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Monthly Archives: April 2018

Qualitative research

Identifying key outcomes for multimorbidity research

April 19, 2018 – 11:52 am

By Susan M Smith, Emma Wallace, Chris Salisbury, Maxime Sasseville, Elizabeth Bayliss, Martin Fortin
A new study has identified the most appropriate outcomes to assess in studies examining interventions for patients who suffer from multiple chronic medical conditions (multimorbidity). It has been conducted by researchers from RCSI (Royal College of Surgeons in Ireland). The study was carried out by the Health Research Board (HRB) Centre for Primary Care Research at RCSI’s Department of General Practice in collaboration with researchers from the University of Bristol, in the United Kingdom, the University of Sherbrooke in Canada and the University of Colorado din the USA . The study was published in the leading US primary care journal, the Annals of Family Medicine [1].
Multimorbidity is present in a patient when the individual has two or more chronic medical conditions. These patients are more likely to experience decreased quality of life, functional decline and increased need for healthcare. They often need to take several medications (polypharmacy) and can experience fragmented care due to involvement with multiple healthcare providers. There is growing interest in trying to identify effective interventions that can improve outcomes for patients with multimorbidity. We conducted a study to identify which outcomes should be prioritised in these studies. We used a Delphi consensus process involving 26 researchers, clinicians and patients from 13 countries.
This panel of international experts agreed that clinical trials of multimorbidity should measure and report, at minimum, quality of life, mortality, and mental health outcomes. The panel reached consensus on 17 core outcomes for multimorbidity research in total. The highest ranked outcomes were health-related quality of life, mental health outcomes and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); outcomes related to the medical visit (communication, shared decision-making, prioritization); and health systems outcomes (healthcare utilization, costs, quality of healthcare). The authors suggest that, when designing studies to capture important domains in multimorbidity, researchers consider the full range of outcomes based on study aims and interventions.
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1. Smith SM, Wallace E, Salisbury C, et al. A Core Outcome Set for Multimorbidity Research (COSmm). Ann Fam Med 2018;16(2):132-38.
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Qualitative research

A general practice street health service

April 12, 2018 – 12:04 pm

By Tom Brett
This qualitative study [1] explores patient and allied health staff perspectives of a street-based, primary health service with the aim of identifying factors that influence patient access and management.
It is a useful companion paper to our recent 10-year retrospective cohort study [2] of multimorbidity among marginalised patients attending the Freo Street Doctor service.
Key themes emerging from the research included better doctor-patient empathy, better understanding of patient circumstances, fostering of social capital and facilitating referral pathways to health and social services.
The researchers noted that the provision of services for homeless and marginalised patients can be challenging for mainstream general practices.
Our findings show that patients attending the Freo Street Doctor service appreciate the open access nature of the clinic, the focus on psycho-social as well as medical needs and the empathy and understanding shown by the GPs, nurses and outreach services who deliver the service. The preparedness of the street health service providers to meet the altered needs of marginalised patients in their own backyard is a key factor in engagement.
Mainstream primary health care services would do well to recognise and adopt strategies that recognise the special needs and social circumstances of these patients.
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1.       Strange C,   Fisher C, Chan She Ping-Delfos W, Arnold-Reed D, Brett T.  A general practice street health service – patient and allied service provider perspectives. AJGP. 2018. 47 (1-2): 44-48.
2.       Arnold-Reed D, Troeung L, Brett T,  Chan She Ping-Delfos W, Geelhoed E, Fisher C, Preen D. Increasing multimorbidity in an Australian street health service – a 10-year retrospective cohort study,. AJGP. 2018; 47 (4): 181-189.
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Epidemiology and outcomes research

Multimorbidity in an Australian street health service

April 5, 2018 – 8:57 am

By Tom Brett
The Freo Street Doctor service is a free, primary care–based, mobile health clinic that has been operating in Fremantle, Western Australia since 2005. It operates from various locations in and around Fremantle, offering homeless and disadvantaged patients access to an accredited general practice service. It is serviced by a number of general practitioners, nurses, social workers and Aboriginal health workers as well as collaborating with numerous ancillary services to improve the health and circumstances of marginalised patients in this population group.
We report on a total of 4285 patients who attended the service over a 10 year period [1]. We found multimorbidity to be associated with increasing age, male sex and Aboriginality. An important finding from our study is the high Aboriginal attendance, comprising 31.5% of the total cohort (with 50.8% female). This attendance ratio is in sharp contrast with the <2% Aboriginal patients attending mainstream GP clinics Australia-wide.
Our research shows that multimorbidity is increasing over the past decade and presents as chronic physical and mental health problems in these marginalised, street health patients. These patients are at increased risk of ongoing neglect unless provided with a no-cost, multidisciplinary approach capable of delivering health and social services in a non-judgemental, comfortable and secure environment.
The progressive increase in attendance by young, especially Aboriginal, patients over the past decade, and the positive feedback from patients and allied services attending the Freo Street Doctor, make compelling arguments that this accredited, general practice–based service is addressing important health and social needs in an environment where they are clearly needed.
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1. Arnold-Reed D, Troeung L,  Brett T, Chan She Ping-Delfos W, Strange C, Geelhoed E, Fischer C,  Preen D. Increasing multimorbidity in an Australian street health service – a 10 year retrospective cohort study. AJGP. 2018; 47 (4): 181-189.
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