Further development and validation of the Multimorbidity Treatment Burden Questionnaire (MTBQ).

OBJECTIVES: To undertake further psychometric testing of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and examine whether reversing the scale reduced floor effects. DESIGN: Survey. SETTING: UK primary care. PARTICIPANTS: Adults (≥18 years) with three or more long-term conditions randomly selected from four general practices and invited by post. MEASURES: Baseline survey: sociodemographics, MTBQ (original or version with scale reversed), Treatment Burden Questionnaire (TBQ), four questions (from QQ-10) on ease of completing the questionnaires. Follow-up survey (1-4 weeks after baseline): MTBQ, TBQ and QQ-10. Anonymous data collected from electronic GP records: consultations (preceding 12 months) and long-term conditions. The proportion of missing data and distribution of responses were examined for the original and reversed versions of the MTBQ and the TBQ. Intraclass correlation coefficient (ICC) and Spearman's rank correlation (Rs) assessed test-retest reliability and construct validity, respectively. Ease of completing the MTBQ and TBQ was compared. Interpretability was assessed by grouping global MTBQ scores into 0 and tertiles (>0). RESULTS: 244 adults completed the baseline survey (consent rate 31%, mean age 70 years) and 225 completed the follow-up survey. Reversing the scale did not reduce floor effects or data skewness. The global MTBQ scores had good test-retest reliability (ICC for agreement at baseline and follow-up 0.765, 95% CI 0.702 to 0.816). Global MTBQ score was correlated with global TBQ score (Rs 0.77, p<0.001), weakly correlated with number of consultations (Rs 0.17, p=0.010), and number of different general practitioners consulted (Rs 0.23, p<0.001), but not correlated with number of long-term conditions (Rs -0.063, p=0.330). Most participants agreed that both the MTBQ and TBQ were easy to complete and included aspects they were concerned about. CONCLUSION: This study demonstrates test-retest reliability and ease of completion of the MTBQ and builds on a previous study demonstrating good content validity, construct validity and internal consistency reliability of the questionnaire.

Translation, cross-cultural adaptation and validation of the Arabic multimorbidity treatment burden questionnaire (MTBQ-A): A study of adults with multimorbidity.

BACKGROUND: Studies internationally have found that a high treatment burden is associated with several long-term conditions and poor quality of life. OBJECTIVES: To translate, culturally adapt, and provide evidence of reliability, validity, and factor structure of the Multimorbidity Treatment Burden Questionnaire for use among Arabic-speaking adults with multimorbidity. METHODS: Standard guidelines for the cross-cultural adaptation of self-report measures were followed. The original 10-item MTBQ was translated into Arabic by professional translators using forward-backward translation. An expert group, including the creator of the MTBQ, participated in the cultural adaptation and content validity, followed by cognitive interviewing and pilot testing. The questionnaire was then tested on 177 Arabic-speaking patients with multimorbidity recruited from community pharmacies in the United Arab Emirates. The distribution of responses, dimensionality, internal consistency reliability, and construct validity were examined. RESULTS: The content validity of the MTBQ-A was good (Content Validity Index = 0.94), and cognitive interviews found that the items were well understood. The scale showed positive skewness and high floor effects. Factor analysis supported a two-dimensional structure (factor loadings >0.4): factor one was named "Self-management and social support," and factor two was named "Burden of visiting health care services and health care professionals". The questionnaire had good internal consistency (α = 0.83). As predicted, a higher MTBQ score in both factors was associated with poor health-related quality of life in all dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (p values < 0.05); and negatively correlated with self-efficacy in taking medication (p < 0.01) and in learning about medication (p < 0.01). CONCLUSIONS: The Arabic MTBQ is a valid and reliable measure of treatment burden with good construct validity and internal consistency. This easy-to-understand questionnaire can be used to assess the perceived treatment burden among Arabic-speaking patients with multimorbidity.

Validation of the Lithuanian multimorbidity treatment burden questionnaire (MTBQ) and its association with primary care patient characteristics.

BACKGROUND: The increasing prevalence of multimorbidity among older people in Lithuania and other Central-Eastern European countries leads to a greater patient treatment burden and puts additional pressure on healthcare services. OBJECTIVES: This study aimed to validate the Lithuanian version of the Multimorbidity Treatment Burden Questionnaire (MTBQ). METHODS: The Lithuanian version of the MTBQ was tested (2021-2022) with 789 patients from seven Lithuanian primary care centres who had two or more long-term conditions. The questionnaire translation's reliability, validity and dimensionality of the were assessed with Spearman's rank correlation, Cronbach's alpha, and factor reduction analysis. Treatment burden and its associations with sociodemographic and other indicators were analysed. RESULTS: Lithuanian version of MTBQ had good internal reliability (Cronbach's alpha 0.711), validity, factor reduction applicability, and interpretability. The MTBQ scores of the questionnaire had a negative association with the quality-of-life scale (r=-0.327, 95% CI [-0.389, -0.264]) and positive associations with the self-rated health scores (r = 0.230, 95% CI [0.163, 0.297]) and with the number of comorbidities (r = 0.164, 95% CI [0.097, 0.233]). Distribution of treatment burden was identified (none (19,4%), low (46,6%), medium (25%), high (9%)). High treatment burden was found to be associated with having five or more long-term diseases, taking five or more medications, having anxiety or depression and living in a rural area. CONCLUSION: The study's findings show that the MTBQ is applicable in assessing the treatment burden of multimorbid patients in Lithuania. Furthermore, the study demonstrates that Lithuanian patients with multimorbidity have average treatment burden scores similar to or higher than participants in previous MTBQ validation studies.

• The Lithuanian version of MTBQ features good content validity, internal reliability, and construct validity, and is suitable for assessing treatment burden of patients with multimorbidity in Lithuania.• The study demonstrated that Lithuanian patients with multimorbidity had average treatment burden scores similar to or higher than participants in previous MTBQ validation studies.

Exploration of reasons for primary care testing (the Why Test study): a UK-wide audit using the Primary care Academic CollaboraTive.

BACKGROUND: Rates of blood testing have increased over the past two decades. Reasons for testing cannot easily be extracted from electronic health record databases. AIM: To explore who requests blood tests and why, and what the outcomes of testing are in UK primary care. DESIGN AND SETTING: A retrospective audit of electronic health records in general practices in England, Wales, Scotland, and Northern Ireland was undertaken. METHOD: Fifty-seven clinicians from the Primary care Academic CollaboraTive (PACT) each reviewed the electronic health records of 50 patients who had blood tests in April 2021. Anonymised data were extracted including patient characteristics, who requested the tests, reasons for testing, test results, and outcomes of testing. RESULTS: Data were collected from 2572 patients across 57 GP practices. The commonest reasons for testing in primary care were investigation of symptoms (43.2%), monitoring of existing disease (30.1%), monitoring of existing medications (10.1%), and follow up of previous abnormalities (6.8%); patient requested testing was rare in this study (1.5%). Abnormal and borderline results were common, with 26.6% of patients having completely normal test results. Around one-quarter of tests were thought to be partially or fully unnecessary when reviewed retrospectively by a clinical colleague. Overall, 6.2% of tests in primary care led to a new diagnosis or confirmation of a diagnosis. CONCLUSION: The utilisation of a national collaborative model (PACT) has enabled a unique exploration of the rationale and outcomes of blood testing in primary care, highlighting areas for future research and optimisation.

Measurement of treatment burden in patients with multimorbidity in the Netherlands: translation and validation of the Multimorbidity Treatment Burden Questionnaire (NL-MTBQ).

BACKGROUND: Multimorbidity is a growing problem. The number and complexity of (non-)pharmaceutical treatments create a great burden for patients. Treatment burden refers to the perception of the weight of these treatments, and is associated with multimorbidity. Measurement of treatment burden is of great value for optimizing treatment and health-related outcomes. OBJECTIVE: We aim to translate and validate the Multimorbidity Treatment Burden Questionnaire (MTBQ) for use in the Dutch population with multimorbidity and explore the level of treatment burden. METHODS: Translating the MTBQ into Dutch included forward-backward translation, piloting, and cognitive interviewing (n = 8). Psychometric properties of the questionnaire were assessed in a cross-sectional study of patients with multimorbidity recruited from a panel in the Netherlands (n = 959). We examined item properties, dimensionality, internal consistency reliability, and construct validity. The level of treatment burden in the population was assessed. RESULTS: The mean age among 959 participants with multimorbidity was 69.9 (17-96) years. Median global NL-MTBQ score was 3.85 (interquartile range 0-9.62), representing low treatment burden. Significant floor effects were found for all 13 items of the instrument. Factor analysis supported a single-factor structure. The NL-MTBQ had high internal consistency (α = 0.845), and provided good evidence on the construct validity of the scale. CONCLUSION: The Dutch version of the 13-item MTBQ is a single-structured, valid, and compact patient-reported outcome measure to assess treatment burden in primary care patients with multimorbidity. It could identify patients experiencing high treatment burden, with great potential to enhance shared decision-making and offer additional support.

Using the Primary care Academic CollaboraTive to explore the characteristics and healthcare use of older housebound patients in England: protocol for a retrospective observational study and clinician survey (the CHiP study).

BACKGROUND: Older housebound people are an under-researched group for whom achieving good primary health care can be resource intensive. AIMS: To describe the characteristics and healthcare use of older (≥65 years) housebound people; explore clinician views on delivery of care to housebound people; and assess the feasibility of using a new network of healthcare professionals to deliver high quality research. DESIGN & SETTING: Retrospective observational study of electronic GP records and clinician survey in England. METHOD: Clinical members of a new UK research network called the Primary care Academic CollaboraTive (PACT) will collect the data. For part A, around 20 GP practices will be recruited and clinicians will identify 20 housebound and 20 non-housebound people, matched by age and gender (around 400 total in each group). Anonymised data will be collected on characteristics (age, gender, ethnicity, deprivation decile), long-term conditions, prescribed medicines, quality of healthcare (via Quality Outcomes Framework targets), and continuity of care. Reports with benchmarked practice-level data will be provided to practices to identify areas for quality improvement and to enhance engagement. For part B, 2-4 clinicians will be recruited from around 50 practices in England (around 150 clinicians) to complete a survey about delivery of healthcare for housebound people. For part C, data will be collected to assess the feasibility of using the PACT network to deliver primary care research. CONCLUSION: Older housebound people are a neglected group both in terms of research and clinical care. Understanding the characteristics and use of primary healthcare of housebound people will help identify how to improve their care.

Treatment burden in multiple long-term conditions: a mixed-methods study protocol.

BACKGROUND: Treatment burden represents the work patients undertake because of their health care, and the impact of that effort on the patient. Most research has focused on older adults (aged >65 years) with multiple long-term conditions (multimorbidity) (MLTC-M), but there are now more younger adults (aged 18-65 years) living with MLTC-M and they may experience treatment burden differently. Understanding experiences of treatment burden, and identifying those most at risk of high treatment burden, are important for designing primary care services to meet their needs. AIM: To understand the treatment burden associated with MLTC-M, for people aged 18-65 years, and how primary care services affect this burden. DESIGN & SETTING: Mixed-methods study in up to 33 primary care practices in two UK regions. METHOD: The following two approaches will be used: (i) in-depth qualitative interviews with adults living with MLTC-M (approximately 40 participants) to understand their experiences of treatment burden and the impact of primary care, with a think-aloud aspect to explore face validity of a novel short treatment burden questionnaire (STBQ) for routine clinical use in the initial 15 interviews; (ii) cross-sectional patient survey (approximately 1000 participants), with linked routine medical record data to examine the factors associated with treatment burden for people living with MLTC-M, and to test the validity of STBQ. CONCLUSION: This study will generate in-depth understanding of the treatment burden experienced by people aged 18-65 years living with MLTC-M, and how primary care services affect this burden. This will inform further development and testing of interventions to reduce treatment burden, and potentially influence MLTC-M trajectories and improve health outcomes.

Multimorbidity Treatment Burden Questionnaire (MTBQ): Translation, Cultural Adaptation, and Validation in French-Canadian.

Reliable treatment burden measures are needed given the aging population and the associated increase in multimorbidity and polypharmacy. Treatment burden is defined as the effort to care for one's health and the resulting impact on one's daily life. This study aimed to translate the Multimorbidity Treatment Burden Questionnaire (MTBQ) for French-Canadians and assess its reliability and validity. The MTBQ was translated and tested with cognitive debriefing interviews, and the French version (MTBQ-F) was then administered 2 times among 105 participants. Reliability and validity were examined using the intra-class correlation coefficient (ICC), Cronbach's alpha, and Spearman's correlations. The median global MTBQ-F scores were 32.69 (interquartile range [IQR]: 21.15-48.08) and 30.77 (IQR: 21.15-46.15) for the first and second administrations, respectively. Test-retest (ICC: 0.73; 95% CI: 0.63-0.81) and internal consistency reliability (Cronbach's alpha: 0.80) were good. There was a moderate positive correlation between the MTBQ-F score and the number of self-reported conditions (rho: 0.28). This valid instrument could identify patients experiencing a high treatment burden and assess the impact of interventions among them.

Patient perceptions and experiences of medication review: qualitative study in general practice.

BACKGROUND: Clinical medication reviews are a recognised strategy to address polypharmacy, a key part of general practice and positively associated with patient safety and clinical effectiveness. To date there has been little investigation of the patient perspective of medication reviews. OBJECTIVE: To explore patient experiences of medication review including the processes and activities that led up to and shaped the review. METHODS: Qualitative interview study within 10 general practices in Bristol. Participants were adults with polypharmacy (≥ 4 medications) and ≥ 2 long-term conditions who had a record of medication review with either a GP or pharmacist. Interviews were transcribed verbatim and analysed thematically using a data driven approach. Co-design work was undertaken with four patient and public involvement advisers to design and develop resources to support patient preparation for medication review. RESULTS: Twenty-one patients were interviewed (10 female, mean age 73 years, range 59-88 years). Medication review was viewed as an opportunity to assess the effectiveness and need for medications. Participants expected the review to focus upon medication related concerns, side-effects and symptoms. Those who were newer to review, were uncertain of the intended purpose, and described their review as a box-ticking exercise. Some participants were unfamiliar with the role of the pharmacist and expressed a lack of confidence in their clinical skills and knowledge. Face-to-face consultation and relationship continuity were considered important for efficient and effective medication review. Results informed co-production of a patient information leaflet to facilitate greater patient engagement and involvement in medication review. CONCLUSIONS: A lack of understanding of the rationale for medication review can limit the value patients attach to these healthcare encounters. Improved prior communication and information around the intended purpose and potential benefits of medication review may enhance patient engagement and improve patient experience and outcomes.

Adaptation and validation of a German version of the Multimorbidity Treatment Burden Questionnaire.

BACKGROUND: Patients with multiple long-term conditions often face a variety of challenges arising from the requirements of their health care. Knowledge of perceived treatment burden is crucial for optimizing treatment. In this study, we aimed to create a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and to evaluate its validity. METHODS: The steps to translate the MTBQ included forward/back translation, cognitive interviews (n = 6) and a pilot test (n = 7). Psychometric properties of the scale were assessed in a cross-sectional survey with primary care patients aged 65 and older with at least 3 long-term conditions (n = 344). We examined the distribution of responses, dimensionality, internal reliability and construct validity. RESULTS: Cognitive interviewing and piloting led to minor modifications and showed overall good face validity and acceptability. As expected, we observed a positively skewed response distribution for all items. Reliability was acceptable with McDonald's omega = 0.71. Factor analysis suggested one common factor while model fit indices were inconclusive. Predefined hypotheses regarding the construct validity were supported by negative associations between treatment burden and health-related quality of life, self-rated health, social support, patient activation and medication adherence, and positive associations between treatment burden and number of comorbidities. Treatment burden was found to be higher in female participants (Mdn1 = 6.82, Mdn2 = 4.55; U = 11,729, p = 0.001) and participants with mental health diagnoses (Mdn1 = 9.10, Mdn2 = 4.55; U = 3172, p = 0.024). CONCLUSIONS: The German MTBQ exhibited good psychometric properties and can be used to assess the perceived treatment burden of patients with multimorbidity.

Why Test study protocol: a UK-wide audit using the Primary Care Academic CollaboraTive (PACT) to explore the reasons for primary care testing.

BACKGROUND: The number of blood tests done in primary care has been increasing over the past 20 years. Some estimates suggest that up to one-quarter of these tests may not have been needed. This could lead to a cascade effect of further investigations, appointments, or referrals, as well as anxiety for patients, increased workload, and costs to the health service. To better understand the impact and sequelae of blood tests on patients, it is necessary to know why blood tests are requested and what is done with the results. AIM: To explore who orders blood tests and why, and how test results are actioned in primary care. DESIGN & SETTING: Retrospective audit of electronic health records in general practices across the UK. METHOD: The Primary care Academic CollaboraTive (PACT), a UK-wide network of primary care health professionals, will be utilised to collect data from individual practices. PACT members will be asked to review the electronic health records of 50 patients who had recent blood tests in their practice, and manually extract anonymised data on who requested the test, the indication, the result, and subsequent actions. Data will also be collected from PACT members to assess the feasibility of the collaborative model. CONCLUSION: PACT offers a unique opportunity to extract clinical data which cannot otherwise be obtained. Understanding the indications for tests will help identify priority areas for research to optimise testing and patient safety in primary care.

Danish validation of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and findings from a population health survey: a mixed-methods study.

OBJECTIVE: To validate the Danish Multimorbidity Treatment Burden Questionnaire (MTBQ) and obtain a population-based evaluation of treatment burden. DESIGN: Mixed-methods. SETTING: Danish population-based survey. PARTICIPANTS: Translation by professional translators and an expert group. The scale was tested by 13 407 participants (aged ≥25 years) in treatment. MEASURES: The 10-item MTBQ was translated into Danish using forward-backward translation and used in a large population health survey. A global MTBQ score was calculated and factor analysis and Cronbach's alpha assessed dimensional structure and internal consistency reliability, respectively. Spearman's rank correlations between global MTBQ scores and scores of self-rated health, health-related quality of life and the number of long-term conditions, respectively, assessed construct validity. MTBQ scores were grouped into four categories (no, low, medium, high burden) to assess interpretability and population-based evaluation of treatment burden. RESULTS: The scale showed high internal consistency (α=0.87), positive skewness and large floor effects. Factor analysis supported a one-dimensional structure of the scale with a three-dimensional structure as a less parsimonious alternative. The MTBQ score was negatively associated with self-rated health (rS-0.45, p<0.0001) and health-related quality of life (rS-0.46/-0.51, p<0.0001), and positively associated with the number of long-term conditions (rS 0.26, p<0.0001) and perceived stress (rS 0.44, p<0.0001). Higher treatment burden was associated with young age, male sex, high educational level, unemployment, being permanently out of work, not living with a spouse/cohabitant, living with child(ren) and long-term conditions (eg, heart attack, stroke, diabetes and mental illness). CONCLUSION: The Danish MTBQ is a valid measure of treatment burden with good construct validity and high internal reliability. This is the first study to explore treatment burden at a population level and provides important evidence to policy makers and clinicians about sociodemographic groups at risk of higher treatment burden.

Treatment burden for patients with multimorbidity: cross-sectional study with exploration of a single-item measure.

BACKGROUND: Treatment burden is the effort required of patients to look after their health, and the impact this has on their wellbeing. Quantitative data on treatment burden for patients with multimorbidity are sparse, and no single-item treatment burden measure exists. AIM: To determine the extent of, and associations with, high treatment burden among older adults with multimorbidity, and to explore the performance of a novel single-item treatment burden measure. DESIGN AND SETTING: Cross-sectional postal survey via general practices in Dorset, UK. METHOD: Patients ≥55 years, living at home, with three or more long-term conditions (LTCs) were identified by practices. Treatment burden was measured using the Multimorbidity Treatment Burden Questionnaire. Data collected were sociodemographics, LTCs, medications, and characteristics including health literacy and financial resource. Associations with high treatment burden were investigated via logistic regression. Performance of a novel single-item measure of treatment burden was also evaluated. RESULTS: A total of 835 responses were received (response rate 42%) across eight practices. Patients' mean age was 75 years, 55% were female (n = 453), and 99% were white (n = 822). Notably, 39% of patients self-reported fewer than three LTCs (n = 325). Almost one-fifth (18%) of responders reported high treatment burden (n = 150); making lifestyle changes and arranging appointments were particular sources of difficulty. After adjustment, limited health literacy and financial difficulty displayed strong associations with high treatment burden; more LTCs and more prescribed regular medications were also independently associated. The single-item measure discriminated moderately between high and non-high burden with a sensitivity of 89%, but a specificity of 58%. CONCLUSION: High treatment burden was relatively common, underlining the importance of minimising avoidable burden. More vulnerable patients, with less capacity to manage, are at greater risk of being overburdened. Further development of a single-item treatment burden measure is required.

A multi-stakeholder approach to the co-production of the research agenda for medicines optimisation.

BACKGROUND: Up to 50% of medicines are not used as intended, resulting in poor health and economic outcomes. Medicines optimisation is 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. The purpose of this exercise was to co-produce a prioritised research agenda for medicines optimisation using a multi-stakeholder (patient, researcher, public and health professionals) approach. METHODS: A three-stage, multiple method process was used including: generation of preliminary research questions (Stage 1) using a modified Nominal Group Technique; electronic consultation and ranking with a wider multi-stakeholder group (Stage 2); a face-to-face, one-day consensus meeting involving representatives from all stakeholder groups (Stage 3). RESULTS: In total, 92 research questions were identified during Stages 1 and 2 and ranked in order of priority during stage 3. Questions were categorised into four areas: 'Patient Concerns' [e.g. is there a shared decision (with patients) about using each medicine?], 'Polypharmacy' [e.g. how to design health services to cope with the challenge of multiple medicines use?], 'Non-Medical Prescribing' [e.g. how can the contribution of non-medical prescribers be optimised in primary care?], and 'Deprescribing' [e.g. what support is needed by prescribers to deprescribe?]. A significant number of the 92 questions were generated by Patient and Public Involvement representatives, which demonstrates the importance of including this stakeholder group when identifying research priorities. CONCLUSIONS: A wide range of research questions was generated reflecting concerns which affect patients, practitioners, the health service, as well the ethical and philosophical aspects of the prescribing and deprescribing of medicines. These questions should be used to set future research agendas and funding commissions.

International prescribing patterns and polypharmacy in older people with advanced chronic kidney disease: results from the European Quality study.

BACKGROUND: People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study. METHODS: The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy. RESULTS: Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73-4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32-2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15-2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17-0.87); P = 0.021]. CONCLUSIONS: Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit.

Translation, cultural adaptation and validation of the Chinese Multimorbidity Treatment Burden Questionnaire(C-MTBQ): a study of older hospital patients.

BACKGROUND: Due to an ageing population, multimorbidity is becoming more common. Treatment burden (the effort required of patients to look after their health and the impact this has on their wellbeing) is prevalent in patients with multimorbidity. The Multimorbidity Treatment Burden Questionnaire (MTBQ) is a patient-reported outcome measure of treatment burden that has been validated amongst patients with multimorbidity in the UK. The aim of this study was to translate and culturally adapt the MTBQ into Chinese and to assess its reliability and validity in elderly patients with multimorbidity in hospital. METHODS: The original English version of the MTBQ was translated into Chinese using Brislin's model of cross-culture translation. The C-MTBQ was piloted on a sample of 30 elderly patients with multimorbidity prior to being completed by 156 Chinese elderly patients with multimorbidity recruited from a hospital in Zhengzhou, China. We examined the proportion of missing data, the distribution of responses and floor and ceiling effects for each question. Factor analysis, Cronbach's alpha, intraclass coefficient and Spearman's rank correlations assessed dimensional structure, internal consistency reliability, test-retest reliability and criterion validity, respectively. RESULTS: The average age of the respondents was 73.5 years (range 60-99 years). The median C-MTBQ global score was 20.8 (interquartile range 12.5-29.2). Significant floor effects were seen for all items. Factor analysis supported a three-factor structure. The C-MTBQ had high internal consistency (Cronbach's alpha coefficient, 0.76) and test-retest reliability (the intraclass correlation coefficient, 0.944), the correlations between every item and global scores scored > 0.4. The scale content validity index(S-CVI) was 0.89, and the item level content validity index(I-CVI)was 0.83 ~ 1.00. The criterion validity was 0.875. CONCLUSION: The Chinese version of MTBQ showed satisfactory reliability and validity in elderly patients with multimorbidity, and could be used as a tool to measure treatment burden of elderly patients with multimorbidity in hospital.

The Impact of Digital-First Consultations on Workload in General Practice: Modeling Study.

BACKGROUND: Health services in many countries are promoting digital-first models of access to general practice based on offering online, video, or telephone consultations before a face-to-face consultation. It is claimed that this will improve access for patients and moderate the workload of doctors. However, improved access could also potentially increase doctors' workload. OBJECTIVE: The aim of this study was to explore whether and under what circumstances digital-first access to general practice is likely to decrease or increase general practice workload. METHODS: A process map to delineate primary care access pathways was developed and a model to estimate general practice workload constructed in Microsoft Excel (Microsoft Corp). The model was populated using estimates of key variables obtained from a systematic review of published studies. A MEDLINE search was conducted for studies published in English between January 1, 2000, and September 30, 2019. Included papers provided quantitative data about online, telephone, or video consultations for unselected patients requesting a general practice in-hours consultation for any problem. We excluded studies of general practitioners consulting specialists, consultations not conducted by doctors, and consultations conducted after hours, in secondary care, in specialist services, or for a specific health care problem. Data about the following variables were extracted from the included papers to form the model inputs: the proportion of consultations managed digitally, the proportion of digital consultations completed without a subsequent consultation, the proportion of subsequent consultations conducted by telephone rather than face-to-face, consultation duration, and the proportion of digital consultations that represent new demand. The outcome was general practice workload. The model was used to test the likely impact of different digital-first scenarios, based on the best available evidence and the plausible range of estimates from the published studies. The model allows others to test the impact on workload of varying assumptions about model inputs. RESULTS: Digital-first approaches are likely to increase general practice workload unless they are shorter, and a higher proportion of patients are managed without a subsequent consultation than observed in most published studies. In our base-case scenarios (based on the best available evidence), digital-first access models using online, telephone, or video consultations are likely to increase general practitioner workload by 25%, 3%, and 31%, respectively. An important determinant of workload is whether the availability of digital-first approaches changes the demand for general practice consultations, but there is little robust evidence to answer this question. CONCLUSIONS: Digital-first approaches to primary care could increase general practice workload unless stringent conditions are met. Justification for these approaches should be based on evidence about the benefits in relation to the costs, rather than assumptions about reductions in workload. Given the potential increase in workload, which in due course could worsen problems of access, these initiatives should be implemented in a staged way alongside careful evaluation.

Barriers and enablers to collaborative working between GPs and pharmacists: a qualitative interview study.

BACKGROUND: Many UK GP practices now employ a practice pharmacist, but little is known about how GPs and pharmacists work together to optimise medications for complex patients with multimorbidity. AIM: To explore GP and pharmacist perspectives on collaborative working within the context of optimising medications for patients with multimorbidity. DESIGN AND SETTING: A qualitative analysis of semi-structured interviews with GPs and pharmacists working in the West of England, Northern England, and Scotland. METHOD: Thirteen GPs and 10 pharmacists were sampled from practices enrolled in the 3D trial (a complex intervention for people with multimorbidity). Participants' views on collaborative working were explored with interviews that were audiorecorded, transcribed, and analysed thematically. Saturation of data was achieved with no new insights arising from later interviews. RESULTS: GPs from surgeries that employed a pharmacist tended to value their expertise more than GPs who had not worked with one. Three key themes were identified: resources and competing priorities; responsibility; and professional boundaries. GPs valued pharmacist recommendations that were perceived to improve patient safety, as opposed to those that were technical and unlikely to benefit the patient. Pharmacists who were not known to GPs felt undervalued and wanted feedback from the GPs about their recommendations, particularly those that were not actioned. CONCLUSION: A good working relationship between the GP and pharmacist, where each profession understood the other's skills and expertise, was key. The importance of face-to-face meetings and feedback should be considered in future studies of interdisciplinary interventions, and by GP practices that employ pharmacists and other allied health professionals.

Health literacy, multimorbidity, and patient-perceived treatment burden in individuals with cardiovascular disease. A Danish population-based study.

OBJECTIVE: The aim was to investigate the association between: 1) multimorbidity and high treatment burden 2) health literacy and high treatment burden, and 3) the interaction between multimorbidity and health literacy in relation to high treatment burden. METHODS: We included respondents with cardiovascular disease who participated in a Danish population-based survey from 2017 (N = 2,111). Logistic regression analyses were used to study associations. RESULTS: The study showed that multimorbid individuals with cardiovascular disease were more likely to experience a high treatment burden than individuals with cardiovascular disease only (2+ additional conditions OR 4.16 [2.80-6.18]). Also, individuals with difficulties in understanding health information were more likely to report a high treatment burden than individuals who found it easy to understand information about health (OR 9.97 [6.23-15.95]). Finally, individuals with multimorbidity and difficulties in understanding health information had markedly higher odds of experiencing a high treatment burden. CONCLUSION: If individuals find it difficult to understand health information, there is a risk they might feel overwhelmed by the treatment. PRACTICE IMPLICATIONS: Healthcare professionals should be aware of health literacy challenges in planning medical treatment particularly for patients with both low health literacy levels and multimorbidity.