Implementation and operationalization of Integrated People-Centred Health Services delivery strategies in integrated osteoporosis care (IOC) initiatives: a systematic review.

Integrated Osteoporosis Care (IOC) has been emerging over the past decade. To support integrated care initiatives, the World Health Organisation (WHO) has developed the Integrated People Centred Health Services (IPCHS) framework, which consists of five interdependent strategies. Five electronic databases (PubMed, Embase, World of Science, CINAHL, and Scopus) were searched for relevant studies published from January 1, 2010 to December 2022. Initiatives implementing collaborative practices and at least two IPCHS strategies were included. Quality assessment was performed using the Effective Public Health Practice Project checklist. Seventy-six publications describing 69 implementations met the inclusion criteria; 90% of them were implemented at the hospital level, and over half focused on secondary fracture prevention. Three implementations captured all five IPCHS strategies, and half applied three. Substrategies targeting individuals as beneficiaries were frequently employed. Substrategies requiring fundamental shifts (e.g., systemic coordination and updating) were seldomly implemented. Substantive heterogeneity in substrategy operationalization was observed. Patient education, standardized care, team-based care, care coordinators, and health care provider training were commonly pursued. IOC interventions have focused mainly on secondary fracture prevention in a hospital setting and have been narrowly operationalized. Future implementation should: employ all five IPCHS strategies; better align programmes, providers, and regulatory frameworks, while adapting funding mechanisms; and operationalize broader and more innovative substrategies.Registration: This review has been registered at the international prospective register of systematic reviews PROSPERO (CRD42021250244).

Cost of illness in patients with post-treatment Lyme disease syndrome in Belgium.

BACKGROUND: A proportion of patients with Lyme borreliosis (LB) report long-term persisting signs and symptoms, even after recommended antibiotic treatment, which is termed post-treatment Lyme disease syndrome (PTLDS). Consensus on guidance regarding diagnosis and treatment is currently lacking. Consequently, patients suffer and are left searching for answers, negatively impacting their quality of life and healthcare expenditure. Yet, health economic data on PTLDS remain scarce. The aim of this article is therefore to assess the cost-of-illness related to PTLDS, including the patient perspective. METHODS: PTLDS patients (N = 187) with confirmed diagnosis of LB were recruited by a patient organization. Patients completed a self-reported questionnaire on LB-related healthcare utilization, absence from work and unemployment. Unit costs (reference year 2018) were obtained from national databases and published literature. Mean costs and uncertainty intervals were calculated via bootstrapping. Data were extrapolated to the Belgian population. Generalized linear models were used to determine associated covariates with total direct costs and out-of-pocket expenditures. RESULTS: Mean annual direct costs amounted to €4618 (95% CI €4070-5152), of which 49.5% were out-of-pocket expenditures. Mean annual indirect costs amounted to €36 081 (€31 312-40 923). Direct and indirect costs at the population level were estimated at €19.4 and 151.5 million, respectively. A sickness or disability benefit as source of income was associated with higher direct and out-of-pocket costs. CONCLUSIONS: The economic burden associated with PTLDS on patients and society is substantial, with patients consuming large amounts of non-reimbursed healthcare resources. Guidance on adequate diagnosis and treatment of PTLDS is needed.

Underlying motivations hampering Flemish primary care physicians from overcoming the barriers in osteoporosis care: an EMR-facilitated clinical reasoning study.

BACKGROUND: Over half of the European population aged minimum 65 years presents with at least two chronic diseases. Attention towards these diseases exhibits disparities, with limited primary care physician (PCP) attention for osteoporosis. This was confirmed in a previous integrated osteoporosis care (IOC) project in which notable difficulties to enlist PCPs arose. Consequently, this study was initiated in Flemish PCPs for in-depth analysis of underlying mechanisms hampering PCPs to fully commit to osteoporosis care. METHODS: A qualitative Electronic Medical Record (EMR)-facilitated clinical reasoning study was conducted. A semi-structured interview guide was employed to guide PCPs from reflections on their own patients to broader views regarding osteoporosis care. An inductive thematic analysis was performed using NVivo 12. RESULTS: Thirteen PCPs were interviewed. They stated that osteoporosis patients often had complex (medical) profiles. PCPs emphasised the ongoing necessity for prioritisation within this context. This leads to a competition for PCP attention during consultations at three levels: i. between acute versus preventive care; ii. between primary fracture prevention and other preventive services and iii. between secondary fracture prevention and other preventive services; spanning eight areas of competition: disease significance, perceived impact, PCP awareness, the patient agenda, PCP competence, PCP support, perceived patient burden, and efficiency of care provision. Applicability of these areas of competition differed between levels. CONCLUSION: The intricate context in which PCPs operate, creates a competition for PCP attention leading to a lack of attention for fracture prevention. To preserve efforts in fracture prevention, areas of competition should be systematically addressed. TRIAL REGISTRATION: Approval for the study has been provided by the Ghent University Hospital Ethics Committee (BC-09797).

Availability of informal caregivers in surviving stroke patients in Belgium.

OBJECTIVE: To quantify the availability of informal caregivers in surviving stroke patients residing at home in Belgium. METHODS: National estimates on the availability of informal caregivers were made using data from a nationwide observational registration of family physicians working in sentinel practices and a nationwide administrative database for reimbursement of hospitals in Belgium. RESULTS: A total of 189 Belgian family physicians (FPs) from 141 practices participated in the study and recorded 326 patients (144 men and 182 women) with stroke. These FPs reach 1.5% of the Belgian population. After 1 month, 71% of the male and 75% of the female stroke survivors received support from family caregivers (p = 0.547). After 6 months, the percentage of male patients who received support from family caregivers decreased to 60% compared with 75% in female (p = 0.038). Of all patients with stroke admitted to Belgian hospitals during the reference year 2009 (n = 16.437), 8.997 returned home. Based on the findings from the sentinel practices, it is estimated that a mean of 73% (n = 6.568) and 67.5% (n = 6.073) of surviving patients with stroke can rely on informal caregivers in their home setting after one and 6 months, respectively. CONCLUSIONS: A vast majority of surviving stroke patients in Belgium can rely on informal caregivers in their home setting, but their availability rapidly decreases 6 months after the event. These findings underline the importance of proactive health policy making in stroke care taking into account the potentially decreasing number of available informal caregivers in the decades to come.

A theoretical lens for revealing the complexity of chronic care.

The increasing prevalence of co-occurring multiple chronic conditions in an aging population has influenced the debate on complexity in chronic care and nowadays provides an impetus to the reform of numerous health systems. This article presents a theoretical lens for understanding the complexity of chronic care based on research and debate conducted in the context of multiple quality improvement programs over the last five years in Belgium and The Netherlands. We consider four major components of complexity in chronic care against a background of complex adaptive systems: (1) case (patient) complexity; (2) care complexity; (3) quality assessment complexity; and (4) health systems complexity. Each of these components represents a range of elements that contribute to the picture of complexity in chronic care. We emphasize that planning for chronic care requires equal attention to the complexity of all four components. It also requires multifaceted interventions and implementation strategies that target improvements in multiple outcomes related to the structural, process, and outcome components of care. Further empirical research is needed to assess the validity of our complexity framework in the health-care environment.

Closing the gap in osteoporosis management: the critical role of primary care in bone health.

OBJECTIVE: The World Health Organization issued a call to action for primary care to lead efforts in managing noncommunicable diseases, including osteoporosis. Although common, osteoporosis remains underdiagnosed and undertreated. Primary care practitioners (PCPs) are critical in identifying individuals at risk for osteoporosis and osteoporotic fractures; however, recent advances in assessment, diagnosis, and treatment of osteoporosis have not been incorporated into clinical practice in primary care due to numerous reasons including time constraints and insufficient knowledge. To close this gap in clinical practice, we believe PCPs need a practical strategy to facilitate osteoporosis assessment and management that is easy to implement. METHODS: In this article, we consolidate information from various global guidelines and highlight areas of agreement to create a streamlined osteoporosis management strategy for a global audience of PCPs. RESULTS: We present a systematic approach to facilitate osteoporosis assessment and management that includes four steps: (1) identifying patients at risk through proactive screening strategies, (2) investigating and diagnosing patients, (3) intervening with personalized treatment plans, and (4) implementing patient-centered strategies for long-term management and monitoring of patients. CONCLUSION: Primary care has a central role in ensuring the incorporation of key elements of holistic care as outlined by the World Health Organization in managing noncommunicable diseases including osteoporosis; namely, a people-centered approach, incorporation of specialist services, and multidisciplinary care. This approach is designed to strengthen the health system's response to the growing osteoporosis epidemic.

Osteoporosis is a chronic condition associated with aging in which bones become "porous" and weak, and are more likely to break (i.e., fracture) even with minimal trauma such as tripping or falling from a standing height. A broken bone is a serious condition that not only affects daily activities, but can also lead to reduced quality of life, need for caregiver support, work loss, hospital and rehabilitation costs, nursing home costs, and increased mortality. Although osteoporosis is common, it is often undiagnosed or untreated, leaving many people at risk for experiencing broken bones. A broken bone increases the risk of more broken bones. Given the growing size of the aging global population, osteoporosis and the risk of broken bones represent an urgent problem and growing burden. We need ways to make it easier for primary care practitioners (PCPs), such as family physicians, internists, physician assistants, nurse practitioners, and nurses, to include osteoporosis care as part of routine clinical visits. In this article, we discuss the critical role of PCPs in early detection, diagnosis, and treatment of osteoporosis as they are often the first point of contact for at-risk patients. We present a simple, four-step approach to help PCPs and patients navigate the journey from osteoporosis diagnosis to a treatment plan. The four steps are to: (1) identify at-risk patients by screening for weak bones or osteoporosis, (2) perform necessary tests to diagnose patients, (3) develop a personalized treatment plan, and (4) determine long-term strategies for managing and monitoring bone health.

Monitoring modifiable cardiovascular risk in type 2 diabetes care in general practice: the use of an aggregated z-score.

BACKGROUND: Because many patients in usual care reach the diabetes treatment goals, it may be more efficacious to focus quality improvement efforts on those general practice populations requiring additional support. We therefore developed a tool based on a composite end point considering blood pressure, lipids, and glycaemia. METHODS: We created an aggregated z(A)-score, calculated as the average of 3 z-scores testing whether the mean practice values of hemoglobin A1c, low density lipoprotein cholesterol, and systolic blood pressure are significantly higher than the corresponding ADA-target (respectively 7%, 100 mg/dL, and 130 mm Hg). This score was used with 100 general practitioners who participated in a Quality Improvement Program. We defined the cut-off value (COV) to determine "Practices Requiring Support" (z(A)

The effectiveness and cost-effectiveness of an integrated osteoporosis care programme for postmenopausal women in Flanders: study protocol of a quasi-experimental controlled design.

Osteoporosis causes high individual and societal burden, due to limited attention to fracture prevention. Integrated care for chronic conditions has shown to facilitate management of these conditions, improving clinical outcomes alongside quality of life and cost-effectiveness. This manuscript describes an integrated osteoporosis care programme that will be implemented in primary care. OBJECTIVE: To provide a comprehensive description of a quasi-experimental study design in which a newly developed integrated osteoporosis care (IOC) programme for the management of postmenopausal osteoporosis (PO) in primary care (PC) is implemented and will be compared with care as usual (CAU). METHODS: A literature research was performed and expert meetings have been taking place, which has led to the development of a complex PC intervention based on framework for integrated people-centred health services (IPCHS). RESULTS: This manuscript describes the developmental process of the preclinical phase of a quasi-experimental real-world design and the interventions as a result of this process that will be implemented during the clinical phase, along with the evaluation that will take place alongside the clinical phase: An integrative approach for the management of PO in primary care was developed and will be implemented in greater region of Ghent (GRG), Belgium. The approach consists of a complex intervention targeting patients and PC stakeholders in osteoporosis care (e.g. general practitioners (GPs), physiotherapists, nurses, pharmacists). A comparison will be made with CAU using medication possession ratios (MPR) of included patients as primary outcome. These data will be obtained from the national health database. Secondary outcomes are physician outcomes, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs). A cost-effectiveness evaluation will be performed if the programme appears to be effective in terms of MPR. TRIAL REGISTRATION: ClinicalTrials.gov : NCT03970902.

Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.

BACKGROUND: Type 2 diabetes mellitus is a complex, progressive disease which requires a variety of quality improvement strategies. Limited information is available on the feasibility and effectiveness of interdisciplinary diabetes care teams (IDCT) operating on the interface between primary and specialty care. A first study hypothesis was that the implementation of an IDCT is feasible in a health care setting with limited tradition in shared care. A second hypothesis was that patients who make use of an IDCT would have significantly better outcomes compared to non-users of the IDCT after an 18-month intervention period. A third hypothesis was that patients who used the IDCT in an Advanced quality Improvement Program (AQIP) would have significantly better outcomes compared to users of a Usual Quality Improvement Program (UQIP). METHODS: This investigation comprised a two-arm cluster randomized trial conducted in a primary care setting in Belgium. Primary care physicians (PCPs, n = 120) and their patients with type 2 diabetes mellitus (n = 2495) were included and subjects were randomly assigned to the intervention arms. The IDCT acted as a cornerstone to both the intervention arms, but the number, type and intensity of IDCT related interventions varied depending upon the intervention arm. RESULTS: Final registration included 67 PCPs and 1577 patients in the AQIP and 53 PCPs and 918 patients in the UQIP. 84% of the PCPs made use of the IDCT. The expected participation rate in patients (30%) was not attained, with 12,5% of the patients using the IDCT. When comparing users and non-users of the IDCT (irrespective of the intervention arm) and after 18 months of intervention the use of the IDCT was significantly associated with improvements in HbA1c, LDL-cholesterol, an increase in statins and anti-platelet therapy as well as the number of targets that were reached. When comparing users of the IDCT in the two intervention arms no significant differences were noted, except for anti-platelet therapy. CONCLUSION: IDCT's operating on the interface between primary and specialty care are associated with improved outcomes of care. More research is required on what team and program characteristics contribute to improvements in diabetes care. TRIAL REGISTRATION: NTR 1369.

An Instrument to Measure Maturity of Integrated Care: A First Validation Study.

INTRODUCTION: Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO (Scaling Integrated Care into Context), a European Union funded project. METHODS: A literature review was conducted to compare B3-MM's 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM. RESULTS: The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round. CONCLUSION AND DISCUSSION: The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM.

A Policy Guide on Integrated Care (PGIC): Lessons Learned from EU Project INTEGRATE and Beyond.

Efforts are underway in many European countries to channel efforts into creating improved integrated health and social care services. But most countries lack a strategic plan that is sustainable over time, and that reflects a comprehensive systems perspective. The Policy Guide on Integrated Care (PGIC) as presented in this paper resulted from experiences with the EU Project INTEGRATE and our own work with healthcare reform for patients with chronic conditions at the national and international level. This project is one of the largest EU funded projects on Integrated Care, conducted over a four-year period (2012-2016) and included partners from nine European countries. Project Integrate aimed to gain insights into the leadership, management and delivery of integrated care to support European care systems to respond to the challenges of ageing populations and the rise of people living with long-term conditions. The objective of this paper is to describe the PGIC as both a tool and a reasoning flow that aims at supporting policy makers at the national and international level with the development and implementation of integrated care. Any Policy Guide on Integrated should build upon three building blocks, being a mission, vision and a strategy that aim at capturing the large amount of factors that directly or indirectly influence the successful development of integrated care.

How to Improve Integrated Care for People with Chronic Conditions: Key Findings from EU FP-7 Project INTEGRATE and Beyond.

BACKGROUND: Political and public health leaders increasingly recognize the need to take urgent action to address the problem of chronic diseases and multi-morbidity. European countries are facing unprecedented demand to find new ways to deliver care to improve patient-centredness and personalization, and to avoid unnecessary time in hospitals. People-centred and integrated care has become a central part of policy initiatives to improve the access, quality, continuity, effectiveness and sustainability of healthcare systems and are thus preconditions for the economic sustainability of the EU health and social care systems. PURPOSE: This study presents an overview of lessons learned and critical success factors to policy making on integrated care based on findings from the EU FP-7 Project Integrate, a literature review, other EU projects with relevance to this study, a number of best practices on integrated care and our own experiences with research and policy making in integrated care at the national and international level. RESULTS: Seven lessons learned and critical success factors to policy making on integrated care were identified. CONCLUSION: The lessons learned and critical success factors to policy making on integrated care show that a comprehensive systems perspective should guide the development of integrated care towards better health practices, education, research and policy.

Results of the Belgian Sentinel Network of General Practitioners on the Involvement of Therapists in Stroke Rehabilitation.

This study examines which therapists are involved in the rehabilitation of stroke survivors in Belgium at different points in time. A nationwide registration of stroke patients was provided by 199 and 189 family physicians working in sentinel practices for the years 2009 and 2010 respectively. 326 patients who were diagnosed with stroke were included. Patients with paralysis/paresis received significant more physiotherapy after one month (63%) compared to non-paralysed patients (38%) (P = 0.005). Residing in a nursing home was associated with higher proportions of patients receiving physiotherapy, both after one (P = 0.003) and six (P = 0.002) months. 31% of patients with aphasia were treated by a speech and language therapist after one month, which decreased after six months to 20%. After six months, the patients in a nursing home received significant more often speech and language therapy (P = 0.004), compared to patients living at home. The proportion of patients receiving stroke rehabilitation services provided by physiotherapists, speech/language therapists and occupational therapists is rather low, especially 6 months after the critical event.

Relevance of chronic lyme disease to family medicine as a complex multidimensional chronic disease construct: a systematic review.

Lyme disease has become a global public health problem and a prototype of an emerging infection. Both treatment-refractory infection and symptoms that are related to Borrelia burgdorferi infection remain subject to controversy. Because of the absence of solid evidence on prevalence, causes, diagnostic criteria, tools and treatment options, the role of autoimmunity to residual or persisting antigens, and the role of a toxin or other bacterial-associated products that are responsible for the symptoms and signs, chronic Lyme disease (CLD) remains a relatively poorly understood chronic disease construct. The role and performance of family medicine in the detection, integrative treatment, and follow-up of CLD are not well studied either. The purpose of this paper is to describe insights into the complexity of CLD as a multidimensional chronic disease construct and its relevance to family medicine by means of a systematic literature review.

Place of residence after a stroke: results of the registration by the Belgian Sentinel Network of general practitioners.

BACKGROUND: Stroke is a major health problem worldwide. The health consequences for the survivors are not to be underestimated. The increased care needs after a stroke result often in a change of residence or an institutionalisation. The aim of the study is to provide an overview in the changes of the place of residence in the first year after stroke. METHODS: A nationwide observational registration by 199 and 189 family physicians (respectively in 2009 and 2010) working in sentinel practices. All cerebrovascular events that occurred in 2009 and 2010 were recorded. Follow-up was provided 1, 6 and 12 month(s) after the initial registration. RESULTS: In total 326 patients were diagnosed with a stroke and 87% were hospitalized. At the time of the event 83% of the patients lived at home and one year after the event 80% did (p = 0.366). Older age (p = 0.008), originally living in a nursing home (p = 0.009) and speech problems (p = 0.003) and incontinence (p = 0.017) were the most important determinants for institutionalisation in a nursing home after one year. CONCLUSION: There is a high proportion of the Belgian stroke survivors that can return home after the initial hospitalization. Mainly older patients with severe disabilities did not return to their home.

Effectiveness of a quality improvement intervention targeting cardiovascular risk factors: are patients responsive to information and encouragement by mail or post?

INTRODUCTION: There is important evidence on the beneficial effects of treatment of cardiovascular risk factors in terms of morbidity and mortality, but important challenges remain in motivating patients to adhere to their treatment regimen. This study aimed to describe the effectiveness of a quality improvement intervention that included information and regular encouragement by email or letter on cardiovascular risk factors for patients at high risk for cardiovascular disease. METHODS: This randomized single-blind study included patients of both sexes aged between 45 and 80 years old who had increased cardiovascular risk. Patients were randomly allocated to either a usual care group (UCG) or advanced care group (ACG). Patients in the UCG received regular care while patients in the ACG received usual care plus regular information and encouragement on cardiovascular risk factors by email or letter. Visits for both groups were planned at 0, 3, and 6 months. The outcome measures were blood pressure, weight, body mass index (BMI), waist circumference (WC), and smoking status. RESULTS: Out of 178 eligible patients from one single primary care practice, 55 participated in the study, three of whom dropped out. After 6 months, there was a significant decrease in mean systolic and diastolic blood pressure in the UCG and ACG (P < 0.05). The decreases were already significant after 3 months, except for systolic blood pressure in the UCG. There was also a significant increase in the proportion of patients who met the target values for blood pressure in the UCG and ACG. There was a nonsignificant decrease of the average weight in the ACG, but significantly more patients lost weight in the UCG (P = 0.02). BMI, WC, and smoking status did not change in either group. CONCLUSION: This study found that there was a significant decrease of systolic and diastolic blood pressure in both study groups. Weight, BMI, WC, and smoking did not improve in either group. Information on cardiovascular risk factors and encouragement by means of letters or email did not provide additional benefits. Thus, effective patient empowerment probably requires more behaviorally sophisticated support to increase self-management, self-efficacy, and self-esteem in patients.

The use of family history in primary health care: a qualitative study.

The aim of this study is to describe how Belgian family physicians register and use the family history data of their patients in daily practice. Qualitative in-depth semistructured one-to-one interviews were conducted including 16 family physicians in Belgium. These interviews were recorded, transcribed, and analysed. Recurring themes were identified and compared with findings from the existing literature. All interviewed family physicians considered the family history as an important part of the medical records. Half of the surveyed physicians confirmed knowing the family history of at least 50% of their patients. The data on family history were mainly collected during the first consultations with the patient. The majority of physicians did not use a standardised questionnaire or form to collect and to record the family history. To estimate the impact of a family history, physicians seldom use official guidance or resources. Physicians perceived a lack of time and unreliable information provided by their patients as obstacles to collect and interpret the family history. Solutions that foster the use of family history data were identified at the level of the physician and also included the development of specific instruments integrated within the electronic medical record.

Patient health information materials in waiting rooms of family physicians: do patients care?

BACKGROUND: Patient health information materials (PHIMs), such as leaflets and posters are widely used by family physicians to reinforce or illustrate information, and to remind people of information received previously. This facilitates improved health-related knowledge and self-management by patients. OBJECTIVE: This study assesses the use of PHIMs by patient. It also addresses their perception of the quality and the impact of PHIMs on the interaction with their physician, along with changes in health-related knowledge and self-management. METHODS: QUESTIONNAIRE SURVEY AMONG PATIENTS OF FAMILY PRACTICES OF ONE TOWN IN BELGIUM, ASSESSING: (1) the extent to which patients read PHIMs in waiting rooms (leaflets and posters) and take them home, (2) the patients' perception of the impact of PHIMs on interaction with their physician, their change in health-related knowledge and self-management, and (3) the patients judgment of the quality of PHIMs. RESULTS: We included 903 questionnaires taken from ten practices. Ninety-four percent of respondents stated they read PHIMs (leaflets), 45% took the leaflets home, and 78% indicated they understood the content of the leaflets. Nineteen percent of respondents reportedly discussed the content of the leaflets with their physician and 26% indicated that leaflets allowed them to ask fewer questions of their physician. Thirty-four percent indicated that leaflets had previously helped them to improve their health-related knowledge and self-management. Forty-two percent reportedly discussed the content of the leaflets with others. Patient characteristics are of significant influence on the perceived impact of PHIMS in physician interaction, health-related knowledge, and self-management. CONCLUSION: This study suggests that patients value health information materials in the waiting rooms of family physicians and that they perceive such materials as being helpful in improving patient-physician interaction, health-related knowledge, and self-management.

Relevance of hypersexual disorder to family medicine and primary care as a complex multidimensional chronic disease construct.

Hypersexual disorder (HD) is not defined in a uniform way in the psychiatric literature. In the absence of solid evidence on prevalence, causes, empirically validated diagnostic criteria, instruments for diagnosis, consistent guidelines on treatment options, medical and psychosocial consequences, and type of caregivers that need to be involved, HD remains a controversial and relatively poorly understood chronic disease construct. The role of family medicine in the detection, treatment, and followup of HD is not well studied. The purpose of this paper is to describe the complexity of HD as a multidimensional chronic disease construct and its relevance to family medicine and primary care.