Journal of Comorbidity
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How to design and evaluate interventions to improve outcomes for patients with multimorbidity
Full text linkMultimorbidity is a major challenge for patients and healthcare providers. The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions. Here we present a consensus view from a group of international researchers working to improve care for people with multimorbidity to guide future studies of interventions. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems.Journal of Comorbidity 2013;3(1):10–17
Increasing clinical, community, and patient-centered health research
Full text linkThe report “Multiple Chronic Conditions: A Strategic Framework,” which was developed by the U.S. Department of Health & Human Services (HSS), has identified as one of the key goals for improving health and the provision of healthcare for people with multiple chronic conditions “to increase clinical, community and patient-centered research.” In their linked commentary of this special journal issue, Parekh and Goodman identify and consider the potential impact of a number of related research initiatives supported by the National Institutes of Health and the Agency for Health Research and Quality, particularly focusing on two very specific areas: behavioral medicine and secondary analyses of available datasets. In this paper, I comment on both documents and discuss the opportunities offered by the current approaches and highlight related research needs; in particular, the need for an improved and expanded conceptual model of healthcare for people with multimorbidity, and the need for further exploration of the use of multimorbidity-relevant outcomes as part of usual clinical practice.Journal of Comorbidity 2013;3(2):41–44
The coexistence of terms to describe the presence of multiple concurrent diseases
Full text linkBackground: Consensus on terminology for multiple diseases is lacking. Because of the clinical relevance and social impact of multiple concurrent diseases, it is important that concepts are clear. Objective: To highlight the diversity of terms in the literature referring to the presence of multiple concurrent diseases/conditions and make recommendations. Design: A bibliometric analysis of English-language publications indexed in the MEDLINE database from 1970 to 2012 for the terms comorbidity, multimorbidity, polymorbidity, polypathology, pluripathology, multipathology, and multicondition, and a review of definitions of multimorbidity found in English-language publications indexed from 1970 to 2012 in the MEDLINE and SCOPUS databases. Results: Comorbidity was used in 67,557 publications, multimorbidity in 434, and the other terms in three to 31 publications. At least 144 publications used the term comorbidity without referring to an index disease. Thirteen general definitions of multimorbidity were identified, but only two were frequently used (91% of publications). The most frequently used definition (48% of publications) was “more than one or multiple chronic or long-term diseases/conditions”. Multimorbidity was not defined in 51% of the publications using the term. Conclusions: Comorbidity was overwhelmingly used to describe any clinical entity coexisting with an index disease under study. Multimorbidity was the term most frequently used when no index disease was designated. Several definitions of multimorbidity were found. However, most authors using the term did not define it. The use of clearly defined terms in the literature is recommended until a general consensus on the terminology of multiple coexistent diseases is reached.Journal of Comorbidity 2013;3(1):4–9
The HHS Strategic Framework on multiple chronic conditions: genesis and focus on research
Full text linkAmong the 21st century’s major emerging health issues, one of the most critical is the increasing prevalence of individuals with comorbidities, or multiple chronic conditions (MCCs), and the myriad challenges this poses for public health, healthcare, social services, and other sectors. Given the increasing prevalence of individuals with MCCs and the paramount role of MCCs as a healthcare cost driver, in 2008 the U.S. Department of Health and Human Services (HHS) launched an initiative to strengthen efforts by the HHS to address the effects of MCCs on health status, quality of life, and cost. In this paper, we first provide an overview of the HHS initiative with a particular focus on the approach used in developing the initiative’s centerpiece, the HHS Strategic Framework on Multiple Chronic Conditions; we next describe progress in implementing one of the framework’s four major goal areas (Goal 4) on facilitating research to fill knowledge gaps about, and interventions and systems to benefit, individuals with MCCs; and we conclude by suggesting additional potential priorities for research on MCCs. Although considerable research on MCCs has been reported over the past decade, the HHS Strategic Framework’s goal on research provides a set of priority areas and a plan for systematically strengthening the evidence and information foundation necessary to address the challenges of MCCs in the USA. More broadly, the Strategic Framework provides a roadmap to help improve coordination between HHS operating divisions and enhance collaboration with external stakeholders to improve the quality of life for those with MCCs.Journal of Comorbidity 2013;3(2)22–29
Improving the external validity of clinical trials: the case of multiple chronic conditions
Full text linkThe U.S. Department of Health and Human Services vision and strategic framework on multiple chronic conditions (MCCs) incorporates recommendations designed to facilitate research that will improve our knowledge about interventions and systems that will benefit individuals with MCCs (or multimorbidity). The evidence base supporting the management of patients with MCCs will be built both through intervention trials specifically designed to address multimorbidity and identification of MCCs in participants across the clinical trial range. This article specifically focuses on issues relating to external validity with specific reference to trials involving patients with MCCs. The exclusion of such patients from clinical trials has been well documented. Randomized control trials (RCTs) are considered the “gold standard” of evidence, but may have drawbacks in relation to external validity, particularly in relation to multimorbidity. It may, therefore, be necessary to consider a broader range of research methods that can provide converging evidence on intervention effects to address MCCs. Approaches can also be taken to increase the usefulness of RCTs in general for providing evidence to inform multimorbidity management. Additional improvements to RCTs would include better reporting of inclusion and exclusion criteria and participant characteristics in relation to MCCs. New trials should be considered in terms of how they will add to the existing evidence base and should inform how interventions may work in different settings and patient groups. Research on treatments and interventions for patients with MCCs is badly needed. It is important that this research includes patient-centered measures and that generalizability issues be explicitly addressed.Journal of Comorbidity 2013;3(2)30–3
Epidemiology of multiple chronic conditions: an international perspective
Full text linkThe epidemiology of multimorbidity, or multiple chronic conditions (MCCs), is one of the research priority areas of the U.S. Department of Health and Human Services (HHS) by its Strategic Framework on MCCs. A conceptual model addressing methodological issues leading to a valid measurement of the prevalence rates of MCCs has been developed and applied in descriptive epidemiological studies. Comparing these results with those from prevalence studies performed earlier and in other countries is hampered by methodological limitations. Therefore, this paper aims to put the size and patterns of MCCs in the USA, as established within the HHS Strategic Framework on MCCs, in perspective of the findings on the prevalence of MCCs in other countries. General common trends can be observed: increasing prevalence rates with increasing age, and multimorbidity being the rule rather than the exception at old age. Most frequent combinations of chronic diseases include the most frequently occurring single chronic diseases. New descriptive epidemiological studies will probably not provide new results; therefore, future descriptive studies should focus on the prevalence rates of MCCs in subpopulations, statistical clustering of chronic conditions, and the development of the prevalence rates of MCCs over time. The finding of common trends also indicates the necessary transition to a next phase of MCC research, addressing the quality of care of patients with MCCs from an organizational perspective and with respect to the content of care.Journal of Comorbidity 2013;3(2)36–4
Inverse comorbidity: the power of paradox in the advancement of science
Full text linkResearch on comorbidity and multimorbidity is finally receiving the attention it deserves, particularly considering the magnitude and impact they have on health and the delivery of healthcare [1,2]. Numerous studies have demonstrated that individuals with Down’s syndrome, Parkinson’s disease, schizophrenia, diabetes, anorexia nervosa, Alzheimer’s disease, allergy related diseases, multiple sclerosis or Huntington’s disease (among other health problems) are protected against many forms of cancer, including solid tumors, smoking-related tumors and prostate cancer. This apparent anti-cancer effect, which we have termed inverse cancer comorbidity, has been observed in many serious CNS and immune disorders, and is the subject of active research [3–5].Journal of Comorbidity 2013;3(1):1–3
Disparities in multiple chronic conditions within populations
Full text linkDisadvantaged populations are disproportionately affected by multiple chronic conditions (MCCs), yet few studies examine the prevalence, outcomes, or effectiveness of MCC interventions in minority and socioeconomically deprived individuals and populations. An important first step in understanding MCCs, not only in such diverse population groups, but also in the general population as a whole, is to broaden the definition and scope of MCC measurement, to encompass more than the simple additive effect of clinical conditions, and to include a wide range of health and health-related aspects that interact and make up the full spectrum of multimorbidity. Only with the use of a comprehensive MCC measurement can some of the differences between the disadvantaged populations be adequately detected. Better understanding of the disparities in access to high quality health and healthcare for persons with MCCs can help guide policy and practice aimed at the prevention and amelioration of the effects of MCCs among disadvantaged groups. Indeed, disparity in MCC populations has been identified as a key goal of the U.S. Department of Health and Human Services’ Strategic Framework on MCCs. The aim of the present paper is to describe current knowledge on disparities in the population of persons with MCCs and to guide efforts for the prevention and management of MCCs in disadvantaged populations.Journal of Comorbidity 2013;3(2):45–5
The acute oncologist’s role in managing patients with cancer and other comorbidities
Full text linkBackground: An Acute Oncology Service (AOS) is paramount to providing timely and improved pathways of care for patients who are admitted to hospital with cancer-related problems or suspected cancer. Objective: To establish an AOS pilot study to decide how best to implement such a service locally. Methods: The AOS, which included collaboration between the oncology and palliative care teams at the Northern General Hospital in Sheffield, UK, ensured that the majority of oncology patients in the region received timely assessment by an oncologist if they became acutely unwell as a result of their cancer or its treatment. The AOS consisted of a thrice-weekly ward round, and daily telephone advice service. Results: We report on patient data during the first 12 months of the pilot study. Delivery of the AOS enhanced communication between the services and provided inter-professional education and support, resulting in earlier oncological team involvement in the management of patients with cancer admitted under other teams, as well as provision of advice to patients and their caregivers and families. Provision of the AOS shortened the mean length of hospital stay by 6 days. Two case studies are presented to illustrate the typical challenges faced when managing these patients. Conclusions: Establishment of the AOS enabled effective collaboration between the oncology and other clinical teams to provide a rapid and streamlined referral pathway of patients to the AOS. Locally, this process has been supported by the development of acute oncology protocols, which are now in use across the local cancer network. Journal of Comorbidity 2012;2(1):10–17
A scoping review and thematic classification of patient complexity: offering a unifying framework
Full text linkThe path to improving healthcare quality for individuals with complex health conditions is complicated by a lack of common understanding of complexity. Modern medicine, together with social and environmental factors, has extended life, leading to a growing population of patients with chronic conditions. In many cases, there are social and psychological factors that impact treatment, health outcomes, and quality of life. This is the face of complexity. Care challenges, burden, and cost have positioned complexity as an important health issue. Complex chronic conditions are now being discussed by clinicians, researchers, and policy-makers around such issues as quantification, payment schemes, transitions, management models, clinical practice, and improved patient experience. We conducted a scoping review of the literature for definitions and descriptions of complexity. We provide an overview of complex chronic conditions, and what is known about complexity, and describe variations in how it is understood. We developed a Complexity Framework from these findings to guide our approach to understanding patient complexity. It is critical to use common vernacular and conceptualization of complexity to improve service and outcomes for patients with complex chronic conditions. Many questions still persist about how to develop this work with a health and social care lens; our framework offers a foundation to structure thinking about complex patients. Further insight into patient complexity can inform treatment models and goals of care, and identify required services and barriers to the management of complexity.Journal of Comorbidity 2012;2(1):1–9