Journal of Comorbidity
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Relationship between continuity of care and adverse outcomes varies by number of chronic conditions among older adults with diabetes
Full text linkBackground: Continuity of care is a basic tenant of primary care practice. However, the evidence on the importance of continuity of care for older adults with complex conditions is mixed. Objective: To assess the relationship between measurement of continuity of care, number of chronic conditions, and health outcomes. Design: We analyzed data from a cohort of 1,600 US older adults with diabetes and ≥1 other chronic condition in a private Medicare health plan from July 2010 to December 2011. Multivariate regression models were used to examine the association of baseline continuity (the first 6 months) and the composite outcome of any emergency room use or inpatient hospitalization occurring in the following 12-month period. Results: After adjusting for baseline covariates, high known provider continuity (KPC) was associated with an 84% (adjusted odds ratio 0.16; 95% confidence interval 0.09–0.26) reduction in the risk of the composite outcome. High KPC was significantly associated with a lower risk of the composite outcome among individuals with ≥6 conditions. However, the usual provider of care and continuity of care indices were not significantly related with the composite outcome in the overall sample or in those with ≥6 conditions. Conclusion: The relationship between continuity of care and adverse outcomes depends on the measure of continuity of care employed. High morbidity patients are more likely to benefit from continuity of care interventions as measured by the KPC, which measures the proportion of a patient’s visits that are with the same providers over time. Journal of Comorbidity 2016;6(2):65–7
Erratum to: Addressing multimorbidity to improve healthcare and economic sustainability
Full text linkErratum to: Colombo F, García-Goñi M, Schwierz C. Addressing multimorbidity to improve healthcare and economic sustainability. J Comorbidity 2016;6(1):21−27. doi: 10.15256/joc.2016.6.74.The first sentence of the Acknowledgements section should read, 'The opinions expressed in this paper are the responsibility of the authors and do not necessarily reflect those of the OECD, the European Commission or its member countries.'Journal of Comorbidity 2016;6(1):33The original article can be found at: http://dx.doi.org/10.15256/joc.2016.6.7
Many diseases, one model of care?
Full text linkThis article has been corrected. See J Comorbidity 2016;6(1):33. http://dx.doi.org/joc.2016.6.78. Patients with multiple chronic conditions (multimorbidity) have complex and extensive health and social care needs that are not well served by current silo-based models of care. A lack of integration between care providers often leads to fragmented, incomplete, and ineffective care, leaving many patients overwhelmed and unable to navigate their way towards better health outcomes. In planning for the future, healthcare policies and models of care are required that cater for the complex needs of patients with multimorbidity and that deliver coordinated care that is patient-centred and focused on disease prevention, multidisciplinary teamwork and shared decision-making, and on empowering patients to self-manage. Salient lessons can be learnt from the work undertaken at a European and national level to develop care models in cancer and diabetes – two complex and often co-occurring conditions requiring coordinated long-term care. Innovative work is also underway in many European countries aimed at improving the integration of care for people with multimorbidity, resulting in more efficient and cost-effective health outcomes. This article reviews some of the most innovative programmes that have been initiated across and within Europe with the aim of improving the way care is delivered to people with complex and multiple long-term conditions. This work provides a foundation upon which to build better, more effective models of care for people with multimorbidity.Journal of Comorbidity 2016;6(1):12–2
Erratum to: Many diseases, one model of care?
No full textErratum to: Albreht T, Dyakova M, Schellevis FG, Van den Broucke S. Many diseases, one model of care? J Comorbidity 2016;6(1):12−20. doi: 10.15256/joc.2016.6.73.The received and accepted dates for this article were incorrectly published as Jan 4, 2015 and Jan 25, 2015, respectively, instead of Jan 4, 2016 and Jan 25, 2016, respectively. The original article has now been updated to reflect the correct submission and acceptance dates.Journal of Comorbidity 2016;6(1):34The original article can be found at: http://dx.doi.org/10.15256/joc.2016.6.7
Multimorbidity and the primary healthcare perspective
No full textThe ageing population is marked by an increase in chronic health problems, raising concerns over the feasibility of healthcare systems and their financial capabilities [1,2]. A central point here is the growing rate of multimorbidity, i.e. the coexistence of multiple chronic conditions in a given individual [3].The concept of multimorbidity conflicts with the ‘single-disease model’, around which healthcare, medicine and health research are traditionally organized. This model has dominated healthcare, research and education for so long that it is only recently that multimorbidity is being presented as a demographic feature.Multimorbidity requires a paradigm shift away from this single-disease model of patient management; a shift that is now increasingly recognized and adopted, albeit at a slow pace. However, the reality in primary healthcare is already somewhat different. Primary healthcare, in its comprehensive approach to all health problems in all individuals at all disease stages and phases of life, has a long experience in dealing with individuals experiencing a range of health problems [4], including chronic health problems as reported in the literature [5–7]. These reports indicate that multimorbidity is substantial, with about a third of the (primary healthcare) population affected; this prevalence is in line with those reported in more recent studies from other countries [8–12]. Journal of Comorbidity 2016;6(2):46–4
Managing multimorbidity: how can the patient experience be improved?
Full text linkThe patient’s experience of their own healthcare is an important aspect of care quality that has been shown to improve clinical and other outcomes. Very little is currently known about patient experience in the management of multimorbidity, although preliminary evidence suggests that it may be poor. Individuals with multimorbidity report better experiences of care when they are knowledgeable and involved in the decision-making, when their care is well coordinated, and communication is good. A greater focus on disease prevention, stronger collaboration between health and social care services, and the provision of more integrated care for people with mental and physical health problems would also help to improve the patient experience. Advocacy groups can amplify the patient voice and improve access to care, as well as provide information and support to patients and their families. Patients have an important role in preventing multimorbidity and improving its management, and should be involved in the development of health policies and the delivery of healthcare services. Inequalities in access to quality healthcare must also be addressed.Journal of Comorbidity 2016;6(1)28–3
Considering the healthcare needs of older people with multimorbidity: managing Alice
No full textManaging elderly patients with multimorbidity can be challenging to clinicians, particularly those in primary care. We discuss the complexities and challenges in this editorial. Introducing AliceAlice is 82 years old. She has type 2 diabetes mellitus and is on metformin – she only takes one 500 mg tablet twice a day as she “can’t stand” the abdominal discomfort and loose stools if she takes more, even though the general practitioner (GP) has told her she should take one with each meal. She takes levothyroxine, has asthma (which is managed with a Seretide® inhaler) and hypertension (which is controlled with ramipril). For the pain in her knees and feet, which the GP says is due to “wear and tear”, she takes paracetamol regularly, but does not feel it works – and it might not, given the recent paper in the Lancet [1] – so she uses a rubefacient, which makes her feel better.She was recently diagnosed with atrial fibrillation and, after much deliberation, agreed to start rivaroxaban. A year ago, Alice was given simvastatin by one of the practice nurses after having a blood pressure check, but often wonders why she needs to take this; and because the instructions are to take at night, Alice often forgets to take it.Journal of Comorbidity 2016;6(2):53–5
What makes stroke rehabilitation patients complex? Clinician perspectives and the role of discharge pressure
No full textBackground: Approximately 80% of people who survive a stroke have on average five other conditions and a wide range of psychosocial issues. Attention to biopsychosocial issues has led to the identification of ‘complex patients’. No single definition of ‘patient complexity’ exists, therefore applied health researchers seek to understand ‘patient complexity’ as it relates to a specific clinical context. Objective: To understand how ‘patient complexity’ is conceptualized by clinicians, and to position the findings within the existing literature on patient complexity. Methods: A qualitative descriptive approach was utilized. Twenty-three rehabilitation clinicians participated in four focus groups. Results: Five elements of patient complexity were identified: medical/functional issues, social determinant factors, social/family support, personal characteristics, and health system factors. Using biopsychosocial factors to identify complexity results in all patients being complex; operationalization of the definition led to the identification of systemic elements. A disconnect between acute, inpatient rehabilitation and community services was identified as a trigger for increased complexity. Conclusions: Patient complexity is not a dichotomous state. If applying existing complexity definitions, all patients are complex. This study extends the understanding by suggesting a structural element of complexity from manageable to less manageable complexity based on ability to discharge.Journal of Comorbidity 2016;6(2):35–4
Integrated multimorbidity management in primary care: why, what, how, and how to?
No full textThe epidemic of multimorbidityPolicymakers regard “the epidemic of multimorbidity” as the greatest threat to the sustainability of healthcare systems. They believe the solution is “integrated care”, “The search to connect the healthcare system (acute, primary medical and skilled) with other human service systems (e.g. long-term care, education and vocational and housing services) in order to improve outcomes (clinical, satisfaction, and efficiency)” [1]. This definition includes key characteristics of complex adaptive systems. People act as agents who evolve in their characteristics and behaviours over time. These agents constantly learn and adapt in real time to changing contexts. These systems display emergent dynamic non-linear behaviours resulting from ongoing iterative feedback amongst their agents.Emergent outcomes do not have linear “cause and effect” relationships and can best be understood in hindsight. Emergent behaviours are highly sensitive to context; consequently, the “same” approach used by different agents in different contexts will not produce the same outcomes. Agents navigate toward mutually agreed outcomes by constantly adapting to evolving changes within the context of local constraints [2].A complex adaptive system approach overcomes many of the dysfunctions in the current health systems, in particular the fragmentation of patient care [3]. Overcoming fragmentation requires continuous adaptation to changing circumstances – a constant challenge for patients, health professionals, community service providers, and policymakers.How can the already overburdened primary healthcare services achieve these goals?To address the complex challenge, we first must reflect on three key questions:What is health?What is disease?What is multimorbidity? Journal of Comorbidity 2016;6(2):114–11
Multimorbidity: What do we know? What should we do?
Full text linkMultimorbidity, which is defined as the co-occurrence of two or more chronic conditions, has moved onto the priority agenda for many health policymakers and healthcare providers. Patients with multimorbidity are high utilizers of healthcare resources and are some of the most costly and difficult-to-treat patients in Europe. Preventing and improving the way multimorbidity is managed is now a key priority for many countries, and work is at last underway to develop more sustainable models of care. Unfortunately, this effort is being hampered by a lack of basic knowledge about the aetiology, epidemiology, and risk factors for multimorbidity, and the efficacy and cost-effectiveness of different interventions. The European Commission recognizes the need for reform in this area and has committed to raising awareness of multimorbidity, encouraging innovation, optimizing the use of existing resources, and coordinating the efforts of different stakeholders across the European Union. Many countries have now incorporated multimorbidity into their own healthcare strategies and are working to strengthen their prevention efforts and develop more integrated models of care. Although there is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems. In low- to middle-income countries, which are facing the double burden of infectious and chronic diseases, integration of care will require capacity building, better quality services, and a stronger evidence base. Journal of Comorbidity 2016;6(1):4–1