Managing patients with multimorbidity: systematic review of interventions in primary care and community settings.

OBJECTIVE: To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011). ELIGIBILITY CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs. DATA SELECTION: Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out. RESULTS: 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings. CONCLUSIONS: Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.

BACKGROUND: Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions for multimorbidity. OBJECTIVES: To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. SEARCH METHODS: We searched MEDLINE, EMBASE, CINAHL, CAB Health, AMED, HealthStar, The Cochrane Central Register of Controlled Trials (CENTRAL), the EPOC Register and the Database of Abstracts of Reviews of Effectiveness (DARE), and the EPOC Register in April 2011. SELECTION CRITERIA: We considered randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS) reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. The outcomes included any validated measure of physical or mental health, psychosocial status including quality of life outcomes, well-being, and measures of disability or functional status. We also included measures of patient and provider behaviour including measures of medication adherence, utilisation of health services, and acceptability of services and costs. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible so we carried out a narrative synthesis of the results from the included studies. MAIN RESULTS: Ten studies examining a range of complex interventions for patients with multimorbidity were identified. All were RCTs and there was low risk of bias. Two of the nine studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings. AUTHORS' CONCLUSIONS: This review highlights the paucity of research into interventions to improve outcomes for multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. The limited results suggest that interventions to date have had mixed effects but have shown a tendency to improve prescribing and medication adherence, particularly if interventions can be targeted at risk factors or specific functional difficulties in people with co-morbid conditions or multimorbidity. There is a need for clear definitions of participants, consideration of appropriate outcomes, and further pragmatic studies based in primary care settings.

Nurses joining family doctors in primary care practices: perceptions of patients with multimorbidity.

BACKGROUND: Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices. METHODS: 18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes. RESULTS: Patients with multimorbidity were open to the participation of nurses in primary care practices. They expected greater accessibility, for both themselves and for new patients. However, the issue of shared roles between nurses and doctors was a source of concern. Many patients held the traditional view of the nurse's role as an assistant to the doctor in his or her various duties. In general, participants said they were confident about nurses' competency but expressed concern about nurses performing certain acts that their doctor used to, notwithstanding a close collaboration between the two professionals. CONCLUSION: Patients with multimorbidity are open to the involvement of nurses in primary care practices. However, they expect this participation to be established using clear definitions of professional roles and fields of practice.

Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity.

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Interprofessional learning in the trenches: fostering collective capability.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value--caring for patients--to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

Relationship between multimorbidity and physical activity: secondary analysis from the Quebec health survey.

BACKGROUND: Abundant literature supports the beneficial effects of physical activity for improving health of people with chronic diseases. The relationship between multimorbidity and physical activity levels, however, has been little evaluated. The purpose of the current exploratory study was to examine the relationship between a) multimorbidity and physical activity levels, and b) long-term limitations on activity, self-rated general health, psychological distress, and physical activity levels for each sex in adults, after age, education, income, and employment factors were controlled for. METHODS: Data from the Quebec Health Survey 1998 were used. The sample included 16,782 adults 18-69 yr of age. Independent variables were multimorbidity, long-term limitations on activity, self-rated general health, and psychological distress. The dependent variable was physical activity levels. Links between the independent and dependent variables were assessed separately for men and women with multinomial regressions while accounting for the survey sampling design and household clustering. RESULTS: About 46% of the participants were men. Multimorbidity was not associated with physical activity levels for either men or women. Men and women with long-term limitations on activity and with poor-to-average self-rated general health were less likely to be physically active. No relationship between psychological distress and physical activity was found for men. Women with high levels of psychological distress were less likely to be physically active. CONCLUSION: Multimorbidity was not associated with physical activity levels in either sex, when age, education, income, and employment factors were controlled for. Long-term limitations on activity and poor-to-average self-rated general health seem related to a reduction in physical activity levels for both sexes, whereas psychological distress was associated with a reduction in physical activity levels only among women. Longitudinal studies using a comorbidity or multimorbidity index to account for severity of the chronic diseases are needed to replicate the results of this exploratory study.

Single risk factor interventions to promote physical activity among patients with chronic diseases: systematic review.

OBJECTIVE: To provide a summary of evidence on the effectiveness of interventions to promote physical activity among patients affected by at least 1 chronic disease. The interventions studied were each targeted at a single risk factor. DATA SOURCES: MEDLINE, CINAHL, and EMBASE were searched from 1966 to 2006 using 2 sets of search terms. First we searched using physical activity or physical fitness or exercise and health care or primary care or primary health care or family practice or medical office or physician's office and health promotion or health education or counselling. Then we used physical activity or exercise and diabetes or hyperlipidemia or hypertension or obesity or cardiovascular disease or pulmonary disease or risk factor or comorbidity and health promotion or health education or counselling or prescription. STUDY SELECTION: We chose randomized controlled trials or trials with a controlled quasi-experimental design that evaluated single risk factor interventions to promote physical activity among adult patients in primary care settings who were affected by at least 1 chronic disease, that reported participation in physical activity as a primary outcome, and that were published in English or French. SYNTHESIS: Of the 4858 articles found, 62 were assessed, and 3 were selected. Two studies concluded that the interventions evaluated had no effect on level of physical activity. The other reported a positive short-term effect with use of an intensive intervention that was based on the theory of planned behaviour and integrated nurses into the general practitioner counseling process. CONCLUSION: There is insufficient evidence to assess the effectiveness of single risk factor interventions to promote physical activity among patients affected by at least 1 chronic disease in primary care settings. Of 3 studies, only 1 reported a short-term positive effect.

[Chronic musculoskeletal conditions and comorbidities in primary care settings]. / Conditions musculo-squelettiques chroniques et comorbidités en soins de première ligne.

OBJECTIVE: To estimate the prevalence of chronic musculoskeletal conditions in primary care. Among patients with these conditions, to estimate the mean number of comorbidities and the prevalence of chronic diseases that could deteriorate with use of nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Secondary analysis of data collected for a study on the prevalence of multimorbidity. SETTING: Twenty-one family medicine practices in the region of Saguenay, Que. PARTICIPANTS: Two-tier sample consisting of family physicians (first tier) and their patients (second tier) recruited during consecutive consultation periods. MAIN OUTCOME MEASURES: Percentage of patients with chronic musculoskeletal conditions. Within this sub-sample, average number of comorbidities and percentage of patients with chronic diseases, such as hypertension, cardiovascular disease, renal disease, and stomach ulcers or reflux, that could deteriorate with use of NSAIDs. RESULTS: Among the 980 patients in the database, 58% had chronic musculoskeletal conditions. Average age of patients was 56 years. Among patients with these conditions,the number of comorbidities ranged from 0 to 11; the average number was 4. About 49% of patients had hypertension; 31% had cardiovascular disease; 31% had urinary problems or renal disease; and 17% had stomach ulcers or reflux. About 70% of patients with chronic musculoskeletal conditions had at least 1 of the 4 comorbidities mentioned. CONCLUSION: More than half the patients who consult in primary care have chronic musculoskeletal conditions. The average number of comorbidities these patients have is high; many present with comorbidities that can deteriorate with use of NSAIDs. Family physicians must, therefore, exercise caution when using NSAIDs for patients with musculoskeletal conditions.

Multimorbidity and quality of life: a closer look.

BACKGROUND: The presence of multiple chronic conditions is associated with lower health related quality of life (HRQOL). Disease severity also influences HRQOL. To analyse the effects of all possible combinations of single diseases along with their severity on HRQOL seems cumbersome. Grouping diseases and their severity in specific organ domains may facilitate the study of the complex relationship between multiple chronic conditions and HRQOL. The goal of this study was to analyse impaired organ domains that affect the most HRQOL of patients with multiple chronic conditions in primary care and their possible interactions. METHODS: We analysed data from 238 patients recruited from the clientele of 21 family physicians. We classified all chronic conditions along with the measure of their severity into the 14 organ domains of the Cumulative Illness Rating Scale (CIRS). Patients also completed the 36-item Medical Outcomes Study questionnaire (SF-36). One-way analyses of variance were performed to study the relationship between the severity score for each CIRS domain and both physical component summary (PCS) and mental component summary (MCS) of HRQOL. Two-way analyses of variance were conducted to investigate the significance of possible organ domains interactions. Variables involved in significant bivariate relationships or interactions were candidates for inclusion in a multivariate model. Five additional variables were included in the multivariate model because of their possible confounding effect: perceived social support, age, education, perceived economic status and residual CIRS. RESULTS: Significant differences in the PCS (p < 0.01) were found in 12 of the 14 CIRS organ domains. A significant difference in MCS was found only in the Psychiatric domain. In the multivariate analysis for the PCS, the CIRS domains Musculoskeletal, Neurological, and Psychiatric, had an independent direct impact on PCS while the Upper gastrointestinal, Vascular, Cardiac and Respiratory domains were involved in interactions. A multivariate model was not necessary for the mental component. CONCLUSION: Vascular, Upper gastrointestinal and Musculoskeletal systems have strong negative effects on HRQOL. Among combinations of systems, the respiratory and cardiac combination is of particular concern because of a synergistic negative effect. This study paves the way for a future study with a bigger sample that could yield a model of wider generalizability.

Caring for body and soul: the importance of recognizing and managing psychological distress in persons with multimorbidity.

Primary care providers routinely encounter patients with interacting physical and psychological conditions that present as undifferentiated symptoms and feelings. Caring for the whole patient requires a good understanding of the interconnection between physical, psychological and social dimensions that may affect patients' well-being. In this article, we review the relationship between psychological distress and multimorbidity through the presentation of clinical vignettes from the real world of primary care, and discuss a team-based approach to managing care for this complex patient population.

Toward an ecosystemic approach to chronic care design and practice in primary care.

Despite the increasing prevalence of chronic conditions and multimorbidities, the essential attributes of the structure and delivery of primary care continue to be defined in terms of disease-specific approaches and acute conditions. Effective improvements will require alternative ways of thinking about chronic care design and practice. This essay argues for an ecosystemic understanding of chronic care founded on a communal and a dynamic view of the response of the patient, family, and health professionals to chronic illness. The communal view highlights the cocreative nature of the response to illness and the need to integrate the skills and resources of all the participants; what and how the participants learn in the course of the illness become central to chronic care. The dynamic view draws attention to the unfolding of illness management activities over time and to the need to engage the illness at specific time points or recurring time intervals that have the potential for important change in the experience of the participants. Chronic care would then include design for community, with an emphasis on the patient and family as necessary participants in the health care team. It would also include design for emergent learning and practice whereby health professionals go beyond standardization of care processes to develop new ways to harness the participants' imagination and learn from the changing experience of illness. Health professionals would also learn to cultivate trust, communal engagement, and openness to experimentation that facilitate collective learning, and help sharpen the participants' responsiveness to the emergent.

Perceived conflict in the couple and chronic illness management: preliminary analyses from the Quebec Health Survey.

BACKGROUND: The quality of the relationship with the spouse/partner appears crucial among patients with multiple chronic conditions where illness management is complex and multifaceted. This study draws on data from the Quebec Health Survey (QHS) to examine, among patients with one or more chronic conditions, the relation between marital status, the perceived conflict with the spouse/partner, and what the patients do to manage their illness as well as how they perceive their health. METHODS: Data from the QHS 1998 were used. The sample included 7547 coupled adults who had one or more chronic health problems lasting more than 6 months. Independent variables included marital status, perceived conflict with the spouse/partner, and the number of chronic conditions. Illness management was defined broadly as a measure of the patient's efforts at self-care and an illness status indicator, including visits to the generalist and the specialist, the use of telephone health line in the last 12 months, self-rated general health, mental health, and a measure of psychological distress. Linkages between the independent variables and illness management were assessed for males and females separately with logistic regressions, while accounting for the survey sampling design and household clustering. RESULTS: Female patients who did not live with their partner and had never been married were more likely to report a negative perception of their general health and a higher psychological distress than those who were married. Perceived conflict with the partner was linked to a negative perception of mental health and a higher psychological distress among both men and women. Compared to patients with only one chronic condition, males who reported more than one chronic condition were more likely to have consulted a generalist prior to the survey and used the telephone health line, whereas females were more likely to have consulted a specialist. Both males and females with more than one chronic condition were more likely to have a negative perception of their general health and mental health. CONCLUSION: The study provides a useful preliminary measure of the importance of living arrangements and the quality of the couple relationship in chronic illness management broadly conceived as a measure of the patient's efforts at self-care and an illness status indicator. Results of this study prod us to examine more closely, within longitudinal designs, the influence of living arrangements and the presence of conflict in the couple on chronic illness management as well as the modifying effect of gender on these associations.

Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life.

BACKGROUND: Measures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL. METHODS: We used data on chronic diseases and on the SF-36 questionnaire assessing HRQOL of 238 adult primary care patients who participated in a previous study. We extracted all the diagnoses for every patient from chart review to score the CIRS, the FCI and the Charlson. Data for potential confounders (age, sex, self-perceived economic status and self-perceived social support) were also collected. We calculated the Pearson correlation coefficients (r) of the SF-36 scores with the three measures of multimorbidity, as well as the coefficient of determination, R2, while controlling for confounders. RESULTS: The r values for the CIRS (range: -0.55 to -0.18) were always higher than those for the FCI (-0.47 to -0.10) and Charlson (-0.31 to -0.04) indices. The CIRS explained the highest percent of variation in all scores of the SF-36, except for the Mental Component Summary Score where the variation was not significant. Variations explained by the FCI were significant in all scores of SF-36 measuring physical health and in two scales evaluating mental health. Variations explained by the Charlson were significant in only three scores measuring physical health. CONCLUSION: The CIRS is a better choice as a measure of multimorbidity than the FCI and the Charlson when HRQOL is the outcome of interest. However, the FCI may provide a good option to evaluate the physical aspect of HRQOL for the ease in its administration and scoring. The Charlson index may not be recommended as a measure of multimorbidity in studies related to either physical or mental aspects of HRQOL.

Neighborhood, family, and child predictors of childhood injury in Canada.

OBJECTIVE: To examine independent and combined effects of child, family and neighborhood on medically attended childhood injuries. METHODS: Logistic modeling of longitudinal data (n=9796) from the Census Linked National Longitudinal Survey of Children and Youth. RESULTS: Child age and gender were strong predictors of injuries. Smaller effects were found for parenting, neighborhood cohesion among difficult children less than 2 years old, and neighborhood disadvantage among aggressive children 2-3 years old. CONCLUSION: Neighborhood in addition to parenting can affect injury risk. Further research is needed into the influence of neighborhood disadvantage and the processes of neighbor's cohesion at different childhood stages.

Family process and parent's leisure time physical activity.

OBJECTIVE: To examine relations between family environment and parent's leisure-time physical activity conceived as a system of interdependent variables (LTPA-specific variables) including family rules, support, and exercise activity. METHODS: Family environment was described using site of residence and a family typology. Two-way MANCOVA on the LTPA-specific scores were conducted for 533 male and 603 female parents from a community sample. RESULTS: Main effects for family type, site of residence, and a significant family type by site of residence interaction were found. There were gender-specific patterns of LTPA-specific scores. CONCLUSION: Different families may have different mechanisms of influence on physical activity habits.

The social context of childhood injury in Canada: integration of the NLSCY findings.

OBJECTIVE: To integrate findings from cross-sectional and longitudinal analyses of the relationships between childhood injury, child behavior, parenting, family functioning and neighborhood characteristics. METHODS: Logistic modeling of cross-sectional (n = 12,666) and longitudinal (n = 9796) data from the National Longitudinal Survey of Children and Youth. RESULTS: Consistent correlates of childhood injury across designs included child's age, gender, difficult temperament, aggressive behavior, positive parenting, neighbors' cohesion, neighborhood problems, and socioeconomic disadvantage. CONCLUSION: Contextual influences on childhood injury vary by child's age, temperament and behavior. In early childhood, neighborhood processes of cohesion show protective effects. For older children, neighborhood disadvantage dominates the risk of injuries.