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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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Care model

Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society

September 19, 2012 – 7:40 am

By Cynthia Boyd

A new report issued by the American Geriatrics Society (AGS) outlines how clinicians can tailor care to better meet the unique needs older adults with multimorbidity.  More than half of adults 65 and older have at least three chronic conditions, such as heart disease, diabetes, and arthritis.

Entitled Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society, the new report was published in today’s early, online edition of the Journal of the American Geriatrics Society (JAGS) and is available at www.americangeriatrics.org, in conjunction with a longer version of the documents with more complete references.  A wealth of related information, tips, and tools for both clinicians and the public are also available on the AGS website.

To help both clinicians and patients make complex treatment decisions, the expert panel that developed the report has outlined five essential elements, or guiding principles, for quality care for older adults with multimorbidity: 

  • Preferences: Elicit and incorporate patient preferences* into medical decision-making for older adults with multimorbidity.

By using the term “patient” preferences, we aim to keep the patient central to the decision-making process while recognizing that family and social supports play a vital role in management and decision-making whether or not cognitive impairment is present.

  • Interpreting the evidence: Recognizing the limitations of the evidence base, interpret and apply the medical literature specifically to older adults with multimorbidity.
  • Prognosis: Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (e.g. remaining life expectancy, functional status, quality of life) for older adults with multimorbidity.
    • Clinical Feasibility: Consider treatment complexity and feasibility when making clinical management decisions for older adults with multimorbidity.
    • Optimizing Therapies and Care Plans: Utilize strategies for choosing therapies that optimize benefit, minimize harm, and enhance quality of life for older adults with multimorbidity.

    The report also describes the urgent need for research to develop and implement evidence-based practices for each of these areas.

    Cynthia Boyd, MD MPH
    Associate Professor of Medicine
    Division of Geriatric Medicine and Gerontology
    Johns Hopkins University School of Medicine

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    Event

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

    September 14, 2012 – 7:08 am

    By Martin Fortin

    2012 North American Primary Care Research Group (NAPCRG) Annual Meeting Forum

    Martin Fortin, MD, MSc, Université de Sherbrooke, Québec (Canada); Elizabeth A. Bayliss, MD, MSPH, University of Colorado School of Medicine, USA; Stewart W. Mercer, MBChB, PhD, University of Glasgow, UK; Susan M. Smith,  MD, MSc, Royal College of Surgeons, Ireland; Jane Gunn, MBBS, FRACGP, PhD, DRANZCOG, The University of Melbourne, Australia; Mogens Vestergaard, MD, PhD, Aarhus University, Denmark.

    A recent Cochrane systematic review on the impact of interventions for patients with multimorbidity (MM) found that there was a paucity of studies and a need for the consideration of appropriate outcomes and further pragmatic studies based in primary care settings (S. Smith et al. see S. Smith posting in IRCMo Blog, April 9, 2012: https://crmcspl-blog.recherche.usherbrooke.ca/?author=10 ). During this NAPCRG annual meeting forum, we will expand on an ongoing dialogue within an existing international community of researchers, decision-makers and health care providers interested in MM (International Research Community on Multimorbidity – IRCMo) and follow-up on discussions initiated during the NAPCRG 2007 meeting, and continued during sessions in Frankfurt, 2011; Glasgow, 2011-2012; and Aarhus, 2012. We aim to accomplish the following tasks in order to lay the groundwork for interventions to improve outcomes for persons with MM:

    1) Identify key elements for interventions aimed at improving outcomes for MM;

    2) Create a list of patient-centered outcomes relevant to interventions in this population and based on patient input;

    3) Propose suitable intervention research designs;

    4) Discuss specific evaluation methods;

    5) Solicit input on potential national and international collaborations including funding opportunities.

    The forum will include short presentations to outline the current focus and direction of interventions in MM followed by group discussions, each of which will address one specific topic. Finally we will synthesize the discussions into a report that will subsequently be shared among forum participants and with members of the IRCMo.

    We welcome members to take part in this forum scheduled on Wednesday, December 5 from 9:30 am. to 12:30 pm.

    Please visit: http://www.napcrg.org/ for more information about the forum.

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    Others

    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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    Others

    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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    Others

    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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    Theory, concept and measure

    Multimorbidity measures

    March 27, 2012 – 9:15 am

    By Alyson Huntley

    In the Academic Unit of Primary Health Care at the University of Bristol, one of our key research themes is organisation and delivery of care led by Professor Chris Salisbury.  This theme relates to providing evidence about the impact of changes in how primary health care is organised and delivered. Our research often combines quantitative, qualitative and economic methods. We have conducted a number of large scale multi-centre evaluations of important initiatives. We are particularly interested in the impact of these new models of care on core values of primary care such as access to care, generalism, co-ordination and continuity of care.

    An important part of this research is the study of multimorbidity. We have several projects running in this area at the moment including:

    • The impact of multimorbidity on the use of resources in primary care
    • Complex consultations. The impact of multimorbidity on consultations.
    • A systematic review of measures of multimorbidity.

    We have recently published the systematic review on multimorbidity measures in the Annals of Family Medicine (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. 2012;10(2):134-41).

    The aims of this review were to identify measures of multimorbidity and morbidity burden suitable for use in research in primary care and community populations, and to investigate their validity in relation to anticipated associations with patient characteristics, process measures, and health outcomes.

    We found that the measures most commonly used in primary care and community settings are disease counts, Charlson index, ACG System, CIRS, CDS, and DUSOI. Different measures are most appropriate according to the outcome of interest. Choice of measure will also depend on the type of data available. More research is needed to directly compare performance of different measures.

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    Epidemiology and outcomes research

    The prevalence of multimorbidity

    March 13, 2012 – 7:46 am

    By Martin Fortin

     

    Multimorbidity is associated with negative outcomes and increased resource use. Both create a burden on the health-care system.

     Concerned healthcare professionals and decision-makers aware of this information may wonder: 

    • What is the magnitude of this problem in our region?
    • What is the prevalence of multimorbidity in our population?

     Some researchers have attempted to answer these questions with studies involving either nation-wide populations or smaller groups. However, studies in different populations have yielded results with differences in prevalence estimates as important as 95% for a given age. Is this information reliable? Can it be used to determine the allocation of resources to deal with the problem of multimorbidity? Differences of this magnitude are unlikely to reflect real differences between populations and more likely due to methods biases.

     In a systematic review recently published in the Annals of Family Medicine  we identified and compared studies reporting the prevalence of multimorbidity in primary care settings and in the general population. Apart from differences in location, we identified differences in recruitment method and sample size, data collection, and in the operational definition of multimorbidity including the number of conditions and the conditions selected. All of these factors may affect prevalence estimates.

     In this review we discussed differences among studies and possible explanations for variations in the results of prevalence estimates. We also promoted the adoption of a more uniform methodology in this type of research by suggesting methodological aspects to be considered in the conduct of such studies.

     Availability of strong epidemiological data for multimorbidity would benefit both the research and care of this problem.

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    Others

    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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