Entete 3
Theory, concept and measure

Risk factors and symptoms in the definition of multimorbidity

March 14, 2016 – 9:30 am


By Tora Grauers Willadsen and Niels de Fine Olivarius
We want to share our new paper”The role of diseases, risk factors and symptoms in the definition of multimorbidity – a systematic review” (Scandinavian Journal of Primary Health Care 2016 March 8, : 1-10) here on the International Research Community on Multimorbidity’s (IRCMo) site.
Our objective was to explore how multimorbidity is defined in the scientific literature, with a focus on the role of diseases, risk factors, and symptoms in the definitions. We used systematic review as design. We searched MEDLINE (PubMed), Embase, and The Cochrane Library for relevant publications up until October 2013. One author extracted the information. Ambiguities were resolved, and consensus reached with one co-author. Our main outcome measures were: cut-off point for the number of conditions included in the definitions of multimorbidity; setting; data sources; number, kind, duration, and severity of diseases, risk factors, and symptoms.
We had the following results: In 61 (37 %) articles, out of the 163 articles we included, the cut-off point for multimorbidity was two or more conditions (diseases, risk factors, or symptoms). The most frequently used setting was the general population (68 articles, 42%), and primary care (41 articles, 25%). Sources of data were primarily self-reports (56 articles, 42%). Out of the 163 articles selected, 115 had individually constructed multimorbidity definitions, and in these articles diseases occurred in all definitions. As earlier found diabetes was the most frequent disease. Risk factors occurred in 98 (85%) and symptoms in 71 (62%) of the definitions. The severity of conditions was used in 26 (23%) of the definitions, but in different ways.
This review demonstrated, as shown previously, a heterogeneous definition of multimorbidity. Furthermore, it shows that risk factors are more often included than symptoms and that severity of conditions is seldom included in the definition. The fundamental role of risk factors in the definition of multimorbidity is one reason for the high prevalence of multimorbidity. Symptoms and severity are included less often and this contributes to making the existing definitions more usable for epidemiologists than for clinicians and patients. We believe this review adds to the discussion about more comprehensive and clinically relevant multimorbidity definitions.
To access the full manuscript, please click the following link:
http://www.tandfonline.com/doi/full/10.3109/02813432.2016.1153242
At The research Unit for General Practice and Department of General Practice at The University of Copenhagen we are working on several projects about multimorbidity, both quantitative register-based studies including the whole Danish population, and qualitative studies. You are very welcome to contact us for more information. E-mail: olivarius@sund.ku.dk
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Others

Publications on multimorbidity September 2015 – January 2016

March 1, 2016 – 10:34 am


By Martin Fortin
Our search for papers on multimorbidity that were published during the period September 2015 – January 2016 has been completed. As in previous searches, we found many new papers and the list is too long for this venue. Therefore, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases”, but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.
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Others

What is the future of general practice academics interested in research on multimorbidity?

February 22, 2016 – 2:09 pm


By Aline Ramond-Roquin and Martin Fortin
In a recent provocative blogpost [1] hosted by the Canadian Medical Association Journal, the associate editor Domhnall MacAuley initiated an interesting discussion on the challenges general practice research currently faces. We would like to extend the reflection and to discuss some issues relevant for multimorbidity research.
First, we somewhat disagree on the fact that academic general practitioners have “become less and less embedded in daily patient care”. Many of them still deliver “personal, primary and continuing care”. The traditional model of single-handed practitioners offering “twenty four hour access to patients” is quite obsolete, but this reflects the evolution of general practice rather than a specific characteristic of academics.
Indeed, general practitioners can no longer single-handedly fill the increasingly complex needs of their patients. Patients living with multimorbidity, who are now considered the rule in primary care, need interdisciplinary care. The current evolution towards increasing interdisciplinary work has generated specific research questions which require lowering some traditional barriers in the academic setting and developing interdisciplinary research, to appropriately address them. In this regard, having non-doctor primary care researchers in academic departments of general practice should neither be reduced to a question of “cost-effectiveness”, nor be considered as a threat for general practice research, as suggested in the CMAJ blogpost. Rather, collaborations within interdisciplinary teams are definitely an advantage to undertake research in complex fields such as multimorbidity. In these teams, general practitioners with significant clinical activity have a crucial and irreplaceable role.
Finally, meaningful research for people living with multimorbidity is often based on complex designs, such as multi-level epidemiological studies or pragmatic trials. We therefore strongly argue for scientific journals not neglecting research grounded in the real world of practice. They should not only focus on “sample size” and “international generalizability”, but should also be concerned by clinical relevance and potential for implementation and transferability in different contexts. Producing and publishing practice-based evidence is required to practice evidence-based medicine relevant to the context, with the potential to eventually improve the life of our patients.
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[1] http://cmajblogs.com/thinking-the-unthinkable-about-general-practice-research/
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Epidemiology and outcomes research

Multimorbidity in Brazil

February 3, 2016 – 2:31 pm


By Bruno P. Nunes, Elaine Thumé, and Luiz A. Facchini
We are very satisfied to disseminate our recent paper in International Research Community on Multimorbidity (IRCMo) site. This community was and continues to be very important for our studies related to this topic in Brazil.
Despite worldwide importance of multimorbidity and the specific Brazilian context (more than 200 million inhabitants, rapid epidemiologic and demographic transitions, and relatively new universal health system), populational information about occurrence of multiple health problems is scarce in the country. Thus, data from a population-based survey that we conducted in 2008 were used to provide information and start works about multimorbidity in Brazilian context. The sample was comprised by 1593 elderly (≥60 years old) who lived in Bagé, a medium-sized city in Southern Brazil. The individuals were interviewed in their households through face-to-face interviews. In total, 17 morbidities were used and we measured multimorbidity according to two cutoff points: ≥2 and ≥3 morbidities. Descriptive analysis, and dyads and triads of diseases were calculated. We found that 94% of the sample presented, at least, one morbidity. High blood pressure – HBP – (55.3%) and spinal column disease (37.4%) were the diseases most frequent. Multimorbidity reached 81.3% (95 % CI: 79.3; 83.3) and 64.0 % (95% CI: 61.5; 66.4) of the individuals for ≥2 and ≥3 morbidities, respectively. As found in others studies, most vulnerable elderly presented higher occurrence of multiple diseases. For example, 87.1% of the elderly without schooling presented 2 or more diseases (22.3 percentage points higher than elderly which studied 8 years or more).  Another challenge to public health system was demonstrated by higher frequency of multimorbidity between individuals without health private plan and those who are living in Family Health Strategy (organizational axis of primary health care) catchment areas.
These results about multimorbidity in older adults from Brazil may provide initial information to address multiple diseases in clinical protocols and contribute to subsidize actions in health services to management of multimorbidity.
To access the full manuscript, please click in the following link: http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2505-8
Furthermore, we are drafting others papers about multimorbidity in Brazil, including evaluation of national-based studies. Therefore, we would like to invite researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others) to contact us. Contact e-mail for further information: nunesbp@gmail.com.
  • Reference: Nunes BP, Thumé E, Facchini LA: Multimorbidity in older adults: magnitude and challenges for the Brazilian health system. BMC Public Health 2015, 15(1):1172

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Others

IMPORTANT ANNOUNCEMENT. Indexing in MEDLINE: Journal of Comorbidity needs your help

January 15, 2016 – 10:16 am


By Martin Fortin, Jane Gunn, Stewart W. Mercer, Susan Smith, Marjan van den Akker
At the Journal of Comorbidity, we recognize the importance of publishing high-quality work in a timely manner, and publishing work that can be discovered by the wider community in bibliographic databases. One of the premier databases that many authors and readers turn to is MEDLINE®, the National Library of Medicine’s (NLM) database containing over 20 million citations of biomedical literature. Indexing in MEDLINE is therefore key to helping any journal seeking the widest dissemination of their published content.
Although the Journal of Comorbidity is indexed in many databases, it currently does not meet the minimum requirements for MEDLINE indexing. The journal is therefore increasing its efforts to achieve this as soon as possible – but first, we need your help.
In order to be considered for MEDLINE indexing, we have to meet a set of minimum requirements, particularly with regard to the quantity of published articles. And this is where we ask for your help. We are inviting all researchers, clinicians and other healthcare professionals with an interest in comorbidity/multimorbidity to submit their work to the Journal of Comorbidity. (refer to the online author guidelines for preparing your article: http://www.jcomorbidity.com/index.php/test/about/submissions#authorGuidelines). We are currently seeking publications – original research papers, but also critical reviews and study protocols – to meet our target. We believe that indexing in MEDLINE will help to increase our visibility, increase access to our content, and will encourage more authors at all levels of experience and expertise to publish their work in the journal.
With your help, we can make the Journal of Comorbidity grow, and enhance its impact in this niche field and beyond.
We would like to thank all members of our editorial board, reviewers, readers, and our contributors, who together have shaped the journal into its current form and who have provided articles of great interest.
We look forward to a continued collaboration in further developing this journal into an authoritative resource on comorbidity/multimorbidity.
About the Journal of Comorbidity
The Journal of Comorbidity is an international, open-access, peer-reviewed journal with a focus on comorbidity and multimorbidity – the only journal of its kind. Established in Switzerland in 2011, the journal has attracted important and well-cited research worldwide. The Journal of Comorbidity is overseen by five co-Editors-in-Chief and by over 40 editors from across the globe. The journal publishes original clinical and experimental research articles, guidelines, policies, editorials, commentaries, protocols, and critical review papers. The journal provides a forum for scientists, researchers and healthcare professionals to share their research, experience and insight into diverse aspects of medicine in order to optimize the management of patients with comorbidity/multimorbidity.
Further information can be found online: www.jcomorbidity.com, or contact one of our editors today: editorial@jcomorbidity.com

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Others

Conceptualising multiple conditions in Australia

November 20, 2015 – 8:57 am



By Christine Walker

Since the 1970s greater numbers of people are now living with several serious long term illnesses. These include rarer genetic conditions and ‘lifestyle conditions’ as well as those of an idiopathic nature. A recently published article [1] examines the growing need for new terms and concepts that reflect the changes in the lives of people living with long-term serious illnesses.

The Chronic Illness Alliance conducted a workshop with its members who had multiple conditions to scope the problems they faced in receiving health care. A literature review using the principles of meta-synthesis which aims to systematise qualitative concepts provided the means to identify whether the concerns raised by consumers were recognised in the literature. The risks identified by consumers were used both as search terms and analytical terms. While the consumer perspective appeared absent in the literature, many authors showed similar concern about the tardiness of health systems to acknowledge the impact of multi-morbidities for consumers and the associated risks. More importantly the literature review demonstrated that problems associated with concepts, definitions and data collection impact on health care and service delivery. This in turn dictates how consumers receive their health care services and ultimately influences the safety and quality of their health care. The article argues that the adoption of better concepts is a first step to achieving systemic change on behalf of people with multiple conditions.

[1] Walker C. Conceptualising multiple conditions in Australia: First steps to systemic change to meet the needs of people with serious long-term illnesses. Patient Experience Journal, Volume 2, Issue 2 -Fall 2015, pp. 69-76.

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Event

PACE in MM Forum at the NAPCRG Annual Meeting in Cancun, Mexico

November 13, 2015 – 11:00 am


By Moira Stewart and Martin Fortin
Co-Principal Investigators of PACE in MM team

Martin Fortin and an international group of collaborators conducted a Forum at the North American Primary Care Research Group Annual Meeting in Cancun, Mexico on October 28, 2015 on “Outcomes for Patient-Centered Interventions for Persons with Multimorbidity.”

Speakers were Maxime Sassville, Elizabeth Bayliss, Chris Salisbury, Martin Fortin and Paul Little.  Moira Stewart summarized the proceedings.

Domhnall MacAuley highlighted this Forum in his CMAJ blog.  Have a look!

http://cmajblogs.com/some-golden-nuggets-and-grumbles-from-napcrg-2015/#more-2703

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Epidemiology and outcomes research

Multimorbidity and functional decline: a systematic review

October 23, 2015 – 10:20 am



By Áine Ryan, Emma Wallace, Paul O’Hara, Susan M. Smith

Multimorbidity is recognised internationally as having a negative impact on patient outcomes. Functional decline is defined as developing difficulties with activities of daily living and is also independently associated with poorer health outcomes. We recently published a systematic review examining the association between multimorbidity and functional decline. We also examined the extent to which multimorbidity predicts future functional decline [1].
The review retrieved 37 relevant studies (nine cohort and 28 cross-sectional).The majority of studies (n= 31) demonstrated a consistent association between multimorbidity and poorer functional status. Future functional decline was more likely with increasing numbers of conditions and was also linked to condition severity.
We can be reasonably confident of the findings of this systematic review; as overall, there was minimal risk of bias in the included studies. However, variation in study participants, multimorbidity definitions, follow-up duration and outcome measures resulted in meta-analysis not being possible.
The findings of this systematic review are consistent with existing evidence linking multimorbidity and poorer health related quality of life. It also highlights a potential cumulative effect, in that both multimorbidity and functional decline independently predict poorer patient outcomes. This review examines one direction of effect, i.e. that baseline multimorbidity predicts future functional decline. Conversely, it is also possible that poor physical functioning will lead to worsening of multimorbidity, a relationship that our study group plans to examine in an ongoing prospective cohort study in Ireland [2].
This review suggests that functional decline needs to be carefully considered in patients with multimorbidity. Future research should focus on the development and testing of interventions which prioritise physical function in this patient group, particularly for patients with higher numbers of conditions and greater disease severity.

The complete article can be accessed at:
http://hqlo.biomedcentral.com/articles/10.1186/s12955-015-0355-9

References
[1] Ryan A, Wallace E, O’Hara P, Smith SM. Multimorbidity and functional decline in community-dwelling adults: a systematic review. Health and Quality of Life Outcomes. DOI: 10.1186/s12955-015-0355-9.
[2] The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Ireland. www.tilda.ie

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Practice guidelines

Invitation to participate in a study related to the multimorbidity issue

October 16, 2015 – 1:35 pm



By Walter Wodchis and Yelena Petrosyan

We would like to invite Canadian primary care physicians/geriatricians to participate in the Delphi study that aims to  define the most appropriate set of quality indicators for assessing quality of overall care of older diabetes patients with comorbid concordant and discordant chronic conditions. Various quality measures have been developed for assessing care for single diseases. However, adherence to disease-specific measures for patients with multiple chronic conditions may lead to the unintended consequence of delivering inappropriate care. Therefore, it is crucial to identify measures that would address the heterogeneity and scope of care for a particular individual with particular types of co-existing conditions to improve the quality of care of people with multimorbidity.

Your participation will be anonymous, and will consist of responding to 2-3 electronic questionnaires, and each round will take approximately 20 minutes to complete. After completion of all three rounds, expected by December 20th 2015, you will be given a cheque for $200 to compensate you for any disruption to your practice.
If you might be interested in participating in our study please contact Walter Wodchis at walter.wodchis@utoronto.ca or Yelena Petrosyan at yelena.petrosyan@mail.utoronto.ca for further information.

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Others

Publications on multimorbidity April-August 2015

October 5, 2015 – 1:55 pm



By Martin Fortin

Our search for papers on multimorbidity that were published during the period April-August 2015 has been completed. As in previous searches, we found many new papers and the list is too long for this venue. Therefore, we have prepared a PDF file that can be accessed following this link.
Probably, there are some publications that were not detected by our search strategy using the terms “multimorbidity”, “multi-morbidity” and the expression “multiple chronic diseases”, but we are sure that most publications on the subject are included in the list.
All references are also included in our library. Feel free to share with anyone interested in multimorbidity.

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