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Monthly Archives: January 2013

A survey on the definition of multimorbidity: WE NEED YOUR INPUT!

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?
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?
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?
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.

International collaborative research initiative to design interventions for patients with multimorbidity in primary health care

By Martin Fortin

As part of the 2012 Annual Meeting of the North American Primary Care Research Group (NAPCRG), participants from different disciplines and fields of expertise had the opportunity to take part in the “International collaborative research initiative to design interventions for patients with multimorbidity in primary health care” to discuss and share ideas and perspectives with each other.

This forum was initiated and organized by six researchers: Martin Fortin, MD, MSc; Elizabeth A. Bayliss, MD, MSPH; Stewart Mercer, MBChB, PhD; Susan Smith, MD, MSc; Jane Gunn, MBBS, FRACGP, PhD, DRANZCOG; Mogens Vestergaard, MD, PhD. The forum aimed to use a group process to identify a set of attributes relevant to interventions in multimorbidity, to share findings and to identify potentially important future directions for improving generalist patient-centered care of persons with multimorbidity in primary care settings.

Participants came from different organizations across the USA, Canada, Australia, Denmark, Ireland and the UK which fostered discussions enlightened by different perspectives and experiences. The forum’s organizers gave very short presentations on a number of topics (list presented below*) before handing the floor over to participants for very enthusiastic small group and plenary discussions.

The organizers would like to thank and congratulate each one of the participants for so generously sharing their wide-ranging perspectives and to inform them that the lead group is planning to write a paper based on the forum’s discussions and the work leading up to it.

*Presentation list (summary):
-Concepts and definitions for multimorbidity interventions (M Fortin)
-Systematic review of interventions to improve outcomes for patients with multimorbidity in primary care and community settings (S Smith)
-Outcomes for multimorbidity interventions (E Bayliss)
-Preliminary findings of an exploratory cluster RCT of a primary care-based complex intervention for multimorbid patients living in areas of high deprivation in Scotland: The CARe Plus Study (S Mercer)
-Co-designing an intervention for improving care for those with severe and enduring mental health problems (J Gunn)
-Integration of chronic disease prevention and management services into primary health care: The PR1MaC Study (M Fortin)
-Interventions for multimorbid patients in Denmark (M Vestergaard)

From left to right:
Chris Salisbury, Stewart Mercer, Susan Smith, Mogens Vestergaard,
Martin Fortin, Jane Gunn, Elizabeth A. Bayliss and Sally Wyke. 

The impact of Multiple Chronic Diseases on ambulatory care use

By Elizabeth Muggah

Our paper, The impact of Multiple Chronic Diseases on ambulatory care use; a population based study in Ontario, Canada, was recently published in BMC Health Services Research. This study is an important addition to what we know about the burden of multimorbidity on the primary care system as we focused specifically on ambulatory health care use and looked at the burden of disease on both the patient and on the health system more broadly.

This research was completed using health administrative data housed at the Institute of Clinical Evaluative Sciences (ICES) in Toronto, Canada. We used well validated methods to search administrative data in one large province of Canada to identify persons who had at least one of nine common chronic diseases (diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure).  We then identified the number of outpatient primary care and specialist visits over a 2 year period.

We found that multiple chronic diseases were common among the Ontario population, (in 2009, 26.3% of Ontarians had one chronic disease, 10.3% had two diseases, and 5.6% had three or more diseases). The annual number of primary health care visits per patient increased significantly with each additional chronic disease and patients with two or more diseases made more than twice as many visits each year to primary health care providers compared to specialists. At the extremes of age we saw an increase in the number of primary care visits across all groups while specialist care dropped off. Looking from a health system perspective we found the largest total number of visits were made by those with no or one chronic disease compared to those with multiple diseases.

This study reinforces what we know about the considerable burden of illness felt by persons with multiple chronic diseases and confirms that these patients seek care disproportionately from their primary care providers.  However from a health system perspective those with no or one chronic disease are responsible for the largest number of ambulatory health care visits.  In our view continued investment in primary health care is needed both to care for those with multiple diseases as well as to maintain a focus on preventing the accumulation of chronic diseases with advancing age.  It would be important to explore these trends over time to see if the pattern of health care use we found is changing given the predicted rise in the prevalence of multiple chronic diseases with the aging of our population.