Entete 3
Theory, concept and measure

The Disease Burden Morbidity Assessment (DBMA) by self-report

February 15, 2012 – 2:49 pm

By Marie-Eve Poitras, RN. M.Sc.

Studies on multimorbidity should rely on valid and robust measurement to assess the disease burden experienced by patients with chronic diseases. There are many instruments designed to measure multimorbidity, however, most of them have to be administered by professionals because of the medical background required to complete them. This is a limitation to using these instruments in large samples of patients either in primary care settings or the general population.

Previous studies have shown that a measure that includes a weighting for severity is a better predictor of patient-related outcomes than a measure based on a simple disease count [1-2]. Severity can be judged on purely clinical grounds by health professionals or on the basis of the illness experienced by patients themselves. However, impact on daily living seems to be best evaluated by the patient because self-reported disease burden correlates with quality of life outcomes more strongly than measures of comorbidity based on other methods of data collection [3].

 The Disease Burden Morbidity Assessment (DBMA) is a self-report questionnaire that seems promising because: 1) it can be administered to large samples of patients and 2) it judges severity on the basis of the illness experienced by patients themselves [3].

 We conducted a study to test and to measure the properties of the French translation of the DBMA (DBMA-Fv). The DBMA-Fv’s properties were similar to its English counterpart as to its median sensitivity and specificity compared to chart reviews. It correlated moderately with an established index of multimorbidity, the Cumulative Illness Rating Scale (CIRS). A high percentage of patients were able to complete the test correctly as a mail questionnaire and it showed high test-retest reliability.

 The article describing the study can be accessed freely on line [4], where the readers can also find both the English and French versions of the DBMA questionnaire as appendices to the paper.

 1. Fortin, M., et al., Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life. Health Qual Life Outcomes, 2005. 3:74.
2.Fortin, M., et al., Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res, 2006. 15:83-91.
3. Bayliss, E.A., J.L. Ellis, and J.F. Steiner, Subjective assessments of comorbidity correlate with quality of life health outcomes: Initial validation of a comorbidity assessment instrument. Health and Quality of life Outcomes, 2005. 3:51.
4. Poitras, M.-E., et al., 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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Multimorbidity publications October – December 2011

January 24, 2012 – 9:46 am

By Martin Fortin

Here are the results of a literature search that I would like to share with you presenting articles on multimorbidity published between October and December 2011, along with the links to the abstracts or full texts:

1-    Caughey GE, Roughead EE. Multimorbidity research challenges: where to go from here? Journal of Comorbidity. 2011;1:8–10.[Full text]
2-    Cohen E, Bruce-Barrett C, Kingsnorth S, Keilty K, Cooper A, Daub S. Integrated Complex Care Model: Lessons Learned from Inter-organizational Partnership. Healthc Q. 2011;14 Spec No 3:64-70.[Abstract]
3-    De Vries NM, Van Ravensberg CD, Hobbelen JS, Olde Rikkert MG, Staak SB, Nijhuis-van der Sanden MW. Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: A meta-analysis. Ageing Resource Review, 11 novembre 2011 (Epub ahead of print). 2011.[Abstract]
4-    Esper AM, Martin GS. The impact of cormorbid conditions on critical illness. Crit Care Med. 2011;39:2728-35.[Abstract]
5-    Gilbert AL, Caughey GE, Vitry AI, Clark A, Ryan P, McDermott RA, et al. Ageing well: Improving the management of patients with multiple chronic health problems. Australas J Ageing. 2011;30 (SUPPL.2):32-7.[Abstract]
6-    Grant RW, Ashburner JM, Hong CC, Chang Y, Barry MJ, Atlas SJ. Defining Patient Complexity From the Primary Care Physician’s Perspective: A Cohort Study. Ann Intern Med. 2011;155:797-804.[Abstract]
7-    Haverhals LM, Lee CA, Siek KA, Darr CA, Linnebur SA, Ruscin JM, et al. Older adults with multi-morbidity: medication management processes and design implications for personal health applications. J Med Internet Res. 2011;13:e44.[Abstract]
8-    Marengoni A, Angleman S, Fratiglioni L. Prevalence of disability according to multimorbidity and disease clustering: a population-based study. Journal of Comorbidity. 2011;1:11–8.[Full text]
9-    Mercer SW, Gunn J, Wyke S. Improving the health of people with multimorbidity: the need for prospective cohort studies. Journal of Comorbidity. 2011;1:4–7.[Full text]
10- Nobili A, Marengoni A, Tettamanti M, Salerno F, Pasina L, Franchi C, et al. Association between clusters of diseases and polypharmacy in hospitalized elderly patients: results from the REPOSI study. Eur J Intern Med. 2011;22:597-602.[Abstract]
11-  Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. Journal of Comorbidity. 2011;1:28–44.[Full text]
12-  Spangenberg L, Forkmann T, Brähler E, Glaesmer H. The association of depression and multimorbidity in the elderly: implications for the assessment of depression. Psychogeriatrics. 2011;11:227-34.[Abstract]
13-  Steinhaeuser J, Miksch A, Ose D, Glassen K, Natanzon I, Szecsenyi J, et al. Questionnaire of chronic illness care in primary care-psychometric properties and test-retest reliability. BMC Health Serv Res. 2011;11:295.[Full text]
14-  Townsend A. Applying Bourdieu’s theory to accounts of living with multimorbidity. Chronic Illn 2011 Dec 2 [Epub ahead of print]. 2011.[Abstract]
15-  Valderas JM, Mercer SW, Fortin M. Research on patients with multiple health conditions: different constructs, different views, one voice. Journal of Comorbidity. 2011;1:1–3.[Full text]

All references are included in our library. Feel free to share with anyone interested in multimorbidity.

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Inauguration of the Journal of Comorbidity

January 19, 2012 – 8:56 am

By Martin Fortin

Good news! A new journal with a special focus on patients with multimorbidity and comorbidity has been created.

The Journal of Comorbidity (JOC), an international, open-access, peer-reviewed journal for the pathophysiology, diagnosis, prevention and management of comorbidity has been inaugurated and its first issue is already posted online.

Although the name of the journal might suggest that it is devoted exclusively to articles related to the well known definition of comorbidity provided by Feinstein “any distinct additional clinical entity that has existed or may occur during the clinical course of a patient who has the index disease under study”, the first issue of JOC makes it clear that this is not the case. 

The inaugural editorial of the Editor-in-Chief clearly states that “the management of patients with comorbidity needs to consider the patient as a whole, extending beyond the primary medical speciality, and encompassing all of the coexisting complications, not just the principal disease or various conditions in isolation”.

In addition, an editorial authored by José M. Valderas, Stewart W. Mercer, and myself further explains that “the journal has opted to use comorbidity in its name, and a number of well founded reasons explain this choice: for reasons of simplicity; in order to acknowledge both the relevance of research on comorbidity for the treatment of specific conditions and the historical pre-eminence of the construct; and finally, for an awareness of evolving concepts”.

 This journal that clearly invites authors to submit papers related to both comorbidity AND multimorbidity represents another opportunity to publish research of great value.

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Epidemiology and outcomes research

“Multimorbidity: epidemiology, utilization patterns and the response of the healthcare system”. A project funded by the Spanish Ministry of Science and Innovation (2012-2014)

December 21, 2011 – 11:53 am

By Alexandra Prados-Torres, Beatriz Poblador-Plou and Amaia Calderón-Larrañaga (from left to right)

The improvement of living conditions and the scientific-technological advancements have led to an increased prevalence of multimorbidity, especially, but not only, in the elderly population. It is also higher than expected in younger aged individuals [1]. Although multimorbidity has a significant impact on population health and healthcare systems, these are still mainly focused on diseases instead of patients, offering fragmented care (i.e. primary vs. specialized, health vs. social, etc.) and lacking evidence-based guidelines and/or appropriate clinical interventions for managing patients with multimorbidity [2,3].

Multimorbidity has not been sufficiently investigated in terms of its underlying pathophysiological mechanisms, specific diseases interactions, its consequences on health services utilization and outcomes, or even its definition and measurement.

This project, which will be carried out by researchers from the Aragon Health Research Institute (IIS Aragón, Spain) between 2012 and 2014 will focus on:

1- Epidemiology of multimorbidity based on methods that help identify the simultaneous non-random occurrence of health problems (i.e. multimorbidity patterns) in different population groups.

2- Health services utilization patterns among patients with multimorbidity which may reveal an unjustified variability among providers regarding prescription drug costs, scheduled visits and referrals to specialty care as a clear sign of inefficiency.

3- Potential ineffective or unsafe healthcare received by patients with multimorbidity due to preventable hospitalizations, in-hospital complications and readmissions, and polypharmacy-driven adverse drug reactions.

To this end, a retrospective cohort study has been designed including the entire population assigned to any of the 119 primary care centres in the region of Aragon (i.e. over 1,200,000 inhabitants). Thus, a person-based integrated database will be generated containing clinical and administrative information from primary care, specialized care and emergency care. This strategy, which has not been sufficiently exploited in the Spanish context to date, will enable the linking of patients’ health services utilization patterns with their multimorbidity profile.

This project is expected to provide evidence in relation to the causes and consequences of multimorbidity so that this hidden public health problem is recognised and urgently addressed by the various actors of healthcare systems.

The research group led by Dr. Alexandra Prados-Torres (sprados.iacs@aragon.es) is interested in establishing international collaborations and would very much appreciate the feedback of any of the members of the “IRCMo”.

1.- van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA: Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol 1998, 51:367-375.
2.- Fortin M, Lapointe L, Hudon C, Vanasse A: Multimorbidity is common to family practice: is it commonly researched? Can Fam Physician 2005, 51:244-245.
3.- Fortin M, Dionne J, Pinho G, Gignac J, Almirall J, Lapointe L: Randomized controlled trials: do they have external validity for patients with multiple comorbidities? Ann Fam Med 2006, 4:104-108.

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Event

“The Impact of Primary Care Teams on Multimorbidity (IMPCT): Optimizing care for patients living with multiple chronic conditions” meeting

December 14, 2011 – 8:55 am

By Tarek Bouhali

On December 8-9, 2011, the first meeting of “The Impact of Primary Care Teams on Multimorbidity (IMPCT): Optimizing care for patients living with multiple chronic conditions” team was held at the INSPQ (Institut national de santé publique du Québec) offices in Montréal (Quebec, Canada). Over the two days, we have greatly benefited from the very animated discussions among our panel of speakers and discussants. We would therefore like to thank and congratulate each one of them for sharing their wide-ranging perspectives.

This gathering of 28 team members and collaborators from various disciplines including academic researchers, policy-makers, public health practitioners, program specialists and representatives from government agencies was convened to examine issues related to multimorbidity in various Canadian jurisdictions (Quebec, Ontario, Alberta) as well as in many other countries such as the USA, the UK, the Netherlands and Australia.

During the consultation process and workshops, we received input and recommendations on intervention strategies that will help the IMPCT team enhance its efforts focused on patients with or at highest risk for multimorbidity and complexity. Although IMPCT interventions will be patient-centered, the IMPCT Panel has paid attention to recommendations of policy-makers to expand the reach to organizational levels.

The team’s leads (Martin Fortin, Jean-Frédéric Levesque and Renée F. Lyons) take pride in having hosted this meeting. They hope that the presentations given and the discussions that followed during this meeting have generated a better appreciation of the nuances on key issues and objectives, as well as research questions and strategic decisions that will be included in the team grant application to the Canadian Institutes of Health Research (CIHR).

Thanks again to all the participants and international collaborators for taking the time to be a part of this important meeting. We value members’ expertise and appreciate their continued support and commitment to the upcoming team grant proposal. A special thank you is owed to Meghan McMahon from CIHR for taking the time to present the details of the Canadian Institutes of Health Research – Community-Based Primary Health Care (CIHR CBPHC) Team Grant Competition to the meeting participants. We would also like to thank our international collaborators (Grant Russell, Australia; Jane Gunn, Australia; Michel Wensing, The Netherlands; Stewart Mercer, UK; Stephen Peckham, UK) who shared their views and experiences via telephone conferences.

The IMPCT team is preparing a meeting summary report that will be made available to all participants by next week.

Top row left to right: Christine Loignon, Guillaume Ruel, William L. Miller, Erin Strumpf, Antoine Boivin, Frances Gallagher, Debbie Feldman, Cecile Bensimon, Maud-Christine Chouinard, Sylvie Provost, Mary Byrnes, William Hogg, Benjamin F. Crabtree, Maxime Ouellette. Front row, left to right: Martin Fortin, Jean-Frédéric Lévesque, Renee F. Lyons, Catherine Hudon, Moira Stewart, Denise Campbell-Scherer. Meeting participants missing from the picture: Jeannie Haggerty, Robert Salois, Marie-Dominique Beaulieu.

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Event

“I also want researchers to specialize in me!”

November 16, 2011 – 1:48 pm

By Maud-Christine Chouinard

 

Greetings from the NAPCRG Conference in beautiful Banff! I am currently amongst a record assistance of more than 750 attendees who is gathered this week in a most enchanting and wintery site in the Rocky Mountains. As a nursing researcher, I am delighted to be able to present a poster and to get to choose among hundreds of presentations and 3 poster sessions on primary care research!

 For the last two days, I have had the opportunity to meet and greet with researchers and clinicians from various disciplines and to hear and see oral and poster presentations on a vast array of subjects such as evidence based medicine, translational research, chronic disease management, patient-centered care, self-management, etc. The captivating conferences were competing with the majestic peaks of the Rocky Mountains in the background.

 Garnering buzzing interest was the keynote presentation given by Professor Martin Fortin: Multimorbidity in primary care: Recognizing and dealing with the elephant in the room. Professor Martin Fortin presented in English in front of a captive audience including established and new researchers as well as members of the editorial committees of medical journals and representatives of funding agencies.

 Martin Fortin provided a clear message to draw the attention of the research community on the importance of prioritizing the thematic research area of multimorbidity and patient-centered care to continue transforming the healthcare system and thus better contend with the current and future boom in chronic diseases, especially in primary care. He also invited researchers of all disciplines to work together to develop interventions aiming to optimize care for people with multimorbidity. His presentation ended with a genuine plea in the defense of the interests of patients suffering from multiple chronic diseases.

 One line created a buzz on Twitter when Professor Fortin, paraphrasing a patient of Ian McWhinney said “I want a doctor who specializes in me”. However, his message really aims to go further with: “I also want researchers to specialize in me!”

 Finally, although we did not see any elephants in the room, Dr. Fortin convinced us of the importance of taking a real interest in the elephants in primary care with his infectious passion for the subject.

 For a copy of his presentation please contact José Almirall at: jose.almirall@usherbrooke.ca

 

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Epidemiology and outcomes research

Summary of Notre Dame multimorbidity TDB

November 2, 2011 – 9:20 am

By Tom Brett

Researchers at the General Practice and Primary Health Care Research Unit at The University of Notre Dame Australia, Fremantle have recently completed extracting patient data from the medical records of attendees at two Perth metropolitan general practices. All patients (over 7000 in total) who attended the practices in a six month period in 2008 were included as were patients who were seen for home visits, hostel and nursing home visits in the same period.

We utilised a similar data extraction process to that employed by Fortin et al.1 and used the Cumulative Illness Rating Scale (CIRS) 2-6 to assess both the prevalence of chronic disease presentations and the severity of the disease burden for each patient. We employed ideas from the geriatric version of the CIRS as developed by Miller and Towers (CIRS-G)3  to improve consistency and help with standardisation amongst the data extractors. Three GPs, three practice nurses, a graduate-entry medical student and a senior receptionist were specially trained in the data extraction process.

A combination of electronic medical records and older hard copy files, including hospital discharge and out-patients letters together with radiology and pathology reports, was used to maximise the available data on each patient. Younger attendees were included so as not to discriminate against any age group and because no similar comprehensive information was available in the Australian primary care literature.

We are currently analysing the data and hope to publish some of our findings in 2012. The data extraction process was long and tedious but we are happy with the outcome and appreciate the efforts of the data extractors. We are hoping to expand and develop the study in the future and would welcome input and suggestions from future collaborators.

References

  1. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005; 3: 223-228.
  2. Linn BS, Linn MW, Gurel L. Cumulative Illness Rating Scale. J Amer Geriatr Soc. 1968; 16: 622-626.
  3. Miller MD, Towers A. A manual of guidelines for scoring the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pittsburg, Pa. University of Pittsburg; 1991.
  4. Hudon C, Fortin M, Vanasse A. Cumulative Illness Rating Scale was a reliable and valid index in a family practice context. J Clin Epidemiol. 2005; 58: 603-608.
  5. De Groot V, Beckerman H, Lankhorst GJ, Bouter LM. How to measure co-morbidity: a critical review of available methods. J Clin Epidemiol. 2003; 56: 221-229.
  6. Hudon C, Fortin M, Soubhi H. Abbreviated guidelines for scoring Cumulative Illness Rating Scale (CIRS) in family practice. J Clin Epidemiol. 2007; 60: 212.
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Multimorbidity Publications June – September 2011

October 25, 2011 – 8:40 am

By Martin Fortin

New papers on multimorbidity have been published during the June-September period of this year. I would like to share with you the titles of the most relevant articles published, along with the links to the abstracts or full texts:

1.    Findley, P., C. Shen, and U. Sambamoorthi, Multimorbidity and persistent depression among veterans with diabetes, heart disease, and hypertension. Health Soc Work, 2011. 36: p. 109-19. [PubMed abstract]
2.    Fried, T.R., et al., Health Outcome Prioritization as a Tool for Decision Making Among Older Persons With Multiple Chronic Conditions. Arch Intern Med. Sep 26. [Epub ahead of print], 2011. [Research letter; no abstract available]
3.    Gulley, S.P., E.K. Rasch, and L. Chan, The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep, 2011. 126: p. 495-507. [PubMed abstract]
4.    Harrison, M., 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. Jul 16. [Epub ahead of print], 2011. [PubMed abstract]
5.    Holden, L., et al., Patterns of multimorbidity in working Australians. Popul Health Metr, 2011. 9: p. 15. [Full text]
6.    Hunger, M., et al., Multimorbidity and health-related quality of life in the older population: results from the German KORA-age study. Health Qual Life Outcomes, 2011. 9: p. 53. [Full text]
7.    Khanam, M.A., et al., Prevalence and patterns of multimorbidity among elderly people in rural Bangladesh: a cross-sectional study. J Health Popul Nutr, 2011. 29: p. 406-14. [Full text]
8.    Lehnert, T., et al., Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev, 2011. 68: p. 387-420. [PubMed abstract]
9.    Parekh, A.K., et al., Managing multiple chronic conditions: a strategic framework for improving health outcomes and quality of life. Public Health Rep, 2011. 126: p. 460-71. [PubMed abstract]
10.    Perruccio, A.V., J.N. Katz, and E. Losina, Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. J Clin Epidemiol. Aug 9. [Epub ahead of print], 2011. [PubMed abstract]
11.    Quiñones, A.R., et al., How Does the Trajectory of Multimorbidity Vary Across Black, White, and Mexican Americans in Middle and Old Age? J Gerontol B Psychol Sci Soc Sci. Oct 3. [Epub ahead of print], 2011. [PubMed abstract]
12.    Richardson, K., et al., Variation over time in the association between polypharmacy and mortality in the older population. Drugs Aging, 2011. 28: p.:547-60. [PubMed abstract]
13.    Starfield, B. and K. Kinder, Multimorbidity and its measurement. Health Policy. Sep 30. [Epub ahead of print], 2011. [PubMed abstract]
14.    Tinetti, M.E., et al., Contribution of Multiple Chronic Conditions to Universal Health Outcomes. J Am Geriatr Soc. Aug 30. [Epub ahead of print], 2011. [PubMed abstract]
15.    Tinetti, M.E. and S.A. Studenski, Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med, 2011. 364(26): p. 2478-81. [Full text]
16.    van Baal, P.H., et al., Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data. Popul Health Metr, 2011. 9: p. 51. [Full text]
17.    van den Bussche, H., et al., Patterns of ambulatory medical care utilization in elderly patients with special reference to chronic diseases and multimorbidity – Results from a claims data based observational study in Germany. BMC Geriatrics, 2011. 11: p. 54. [Full text]
18.    Vyas, A. and U. Sambamoorthi, Multimorbidity and depression treatment. Gen Hosp Psychiatry, 2011. 33: p. 238-45. [PubMed abstract]

Publication number 15 on the list is an article by Mary E. Tinetti and Stephanie A. Studenski published in the ‘Perspective’ section of the New England Journal of Medicine. I would like to bring to your attention its most important statements in my opinion:

“Primary outcomes tend to be disease-specific… Such outcomes work well in efficacy studies, which reveal a therapy’s effect on a specific outcome under ideal circumstances in a homogeneous population. They make less sense, however, for comparing treatments in patients with multiple chronic conditions.”

“Researchers have largely shied away from the complexity of multiple chronic conditions — avoidance that results in expensive, potentially harmful care of unclear benefit. We cannot improve health care’s quality, effectiveness, and efficiency without addressing its greatest consumers.”

It is well worth the read.

All references are included in our blog’s library. Feel free to share with anyone interested in multimorbidity.

Martin

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Event

60-second lecture at AHRQ Grantees conference (9/2011)

October 7, 2011 – 1:12 pm

By Elizabeth A. Bayliss

In delivering patient-centered care to complex patients, success is measured by achieving health outcomes that matter to patients. 

Historically health outcomes have been disease-specific. These reflect appropriate treatment intensification by clinicians and appropriate adherence to recommendations by patients in order to achieve the best outcomes for a single condition. Goal attainment is facilitated by incentives and protocols that make it relatively easy for both groups to adhere to guidelines. For example, our current investigation suggests that attainment of cholesterol goals in cancer survivors—a protocol-driven outcome—is not associated with cancer stage, but is associated with overall morbidity.  

But which outcomes matter to patients? These often fall into the category of patient-reported outcomes and are increasingly recognized as equally important. Many clinicians are in favor of systematic collection of these outcomes as well. Thanks to extensive validation, we know which measures of patient-reported outcomes are valid, but do we know which outcomes matter? And to whom?

It may be worth pausing before we systematize the collection of patient-reported outcomes in order to check in with patients. We should ask them which health outcomes they consider meaningful, how they would like their clinicians to use this information, and how they would like to have it collected. At that point we will be better prepared to collect –and jointly use– health outcomes relevant to complex patients. 

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Epidemiology and outcomes research

Health Care Utilization and Costs of Elderly Persons with Multiple Chronic Conditions: Findings from Systematic Literature Review

September 13, 2011 – 12:53 pm

By Thomas Lehnert

In almost all developed countries the proportion of elderly people is steadily increasing. Many elderly persons suffer from multimorbidity (multiple chronic conditions), which has been linked to poor outcomes in various dimensions of health and health care (1, 2). In trying to meet the care demands of more and more patients with multiple chronic diseases, health care systems originally designed to handle acute and episodic illnesses are faced with substantial organizational and possibly additional financial challenges.

Multimorbidity has not been extensively researched as of yet (3). We know particularly little about health care utilization (patterns) and health care costs of (elderly) patients with multiple chronic conditions (4, 5). Considering this gap in knowledge, we conducted a systematic literature review with studies that investigated the relationship between multimorbidity and health care utilization outcomes (physician use, hospital use, medication use) and cost outcomes (medication costs, out-of-pocket costs, total health care costs) for elderly general populations. This study was published in Medical Care Research and Review 2011, 68(4) 387-420 [PubMed abstract].

Although synthesis of studies was complicated (e.g. because of ambiguous definitions and measurements of multiple chronic conditions), almost all included studies observed a positive association between multimorbidity and utilization/cost outcomes, many of which found that utilization/costs significantly increased with each additional condition. In terms of health care utilization, most of the evidence points to more complex in- and outpatient care scenarios. For instance, the more co-existing conditions an elderly patient had, the more physicians he/she saw (more pronounced increases for specialists) and the more medications he/she took (polypharmacy). Polypharmacy constitutes a risk factor for adverse drug events, while adverse drug events pose a significant cost to health care systems. It is therefore not surprising that multimorbid individuals had substantially increased health care costs as well. Several included studies indicate a curvilinear, near exponential relationship between multiple chronic conditions and costs.

In light of the rising prevalence of multimorbidity, substantial (additional) costs attributable to patients with co-existing diseases, and the fear that current care arrangements/guidelines may be inappropriate for at least some (elderly) multimorbid patients (6), we point out and discuss a variety of implications for health care policy and research.    

1.         Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes 2004;2:51.
2.         Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev2011 Sep;10(4):430-9.
3.         Fortin M, Lapointe L, Hudon C, Vanasse A. Multimorbidity is common to family practice: is it commonly researched? Can Fam Physician2005 Feb;51:244-5.
4.         Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med2007 Dec;22 Suppl 3:391-5.
5.         Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, van den Bos GA. Causes and consequences of comorbidity: a review. J Clin Epidemiol2001 Jul;54(7):661-74.
6.         Fortin M, Contant E, Savard C, Hudon C, Poitras ME, Almirall J. Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity. BMC Fam Pract2011;12:74.

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