Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review.

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

Prevalence and patterns of comorbidities in older people with type 2 diabetes in Australian primary care settings.

OBJECTIVE: The aim of this study was to identify the prevalence and patterns of comorbidity in community-dwelling older people with type 2 diabetes mellitus (T2DM) attending general practice settings in Australia. METHODS: This study involved a cross-sectional analysis using the Bettering the Evaluation and Care of Health (BEACH) sub-study data. In a series of sub-studies, a representative sample of general practitioners was asked to record all diagnosed chronic conditions for patients at 40 consecutive encounters using structured paper-based recording forms. The dataset was analysed with descriptive analyses, and exploratory factor analyses were applied to examine comorbidity patterns. RESULTS: Of the 14,042 patients aged 65 years or older, 2688 had a diagnosis of T2DM (19%). Of the 2688 patients with T2DM, hypertension was present in 67% (95% CI: 64.6-70.0), followed by arthritis 52% (95% CI: 48.8-54.8), hyperlipidaemia 45% (95% CI: 41.8-47.9), ischemic heart disease, 23% (95% CI: 20.7-24.9), depression 16% (95% CI: 48.8-54.8), atrial fibrillation 10% (95% CI: 8.9-11.6), congestive heart failure 7% (95% CI: 6.0-8.1), stroke/cerebrovascular accident 7% (95% CI: 5.4-8.2) and peripheral vascular disease 5% (95% CI: 4.4-6.2). We identified two comorbidity patterns among older people with T2DM. The first were psychological and musculoskeletal conditions and the second were cardiovascular conditions and chronic renal failure. CONCLUSIONS: The prevalence of cardiovascular and non-cardiovascular comorbidities in community-dwelling older people with T2DM was high. Adequate primary care strategies should be in place to support the long-term care for this population.

Multimorbidity and Blood Pressure Control in Patients Attending Primary Care in Canada.

BACKGROUND: There has been conflicting evidence on the association between multimorbidity and blood pressure (BP) control. This study aimed to investigate this associations in people with hypertension attending primary care in Canada, and to assess whether individual long-term conditions are associated with BP control. METHODS: This was a cross-sectional study in people with hypertension attending primary care in Toronto between January 1, 2017 and December 31, 2019. Uncontrolled BP was defined as systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. A list of 11 a priori selected chronic conditions was used to define multimorbidity. Multimorbidity was defined as having ≥1 long-term condition in addition to hypertension. Logistic regression models were used to estimate the association between multimorbidity (or individual long-term conditions) with uncontrolled BP. RESULTS: A total of 67 385 patients with hypertension were included. They had a mean age of 70, 53.1% were female, 80.6% had multimorbidity, and 35.7% had uncontrolled BP. Patients with multimorbidity had lower odds of uncontrolled BP than those without multimorbidity (adjusted OR = 0.72, 95% CI 0.68-0.76). Among the long-term conditions, diabetes (aOR = 0.73, 95%CI 0.70-0.77), heart failure (aOR = 0.81, 95%CI 0.73-0.91), ischemic heart disease (aOR = 0.74, 95%CI 0.69-0.79), schizophrenia (aOR = 0.79, 95%CI 0.65-0.97), depression/anxiety (aOR = 0.91, 95%CI 0.86-0.95), dementia (aOR = 0.87, 95%CI 0.80-0.95), and osteoarthritis (aOR = 0.89, 95%CI 0.85-0.93) were associated with a lower likelihood of uncontrolled BP. CONCLUSION: We found that multimorbidity was associated with better BP control. Several conditions were associated with better control, including diabetes, heart failure, ischemic heart disease, schizophrenia, depression/anxiety, dementia, and osteoarthritis.

Long-Term Consequences of COVID-19 in Predominantly Immunonaive Patients: A Canadian Prospective Population-Based Study.

Background: Lingering symptoms are frequently reported after acute SARS-CoV-2 infection, a condition known as post-COVID-19 condition (PCC). The duration and severity of PCC in immunologically naïve persons remain unclear. Furthermore, the long-term consequences of these chronic symptoms on work and mental health are poorly documented. Objective: To determine the outcome, the risk factors, and the impact on work and mental health associated with post-COVID-19 symptoms. Methods: This prospective population-based study assessed acute COVID-19 symptoms and their evolution for up to nine months following infection. Individuals aged 18 years and older with COVID-19 in three Canadian regions between 1 November 2020 and 31 May 2021 were recruited. Participants completed a questionnaire that was either administered by trained student investigators over the phone or self-administered online. Results: A total of 1349 participants with a mean age of 46.6 ± 16.0 years completed the questionnaire. Participants were mostly unvaccinated at the time of their COVID-19 episode (86.9%). Six hundred and twenty-two participants (48.0%) exhibited one symptom or more, at least three months post-COVID-19. Among participants with PCC, 23.0% to 37.8% experienced fatigue at the time of survey. Moreover, 6.1% expressed psychological distress. Risk factors for PCC and fatigue included female sex (OR = 1.996), higher number of symptoms (OR = 1.292), higher severity of episode (OR = 3.831), and having a mental health condition prior to the COVID-19 episode (OR = 5.155). Conclusions: In this multicenter cohort study, almost half (47%) of the participants reported persistent symptoms >3 months after acute infection. Baseline risk factors for PCC include female sex, number and severity of symptoms during acute infection, and a previous diagnosis of mental health disorder. Having PCC negatively impacted health-related quality of life and these patients were more likely to exhibit psychological distress, as well as fatigue.

Understanding the impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity: protocol for a mixed methods study.

BACKGROUND: Primary care and other health services have been disrupted during the COVID-19 pandemic, yet the consequences of these service disruptions on patients' care experiences remain largely unstudied. People with mental-physical multimorbidity are vulnerable to the effects of the pandemic, and to sudden service disruptions. It is thus essential to better understand how their care experiences have been impacted by the current pandemic. This study aims to improve understanding of the care experiences of people with mental-physical multimorbidity during the pandemic and identify strategies to enhance these experiences. METHODS: We will conduct a mixed-methods study with multi-phase approach involving four distinct phases. Phase 1 will be a qualitative descriptive study in which we interview individuals with mental-physical multimorbidity and health professionals in order to explore the impacts of the pandemic on care experiences, as well as their perspectives on how care can be improved. The results of this phase will inform the design of study phases 2 and 3. Phase 2 will involve journey mapping exercises with a sub-group of participants with mental-physical multimorbidity to visually map out their care interactions and experiences over time and the critical moments that shaped their experiences. Phase 3 will involve an online, cross-sectional survey of care experiences administered to a larger group of people with mental disorders and/or chronic physical conditions. In phase 4, deliberative dialogues will be held with key partners to discuss and plan strategies for improving the delivery of care to people with mental-physical multimorbidity. Pre-dialogue workshops will enable us to synthesize an prepare the results from the previous three study phases. DISCUSSION: Our study results will generate much needed evidence of the positive and negative impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity and shed light on strategies that could improve care quality and experiences.

Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses.

BACKGROUND: Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched). METHODS: Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls. RESULTS: There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]). INTERPRETATION: Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods. ONTARIO: ClinicalTrials.gov : 104191.

Multimorbidity.

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

General practitioners' attitude towards cooperation with other health professionals in managing patients with multimorbidity and polypharmacy: A cross-sectional study.

BACKGROUND: Cooperation between general practitioners (GPs) and other healthcare professionals appears to help reduce the risk of polypharmacy-related adverse events in patients with multimorbidity. OBJECTIVES: To investigate GPs profiles according to their opinions and attitudes about interprofessional cooperation and to study the association between these profiles and GPs' characteristics. METHODS: Between May and July 2016, we conducted a cross-sectional survey of a panel of French GPs about their management of patients with multimorbidity and polypharmacy, focussing on their opinions on the roles of healthcare professionals and interprofessional cooperation. We used agglomerative hierarchical cluster analysis to identify GPs profiles, then multivariable logistic regression models to study their associations with the characteristics of these doctors. RESULTS: 1183 GPs responded to the questionnaire. We identified four profiles of GPs according to their declared attitudes towards cooperation: GPs in the 'very favourable' profile (14%) were willing to cooperate with various health professionals, including the delegation of some prescribing tasks to pharmacists; GPs in the 'moderately favourable' profile (47%) had favourable views on the roles of health professionals, with the exception for this specific delegation of the task; GPs from the 'selectively favourable' profile (27%) tended to work only with doctors; GPs from the 'non-cooperative' profile (12%) did not seem to be interested in cooperation. Some profiles were associated with GPs' ages or participation in continuing medical education. CONCLUSION: Our study highlights disparities between GPs regarding cooperation with other professionals caring for their patients and suggests ways to improve cooperation.

Challenges in Multimorbidity Research: Lessons Learned From the Most Recent Randomized Controlled Trials in Primary Care.

Multimorbidity has received much attention and there is a growing number of original studies. However, randomized controlled trials (RCTs) have failed to demonstrate effectiveness of interventions aimed at improving outcomes for patient with multimorbidity in primary care. The purpose of this article is to synthesize and analyze the most recent RCTs to identify the factors that may have contribute to the success or lack of success in order to draw lessons to inform further development in intervention research. A scoping review was conducted to include current up-to-date state-of-the-art studies in primary care published from 2019. Nine articles reporting on six RCTs studies were included in the review. The findings were mixed, with primary outcomes showing no differences between intervention and control groups in four of the six but differences in secondary outcomes in all six. All studies involved family practice patients but interventions took place at different sites, and the time between the beginning of the intervention and the time of evaluation of outcomes varied across studies. Authors reported issues regarding the need for training of care teams, the roles and composition of the teams, the selection of patients and implementation barriers of the complex interventions in trying contexts with not enough time for the changes required. The randomized controlled design may not be the best evaluation design given the complexity of the interventions, and alternative designs should be considered in which qualitative components are included. Further attention to outcome measures and to equity issues is recommended.

Responding to vulnerable patients with multimorbidity: an interprofessional team approach.

BACKGROUND: People with multimorbidity, who may be more vulnerable to certain social determinants of health, often require care by an interprofessional primary healthcare (PHC) team that can tailor their approach to address the multiple and complex needs of this population. This paper describes how the needs of vulnerable patients experiencing multimorbidity are identified and provided care by innovative interprofessional PHC teams during an innovative one-hour consultation, outside of usual care. METHODS: This was a descriptive qualitative study. Forty-eight interviews were conducted with 20 allied healthcare professionals: (e.g., social work, pharmacy); 19 physicians (e.g., psychiatry, internal medicine, family medicine); and 9 decision makers. The thematic analysis was iterative using an individual and team approach to identify the main themes and exemplar quotations for illustration. RESULTS: Participants described patients with multimorbidity who were vulnerable as those experiencing major challenges accessing and navigating the healthcare system. Mental health issues were a major contributor to being vulnerable and often linked to common social determinants of health. Cultural factors were identified as potentially causing patients to be vulnerable. Participants articulated how the collaborative nature of the team generated new ideas and facilitated creative recommendations designed to meet the specific needs of each patient. CONCLUSIONS: This one-time consultation went beyond the assessment of a patient's multimorbidity by including a psycho-social-contextual understanding of vulnerability within the healthcare system. Findings may have important clinical and policy implications in the adoption and implementation of this approach and further assist vulnerable patients with multimorbidity in having their complex needs addressed.

One year follow-up and exploratory analysis of a patient-centered interdisciplinary care intervention for multimorbidity.

CONTEXT: Interventions for people with multimorbidity have obtained mixed results. We aimed to document the long-term effect of an intervention for people with multimorbidity. METHODS: 284 patients (18-80 years) presenting three or more chronic conditions were recruited from seven family medicine groups in the Saguenay-Lac St-Jean region, Quebec, Canada. The patient-centered intervention was based on motivational approach and self-management support. Outcomes were evaluated in a one-year pre-post study design with questionnaires that included the Health Education Questionnaire (heiQ), the Self-Efficacy for Managing Chronic Diseases, the Veteran RAND-12 Health Survey (VR-12), the EuroQoL 5-Domains questionnaire, the Kessler six item Psychological Stress Scale, and measures of smoking habit, physical activity, healthy eating and alcohol consumption. Subgroup analyses by age, number of conditions, sex, and income were also conducted. RESULTS: The heiQ domain of emotional wellbeing improved significantly. Improvement was also observed for the VR-12 and the K6. Among the health behaviours, only healthy eating was improved. Subgroup analyses in this exploratory study suggest that younger patients, those with lower number of chronic conditions or higher incomes may respond better in relation to self-management, health status and health behaviours. CONCLUSION: One year after the intervention, participants significantly improved a variety of outcomes. Subgroup analyses suggest that younger patients, those with lower number of chronic conditions or higher incomes may respond better in relation to self-management, health status and health behaviours. This suggests that future interventions should be tailored to patients' characteristics including age, sex, income and number of conditions.

Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review.

BACKGROUND: Multimorbidity, defined as the co-existence of two or more chronic conditions, presents significant challenges to patients, healthcare providers and health systems. Despite this, there is ongoing uncertainty about the most effective ways to manage patients with multimorbidity. This review updated and narrowed the focus of a previous Cochrane review and aimed to determine the effectiveness of interventions designed to improve outcomes in people with multimorbidity in primary care and community settings, compared to usual care. METHODS: We searched eight databases and two trials registers up to 9 September 2019. Two review authors independently screened potentially eligible titles and selected studies, extracted data, evaluated study quality and judged the certainty of the evidence (GRADE). Interventions were grouped by their predominant focus into care-coordination/self-management support, self-management support and medicines management. Main outcomes were health-related quality of life (HRQoL) and mental health. Meta-analyses were conducted, where possible, but the synthesis was predominantly narrative. RESULTS: We included 16 RCTs with 4753 participants, the majority being older adults with at least three conditions. There were eight care-coordination/self-management support studies, four self-management support studies and four medicines management studies. There was little or no evidence of an effect on primary outcomes of HRQoL (MD 0.03, 95% CI -0.01 to 0.07, I2 = 39%) and mental health or on secondary outcomes with a small number of studies reporting that care coordination may improve patient experience of care and self-management support may improve patient health behaviours. Overall, the certainty of the evidence was graded as low due to significant variation in study participants and interventions. CONCLUSIONS: There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity, despite the growing number of RCTs conducted in this area. Our findings suggest that future research should consider patient experience of care, optimising medicines management and targeted patient health behaviours such as exercise.

Evaluating the implementation of interdisciplinary patient-centred care intervention for people with multimorbidity in primary care: a qualitative study.

OBJECTIVE: A patient-centred care interdisciplinary pragmatic intervention to support self-management for patients with multimorbidity was implemented in one region of Quebec, Canada. This embedded study aimed to evaluate the process of implementation. DESIGN: A descriptive qualitative study was conducted in 2016-2017 using semistructured individual interviews. The Consolidated Framework for Implementation Research (CFIR) was used to guide the data coding, analysis and reporting of the findings. SETTING: The study took place in seven Family Medicine Groups in one region (Saguenay-Lac-Saint-Jean) of Quebec, Canada. PARTICIPANTS: Ten managers (including two family physicians) and 19 healthcare professionals (HCPs), nurses, kinesiologists, nutritionists and a respiratory therapist, were interviewed. RESULTS: Many key elements within the five CFIR domains were identified as impacting the implementation of the intervention : (1) intervention characteristics-evidence strength and quality, design quality and packaging, relative advantage and complexity; (2) outer setting-patients' needs and resources, external policies and incentives; (3) inner setting-structural characteristics, networks and communication, culture, compatibility, readiness for implementation and leadership engagement; (4) characteristics of the managers and HCPs-knowledge and belief about the intervention; (5) process-planning, opinion leaders, formally appointed internal implementation leaders, reflecting and evaluating. CONCLUSION: This study revealed the organisational and contextual aspects of the implementation based on different and complementary perspectives. With the growing demand for interdisciplinary teams in primary care, we believe that our insights will be helpful for practices, researchers, and policymakers interested in the implementation of disease prevention and management programmes for people with multiple chronic conditions in primary care. TRIAL REGISTRATION NUMBER: NCT02789800.

The incidence of multimorbidity and patterns in accumulation of chronic conditions: A systematic review.

Multimorbidity, the presence of 1+ chronic condition in an individual, remains one of the greatest challenges to health on a global scale. Although the prevalence of multimorbidity has been well-established, its incidence is not fully understood. This systematic review determined the incidence of multimorbidity across the lifespan; the order in which chronic conditions accumulate to result in multimorbidity; and cataloged methods used to determine and report accumulation of chronic conditions resulting in multimorbidity. Studies were identified by searching MEDLINE, Embase, CINAHL, and Cochrane electronic databases. Two independent reviewers evaluated studies for inclusion and performed quality assessments. Of 36 included studies, there was high heterogeneity in study design and operational definitions of multimorbidity. Studies reporting incidence (n = 32) reported a median incidence rate of 30.7 per 1,000 person-years (IQR 39.5 per 1,000 person-years) and a median cumulative incidence of 2.8% (IQR 28.7%). Incidence was notably higher for persons with older age and 1+ chronic conditions at baseline. Studies reporting patterns in accumulation of chronic conditions (n = 5) reported hypertensive and heart diseases, and diabetes, as among the common starting conditions resulting in later multimorbidity. Methods used to discern patterns were highly heterogenous, ranging from the use of latent growth trajectories to divisive cluster analyses, and presentation using alluvial plots to cluster trajectories. Studies reporting the incidence of multimorbidity and patterns in accumulation of chronic conditions vary greatly in study designs and definitions used. To allow for more accurate estimations and comparison, studies must be transparent and consistent in operational definitions of multimorbidity applied.

The prevalence of multimorbidity in primary care: a comparison of two definitions of multimorbidity with two different lists of chronic conditions in Singapore.

BACKGROUND: The prevalence of multimorbidity varies widely due to the lack of consensus in defining multimorbidity. This study aimed to measure the prevalence of multimorbidity in a primary care setting using two definitions of multimorbidity with two different lists of chronic conditions. METHODS: We conducted a cross-sectional study of 787,446 patients, aged 0 to 99 years, who consulted a family physician between July 2015 to June 2016. Multimorbidity was defined as 'two or more' (MM2+) or 'three or more' (MM3+) chronic conditions using the Fortin list and Chronic Disease Management Program (CDMP) list of chronic conditions. Crude and standardised prevalence rates were reported, and the corresponding age, sex or ethnic-stratified standardised prevalence rates were adjusted to the local population census. RESULTS: The number of patients with multimorbidity increased with age. Age-sex-ethnicity standardised prevalence rates of multimorbidity using MM2+ and MM3+ for Fortin list (25.9, 17.2%) were higher than those for CDMP list (22.0%; 12.4%). Sex-stratified, age-ethnicity standardised prevalence rates for MM2+ and MM3+ were consistently higher in males compared to females for both lists. Chinese and Indians have the highest standardised prevalence rates among the four ethnicities using MM2+ and MM3+ respectively. CONCLUSIONS: MM3+ was better at identifying a smaller number of patients with multimorbidity requiring higher needs compared to MM2+. Using the Fortin list seemed more appropriate than the CDMP list because the chronic conditions in Fortin's list were more commonly seen in primary care. A consistent definition of multimorbidity will help researchers and clinicians to understand the epidemiology of multimorbidity better.

Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source.

BACKGROUND: Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE: The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN: Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS: Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS: The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

Nurturing a culture of curiosity in family medicine and primary care: The Section of Researchers' Blueprint 2 (2018-2023).

OBJECTIVE: To describe Blueprint 2 (2018-2023), the 5-year strategic plan launched in 2018 by the Section of Researchers (SOR), as well as its guiding principles and the process used to develop it. COMPOSITION OF THE COMMITTEE: Blueprint 2 was co-created by many stakeholders from across Canada and led by the SOR Council (SORC). The process started with an external, commissioned program evaluation in 2017 of the effect of the first SOR Blueprint (2012-2017). The findings and recommendations arising from the evaluation were presented in a day-long facilitated invitational retreat, hosted by the SORC in September 2017 and involving 40 key stakeholders. METHODS: Blueprint 2 was created using a multi-pronged, participatory, and iterative process to ensure broad input and alignment with current and future opportunities and priorities. REPORT: Blueprint 2 incorporates 4 strategic priority areas, each supported by objectives and actions. The strategic priority areas are membership, capacity building, advocacy, and partnerships. This updated Blueprint provides a useful, membership-driven strategic plan specifically for the SOR. The implementation of its objectives will promote research and quality improvement and contribute to building a culture of curiosity. Blueprint 2 emphasizes research and quality improvement that emanate from the realities of everyday practice and are rooted in everyday work. At its core are patient- and community-oriented approaches; it also contributes to achieving the Quadruple Aim. These outcomes will further the integration of the scholar role into daily practice for family physicians and primary care clinicians and teams. CONCLUSION: The ability of family physicians to identify, study, and cite their own evidence is essential to establishing the value and effect of primary care, including family medicine, in relation to Canadians' health and the Canadian health care system.

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes.

OBJECTIVES: There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes. METHODS: We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the Journal of Comorbidity between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment. RESULTS: Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases. CONCLUSIONS: We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.

Evaluating the content of a patient-reported outcome measure for people with multimorbidity: a Delphi consensus.

PURPOSE: Evidence supporting multimorbidity-adapted interventions is scarce, mostly due to a lack of adapted outcome measures. Measurement constructs for a novel patient-reported outcome measure (PROM) were defined in previous studies using a literature review, a qualitative description from stakeholders, and an item pool identification process. The aim of this study was to attain consensus on the content of this novel PROM. METHODS: A three-round electronic modified Delphi technique was conducted using an academic and clinical expert panel. Using a Likert scale, the panel rated the relevance, improvability, and self-ratability of each construct and item of the preliminary version of the PROM. The main outcome was consensus attainment, defined as strong (≥ 70%), moderate (50-69%) or low agreement (< 50%). Constructs and items with strong consensus were kept, moderate were sent to the next round and low agreement were rejected. RESULTS: From the 61 experts contacted, 39 participated in the first round of the Delphi, with a 12.8% attrition at the second round (n = 34) and 38.2% at the third round (n = 21). The panel included mostly female academic experts from nursing and medicine backgrounds. The preliminary PROM included 19 constructs and 70 items; from these, 16 constructs and 50 items attained consensus. The consensus attainment process excluded three constructs and their items: awareness, weight control and social integration. CONCLUSION: Consensus was reached for a patient-reported outcome measure adapted for people with multimorbidity including 50 relevant, improvable and self-ratable items categorized under 16 constructs. As more interventions tailored to multimorbidity are implemented, there is an increasing need for a valid measure of the effectiveness of these interventions.