Journal of Comorbidity
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Towards increased visibility of multimorbidity research
No full textThe number of people living with comorbidity, multimorbidity, or multiple chronic conditions, hereafter referred to as “multimorbidity” (see Box 1) [1,2], has become the norm rather than the exception in healthcare. In developed countries, approximately one in four adults have at least two chronic conditions [3,4], and over half of older adults have three or more [5]. Although the prevalence of multimorbidity increases with age, many studies have reported high rates of multimorbidity even among younger adults [6].Multimorbidity negatively impacts patient outcomes, including physical and psychological functioning, quality of life, and life expectancy [7,8]. It also complicates treatment and increases healthcare utilization and costs [9–11]. Despite representing a large – and growing – proportion of adults seen in primary care today, there is a major gap in our understanding of how best to address, meet, and satisfy the complex care needs of patients with multimorbidity [11]. The traditional single-disease model of care does not work for them, and multimorbidity should definitively not be considered as the simple juxtaposition of independent conditions [12,13].Fortunately though, interest in multimorbidity is growing worldwide, and has become a healthcare and research priority [14,15]. An international community interested in multimorbidity research has recently emerged and become organized through different activities, such as the creation of the Journal of Comorbidity, a weblog that hosts and supports the exchanges from the International Research Community on Multimorbidity [16], the organization of an international forum [17] at the North American Primary Care Research Group (NAPCRG) congress, and the publication of an “ABC of Multimorbidity” [1]. Journal of Comorbidity 2016;6(2):42–4
Development of the C4 Inventory: a measure of common characteristics that complicate care in outpatient psychiatry
No full textBackground: Psychiatric syndromes are complicated by comorbidity and other factors that burden patients, making guideline-informed psychiatric care challenging, and negatively affecting outcome. A comprehensive intake tool could improve the quality of care. Existing tools to quantify these characteristics do not identify specific complications and may not be sensitive to phenomena that are common in psychiatric outpatients. Objective: To develop a practical inventory to capture observations related to complex care in psychiatric outpatients and quantify the overall burden of complicating factors. Design: We developed a checklist inventory through literature review and clinical experience. The inventory was tested and compared with related measures in a cross-sectional study of 410 consenting outpatients at the time of initial assessment. Results: The summed score of inventory checklist items was significantly correlated with patient-assessed measures of distress (K10, r=0.36) and function (WHODAS 2.0, r=0.31), and physician-assessed measures of function (GAF, r=−0.42), number of psychiatric diagnoses [F(df3)=33.6], and most complex diagnosis [F(df3)=37.4]. In 53 patients whose assessment was observed by two clinicians, inter-rater reliability was acceptable for both total inventory score (intraclass correlation, single measures = 0.74) and agreement on specific items (mean agreement score = 90%). Conclusions: The Psychiatric C4 Inventory is a reliable instrument for psychiatrists that captures information that may be useful for quality improvement and resource planning. It demonstrates convergent validity with measures of patient distress, function, and complexity. Further tests of validity and replication in other settings are warranted.Journal of Comorbidity 2016;6(2):56–6
A qualitative interpretation of challenges associated with helping patients with multiple chronic diseases identify their goals
No full textBackground: Patients with multiple chronic diseases are usually treated according to disease-specific guidelines, with outcome measurements focusing mostly on biomedical indicators (e.g. blood sugar levels or lung function). However, for multimorbidity, a goal-oriented approach focusing on the goals defined by the individual patient, may be more suitable. Despite the clear theoretical and conceptual advantages of including patient-defined goals in clinical decision-making for multimorbidity, it is not clear how patients define their goals and which aspects play a role in the process of defining them. Objective: To explore goal-setting in patients with multimorbidity. Design: Qualitative analysis of interviews with 19 patients diagnosed with chronic obstructive pulmonary disease and comorbidities. Results: Patients do not naturally present their goals. Their goals are difficult to elicit, even when different interviewing techniques are used. Four underlying hypotheses which may explain this finding were identified from the interviews: (1) patients cannot identify with the concept of goal-setting; (2) goal-setting is reduced due to acceptation; (3) actual stressors predominate over personal goal-setting; and (4) patients may consider personal goals as selfish. Conclusions: Our findings advocate for specific attention to provider skills and strategies that help patients identify their personal goals. The hypotheses on why patients may struggle with defining goals may be useful to prompt patients in this process and support the development of a clinical method for goal-oriented care.Journal of Comorbidity 2016;6(2):120–12
Training doctors to manage patients with multimorbidity: a systematic review
No full textBackground: Patients with multimorbidity (two or more chronic conditions) are now the norm in clinical practice, and place an increasing burden on the healthcare system. Management of these patients is challenging, and requires doctors who are skilled in the complexity of multiple chronic diseases. Objective: To perform a systematic review of the literature to ascertain whether there are education and training formats which have been used to train postgraduate medical doctors in the management of patients with multimorbidity in primary and/or secondary care, and which have been shown to improve knowledge, skills, attitudes, and/or patient outcomes. Methods: Overall, 75,110 citations were screened, of which 65 full-text articles were then independently assessed for eligibility by two reviewers, and two studies met the inclusion criteria for the review. Results: The two included studies implemented and evaluated multimorbidity workshops, and highlight the need for further research addressing the learning needs of doctors tasked with managing patients with multimorbidity in their daily practice. Conclusion: While much has been published about the challenges presented to medical staff by patients with multimorbidity, published research regarding education of doctors to manage these problems is lacking. Further research is required to determine whether there is a need for, or benefit from, specific training for doctors to manage patients with multimorbidity. PROSPERO registration number: CRD42013004010.Journal of Comorbidity 2016;6(2):85–94
Facing the challenge of multimorbidity
Full text linkMultimorbidity is a major public health challenge that is rising up the political and health agenda at an accelerated rate. Although the prevalence of multimorbidity increases with age, more than half of the population with multimorbidity are under the age of 65 years [1], with social deprivation a key determinant of multimorbidity in young and middle-aged adults [2,3].From an individual’s perspective, multimorbidity reduces life expectancy [4–6], decreases physical functioning and quality of life [7], and increases the risk of depression and other mental health disorders [3]. From a healthcare provider’s perspective, multimorbidity is associated with increased health service use, a high risk of emergency and other hospital admissions, high rates of polypharmacy, and spiralling costs [8]. Current health systems, which are typically built around a single-disease framework, are poorly adapted to cope with patients with multimorbidity, who typically experience fragmented healthcare services, leading to potentially inefficient and ineffective care.It is increasingly clear that we need to change our perspective on multimorbidity in order to address it as a specific condition that requires tailored solutions and approaches. The urgent need to tackle multimorbidity in a more strategic, holistic, and cost-effective manner was evident at the 18th European Health Forum Gastein, a leading annual health policy event in the European Union (EU), held in the autumn of 2015. This Forum attracted policymakers, clinicians, health service managers, patients, and a broad range of other stakeholders, all of whom were invited to attend a session entitled “Facing the Challenge of Multimorbidity”.Journal of Comorbidity 2016;6(1):1–
Are care plans suitable for the management of multiple conditions?
No full textBackground: Care plans have been part of the primary care landscape in Australia for almost two decades. With an increasing number of patients presenting with multiple chronic conditions, it is timely to consider whether care plans meet the needs of patients and clinicians. Objectives: To review and benchmark existing care plan templates that include recommendations for comorbid conditions, against four key criteria: (i) patient preferences, (ii) setting priorities, (iii) identifying conflicts and synergies between conditions, and (iv) setting dates for reviewing the care plan. Design: Document analysis of Australian care plan templates published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Results: Sixteen templates were reviewed. All of the care plan templates addressed patient preference, but this was not done comprehensively. Only three templates included setting priorities. None assisted in identifying conflicts and synergies between conditions. Fifteen templates included setting a date for reviewing the care plan. Conclusions: Care plans are a well-used tool in primary care practice, but their current format perpetuates a single-disease approach to care, which works contrary to their intended purpose. Restructuring care plans to incorporate shared decision-making and attention to patient preferences may assist in shifting the focus back to the patient and their care needs.Journal of Comorbidity 2016;6(2):103–11
Secondary prevention of chronic health conditions in patients with multimorbidity: what can physiotherapists do?
No full textMultimorbidity is the co-occurrence of two or more diseases in an individual without a defining index disease [1,2]. In developed countries, the prevalence of multimorbidity has been estimated from both general practice and population data [3,4]. Data from general practices in Scotland found that 23% of patients had multimorbidity [3], whereas the prevalence of multimorbidity in Québec, Canada, was 46–51% in the general practice population and 10–13% in the general population aged over 24 years [4]. Australian data indicate that almost 40% of people aged over 44 years have multimorbidity, and this proportion increases to around 50% of those aged 65–74 years and to 70% of those aged 85 and over [5]. Data from a study of Australian general practice activity reported prevalence estimates for the most common combinations of chronic conditions [6]. Of the 12 most common combinations, the majority included conditions that can be positively impacted by physiotherapy interventions, such as low back pain [7], arthritis [8], chronic obstructive pulmonary disease [9], cardiac disease [10] and type 2 diabetes [11]. However, for some of these conditions, the uptake and access to physiotherapy interventions was suboptimal, especially in the primary care setting, due to poor referral from general practitioners (GPs) [12,13] and/or restricted access to physiotherapy associated with workforce shortages, as well as high cost to the patient for private consultation.Journal of Comorbidity 2016;6(2):50–5
Meeting the needs of a complex population: a functional health- and patient-centered approach to managing multimorbidity
No full textIndividuals with multimorbidity have complex care needs along with significant impacts to their functional health and quality of life. Recent evidence-based and experience-based explorations have revealed the importance of patient perspectives and functional health management in improving care delivery and health outcomes for individuals with multimorbidity. The impact of managing multimorbidity is evident at multiple levels of healthcare – the individual, the provider, and the system. Our local experience dealing with these challenges has led to the development of a functional health model that includes patient perspectives in care delivery within the Integrated Chronic Care Service (ICCS) of the health authority in Nova Scotia. In this paper, we present a discussion of the challenges, guiding models, and service-level transformations that have been integrated into care delivery at the ICCS to meet the healthcare needs of people with multiple health conditions. We describe our redesign strategies for care team planning, treatment approach, and patient inclusion. Journal of Comorbidity 2016;6(2):76–8
The Journal of Comorbidity affiliates with the Society for Academic Primary Care
No full textThe Journal of Comorbidity and the Society for Academic Primary Care (SAPC) are pleased to announce an exciting new partnership aimed at strengthening collaborations and enhancing opportunities among primary care professionals with an interest in comorbidity and multimorbidity. The Journal of Comorbidity and SAPC share a mutual goal to improve the management and care of patients by making clinical and research information and perspectives available to a global network of healthcare professionals. This new partnership will be an invaluable contribution to expanding the research platform for discussions and the scholarly exchange of knowledge, ideas, and research on comorbidity and multimorbidity.Journal of Comorbidity 2016;6(2):73–7
Addressing multimorbidity to improve healthcare and economic sustainability
Full text linkPatients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level – something that is now supported within the framework of the European Union’s Stability and Growth Pact.Journal of Comorbidity 2016;6(1):21–27An erratum to this article can be found here: http://dx.doi.org/10.15256/joc.2016.6.7