Managing patients with multimorbidity in primary care

Integration of mental health comorbidity in medical specialty programs in 20 countries

METHODS

A systematic analysis was performed of the medical specialization academic programs of 20 different countries to establish which medical specialties take into account mental health issues in the specialty curricular design and which mental health content these programs address. The criteria that were explored in the educational programs include: 1) name of the medical specialties that take into account mental health content in curriculum design, 2) name of the mental health issues addressed by these programs. After independent review and data extraction, paired investigators compared the findings and reached consensus on all discrepancies before the final presentation of the data. Descriptive statistics evaluated the frequency of the data presented.

RESULTS

Internal medicine, family medicine, neurology, pediatrics and geriatrics were the specialties that included mental health topics in their programs. In four countries: Bangladesh, Serbia, the Netherlands and France, 50%of all graduate specialty training programs include mental health content. In ten countries: Germany, Sweden, the United Kingdom, Mexico, Belgium, India, Russia, Canada, Israel and Spain, between 20% and 49% of all graduate specialty training programs include mental health content. In six countries - Brazil, Chile, Colombia, Croatia, Kenya, and the United States-less than 20% of all graduate specialty training programs include mental health content.

DISCUSSION

The proposal that we have made in this article should be taken into account by decision-makers, in order to complement the different postgraduate training programs with mental health issues that are frequently present with other physical symptoms. It is not our intention that the different specialists know how to treat psychiatric comorbidities, but rather pay attention to their existence and implications in the diagnosis, evolution and prognosis of many other diseases. The current fragmentation of medicine into ever finer specialties makes the management of comorbidity ever more difficult: a reorientation of post- graduate training might improve the situation.

Clustering of comorbidities

Within the last decade, clustering of comorbidities has become an increasing health problem on a global scale and will continue to challenge healthcare professionals in the coming years. People with multiple diseases find difficulties in managing their daily lives due to the implications each disease brings; attending and keeping up to date with hospital appointments, being prescribed and taking various medications, the effects of mental health and quality of life, and the impact it has on their families. Most research in clinical trials often exclude individuals with multimorbidity and observational studies mainly focus on single disease outcomes, therefore there is an opportunity to encourage future research in an area which could help prevent further cases and improve the lives of those already living with multimorbidity. This review aims to summarise the rising prevalence and most common clusters, highlight the challenges faced in healthcare, and explore ways to improve future research.

GLP-1 based therapies and disease course of inflammatory bowel disease

BACKGROUND

The disease course of inflammatory bowel disease (IBD) following treatment with glucagon-like peptide (GLP)-1 based therapies is unclear. The aim of this study was to examine the disease course of IBD in patients treated with GLP-1 based therapies compared with treatment with other antidiabetics.

METHODS

Using nationwide Danish registries, we identified patients with IBD and type 2 diabetes who received antidiabetic treatment between 1 January 2007 and 31 March 2019. The primary outcome was a composite of the need for oral corticosteroids, tumour necrosis factor-α inhibitors, IBD-related hospitalisation, or IBD-related surgery. In the setting of a new-user active comparator design, we used Poisson regression to estimate incidence rate ratios (IRR) comparing treatment with GLP-1 receptor agonists and dipeptidyl peptidase (DPP)-4 inhibitors with other antidiabetic therapies. The analyses were adjusted for age, sex, calendar year, IBD severity, and metformin use.

FINDINGS

We identified 3751 patients with a diagnosis of IBD and type 2 diabetes and with a prescription of an antidiabetic drug (GLP-1 receptor agonists/DPP-4 inhibitors: 982 patients; other antidiabetic treatment: 2769 patients). The adjusted IRR of the composite outcome was 0·52 (95% CI: 0·42-0·65) for patients exposed to GLP-1 receptor agonists/DPP-4 inhibitors compared with patients exposed to other antidiabetics.

INTERPRETATION

In patients with IBD and type 2 diabetes, we observed a lower risk of adverse clinical events amongst patients treated with GLP-1 based therapies compared with treatment with other antidiabetics. These findings suggest that treatment with GLP-1 based therapies may improve the disease course of IBD.

Medical costs and out-of-pocket expenditures associated with multimorbidity in China: quantile regression analysis

Objective

Multimorbidity is a growing challenge in low-income and middle-income countries. This study investigates the effects of multimorbidity on annual medical costs and the out-of-pocket expenditures (OOPEs) along the cost distribution.

Methods

Data from the nationally representative China Health and Retirement Longitudinal Study (CHARLS 2015), including 10 592 participants aged ≥45 years and 15 physical and mental chronic diseases, were used for this nationally representative cross-sectional study. Quantile multivariable regressions were employed to understand variations in the association of chronic disease multimorbidity with medical cost and OOPE.

Results

Overall, 69.5% of middle-aged and elderly Chinese had multimorbidity in 2015. Increased number of chronic diseases was significantly associated with greater health expenditures across every cost quantile groups. The effect of chronic diseases on total medical cost was found to be larger among the upper tail than those in the lower tail of the cost distributions (coefficients 12, 95% CI 6 to 17 for 10th percentile; coefficients 296, 95% CI 71 to 522 for 90th percentile). Annual OOPE also increased with chronic diseases from the 10th percentile to the 90th percentile. Multimorbidity had larger effects on OOPE and was more pronounced at the upper tail of the health expenditure distribution (regression coefficients of 8 and 84 at the 10th percentile and 75th percentile, respectively).

Conclusion

Multimorbidity is associated with escalating healthcare costs in China. Further research is required to understand the impact of multimorbidity across different population groups.

Quality of care for people with multimorbidity: a focus group study with patients and their relatives

BACKGROUND

Prevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients' perspective and match them to a literature-based set of QIs.

METHODS

We conducted eight focus groups with patients with multimorbidity and three focus groups with patients' relatives using a semistructured guide. Data were analysed using Kuckartz's qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI.

RESULTS

We created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants' accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups.

CONCLUSION

We show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity.

TRIAL REGISTRATION NUMBER

German clinical trials registry (DRKS00015718), Pre-Results.

Effect of multimorbidity patterns on the decline in health-related quality of life: a nationwide prospective cohort study in Japan

OBJECTIVES

Longitudinal studies, which consider multimorbidity patterns, are useful for better clarifying the effect of multimorbidity on health-related quality of life (HRQoL) and for identifying the target population with poorer clinical outcomes among patients with multimorbidity. This study aimed to examine the effects of different multimorbidity patterns on the decline in HRQoL.

DESIGN

Nationwide prospective cohort study.

SETTING

Japanese adult residents.

PARTICIPANTS

Residents aged ≥50 years selected by the quota sampling method.

PRIMARY OUTCOME MEASURE

Clinically relevant decline in HRQoL was defined as a 0.50 SD (5-point) decrease in the 36-Item Short Form Health Survey (SF-36) component summary scores for 1 year.

RESULTS

In total, 1211 participants completed the follow-up survey. Among the multimorbidity patterns identified using confirmatory factor analysis, multivariable logistic regression analyses revealed that high cardiovascular/renal/metabolic and malignant/digestive/urologic pattern scores were significantly associated with the clinically relevant decline in SF-36 physical component summary score (adjusted OR (aOR)=1.25, 95% CI: 1.08 to 1.44 and aOR=1.28, 95% CI: 1.04 to 1.58, respectively). High cardiovascular/renal/metabolic pattern score was also significantly associated with the clinically relevant decline in SF-36 role/social component summary score (aOR=1.23, 95% CI: 1.06 to 1.42).

CONCLUSIONS

Our study revealed that multimorbidity patterns have different effects on the clinically relevant decline in HRQoL for 1 year. These findings can be useful in identifying populations at high risk and with poor clinical outcomes among patients with chronic diseases and multimorbidity for efficient resource allocation.

Psychometric properties of Brief Coping Orientation to Problems Experienced in patients with multiple chronic conditions: A preliminary study

BACKGROUND

Multiple chronic conditions (MCCs) are highly prevalent in primary care. Coping is an important psychological factor that influences patients' ability to adapt physically and mentally to MCCs. Testing a reliable and valid psychometric inventory is necessary to identify coping strategies before developing coping-oriented interventions.

PURPOSE

The purpose of this study is to examine the psychometric properties of the Chinese version of the Brief Coping Orientation to Problems Experienced (Brief COPE-CN) inventory in patients with MCCs.

METHOD

This study adopted a cross-sectional design. A convenience sample of 290 Chinese patients with MCCs was recruited from a tertiary hospital in East China. The Brief COPE-CN, sociodemographic characteristics and clinical data were collected using a self-reported questionnaire from November 2017 to May 2018. Factor analysis and reliability analysis were performed.

RESULTS

The mean age of the participants was 58.5 years (range from 23 to 95 years), and approximately half of the participants were female (49.3%). Most participants had two chronic conditions (82.1%) and reported having had MCCs for more than 2 years. The explanatory factor analysis (EFA) identified five factors in the Brief COPE-CN that explained 58.4% of the total variance. The Cronbach's α coefficients ranged from .65 to .85 for the five subscales.

CONCLUSIONS

The psychometric properties of the Brief COPE-CN were acceptable for use with Chinese patients with MCCs. With further evaluation, this instrument may help health-care professionals understand patients' coping and develop coping-based interventions to promote coping in this population.

Multi-morbidity and blood pressure trajectories in hypertensive patients: A multiple landmark cohort study

BACKGROUND

Our knowledge of how to better manage elevated blood pressure (BP) in the presence of comorbidities is limited, in part due to exclusion or underrepresentation of patients with multiple chronic conditions from major clinical trials. We aimed to investigate the burden and types of comorbidities in patients with hypertension and to assess how such comorbidities and other variables affect BP levels over time.

METHODS AND FINDINGS

In this multiple landmark cohort study, we used linked electronic health records from the United Kingdom Clinical Practice Research Datalink (CPRD) to compare systolic blood pressure (SBP) levels in 295,487 patients (51% women) aged 61.5 (SD = 13.1) years with first recorded diagnosis of hypertension between 2000 and 2014, by type and numbers of major comorbidities, from at least 5 years before and up to 10 years after hypertension diagnosis. Time-updated multivariable linear regression analyses showed that the presence of more comorbidities was associated with lower SBP during follow-up. In hypertensive patients without comorbidities, mean SBP at diagnosis and at 10 years were 162.3 mm Hg (95% confidence interval [CI] 162.0 to 162.6) and 140.5 mm Hg (95% CI 140.4 to 140.6), respectively; in hypertensive patients with ≥5 comorbidities, these were 157.3 mm Hg (95% CI 156.9 to 157.6) and 136.8 mm Hg (95% 136.4 to 137.3), respectively. This inverse association between numbers of comorbidities and SBP was not specific to particular types of comorbidities, although associations were stronger in those with preexisting cardiovascular disease. Retrospective analysis of recorded SBP showed that the difference in mean SBP 5 years before diagnosis between those without and with ≥5 comorbidities was -9 mm Hg (95% CI -9.7 to -8.3), suggesting that mean recorded SBP already differed according to the presence of comorbidity before baseline. Within 1 year after the diagnosis, SBP substantially declined, but subsequent SBP changes across comorbidity status were modest, with no evidence of a more rapid decline in those with more or specific types of comorbidities. We identified factors, such as prescriptions of antihypertensive drugs and frequency of healthcare visits, that can explain SBP differences according to numbers or types of comorbidities, but these factors only partly explained the recorded SBP differences. Nevertheless, some limitations have to be considered including the possibility that diagnosis of some conditions may not have been recorded, varying degrees of missing data inherent in analytical datasets extracted from routine health records, and greater measurement errors in clinical measurements taken in routine practices than those taken in well-controlled clinical study settings.

CONCLUSIONS

BP levels at which patients were diagnosed with hypertension varied substantially according to the presence of comorbidities and were lowest in patients with multi-morbidity. Our findings suggest that this early selection bias of hypertension diagnosis at different BP levels was a key determinant of long-term differences in BP by comorbidity status. The lack of a more rapid decline in SBP in those with multi-morbidity provides some reassurance for BP treatment in these high-risk individuals.

Perceived need for treatment and non-utilization of outpatient psychotherapy in old age: two cohorts of a nationwide survey

BEACKGROUND

Older adults with mental health problems may benefit from psychotherapy; however, their perceived need for treatment in relation to rates of non-utilization of outpatient psychotherapy as well as the predisposing, enabling, and need factors proposed by Andersen's Model of Health Care Utilization that account for these differences warrant further investigation.

METHODS

We used two separate cohorts (2014 and 2019) of a weighted nationwide telephone survey in Germany of German-speaking adults with N = 12,197 participants. Across the two cohorts, 12.9% (weighted) reported a perceived need for treatment for mental health problems and were selected for further analyses. Logistic Generalized Estimation Equations (GEE) was applied to model the associations between disposing (age, gender, single habiting, rural residency, general health status), enabling (education, general practitioner visit) non-utilization of psychotherapy (outcome) across cohorts in those with a need for treatment (need factor).

RESULTS

In 2014, 11.8% of 6087 participants reported a perceived need for treatment due to mental health problems. In 2016, the prevalence increased significantly to 14.0% of 6110 participants. Of those who reported a perceived need for treatment, 36.4% in 2014 and 36.9%in 2019 did not see a psychotherapist - where rates of non-utilization of psychotherapy were vastly higher in the oldest age category (59.3/52.5%; 75+) than in the youngest (29.1/10.7%; aged 18-25). Concerning factors associated with non-utilization, multivariate findings indicated participation in the cohort of 2014 (OR 0.94), older age (55-64 OR 1.02, 65-74 OR 1.47, 75+ OR 4.76), male gender (OR 0.83), lower educational status (OR 0.84), rural residency (OR 1.38), single habiting (OR 1.37), and seeing a GP (OR 1.39) to be related with non-utilization of psychotherapy; general health status was not significantly associated with non-utilization when GP contact was included in the model.

CONCLUSION

There is a strong age effect in terms of non-utilization of outpatient psychotherapy. Individual characteristics of both healthcare professionals and patients and structural barriers may add to this picture. Effective strategies to increase psychotherapy rates in those older adults with unmet treatment needs are required.

SymTrak-8 as a Brief Measure for Assessing Symptoms in Older Adults

BACKGROUND

Patient- and caregiver-reported 23-item SymTrak scales were validated for monitoring clinically actionable symptoms and impairments associated with multiple chronic conditions (MCCs) in older adults. Items capture physical and emotional symptoms and impairments in physical and cognitive functioning. An abbreviated SymTrak is desirable when response burden is a concern.

OBJECTIVE

Develop and validate the 8-item SymTrak.

DESIGN AND PARTICIPANTS

Secondary analysis of SymTrak validation study; 600 participants (200 patient-caregiver dyads; 200 patients without an identified caregiver).

MAIN MEASURES

Demographic questions, SymTrak, and Health Utility Index Mark 3 (HUI3).

KEY RESULTS

SymTrak-8 demonstrated good fit to a one-factor model using confirmatory factor analysis (CFA). Concurrent criterion validity was supported by high standardized linear regression coefficients (STB) between baseline SymTrak-8 total score (independent variable) and baseline HUI3 preference-based overall HRQOL utility score (dependent variable; 0 = death, 1 = perfect health), after adjusting for demographics, comorbid conditions, and medications, with strength comparable to SymTrak-23 (STB = - 0.81 and - 0.84, respectively, for SymTrak-8 and SymTrak-23, when patient-reported; and - 0.60 and - 0.62, respectively, when caregiver-reported). Coefficient alpha (0.74; 0.76) and 24-h test-retest reliability (0.83; 0.87) were high for SymTrak-8 for patients and caregivers, respectively. The convergent correlation between brief and parent SymTrak scales was high (0.94). SymTrak-8 demonstrated approximate normality and a linear relationship with SymTrak-23 and HUI3. Importantly, a 3-month change in SymTrak-8 was sensitive to detecting the criterion (3-month reliable change categories; improved, stable, declined in HUI3 overall utility), with results comparable to SymTrak-23.

CONCLUSIONS

SymTrak-8 total score demonstrates internal reliably, test-retest reliability, criterion validity, and sensitivity to change that are comparable to SymTrak-23. Thus, patient- or caregiver-reported SymTrak-8 is a viable option for identifying and monitoring the aggregate effect of symptoms and functional impairments in patients with multimorbidity when response burden is a concern.

Protocol for a mixed methods process evaluation of the LinkMM randomised controlled trial "Use of link workers to provide social prescribing and health and social care coordination for people with complex multimorbidity in socially deprived areas"

Background  Multimorbidity, defined as two or more chronic conditions is increasing in prevalence and is associated with increased health care use, fragmented care and poorer health outcomes. Link workers are non-health or social care professionals who support people to connect with resources in their community to improve their well-being, a process commonly referred to as social prescribing. The use of link workers in primary care may be an effective intervention in helping those with long-term conditions manage their illness and improve health and well-being, but the evidence base in limited. The LinkMM study is a randomised controlled trial of the effectiveness of link workers based in primary care, providing social prescribing and health and social care coordination for people with multimorbidity. The aim of the LinkMM process evaluation is to investigate the implementation of the link worker intervention, mechanisms of impact and influence of the specific context on these, as per the Medical Research Council framework, using quantitative and qualitative methods. Methods  Quantitative data will be gathered from a number of sources including researcher logbooks, participant baseline questionnaires, client management database, and will be analysed using descriptive statistics. Semi structured interviews with participants will investigate their experiences of the intervention. Interviews with link workers, practices and community stakeholders will explore how the intervention was implemented and barriers and facilitators to this. Thematic analysis of interview transcripts will be conducted. Discussion  The process evaluation of the LinkMM trial will provide important information allowing a more in-depth understanding of how the intervention worked and lessons for future wider scale implementation.

Prevalence of multimorbidity in adults with cancer, and associated health service utilization in Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

The majority of people with cancer have at least one other chronic health condition. With each additional chronic disease, the complexity of their care increases, as does the potential for negative outcomes including premature death. In this paper, we describe cancer patients' clinical complexity (i.e., multimorbidity; MMB) in order to inform strategic efforts to improve care and outcomes for people with cancer of all types and commonly occurring chronic diseases.

METHODS

We conducted a population-based, retrospective cohort study of adults diagnosed with cancer between 2003 and 2013 (N = 601,331) identified in Ontario, Canada healthcare administrative data. During a five to 15-year follow-up period (through March 2018), we identified up to 16 co-occurring conditions and patient outcomes for the cohort, including health service utilization and death.

RESULTS

MMB was extremely common, affecting more than 91% of people with cancer. Nearly one quarter (23%) of the population had five or more co-occurring conditions. While we saw no differences in MMB between sexes, MMB prevalence and level increased with age. MMB prevalence and type of co-occurring conditions also varied by cancer type. Overall, MMB was associated with higher rates of health service utilization and mortality, regardless of other patient characteristics, and specific conditions differentially impacted these rates.

CONCLUSIONS

People with cancer are likely to have at least one other chronic medical condition and the presence of MMB negatively affects health service utilization and risk of premature death. These findings can help motivate and inform health system advances to improve care quality and outcomes for people with cancer and MMB.

Rising burden of multimorbidity and related socio-demographic factors: a repeated cross-sectional study of Ontarians

OBJECTIVE

This study aimed to provide population-level data regarding trends in multimorbidity over 13 years.

METHODS

We linked provincial health administrative data in Ontario, Canada, to create 3 cross-sectional panels of residents of any age in 2003, 2009, and 2016 to describe: (i) 13-year trends in multimorbidity prevalence and constellations among residents and across age, sex, and income; and (ii) chronic condition clusters. Multimorbidity was defined as having at least any 2 of 18 selected conditions, and further grouped into levels of 2, 3, 4, or 5 or more conditions. Age-sex standardized multimorbidity prevalence was estimated using the 2009 population as the standard. Clustering was defined using the observed combinations of conditions within levels of multimorbidity.

RESULTS

Standardized prevalence of multimorbidity increased over time (26.5%, 28.8%, and 30.0% across sequential panels), across sex, age, and area-based income. Females, older adults and those living in lower income areas exhibited higher rates in all years. However, multimorbidity increased relatively more among males, younger adults, and those with 4 or 5 or more conditions. We observed numerous and increasing diversity in disease clusters, namely at higher levels of multimorbidity.

CONCLUSION

Our study provides relevant and needed population-based information on the growing burden of multimorbidity, and related socio-demographic risk factors. Multimorbidity is markedly increasing among younger age cohorts. Also, there is an increasing complexity and lack of common clustering patterns at higher multimorbidity levels.

Are we measuring the right function outcomes for older adults in reviews by the Cochrane Musculoskeletal Group?

BACKGROUND

Musculoskeletal conditions are the leading cause of years lived with disability for older adults. Limitations in functional ability affect healthy aging for aging populations worldwide. Thus, it is important to assess effects of interventions on the multiple dimensions of function for older adults.

OBJECTIVES

To assess: (1) which domains of function are assessed in reviews published by the Cochrane Musculoskeletal Group inclusive of older adults, and (2) the extent to which these reviews evaluate effects and/or applicability of findings for older adults.

METHODS

We included all reviews published by the Cochrane Musculoskeletal Review Group after 2015 including participants over the age of 50 (n = 52). We extracted data on how the activities and participation domains of the International Classification of Functioning (ICF) were measured. We assessed the extent to which reviews included methods to evaluate effects across age, according to the framework in the Cochrane Handbook chapter on equity and specific populations.

RESULTS

The median age of participants across reviews was 54 years (range 16-94). ICF domains assessed in reviews, in descending order of frequency, were: domestic life (90%), mobility (89%), self-care (87%), interpersonal interactions and relationships (65%), community, social, and civic life (64%), major life areas (31%), communication (2%), general tasks and demands (0%) and learning and applying knowledge (0%). In evaluating effects across age, the age of participants was described by 73% of reviews and 54% mentioned age in the description of the condition, 21% planned subgroup analysis by age and none were able to conduct this analysis. Only 17% described applicability of results to older people.

CONCLUSIONS

Reviews published by the Cochrane Musculoskeletal Group inclusive of older adults assess most domains of functional ability with the exception of communication, general tasks and knowledge domains. None of these reviews were able to conduct a subgroup analysis across age, indicating a need to improve the consideration of age in both Cochrane reviews as well as in primary studies.

Moving from "let's fix them" to "actually listen": the development of a primary care intervention for mental-physical multimorbidity

Background

Effective person-centred interventions are needed to support people living with mental-physical multimorbidity to achieve better health and wellbeing outcomes. Depression is identified as the most common mental health condition co-occurring with a physical health condition and is the focus of this intervention development study. The aim of this study is to identify the key components needed for an effective intervention based on a clear theoretical foundation, consideration of how motivational interviewing can inform the intervention, clinical guidelines to date, and the insights of primary care nurses.

Methods

A multimethod approach to intervention development involving review and integration of the theoretical principles of Theory of Planned Behavior and the patient-centred clinical skills of motivational interviewing, review of the expert consensus clinical guidelines for multimorbidity, and incorporation of a thematic analysis of group interviews with Australian nurses about their perspectives of what is needed in intervention to support people living with mental-physical multimorbidity.

Results

Three mechanisms emerged from the review of theory, guidelines and practitioner perspective; the intervention needs to actively ‘engage’ patients through the development of a collaborative and empathic relationship, ‘focus’ on the patient’s priorities, and ‘empower’ people to make behaviour change.

Conclusion

The outcome of the present study is a fully described primary care intervention for people living with mental-physical multimorbidity, with a particular focus on people living with depression and a physical health condition. It builds on theory, expert consensus guidelines and clinician perspective, and is to be tested in a clinical trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06307-5.

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment

OBJECTIVES

The study aims to investigate GPs' experiences of how UK COVID-19 policies have affected the management and safety of complex elderly patients, who suffer from multimorbidity, at the primary care level in North West London (NWL).

DESIGN

This is a service evaluation adopting a qualitative approach.

SETTING

Individual semi-structured interviews were conducted between 6 and 22 May 2020, 2 months after the introduction of the UK COVID-19 Action Plan, allowing GPs to adapt to the new changes and reflect on their impact.

PARTICIPANTS

Fourteen GPs working in NWL were interviewed, until data saturation was reached.

OUTCOME MEASURES

The impact of COVID-19 policies on the management and safety of complex elderly patients in primary care from the GPs' perspective.

RESULTS

Participants' average experience was fourteen years working in primary care for the NHS. They stated that COVID-19 policies have affected primary care at three levels, patients' behaviour, work conditions, and clinical practice. GPs reflected on the impact through five major themes; four of which have been adapted from the Safety Attitudes Questionnaire (SAQ) framework, changes in primary care (at the three levels mentioned above), involvement of GPs in policy making, communication and coordination (with patients and in between medical teams), stressors and worries; in addition to a fifth theme to conclude the GPs' suggestions for improvement (either proposed mitigation strategies, or existing actions that showed relative success). A participant used an expression of "infodemic" to describe the GPs' everyday pressure of receiving new policy updates with their subsequent changes in practice.

CONCLUSION

The COVID-19 pandemic has affected all levels of the health system in the UK, particularly primary care. Based on the GPs' perspective in NWL, changes to practice have offered opportunities to maintain safe healthcare as well as possible drawbacks that should be of concern.

Physical multimorbidity and cancer prevalence in the National Health and Nutrition Examination Survey

OBJECTIVES

As the US population ages, both cancer and multimorbidity become more common and pose challenges to the healthcare system. Limited studies have examined the association between multimorbidity and cancer prevalence in the US adult population. To help address this gap, we evaluated the associations between individual chronic conditions and all-site cancer, multimorbidity and all-site cancer, and multimorbidity and site-specific cancers.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Data from 10,731 adults aged 20 years or older who participated in the 2013-2016 National Health and Nutrition Examination Survey were used in our study. Self-reported demographics, smoking status, sedentary behavior, body mass index, individual chronic conditions, multimorbidity status, cancer history, and cancer sites were assessed.

RESULTS

In our sample, the prevalence of having any type of cancer or multimorbidity was 9% (N = 861) and 38% (N = 4248), respectively. Respiratory conditions (multivariable-adjusted odds ratio [OR]: 1.3; 95% confidence interval [CI]: 1.1-1.6) and arthritis (multivariable-adjusted OR: 1.5; 95% CI: 1.2-1.8) were observed to be statistically significantly associated with having all-site cancer after adjusting for potential confounders. Having multimorbidity was also statistically significantly associated with having all-site cancer (multivariable-adjusted OR: 1.4; 95% CI: 1.2-1.7), cervical cancer (multivariable-adjusted OR: 2.6; 95% CI: 1.2-5.4), and bladder cancer (multivariable-adjusted OR: 2.8; 95% CI: 1.0-7.6).

CONCLUSIONS

Multimorbidity was associated with all-site cancer, cervical cancer, and bladder cancer. The present study provides new evidence of the potential relationships between multimorbidity and cancer. Future longitudinal studies are warranted to clarify the temporality and potential biological mechanisms of the associations between multimorbidity and cancer.

Association between Participation Activities, Pain Severity, and Psychological Distress in Old Age: A Population-Based Study of Swedish Older Adults

Although chronic pain is common in old age, previous studies on participation activities in old age seldom consider pain aspects and its related consequences. This study analyses associations between participation activities, pain severity, and psychological distress in an aging population of Swedish older adults (N = 6611). We examined older adults' participation in five common leisure activities using the Multidimensional Pain Inventory (MPI), sociodemographic factors, pain severity, weight status, comorbidities, and pain-related psychological distress (anxiety, depression, insomnia severity, and pain catastrophising). We found that gender, body mass index (BMI) levels, and psychological distress factors significantly affected older adults' participation in leisure activities. Pain severity and multimorbidity were not significantly associated with older adults' participation in leisure activities nor with gender stratification in generalised linear regression models. The potentially modifiable factors, such as high levels of BMI and psychological distress, affected activity participation in men and women differently. Health professionals and social workers should consider gender and target potentially modifiable factors such as weight status and psychological distress to increase older adults' participation in leisure activities.

Preservation of Person-Centered Care Through Videoconferencing for Patient Follow-up During the COVID-19 Pandemic: Case Study of a Multidisciplinary Care Team

Background

The Patient-Centered Team (PACT) focuses on the transitional phase between hospital and primary care for older patients in Northern Norway with complex and long-term needs. PACT emphasizes a person-centered care approach whereby the sharing of power and the patient’s response to “What matters to you?” drive care decisions. However, during the COVID-19 pandemic, videoconferencing was the only option for assessing, planning, coordinating, and performing treatment and care.

Objective

The aim of this study is to report the experience of the PACT multidisciplinary health care team in shifting rapidly from face-to-face care to using videoconferencing for clinical and collaborative services during the initial phase of the COVID-19 pandemic. This study explores how PACT managed to maintain person-centered care under these conditions.

Methods

This case study takes a qualitative approach based on four semistructured focus group interviews carried out in May and June 2020 with 19 PACT members and leaders.

Results

The case study illustrates that videoconferencing is a good solution for many persons with complex and long-term needs and generates new opportunities for interaction between patients and health care personnel. Persons with complex and long-term needs are a heterogeneous group, and for many patients with reduced cognitive capacity or hearing and vision impairment, the use of videoconferencing was challenging and required support from relatives or health care personnel. The study shows that using videoconferencing offered an opportunity to use health care personnel more efficiently, reduce travelling time for patients, and improve the information exchange between health care levels. This suggests that the integration of videoconferencing contributed to the preservation of the person-centered focus on care during the COVID-19 pandemic. There was an overall agreement in PACT that face-to-face care needed to be at the core of the person-centered care approach; the main use of videoconferencing was to support follow-up and coordination.

Conclusions

The COVID-19 pandemic and the rapid adoption of digital care have generated a unique opportunity to continue developing a health service to both preserve and improve the person-centered care approach for persons with complex and long-term needs. This creates demand for overall agreements, including guidelines and procedures for how and when to use videoconferencing to supplement face-to-face treatment and care. Implementing videoconferencing in clinical practice generates a need for systematic training and familiarization with the equipment and technology as well as for an extensive support organization. Videoconferencing can then contribute to better preparing health care services for future scenarios.

Attitudes of General Practitioners Toward Prescription of Mobile Health Apps: Qualitative Study

BACKGROUND

Mobile health (mHealth) apps are a potential means of empowering patients, especially in the case of multimorbidity, which complicates patients' care needs. Previous studies have shown that general practitioners (GPs) have both expectations and concerns regarding patients' use of mHealth apps that could impact their willingness to recommend the apps to patients.

OBJECTIVE

The aim of this qualitative study is to investigate French GPs' attitudes toward the prescription of mHealth apps or devices aimed toward patients by analyzing GPs' perceptions and expectations of mHealth technologies.

METHODS

A total of 36 GPs were interviewed individually (n=20) or in a discussion group (n=16). All participants were in private practice. A qualitative analysis of each interview and focus group was conducted using grounded theory analysis.

RESULTS

Considering the value assigned to mHealth apps by participants and their willingness or resistance to prescribe them, 3 groups were defined based on the attitudes or positions adopted by GPs: digital engagement (favorable attitude; mHealth apps are perceived as additional resources and complementary tools that facilitate the medical work, the follow-up care, and the monitoring of patients; and apps increase patients' compliance and empowerment); patient protection (related to the management of patient care and fear of risks for patients, concerns about patient data privacy and security, doubt about the usefulness for empowering patients, standardization of the medical decision process, overmedicalization, risks for individual freedom, and increasing social inequalities in health); doctor protection (fear of additional tasks and burden, doubt about the actionability of patient-gathered health data, risk for medical liability, dehumanization of the patient-doctor relationship, fear of increased drug prescription, and commodification of patient data).

CONCLUSIONS

A deep understanding of both the expectations and fears of GPs is essential to motivate them to recommend mHealth apps to their patients. The results of this study show the need to provide appropriate education and training to enhance GPs' digital skills. Certification of the apps by an independent authority should be encouraged to reassure physicians about ethical and data security issues. Our results highlight the need to overcome technical issues such as interoperability between data collection and medical records to limit the disruption of medical work because of data flow.

Community assets and multimorbidity: A qualitative scoping study

Little is known of how community assets can play a role in multimorbidity care provision. Using a rapid ethnographic approach, the study explored perceptions of the role of community assets in how multimorbidity is managed within Southwark and Lambeth in Southeast London, England. The scoping work comprised of four micro-studies covering (1) Rapid review of the literature (2) Documentary analysis of publicly available local policy documents (3) Thematic analysis of community stories and (4) Semi-structured stakeholder interviews. The data were analysed using framework thematic analysis. Themes are presented for each of the microstudies. The literature review analysis highlights the role of attitudes and understandings in the management of multiple long-term conditions and the need to move beyond silos in their management. Documentary analysis identifies a resource poor climate, whilst recognising the role of community assets and solution-focussed interventions in the management of multimorbidity. Community patient stories underline the lack of joined up care, and psychosocial issues such as the loss of control and reducing isolation. The stakeholder interview analysis reveals again a sense of disjointed care, the need for holism in the understanding and treatment of multimorbidity, whilst recognising the important role of community-based approaches, beyond the biomedical model. Recommendations stemming from the study's findings are proposed. Upholding access to and resourcing community assets have key practical importance.

AI and Big Data in Healthcare: Towards a More Comprehensive Research Framework for Multimorbidity

Multimorbidity refers to the coexistence of two or more chronic diseases in one person. Therefore, patients with multimorbidity have multiple and special care needs. However, in practice it is difficult to meet these needs because the organizational processes of current healthcare systems tend to be tailored to a single disease. To improve clinical decision making and patient care in multimorbidity, a radical change in the problem-solving approach to medical research and treatment is needed. In addition to the traditional reductionist approach, we propose interactive research supported by artificial intelligence (AI) and advanced big data analytics. Such research approach, when applied to data routinely collected in healthcare settings, provides an integrated platform for research tasks related to multimorbidity. This may include, for example, prediction, correlation, and classification problems based on multiple interaction factors. However, to realize the idea of this paradigm shift in multimorbidity research, the optimization, standardization, and most importantly, the integration of electronic health data into a common national and international research infrastructure is needed. Ultimately, there is a need for the integration and implementation of efficient AI approaches, particularly deep learning, into clinical routine directly within the workflows of the medical professionals.

Understanding patient outcomes to develop a multimorbidity adapted patient-reported outcomes measure: a qualitative description of patient and provider perspectives

Background

Multimorbidity is a complex health situation that requires interventions tailored to patient needs; the outcomes of such interventions are difficult to evaluate. The purpose of this study was to describe the outcomes of patient-centred interventions for people with multimorbidity from the patients’ and healthcare providers’ perspectives.

Methods

This study followed a qualitative descriptive design. Nine patients with multimorbidity and 18 healthcare professionals (nurses, general practitioners, nutritionists, and physical and respiratory therapists), participating in a multimorbidity-adapted intervention in primary care were recruited. Data were collected using semi-structured interviews with 12 open-ended questions. Triangulation of disciplines among interviewers, research team debriefing, data saturation assessment and iterative data collection and analysis ensured a rigorous research process.

Results

Outcome constructs described by participants covered a wide range of themes and were grouped into seven outcome domains: Health Management, Physical Health, Functional Status, Psychosocial Health, Health-related Behaviours, General Health and Health Services. The description of constructs by stakeholders provides valuable insight on how outcomes are experienced and worded by patients.

Conclusion

Participants described a wide range of outcome constructs, which were relevant to and observable by patients and were in line with the clinical reality. The description provides a portrait of multimorbidity-adapted intervention outcomes that are significant for the selection and development of clinical research outcome measures.

Link workers providing social prescribing and health and social care coordination for people with multimorbidity in socially deprived areas (the LinkMM trial): protocol for a pragmatic randomised controlled trial

INTRODUCTION

Link workers are non-health or social care professionals based in primary care who support people to develop and achieve a personalised set of health and social goals by engaging with community resources. Link workers have been piloted in areas of deprivation, but there remains insufficient evidence to support their effectiveness. Multimorbidity is increasing in prevalence, but there are limited evidence-based interventions. This paper presents the protocol for a randomised controlled trial (RCT) that will test the effectiveness of link workers based in general practices in deprived areas in improving health outcomes for people with multimorbidity.

METHODS AND ANALYSIS

The protocol presents the proposed pragmatic RCT, involving 10 general practitioner (GP) practices and 600 patients. Eligible participants will be community dwelling adults with multimorbidity (≥two chronic conditions) identified as being suitable for referral to a practice-based link worker. Following baseline data collection, the patients will be randomised into intervention group that will meet the link worker over a1-month period, or a 'wait list' control that will receive usual GP care. Primary outcomes are health-related quality of life as assessed by EQ-5D-5L and mental health assessed by Hospital Anxiety and Depression Scale. Secondary outcomes are based on the core outcome set for multimorbidity. Data will be collected at baseline and on intervention completion at 1 month using questionnaires self-completed by participants and GP records. Parallel process and economic analyses will be conducted to explore participants' experiences and examine cost-effectiveness of the link worker intervention.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Irish College of General Practitioners Ethics Committee. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN10287737;Pre-results.

Person-centred rhetoric in chronic care: a review of health policies

PURPOSE

The purpose of the paper is to explore how the national, state and organisational health policies in Australia support the implementation of person-centred care in managing chronic care conditions.

DESIGN/METHODOLOGY/APPROACH

A qualitative content analysis was performed regarding the national, state and organisational Queensland Health policies using Elo and Kyngas' (2008) framework.

FINDINGS

Although the person-centred care as an approach is well articulated in health policies, there is still no definitive measure or approach to embedding it into operational services. Complex funding structures and competing priorities of the governments and the health organisations carry the risk that person-centred care as an approach gets lost in translation. Three themes emerged: the patient versus the government; health care delivery versus the political agenda; and health care organisational processes versus the patient.

RESEARCH LIMITATIONS/IMPLICATIONS

Given that person-centred care is the recommended approach for responding to chronic health conditions, further empirical research is required to evaluate how programs designed to deliver person-centred care achieve that objective in practice.

PRACTICAL IMPLICATIONS

This research highlights the complex environment in which the person-centred approach is implemented. Short-term programmes created specifically to focus on person-centred care require the right organisational infrastructure, support and direction. This review demonstrates the need for alignment of policies related to chronic disease management at the broader organisational level.

ORIGINALITY/VALUE

Given the introduction of the nurse navigator program to take up a person-centred care approach, the review of the recent policies was undertaken to understand how they support this initiative.

The impact of nurse practitioner and physician assistant workforce supply on Medicaid-related emergency department visits and hospitalizations

BACKGROUND

New York State (NYS) has approximately 4.7 million Medicaid beneficiaries with 75% having at least one or more chronic conditions. An estimated 10% of Medicaid beneficiaries seek emergency department (ED) services for nonurgent matters. It is unclear if an increased supply of nurse practitioners (NPs) and physician assistants (PAs) impact utilization of ED and subsequent hospitalizations for chronic conditions.

PURPOSE

To investigate the relationship between NYS workforce supply (physicians, NPs, and PAs) and 1) ED use and 2) in-patient hospitalizations for chronically ill Medicaid beneficiaries.

METHODS

A cross-sectional study design was employed by calculating total workforce supply per NYS county and the proportion of physicians, NPs, and PAs per total number of Medicaid beneficiaries. We extracted the frequencies of all NYS Medicaid beneficiary chronic condition-related ED visits and in-patient admissions. Medicaid beneficiaries were considered to have a chronic condition if there was a claim indicating that the beneficiary received a service or treatment for this specific condition. We calculated the proportion of ED visits/beneficiary for each chronic disease category and the proportion of category-specific in-patient hospitalizations per the number of beneficiaries with that diagnosis.

RESULTS

As the NP/beneficiary proportion increased, ED visits for dual and nondual eligible beneficiaries decreased (p = .007; β = -2.218; 95% confidence interval [CI]: -3.79 to -0.644 and p = .04; β = -2.698; 95% CI: -5.268 to -0.127, respectively).

IMPLICATIONS FOR PRACTICE

Counties with a higher proportion of NPs and PAs had significantly lower numbers of ED visits and hospitalizations for Medicaid beneficiaries.

Experiences of older primary care patients with multimorbidity and their caregivers in navigating the healthcare system: A qualitative study protocol

Background

Patients with multimorbidity must bear not just the burden of their illness, but also the burden of treatment which is, in part, induced by their interactions with the healthcare system. The need to shuttle between different healthcare institutions and multiple healthcare providers can make navigating the healthcare system challenging, and this may be even more so for older patients with limited resources and support.

Objectives

Few qualitative studies have explored the experiences of patients with multimorbidity in navigating the healthcare system. This study will explore the experiences of older patients with multimorbidity and their caregivers as they navigate through the healthcare system. We aim to arrive at a better understanding of patient experiences of possible gaps in the continuity of care and how the current system can be modified and adapted to better address the needs of older patients with multimorbidity.

Method

Semi-structured, in-depth interviews will be conducted with purposively sampled older patients with multimorbidity, aged 60 and above seen in primary care, together with their caregivers. Interviews will be transcribed verbatim and analysed by the study team using inductive thematic analysis.

Conclusions

Our study seeks to explore the navigational experiences within the healthcare system for older patients with multimorbidity in an Asian, multi-ethnic society. The findings will be shared with decision-makers in the healthcare setting in order to improve patient care for this population and ultimately maximise their positive health outcomes, and will add to better understanding how the burden of treatment arising from navigational challenges within the healthcare system may be reduced for older patients with multimorbidity.

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. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. 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 to improve outcomes for people with multimorbidity.

OBJECTIVES

To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people 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 and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies.

SELECTION CRITERIA

Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating 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. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types.

MAIN RESULTS

We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited.

AUTHORS' CONCLUSIONS

This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.

Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a cross-sectional cohort study in a care management setting

OBJECTIVES

To assess whether the extent of deviation from chronic disease guideline recommendations is more prominent for specific diseases compared with combined-care across multiple conditions among multimorbid patients, and to examine reasons for this deviation.

DESIGN

A cross-sectional cohort.

SETTING

Multimorbidity care management programme across 11 primary care clinics.

PATIENTS

Patients aged 45-95 years with at least two common chronic conditions, sampled according to being new (≤6 months) or veteran (≥1 year) to the programme.

MAIN OUTCOME MEASURES

Deviation from guideline-recommended care was measured for each patient's relevant conditions, aggregated and stratified across disease groups, calculated as measures of 'disease-specific' guideline deviation and 'combined-care' (all conditions) guideline deviation for: atrial fibrillation, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disorder, depression, diabetes, dyslipidaemia, hypertension and ischaemic heart disease. Combined-care deviation was evaluated for its association with specific diseases. Frequencies of previously derived reason types for deviation (biomedical, patient personal and contextual) were reported by nurse care managers, assessed across diseases and evaluated for their association with specific diseases.

RESULTS

Among 204 patients, disease-specific deviation varied more (from 14.7% to 48.2%) across diseases than combined-care deviation (from 14.7% to 25.6%). Depression and diabetes were significantly associated with more deviation (mean: 6% (95% CI: 2% to 10%) and 5% (95% CI: 2% to 9%), respectively). For some conditions, assessments were among small patient samples. Guideline deviation was often attributed to non-disease-specific reasons, such as physical limitations or care burden, as much as disease-specific reasons, which was reflected in the likelihood for guideline deviation to be due to different types of reasons for some diseases.

CONCLUSIONS

When multimorbid patients are considered in disease groups rather than as 'whole persons', as in many quality of care studies, the cross-cutting factors in their care delivery can be missed. The types of reasons more likely to occur for specific diseases may inform improvement strategies.

TRIAL REGISTRATION NUMBER

NCT01811173; Pre-results.

Comparing Charlson and Elixhauser comorbidity indices with different weightings to predict in-hospital mortality: an analysis of national inpatient data

Background

Understanding how comorbidity measures contribute to patient mortality is essential both to describe patient health status and to adjust for risks and potential confounding. The Charlson and Elixhauser comorbidity indices are well-established for risk adjustment and mortality prediction. Still, a different set of comorbidity weights might improve the prediction of in-hospital mortality. The present study, therefore, aimed to derive a set of new Swiss Elixhauser comorbidity weightings, to validate and compare them against those of the Charlson and Elixhauser-based van Walraven weights in an adult in-patient population-based cohort of general hospitals.

Methods

Retrospective analysis was conducted with routine data of 102 Swiss general hospitals (2012–2017) for 6.09 million inpatient cases. To derive the Swiss weightings for the Elixhauser comorbidity index, we randomly halved the inpatient data and validated the results of part 1 alongside the established weighting systems in part 2, to predict in-hospital mortality. Charlson and van Walraven weights were applied to Charlson and Elixhauser comorbidity indices. Derivation and validation of weightings were conducted with generalized additive models adjusted for age, gender and hospital types.

Results

Overall, the Elixhauser indices, c-statistic with Swiss weights (0.867, 95% CI, 0.865–0.868) and van Walraven’s weights (0.863, 95% CI, 0.862–0.864) had substantial advantage over Charlson’s weights (0.850, 95% CI, 0.849–0.851) and in the derivation and validation groups. The net reclassification improvement of new Swiss weights improved the predictive performance by 1.6% on the Elixhauser-van Walraven and 4.9% on the Charlson weights.

Conclusions

All weightings confirmed previous results with the national dataset. The new Swiss weightings model improved slightly the prediction of in-hospital mortality in Swiss hospitals. The newly derive weights support patient population-based analysis of in-hospital mortality and seek country or specific cohort-based weightings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05999-5.

Urban-rural differences in the impacts of multiple chronic disease on functional limitations and work productivity among Chinese adults

BACKGROUND

Chronic disease multimorbidity has become a major challenge for health systems. While a lot of research has evaluated the direct economic burden of multimorbidity on health care utilization and cost, little attention has been given to the impacts on work productivity and functional limitations, as indirect indicators of disease burden.

OBJECTIVES

This study aims to examine the prevalence of multimorbidity among Chinese adults and its impact on functional disability and work productivity. It also investigates urban-rural differences in these relationships.

METHOD

This study utilized the data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015, including 11,176 participants aged 45 years and older. Multivariable logistic regression models were used to estimate the effect of multimorbidity on functional disability (i.e. ADL: activities of daily life; IADL: instrumental activities of daily life), and work productivity loss due to health problems. Negative binomial regression models were used to assess the association of multimorbidity with sickness absences from agricultural work and employed non-agricultural work.

RESULTS

68.8% of total participants in CHARLS had multimorbidity in China in 2015. Rural residents with multimorbidity reported higher proportions of physical functions and days of sick leave than urban residents. Multimorbidity was positively associated with ADL limitation (odds ratio 1.924, 95% CI 1.656-2.236), IADL limitation (1.522, 1.326-1.748), limited work due to health problems (1.868, 1.601-2.178) and days of sick leave (for agricultural work, incidence rate ratio 1.676, 95% CI 1.390-2.020; for employed non-agricultural work, 2.418, 1.245-4.696). For the rural group, the impact of multimorbidity on functional limitations and work productivity loss (except for early retirement), was less than the urban group.

CONCLUSIONS

Multimorbidity poses significant challenges for functional health and work productivity These have significant negative economic consequences for individuals, the Chinese health system and the society.

Polypharmacy and pattern of medication use in community-dwelling older adults: A systematic review

AIM

To synthesise current study findings on the diseases and the corresponding medications that are potentially associated with polypharmacy in community-dwelling older adults.

BACKGROUND

Polypharmacy is receiving increased attention as a potential problem for the older population. Although several scientific investigations have studied polypharmacy, most of them were carried out in long-term care facilities or mixed settings rather than in community settings solely.

METHODS

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Relevant studies published in the English language in peer-reviewed journals were identified from searches of seven electronic databases for the period of January 2000 through December 2019. Inclusion criteria were: (1) Participants were older adults aged 65 years and older; (2) Polypharmacy was defined by medication count; (3) Medication classes associated with polypharmacy were revealed; (4) Studies were conducted in outpatient care or community settings. The Joanna Briggs Institute critical appraisal checklists for cross-sectional studies and for cohort studies were used to assess the methodological quality.

RESULTS

Ten studies were considered having appropriate and acceptable quality to be reviewed, comprising nine cross-sectional studies and one cohort study. Polypharmacy was most defined as concurrently using five or more medications. Polypharmacy prevalence ranged between 7%-45%. Older age, comorbidity, poor self-perceived health status, limitations in physical activity, history of falls, depression, and pain were positively associated with polypharmacy. The most prevalent medication taken by older adults with polypharmacy was cardiovascular drugs.

CONCLUSIONS

The prevalence of polypharmacy in older adults varying widely may be due to geographical locations, clinical practice guidelines, and polypharmacy definition used.

RELEVANCE TO CLINICAL PRACTICE

Validated measurements to investigate medications associated with polypharmacy are required. How polypharmacy develops over time needs to be investigated in longitudinal studies in order to formulate strategies for reducing polypharmacy.

Comparing the prevalence of multimorbidity using different operational definitions in primary care in Singapore based on a cross-sectional study using retrospective, large administrative data

OBJECTIVES

Multimorbidity is a norm in primary care. A consensus on its operational definition remains lacking especially in the list of chronic conditions considered. This study aimed to compare six different operational definitions of multimorbidity previously reported in the literature for the context of primary care in Singapore.

DESIGN, SETTING AND PARTICIPANTS

This is a retrospective study using anonymised primary care data from a study population of 787 446 patients. We defined multimorbidity as having three or more chronic conditions in an individual. The prevalence of single conditions and multimorbidity with each operational definition was tabulated and standardised prevalence rates (SPRs) were obtained by adjusting for age, sex and ethnicity. We compared the operational definitions based on (1) number of chronic diseases, (2) presence of chronic diseases of high burden and (3) relevance in primary care in Singapore. IBM SPSS V.23 and Microsoft Office Excel 2019 were used for all statistical calculations and analyses.

RESULTS

The SPRs of multimorbidity in primary care in Singapore varied from 5.7% to 17.2%. The lists by Fortin et al, Ge et al, Low et al and Quah et al included at least 12 chronic conditions, the recommended minimal number of conditions. Quah et al considered the highest proportion of chronic diseases (92.3%) of high burden in primary care in Singapore, with SPRs of at least 1.0%. Picco et al and Subramaniam et al considered the fewest number of conditions of high relevance in primary care in Singapore.

CONCLUSIONS

Fortin et al's list of conditions is most suitable for describing multimorbidity in the Singapore primary care setting. Prediabetes and 'physical disability' should be added to Fortin et al's list to augment its comprehensiveness. We propose a similar study methodology be performed in other countries to identify the most suitable operational definition in their own context.

European Forum for Primary Care: Position Paper for Primary Care Mental Health

There is a need for a paradigm shift across mental health in primary care to improve the lives of millions of Europeans. To contribute to this paradigm shift, the European Forum for Primary Care (EFPC-MH) working group for Mental Health, produced a Position Paper for Primary Care Mental Health outlining 14 themes that needed prioritizing. These themes were developed and discussed interactively during the EFPC conferences between 2012 and 2019. The Position Paper on Mental Health gives direction to the necessary improvements over the next ten years. The themes vary from preferable healthcare model to the social determinants highlighting issues such as inequalities. The Statement of Mental Health in Primary Care will be established in cooperation with fellow organizations.

The experience of financial burden for people with multimorbidity: A systematic review of qualitative research

Background

Multimorbidity prevalence is increasing globally. People with multimorbidity have higher health care costs, which can create a financial burden.

Objective

To synthesize qualitative research exploring experience of financial burden for people with multimorbidity.

Search strategy

Six databases were searched in May 2019. A grey literature search and backward and forward citation checking were also conducted.

Inclusion criteria

Studies were included if they used a qualitative design, conducted primary data collection, included references to financial burden and had at least one community‐dwelling adult participant with two or more chronic conditions.

Data extraction and synthesis

Screening and critical appraisal were conducted by two reviewers independently. One reviewer extracted data from the results section; this was checked by a second reviewer. GRADE‐CERQual was used to summarize the certainty of the evidence. Data were analysed using thematic synthesis.

Main results

Forty‐six studies from six continents were included. Four themes were generated: the high costs people with multimorbidity experience, the coping strategies they use to manage these costs, and the negative effect of both these on their well‐being. Health insurance and government supports determine the manageability and level of costs experienced.

Discussion

Financial burden has a negative effect on people with multimorbidity. Continuity of care and an awareness of the impact of financial burden of multimorbidity amongst policymakers and health care providers may partially address the issue.

Patient or public contribution

Results were presented to a panel of people with multimorbidity to check whether the language and themes ‘resonated’ with their experiences.

Mixed Methods Evaluation of Reasons Why Care Deviates From Clinical Guidelines Among Patients With Multimorbidity

Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients' specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.

Polypharmacy is a risk factor for hospital admission due to a fall: evidence from the English Longitudinal Study of Ageing

Background

Falls amongst older people are common; however, around 40% of falls could be preventable. Medications are known to increase the risk of falls in older adults. The debate about reducing the number of prescribed medications remains controversial, and more evidence is needed to understand the relationship between polypharmacy and fall-related hospital admissions. We examined the effect of polypharmacy on hospitalization due to a fall, using a large nationally representative sample of older adults.

Methods

Data from the English Longitudinal Study of Ageing (ELSA) were used. We included 6220 participants aged 50+ with valid data collected between 2012 and 2018.The main outcome measure was hospital admission due to a fall. Polypharmacy -the number of long-term prescription drugs- was the main exposure coded as: no medications, 1–4 medications, 5–9 medications (polypharmacy) and 10+ medications (heightened polypharmacy). Competing-risk regression analysis was used (with death as a potential competing risk), adjusted for common confounders, including multi-morbidity and fall risk-increasing drugs.

Results

The prevalence of people admitted to hospital due to a fall increased according to the number of medications taken, from 1.5% of falls for people reporting no medications, to 4.7% of falls among those taking 1–4 medications, 7.9% of falls among those with polypharmacy and 14.8% among those reporting heightened polypharmacy. Fully adjusted SHRs for hospitalization due to a fall among people who reported taking 1–4 medications, polypharmacy and heightened polypharmacy were 1.79 (1.18; 2.71), 1.75 (1.04; 2.95), and 3.19 (1.61; 6.32) respectively, compared with people who were not taking medications.

Conclusions

The risk of hospitalization due to a fall increased with polypharmacy. It is suggested that prescriptions in older people should be revised on a regular basis, and that the number of medications prescribed be kept to a minimum, in order to reduce the risk of fall-related hospital admissions.

Effectiveness of link workers providing social prescribing on health outcomes and costs for adult patients in primary care and community settings. A protocol for a systematic review of the literature

Introduction: The use of link workers for social prescribing and health and social care coordination is increasing, but there is insufficient data to demonstrate their effectiveness or for whom they work best. Multimorbidity is increasing in prevalence and affects those living in deprived areas ten years earlier than affluent areas. This systematic review aims to examine the evidence for the effectiveness and costs of link workers in improving health outcomes. We will also look for evidence for the use of link workers specifically for people living with multimorbidity and in deprived areas. Methods: Databases of published and grey literature will be searched for randomised and non-randomised controlled trials examining use of link workers based in primary care for community dwelling adults compared to usual care. Primary outcomes will be health related quality of life and mental health. Data on costs will be extracted. Studies will be selected for inclusion by title and abstract review by two reviewers. A Preferred Reporting Items for Systematic Reviews (PRISMA) flow diagram will document the selection process. A standardised form will be used to extract data. Data quality will be assessed using the Cochrane Risk of Bias tool for randomised controlled trials, a narrative synthesis will be completed and the GRADE assessment tool used to comment on evidence quality. A meta-analysis of effect size of primary outcomes and subgroup analysis for multimorbidity and social deprivation will be performed if there are sufficient comparable data. Conclusion: This systematic review will give an important overview of the evidence for the use of link workers providing social prescribing and health and social care coordination in primary care. This will help inform intervention development and guide policy makers on whether these interventions are cost effective and which groups stand to benefit most. Prospero registration: CRD42019134737 (04/07/2019).

"Standing on common ground" - a qualitative study of self-management support for patients with multimorbidity in primary health care

BACKGROUND

Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals', patients', and family caregivers' perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management.

METHODS

A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants (20 physicians, 3 registered nurses, 12 patients, and 7 family caregivers) were interviewed using focus group interviews (PHC professionals), pair interviews (patients and family caregivers), and individual interviews (registered nurses, patients, and family caregivers). The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis.

RESULTS

The main theme that emerged was "Standing on common ground enables individualized support." To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients' self-management, as well as patients' self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals.

CONCLUSION

Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients' self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients' inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.

Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial

Background

Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients.

Methods

This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures.

Results

Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures.

Conclusion

Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success.

Trial registration

Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014.

The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01870-8.

Are the needs of people with multiple long-term conditions being met? Evidence from the 2018 General Practice Patient Survey

OBJECTIVES

To investigate individual, practice and area level variation in patient-reported unmet need among those with long-term conditions, in the context of general practice (GP) appointments and support from community-based services in England.

DESIGN

Cross-sectional study using data from 199 150 survey responses.

SETTING

Primary care and community-based services.

PARTICIPANTS

Respondents to the 2018 English General Practice Patient Survey with at least one long-term condition.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the levels of unmet need in GP and local services among patients with multiple long-term conditions. Secondary outcomes were the proportion of variation explained by practice and area-level factors.

RESULTS

There was no relationship between needs being fully met in patients' last practice appointment and number of long-term conditions once sociodemographic characteristics and health status were taken into account (5+conditions-OR=1.04, 95% CI 0.99 to 1.09), but there was a relationship for having enough support from local services to manage conditions (5+conditions-OR=0.84, 95% CI 0.80 to 0.88). Patients with multimorbidity that were younger, non-white or frail were less likely to have their needs fully met, both in GP and from local services. Differences between practices and local authorities explained minimal variation in unmet need.

CONCLUSIONS

Levels of unmet need are high, particularly for support from community services to manage multiple conditions. Patients who could be targeted for support include people who feel socially isolated, and those who have difficulties with their day-to-day living. Younger patients and certain ethnic groups with multimorbidity are also more likely to have unmet needs. Increased personalisation and coordination of care among these groups may help in addressing their needs.

Evaluating a cardiovascular disease risk management care continuum within a learning healthcare system: a prospective cohort study

BACKGROUND

Many patients now present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care.

AIM

To evaluate cardiovascular risk management (CVRM) via linkage of health data sources, as an example of a multidisciplinary continuum within a learning healthcare system (LHS).

DESIGN & SETTING

In this prospective cohort study, data were linked from the Utrecht Cardiovascular Cohort (UCC) to the Julius General Practitioners' Network (JGPN) database. UCC offers structured CVRM at referral to the University Medical Centre (UMC) Utrecht. JGPN consists of electronic health record (EHR) data from referring GPs.

METHOD

The cardiovascular risk factors were extracted for each patient 13 months before referral (JGPN), at UCC inclusion, and during 12 months follow-up (JGPN). The following areas were assessed: registration of risk factors; detection of risk factor(s) requiring treatment at UCC; communication of risk factors and actionable suggestions from the specialist to the GP; and change of management during follow-up.

RESULTS

In 52% of patients, ≥1 risk factors were registered (that is, extractable from structured fields within routine care health records) before UCC. In 12%-72% of patients, risk factor(s) existed that required (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients, at least one risk factor was registered after UCC. Change in management in GP records was seen in 21%-58% of them.

CONCLUSION

Evaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.

A bibliometric analysis of multimorbidity from 2005 to 2019

Context:

Multimorbidity is frequently seen in primary care. We aimed to identify and analyze publications on multimorbidity, including those that most influenced this field.

Method:

A bibliometric analysis of publications from 2005 to 2019 in the PubMed database containing “multimorbidity” or “multi-morbidity” identified with the tool iCite. We analyzed the number of publications, total citations, the article-level metric Relative Citation Ratio (RCR), type of study, and journals with the most cited articles.

Results:

The number of publications using “multimorbidity” has continuously increased since 2005 (2005–2009: 138; 2010–2014: 823; 2015–2019: 3068). The median number of total citations per article was 3. The median RCR was 1.04. Articles with RCR at or above the 97th percentile (RCR = 7.43) were analyzed in detail (n = 104). In 34 publications of this subgroup (33%), the word multimorbidity was used but was not the subject of study. The remaining top 70 publications included 32 observational studies, 22 reviews, five guideline statements, three analysis papers, two randomized trials, three qualitative studies, two measurement development reports, and one conceptual framework development report. The publications were produced by authors from 32 countries. They were published in 37 different journals, ranging from one to four articles in the same journal.

Conclusions:

We found a continuous increase in the number of publications about multimorbidity since 2005. However, our study suggests that the numbers should be considered only a general trend because multimorbidity was not the main subject in 33% of publications in a subgroup of 104 analyzed in detail.

Potentially inappropriate medication and attitudes of older adults towards deprescribing

INTRODUCTION

Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe.

METHOD

We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness.

RESULTS

Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81).

CONCLUSION

The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.

Self-management strategies and comorbidities in chronic disease patients: associations with quality of life and depression

Self-management strategies are essential for improving prognosis in chronic illnesses. This study aimed to investigate the association between comorbidity and self-management strategies. A total of 700 patients with one or more chronic diseases including diabetes, dyslipidemia, hypertension, osteoporosis, chronic lung disease, chronic kidney disease and arthritis were enrolled. A questionnaire including the Smart Management Strategy for Health Assessment Tool Short Form (SAT), the Short Form-12, the McGill Quality of Life questionnaire, and the Patient Health Questionnaire-9 was administered to participants. The trend of each SAT according to number of comorbidities was evaluated, and the difference in quality of life and depression according to self-management strategies was examined in the model classified by the number of diseases. Self-management strategy scores tended to decrease as the number of comorbidities increased from one to four (p-value: 0.001 to 0.008). Regardless of the number of comorbidities, the MQOL score was higher in the good self-management strategy group (p: <0.001 to 0.016). The prevalence of mild depression was higher in patients with low self-management strategy, but the differences were not significant. Based on these findings, self-management strategies should be evaluated multidimensionally, and patients should be encouraged to develop effective self-management strategies to manage multiple chronic diseases.

Protocol for a scoping review to understand what is known about how GPs make decisions with, for and on behalf of patients who lack capacity

INTRODUCTION

General Practitioners (GPs) and allied healthcare professionals working in primary care are regularly required to make decisions with, for and on behalf of patients who lack capacity. In England and Wales, these decisions are made for incapacitated adult patients under the Mental Capacity Act 2005, which primarily requires that decisions are made in the patient's 'best interests'. Regarding children, decisions are also made in their best interests but are done so under the Children Act 1989, which places paramount importance on the welfare of the child. Decisions for children are usually made by parents, but a GP may become involved if he or she feels a parent is not acting in the best interests of the child. Internationally, including elsewhere in the UK, different approaches are taken. We hypothesise that, despite the legislation and professional guidelines, there are many different approaches taken by GPs and allied healthcare professionals in England and Wales when making these complex decisions with, for and on behalf of patients who lack capacity. To better understand what is known about how these decisions are made, we plan to undertake a scoping review and directed content analysis of the literature. While the majority of decisions made in primary care are made by GPs, for completeness, this review will include all allied healthcare professionals working in primary care.

METHODS AND ANALYSIS

To ensure a wide breadth of literature is captured, a scoping review will be undertaken as described by Arksey and O'Malley (2005). A five-stage approach will be taken when conducting this review: (1) identifying the research question; (2) identifying relevant papers; (3) study selection; (4) data extraction and (5) summarising and synthesis. The final stage will include a directed content analysis of the data to help establish the cross-cutting themes.

ETHICS AND DISSEMINATION

The scoping review will be disseminated through conferences and peer-reviewed publications. This scoping review is the first (mapping) phase in a proposed larger study to explore how GPs make decisions with, for and on behalf of those who lack capacity. Qualitative research with GPs, patients and their families will follow, before all the results are synthesised using an 'empirical bioethics' methodology.

Patient Preferences in Surveillance: Findings From a Discrete Choice Experiment in the "My Follow-Up" Study

OBJECTIVES

Approximately 800 000 people die globally from colorectal cancer (CRC) every year. Prevention programs promote early detection, but for people with precancerous lesions, tailoring surveillance to include lifestyle-change programs could enhance prevention potential and improve outcomes.

METHODS

Those with intermediate or high-risk polyps removed during CRC screening colonoscopy within the Northern Ireland CRC Screening Programme were invited to complete 8 discrete choice questions about tailored surveillance, analyzed using random-parameters logit and a latent class modeling approach.

RESULTS

A total of 231 participants (77% male) self-reported comorbid hypertension (53%), high cholesterol (48%), and mean body mass index of 28.7 (overweight). Although 39% of participants were unaware of their CRC risk status, 30.9% indicated they were already making changes to reduce their risk. Although all respondents were significantly risk- and cost-averse, the latent class analysis identified 3 segments (classes): 1. Class 1 (26.8%) significantly favored phone or email support for a lifestyle change, a 17-month testing interval, and noninvasive testing. 2. Class 2 (48.4%) preferred the status quo. 3. Class 3 (24.7%) significantly favored further risk reduction and invasive testing.

CONCLUSIONS

This is the first documented preference study focusing on postpolypectomy surveillance offering lifestyle interventions. Although current care is strongly preferred, risk and cost aversion are important for participants. Latent class analysis shows that some respondents are willing to change diet and lifestyle behaviors, reflecting a teachable moment, with opportunities to personalize and optimize surveillance. Significant discordance between perceived and known risk of recurrence and limited recall of risk information provided within current practice suggest necessary improvements to surveillance programs.