January 19, 2017 – 2:06 pm
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.
.
Reference
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.
February 22, 2016 – 2:09 pm
By Aline Ramond-Roquin and Martin Fortin
In a recent
provocative blogpost [1] hosted by the Canadian Medical Association Journal, the associate editor Domhnall MacAuley initiated an interesting discussion on the challenges general practice research currently faces. We would like to extend the reflection and to discuss some issues relevant for multimorbidity research.
First, we somewhat disagree on the fact that academic general practitioners have “become less and less embedded in daily patient care”. Many of them still deliver “personal, primary and continuing care”. The traditional model of single-handed practitioners offering “twenty four hour access to patients” is quite obsolete, but this reflects the evolution of general practice rather than a specific characteristic of academics.
Indeed, general practitioners can no longer single-handedly fill the increasingly complex needs of their patients. Patients living with multimorbidity, who are now considered the rule in primary care, need interdisciplinary care. The current evolution towards increasing interdisciplinary work has generated specific research questions which require lowering some traditional barriers in the academic setting and developing interdisciplinary research, to appropriately address them. In this regard, having non-doctor primary care researchers in academic departments of general practice should neither be reduced to a question of “cost-effectiveness”, nor be considered as a threat for general practice research, as suggested in the CMAJ blogpost. Rather, collaborations within interdisciplinary teams are definitely an advantage to undertake research in complex fields such as multimorbidity. In these teams, general practitioners with significant clinical activity have a crucial and irreplaceable role.
Finally, meaningful research for people living with multimorbidity is often based on complex designs, such as multi-level epidemiological studies or pragmatic trials. We therefore strongly argue for scientific journals not neglecting research grounded in the real world of practice. They should not only focus on “sample size” and “international generalizability”, but should also be concerned by clinical relevance and potential for implementation and transferability in different contexts. Producing and publishing practice-based evidence is required to practice evidence-based medicine relevant to the context, with the potential to eventually improve the life of our patients.
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[1] http://cmajblogs.com/thinking-the-unthinkable-about-general-practice-research/
By Aline Ramond-Roquin
This recently published study (1) is part of my thesis in public health untitled “Risk factors, comorbidity and management of non-specific low back pain in general practice”, undertaken in the University of Angers, France, in partnership with the Department of Primary and Community Care of Nijmegen, The Netherlands.
Literature has suggested that patients with chronic low back pain (CLBP) presented higher level of psychosocial, musculoskeletal and somatoform comorbidity than general population. As such morbidity is particularly common in primary care, we were interested in the following question: in general practice, do patients presenting with CLBP more often present psychosocial, musculoskeletal and somatoform problems than patients presenting with other problems?
We extracted data from the Transition Project, a long-standing, experienced primary care practice-based network that has been systematically and prospectively coding the diagnoses related to all the encounters between the patients and their general practitioners, using the international classification of primary care. We compared the prevalence of the problems presented by 1511 patients with CLBP with those of their 1511 matched patients without CLBP, focusing on the period from one year before the beginning of an episode of care for CLBP to two years after it. Patients with CLBP presented higher prevalence of musculoskeletal problems but similar prevalence of psychosocial and non-musculoskeletal somatoform problems, compared to other patients consulting in the same setting. Therefore we concluded that:
1) General practitioners should be aware of the frequency of multi-site musculoskeletal disorders, whether synchronous or metachronous, and adopt an integrated approach when caring for patients with such problems.
2) Rather than systematically screening for specific psychological, social or somatoform disorders, they should consider with the patient how CLBP and any type of potential comorbidity interfere with his/her daily functioning.
Reference
1) Ramond-Roquin A, Pecquenard F, Schers H, Van Weel C, Oskam S, Van Boven K. Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project. Fam Pract. 2015 Jun;32(3):297–304
