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.
By Carol Sinnott
Using clinical guidelines in the management of patients with multimorbidity can lead to the prescription of multiple and sometimes conflicting medications. Our research group has just published a qualitative study exploring how GPs make decisions when prescribing for complicated multimorbid patients, with a view to informing intervention design in this field [1].
In qualitative interviews with GPs, we used case-specific information to reveal how GPs make compromises between patient centred and evidence based care in multimorbidity.
In the management of these cases, GPs integrated information from multiple sources including the patient, specialists and evidence based medicine. Difficulties arose if the recommendations or preferences conflicted with each other. GPs responded to this scenario by ‘satisficing’: accepting care that they deemed satisfactory and sufficient for a particular patient. In multimorbid patients perceived as stable, GPs’ preferred to ‘maintain the status quo’ rather than rationalize medications. This approach was due to GPs’ perceptions of the potential negative repercussions associated with changing medications. Proactive changes in medications were facilitated by continuity of care, sufficient consultation time and open lines of communication with the patient, other healthcare professionals and other GPs.
These new understandings will help to inform the design of behavioural interventions to assist medication management and patient centred care in multimorbidity.
The complete article can be accessed at: http://bjgp.org/content/65/632/e184
1: Sinnott C, Hugh SM, Boyce MB, Bradley CP. What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care. Br J Gen Pract. 2015 Mar;65(632):e184-91. doi: 10.3399/bjgp15X684001. PubMed PMID: 25733440.
February 27, 2015 – 10:13 am
By Donna Zulman
Patients with multiple chronic conditions (MCCs) face substantial self-management challenges related to having multiple health issues. For example, patients with MCCs frequently face unwieldy medication regimens and daily self-care routines that may reduce adherence to recommended treatment plans. They also often need to track and coordinate health information from different health care providers and monitor and distinguish between symptoms from different diseases. As a result, there is a great need for effective tools to support the self-care activities associated with multimorbidity. Patient-facing “eHealth” technology may provide opportunities to address these patients’ needs.
We conducted a qualitative study [1] (published in the Journal of General Internal Medicine) with patients with MCCs to explore their self-management and health care navigation challenges, and to identify opportunities to support these patients through new and enhanced eHealth technology. Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; and (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.
The abstract of the article can be found at http://www.ncbi.nlm.nih.gov/pubmed/25691239
1) Zulman DM, Jenchura EC, Cohen DM, Lewis ET, Houston TK, Asch SM. How can eHealth technology address challenges related to multimorbidity? Perspectives from patients with multiple chronic conditions. J Gen Intern Med. 2015 [Epub ahead of print]).
February 20, 2015 – 2:32 pm
By Martin Fortin and Moira Stewart
The research team PACE in MM “Patient-Centred Innovations for Persons with Multimorbidity” is happy to report its website (www. paceinmm.recherche.usherbrooke.ca) is now online in both French and English. The site outlines the PACE in MM research goals, objectives and research plan.
Visitors to the site are able to view the governance, type and structure of Committees within the team as well as review the research team members. A glossary of key terms related to the topic areas of PACE in MM is presented.
This resource will also allow visitors to keep updated on current news and events. A special section for output and activities will be updated regularly outlining presentations, publications, and meetings. A link to other helpful resources has also been developed.
If you have any suggestions or feedback for the website please send your comments to Research Coordinators, Tarek and Louisa.
Tarek.Bouhali@usherbrooke.ca
Louisa.Bestard-Denomme@schulich.uwo.ca
February 6, 2015 – 10:10 am
By Emma Wallace and Susan Smith
Along with colleagues in the UK, we have recently published a Clinical Review on managing patients with multimorbidity in primary care in the BMJ [1]. The review outlines challenges for Family Physicians or General Practitioners (GPs) in care delivery. We identified areas where GPs experience difficulties in caring for patients with multimorbidity and suggest evidence-based practice management strategies:
1. Disorganisation and fragmentation of care.
Identify patients as having complex multimorbidity and adopt a practice policy of continuity of care for these patients by assigning a named GP to the patient. Consider the following groups; a) Patients with ‘complex’ multimorbidity defined as ≥3 chronic conditions affecting ≥3 body systems; b) Patients with comorbid physical conditions and depression; c) Patients prescribed ≥10 medications; d) Patients who are housebound or resident in nursing homes.
2. Inadequacy of current disease-specific guidelines.
At times, clinical judgement may mean an acceptance that in certain circumstances, pursuing stringent disease specific targets is unlikely to be beneficial and may in fact be harmful. Consider an approach of targeting function not disease and a focus on medicines management, including deprescribing where possible.
3. Challenges in delivering patient centred care and barriers to shared decision making. Asking a patient at the outset of a consultation ‘What is bothering you most?’ or ‘What would you like to focus on today?’ can help prioritise management of aspects of care that will have most impact for the patient. Once patient priorities are identified, using available shared decision making tools may help support the process. Patient preference should guide the utilisation of lay-led self-management groups.
4. Consultation time.
Consider adopting a practice policy of routine extended or ‘specific extended’ consultations for particularly complex patients. Ensure practice systems are in place to maximise the value of the GP consultation for both patient and doctor in reaching management decisions. Multidisciplinary team involvement is important and should be arranged where appropriate.
Reference
1) Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ 2015;350:h176.
January 30, 2015 – 1:45 pm
By Marjan van den Akker
An international group of scientists working around the themes of multimorbidity and polypharmacy have recently published a paper in
BMC Medicine [1] on the management of patients with multimorbidity in primary care consultations. The article aims to support decision making in primary care consultations, through a set of guiding principles. These principles are named after the Greek mythological figure Ariadne, who helped the Greek hero Theseus escape from the labyrinth.
The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process.
1-Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, Becker A, Beyer M, Gensichen J, Kirchner H, Perera R, Prados-Torres A, Scherer M, Thiem U, van den Bussche H, Glasziou PP. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med 2014; 12:223.
January 23, 2015 – 10:25 am
By Clare Liddy
In our systematic review of the qualitative literature examining the patient’s perspectives of living with multiple chronic conditions published in Canadian Family Physician [1], we found that patients were able to clearly identify challenges associated with self-management and develop strategies to address these factors. The barriers to self-management are many and yet common between people with many different diseases. However, while most studies were disease-specific, we found that discussion among patients that related to specific medical conditions and disease-specific symptoms was strikingly absent. People did not complain about lack of skill to manage medical tasks such as injecting insulin or blood pressure monitoring; rather, they reported difficulties in dealing with physical and emotional symptoms, with depression, pain and fatigue being prominent. In addition, issues related to knowledge about self-management of conditions commonly arose because of confusing and often contradictory information provided by multiple health care providers. The use of cognitive strategies including reframing, prioritizing, and changing beliefs was reported to improve people’s ability to self-manage their multiple chronic conditions.
This study provides a unique view into the patients’ perspectives of living with multiple chronic conditions which are clearly linked to common functional challenges as opposed to specific diseases. Future policy and programming in self-management support should be better aligned with the patient’s perspectives of living with multiple chronic conditions and this may be achieved by ensuring a more patient-centered approach is adopted by providers and health service organizations.
1. Liddy, C., Blazkho, V. & Mill, K. (2014). “Challenges of self-management when living with multiple chronic conditions. Systematic review of the qualitative literature.” Canadian Family Physician, 60, 1123-1133.
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)
