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
By Alessandra Marengoni
Despite the increasing interest of the researchers in the topic of multimorbidity, there is still a remarkable gap between the harmful impact of multimorbidity at the individual and societal level and the amount of scientific and clinical research devoted to this topic. To (partly) cover for this lack of multimorbidity research Alessandra Marengoni (lead guest editor, Brescia, Italy), Alexandra Prados Torres (Zaragosa, Spain), Graziano Onder (Rome, Italy) and René Melis (Nijmegen, the Netherlands) are guest editing a special issue with Biomed Research International on the topic of multimorbidity. We believe that this maybe a very nice opportunity to provide a comprehensive, impactful overview of this highly relevant topic. We warmly welcome original research articles as well as review articles that seek to address epidemiology of multimorbidity both in the general population and in clinical settings.
Do not hesitate to contact one of us for any questions you may have related to this call or pre-submission inquiries.
For details on the call:
http://www.hindawi.com/journals/bmri/si/217914/cfp/
By Martin Fortin
Our search for papers on multimorbidity that were published during the period November 2014-March 2015 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.
By Elizabeth Magnan
To support research on patients with multiple chronic conditions, researchers and clinicians (Principal Investigator: Elizabeth Magnan, MD, PhD) at the University of Wisconsin-Madison School of Medicine & Public Health and the University of California-Davis have created indicator variables for the presence or absence of 69 chronic conditions that are available in a toolkit for free download at www.HIPxChange.org/Comorbidities. These variables can be used to identify patient chronic conditions in health care and billing records.
To create this comprehensive set of variables, we combined 358 clinical categories from the Agency for Health Care Quality and Research (AHRQ) Healthcare Cost and Utilization Project’s (HCUP) Clinical Classification Software (CCS) that cover 4,427 ICD-9 codes, identified as chronic conditions by HCUP’s Chronic Condition Indicator, into 69 clinically-relevant condition categories, including modifications from a previous set of conditions to incorporate recent CCS updates and further highlight metabolic and cardiovascular conditions.
The toolkit is intended for researchers interested in examining the effect of multiple chronic conditions or specific comorbidities on health and outcomes, or for those who are interested in quality improvement or public reporting on patients with comorbid conditions. Results could be utilized to inform policy development, provision of care, and allocation of resources.
The toolkit contains an Excel file that you can download and then import into your statistical program. It contains ICD-9 diagnostic codes mapped to AHRQ Clinical Classification Software (CCS) codes that have been identified as chronic conditions per the AHRQ chronic condition indicator. The CCS codes are then bundled into 69 clinically relevant chronic condition categories.
The chronic conditions diagnostic codes can be assessed in any patient timeframe desired. Past work has identified multiple chronic conditions during the baseline year and during both baseline and reporting years.
January 16, 2015 – 10:46 am
By Martin Fortin
A recent editorial of the Journal of Comorbidity, Susan Smith, Stewart Mercer, Jane Gunn, Marjan van den Akker, and Martin Fortin announced that the journal is now offering authors the opportunity to publish a summary of their study protocols. As the focus and scope of the journal (pathophysiology, prevention, diagnosis and management of comorbidity/multimorbidity) are in line with the interests of the readers of this blog, we considered that it was important to share this information with our readers.
The publication of study protocols in a peer-reviewed journal contributes to increase research quality and transparency, encourages communication and collaboration between research groups, helps avoid research duplication, and engenders the expectation of dissemination of final results.
We think that this new move of the Journal of Comorbidity may contribute to enhance research quality and reporting of studies in the field of multimorbidity.
December 10, 2014 – 11:01 am
By Martin Roland
Are single disease guidelines and indicators are going out of fashion? Well they are with people interested in multi-morbidity. The argument is straightforward. Single disease guidelines are usually based on trials which exclude people with multiple complex problems. So how does the physician know how a cholesterol guideline developed from trials on 65 year old CHD patients relates to the 85 year old in front of him with seven other comorbid conditions? The risks of polypharmacy are increased as the number of prescribed meds goes up, so what is the physician to do? Does he follow eight disease guidelines for the old lady in front of him? Or is there another way?
Well, Victor Montori thinks there needs to be. He gave the opening keynote at this year’s NAPCRG conference. Despite being an endocrinologist, he sees clear problems in attempting to apply multiple single disease guidelines to our increasingly multi-morbid patients. His answers were about meaningful engagement with patients and their priorities, and shared decision making which takes into account a clear explanation of risks, benefits and alternative treatment approaches. That’s good, but it’s not good enough. We’ve opened up an intellectual space by criticising the single disease approach in multi-morbid older populations, but we haven’t yet filled it adequately.
A number of major problems remain. Here are two.
First is the assumption that more is worse. This may be true, and certainly polypharmacy is both hazardous and responsible for substantial morbidity. However, although many trials exclude people with multi-morbidity, the absolute risks faced by the very elderly may be greater than for patients included in trials. So the benefits may be greater too. We often just don’t know. But we certainly shouldn’t assume we shouldn’t be treating people just because they’re old and frail. Surprisingly, polypharmacy doesn’t seem to be a risk factor for unscheduled hospital admission in highly multi-morbid patients.
Second, a primary care physician may be uneasy about the patient in front of him on 15 medications, but it’s hard to know which one to stop. Which diabetic patient doesn’t need tight glucose control? Which stroke patient doesn’t need close blood pressure monitoring? So it’s not only hard for the physician to know if he or she is providing the best care for people, it’s hard for other people to know too. Part of the reason that quality indicators for single diseases have gained such prominence (e.g. in P4P schemes) is that physicians increasingly have to demonstrate that they are providing high quality care. And that won’t go away just because our patients are becoming older and more complex.
So here’s a real challenge to the academic primary care community. We’ve exposed many of the weaknesses of single disease guidelines and quality indicators. But we haven’t put anything adequate in their place. We’ve opened up an intellectual space, but we haven’t filled it. No-one else is going to lead the way on this. It’s up to us, or the single disease paradigm will continue to dominate.
(This post was originally published in CMAJBlogs.com)
November 27, 2014 – 11:31 am
By Martin Fortin
Our search for papers on multimorbidity that were published during the period July-October 2014 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.
October 22, 2014 – 7:37 am
By Stewart Mercer, Chris Salisbury and Martin Fortin
The ABC of multimorbidity is a book (64 pages) recently published by WILEY Blackwell seeking to explore some important issues on the subject. Contributors to the book were Marjan van den Akker, Elizabeth A. Bayliss, Peter Bower, Sonny Cejic, Peter Coventry, Martin Fortin, Katie I. Gallacher, Linda Gask, Jane Gunn, Karen Kinder, Frances Mair, Carl May, Stewart W. Mercer, Victor Montori, Christiane Muth, Ignacio Ricci-Cabello, Martin Roland, Chris Salisbury, Efrat Shadmi, Moira Stewart, Amanda L. Terry, José M. Valderas, Concepción Violán, and Jonathan P. Weiner.
Divided in 12 chapters, the book addresses the prevalence of multimorbidity, its impact on patients, the relationship between physical and mental health problems, and how managing multiple health problems concurrently can create a heavy burden of treatment for patients. At the heart of the book is the authors’ shared conviction that health care should be person -centered.
Due to space limitations each chapter is rather short. We hope that experts on the subject do not judge us too severely for the limited amount of information we could provide, and that busy physicians looking for an informative and practical source of knowledge will find this book useful.
By Martin Fortin
Our search for papers on multimorbidity that were published during the period March-June 2014 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.
