Proposed model of integrated care to improve health outcomes for individuals with multimorbidities.

Multimorbidity is defined as the coexistence of multiple chronic conditions. Individuals with multimorbidity typically present with complex needs and show significant changes in their functional health and quality of life. Multimorbidity in the aging population is well recognized, but there has been limited research on ways to manage the problem effectively. More recent studies have demonstrated a high prevalence of multimorbidity in the younger demographics aged under 65 years. There is a definite need to develop models of care that can manage these individuals effectively and mitigate the impact of illness on individuals and the financial burden to the health care system. An integrated model of care has been developed and implemented in a facility in Nova Scotia that routinely treats individuals with multiple chronic conditions. This care model is designed to address the specific needs of this complex patient population, with integrated and coordinated care modules that meet the needs of the person versus the disease. The results of a pilot evaluation of this care model are also discussed.

The impact of a multidisciplinary, holistic approach to management of patients diagnosed with multiple chemical sensitivity on health care utilization costs: an observational study.

OBJECTIVE: The aim of this study was to look at the impact of a multidisciplinary approach to treatment of individuals with multiple chemical sensitivity (MCS) and to present preliminary results which compare health care utilization pre- and postmanagement of individuals with MCS. STUDY DESIGN: The design for this study was that for a cohort study. SETTINGS/LOCATION: The setting for this study was the Nova Scotia Environmental Health Centre (NSEHC; Fall River, Nova Scotia, Canada). PATIENTS AND METHODS: Following ethical approval, individuals who had filled a detailed-symptoms questionnaire and had agreed to participate in research activities were linked to their medical insurance records, using encrypted numbers and a blind procedure for confidentiality. Diagnosis by the NSEHC; physicians followed the consensus criteria for multiple chemical sensitivity (MCS). A total of 563 patients formed 3 cohorts (145 in 1998; 181 in 1999; and 237 in 2000). RESULTS: Physicians' visits by general practitioner and by specialists, emergency and hospital separations, and associated costs showed a relative decrease in the years following the consultation at the NSEHC. The overall yearly decline in consultations between the years before the initial consultation until 2002, for each cohort, was: 9.1% for the 1998 cohort; 8% for the 1999 cohort; and 10.6% for the 2000 cohort; compared with 1.3% for the overall Nova Scotia population. Relative to the provincial utilization costs, the standardized average yearly decrease in utilization costs for the 3 cohorts combined was 8.7%, or a total savings of $77,440. The 1998 cohort showed a sustained decrease up to 2002, reaching a level similar to the overall Nova Scotia population. Those with high symptom scores had the highest reduction in mean physician visits (31% for the 1998 cohort) in the following years. CONCLUSIONS: Presented in this paper are the preliminary results of the health care utilization costs in the management of individuals with MCS. Despite the limitations of our study design, the initial findings from this study are encouraging and warrant further exploration. These results indicate a possible impact on the long-term health care utilization from the NSEHC's management strategies, although a further controlled study, with a longer follow-up, may be necessary to confirm these findings.

Physiologic and symptomatic responses to low-level substances in individuals with and without chemical sensitivities: a randomized controlled blinded pilot booth study.

We conducted a pilot study using a randomized, single-blind, placebo-controlled exposure among 10 individuals with and 7 without reported chemical sensitivities in a dedicated testing chamber. Objectives of the study were to explore the length of the adaptation period to obtain stable readings, evaluate responses to different substances, and measure the level and type of symptomatic and physiologic reactions to low-level exposures. Reported and observed symptoms, electrodermal response, heart rate, skin temperature, surface electromyogram, respiratory rate, contrast sensitivity, and the Brown-Peterson cognitive test were used and compared between cases and controls and between test substances (glue, body wash solution, dryer sheet) and control substances (unscented shampoo and clean air). Subjects with chemical sensitivities (cases) took longer to adapt to baseline protocols than did controls. After adaptation, despite small study numbers, cases displayed statistically significant responses (all measures, p < 0.02) in tonic electrodermal response to test substances compared with controls and compared with the control substance. Symptoms were also higher in cases than in controls for the body wash solution (p = 0.05) and dryer sheets (p = 0.02). Test-retest showed good agreement for both symptoms and tonic electrodermal responses (McNemar's test, p = 0.32 and p = 0.33, respectively). Outside of skin conductance, other measures had no consistent patterns between test and control substances and between cases and controls. This study shows the importance of using an adaptation period in testing individuals with reported chemical sensitivities and, despite small numbers, raises questions about underlying mechanisms and level of reactivity to low-level chemical exposures in sensitive individuals.