Development of a research tool to document self-reported chronic conditions in primary care

Patients, caregivers and health-care professionals' experience with an interdisciplinary intervention for people with multimorbidity in primary care: A qualitative study

Background

Multimorbidity challenges the health‐care system and requires innovative approaches. In 2015, a 4‐month patient‐centred interdisciplinary pragmatic intervention was implemented in primary care with the aim of supporting self‐management for patients with multimorbidity.

Objective

To explore the perceptions and experiences of health‐care professionals, patients and their caregivers with a 4‐month patient‐centred interdisciplinary pragmatic intervention in primary care.

Design

A descriptive, qualitative study using semi‐structured interviews was conducted.

Setting and participants

A purposive sample of 30 participants was recruited from seven family medicine groups including patients, caregivers and health‐care professionals (HCPs). Interviews were analysed using Thorne's interpretive description approach.

Results

Findings were grouped into the benefits and challenges of participating in the intervention. The programme allowed patients to adopt realistic and adapted objectives; to customize interventions to the patient's reality; and to help patients gain confidence, improve their knowledge, skills and motivation to manage their condition. Interprofessional collaboration eased the exchange of information via team meetings and electronic medical records. Challenges were related to collaboration, communication, coordination of work and integration of newly relocated HCPs mainly due to part‐time assignments and staff turnover. HCPs part‐time schedules limited their availability and hindered patients’ follow‐up.

Discussion and conclusion

This intervention was useful and rewarding from the HCPs, patients and caregivers’ perspective. However, to ensure the success of this complex interdisciplinary intervention, implementers and managers should anticipate organizational barriers such as availability and time management of relocated HCPs.

Multimorbidity of chronic non-communicable diseases in low- and middle-income countries: A scoping review

BACKGROUND

Multimorbidity is rising in low- and middle-income countries (LMICs). However, the evidence on its epidemiology from LMICs settings is limited and the available literature has not been synthesized as yet.

OBJECTIVES

To review the available evidence on the epidemiology of multimorbidity in LMICs.

METHODS

PubMed, Scopus, PsycINFO and Grey literature databases were searched. We followed the PRISMA-ScR reporting guideline.

RESULTS

Of 33, 110 articles retrieved, 76 studies were eligible for the epidemiology of multimorbidity. Of these 76 studies, 66 (86.8%) were individual country studies. Fifty-two (78.8%) of which were confined to only six middle-income countries: Brazil, China, South Africa, India, Mexico and Iran. The majority (n = 68, 89.5%) of the studies were crosssectional in nature. The sample size varied from 103 to 242, 952. The largest proportion (n = 33, 43.4%) of the studies enrolled adults. Marked variations existed in defining and measuring multimorbidity. The prevalence of multimorbidity in LMICs ranged from 3.2% to 90.5%.

CONCLUSION AND RECOMMENDATIONS

Studies on the epidemiology of multimorbidity in LMICs are limited and the available ones are concentrated in few countries. Despite variations in measurement and definition, studies consistently reported high prevalence of multimorbidity. Further research is urgently required to better understand the epidemiology of multimorbidity and define the best possible interventions to improve outcomes of patients with multimorbidity in LMICs.

Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada

BACKGROUND

Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed.

AIM

To determine the prevalence, characteristics, and patterns of patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care.

DESIGN AND SETTING

A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database.

METHOD

Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations.

RESULTS

Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased.

CONCLUSION

This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.

Measuring multimorbidity in older adults: comparing different data sources

Background

Multimorbidity is a global health issue, particularly for older adults in the primary care setting. An adequate portrayal of its epidemiology is essential to properly identify and understand the health care needs of this population. This study aimed to compare the differences in the prevalence of selected chronic conditions and multimorbidity, including its associated characteristics, using health survey/self-reported (SR) information only, administrative (Adm) data only and the combined (either) sources.

Methods

This was a secondary analysis of survey data from the first cycle of the Longitudinal Survey on Senior’s Health and Health Services Use linked to health-Adm data. The analytical sample consisted of 1625 community-dwelling older adults (≥65 years) recruited in the waiting rooms of primary health clinics in a selected administrative region of the province of Quebec. Seventeen chronic conditions were assessed according to two different data sources. We examined the differences in the observed prevalence of chronic conditions and multimorbidity and the agreement between data sources.

Results

The prevalence of each of the 17 chronic conditions ranged from 1.2 to 68.7% depending on the data source. The agreement between different data sources was highly variable, with kappa coefficients (κ) ranging from 0.05 to 0.73. Multimorbidity was very high in this population, with an estimated prevalence of up to 95.9%. In addition, we found that the association between sociodemographic and behavioural factors and the presence of multimorbidity varied according to the different data sources and thresholds.

Conclusions

This is the first study to simultaneously investigate chronic conditions and multimorbidity prevalence among primary care older adults using combined SR and health-Adm data. Our results call attention to (1) the possibility of underestimating cases when using a single data source and (2) the potential benefits of integrating information from different data sources to increase case identification. This is an important aspect of characterizing the health care needs of this fast-growing population.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1173-4) contains supplementary material, which is available to authorized users.

Social Vulnerability in Patients with Multimorbidity: A Cross-Sectional Analysis

BACKGROUND

Social aspects play an important role in individual health and should be taken into consideration in the long-term care for people with multimorbidity.

PURPOSES

To describe social vulnerability, to examine its correlation with the number of chronic conditions, and to investigate which chronic conditions were significantly associated with the most socially vulnerable state in patients with multimorbidity.

METHODS

Cross-sectional analysis from the baseline data of the Patient-Centred Innovations for Persons with Multimorbidity (PACEinMM) Study. Participants were patients attending primary healthcare settings in Quebec, Canada. A social vulnerability index was applied to identify social vulnerability level. The index value ranges from 0 to 1 (1 as the most vulnerable). Spearman's rank correlation coefficient was calculated for the correlation between the social vulnerability index and the number of chronic conditions. Logistic regression was applied to investigate which chronic conditions were independently associated with the most socially vulnerable state.

RESULTS

There were 301 participants, mean age 61.0 ± 10.5, 53.2% female. The mean number of chronic health conditions was 5.01 ± 1.82, with the most common being hyperlipidemia (78.1%), hypertension (69.4%), and obesity (54.2%). The social vulnerability index had a median value of 0.13 (range 0.00⁻0.78). There was a positive correlation between the social vulnerability index and the number of chronic conditions (r = 0.24, p < 0.001). Obesity, depression/anxiety, and cardiovascular diseases were significantly associated with the most socially vulnerable patients with multimorbidity.

CONCLUSIONS

There was a significant correlation between social vulnerability and the total number of chronic conditions, with depression/anxiety, obesity, and cardiovascular diseases being the most related to social vulnerability.

Multimorbidity Frameworks Impact Prevalence and Relationships with Patient-Important Outcomes

OBJECTIVES

To explore how different frameworks and categories of chronic conditions impact multimorbidity (defined as two or more chronic conditions) prevalence estimates and associations with patient-important functional outcomes.

DESIGN

Baseline data from a population-based cohort study.

SETTING

National sample of Canadians.

PARTICIPANTS

A total of 51 338 community-living adults, aged 45 to 85 years.

MAIN OUTCOME MEASURES

Chronic conditions from three commonly recognized frameworks were categorized as: (1) diseases, (2) risk factors, or (3) symptoms. Estimates of multimorbidity prevalence were compared among frameworks by age and sex. Separate weighted logistic regression models were used to explore the impact of the different frameworks and categories of chronic conditions on odds ratios (ORs) for multimorbidity for four patient-important functional outcomes: disability, social participation restriction, and self-rated physical and mental health.

RESULTS

One framework included diseases and risk factors, and two frameworks included diseases, risk factors, and symptoms. The prevalence of multimorbidity differed among the frameworks, ranging from 33.5% to 60.6% having two or more chronic conditions. Including risk factors in frameworks increased prevalence estimates, while including symptoms increased prevalence estimates and associations with most patient-important outcomes. The two frameworks that included symptoms had the largest ORs for associations with disability, social participation restriction, and self-rated physical health but not self-rated mental health. Similar results were found when we compared ORs for patient-important outcome for multimorbidity based on three subframeworks: one including diseases only, one including diseases and risk factors, and one including diseases, risk factors, and symptoms.

CONCLUSIONS

Including risk factors appeared to increase only the prevalence of multimorbidity without significantly altering relationships to outcomes. The inclusion of symptoms increased prevalence and associations with patient-important outcomes. These findings underscore the importance of considering not only the number, but also the category, of conditions included in multimorbidity frameworks, as simply counting the number of diagnoses may reduce sensitivity to outcomes that are important to individuals. J Am Geriatr Soc 67:1632-1640, 2019.

Prospective associations of low muscle mass and strength with health-related quality of life over 10-year in community-dwelling older adults

AIMS

This study aims to describe the associations of low muscle mass, handgrip (HGS) and lower-limb muscle strength (LMS) with health-related quality of life (HRQoL) over 10 years in community-dwelling older adults.

METHODS

Participants (N = 1002; 51% women; mean age 63 ± 7.4 years) were prospectively followed for 10 years. HRQoL was measured using the validated assessment of quality of life (AQoL) instrument. Appendicular lean mass (ALM) was assessed using dual energy X-ray absorptiometry and normalized to body mass index (BMI). HGS and LMS were assessed using dynamometers. Low ALM/BMI (ALM/BMI_LOW), LMS (LMS_LOW) and HGS (HGS_LOW) at baseline were defined as the lowest 20% of the sex-specific distribution for each measure. Linear mixed effect regression models, adjusting for confounders, were used to estimate the association between ALM/BMI_LOW, LMS_LOW, and HGS_LOW at baseline and HRQoL over 10 years.

RESULTS

Participants with LMS_LOW (β = -0.061, 95% CI: -0.089, -0.033) and women (β = -0.089, 95% CI: -0.129, -0.049) but not men (β = -0.023, 95% CI: -0.064, 0.019) with HGS_LOW had clinically meaningful reductions in HRQoL over 10 years compared to those with normal strength. There was a weaker but statistically significant association between ALM/BMI_LOW and 10-year HRQoL (β = -0.038, 95% CI: -0.068, -0.008).

CONCLUSIONS

Lower-limb muscle strength and handgrip strength (in women only), which can be easily measured in clinical practice, appear more important than muscle mass for HRQoL.

The "Patient-centered coordination by a care team" questionnaire achieves satisfactory validity and reliability

Increasing prevalence of chronic conditions and multimorbidity challenges health care systems and calls for patient-centered coordination of care. Implementation and evaluation of health policies focusing on the development of patient-centered coordination of care needs valid instruments measuring this dimension of care. The aim of this validation study was to assess the psychometric properties of the French version of the 14-item Patient-Centered Coordination by a Care Team (PCCCT) questionnaire in a primary care setting. PCCCT provides a total score from 0 (worst coordination) to 42 (best coordination). 165 adult patients consulting in primary care with one or more chronic condition(s) completed questionnaires (including PCCCT) at recruitment. After three weeks, participants completed PCCCT again, either by mail (group A) or during a telephone interview (group B). At recruitment, the mean (SD) PCCCT score was 33.3 (7.7). Exploratory factor analysis revealed a 2-dimension structure, 8 items relating to patient involvement and 6 items relating to coordination (factors loadings ranging from 0.34 to 0.88). PCCCT score correlated significantly with subscales of Haggerty's continuity questionnaire, Spearman correlation coefficients (95% confidence interval) ranging from 0.40 (0.22-0.57) to 0.52 (0.38-0.63). Internal consistency was excellent: Cronbach alpha 0.90 (0.79-0.92). Reliability was good, with an intraclass correlation coefficient of 0.68 (0.55-0.78) for test-retest reliability (group A) and of 0.65 (0.46-0.79) for reliability between the self-administered and the interviewer-administered versions of the questionnaire (group B,). The PCCCT questionnaire presents satisfactory validity and reliability; it can be used for the evaluation of health organizations involving team work in primary care.

Beyond the grey tsunami: a cross-sectional population-based study of multimorbidity in Ontario

OBJECTIVES

To determine volumes and rates of multimorbidity in Ontario by age group, sex, material deprivation, and geography.

METHODS

A cross-sectional population-based study was completed using linked provincial health administrative databases. Ontario residents were classified as having multimorbidity (3+ chronic conditions) or not, based on the presence of 17 chronic conditions. The volumes (number of residents) of multimorbidity were determined by age categories in addition to crude and age-sex standardized rates.

RESULTS

Among the 2013 Ontario population, 15.2% had multimorbidity. Multimorbidity rates increased across successively older age groups with lowest rates observed in youngest (0-17 years, 0.2%) and highest rates in the oldest (80+ years, 73.5%). The rate of multimorbidity increased gradually from ages 0 to 44 years, with a substantial and graded increase in the rates as the population aged. The top five chronic conditions, of the 17 examined, among those with multimorbidity were mood disorders, hypertensive disorders, asthma, arthritis, and diabetes.

CONCLUSION

Much of the common rhetoric around multimorbidity concerns the aging 'grey tsunami'. This study demonstrated that the volume of multimorbidity is derived from adults beginning as young as age 35 years old. A focus only on the old underestimates the absolute burden of multimorbidity on the health care system. It can mask the association of material deprivation and geography with multimorbidity which can turn our attention away from two critical issues: (1) potential inequality in health and health care in Ontario and (2) preventing younger and middle-aged people from moving into the multimorbidity category.

Key factors to consider when measuring multimorbidity: Results from an expert panel and online survey

Background:

There are multiple multimorbidity measures but little consensus on which measures are most appropriate for different circumstances.

Objective:

To share insights gained from discussions with experts in the fields of ageing research and multimorbidity on key factors to consider when measuring multimorbidity.

Design:

Descriptive study of expert opinions on multimorbidity measures, informed by literature to identify available measures followed by a face-to-face meeting and an online survey.

Results:

The expert group included clinicians, researchers and policymakers in Canada with expertise in the fields of multimorbidity and ageing. Of the 30 experts invited, 15 (50%) attended the in-person meeting and 14 (47%) responded to the subsequent online survey. Experts agreed that there is no single multimorbidity measure that is suitable for all research studies. They cited a number of factors that need to be considered in selecting a measure for use in a research study including: (1) fit with the study purpose; (2) the conditions included in multimorbidity measures; (3) the role of episodic conditions or diseases; and (4) the role of social factors and other concepts missing in existing approaches.

Conclusions:

The suitability of existing multimorbidity measures for use in a specific research study depends on factors such as the purpose of the study, outcomes examined and preferences of the involved stakeholders. The results of this study suggest that there are areas that require further building out in both the conceptualization and measurement of multimorbidity for the benefit of future clinical, research and policy decisions.