Entete 3
Intervention

The integration of physician-patient-nurse collaboration for patients with multimorbidity seen in a Family Medicine Group setting: A pilot study

August 26, 2011 – 12:36 pm

By Tarek Bouhali

A Family medicine group (FMG) is a group of family physicians who work in close cooperation with nurses to offer health care services to registered individuals. On average, a FMG serves 15,000 people, and involves 10 doctors and two nurses [1]. This new form of group practice based on patient-centered approaches leads to interprofessional collaboration.

Interprofessional collaboration usually involves two disciplines or professionals, who interact continuously in a joint effort to solve or explore common issues. This approach involves active patient participation, gives priority to his/her goals and values, and establishes mechanisms for continuous communication among health care providers. Working within such a structure requires a redefinition of the physician-nurse partnership. Evidence-based interprofessional collaboration should involve intra-disciplinary and interdisciplinary participation in clinical decision making, and encourages the contribution of all professionals [2]. A number of studies has highlighted the need to redefine inter-professional collaboration to include the patient as participant as his/her perspective has been missing so far [2-4].

In this regard, the present pilot study aims to:

1) clarify the expectations of physicians, patients, and nurses involved in a collaborative approach;

2) identify the elements of collaboration that are prioritized by the participating professionals;

3) document the experience of collaboration among physicians, nurses and patients;

4) assess the feasibility of using generic outcome measures;

5) collect preliminary data on the variability of results and their sensitivity to changes in patients with multimorbidity.

Patients included in this study are adults (40 to 65 years) with at least two chronic diseases from two FMGs in the Saguenay-Lac-St-Jean region (Quebec, Canada). Two family physicians and two nurses from each FMG will form four physician-nurse teams. Ten patients will be recruited among each of the participating physician’s practice, for a total of 40 patients.

Physicians and nurses will take part in a training session on physician-patient-nurse collaboration. They will then participate in individual interviews to express their expectations (T0), and discuss strategies and tools used to make collaboration more relevant and responsive to patients with multiple chronic conditions at two other times (T1 and T2).

Two evaluations are planned for patients: before the first visit (T0), and 24 weeks later (T2). Before starting the collaborative process (T0), patients will be invited to participate in a focus group to clarify their expectations. Patients met at T0 will be asked to participate in a second focus group at T2 to discuss elements of satisfaction or dissatisfaction regarding physician-patient-nurse collaboration. At T0 and T2, they will be asked to complete a self-administered questionnaire on quality of life, self-efficacy, functional level, process of care and the achievement of personal goals.

Interprofessional collaboration in patient care has the potential to lead to positive impacts on the process of patient empowerment and self-efficacy. It can also contribute to an improvement in patients’ quality of life and a decrease in their level of psychological distress. Their perception of health care quality should improve as well. This pilot study will allow us to define the form that may take the intervention and methodological elements of a subsequent larger demonstration project.

1.         Commissaire à la santé et au bien-être. Rapport d’appréciation de la performance du système de santé et de services sociaux 2009: État de situation portant sur le système de santé et de services sociaux sur sa première ligne de soins. Québec; 2009.
2.         Juanita Barrett, Vernon Curran, Lindsay Glynn. Canadian Health Services Research Foundation (CHSRF) Synthesis: Interprofessional Collaboration and Quality Primary Healthcare, December 2007. http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/SynthesisReport_E_rev4_FINAL.pdf)
3.         Beaulieu M-D, Denis JL, D’ Amour D, et al. L’implantation des Groupes de médecine de famille : un défi de la réorganisation de la pratique et de la collaboration interprofessionnelle. Montréal: Canadian Health Services Research Foundation (CHSRF); 2006. (http://www.chsrf.ca/migrated/pdf/pastprograms/beaulieu_final.pdf )
4.         Ivy Oandasan, G.Ross Baker, et al. Teamwork in Healthcare: Promoting effective teamwork in healthcare in Canada. Canadian Health Services Research Foundation (CHSRF). Ottawa: FCRSS; 2006. (http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/teamwork-synthesis-report_e.pdf )

Comments (2)
Others

A request to the International Research Community on Multimorbidity

August 8, 2011 – 1:18 pm

By Helene Rosenbrandt

In Denmark the health sector is split in three: regions (responsible for hospitals), general practitioners and communities. I am planning process and content in a series of meetings in a political committee regarding multimorbidity. The political committee is interested in performing a study trip to other countries (if possible in Europe) who are working with handling challenges regarding multimorbidity in a yet more specialised health service. Our interest is in projects/activities that “can be seen” for example including interventions for patients (more than research on databases etc). I contact you with hope that you have ideas regarding interesting projects and solutions on this topic?

 We work with two different meanings of the area:
–      Multimorbidity where the perspective is the “whole” patient – all diseases are seen as equal.
–      Comorbidity where one disease is the primary and other diseases are seen as comorbidity to the primary disease – the perspective is a specialist one where a specialist in one primary disease tries to take other diseases (comorbidity) into consideration.

 Our focus is multimorbidity.

Some of the problems we see are:
–      That the hospital sector gets more and more specialized and if one follows the clinical guidelines for the individual diagnoses it leads to overwhelming treatment plans for the patient with 2, 3 or more simultaneous diseases – including polypharmacy.
–      In the actual process of diagnosing the patient a more general or cooperating view on the patient may lead to quicker diagnosis and start of relevant treatment.
–      The general practitioner have a role in this broad look on the patient but does not possess the specialist competences needed with more severe diseases.
–      One or more chronic diseases often lead to even more diseases – partly through negative feedback on lifestyle factors (arthritis may lead to inactivity which may then increase the risk of getting diabetes etc..).

We are interested in a broad range of projects and activities which deal with multimorbidity:
–      Handling multimorbidity in a specialised hospital sector.
–      The general practitioners role as an anchor/coordinator.
–      Cooperation between primary and secondary health sector.
–      Polypharmacy issues.
–      Patients own role in handling multimorbidity (self efficacy, social inequalities in health).

Best wishes,

Helene Rosenbrandt
(Administrator in the Regional part of the Danish Health sector)

Comment (1)
Practice guidelines

Canadian clinical guidelines and multimorbidity

July 14, 2011 – 8:58 am

By Martin Fortin

Clinical guidelines aim to improve the quality of care provided to patients. However, given that guidelines are mostly disease-oriented, we may discover conflicting recommendations when implementing those guidelines with patients presenting multiple concurrent chronic conditions. As a result, physicians frequently use their own clinical experience and patients’ views on treatment choice instead of national guidelines recommendations.

This situation prompted us to examine the relevance of Canadian clinical guidelines for patients with comorbidity for selected chronic diseases. The study was published by BMC Family Practice and is accessible through their website (http://www.biomedcentral.com/1471-2296/12/74). In summary, we found that despite the good to very good quality of the guidelines, only a few addressed specific recommendations for patients with two or more comorbid conditions.

The subject had been  previously addressed from different angles, but in this study we followed the steps of Australian colleagues [1] in the use of a tool developed by Boyd and colleagues [2] that allows to evaluate the applicability of guidelines on chronic diseases for the treatment of subjects with comorbidity. The tool is a checklist in which each item is scored as “yes” or “no”, and assesses whether guidelines address treatment for people with several comorbid conditions, as well as patient-centered aspects such as patient preferences and quality of life. We improved its comprehensiveness with the addition of items related to medication. To our knowledge, this is the only tool available for this purpose.

This study may potentially stimulate other researchers to follow suit with the assessment of their respective national guidelines, and further highlight the need for improved clinical guidelines relevant to patients with two or more chronic conditions worldwide.

1.    Vitry, A.I. and Y. Zhang, Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions. Med J Aust, 2008. 189: p. 360-5.

2.    Boyd, C.M., et al., Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. J.A.M.A., 2005. 294: p. 716-24.

Comments (2)
Others

Barbara Starfield (1932-2011)

June 15, 2011 – 7:04 am



By Martin Fortin

Professor Barbara Starfield, a prominent figure in primary care and other fields, died suddenly in California on Friday 10 June 2011. My colleagues and I would like to express our sincere condolences to her family, friends and colleagues.

Dr. Starfield made landmark contributions in primary care. The coexistence of multiple diseases did not escape her attention. Before the introduction of the concept of multimorbidity, Dr. Starfield realized that people should be characterized by their morbidity burden, and her work led to the development of an important methodological tool for assessing diagnosed morbidity burden: the Adjusted Clinical Groups system.1 With its use, populations can be described according to the mix of types of all conditions they experience in any given time period (including signs and symptoms as well as all types of diagnoses).

The subjects of comorbidity and multimorbidity are present in several of her publications,2-5 and my colleagues and I had the privilege of motivating her to write an editorial on one of our publications.6

In the June 9, 2011 posting that precedes this one, I brought to your attention the essential ideas I found in her last editorial published this year, which was also dedicated to co- and multi-morbdity.7 In essence, she alerted us to the fact that “it is not chronicity per se that creates a burden on the health-care system… it is the number of types of conditions, that is, multi-morbidity “.7 I believe it is our duty to honour her visionary statement and carry on her legacy.

Thank you Dr. Starfield for your inspiration.

1. Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Services Research. 1991;26(1):53-74.
2. Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med. May-Jun 2003;1(1):8-14.
3. Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med. 2005;3:215-222.
4. Valderas JM, Starfield B, Roland M. Multimorbidity’s many challenges: A research priority in the UK. BMJ. Jun 2 2007;334(7604):1128.
5. Starfield B. Co-morbidity and its challenges for quality of primary care. Rev Port Clin Geral. 2007;223:179-180.
6. Starfield B. Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med. 2006;4:101-103.
7. Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev. 2011;12:1-2.

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Others

Multimorbidity Publications January – May 2011

June 9, 2011 – 12:18 pm

By Martin Fortin

Searching for articles published on multimorbidity this year, it has been nice to note that already there is an important new body of information covering different aspects of the subject. I would like to share with you blog visitors the titles of the most relevant publications found, along with the links to the abstracts:

–          Marengoni A et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev Mar 23 [Epub ahead of print] 2011. [PubMed abstract]

–          Salisbury C et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 2011;61:e12-21. [PubMed abstract]

–          Bower P et al. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study. Fam Pract May 25 [Epub ahead of print] 2011. [PubMed abstract]

–          Tucker-Seeley RD et al. Lifecourse socioeconomic circumstances and multimorbidity among older adults. BMC Public Health 2011;11:313. [PubMed abstract]

–          Wong A et al. Longitudinal administrative data can be used to examine multimorbidity, provided false discoveries are controlled for. J Clin Epidemiol Mar 29 [Epub ahead of print] 2011. [PubMed abstract]

–          Galenkamp H et al. Somatic Multimorbidity and Self-rated Health in the Older Population. J Gerontol B Psychol Sci Soc Sci 2011;66:380-6. [PubMed abstract]

–          Glynn LG et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract Mar 24 [Epub ahead of print] 2011. [PubMed abstract]

–          Drewes YM et al. The effect of cognitive impairment on the predictive value of multimorbidity for the increase in disability in the oldest old: the Leiden 85-plus Study. Age Ageing 2011;40:352-7. [PubMed abstract]

–          Holzhausen M et al. Operationalizing multimorbidity and autonomy for health services research in aging populations–the OMAHA study. BMC Health Serv Res 2011;11:47. [PubMed abstract]

–          Morris RL et al. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient’s prioritization of multiple conditions. Chronic Illn 2011;7:147-61. [PubMed abstract]

–          van den Bussche H et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 2011;11:101. [PubMed abstract]

–          Schüz B et al. Medication beliefs predict medication adherence in older adults with multiple illnesses. J Psychosom Res 37(6):565-74 2011;70:179-87. [PubMed abstract]

–          Schäfer I et al. Multimorbidity patterns in the elderly: a new approach of disease clustering identifies complex interrelations between chronic conditions. PLoS ONE 2010;5:e15941. [PubMed abstract]

–          Gunn JM et al. The association between chronic illness, multimorbidity and depressive symptoms in an Australian primary care cohort. Soc Psychiatry Psychiatr Epidemiol Dec 25 [Epub ahead of print] 2010. [PubMed abstract]

–          Thiem U et al. Prerequisites for a new health care model for elderly people with multimorbidity: the PRISCUS research consortium. Z Gerontol Geriatr 2011;44:115-20. [PubMed abstract]

–          Naessens JM et al. Effect of multiple chronic conditions among working-age adults. Am J Manag Care 2011;17:118-22. [PubMed abstract]

–          Diederichs C et al. The Measurement of Multiple Chronic Diseases–A Systematic Review on Existing Multimorbidity Indices. J Gerontol A Biol Sci Med Sci 2011;66:301-11. [PubMed abstract]

–          Lupari M et al. We’re just not getting it right’–how should we provide care to the older person with multi-morbid chronic conditions? J Clin Nurs 2011;20. [PubMed abstract]

–          Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev 2011;12:1-2. [Full text]

A comment on each of these publications is not possible here. However, I want to bring to your attention the main idea I found in the last publication on the list, which is an editorial by Barbara Starfield:

“…it is not chronic conditions by themselves that raise resource use. Rather, it is the number of types of conditions, that is, multi-morbidity.”

“…despite the attention to chronic diseases in many countries of the world, it is not chronicity per se that creates a burden on the health-care system.”

It’s worth reading entirely!

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

Martin

Comment (1)
Theory, concept and measure

Can we exclude exclusion criteria?

May 19, 2011 – 2:17 pm
By Graham Watt
 
I keep a cartoon in which a patient tells a flummoxed psychiatrist,

” I have neither illusions nor delusions, Doc. My problem is that I exist day after day in grim reality”.

In seeking to pigeon-hole the patient as a case, the doctor ignores her reality.
Does the same thing happen in multiple morbidity?
Shakespeare first noted, “When troubles come, they come not single spies but in batallions”

That seems true of multiple morbidity in socio-economically deprived areas, defined as the “number, severity and complexity of health and social problems within families”.

Operational definitions of multiple morbidity in research studies, based on counts of conditions, get nowhere near this, largely missing out on social and family aspects.

The problem is heterogenity, something that research tries to eliminate.
How can multiple morbidity research put heterogenity centre stage, so that results inform the majority of patients’ circumstances and not only those meeting case definitions?

Of course, asking the question is the easy part.

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Event

International Workshop, Glasgow, April 18th, 2011

May 13, 2011 – 8:51 am

By Stewart Mercer

The challenge of multimorbidity – what can we learn from cohort studies? 

This one day meeting was organised by Professor Stewart Mercer, Professor of Primary Care Research at the University of Glasgow, who leads a national research programme on multimorbidity in Scotland with the Scottish School of Primary Care.

The morning seminar, which was the inaugural event of the newly established Institute of Health and Well-being at the University of Glasgow, and was chaired by Professor Sally Wyke, welcomed Professor Jane Gunn from Melbourne University, who is Visiting Professor with the Scottish School of Primary Care, who described her work over several years on the DIAMOND primary care cohort on depression and multimorbidity. Professor Martin Fortin from Sherbrooke University in Canada, then described the cohort studies he has recently been involved in setting up in primary care in Canada with Professor Jeannie Haggerty. This was followed by Professor Frances Mair, Head of the Academic Unit of General Practice and Primary Care at the University of Glasgow, who spoke of the treatment burden in multimorbidity, and the need for ‘minimally disruptive medicine.’ Finally, Professor Mercer described work to date on multimorbidity in Scotland, and work in progress in developing the MALT (Multiple and Long-Term conditions) cohort in Scotland.

 The afternoon consisted of a workshop to discuss multimorbidity cohort studies further, and the MALT Cohort development. Attendees included experts from Scotland, Ireland, England, as well as our morning speakers. The need for cohort studies on multimorbidity was agreed, based on simple models, and as far as possible based on collaboration between countries. The lack of evidence on multimorbid patients’ views and experiences of health and healthcare was a strong theme of the afternoon. It was agreed that those at the workshop would continue to debate these issues collaboratively.

 Overall, this was a very enjoyable and stimulating meeting and we look forward to seeing more guests in the future at our next ‘Glasgow Meeting’ on interventions in multimorbidity in March next year.

University of Glasgow

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Event

A Masterclass on Multimorbidity Research

May 2, 2011 – 8:12 am

By François Schellevis

On the occasion of the stay of prof. Martin Fortin in the Netherlands, we organised on April 27th, 2011 a Masterclass on Multimorbidity Research under the auspices of the Dutch Primary Care Research School “CaRe”. CaRe represents the cooperation between the departments of general practice of three Dutch universities and NIVEL, the Netherlands Institute for Health Services Research (www.researchschoolcare.nl). We used this opportunity to bring together researchers working on different multimorbidity issues. It was unique experience with a very fruitful exchange and discussions with prof. Fortin, the “Master”, and with colleagues.

The Masterclass started with a presentation of prof. Fortin about Multimorbidity research in Canada. Research is focused on three themes: conceptual issues (including how to measure multimorbidity), the epidemiology of multimorbidity, and interventions focusing on improving health and health care. After this, four researchers from each CaRe partner presented their work, followed by a discussion with the audience. Mrs. Ruth van Nispen (EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam) showed how multimorbidity affects the quality of life of severely impaired visually handicapped persons. Mrs. Sil Aarts (CAPHRI/MENS, University of Maastricht) discussed the issue of measuring the physical and mental aspects of quality of life in multimorbid patients in general practice. Mrs. Annemarie Uijen (Department of Primary Care, St Radboud University Medical Center Nijmegen) presented the development of a generic questionnaire to measure continuity of care among multimorbid patients in different care settings. Finally, Mrs. Nathalie Versnel (NIVEL, Utrecht and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam) presented the design of a randomized controlled trial to establish the effectiveness of case management in diabetes patients with comorbidity.

All participants were very positive about the Masterclass which provided many new insights into research issues regarding multimorbidity. They considered the setting of a Masterclass with an expert from abroad and discussions in a small group of colleagues working on comparable issues as very fruitful. We were very grateful to prof. Fortin for providing us with this opportunity.

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Epidemiology and outcomes research

PRECISE: Program of Research on the Evolution of a Cohort Investigating Health System Effects

April 27, 2011 – 2:54 pm

By Martin Fortin

Pr Jeannie Haggerty (PhD), principal investigator, and Dr Martin Fortin (MSc), co-principal investigator, are currently leading a research program designed to explain the changes operated by the transformation of primary healthcare services and to measure its effects on population health and in particularly vulnerable groups: the multi-morbid and the poor. This longitudinal cohort study is being conducted using mixed methods. Four interrelated studies, using three embedded cohorts (sentinel medical clinics, clinic patients and a population sample) in four local healthcare networks from three regions of Quebec (Canada) are at different stages of the research process.

Study 1, Integration of Local Services Network, explores primary care organizations’ responses to the government mandate and inter-organizational exchanges. Data collection including organizational questionnaires (self-completed by 66 primary care providers), semi-structured interviews (conducted with 17 clinicians) and document review is complete. Studies 2 and 3, Follow-up of a Patient and a Population Cohort, are measuring the effects of efficient and patient-centered healthcare services on evolution of functional health, chronic illness burden and health functioning in individuals over time. Data for the first of this three-year study were collected using questionnaires (self-completed by 786 patients and 1700 individuals of the general population) and analysis is ongoing. Study 4, Validation of Measurement Instruments, is planned for year 2 of the program.

For more information about this program and the research team, follow this link

http://www.programmeprecise.ca/en/home/

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Intervention

Adaptation, implementation and evaluation of an intervention involving the integration of chronic disease rehabilitation services into primary care

April 27, 2011 – 2:30 pm


(Funded by: Pfizer-FRSQ-MSSS Chronic Disease Fund)

 By Martin Fortin and Maud-Christine Chouinard

 

Aging is associated with an increasing number of chronic diseases (CD) which represents a challenge for the healthcare system [1-2]. While traditional health care funding and management are mainly designed to address acute health conditions, the bulk of health funds is allocated to patients with CD [3]. The Chronic Care Model (CCM) suggested a multi-component remodeling of CD services to improve patient outcomes [4]. To meet the complex and ongoing needs of patients with CD, rehabilitation has been advocated as a key feature of primary care [5]. Moreover, patients with multimorbidity represent a greater challenge to primary healthcare as they are associated with high healthcare costs and poor compliance to treatment and recommendations [6-7]. In the presence of multimorbidity, health care providers acting in primary care face difficulties in applying guidelines and in maintaining continuity of care. To prevent potential health care system gaps in quality, efficiency, and effectiveness, primary care physicians have to play a gatekeeping role in the management of multimorbid patients and should be assisted in CCM integration and application. Consequently, decision makers and physicians have to look to evidence-based practice guidelines to improve the quality of care and to manage the allocation of resources as efficiently as possible[8].

In this regard, we aim to establish a clinical intervention that will adapt and permanently integrate rehabilitation services into primary care settings and to develop objective tools to assess the adaptation and implementation of this intervention in eight primary care practices in the Saguenay region (Quebec, Canada), in order to ensure the sustainability of interventions beyond the rehabilitation period. More specifically, the intervention will aim to clinically operationalize the mechanisms and tools necessary for the delivery of integrated CD services, promoting continuity of care in response to the needs expressed by stakeholders and to deploy rehabilitation services adapted to the realities of various primary care settings.

The evaluation of the implementation will be conducted using descriptive qualitative methods, while the evaluation of the effects will be based on a combination of experimental designs: randomized trial using a delayed intervention arm (n=326), a before and after design with repeated measures (n=163), and a quasi-experimental design using a comparative cohort (n=326). The qualitative evaluation will be based on focus groups and individual interviews before, during and after the implementation with various stakeholders (decision makers, primary care professionals, rehabilitation professionals and patients). Assessment of effects on patients will use self-administered questionnaires measuring chronic disease self-efficacy, health education impacts, health behaviors, quality of life, and psychological well-being.

Patients included in this study will be referred by their primary care provider and have to present at least one of the conditions for which rehabilitation is currently available (or their risk factors): diabetes, cardiovascular diseases, COPD, asthma. Total disease burden will be assessed for each patient. Data collected from participants will be analyzed in three steps according to a qualitative content analysis procedure to identify emerging themes and trends: coding, sorting of text content and analysis. In addition, the analysis will focus on shedding light on: (1) the interaction between the implementation context and the intervention on the effects obtained; (2) contextual determinants of the changes that occurred from various perspectives on organizational change, including political, structural, psychological and organizational models.

In the short-term, we are expecting improved patient self-efficacy, empowerment and self-management. In the long-term, this should result in a reduction of their risk factors, with an improvement in quality of life and psychological distress. At the organization level, the project should lead to a coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration.

Multimorbidity represents a crucial step in the process of adaptation of evidence-based medicine to the primary care reality. Among patients with CD, those presenting multimorbidity show high levels of health care utilization. It is important to increase our understanding of primary care needs in rehabilitation services and the characteristics of conceptual models of interventional approaches designed for patients followed up by family physicians. In conclusion, the integration of specialized rehabilitation services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated.

1. Fried, L.P., Epidemiology of aging. Epidemiol Rev, 2000. 22(1): p. 95-106.
2. WHO, Chronic disease risk factors. 2003.
3. Mirolla, M., The cost of chronic disease in Canada The Chronic Disease Prevention Alliance of Canada, 2008.
4. Wagner, E.H., et al., Improving chronic illness care: translating evidence into action. Health Aff (Millwood), 2001. 20(6): p. 64-78.
5. McColl, M.A., Structural determinants of access to health services for people with disabilities. Disability and social policy in Canada. 2nd ed.. Toronto: Captus Pr;, 2006: p. 293–313.
6. DiMatteo, M.R., et al., Patient adherence and medical treatment outcomes: a meta-analysis. Med Care, 2002. 40(9): p. 794-811.
7. Hughes, C.M., Medication non-adherence in the elderly: how big is the problem? Drugs Aging, 2004. 21(12): p. 793-811.
8. Wagner, E.H., B.T. Austin, and M. Von Korff, Organizing care for patients with chronic illness. Milbank Q, 1996. 74(4): p. 511-44.

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