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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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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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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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Obstructive sleep apnea and multimorbidity

October 31, 2012 – 9:01 am

By Laurence Robichaud-Hallé

A paper entitled Obstructive sleep apnea and multimorbidity was recently published in BMC Pulmonary Medicine. The work described was carried out in the course of completing a Master’s degree in Clinical Sciences at the Université de Sherbrooke, Quebec, Canada, under the supervision of Dr. Martin Fortin and Dr. Michel Beaudry. Obstructive sleep apnea (OSA) poses a major public health problem due to its prevalence, severity and socioeconomic burden. According to the Public Health Agency of Canada, 858,900 Canadians reported suffering from sleep apnea, and almost 26% of Canadians are at high risk of developing the condition (http://www.phac-aspc.gc.ca/cd-mc/sleepapnea-apneesommeil/ff-rr-2009-eng.php).

Multimorbidity—defined as the co-occurrence of two or more chronic diseases—is highly prevalent in primary care. One study reported that multimorbidity is observed in patients with OSA (1), but, to our knowledge, ours is the first to analyse the association between OSA and multimorbidity.

Our study revealed an association between severe OSA and severity of multimorbidity as measured by the Disease Burden Morbidity Assessment (DBMA) (2). The relationship was still present after adjusting for several potential confounders. The study also showed an association between OSA and multimorbidity sub-scores (cardiac, vascular, metabolic syndrome).

Primary care providers should be aware of these potential associations and investigate OSA when deemed appropriate.

This research received financial support from the CIHR Applied Research Chair – Health Services and Policy Research on Chronic Diseases in Primary Care/Canadian Institutes of Health Research-Institute of Health Services and Policy Research, Canadian Health Services Research Foundation and Centre de santé et de services sociaux de Chicoutimi.

References

1)     Smith R, Ronald J, Delaive K, Walld R, Manfreda J, Kryger M: What are obstructive sleep apnea patients being treated for prior to this diagnosis? Chest 2002, 121:164–172.

2)     Poitras M-E, Fortin M, Hudon C, Haggerty J, Almirall J: Validation of the disease burden morbidity assessment by self-report in a French-speaking population. BMC Health Service Research 2012, 12:35.

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Publications on multimorbidity May – August 2012

October 10, 2012 – 7:47 am

By Martin Fortin

Since last year, I have been sharing with you blog visitors the results of literature searches for the latest published papers on multimorbidity that we do on a regular basis. Many new papers on multimorbidity have been published during the May-August period of this year. Usually, the titles of all publications are listed here in the post. However, this time the number of publications in the list is too long for this venue so instead of listing the publications here, a pdf document including the publications has been prepared and can be accessed following this link.

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

It is nice to note that an important body of information covering different aspects of the subject is growing each year. To provide an idea of the increase of the number of publications on multimorbidity we did a simple search in Medline using the word multimorbidity. Articles published in any language were considered. The graph below shows how the number of publications at least mentioning multimorbidity has increased since the year 2000.

It looks like the many challenges of multimorbidity are attracting more researchers on the subject.

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Multimorbidity publications January – April 2012

June 13, 2012 – 9:07 am

By Martin Fortin

Dear colleagues,

I would like to share with you the results of our latest literature search for papers on multimorbidity published between January and April 2012, along with the links to the abstracts or full texts:

1. Hudon C, Fortin M, Poitras M-E, Almirall J. The relationship between literacy and multimorbidity in a primary care setting. BMC Family Practice. 2012;13:33. [Full Text]

2. France EF, Wyke S, Gunn JM, Mair FS, McLean G, Mercer SW. Multimorbidity in primary care: a systematic review of prospective cohort studies. Br J Gen Pract. Apr 2012;62(597):297-307.[Abstract]

3. Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev (2):CD003638. 2012;4:CD006560.[Abstract]

4. Schafer I, Hansen H, Schon G, et al. The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. first results from the multicare cohort study. BMC Health Serv Res. 2012;12:89.[Full Text]

5. Spruit-van Eijk M, Zuidema SU, Buijck BI, Koopmans RT, Geurts AC. To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients? Arch Phys Med Rehabil 2012.93(6):1021-1026.[Abstract]

6. Fuchs J, Busch M, Lange C, Scheidt-Nave C. Prevalence and patterns of morbidity among adults in Germany. Results of the German telephone health interview survey German Health Update (GEDA) 2009. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. Apr 2012;55(4):576-586. [Abstract]

7. Agborsangaya CB, Lau D, Lahtinen M, Cooke T, Johnson JA. Multimorbidity prevalence and patterns across socioeconomic determinants: a cross-sectional survey. BMC Public Health. 2012;12:201.[Full text]

8. Diederichs CP, Wellmann J, Bartels DB, Ellert U, Hoffmann W, Berger K. How to weight chronic diseases in multimorbidity indices? Development of a new method on the basis of individual data from five population-based studies. J Clin Epidemiol. Jun 2012;65(6):679-685.[Abstract]

9. Fortin M, Stewart M, Poitras M-E, Almirall J, Maddocks H. A Systematic Review of Prevalence Studies on Multimorbidity: Toward a More Uniform Methodology. Ann Fam Med. 2012;10:142-151.[Full Text]

10. Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med. Mar-Apr 2012;10(2):134-141.[Full Text]

11. Goodman RA, Parekh AK, Koh HK. Toward a more cogent approach to the challenges of multimorbidity. Ann Fam Med. Mar-Apr 2012;10(2):100-101. [Full Text]

12. Schneider F, Kaplan V, Rodak R, Battegay E, Holzer B. Prevalence of multimorbidity in medical inpatients. Swiss Med Wkly. 2012;142:w13533. [Full Text]

13. Prados-Torres A, Poblador-Plou B, Calderon-Larranaga A, et al. Multimorbidity patterns in primary care: interactions among chronic diseases using factor analysis. PLoS One. 2012;7(2):e32190. [Full Text]

14. Bower P, Harkness E, Macdonald W, Coventry P, Bundy C, Moss-Morris R. Illness representations in patients with multimorbid long-term conditions: Qualitative study. Psychol Health. Mar 5 2012. [Abstract]

15. Garcia-Olmos L, Salvador CH, Alberquilla A, et al. Comorbidity patterns in patients with chronic diseases in general practice. PLoS One. 2012;7(2):e32141. [Full Text]

16. Nagl A, Witte J, Hodek JM, Greiner W. Relationship between multimorbidity and direct healthcare costs in an advanced elderly population. Results of the PRISCUS trial. Z Gerontol Geriatr. Feb 2012;45(2):146-154. [Abstract]

17. Poitras M-E, Fortin M, Hudon C, Haggerty J, Almirall J. Validation of the disease burden morbidity assessment by self-report in a French-speaking population. BMC Health Service Research. 2012;12:35. [Full Text]

18. Cheung CL, Nguyen US, Au E, Tan KC, Kung AW. Association of handgrip strength with chronic diseases and multimorbidity : A cross-sectional study. Age (Dordr). Feb 8 2012. [Abstract]

19. Freund T, Kunz CU, Ose D, Szecsenyi J, Peters-Klimm F. Patterns of multimorbidity in primary care patients at high risk of future hospitalization. Popul Health Manag. Apr 2012;15(2):119-124. [Abstract]

20. Kirchberger I, Meisinger C, Heier M, et al. Patterns of multimorbidity in the aged population. Results from the KORA-Age study. PLoS One. 2012;7(1):e30556. [Full Text]

21. Perruccio AV, Katz JN, Losina E. Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. J Clin Epidemiol. Jan 2012;65(1):100-106. [Abstract]

22. Harrison M, Reeves D, Harkness E, 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. Apr 2012;87(1):67-73. [Abstract]

23. Schuz B, Wurm S, Warner LM, Ziegelmann JP. Self-efficacy and multiple illness representations in older adults: a multilevel approach. Psychol Health. Jan 2012;27(1):13-29. [Abstract]

24. Gunn JM, Ayton DR, Densley K, et al. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol. Feb 2012;47(2):175-184. [Abstract]

25. McCann L, Lloyd F, Parsons C, et al. “They come with multiple morbidities”: a qualitative assessment of pharmacist prescribing. J Interprof Care. Mar 2012;26(2):127-133. [Abstract]

26. Vogel I, Miksch A, Goetz K, Ose D, Szecsenyi J, Freund T. The impact of perceived social support and sense of coherence on health-related quality of life in multimorbid primary care patients. Chronic Illn. Apr 19 2012. [Epub ahead of print] [Abstract]

27. Henninger DE, Whitson HE, Cohen HJ, Ariely D. Higher medical morbidity burden is associated with external locus of control. J Am Geriatr Soc. Apr 2012;60(4):751-755. [Abstract]

28. Kamerow D. How can we treat multiple chronic conditions? BMJ. 2012;344:e1487. (No abstract available)

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

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Literacy and multimorbidity

May 7, 2012 – 8:00 am

By Catherine Hudon

In the wake of prevention and intervention strategies developed to address multimorbidity, the identification of risk factors and of people most at risk, is an important aspect. Aging and low socioeconomic status are already clearly associated with an increased incidence of multimorbidity. Without directly measuring multimorbidity, many studies have also assessed a relationship between low literacy and poorer health status using global health measures which raises the possibility of an independent association between literacy or health literacy and multimorbidity.

We conducted a study to evaluate the relationship between literacy and multimorbidity while controlling for potential confounders. In this research, we used a more detailed instrument to measure patients’ disease burden than the studies supporting the existence of a relationship between health literacy and global health measures. The results of the study, recently published in BMC Family Practice, suggest that low literacy is associated with the presence of multimorbidity in adults consulting in primary care in bivariate analysis, but this association was no longer present when controlling for age and family income.

Patients with multimorbidity may have specific diseases that are associated with low literacy, but further studies are needed to identify individual diseases and combinations of diseases linked to literacy while controlling for potential confounding variables.

Although we did not observe a direct association between literacy and multimorbidity, it is still important to continue taking this variable into account in patient care in order to tailor health information to patient needs and in a format they can understand.

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Review of Interventions for improving outcomes in patients with multimorbidity

April 19, 2012 – 8:43 am

By Susan Smith

We have finally published our Cochrane systematic review of Interventions for improving outcomes in patients with multimorbidity in primary care and community settings (1). This is now available on the Cochrane Library with related podcasts in English, French and Spanish.

The review aimed to determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings.

 We searched a range of international databases in April 2011. We included randomised controlled trials, controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS). Participants included any patients identified as having multimorbidity, i.e., two or more chronic conditions but we excluded studies where multimorbidity was not explicitly defined and reported. Outcomes included any validated measure of physical or mental health, psychosocial status including quality of life and measures of disability or functional status. We also included measures of patient and provider behaviour including medication adherence, utilisation of services and costs. Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible due to the variation in study participants and in interventions so we carried out a narrative synthesis of the results from the included studies. 

 We identified ten studies examining a range of complex interventions for patients with multimorbidity. All were randomised controlled trials with a low risk of bias. Two of the ten studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team-work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings. 

 The review highlights the paucity of research into interventions to improve outcomes for people with multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. There is a need for further studies with clear definitions of participants, consideration of appropriate outcomes, and interventions targeted at specific patient difficulties.

 1-  Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD006560. DOI: 10.1002/14651858.CD006560.pub2.

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The thematic analysis of patient-centered care: Looking at patients with chronic diseases seen in family medicine

February 28, 2012 – 4:25 pm

By Catherine Hudon

For the management of patients with multiple chronic conditions, patient-centered care suggests taking a holistic approach to these patients and their health care by considering all aspects of the person’s situation [1-2]. Much patient-centered care evidence in family medicine relies on Stewart et al.’s model [3-5]. Therefore, we decided to present a synthesis of the results of research and discourse lines on main dimensions of patient-centered care in the context of chronic disease management in family medicine, building on Stewart et al.’s model.

We conducted a systematic review of the literature and performed a thematic analysis of the 32 articles included. We identified six majors themes: (1) starting from the patient’s situation; (2) legitimizing the illness experience; (3) acknowledging the patient’s expertise; (4) offering realistic hope; (5) developing an ongoing partnership; (6) providing advocacy for the patient in the health care system.

Our analysis shows that the context of chronic disease management brings forward new dimensions of a patient-centered interaction between the patient and the physician such as legitimizing the illness experience, acknowledging patients’ expertise and offering hope, and proposes the involvement of the family physician in transitions in care as a component of patient-centered care. Chronic disease management also brings a longitudinal component into perspective and all the dimensions of the concept could be better captured with a measure considering a certain period of time, not only the last visit with a physician.

The abstract can be accessed online [6]:

[1] Boyd CM, Fortin M. Future of Multimorbidity research: How Should Understanding of Multimorbidity Inform Health System Design? Public Health Reviews. 2010;32:451-74 (available at http://www.publichealthreviews.eu/upload/pdf_files/8/Boyd_forwebsite.pdf).
[2] Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care desired by elderly patients with multimorbidities. Fam Pract. 2008;25:287-93.
[3] Stewart MA, Belle Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. 2e ed. Cornwall: Radcliffe Medical Press Ltd; 2003.
[4] Stewart M, Belle Brown J, Donner A, McWhinney IR, Oates J, Weston WW, et al. The Impact of Patient-Centered Care on Outcomes. The Journal of Family Practice. 2000;49:796-804.
[5] Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ. 2001;323:908-11.
[6] Hudon C, Fortin M, Haggerty J, Loignon C, Lambert M, Poitras ME. Patient-centered care in chronic disease management: a thematic analysis of the literature in family medicine. Patient Education and Counseling. 2012;8:170-176.

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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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