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Monthly Archives: December 2013


Quality indicators for functional status and quality of life in people with multimorbidity: Are we ready?

Sydney Dy, Elizabeth Pfoh, and Cynthia Boyd

Patients with multimorbidity suffer from multiple concurrent diseases that may affect their functional status and quality of life. Quality measurement that incorporates functional status and quality of life domains could be a valuable approach to complement the many disease-centered quality measures, and might help guide improvement in care. However, since multiple factors can influence functional status and quality of life, incorporating these outcomes into measures of the quality of health care may be challenging, especially in the population with multimorbidity.  To address this concern, we published a review in the Journal of the American Geriatrics Society [1] that aimed to inform initiatives that are developing quality indicators addressing functional status and health-related quality of life for patients with multimorbidity.  

We reviewed key sources of indicators (such as the National Quality Forum and Agency for Healthcare Research and Quality) to find quality indicators for quality of life and functional status relevant to this population in the outpatient arena. We also interviewed key informants who are using these outcomes in quality indicator projects that include or focus on the population with multimorbidity.

We found few relevant quality indicators for people with multimorbidity; existing indicators are used only for specific populations or settings, are challenging to implement, and have issues with validity. Key informants discussed concerns about the validity of existing indicators for differentiating quality of care between systems, and concerns about their use in a population where physical function for many people is naturally declining over time. Additionally, they raised concerns about consistent documentation for these quality indicators across providers.  Another challenge is defining the appropriate sampling population for the indicators.  

Across countries, quality measurement is used for varied purposes, ranging from financial incentives to accountability and quality improvement.  Avoiding unintended consequences through the use of such quality indicators is essential, as it may be most challenging to improve these outcomes in the most vulnerable populations.  Fundamental to the consideration of using quality indicators that focus on functional status and quality of life is improving the evidence base for how to improve these outcomes for people with multimorbidity – and this is still a limited, albeit growing, evidence base.

A potential first step to better integrate these outcomes into quality initiatives might be to implement standards for infrastructure to routinely collect this data from patients in clinical care.

1. Dy SM, Pfoh ER, Salive ME, Boyd CM. Health-Related Quality of Life and Functional Status Quality Indicators for Older Persons with Multiple Chronic Conditions. Epub, J Am Geriatr Soc. 2013 Dec 9.

Multimorbidity in two large Australian primary care practices

By Tom Brett

The Annals of Family Medicine recently published our research on multimorbidity among 7,247 patients attending two large Australian primary care practices (1). Our study set out to examine patterns and prevalence of multimorbidity and to estimate disease severity burden using the Cumulative Illness Rating Scale (CIRS).
We adhered strictly to Miller et al’s approach (2,3) in assessing number of body domains affected, the total score, the ratio of total score to number of domains (yielding a severity index), and importantly, the number of domains with maximum scores at levels 3 and 4. Highlighting the number of domains with severity scores of 3 and 4 is important as it helps guard against severity underestimation especially if there is a risk of severity index dilution with increased numbers of level 1 and 2 scores.
Our purposefully collected data, using combination of free-text electronic records, older hard copy files based on histories recorded by primary care physician, hospital discharge and outpatient letters and radiology and pathology reports, was extremely hard work and not for the fainted hearted! We feel our purposefully collected, multisource medical record data, based on 42 conditions across 14 domains and involving patients across the entire age spectrum provides further useful information for those interested in multimorbidity in primary care.
Our current research interest in the area involves patterns and prevalence of multimorbidity and disease severity burden involving disadvantaged and street-based populations.

1.    Brett T, Arnold-Reed DE, Popescu A, et al. Multimorbidity in patients attending 2 Australian primary care practices. Ann Fam Med 2013; 11(6): 535-542.
2.    Miller MD, Towers A. A manual of guidelines for scoring the Cumulative Illness Rating Scale for geriatrics (CIRS-G). Pittsburg, PA: University of Pittsburgh, 1991.
3.    Miller MD, Paradis CF, Houch PR, et al. Rating chronic illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res. 1992; 41 (3): 237-248.

The definition of multimorbidity: looking for a consensus

By Martin Fortin

We published recently a bibliometric study of English language publications indexed from 1970 to 2012 that showed a diversity of terms used to describe the presence of multiple concurrent diseases: comorbidity, multimorbidity, polymorbidity, polypathology, pluripathology, multipathology, multicondition [1]. Comorbidity was overwhelmingly used when one disease/condition was designated as index, as described by Feinstein [2]. Multimorbidity was the term most often used when no disease/condition was designated as index, but several different definitions exist.
We would like to invite you to have a look at the results of the bibliometric study and then to complete a two-question survey that should take you approximately one minute to complete. The questions are:
1-Which definition do you think should be used for multimorbidity?
a) Multiple co-occurring chronic or long-term diseases or conditions, none considered as index disease.
b) Multiple co-occurring diseases or conditions, none considered as index disease.
c) Any of the above definitions.
d) Another definition (please, provide a definition or a reference):


2-What is your country of origin? ____________________________

The deadline to participate in the survey is January 31, 2014. We would like to receive input from as many people as possible. Please consider completing the survey as your input is very important. Many thanks for your help.
Results of the survey will be posted in February 2014.

Click here to complete the survey

[1] Almirall J, Fortin M. The coexistence of terms to describe the presence of multiple concurrent diseases. Journal of Comorbidity. 2013;3(1):4-9.
[2] Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic diseases. J Chronic Diseases. 1970;23:455-469.