GE, Roughead EE. Multimorbidity research challenges: where to go from here? Journal of Comorbidity. 2011;1:8–10.[Full text]
2-    Cohen E, Bruce-Barrett C, Kingsnorth S, Keilty K, Cooper A, Daub S. Integrated Complex Care Model: Lessons Learned from Inter-organizational Partnership. Healthc Q. 2011;14 Spec No 3:64-70.[Abstract]
3-    De Vries NM, Van Ravensberg CD, Hobbelen JS, Olde Rikkert MG, Staak SB, Nijhuis-van der Sanden MW. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: A meta-analysis. Ageing Resource Review, 11 novembre 2011 (Epub ahead of print). 2011.[Abstract]
4-    Esper AM, Martin GS. The impact of cormorbid conditions on critical illness. Crit Care Med. 2011;39:2728-35.[Abstract]
5-    Gilbert AL, Caughey GE, Vitry AI, Clark A, Ryan P, McDermott RA, et al. Ageing well: Improving the management of patients with multiple chronic health problems. Australas J Ageing. 2011;30 (SUPPL.2):32-7.[Abstract]
6-    Grant RW, Ashburner JM, Hong CC, Chang Y, Barry MJ, Atlas SJ. Defining Patient Complexity From the Primary Care Physician’s Perspective: A Cohort Study. Ann Intern Med. 2011;155:797-804.[Abstract]
7-    Haverhals LM, Lee CA, Siek KA, Darr CA, Linnebur SA, Ruscin JM, et al. Older adults with multi-morbidity: medication management processes and design implications for personal health applications. J Med Internet Res. 2011;13:e44.[Abstract]
8-    Marengoni A, Angleman S, Fratiglioni L. Prevalence of disability according to multimorbidity and disease clustering: a population-based study. Journal of Comorbidity. 2011;1:11–8.[Full text]
9-    Mercer SW, Gunn J, Wyke S. Improving the health of people with multimorbidity: the need for prospective cohort studies. Journal of Comorbidity. 2011;1:4–7.[Full text]
10- Nobili A, Marengoni A, Tettamanti M, Salerno F, Pasina L, Franchi C, et al. Association between clusters of diseases and polypharmacy in hospitalized elderly patients: results from the REPOSI study. Eur J Intern Med. 2011;22:597-602.[Abstract]
11-  Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. Journal of Comorbidity. 2011;1:28–44.[Full text]
12-  Spangenberg L, Forkmann T, Brähler E, Glaesmer H. The association of depression and multimorbidity in the elderly: implications for the assessment of depression. Psychogeriatrics. 2011;11:227-34.[Abstract]
13-  Steinhaeuser J, Miksch A, Ose D, Glassen K, Natanzon I, Szecsenyi J, et al. Questionnaire of chronic illness care in primary care-psychometric properties and test-retest reliability. BMC Health Serv Res. 2011;11:295.[Full text]
14-  Townsend A. Applying Bourdieu’s theory to accounts of living with multimorbidity. Chronic Illn 2011 Dec 2 [Epub ahead of print]. 2011.[Abstract]
15-  Valderas JM, Mercer SW, Fortin M. Research on patients with multiple health conditions: different constructs, different views, one voice. Journal of Comorbidity. 2011;1:1–3.[Full text]

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

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Inauguration of the Journal of Comorbidity

January 19, 2012 – 8:56 am

By Martin Fortin

Good news! A new journal with a special focus on patients with multimorbidity and comorbidity has been created.

The Journal of Comorbidity (JOC), an international, open-access, peer-reviewed journal for the pathophysiology, diagnosis, prevention and management of comorbidity has been inaugurated and its first issue is already posted online.

Although the name of the journal might suggest that it is devoted exclusively to articles related to the well known definition of comorbidity provided by Feinstein “any distinct additional clinical entity that has existed or may occur during the clinical course of a patient who has the index disease under study”, the first issue of JOC makes it clear that this is not the case. 

The inaugural editorial of the Editor-in-Chief clearly states that “the management of patients with comorbidity needs to consider the patient as a whole, extending beyond the primary medical speciality, and encompassing all of the coexisting complications, not just the principal disease or various conditions in isolation”.

In addition, an editorial authored by José M. Valderas, Stewart W. Mercer, and myself further explains that “the journal has opted to use comorbidity in its name, and a number of well founded reasons explain this choice: for reasons of simplicity; in order to acknowledge both the relevance of research on comorbidity for the treatment of specific conditions and the historical pre-eminence of the construct; and finally, for an awareness of evolving concepts”.

 This journal that clearly invites authors to submit papers related to both comorbidity AND multimorbidity represents another opportunity to publish research of great value.

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Multimorbidity Publications June – September 2011

October 25, 2011 – 8:40 am

By Martin Fortin

New papers on multimorbidity have been published during the June-September period of this year. I would like to share with you the titles of the most relevant articles published, along with the links to the abstracts or full texts:

1.    Findley, P., C. Shen, and U. Sambamoorthi, Multimorbidity and persistent depression among veterans with diabetes, heart disease, and hypertension. Health Soc Work, 2011. 36: p. 109-19. [PubMed abstract]
2.    Fried, T.R., et al., Health Outcome Prioritization as a Tool for Decision Making Among Older Persons With Multiple Chronic Conditions. Arch Intern Med. Sep 26. [Epub ahead of print], 2011. [Research letter; no abstract available]
3.    Gulley, S.P., E.K. Rasch, and L. Chan, The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep, 2011. 126: p. 495-507. [PubMed abstract]
4.    Harrison, M., et al., A secondary analysis of the moderating effects of depression and multimorbidity on the effectiveness of a chronic disease self-management programme. Patient Educ Couns. Jul 16. [Epub ahead of print], 2011. [PubMed abstract]
5.    Holden, L., et al., Patterns of multimorbidity in working Australians. Popul Health Metr, 2011. 9: p. 15. [Full text]
6.    Hunger, M., et al., Multimorbidity and health-related quality of life in the older population: results from the German KORA-age study. Health Qual Life Outcomes, 2011. 9: p. 53. [Full text]
7.    Khanam, M.A., et al., Prevalence and patterns of multimorbidity among elderly people in rural Bangladesh: a cross-sectional study. J Health Popul Nutr, 2011. 29: p. 406-14. [Full text]
8.    Lehnert, T., et al., Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev, 2011. 68: p. 387-420. [PubMed abstract]
9.    Parekh, A.K., et al., Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep, 2011. 126: p. 460-71. [PubMed abstract]
10.    Perruccio, A.V., J.N. Katz, and E. Losina, Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. J Clin Epidemiol. Aug 9. [Epub ahead of print], 2011. [PubMed abstract]
11.    Quiñones, A.R., et al., How Does the Trajectory of Multimorbidity Vary Across Black, White, and Mexican Americans in Middle and Old Age? J Gerontol B Psychol Sci Soc Sci. Oct 3. [Epub ahead of print], 2011. [PubMed abstract]
12.    Richardson, K., et al., Variation over time in the association between polypharmacy and mortality in the older population. Drugs Aging, 2011. 28: p.:547-60. [PubMed abstract]
13.    Starfield, B. and K. Kinder, Multimorbidity and its measurement. Health Policy. Sep 30. [Epub ahead of print], 2011. [PubMed abstract]
14.    Tinetti, M.E., et al., Contribution of Multiple Chronic Conditions to Universal Health Outcomes. J Am Geriatr Soc. Aug 30. [Epub ahead of print], 2011. [PubMed abstract]
15.    Tinetti, M.E. and S.A. Studenski, Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med, 2011. 364(26): p. 2478-81. [Full text]
16.    van Baal, P.H., et al., Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data. Popul Health Metr, 2011. 9: p. 51. [Full text]
17.    van den Bussche, H., et al., Patterns of ambulatory medical care utilization in elderly patients with special reference to chronic diseases and multimorbidity – Results from a claims data based observational study in Germany. BMC Geriatrics, 2011. 11: p. 54. [Full text]
18.    Vyas, A. and U. Sambamoorthi, Multimorbidity and depression treatment. Gen Hosp Psychiatry, 2011. 33: p. 238-45. [PubMed abstract]

Publication number 15 on the list is an article by Mary E. Tinetti and Stephanie A. Studenski published in the ‘Perspective’ section of the New England Journal of Medicine. I would like to bring to your attention its most important statements in my opinion:

“Primary outcomes tend to be disease-specific… Such outcomes work well in efficacy studies, which reveal a therapy’s effect on a specific outcome under ideal circumstances in a homogeneous population. They make less sense, however, for comparing treatments in patients with multiple chronic conditions.”

“Researchers have largely shied away from the complexity of multiple chronic conditions — avoidance that results in expensive, potentially harmful care of unclear benefit. We cannot improve health care’s quality, effectiveness, and efficiency without addressing its greatest consumers.”

It is well worth the read.

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

Martin

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Canadian clinical guidelines and multimorbidity

July 14, 2011 – 8:58 am

By Martin Fortin

Clinical guidelines aim to improve the quality of care provided to patients. However, given that guidelines are mostly disease-oriented, we may discover conflicting recommendations when implementing those guidelines with patients presenting multiple concurrent chronic conditions. As a result, physicians frequently use their own clinical experience and patients’ views on treatment choice instead of national guidelines recommendations.

This situation prompted us to examine the relevance of Canadian clinical guidelines for patients with comorbidity for selected chronic diseases. The study was published by BMC Family Practice and is accessible through their website (http://www.biomedcentral.com/1471-2296/12/74). In summary, we found that despite the good to very good quality of the guidelines, only a few addressed specific recommendations for patients with two or more comorbid conditions.

The subject had been  previously addressed from different angles, but in this study we followed the steps of Australian colleagues [1] in the use of a tool developed by Boyd and colleagues [2] that allows to evaluate the applicability of guidelines on chronic diseases for the treatment of subjects with comorbidity. The tool is a checklist in which each item is scored as “yes” or “no”, and assesses whether guidelines address treatment for people with several comorbid conditions, as well as patient-centered aspects such as patient preferences and quality of life. We improved its comprehensiveness with the addition of items related to medication. To our knowledge, this is the only tool available for this purpose.

This study may potentially stimulate other researchers to follow suit with the assessment of their respective national guidelines, and further highlight the need for improved clinical guidelines relevant to patients with two or more chronic conditions worldwide.

1.    Vitry, A.I. and Y. Zhang, Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions. Med J Aust, 2008. 189: p. 360-5.

2.    Boyd, C.M., et al., Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. J.A.M.A., 2005. 294: p. 716-24.

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Barbara Starfield (1932-2011)

June 15, 2011 – 7:04 am



By Martin Fortin

Professor Barbara Starfield, a prominent figure in primary care and other fields, died suddenly in California on Friday 10 June 2011. My colleagues and I would like to express our sincere condolences to her family, friends and colleagues.

Dr. Starfield made landmark contributions in primary care. The coexistence of multiple diseases did not escape her attention. Before the introduction of the concept of multimorbidity, Dr. Starfield realized that people should be characterized by their morbidity burden, and her work led to the development of an important methodological tool for assessing diagnosed morbidity burden: the Adjusted Clinical Groups system.1 With its use, populations can be described according to the mix of types of all conditions they experience in any given time period (including signs and symptoms as well as all types of diagnoses).

The subjects of comorbidity and multimorbidity are present in several of her publications,2-5 and my colleagues and I had the privilege of motivating her to write an editorial on one of our publications.6

In the June 9, 2011 posting that precedes this one, I brought to your attention the essential ideas I found in her last editorial published this year, which was also dedicated to co- and multi-morbdity.7 In essence, she alerted us to the fact that “it is not chronicity per se that creates a burden on the health-care system… it is the number of types of conditions, that is, multi-morbidity “.7 I believe it is our duty to honour her visionary statement and carry on her legacy.

Thank you Dr. Starfield for your inspiration.

1. Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Services Research. 1991;26(1):53-74.
2. Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med. May-Jun 2003;1(1):8-14.
3. Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med. 2005;3:215-222.
4. Valderas JM, Starfield B, Roland M. Multimorbidity’s many challenges: A research priority in the UK. BMJ. Jun 2 2007;334(7604):1128.
5. Starfield B. Co-morbidity and its challenges for quality of primary care. Rev Port Clin Geral. 2007;223:179-180.
6. Starfield B. Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med. 2006;4:101-103.
7. Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev. 2011;12:1-2.

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Multimorbidity Publications January – May 2011

June 9, 2011 – 12:18 pm

By Martin Fortin

Searching for articles published on multimorbidity this year, it has been nice to note that already there is an important new body of information covering different aspects of the subject. I would like to share with you blog visitors the titles of the most relevant publications found, along with the links to the abstracts:

–          Marengoni A et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev Mar 23 [Epub ahead of print] 2011. [PubMed abstract]

–          Salisbury C et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 2011;61:e12-21. [PubMed abstract]

–          Bower P et al. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study. Fam Pract May 25 [Epub ahead of print] 2011. [PubMed abstract]

–          Tucker-Seeley RD et al. Lifecourse socioeconomic circumstances and multimorbidity among older adults. BMC Public Health 2011;11:313. [PubMed abstract]

–          Wong A et al. Longitudinal administrative data can be used to examine multimorbidity, provided false discoveries are controlled for. J Clin Epidemiol Mar 29 [Epub ahead of print] 2011. [PubMed abstract]

–          Galenkamp H et al. Somatic Multimorbidity and Self-rated Health in the Older Population. J Gerontol B Psychol Sci Soc Sci 2011;66:380-6. [PubMed abstract]

–          Glynn LG et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract Mar 24 [Epub ahead of print] 2011. [PubMed abstract]

–          Drewes YM et al. The effect of cognitive impairment on the predictive value of multimorbidity for the increase in disability in the oldest old: the Leiden 85-plus Study. Age Ageing 2011;40:352-7. [PubMed abstract]

–          Holzhausen M et al. Operationalizing multimorbidity and autonomy for health services research in aging populations–the OMAHA study. BMC Health Serv Res 2011;11:47. [PubMed abstract]

–          Morris RL et al. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient’s prioritization of multiple conditions. Chronic Illn 2011;7:147-61. [PubMed abstract]

–          van den Bussche H et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 2011;11:101. [PubMed abstract]

–          Schüz B et al. Medication beliefs predict medication adherence in older adults with multiple illnesses. J Psychosom Res 37(6):565-74 2011;70:179-87. [PubMed abstract]

–          Schäfer I et al. Multimorbidity patterns in the elderly: a new approach of disease clustering identifies complex interrelations between chronic conditions. PLoS ONE 2010;5:e15941. [PubMed abstract]

–          Gunn JM et al. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol Dec 25 [Epub ahead of print] 2010. [PubMed abstract]

–          Thiem U et al. Prerequisites for a new health care model for elderly people with multimorbidity: the PRISCUS research consortium. Z Gerontol Geriatr 2011;44:115-20. [PubMed abstract]

–          Naessens JM et al. Effect of multiple chronic conditions among working-age adults. Am J Manag Care 2011;17:118-22. [PubMed abstract]

–          Diederichs C et al. The Measurement of Multiple Chronic Diseases–A Systematic Review on Existing Multimorbidity Indices. J Gerontol A Biol Sci Med Sci 2011;66:301-11. [PubMed abstract]

–          Lupari M et al. We’re just not getting it right’–how should we provide care to the older person with multi-morbid chronic conditions? J Clin Nurs 2011;20. [PubMed abstract]

–          Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev 2011;12:1-2. [Full text]

A comment on each of these publications is not possible here. However, I want to bring to your attention the main idea I found in the last publication on the list, which is an editorial by Barbara Starfield:

“…it is not chronic conditions by themselves that raise resource use. Rather, it is the number of types of conditions, that is, multi-morbidity.”

“…despite the attention to chronic diseases in many countries of the world, it is not chronicity per se that creates a burden on the health-care system.”

It’s worth reading entirely!

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

Martin

Comment (1)

PRECISE: Program of Research on the Evolution of a Cohort Investigating Health System Effects

April 27, 2011 – 2:54 pm

By Martin Fortin

Pr Jeannie Haggerty (PhD), principal investigator, and Dr Martin Fortin (MSc), co-principal investigator, are currently leading a research program designed to explain the changes operated by the transformation of primary healthcare services and to measure its effects on population health and in particularly vulnerable groups: the multi-morbid and the poor. This longitudinal cohort study is being conducted using mixed methods. Four interrelated studies, using three embedded cohorts (sentinel medical clinics, clinic patients and a population sample) in four local healthcare networks from three regions of Quebec (Canada) are at different stages of the research process.

Study 1, Integration of Local Services Network, explores primary care organizations’ responses to the government mandate and inter-organizational exchanges. Data collection including organizational questionnaires (self-completed by 66 primary care providers), semi-structured interviews (conducted with 17 clinicians) and document review is complete. Studies 2 and 3, Follow-up of a Patient and a Population Cohort, are measuring the effects of efficient and patient-centered healthcare services on evolution of functional health, chronic illness burden and health functioning in individuals over time. Data for the first of this three-year study were collected using questionnaires (self-completed by 786 patients and 1700 individuals of the general population) and analysis is ongoing. Study 4, Validation of Measurement Instruments, is planned for year 2 of the program.

For more information about this program and the research team, follow this link

http://www.programmeprecise.ca/en/home/

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Adaptation, implementation and evaluation of an intervention involving the integration of chronic disease rehabilitation services into primary care

April 27, 2011 – 2:30 pm


(Funded by: Pfizer-FRSQ-MSSS Chronic Disease Fund)

 By Martin Fortin and Maud-Christine Chouinard

 

Aging is associated with an increasing number of chronic diseases (CD) which represents a challenge for the healthcare system [1-2]. While traditional health care funding and management are mainly designed to address acute health conditions, the bulk of health funds is allocated to patients with CD [3]. The Chronic Care Model (CCM) suggested a multi-component remodeling of CD services to improve patient outcomes [4]. To meet the complex and ongoing needs of patients with CD, rehabilitation has been advocated as a key feature of primary care [5]. Moreover, patients with multimorbidity represent a greater challenge to primary healthcare as they are associated with high healthcare costs and poor compliance to treatment and recommendations [6-7]. In the presence of multimorbidity, health care providers acting in primary care face difficulties in applying guidelines and in maintaining continuity of care. To prevent potential health care system gaps in quality, efficiency, and effectiveness, primary care physicians have to play a gatekeeping role in the management of multimorbid patients and should be assisted in CCM integration and application. Consequently, decision makers and physicians have to look to evidence-based practice guidelines to improve the quality of care and to manage the allocation of resources as efficiently as possible[8].

In this regard, we aim to establish a clinical intervention that will adapt and permanently integrate rehabilitation services into primary care settings and to develop objective tools to assess the adaptation and implementation of this intervention in eight primary care practices in the Saguenay region (Quebec, Canada), in order to ensure the sustainability of interventions beyond the rehabilitation period. More specifically, the intervention will aim to clinically operationalize the mechanisms and tools necessary for the delivery of integrated CD services, promoting continuity of care in response to the needs expressed by stakeholders and to deploy rehabilitation services adapted to the realities of various primary care settings.

The evaluation of the implementation will be conducted using descriptive qualitative methods, while the evaluation of the effects will be based on a combination of experimental designs: randomized trial using a delayed intervention arm (n=326), a before and after design with repeated measures (n=163), and a quasi-experimental design using a comparative cohort (n=326). The qualitative evaluation will be based on focus groups and individual interviews before, during and after the implementation with various stakeholders (decision makers, primary care professionals, rehabilitation professionals and patients). Assessment of effects on patients will use self-administered questionnaires measuring chronic disease self-efficacy, health education impacts, health behaviors, quality of life, and psychological well-being.

Patients included in this study will be referred by their primary care provider and have to present at least one of the conditions for which rehabilitation is currently available (or their risk factors): diabetes, cardiovascular diseases, COPD, asthma. Total disease burden will be assessed for each patient. Data collected from participants will be analyzed in three steps according to a qualitative content analysis procedure to identify emerging themes and trends: coding, sorting of text content and analysis. In addition, the analysis will focus on shedding light on: (1) the interaction between the implementation context and the intervention on the effects obtained; (2) contextual determinants of the changes that occurred from various perspectives on organizational change, including political, structural, psychological and organizational models.

In the short-term, we are expecting improved patient self-efficacy, empowerment and self-management. In the long-term, this should result in a reduction of their risk factors, with an improvement in quality of life and psychological distress. At the organization level, the project should lead to a coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration.

Multimorbidity represents a crucial step in the process of adaptation of evidence-based medicine to the primary care reality. Among patients with CD, those presenting multimorbidity show high levels of health care utilization. It is important to increase our understanding of primary care needs in rehabilitation services and the characteristics of conceptual models of interventional approaches designed for patients followed up by family physicians. In conclusion, the integration of specialized rehabilitation services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated.

1. Fried, L.P., Epidemiology of aging. Epidemiol Rev, 2000. 22(1): p. 95-106.
2. WHO, Chronic disease risk factors. 2003.
3. Mirolla, M., The cost of chronic disease in Canada The Chronic Disease Prevention Alliance of Canada, 2008.
4. Wagner, E.H., et al., Improving chronic illness care: translating evidence into action. Health Aff (Millwood), 2001. 20(6): p. 64-78.
5. McColl, M.A., Structural determinants of access to health services for people with disabilities. Disability and social policy in Canada. 2nd ed.. Toronto: Captus Pr;, 2006: p. 293–313.
6. DiMatteo, M.R., et al., Patient adherence and medical treatment outcomes: a meta-analysis. Med Care, 2002. 40(9): p. 794-811.
7. Hughes, C.M., Medication non-adherence in the elderly: how big is the problem? Drugs Aging, 2004. 21(12): p. 793-811.
8. Wagner, E.H., B.T. Austin, and M. Von Korff, Organizing care for patients with chronic illness. Milbank Q, 1996. 74(4): p. 511-44.

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Online discussions from the early International Research Community on Multimorbidity

March 24, 2011 – 3:03 pm

By Martin Fortin

In the original website of the International Research Community on Multimorbidity, (IRCMo) most parts of the site were open access and visitors were able to navigate through different sections containing information about publications on multimorbidity, events, and links to other websites related to the subject.

However, the virtual community was a private network of researchers and clinicians who shared ideas and knowledge on multimorbidity. Access to the discussion section of the virtual community was restricted to members with a user name and a password.

Discussions within the virtual community were about two main subjects:
1)    Multimorbidity: the concept and its measure
2)    Toward a new care model for patients with multimorbidity.

Comments and ideas written by different IRCMo members in 2007 are still valid in the present time and are now openly accessible on the website of the CIHR Applied Research Chair – Health Services and Policy Research on Chronic Diseases in Primary Care (link) under the heading ‘Archives of discussions in IRCMo’.

Those interested in reading the content of early discussions of the IRCMo can access the above website directly by following this link.

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Coming soon: A new tool for multimorbidity

February 23, 2011 – 11:32 am

By Martin Fortin

Published data on chronic diseases and multimorbidity prevalence are mainly based on self-report, billing data and registries. Data, so far, show a large gap in their magnitude from one study to the other. Population-based data and primary care practice data show important discrepancies (1). Studies from several countries (2-4) used administrative data, but much variation in results is attributed to different conceptualizations of multimorbidity and various chronic disease definitions and classifications (5). The use of a validated measure or index appears promising but so far, no instrument has been formally identified for measuring multimorbidity and the resulting burden of disease either for the patient or at the practice level (6). Such an instrument would be a major contribution to the study of multimorbidity and for comparison purposes among practices, regions and countries. Resource allocation and policy making would also benefit from a robust measure that could be scored in various ways including the use of Electronic Medical Record (EMR) data.

We validated and used the Cumulative Illness Rating Scale (CIRS) in previous studies for the measure of multimorbidity using chart review (7-10).  Advantages were its exhaustive quality and the built-in assessment of severity. We have shown it to be a better predictor of health related quality of life (HRQoL) and psychological distress than the simple count of chronic diseases and it compared advantageously with other morbidity indexes when HRQoL was the outcome of interest (11-13). Others have used the count of CIRS domains as a measure of multimorbidity and have linked the domain to International Classification of Primary Care (ICPC) rubrics thus facilitating the link with EMR (14). We have shown that some domains of the CIRS did not correlate with outcomes for patients. Based on previous studies on multimorbidity (7-9, 12, 14-15) and our experience with the use of the CIRS, we developed the Multimorbidity Assessment Tool (MAT) aimed at measuring the burden of disease at patient level and to reflect on the burden for practices. The tool builds on the CIRS structure but redefines the domains to facilitate scoring. We removed the domains that were not associated with HRQoL (15). We also added other domains that were deemed more appropriate. For each domain, the score may vary from 0 to 3 depending on the number of conditions affecting the domain and their severity. The tool may generate various continuous scores depending on its use. The tool will be assessed for reliability and validity and is expected to be available in 2012..

References
1. 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.
2. van den Akker, M., et al., Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol, 1998. 51: p. 367-375.
3. Macleod, U., et al., Comorbidity and socioeconomic deprivation: an observational study of the prevalence of comorbidity in general practice. European Journal of General Practice, 2004. 10(1): p. 24-6.
4. Uijen AA, van de Lisdonk EH. Multimorbidity in primary care: prevalence and trend over the last 20 years. Eur J Gen Pract. 2008;14 Suppl 1:28-32.
5. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009 Jul-Aug;7(4):357-63.
6. van den Akker, M., et al., Problems in determining occurrence rates of multimorbidity. J Clin Epidemiol, 2001. 54: p. 675-9.
7. Hudon C, Fortin M, Vanasse A. Cumulative Illness Rating Scale was a reliable and valid index in the family practice context. J Clin Epidemiol. 2005;58:603-8.
8. Hudon C, Fortin M, Soubhi H. Abbreviated guidelines for scoring the Cumulative Illness Rating Scale (CIRS) in family practice. Disponible à : www.elsevier.com/locate/clinepi J Clin Epidemiol. 2007; 60 :212.e1-e3.
9.  Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005;3:223-28.
10. Fortin M, Steenbakkers K, Hudon C, Poitras ME, Almirall J, van den Akker M. The electronic Cumulative Illness Rating Scale: a reliable and valid tool to assess multimorbidity in primary care. Journal of Evaluation in Clinical Practice. Published online June 25th, 2010.
11. Fortin M, Bravo G, Hudon C, Lapointe L, Dubois MF, Almirall J. Psychological distress and multimorbidity in primary care. Ann Fam Med. 2006;4:417-22.
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