301
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Gawande R, Pine E, Griswold T, Creedon T, Vallejo Z, Rosenbaum E, Lozada A, Schuman-Olivier Z. Insurance-Reimbursable Mindfulness for Safety-Net Primary Care Patients: A Pilot Randomized Controlled Trial. Mindfulness (N Y) 2019; 10:1744-1759. [PMID: 32042349 DOI: 10.1007/s12671-019-01116-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives Mindfulness is effective for reducing anxiety and depression and increasing chronic disease self-management. An accessible, insurance-reimbursable model for implementation in patient-centered medical homes within US healthcare systems has promise for patients with multi-morbid conditions. Clarifying both the dose needed to impact anxiety, depression and self-management, and the design requirements for accessible primary care implementation, is essential. Methods We tested feasibility, acceptability, and effectiveness of Mindfulness Training for Primary Care (MTPC), an 8-week, referral-based, insurance-reimbursable mindfulness program integrated within primary care, compared with a Low-Dose Comparator (LDC), consisting of a 60-minute mindfulness introduction plus referral to community and digital resources. Outcome measures were assessed at baseline and 8 weeks. MTPC is trauma-informed, incorporates mindfulness-oriented behavior change skills, and is designed to target anxiety, depression, stress, and chronic illness selfmanagement. Participants schedule a PCP visit to co-create a self-management action plan during week 6. Results Primary care providers (PCP) referred 344 patients over 14 months. Eighty-one participants with DSM-V anxiety disorders, depressive disorders, trauma- and stress-related disorders participated in this pilot randomized-controlled comparative effectiveness trial [MTPC (n=54); LDC (n=27)]. These data suggest that MTPC was more effective than LDC for reducing anxiety (p=0.01), enhancing mindfulness (p=0.02) and self-compassion (p=0.001), and for catalyzing selfmanagement behavior change through action plan initiation (OR=4.34, p=0.03). Conclusions MTPC was successfully integrated into a health system, was billed to insurance, and was acceptable to a diverse primary care population. Replication with a larger study and further accessibility adaptations are needed to confirm and expand these pilot results.
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Affiliation(s)
- Richa Gawande
- Harvard Medical School, Department of Psychiatry.,Cambridge Health Alliance
| | | | - Todd Griswold
- Harvard Medical School, Department of Psychiatry.,Cambridge Health Alliance
| | - Timothy Creedon
- The Heller School for Social Policy and Management, Brandeis University.,IBM Watson Health
| | - Zayda Vallejo
- Cambridge Health Alliance.,The Heller School for Social Policy and Management, Brandeis University
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302
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Fletcher S, Chondros P, Palmer VJ, Chatterton ML, Spittal MJ, Mihalopoulos C, Wood A, Harris M, Burgess P, Bassilios B, Pirkis J, Gunn J. Link-me: Protocol for a randomised controlled trial of a systematic approach to stepped mental health care in primary care. Contemp Clin Trials 2019; 78:63-75. [PMID: 30593884 DOI: 10.1016/j.cct.2018.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/12/2018] [Accepted: 12/25/2018] [Indexed: 11/16/2022]
Abstract
Primary care in Australia is undergoing significant reform, with a particular focus on cost-effective tailoring of mental health care to individual needs. Link-me is testing whether a patient-completed Decision Support Tool (DST), which predicts future severity of depression and anxiety symptoms and triages individuals into care accordingly, is clinically effective and cost-effective relative to usual care. The trial is set in general practices, with English-speaking patients invited to complete eligibility screening in their general practitioner's waiting room. Eligible and consenting patients will then complete the DST assessment and are randomised and stratified according to predicted symptom severity. Participants allocated to the intervention arm will receive feedback on DST responses, select treatment priorities, assess motivation to change, and receive a severity-matched treatment recommendation (information about and links to low intensity services for those with mild symptoms, or assistance from a specially trained health professional (care navigator) for those with severe symptoms). All patients allocated to the comparison arm will receive usual GP care plus attention control. Primary (psychological distress) and secondary (depression, anxiety, quality of life, days out of role) outcomes will be assessed at 6 and 12 months. Differences in outcome means between trial arms both across and within symptom severity group will be examined using intention-to-treat analyses. Within trial and modelled economic evaluations will be conducted to determine the value for money of credentials of Link-me. Findings will be reported to the Federal Government to inform how mental health services across Australia are funded and delivered in the future.
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Affiliation(s)
- Susan Fletcher
- The Department of General Practice, Melbourne Medical School, University of Melbourne.
| | - Patty Chondros
- The Department of General Practice, Melbourne Medical School, University of Melbourne
| | - Victoria J Palmer
- The Department of General Practice, Melbourne Medical School, University of Melbourne
| | | | - Matthew J Spittal
- Melbourne School of Population and Global Health, University of Melbourne
| | | | - Anna Wood
- The Department of General Practice, Melbourne Medical School, University of Melbourne
| | | | | | - Bridget Bassilios
- Melbourne School of Population and Global Health, University of Melbourne
| | - Jane Pirkis
- Melbourne School of Population and Global Health, University of Melbourne
| | - Jane Gunn
- The Department of General Practice, Melbourne Medical School, University of Melbourne
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303
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Muth C, Blom JW, Smith SM, Johnell K, Gonzalez-Gonzalez AI, Nguyen TS, Brueckle MS, Cesari M, Tinetti ME, Valderas JM. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. J Intern Med 2019; 285:272-288. [PMID: 30357955 DOI: 10.1111/joim.12842] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complexity and heterogeneity of patients with multimorbidity and polypharmacy renders traditional disease-oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have been developed on multimorbidity or polypharmacy. To systematically analyse their recommendations, we conducted a systematic guideline review using the Ariadne principles for managing multimorbidity as analytical framework. The information synthesis included a multistep consensus process involving 18 multidisciplinary experts from seven countries. We included eight guidelines (four each on multimorbidity and polypharmacy) and extracted about 250 recommendations. The guideline addressed (i) the identification of the target population (risk factors); (ii) the assessment of interacting conditions and treatments: medical history, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providers highlighting informational continuity; (iii) the need to incorporate patient preferences and goal setting: eliciting preferences and expectations, the process of shared decision making in relation to treatment options and the level of involvement of patients and carers; (iv) individualized management: guiding principles on optimization of treatment benefits over possible harms, treatment communication and the information content of medication/care plans; (v) monitoring and follow-up: strategies in care planning, self-management and medication-related aspects, communication with patients including safety instructions and adherence, coordination of care regarding referral and discharge management, medication appropriateness and safety concerns. The spectrum of clinical and self-management issues varied from guiding principles to specific recommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proven effectiveness and decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. An integrated approach to both multimorbidity and polypharmacy should be considered in future guidelines.
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Affiliation(s)
- C Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - J W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S M Smith
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - K Johnell
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - A I Gonzalez-Gonzalez
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - T S Nguyen
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - M-S Brueckle
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - M Cesari
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | - M E Tinetti
- Division of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - J M Valderas
- Health Services and Policy Research Group, APEx Collaboration for Academic Primary Care, NIHR PenCLAHRC, University of Exeter Medical School, Exeter, UK
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304
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Tactics of Safe Management of Comorbid Patients with Osteoarthritis in the Practice of a Family Doctor: What is the Choice? Fam Med 2019. [DOI: 10.30841/2307-5112.1.2019.172068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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305
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Peters M, Potter CM, Kelly L, Fitzpatrick R. Self-efficacy and health-related quality of life: a cross-sectional study of primary care patients with multi-morbidity. Health Qual Life Outcomes 2019; 17:37. [PMID: 30764833 PMCID: PMC6376655 DOI: 10.1186/s12955-019-1103-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Multi-morbidity in chronic long-term conditions is a major concern for health services. Self-management in concert with clinical care forms part of the effective management of multi-morbidity. Self-efficacy is a mechanism through which self-management can be achieved. Quality of life is adversely impacted by multi-morbidity but could be improved by effective self-management. This study examines the relationship between self-efficacy and quality of life in primary care patients with multi-morbidity. METHODS A cross-sectional survey was conducted with primary care patients in England. Potential participants were mailed a questionnaire containing quality of life measures (the EQ-5D-5L and the Long-Term Conditions Questionnaire (LTCQ)), the Disease Burden Impact Scale (DBIS) and the Self-efficacy for Managing Chronic Disease Scale. Descriptive statistics, analysis of variance and linear regression analyses were conducted to examine the relationship between quality of life (dependent variable), self-efficacy, and demographic and disease-related variables. RESULTS The 848 participants living with multi-morbidity reported a mean of 6.46 (SD 3.49) chronic long-term conditions, with the mean number of physical conditions 5.99 (SD 3.34) and mental health conditions 0.47 (SD 0.66). The mean scores were 15.45 (SD 12.00) for disease burden, 0.69 (SD 0.28) for the EQ-5D-5L, 65.44 (SD 23.66) for the EQ-VAS, and 69.31 (SD 21.77) for the LTCQ. The mean self-efficacy score was 6.69 (SD 2.53). The regression models were all significant at p < 0.001 (adjusted R2 > 0.70). Significant factors in all models were self-efficacy, disease burden and being permanently sick or disabled. Other factors varied between models, with the most notable being the presence of a mental health condition in the LTCQ model. CONCLUSIONS Multi-morbid primary care patients with lower self-efficacy and higher disease burden have lower quality of life. Awareness of self-efficacy levels among patients with multi-morbidity may help health professionals identify patients who are in need of enhanced self-management support. Providing self-management support for chronic disease has been hailed as a hallmark of good care. Higher self-efficacy may lead to enhanced quality of life in multi-morbidity.
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Affiliation(s)
- Michele Peters
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
| | - Caroline M. Potter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
| | - Laura Kelly
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
| | - Ray Fitzpatrick
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
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306
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A descriptive, cross-sectional study examining treatment burden in people living with HIV. Appl Nurs Res 2019; 46:31-36. [PMID: 30853073 DOI: 10.1016/j.apnr.2019.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/28/2018] [Accepted: 02/10/2019] [Indexed: 12/20/2022]
Abstract
AIM (1) describe the percentage of people living with HIV (PLWH) experiencing high levels of treatment burden who are at risk for self-management non-adherence, and (2) examine the relationship between known antecedent correlates (the number of chronic conditions, social capital, and age) of self-management and treatment burden while controlling for sample socio-demographics. BACKGROUND Chronic condition self-management is key to maintaining optimal health in the aging population of PLWH. Despite the efforts of providers, patients, and caregivers, self-management non-adherence is still a factor contributing to poor chronic condition self-management and subsequent poor health outcomes. Recent research has identified treatment burden as a risk factor of poor chronic disease self-management adherence. METHOD Cross-sectional, secondary analysis of a sub-sample of 103 community dwelling, men and women diagnosed with HIV/AIDS derived from a larger parent study examining physical activity patterns in PLWH. RESULTS Participants reported an overall low level of treatment burden (M = 22.84; SD = 24.57), although 16% (n = 16) of the sample indicated experiencing high treatment burden. The number of chronic conditions (r = 0.25; p ≤ .01) and social capital (r = -0.19; p = .03) were significantly correlated with treatment burden. Multivariate analysis testing known antecedent correlates of treatment burden was statistically significant (p < .05), but only explained 8% of treatment burden's variance. CONCLUSION Findings have implications for nursing care of PLWH demonstrating a subset of PLWH experience high treatment burden related to chronic condition self-management. Findings also identify characteristics of PLWH who may be at high risk for treatment burden and subsequent self-management non-adherence.
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307
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Mitsutake S, Ishizaki T, Teramoto C, Shimizu S, Ito H. Patterns of Co-Occurrence of Chronic Disease Among Older Adults in Tokyo, Japan. Prev Chronic Dis 2019; 16:E11. [PMID: 30703000 PMCID: PMC6362710 DOI: 10.5888/pcd16.180170] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Multimorbidity, the co-occurrence of 2 or more disorders in a patient, can complicate treatment planning and affect health outcomes. Improvements in prevention and management strategies for patients with 3 or more or more co-occurring chronic diseases requires an understanding of the epidemiology of common 3-way disease patterns and their interactions. Our study aimed to describe these common 3-way disease patterns and examine the factors associated with the co-occurrence of 3 or more diseases in elderly Japanese patients. Methods We included all Japanese citizens aged 75 or older living in Tokyo who used medical care between September 2013 and August 2014 (N = 1,311,116) in our analysis. The 15 most common 3-way patterns of 22 target diseases according to sex and age were identified from among all possible combinations by using an anonymized medical claims database. We examined the associations of sociodemographic characteristics and health care use with the presence of 1 or 2 co-occurring diseases and 3 or more co-occurring diseases by using multinomial logistic regression. Results Approximately 65% of patients had 3 or more co-occurring diseases. The most common 3-way pattern was hypertension, coronary heart disease, and peptic ulcer disease in men (12.4%) and hypertension, dyslipidemia, and peptic ulcer disease in women (12.8%). The prevalence of 3 or more diseases was positively associated with men, patients aged 85 to 90, the use of home medical care services, the number of outpatient facilities visited, and hospital admissions. Conclusion The common 3-way disease patterns and multimorbidity factors identified in our study may facilitate the recognition of high-risk patients and support the development of clinical guidelines for multimorbidity.
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Affiliation(s)
- Seigo Mitsutake
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015 Japan.
| | - Chie Teramoto
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Hideki Ito
- Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
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308
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Larsson B, Dragioti E, Gerdle B, Björk J. Positive psychological well-being predicts lower severe pain in the general population: a 2-year follow-up study of the SwePain cohort. Ann Gen Psychiatry 2019; 18:8. [PMID: 31164910 PMCID: PMC6543656 DOI: 10.1186/s12991-019-0231-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/17/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Positive psychology indicators like well-being and life satisfaction may play a pivotal role in pain-related outcomes. In this study, we aimed to examine the prospective associations of positive well-being and life satisfaction with pain severity. METHODS AND SUBJECTS This longitudinal study, with a follow-up of 2 years, included 9361 participants (4266 males, 5095 females; mean age: 52.5 years; SD: 17.5) without and with chronic pain (CP) at baseline. All analyses were stratified by the two sub-cohorts-participants without CP (sub-cohort 1) and participants with CP (sub-cohort 2) at baseline. The predictive associations, assessed using ordinal regression in a Generalized Linear Model, were adjusted for baseline potential confounders and reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). RESULTS After adjustments, in sub-cohort 1 positive well-being at baseline was associated with lower severe pain at follow-up compared to participants with severe distress (OR: 0.64; 95% CI 0.49-0.84; p < 0.001). In sub-cohort 2, both positive well-being and life satisfaction at baseline were associated with lower severe pain at follow-up compared to participants with severe distress and not satisfied with life (OR: 0.80; 95% CI 0.65-0.98; p = 0.031 and OR: 0.82; 95% CI 0.69-0.96; p = 0.014, respectively). CONCLUSIONS Positive well-being is predictive of lower pain severity both among participants without and with CP at baseline, whereas life satisfaction was found predictive of lower pain severity only for subjects with CP. Future research should emphasize implementing treatments associated with promoting and maintaining positive well-being and life satisfaction in patients who suffer from chronic pain and in risk populations.
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Affiliation(s)
- Britt Larsson
- 1Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Elena Dragioti
- 1Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Björn Gerdle
- 1Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jonas Björk
- 2Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.,3Clinical Studies Sweden, Forum South, Skåne University Hospital Lund, Lund, Sweden
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309
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Wastesson JW, Morin L, Tan ECK, Johnell K. An update on the clinical consequences of polypharmacy in older adults: a narrative review. Expert Opin Drug Saf 2018; 17:1185-1196. [PMID: 30540223 DOI: 10.1080/14740338.2018.1546841] [Citation(s) in RCA: 271] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Polypharmacy, the use of multiple medications by one individual, is increasingly common among older adults. Caring for the growing number of older people with complex drug regimens and multimorbidity presents an important challenge in the coming years. AREAS COVERED This article reviews the international trends in the prevalence of polypharmacy, summarizes the results from previous reviews on polypharmacy and negative health outcomes, and updates a previous review on the clinical consequences of polypharmacy by focusing on studies published after 2013. This narrative review, which is based on a literature search in MEDLINE and EMBASE from January 1990 to June 2018, was undertaken to identify relevant articles. Search terms included variations of polypharmacy and multiple medications. EXPERT OPINION The prevalence of polypharmacy is increasing worldwide. More than half of the older population is exposed to polypharmacy in some settings. Polypharmacy is associated with a broad range of clinical consequences. However, methods to assess the dangers of polypharmacy should be refined. In our opinion, the issue of 'confounding by multimorbidity' has been underestimated and should be better accounted for in future studies. Moreover, researchers should develop more clinically relevant definitions of polypharmacy, including measures of inappropriate or problematic polypharmacy.
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Affiliation(s)
- Jonas W Wastesson
- a Aging Research Center, Department of Neurobiology , Care Sciences and Society, Karolinska Institutet & Stockholm University , Stockholm , Sweden
| | - Lucas Morin
- a Aging Research Center, Department of Neurobiology , Care Sciences and Society, Karolinska Institutet & Stockholm University , Stockholm , Sweden
| | - Edwin C K Tan
- a Aging Research Center, Department of Neurobiology , Care Sciences and Society, Karolinska Institutet & Stockholm University , Stockholm , Sweden.,b Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences , Monash University , Parkville , Australia
| | - Kristina Johnell
- a Aging Research Center, Department of Neurobiology , Care Sciences and Society, Karolinska Institutet & Stockholm University , Stockholm , Sweden
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310
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Han BH, Termine DJ, Moore AA, Sherman SE, Palamar JJ. Medical multimorbidity and drug use among adults in the United States. Prev Med Rep 2018; 12:214-219. [PMID: 30370208 PMCID: PMC6202656 DOI: 10.1016/j.pmedr.2018.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/17/2018] [Accepted: 10/14/2018] [Indexed: 02/07/2023] Open
Abstract
Adults with medical multimorbidity (≥2 chronic conditions) present challenges for health care systems to provide coordinated care. Substance use can complicate the management of chronic medical conditions, but little research has focused on the intersection of medical multimorbidity and substance use. This study uses cross-sectional analysis of 115,335 adult respondents of the 2012-2014 administrations of the National Survey on Drug Use and Health to estimate the prevalence and correlates of past-year drug use among adults with multimorbidity. The prevalence of past-year drug use was compared between individuals reporting 0, 1, and ≥2 chronic medical conditions. We used multivariable logistic regression to determine correlates of past-year drug use among adults with ≥2 chronic medical conditions. 53.1% reported no chronic conditions, 29.5% reported one chronic condition, and 17.4% reported ≥2 chronic conditions. Past-year drug use was reported by 18.3% of those with no chronic conditions, 14.8% with 1 chronic condition, and 11.6% with ≥2 chronic conditions. Cannabis and opioid analgesics (nonmedical use) were the most common drugs used across all three groups. In the adjusted model, among adults with medical multimorbidity, adults with past-year drug use were more likely to be younger, male, have lower income, and report current tobacco use, alcohol dependence, past-year depression, and having received mental health treatment in the past year. In this national cohort, fewer adults with multimorbidity reported substance use compared to adults with no or one chronic condition, however, this population with high multimorbidity may be particularly vulnerable to the negative effects of drug use.
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Affiliation(s)
- Benjamin H. Han
- New York University School of Medicine, Department of Medicine, Division of Geriatric Medicine and Palliative Care, 550 First Avenue, BCD 615, New York, NY 10016, United States of America
- New York University Langone Medical Center, Department of Population Health, 550 First Avenue, New York, NY 10016, United States of America
- Center for Drug Use and HIV/HCV Research, New York University Rory College of Nursing, 433 First Avenue, 7th Floor, New York, NY 10010, United States of America
| | - Domenic J. Termine
- University of Cincinnati, College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, United States of America
| | - Alison A. Moore
- University of California, San Diego, Department of Medicine, Division of Geriatrics, 9500 Gilman Drive, La Jolla, CA 92093, United States of America
| | - Scott E. Sherman
- New York University School of Medicine, Department of Medicine, Division of Geriatric Medicine and Palliative Care, 550 First Avenue, BCD 615, New York, NY 10016, United States of America
- New York University Langone Medical Center, Department of Population Health, 550 First Avenue, New York, NY 10016, United States of America
- Center for Drug Use and HIV/HCV Research, New York University Rory College of Nursing, 433 First Avenue, 7th Floor, New York, NY 10010, United States of America
- VA New York Harbor Healthcare System, New York, NY 10010, United States of America
| | - Joseph J. Palamar
- New York University Langone Medical Center, Department of Population Health, 550 First Avenue, New York, NY 10016, United States of America
- Center for Drug Use and HIV/HCV Research, New York University Rory College of Nursing, 433 First Avenue, 7th Floor, New York, NY 10010, United States of America
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311
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Lee WC, Lee YT, Li LC, Ng HY, Kuo WH, Lin PT, Liao YC, Chiou TTY, Lee CT. The Number of Comorbidities Predicts Renal Outcomes in Patients with Stage 3⁻5 Chronic Kidney Disease. J Clin Med 2018; 7:E493. [PMID: 30486496 PMCID: PMC6306906 DOI: 10.3390/jcm7120493] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 11/23/2018] [Accepted: 11/26/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a global health threat affecting approximately 10% of the adult population worldwide. Multimorbidity is common in CKD, but its impacts on disease outcomes are seldom investigated. METHODS This prospective cohort analysis followed patients, who were part of a multidisciplinary CKD care program, for 10 years. We aimed to determine the impact of multimorbidity on renal outcomes. RESULTS Overall, 1463 patients with stage 3⁻5 CKD were enrolled and stratified by the number of comorbidities. Mean follow-up time was 6.39 ± 1.19 years. We found that stage 3⁻5 CKD patients with at least three comorbidities at enrollment initiated dialysis earlier (hazard ratio (HR): 2.971) than patients without comorbidities. Risk factors for multimorbidity included old age, smoking, and proteinuria. CONCLUSIONS By analyzing the number of comorbidities, a simple and readily applicable method, we demonstrated an association between multimorbidity and poor renal outcomes in stage 3⁻5 CKD patients. In addition to current guideline-based approaches, our results suggest an urgent need for tailored CKD care strategies for high-risk groups.
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Affiliation(s)
- Wen-Chin Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Yueh-Ting Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Lung-Chih Li
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Hwee-Yeong Ng
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Wei-Hung Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Pei-Ting Lin
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Ying-Chun Liao
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Terry Ting-Yu Chiou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Chien-Te Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
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312
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Uwimana Nicol J, Rohwer A, Young T, Bavuma CM, Meerpohl JJ. Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs) : Protocol for a systematic review. Syst Rev 2018; 7:203. [PMID: 30458841 PMCID: PMC6247752 DOI: 10.1186/s13643-018-0865-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/31/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs. METHODS We will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χ 2 and I 2 tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table. DISCUSSION In light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018099314 .
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Affiliation(s)
- Jeannine Uwimana Nicol
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa.
- School of Public Health, College of Medicine and Health Science, University of Rwanda, Kicukiro, Kigali, Rwanda.
| | - Anke Rohwer
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa
| | - Taryn Young
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa
| | - Charlotte M Bavuma
- College of Medicine and Health Science, University of Rwanda, Kicukiro, Kigali, Rwanda
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Breisacher Strasse 153, 79110, Freiburg, Germany
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313
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Ofori-Asenso R, Zomer E, Chin KL, Si S, Markey P, Tacey M, Curtis AJ, Zoungas S, Liew D. Effect of Comorbidity Assessed by the Charlson Comorbidity Index on the Length of Stay, Costs and Mortality among Older Adults Hospitalised for Acute Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15112532. [PMID: 30424531 PMCID: PMC6267000 DOI: 10.3390/ijerph15112532] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/07/2018] [Accepted: 11/07/2018] [Indexed: 11/16/2022]
Abstract
The burden of comorbidity among stroke patients is high. The aim of this study was to examine the effect of comorbidity on the length of stay (LOS), costs, and mortality among older adults hospitalised for acute stroke. Among 776 older adults (mean age 80.1 ± 8.3 years; 46.7% female) hospitalised for acute stroke during July 2013 to December 2015 at a tertiary hospital in Melbourne, Australia, we collected data on LOS, costs, and discharge outcomes. Comorbidity was assessed via the Charlson Comorbidity Index (CCI), where a CCI score of 0⁻1 was considered low and a CCI ≥ 2 was high. Negative binomial regression and quantile regression were applied to examine the association between CCI and LOS and cost, respectively. Survival was evaluated with the Kaplan⁻Meier and Cox regression analyses. The median LOS was 1.1 days longer for patients with high CCI than for those with low CCI. In-hospital mortality rate was 18.2% (22.1% for high CCI versus 11.8% for low CCI, p < 0.0001). After controlling for confounders, high CCI was associated with longer LOS (incidence rate ratio [IRR]; 1.35, p < 0.0001) and increased likelihood of in-hospital death (hazard ratio [HR]; 1.91, p = 0.003). The adjusted median, 25th, and 75th percentile costs were AUD$2483 (26.1%), AUD$1446 (28.1%), and AUD$3140 (27.9%) higher for patients with high CCI than for those with low CCI. Among older adults hospitalised for acute stroke, higher global comorbidity (CCI ≥ 2) was associated adverse clinical outcomes. Measures to better manage comorbidities should be considered as part of wider strategies towards mitigating the social and economic impacts of stroke.
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Affiliation(s)
- Richard Ofori-Asenso
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
- Epidemiological Modelling Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
- Division of Metabolism, Ageing and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Ella Zomer
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Ken Lee Chin
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Si Si
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Peter Markey
- Alfred Hospital, Melbourne, VIC 3004, Australia.
| | - Mark Tacey
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Andrea J Curtis
- Division of Metabolism, Ageing and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Sophia Zoungas
- Division of Metabolism, Ageing and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Danny Liew
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
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314
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Wijers IGM, Ayala A, Rodriguez-Blazquez C, Rodriguez-Laso A, Rodriguez-García P, Prados-Torres A, Rodriguez-Rodriguez V, Forjaz MJ. The Disease Burden Morbidity Assessment in older adults and its association with mortality and other health outcomes. Eur J Ageing 2018; 16:193-203. [PMID: 31139033 DOI: 10.1007/s10433-018-0491-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The objective of this study was to assess how disease burden caused by chronic conditions is related to mortality (predictive validity) and other health outcomes (convergent validity). This was studied in 625 community-dwelling adults living in Spain aged 65 years and older. Disease burden was measured with the Disease Burden Morbidity Assessment (DBMA). The association with 5-year mortality was assessed using a Cox model and Kaplan-Meier curves. For convergent validity, mean age, sex ratio, patient-centered outcomes and healthcare utilization were compared for high and low DBMA scores (< 10 vs. ≥ 10). Also, a multivariable linear regression model was used to evaluate the DBMA as a function of these variables. Mean DBMA score in our sample was 7.5. After 5 years, 35 participants had died (5.5%). The Cox model displayed a hazard ratio of 1.07, and the Kaplan-Meier curves showed lower survival for high DBMA scores. Among participants with high DBMA scores, low self-perceived health, disability and female sex were more frequent, and this group showed lower mean scores for quality of life (Personal Wellbeing Index), affect balance (Scale of Positive and Negative Experience) and physical activity (Yale Physical Activity Survey), higher mean age and higher healthcare utilization than persons with low DBMA scores. In the multivariable regression, all variables but age were significantly associated with the DBMA. In conclusion, the DBMA showed satisfactory predictive and convergent validity. In our aging society, it can be applied to better understand and improve care for older persons with multiple chronic conditions.
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Affiliation(s)
- Irene G M Wijers
- 1Department of Preventive Medicine and Quality Management, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Alba Ayala
- 2National School of Public Health, Institute of Health Carlos III and REDISSEC, Avda. Monforte de Lemos 5, 28029 Madrid, Spain
| | | | - Angel Rodriguez-Laso
- Biomedical Research Foundation of the University Hospital of Getafe, Madrid, Spain
| | | | - Alexandra Prados-Torres
- Aragón Health Sciences Institute (IACS), IIS Aragón, Institute of Health Carlos III and REDISSEC, Zaragoza, Spain
| | | | - Maria João Forjaz
- 2National School of Public Health, Institute of Health Carlos III and REDISSEC, Avda. Monforte de Lemos 5, 28029 Madrid, Spain
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315
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Heale R, James S, Wenghofer E, Garceau ML. Nurse practitioner's perceptions of the impact of the nurse practitioner-led clinic model on the quality of care of complex patients. Prim Health Care Res Dev 2018; 19:553-560. [PMID: 29310746 PMCID: PMC6692965 DOI: 10.1017/s1463423617000913] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 11/30/2017] [Accepted: 12/15/2017] [Indexed: 11/06/2022] Open
Abstract
AimTo evaluate the organizational processes that influence the quality of care for patients with multimorbidity at nurse practitioner-led clinics (NPLCs). BACKGROUND: People are living longer, most with one or more chronic diseases (mulitmorbidity) and primary healthcare for these patients has become increasingly complex. One response was the establishment of new models of primary healthcare. NPLCs are an example of a model developed in Ontario, Canada, which feature nurse practitioners as the primary care providers practicing within an interprofessional team. Evaluation of the extent to which the processes within NPLC model addressed the needs of patients with multimorbidity is warranted. METHODS: Eight nurse practitioners were interviewed to determine their perception of the quality of care provided to patients with multimorbidity at NPLCs. Interpretive description guided the analysis and themes were identified.FindingsThree themes arose from the analysis, each of which has an impact on the quality of care. The level of patient vulnerability at the NPLCs was high resulting in the need to address social and financial issues before the care of chronic conditions. Dynamics within the interprofessional team impacted the quality of patient care, including NP recruitment and retention, leaves of absence and turnover in staff at the NPLCs had an effect on interprofessional team functioning and patient care. Finally, coordination of care at the NPLCs, such as length of appointments, determined the extent to which attention was given to individual clinical issues was a factor. Strategies to address social determinants of health and for recruitment and retention of NPs is essential for improved quality of care. Comprehensive orientation to the interprofessional team as well as flexibility in care processes may also have positive effects on the quality of care of patients with complex clinical issues.
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Affiliation(s)
- Roberta Heale
- Associate Professor, School of Nursing, Laurentian University, Sudbury, ON, Canada
| | - Susan James
- Associate Professor, Director, School of Midwifery, Laurentian University, Sudbury, ON, Canada
| | - Elizabeth Wenghofer
- Associate Professor, Director, School of Rural and Northern Health Laurentian University, Sudbury, ON, Canada
| | - Marie-Luce Garceau
- Retired Professor, Services Sociale, Laurentian University, Sudbury, ON, Canada
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316
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Cadel L, DeLuca C, Hitzig SL, Packer TL, Lofters AK, Patel T, Guilcher SJT. Self-management of pain and depression in adults with spinal cord injury: A scoping review. J Spinal Cord Med 2018; 43:280-297. [PMID: 30335601 PMCID: PMC7241513 DOI: 10.1080/10790268.2018.1523776] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.
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Affiliation(s)
- Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Claudia DeLuca
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sander L. Hitzig
- St. John’s Rehab, Sunnybrook Research Institute, Toronto, Ontario, Canada,Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tanya L. Packer
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aisha K. Lofters
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada,Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada,Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
| | - Sara J. T. Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada,Correspondence to: Sara J. T. Guilcher, Leslie Dan Faculty of Pharmacy, 144 College Street, room 604, Toronto ON M5S 3M2.
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317
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McGilton KS, Vellani S, Yeung L, Chishtie J, Commisso E, Ploeg J, Andrew MK, Ayala AP, Gray M, Morgan D, Chow AF, Parrott E, Stephens D, Hale L, Keatings M, Walker J, Wodchis WP, Dubé V, McElhaney J, Puts M. Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a scoping review. BMC Geriatr 2018; 18:231. [PMID: 30285641 PMCID: PMC6167839 DOI: 10.1186/s12877-018-0925-x] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As the population is aging, the number of persons living with multiple chronic conditions (MCC) is expected to increase. This review seeks to answer two research questions from the perspectives of older adults with MCC, their caregivers and their health care providers (HCPs): 1) What are the health and social care needs of community-dwelling older adults with MCC and their caregivers? and 2) How do social and structural determinants of health impact these health and social care needs? METHODS We conducted a scoping review guided by a refinement of the Arksey & O'Malley framework. Articles were included if participants were 55 years or older and have at least two chronic conditions. We searched 7 electronic databases. The data were summarized using thematic analysis. RESULTS Thirty-six studies were included in this review: 28 studies included participants with MCC; 12 studies included HCPs; 5 studies included caregivers. The quality of the studies ranged from moderate to good. Five main areas of needs were identified: need for information; coordination of services and supports; preventive, maintenance and restorative strategies; training for older adults, caregivers and HCPs to help manage the older adults' complex conditions; and the need for person-centred approaches. Structural and social determinants of health such as socioeconomic status, education and access influenced the needs of older adults with MCC. CONCLUSION The review highlights that most of the needs of older adults with MCC focus on lack of access to information and coordination of care. The main structural and social determinants that influenced older adults' needs were their level of education/health literacy and their socioeconomic status.
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Affiliation(s)
- Katherine S McGilton
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. .,Toronto Rehabilitation Institute, University Health Network, 550 University Avenue, Toronto, ON, M6K 2R7 416 597 3422 (2500), Canada.
| | - Shirin Vellani
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Lily Yeung
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Jawad Chishtie
- Toronto Rehabilitation Institute, University Health Network, 550 University Avenue, Toronto, ON, M6K 2R7 416 597 3422 (2500), Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Elana Commisso
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jenny Ploeg
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Melissa K Andrew
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ana Patricia Ayala
- Gerstein Information Science Centre, University of Toronto, Toronto, ON, Canada
| | - Mikaela Gray
- Gerstein Information Science Centre, University of Toronto, Toronto, ON, Canada
| | - Debra Morgan
- Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, SK, Canada
| | - Amanda Froehlich Chow
- Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | - Lori Hale
- The Change Foundation, Toronto, ON, Canada
| | | | | | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Veronique Dubé
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
| | - Janet McElhaney
- Health Sciences North Research Institute and Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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318
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Manca DP, Fernandes C, Grunfeld E, Aubrey-Bassler K, Shea-Budgell M, Lofters A, Campbell-Scherer D, Sopcak N, O'Brien MA, Meaney C, Moineddin R, McBrien K, Salvalaggio G, Krueger P. The BETTER WISE protocol: building on existing tools to improve cancer and chronic disease prevention and screening in primary care for wellness of cancer survivors and patients - a cluster randomized controlled trial embedded in a mixed methods design. BMC Cancer 2018; 18:927. [PMID: 30257655 PMCID: PMC6158893 DOI: 10.1186/s12885-018-4839-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background There is a pressing need to reduce the burden of chronic disease and improve healthcare system sustainability through improved cancer and chronic disease prevention and screening (CCDPS) in primary care. We aim to create an integrated approach that addresses the needs of the general population and the special concerns of cancer survivors. Building on previous research, we will develop, implement, and test the effectiveness of an approach that proactively targets patients to attend an individualized CCDPS intervention delivered by a Prevention Practitioner (PP). The objective is to determine if patients randomized to receive an individualized PP visit (vs standard care) have improved cancer surveillance and CCDPS outcomes. Implementation frameworks will help identify and address facilitators and barriers to the approach and inform future dissemination and uptake. Methods/design The BETTER WISE project is a pragmatic two-arm cluster randomized controlled trial embedded in a mixed methods design, including a qualitative evaluation and an economic assessment. The intervention, informed by the expanded chronic care model and previous research, will be refined by engaging researchers, practitioners, policy makers, and patients. The BETTER WISE tool kit includes blended care pathways for cancer survivors (breast, colorectal, prostate) and CCDPS including lifestyle risk factors and screening for poverty. Patients aged 40–65, including both cancer survivors and general population patients, will be randomized at the physician level to an intervention group or to a wait-list control group. Once the intervention is completed, patients randomized to wait-list control will be invited to receive a prevention visit. The main outcome, calculated at 12-months follow-up, will be an individual patient-level summary composite index, defined as the proportion of CCDPS actions achieved relative to those for which the patient was eligible at baseline. A qualitative evaluation will capture information related to program outcome, implementation (facilitators and barriers), and sustainability. An economic assessment will examine the projected cost-benefit impact of investing in the BETTER WISE approach. Discussion This project builds on existing work and engages end users throughout the process to develop, implement, and determine the effectiveness of a multi-faceted intervention that addresses CCDPS and cancer survivorship in primary care settings. Trial registration ISRCTN21333761. Registered on December 19, 2016
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Affiliation(s)
- Donna Patricia Manca
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada. .,Covenant Health, Grey Nuns Community Hospital, 1100 Youville Drive Northwest, Edmonton, AB, T6L 5X8, Canada.
| | - Carolina Fernandes
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada
| | - Eva Grunfeld
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada.,Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada
| | - Kris Aubrey-Bassler
- Discipline of Family Medicine, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John's, NF, A1B 3V6, Canada
| | - Melissa Shea-Budgell
- Charbonneau Cancer Institute and Department of Oncology, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Aisha Lofters
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Denise Campbell-Scherer
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada.,Covenant Health, Grey Nuns Community Hospital, 1100 Youville Drive Northwest, Edmonton, AB, T6L 5X8, Canada
| | - Nicolette Sopcak
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Kerry McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Ginetta Salvalaggio
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada
| | - Paul Krueger
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, ON, M5G 1V7, Canada
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319
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Pouplier S, Olsen MÅ, Willadsen TG, Sandholdt H, Siersma V, Andersen CL, Olivarius NDF. The development of multimorbidity during 16 years after diagnosis of type 2 diabetes. JOURNAL OF COMORBIDITY 2018; 8:2235042X18801658. [PMID: 30363325 PMCID: PMC6169975 DOI: 10.1177/2235042x18801658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 08/14/2018] [Indexed: 12/21/2022]
Abstract
Objective: The aims of this study were to (1) quantify the development and composition
of multimorbidity (MM) during 16 years following the diagnosis of type 2
diabetes and (2) evaluate whether the effectiveness of structured personal
diabetes care differed between patients with and without MM. Research design and methods: One thousand three hundred eighty-one patients with newly diagnosed type 2
diabetes were randomized to receive either structured personal diabetes care
or routine diabetes care. Patients were followed up for 19 years in Danish
nationwide registries for the occurrence of outcomes. We analyzed the
prevalence and degree of MM based on 10 well-defined disease groups. The
effect of structured personal care in diabetes patients with and without MM
was analyzed with Cox regression models. Results: The proportion of patients with MM increased from 31.6% at diabetes diagnosis
to 80.4% after 16 years. The proportion of cardiovascular and
gastrointestinal diseases in surviving patients decreased, while, for
example, musculoskeletal, eye, and neurological diseases increased. The
effect of the intervention was not different between type 2 diabetes
patients with or without coexisting chronic disease. Conclusions: In general, the proportion of patients with MM increased after diabetes
diagnosis, but the composition of chronic disease changed during the 16
years. We found cardiovascular and musculoskeletal disease to be the most
prevalent disease groups during all 16 years of follow-up. The post hoc
analysis of the intervention showed that its effectiveness was not different
among patients who developed MM compared to those who continued to have
diabetes alone.
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Affiliation(s)
- Sandra Pouplier
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Maria Åhlander Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Tora Grauers Willadsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Håkon Sandholdt
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Christen Lykkegaard Andersen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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320
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The synergic effects of frailty on disability associated with urbanization, multimorbidity, and mental health: implications for public health and medical care. Sci Rep 2018; 8:14125. [PMID: 30237508 PMCID: PMC6148070 DOI: 10.1038/s41598-018-32537-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/05/2018] [Indexed: 01/16/2023] Open
Abstract
Frailty is garnering increasing interest as a potential target in disability prevention. Since it is uncertain how frailty interacts with multimorbidity, urbanization, and mental health to affect disability, we investigated the epidemiology of frailty and its synergies with these factors. The study enrolled 20,898 participants aged 65 and older living in New Taipei city. All participants received face to face interview to assess frailty, multimorbidity, urban or rural residence, and mental health. Individual versus combined effects of risk factors were evaluated using the Rothman synergy index. Prevalence of frailty was 5.2% overall, 7.2% in multimorbid participants, 9.6% in rural residents, and 20.8% in those with mental disorders. Logistic regression, adjusted for age and sex, showed significant associations between disability and frailty (OR 8.5, 95% CI 6.4–11.2), multimorbidity (OR 1.3, 95% CI 1.0–1.6), urbanization (OR 1.3, 95% CI 1.0–1.7), and mental disorders (OR 7.3, 95% CI 5.6–9.5); these factors had a significant synergic effect on disability. Frailty is common in older adults and associated with disability, and was synergetic with multimorbidity, mental disorders, and residing rurally. Targeting frailty prevention and intervention needs a special attention on those vulnerable groups.
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321
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Braillard O, Slama-Chaudhry A, Joly C, Perone N, Beran D. The impact of chronic disease management on primary care doctors in Switzerland: a qualitative study. BMC FAMILY PRACTICE 2018; 19:159. [PMID: 30205832 PMCID: PMC6134721 DOI: 10.1186/s12875-018-0833-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/14/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patient-centeredness and therapeutic relationship are widely explored as a means to address the challenge of chronic disease and multi-morbidity management, however research focusing on the perspective of doctors is still rare. In this study, we aimed to explore the impact of the patient's chronic disease(s) on their healthcare provider. METHODS A qualitative approach was taken using semi-structured interviews with general practitioners working in outpatient clinics either in individual practices or in a hospital setting in Geneva, Switzerland. Codes were developed through an iterative process and using grounded theory an inductive coding scheme was performed to identify the key themes. Throughout the analysis process the research team reviewed the analysis and refined the coding scheme. RESULTS Twenty interviews, 10 in each practice type, allowed for saturation to be reached. The following themes relevant to the impact of managing chronic diseases emerge around the issue of feeling powerless as a doctor; facing the patient's socio-economic context; guidelines versus the reality of the patient; time; and taking on the patient's burden. Primary care practitioners face an emotional burden linked with their powerlessness and work conditions, but also with the empathetic bond with their patients and their circumstances. Doctors seem poorly prepared for this emotional strain. The health system is also not facilitating this with time constraints and guidelines unsuitable for the patient's reality. CONCLUSIONS Chronic disease and multi-morbidity management is a challenge for healthcare providers. This has its roots in patient characteristics, the overall health system and healthcare providers themselves. Structural changes need to be implemented at different levels: medical education; health systems; adapted guidelines; leading to an overall environment that favors the development of the therapeutic relationship.
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Affiliation(s)
- Olivia Braillard
- Department of Community Medicine, Primary and Emergency Care, Geneva University Hospitals, 1205, Geneva, Switzerland.
| | - Anbreen Slama-Chaudhry
- Department of Community Medicine, Primary and Emergency Care, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Catherine Joly
- Department of Community Medicine, Primary and Emergency Care, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Nicolas Perone
- Department of Community Health and Care, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, 1205, Geneva, Switzerland
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322
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Irfan Khan A, Gill A, Cott C, Hans PK, Steele Gray C. mHealth Tools for the Self-Management of Patients With Multimorbidity in Primary Care Settings: Pilot Study to Explore User Experience. JMIR Mhealth Uhealth 2018; 6:e171. [PMID: 30154073 PMCID: PMC6134226 DOI: 10.2196/mhealth.8593] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 05/20/2018] [Accepted: 06/21/2018] [Indexed: 12/19/2022] Open
Abstract
Background Given the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions. Objective The objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts. Methods We conducted a 4-week pilot study of the ePRO tool. Patients’ and providers’ experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method. Results In this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool’s potential in helping to improve access to different providers in a team-based primary care setting. Conclusions This study identifies a more explicit recognition of the contextual factors that influence patients’ ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial.
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Affiliation(s)
- Anum Irfan Khan
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ashlinder Gill
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Cheryl Cott
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Parminder Kaur Hans
- Bridgepoint Campus, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Carolyn Steele Gray
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Bridgepoint Campus, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
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323
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Grimsmo A. Antall kroniske sykdommer og persontilpasning bør ligge til grunn for prioriteringer i kommunale helse- og omsorgstjenester. TIDSSKRIFT FOR OMSORGSFORSKNING 2018. [DOI: 10.18261/issn.2387-5984-2018-02-03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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324
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Hussain MA, Katzenellenbogen JM, Sanfilippo FM, Murray K, Thompson SC. Complexity in disease management: A linked data analysis of multimorbidity in Aboriginal and non-Aboriginal patients hospitalised with atherothrombotic disease in Western Australia. PLoS One 2018; 13:e0201496. [PMID: 30106971 PMCID: PMC6091927 DOI: 10.1371/journal.pone.0201496] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/16/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hospitalisation for atherothrombotic disease (ATD) is expected to rise in coming decades. However, increasingly, associated comorbidities impose challenges in managing patients and deciding appropriate secondary prevention. We investigated the prevalence and pattern of multimorbidity (presence of two or more chronic conditions) in Aboriginal and non-Aboriginal Western Australian residents with ATDs. METHODS AND FINDINGS We used population-based de-identified linked administrative health data from 1 January 2000 to 30 June 2014 to identify a cohort of patients aged 25-59 years admitted to Western Australian hospitals with a discharge diagnosis of ATD. The prevalence of common chronic diseases in these patients was estimated and the patterns of comorbidities and multimorbidities empirically explored using two different approaches: identification of the most commonly occurring pairs and triplets of comorbid diseases, and through latent class analysis (LCA). Half of the cohort had multimorbidity, although this was much higher in Aboriginal people (Aboriginal: 79.2% vs. non-Aboriginal: 39.3%). Only a quarter were without any documented comorbidities. Hypertension, diabetes, alcohol abuse disorders and acid peptic diseases were the leading comorbidities in the major comorbid combinations across both Aboriginal and non-Aboriginal cohorts. The LCA identified four and six distinct clinically meaningful classes of multimorbidity for Aboriginal and non-Aboriginal patients, respectively. Out of the six groups in non-Aboriginal patients, four were similar to the groups identified in Aboriginal patients. The largest proportion of patients (33% in Aboriginal and 66% in non-Aboriginal) was assigned to the "minimally diseased" (or relatively healthy) group, with most patients having less than two conditions. Other groups showed variability in degree and pattern of multimorbidity. CONCLUSION Multimorbidity is common in ATD patients and the comorbidities tend to interact and cluster together. Physicians need to consider these in their clinical practice. Different treatment and secondary prevention strategies are likely to be useful for management in these cluster groups.
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Affiliation(s)
- Mohammad Akhtar Hussain
- Western Australian Centre for Rural Health, The University of Western Australia, Geraldton, Western Australia, Australia
| | - Judith M. Katzenellenbogen
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Frank M. Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Sandra C. Thompson
- Western Australian Centre for Rural Health, The University of Western Australia, Geraldton, Western Australia, Australia
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325
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Martín Lesende I, Mendibil Crespo LI, Castaño Manzanares S, Otter ASD, Garaizar Bilbao I, Pisón Rodríguez J, Negrete Pérez I, Sarduy Azcoaga I, de la Rua Fernández MJ. Functional decline and associated factors in patients with multimorbidity at 8 months of follow-up in primary care: the functionality in pluripathological patients (FUNCIPLUR) longitudinal descriptive study. BMJ Open 2018; 8:e022377. [PMID: 30056392 PMCID: PMC6067403 DOI: 10.1136/bmjopen-2018-022377] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To analyse short-term functional decline and associated factors in over 65-year-olds with multimorbidity. DESIGN AND SETTING Prospective multicentre study conducted in three primary care centres, over an 8-month period. During this period, we also analysed admissions to two referral hospitals. PARTICIPANTS Of the 241 patients ≥65 years included randomly in the study, 155 were already part of a multimorbidity programme (stratified by 'Adjusted Clinical Groups') and 86 were newly included (patients who met Ollero's criteria and with ≥1 hospital admission the previous year). Patients who were institutionalised, unable to complete follow-up or receiving dialysis were excluded. OUTCOMES AND VARIABLES The primary outcome was the decrease in functional status category (Barthel Index or Lawton Scale). Other variables considered were sociodemographic characteristics, comorbidity, medications, number of admissions and functional status on discharge. RESULTS Patients had a median age of 82 years (P75 86) and of five selected chronic conditions (IQR 4-6), and took 11 (IQR 9-14) regular medications; 46.9% were women; 38.2% had impaired function at baseline.Overall, 200 persons completed the follow-up; 10.4% (n=25) of the initial sample died within the 8 months. In 20.5% (95% CI 15.5% to 26.6%) of them we recorded a decrease in functionality, associated with older age (OR 1.1, 95% CI 1.0 to 1.2) and with having ≥1 admission during the follow-up (OR 3.6, 95% CI 1.6 to 7.7). There were 133 hospital admissions in total during the follow-up considering all the patients included, and a functional decline was observed in 35.5% (95% CI 25.7% to 46.7%) of the 76 discharges in which functional status was assessed. CONCLUSIONS A fifth of patients showed functional decline or loss of independence in just 8 months. These findings are important as functional decline and the increasing care needs are potentially predictable and modifiable. Age and hospitalisation were closely associated with this decline.
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Affiliation(s)
- Iñaki Martín Lesende
- San Ignacio Health Centre, Bilbao-Basurto Integrated Healthcare Organisation (IHO), Basque Health Service (Osakidetza), Bilbao, Spain
| | | | | | | | | | | | - Ion Negrete Pérez
- Emergency Department, Basurto University Hospital, Bilbao-Basurto IHO, Osakidetza, Bilbao, Spain
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326
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Uvhagen H, Hasson H, Hansson J, von Knorring M. Leading top-down implementation processes: a qualitative study on the role of managers. BMC Health Serv Res 2018; 18:562. [PMID: 30021569 PMCID: PMC6052667 DOI: 10.1186/s12913-018-3360-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/05/2018] [Indexed: 11/28/2022] Open
Abstract
Background Leadership has been identified as an influential factor in implementation processes in healthcare organizations. However, the processes through which leaders affect implementation outcomes are largely unknown. The purpose of this study is to analyse how managers interpret and make sense of a large scale top-down implementation initiative and what implications this has for the implementation process. This was studied at the implementation of an academic primary healthcare initiative covering 210 primary healthcare centres in central Sweden. The aim of the initiative was to integrate research and education into regular primary healthcare services. Methods The study builds on 16 in-depth individual semi-structured interviews with all managers (n = 8) who had operative responsibility for the implementation. Each manager was interviewed twice during the initial phase of the implementation. Data were analysed using a thematic approach guided by theory on managerial role taking based on the Transforming Experience Framework. Results How the managers interpreted and made sense of the implementation task built on three factors: how they perceived the different parts of the initiative, how they perceived themselves in relation to these parts, and the resources available for the initiative. Based on how they combined these three factors the managers chose to integrate or separate the different parts of the initiative in their management of the implementation process. Conclusions This research emphasizes that managers in healthcare seem to have a substantial impact on how and to what extent different tasks are addressed and prioritized in top-down implementation processes. This has policy implications. To achieve intended implementation outcomes, the authors recognize the necessity of an early and on-going dialogue about how the implementation is perceived by the managers responsible for the implementation. Electronic supplementary material The online version of this article (10.1186/s12913-018-3360-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Håkan Uvhagen
- Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institutet, 171 77, Stockholm, Sweden. .,Research and Development Unit for Elderly Persons (FOU nu) Stockholm County Council, Stockholm, Sweden.
| | - Henna Hasson
- Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Johan Hansson
- Department of Public Health Analysis and Data Management, Public Health Agency of Sweden, 171 82, Solna, Sweden
| | - Mia von Knorring
- Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institutet, 171 77, Stockholm, Sweden
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327
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Cardwell K, Clyne B, Moriarty F, Wallace E, Fahey T, Boland F, McCullagh L, Clarke S, Finnigan K, Daly M, Barry M, Smith SM. Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care. Pilot Feasibility Stud 2018; 4:122. [PMID: 30002869 PMCID: PMC6034254 DOI: 10.1186/s40814-018-0311-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Prescribing for patients taking multiple medicines (i.e. polypharmacy) is challenging for general practitioners (GPs). Limited evidence suggests that the integration of pharmacists into the general practice team could improve the management of these patients. The aim of this study is to develop and test an intervention involving pharmacists, working within GP practices, to optimise prescribing in Ireland, which has a mixed public and private primary healthcare system. Methods This non-randomised pilot study will use a mixed-methods approach. Four general practices will be purposively sampled and recruited. A pharmacist will join the practice team for 6 months. They will participate in the management of repeat prescribing and undertake medication reviews (which will address high-risk prescribing and potentially inappropriate prescribing, deprescribing and cost-effective and generic prescribing) with adult patients. Pharmacists will also provide prescribing advice regarding the use of preferred drugs, undertake clinical audits, join practice team meetings and facilitate practice-based education. Throughout the 6-month intervention period, anonymised practice-level medication (e.g. medication changes) and cost data will be collected. A nested Patient Reported Outcome Measure (PROM) study will be undertaken during months 4 and 5 of the 6-month intervention period to explore the impact of the intervention in older adults (aged ≥ 65 years). For this, a sub-set of 50 patients aged ≥ 65 years with significant polypharmacy (≥ 10 repeat medicines) will be recruited from each practice and invited to a medication review with the pharmacist. PROMs and healthcare utilisation data will be collected using patient questionnaires, and a 6-week follow-up review conducted. Acceptability of the intervention will be explored using pre- and post-intervention semi-structured interviews with key stakeholders. Quantitative and qualitative data analysis will be undertaken and an economic evaluation conducted. Discussion This non-randomised pilot study will provide evidence regarding the feasibility and potential effectiveness of general practice-based pharmacists in Ireland and provide data on whether a randomised controlled trial of this intervention is indicated. It will also provide a deeper understanding as to how a pharmacist working as part of the general practice team will affect organisational processes and professional relationships in a mixed public and private primary healthcare system.
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Affiliation(s)
- Karen Cardwell
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - B Clyne
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - F Moriarty
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - E Wallace
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - T Fahey
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - F Boland
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
| | - L McCullagh
- 2Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - S Clarke
- 3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - K Finnigan
- 3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - M Daly
- 3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - M Barry
- 2Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland.,3Health Service Executive Medicines Management Programme, Dublin, Ireland
| | - S M Smith
- 1Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin, Ireland
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328
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Corre LJ, Hotham E, Tsimbinos J, Todd I, Scarlett G, Suppiah V. Assessment of patient understanding of their medicines: interviews with community dwelling older Australians. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 26:568-572. [DOI: 10.1111/ijpp.12466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/01/2018] [Indexed: 11/28/2022]
Abstract
Abstract
Objective
To identify patterns of medication load, client’s care team, coordination of healthcare and clients’ understanding of their medications.
Methods
Face-to-face interviews were conducted with community-dwelling older Australians between June and August 2017 in three community pharmacies in Adelaide, South Australia.
Key findings
Forty interviews were conducted. On average, participants were taking 7.53 medicines with 77.5% using five or more regularly. Lack of collaboration between healthcare professionals, need for increased communication between prescribers and increased patient education on medicines, were highlighted. This study demonstrates that polypharmacy and inappropriate prescribing are occurring within the community pharmacy setting, but shows insight into how these concerns can be overcome, by implementing pharmacist-led services such as non-dispensing pharmacists in community pharmacies.
Conclusion
Careful consideration when prescribing and effective communication are required to minimise risks associated with polypharmacy in this population.
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Affiliation(s)
- Lauren J Corre
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Elizabeth Hotham
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | | | - Ian Todd
- Pharmacy Guild of Australia, South Australian Branch, Adelaide, SA, Australia
| | | | - Vijayaprakash Suppiah
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
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329
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Johnston MC, Crilly M, Black C, Prescott GJ, Mercer SW. Defining and measuring multimorbidity: a systematic review of systematic reviews. Eur J Public Health 2018; 29:182-189. [DOI: 10.1093/eurpub/cky098] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
| | - Michael Crilly
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Public Health, NHS Grampian, Summerfield House, Aberdeen, UK
| | - Corri Black
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Public Health, NHS Grampian, Summerfield House, Aberdeen, UK
| | - Gordon J Prescott
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Stewart W Mercer
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
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330
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Grimsmo A, Løhre A, Røsstad T, Gjerde I, Heiberg I, Steinsbekk A. Disease-specific clinical pathways - are they feasible in primary care? A mixed-methods study. Scand J Prim Health Care 2018; 36:152-160. [PMID: 29644927 PMCID: PMC6066276 DOI: 10.1080/02813432.2018.1459167] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVE To explore the feasibility of disease-specific clinical pathways when used in primary care. DESIGN A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. SETTING Primary care and specialist care collaborating to manage care coordination. RESULTS Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. CONCLUSIONS The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care. In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.
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Affiliation(s)
- Anders Grimsmo
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
- CONTACT Anders GrimsmoDepartment of Public Health and Nursing, Norwegian University of Science and Technology, P.O. Box 8905, 7491Trondheim, Norway
| | - Audhild Løhre
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
| | - Tove Røsstad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
| | - Ingunn Gjerde
- Faculty of Business Administration and Social Sciences, Molde University College, Specialized University in Logistics, Molde, Norway;
| | - Ina Heiberg
- Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway
| | - Aslak Steinsbekk
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway;
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331
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Stanley J, Semper K, Millar E, Sarfati D. Epidemiology of multimorbidity in New Zealand: a cross-sectional study using national-level hospital and pharmaceutical data. BMJ Open 2018; 8:e021689. [PMID: 29794103 PMCID: PMC5988147 DOI: 10.1136/bmjopen-2018-021689] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To describe the prevalence of multimorbidity (presence of two or more long-term health conditions) in the New Zealand (NZ) population, and compare risk of health outcomes by multimorbidity status. DESIGN Cross-sectional analysis for prevalence of multimorbidity, with 1-year prospective follow-up for health outcomes. SETTING NZ general population using national-level routine health data on hospital discharges and pharmaceutical dispensing. PARTICIPANTS All NZ adults (aged 18+, n=3 489 747) with an active National Health Index number at the index date (1 January 2014). OUTCOME MEASURES Prevalence of multimorbidity was calculated using two data sources: prior routine hospital discharge data (61 ICD-10 coded diagnoses from the M3 multimorbidity index); and recent pharmaceutical dispensing records (30 conditions from the P3 multimorbidity index). METHODS Prevalence of multimorbidity was calculated separately for the two data sources, stratified by age group, sex, ethnicity and socioeconomic deprivation, and age and sex standardised to the total population. One-year risk of poor health outcomes (mortality, ambulatory sensitive hospitalisation (ASH) and overnight hospital admission) was compared by multimorbidity status using logistic regression adjusted for confounders. RESULTS Prevalence of multimorbidity was 7.9% using past hospital discharge data, and 27.9% using past pharmaceutical dispensing data. Prevalence increased with age, with a clear socioeconomic gradient and differences in prevalence by ethnicity. Age and sex standardised risk of 1-year mortality was 2.7% for those with multimorbidity (defined on hospital discharge data), and 0.5% for those without multimorbidity (age and sex-adjusted OR 4.8, 95% CI 4.7 to 5.0). Risk of ASH was also increased for those with multimorbidity (eg, pharmaceutical discharge definition: age and sex-standardised risk 6.2%, compared with 1.8% for those without multimorbidity; age and sex-adjusted OR 3.6, 95% CI 3.5 to 3.6). CONCLUSIONS Multimorbidity is common in the NZ adult population, with disparities in who is affected. Providing for the needs of individuals with multimorbidity requires collaborative and coordinated work across the health sector.
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Affiliation(s)
- James Stanley
- C3 Research Group, Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| | - Kelly Semper
- C3 Research Group, Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| | - Elinor Millar
- C3 Research Group, Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| | - Diana Sarfati
- C3 Research Group, Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
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Chanoine S, Sanchez M, Pin I, Temam S, Le Moual N, Fournier A, Pison C, Bousquet J, Bedouch P, Boutron-Ruault MC, Varraso R, Siroux V. Multimorbidity medications and poor asthma prognosis. Eur Respir J 2018; 51:13993003.02114-2017. [PMID: 29545275 DOI: 10.1183/13993003.02114-2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 03/01/2018] [Indexed: 11/05/2022]
Abstract
Multimedication related to multimorbidity is common in the elderly with asthma. We aimed at comprehensively characterising medications used by elderly women and assessing how multimedication impacts on asthma prognosis.We performed network-based analyses on drug administrative databases to visualise the prevalence of drug classes and their interconnections among 17 458 elderly women from the Asthma-E3N study, including 4328 women with asthma. Asthma groups sharing similar medication profiles were identified by a clustering method relying on all medications and were studied in association with adverse asthma events (uncontrolled asthma, attacks/exacerbations and poor asthma-related quality of life).The network-based analysis showed more multimedication in women with asthma than in those without asthma. The clustering method identified three multimedication profiles in asthma: "Few multimorbidity-related medications" (43.5%), "Predominantly allergic multimorbidity-related medications" (32.8%) and "Predominantly metabolic multimorbidity-related medications" (23.7%). Compared with women belonging to the "Few multimorbidity-related medications" profile, women belonging to the two other profiles had an increased risk of uncontrolled asthma and asthma attacks/exacerbations, and had lower asthma-related quality of life.The integrative data-driven approach on drug administrative databases identified specific multimorbidity-related medication profiles that were associated with poor asthma prognosis. These findings support the importance of multimorbidity in the unmet needs in asthma management.
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Affiliation(s)
- Sébastien Chanoine
- Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Institute for Advanced Biosciences, INSERM U1209, CNRS UMR 5309, Université Grenoble Alpes, Grenoble, France.,Pôle Pharmacie, CHU Grenoble Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France
| | - Margaux Sanchez
- INSERM U1168, VIMA, Aging and Chronic Diseases: Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS-S 1168, Montigny le Bretonneux, France
| | - Isabelle Pin
- Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Institute for Advanced Biosciences, INSERM U1209, CNRS UMR 5309, Université Grenoble Alpes, Grenoble, France.,Clinique de Pédiatrie, Pôle Couple Enfant, CHU Grenoble Alpes, Grenoble, France
| | - Sofia Temam
- INSERM U1168, VIMA, Aging and Chronic Diseases: Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS-S 1168, Montigny le Bretonneux, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Nicole Le Moual
- INSERM U1168, VIMA, Aging and Chronic Diseases: Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS-S 1168, Montigny le Bretonneux, France
| | - Agnès Fournier
- INSERM, Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France.,Institut Gustave Roussy, Villejuif, France
| | - Christophe Pison
- Université Grenoble Alpes, Grenoble, France.,Service Hospitalier Universitaire Pneumologie-Physiologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France.,INSERM, Laboratoire de Bioénergétique Fondamentale et Appliquée, U1055, Grenoble, France
| | - Jean Bousquet
- INSERM U1168, VIMA, Aging and Chronic Diseases: Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS-S 1168, Montigny le Bretonneux, France.,Clinique de Pneumologie, CHU de Montpellier, Montpellier, France.,MACVIA-France, Contre les Maladies Chroniques pour un VIeillissement Actif en France, European Innovation Partnership on Active and Healthy Ageing Reference Site, Montpellier, France
| | - Pierrick Bedouch
- Pôle Pharmacie, CHU Grenoble Alpes, Grenoble, France.,Université Grenoble Alpes, Grenoble, France.,CNRS, TIMC-IMAG UMR5525/ThEMAS, Université Grenoble Alpes, Grenoble, France
| | - Marie-Christine Boutron-Ruault
- INSERM, Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, Université Paris-Sud, UVSQ, Université Paris-Saclay, Villejuif, France.,Institut Gustave Roussy, Villejuif, France
| | - Raphaëlle Varraso
- INSERM U1168, VIMA, Aging and Chronic Diseases: Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS-S 1168, Montigny le Bretonneux, France
| | - Valérie Siroux
- Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Institute for Advanced Biosciences, INSERM U1209, CNRS UMR 5309, Université Grenoble Alpes, Grenoble, France
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333
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Cassell A, Edwards D, Harshfield A, Rhodes K, Brimicombe J, Payne R, Griffin S. The epidemiology of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract 2018; 68:e245-e251. [PMID: 29530918 PMCID: PMC5863678 DOI: 10.3399/bjgp18x695465] [Citation(s) in RCA: 288] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/09/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Multimorbidity places a substantial burden on patients and the healthcare system, but few contemporary epidemiological data are available. AIM To describe the epidemiology of multimorbidity in adults in England, and quantify associations between multimorbidity and health service utilisation. DESIGN AND SETTING Retrospective cohort study, undertaken in England. METHOD The study used a random sample of 403 985 adult patients (aged ≥18 years), who were registered with a general practice on 1 January 2012 and included in the Clinical Practice Research Datalink. Multimorbidity was defined as having two or more of 36 long-term conditions recorded in patients' medical records, and associations between multimorbidity and health service utilisation (GP consultations, prescriptions, and hospitalisations) over 4 years were quantified. RESULTS In total, 27.2% of the patients involved in the study had multimorbidity. The most prevalent conditions were hypertension (18.2%), depression or anxiety (10.3%), and chronic pain (10.1%). The prevalence of multimorbidity was higher in females than males (30.0% versus 24.4% respectively) and among those with lower socioeconomic status (30.0% in the quintile with the greatest levels of deprivation versus 25.8% in that with the lowest). Physical-mental comorbidity constituted a much greater proportion of overall morbidity in both younger patients (18-44 years) and those patients with a lower socioeconomic status. Multimorbidity was strongly associated with health service utilisation. Patients with multimorbidity accounted for 52.9% of GP consultations, 78.7% of prescriptions, and 56.1% of hospital admissions. CONCLUSION Multimorbidity is common, socially patterned, and associated with increased health service utilisation. These findings support the need to improve the quality and efficiency of health services providing care to patients with multimorbidity at both practice and national level.
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Affiliation(s)
- Anna Cassell
- School of Medicine, University of Utah, Salt Lake City, US
| | - Duncan Edwards
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Amelia Harshfield
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kirsty Rhodes
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - James Brimicombe
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rupert Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Simon Griffin
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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334
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Cardwell K, Smith SM. Clinical pharmacists working within family practice: what is the evidence? Fam Pract 2018; 35:120-121. [PMID: 29420724 DOI: 10.1093/fampra/cmy003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Karen Cardwell
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Irel
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Irel
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335
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Morin L, Johnell K, Laroche ML, Fastbom J, Wastesson JW. The epidemiology of polypharmacy in older adults: register-based prospective cohort study. Clin Epidemiol 2018; 10:289-298. [PMID: 29559811 PMCID: PMC5856059 DOI: 10.2147/clep.s153458] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Polypharmacy is the concomitant use of several drugs by a single person, and it increases the risk of adverse drug-related events in older adults. Little is known about the epidemiology of polypharmacy at the population level. We aimed to measure the prevalence and incidence of polypharmacy and to investigate the associated factors. Methods A prospective cohort study was conducted using register data with national coverage in Sweden. A total of 1,742,336 individuals aged ≥65 years at baseline (November 1, 2010) were included and followed until death or the end of the study (December 20, 2013). Results On average, individuals were exposed to 4.6 (SD =4.0) drugs at baseline. The prevalence of polypharmacy (5+ drugs) was 44.0%, and the prevalence of excessive polypharmacy (10+ drugs) was 11.7%. The incidence rate of polypharmacy among individuals without polypharmacy at baseline was 19.9 per 100 person-years, ranging from 16.8% in individuals aged 65-74 years to 33.2% in those aged ≥95 years (adjusted hazard ratio [HR] =1.49, 95% confidence interval [CI] 1.42-1.56). The incidence rate of excessive polypharmacy was 8.0 per 100 person-years. Older adults using multi-dose dispensing were at significantly higher risk of developing incident polypharmacy compared with those receiving ordinary prescriptions (HR =1.51, 95% CI 1.47-1.55). When adjusting for confounders, living in nursing home was found to be associated with lower risks of incident polypharmacy and incident excessive polypharmacy (HR =0.79 and HR =0.86, p<0.001, respectively). Conclusion The prevalence and incidence of polypharmacy are high among older adults in Sweden. Interventions aimed at reducing the prevalence of polypharmacy should also target potential incident polypharmacy users as they are the ones who fuel future polypharmacy.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | | | - Marie-Laure Laroche
- University Hospital of Limoges, Service de Pharmacologie, Toxicologie et Pharmacovigilance, Limoges, France.,Faculté de Médecine, Université de Limoges, Limoges, France
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
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336
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Smith SM, Wallace E, Salisbury C, Sasseville M, Bayliss E, Fortin M. A Core Outcome Set for Multimorbidity Research (COSmm). Ann Fam Med 2018; 16. [PMID: 29531104 PMCID: PMC5847351 DOI: 10.1370/afm.2178] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We aimed to develop a consensus-based set of core outcomes specifically for studies in multimorbidity. METHODS We undertook a consensus study following the COS-STAR (Core Outcome Set-STAndards for Reporting) guidelines for the design and reporting of core outcome sets. A Delphi panel of experts completed a web-based survey with 2 rounds. Panelists were presented with a range of outcomes that had been identified in previous workshops and a related systematic review. They indicated their level of agreement on whether each outcome should be included in the core set using a 5-point Likert scale, and outcomes reaching a prespecified consensus level were included. RESULTS Of 30 individuals invited to be panelists, 26 from 13 countries agreed. All 26 completed both rounds of the survey. The Delphi panel reached consensus on 17 outcomes for inclusion in a core outcome set for multimorbidity (COSmm). The highest-ranked outcomes were health-related quality of life, mental health outcomes, and mortality. Other outcomes were grouped into overarching themes of patient-reported impacts and behaviors (treatment burden, self-rated health, self-management behavior, self-efficacy, adherence); physical activity and function (activities of daily living, physical function, physical activity); consultation related (communication, shared decision making, prioritization); and health systems (health care use, costs, quality of health care). CONCLUSIONS This consensus study involved a wide range of international experts who identified a large number of outcomes for multimorbidity intervention studies. Our results suggest that quality of life, mental health outcomes, and mortality should be regarded as essential core outcomes. Researchers should, however, also consider the full range of outcomes when designing studies to capture important domains in multimorbidity depending on individual study aims and interventions.
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Affiliation(s)
- Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Chris Salisbury
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Maxime Sasseville
- Department of Health Sciences Research, Research Chair on Chronic Diseases in Primary Care, Chicoutimi (Quebec), Canada
| | - Elizabeth Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, University of Colorado School of Medicine, Denver, Colorado
| | - Martin Fortin
- Département de médecine de famille, Université de Sherbrooke, Sherbrooke (Québec), Canada
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337
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Muth C, Uhlmann L, Haefeli WE, Rochon J, van den Akker M, Perera R, Güthlin C, Beyer M, Oswald F, Valderas JM, Knottnerus JA, Gerlach FM, Harder S. Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial. BMJ Open 2018; 8:e017740. [PMID: 29478012 PMCID: PMC5855483 DOI: 10.1136/bmjopen-2017-017740] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice. DESIGN Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation. SETTING 72 general practices in Hesse, Germany. PARTICIPANTS 505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study. INTERVENTIONS Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care. OUTCOME MEASURES The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on. RESULTS At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence). CONCLUSIONS The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement. TRIAL REGISTRATION NUMBER ISRCTN99526053. NCT01171339; Results.
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Affiliation(s)
- Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Justine Rochon
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Marjan van den Akker
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Leuven, Belgium
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Corina Güthlin
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Martin Beyer
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Frank Oswald
- Interdisciplinary Ageing Research (IAW), Faculty of Educational Sciences, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jose Maria Valderas
- APEx Collaboration for Academic Primary Care, University of Exeter Medical School, Exeter, UK
| | - J André Knottnerus
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, Johann Wolfgang Goethe University Hospital, Frankfurt / Main, Germany
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338
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The influence of pharmacist-led adherence support on glycaemic control in people with type 2 diabetes. Int J Clin Pharm 2018; 40:354-359. [DOI: 10.1007/s11096-018-0606-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 02/13/2018] [Indexed: 10/18/2022]
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339
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Byrne P, Cullinan J, Murphy C, Smith SM. Cross-sectional analysis of the prevalence and predictors of statin utilisation in Ireland with a focus on primary prevention of cardiovascular disease. BMJ Open 2018; 8:e018524. [PMID: 29439070 PMCID: PMC5829660 DOI: 10.1136/bmjopen-2017-018524] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To describe the prevalence of statin utilisation by people aged over 50 years in Ireland and the factors associated with the likelihood of using a statin, focusing particularly on those using statins for primary prevention of cardiovascular disease (CVD). METHODS This is a cross-sectional analysis of cardiovascular risk and sociodemographic factors associated with statin utilisation from wave 1 of The Irish Longitudinal Study on Ageing. A hierarchy of indications for statin utilisation, consisting of eight mutually exclusive levels of CVD-related diagnoses, was created. Participants were assigned one level of indication. The prevalence of statin utilisation was calculated. The likelihood that an individual was using a statin was estimated using a multivariable logistic regression model, controlling for cardiovascular risk and sociodemographic factors. RESULTS In this nationally representative sample (n=5618) of community-dwelling participants aged 50 years and over, 1715 (30.5%) were taking statins. Of these, 65.0% (57.3% of men and 72.7% of women) were doing so for the primary prevention of CVD. Thus, almost two-thirds of those taking statins did so for primary prevention and there was a notable difference between women and men in this regard. We also found that statin utilisation was highest among those with a prior history of CVD and was significantly associated with age (compared with the base category 50-64 years; 65-74 years OR 1.38 (95% CI 1.16 to 1.65); 75+ OR 1.33 (95% CI 1.04 to 1.69)), living with a spouse or partner (compared with the base category living alone; OR 1.35 (95% CI 1.10 to 1.65)), polypharmacy (OR 1.74 (95% CI 1.39 to 2.19)) and frequency of general practitioner visits (compared with the base category 0 visits per year; 1-2 visits OR 2.46 (95% CI 1.80 to 3.35); 3-4 visits OR 3.24 (95% CI 2.34 to 4.47); 5-6 visits OR 2.98 (95% CI 2.08 to 4.26); 7+ visits OR 2.51 (95% CI 1.73 to 3.63)), even after controlling for clinical need. There was no association between using statins and gender, education, income, social class, health insurance status, location or Systematic Coronary Risk Evaluation (SCORE) risk in the multivariable analysis. CONCLUSION Statin utilisation among those with no history of CVD accounted for almost two-thirds of all statin use, in part reflecting the high proportion of the population with no history of CVD, although utilisation rates were highest among those with a history of CVD.
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Affiliation(s)
- Paula Byrne
- National University of Ireland Galway, Galway, Ireland
| | - John Cullinan
- National University of Ireland Galway, Galway, Ireland
| | - Catríona Murphy
- Dublin City University, Dublin, Ireland
- The Irish Longitudinal Study on Ageing (TILDA), Dublin, Ireland
| | - Susan M Smith
- Royal College of Surgeons in Ireland, Dublin, Ireland
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340
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Sum G, Hone T, Atun R, Millett C, Suhrcke M, Mahal A, Koh GCH, Lee JT. Multimorbidity and out-of-pocket expenditure on medicines: a systematic review. BMJ Glob Health 2018; 3:e000505. [PMID: 29564155 PMCID: PMC5859814 DOI: 10.1136/bmjgh-2017-000505] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/21/2017] [Accepted: 11/29/2017] [Indexed: 01/11/2023] Open
Abstract
Background Multimorbidity, the presence of two or more non-communicable diseases (NCD), is a costly and complex challenge for health systems globally. Patients with NCDs incur high levels of out-of-pocket expenditure (OOPE), often on medicines, but the literature on the association between OOPE on medicines and multimorbidity has not been examined systematically. Methods A systematic review was conducted via searching medical and economics databases including Ovid Medline, EMBASE, EconLit, Cochrane Library and the WHO Global Health Library from year 2000 to 2016. Study quality was assessed using Newcastle-Ottawa Scale. PROSPERO: CRD42016053538. Findings 14 articles met inclusion criteria. Findings indicated that multimorbidity was associated with higher OOPE on medicines. When number of NCDs increased from 0 to 1, 2 and ≥3, annual OOPE on medicines increased by an average of 2.7 times, 5.2 times and 10.1 times, respectively. When number of NCDs increased from 0 to 1, 2, ≥2 and ≥3, individuals spent a median of 0.36% (IQR 0.15%–0.51%), 1.15% (IQR 0.62%–1.64%), 1.41% (IQR 0.86%–2.15%), 2.42% (IQR 2.05%–2.64%) and 2.63% (IQR 1.56%–4.13%) of mean annual household net adjusted disposable income per capita, respectively, on annual OOPE on medicines. More multimorbidities were associated with higher OOPE on medicines as a proportion of total healthcare expenditures by patients. Some evidence suggested that the elderly and low-income groups were most vulnerable to higher OOPE on medicines. With the same number of NCDs, certain combinations of NCDs yielded higher medicine OOPE. Non-adherence to medicines was a coping strategy for OOPE on medicines. Conclusion Multimorbidity of NCDs is increasingly costly to healthcare systems and OOPE on medicines can severely compromise financial protection and universal health coverage. It is crucial to recognise the need for better equity and financial protection, and policymakers should consider health system financial options, cost sharing policies and service patterns for those with NCD multimorbidities.
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Affiliation(s)
- Grace Sum
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Thomas Hone
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Rifat Atun
- Harvard T.H Chan, School of Public Health, and Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Christopher Millett
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Marc Suhrcke
- Centre for Health Economics, University of York, England, UK.,Luxembourg Institute for Socio-economic Research, Luxembourg, Europe
| | - Ajay Mahal
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | - John Tayu Lee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore.,Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.,Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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341
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Patton DE, Cadogan CA, Ryan C, Francis JJ, Gormley GJ, Passmore P, Kerse N, Hughes CM. Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators. Health Expect 2018; 21:138-148. [PMID: 28766816 PMCID: PMC5750691 DOI: 10.1111/hex.12595] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst multimorbid older people prescribed multiple medications. Interventions targeting adherence often lack a theoretical underpinning and this may impact on effectiveness. The theoretical domains framework (TDF) of behaviour can aid intervention development by systematically identifying key determinants of medication adherence. OBJECTIVES This study aimed to (i) identify determinants (barriers, facilitators) of adherence to multiple medications from older people's perspectives; (ii) identify key domains to target for behaviour change; and (iii) map key domains to intervention components [behaviour change techniques (BCTs)] that could be delivered in an intervention by community pharmacists. METHOD Focus groups were conducted with older people (>65 years) receiving ≥4 medications. Questions explored the 12 domains of the TDF (eg "Knowledge," "Emotion"). Data were analysed using the framework method and content analysis. Identification of key domains and mapping to intervention components (BCTs) followed established methods. RESULTS Seven focus groups were convened (50 participants). A wide range of determinants were identified as barriers (eg forgetfulness, prioritization of medications) and facilitators (eg social support, personalized routines) of adherence to multiple medications. Eight domains were identified as key targets for behaviour change (eg "Social influences," "Memory, attention and decision processes," "Motivation and goals") and mapped to 11 intervention components (BCTs) to include in an intervention [eg "Social support or encouragement (general)," "Self-monitoring of the behaviour," "Goal-setting (behaviour)"]. CONCLUSION This study used a theoretical underpinning to identify potential intervention components (BCTs). Future work will incorporate the selected BCTs into an intervention that will undergo feasibility testing in community pharmacies.
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Affiliation(s)
| | - Cathal A. Cadogan
- School of PharmacyQueen's University BelfastBelfastUK
- School of PharmacyRoyal College of Surgeons in IrelandDublinIreland
| | - Cristín Ryan
- School of PharmacyQueen's University BelfastBelfastUK
- School of PharmacyRoyal College of Surgeons in IrelandDublinIreland
| | | | | | - Peter Passmore
- Centre for Public HealthQueen's University BelfastBelfastUK
| | - Ngaire Kerse
- School of Population HealthUniversity of AucklandAucklandNew Zealand
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Partanen R. Don't miss the boat: maximise ad hoc teaching with general practice trainees. MEDICAL EDUCATION 2018; 52:143-145. [PMID: 29356082 DOI: 10.1111/medu.13507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Mohammed MA, Moles RJ, Hilmer SN, Kouladjian O'Donnel L, Chen TF. Development and validation of an instrument for measuring the burden of medicine on functioning and well-being: the Medication-Related Burden Quality of Life (MRB-QoL) tool. BMJ Open 2018; 8:e018880. [PMID: 29330175 PMCID: PMC5781060 DOI: 10.1136/bmjopen-2017-018880] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Medication-related burden (MRB) is a negative experience with medicine, which may impact on psychological, social, physical and financial well-being of an individual. This study describes the development and initial validation of an instrument specifically designed to measure MRB on functioning and well-being-the Medication-Related Burden Quality of Life (MRB-QoL) tool. METHODS An initial pool of 76-items for MRB-QoL was generated. The link to MRB-QoL survey was sent to a sample of consumers living with at least one chronic medical condition and taking ≥3 prescription medicines on a regular basis. Exploratory factor analysis (EFA) was used to determine the underlining factor structure. Internal consistency (Cronbach's α) and construct validity were examined. The latter was examined through correlation with Medication Regimen Complexity Index (MRCI), Drug Burden Index (DBI) and Charlson's Comorbidity Index (CCI). RESULTS 367 consumers completed the survey (51.2% male). EFA resulted in a 31-item, five-factor solution explaining 72% of the total variance. The five subscales were labelled as 'Routine and Regimen Complexity' (11 items), 'Psychological Burden' (six items), 'Functional and Role Limitation' (seven items), 'Therapeutic Relationship' (three items) and 'Social Burden' (four items). All subscales showed good internal consistency (Cronbach's α 0.87 to 0.95). Discriminant validity of MRB-QoL was demonstrated via its correlations with MRCI (Spearman's r -0.16 to 0.08), DBI (r 0.12 to 0.28) and CCI (r -0.23 to -0.15). Correlation between DBI and 'Functional and Role Limitation' subscale (r 0.36) indicated some evidence of convergent validity. Patients with polypharmacy, multiple morbidity and DBI >0 had higher median scores of MRB-QoL providing evidence for known group validity. CONCLUSIONS The MRB-QoL V.1 has good construct validity and internal consistency. The MRB-QoL may be a useful humanistic measure for evaluating the impact of pharmaceutical care interventions on patients' quality of life. Future research is warranted to further examine additional psychometric properties of MRB-QoL V.1 and its utility in patient care.
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Affiliation(s)
- Mohammed A Mohammed
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
| | - Rebekah J Moles
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
| | - Sarah N Hilmer
- Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Cognitive Decline Partnership Centre, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Kouladjian O'Donnel
- Department of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
- Cognitive Decline Partnership Centre, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Timothy F Chen
- Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
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Catalá-López F, Alonso-Arroyo A, Page MJ, Hutton B, Tabarés-Seisdedos R, Aleixandre-Benavent R. Mapping of global scientific research in comorbidity and multimorbidity: A cross-sectional analysis. PLoS One 2018; 13:e0189091. [PMID: 29298301 PMCID: PMC5751979 DOI: 10.1371/journal.pone.0189091] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 11/18/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The management of comorbidity and multimorbidity poses major challenges to health services around the world. Analysis of scientific research in comorbidity and multimorbidity is limited in the biomedical literature. This study aimed to map global scientific research in comorbidity and multimorbidity to understand the maturity and growth of the area during the past decades. METHODS AND FINDINGS This was a cross-sectional analysis of the Web of Science. Searches were run from inception until November 8, 2016. We included research articles or reviews with no restrictions by language or publication date. Data abstraction was done by one researcher. A process of standardization was conducted by two researchers to unify different terms and grammatical variants and to remove typographical, transcription, and/or indexing errors. All potential discrepancies were resolved via discussion. Descriptive analyses were conducted (including the number of papers, citations, signatures, most prolific authors, countries, journals and keywords). Network analyses of collaborations between countries and co-words were presented. During the period 1970-2016, 85994 papers (64.0% in 2010-2016) were published in 3500 journals. There was wide diversity in the specialty of the journals, with psychiatry (16558 papers; 19.3%), surgery (9570 papers; 11.1%), clinical neurology (9275 papers; 10.8%), and general and internal medicine (7622 papers; 8.9%) the most common. PLOS One (1223 papers; 1.4%), the Journal of Affective Disorders (1154 papers; 1.3%), the Journal of Clinical Psychiatry (727 papers; 0.8%), the Journal of the American Geriatrics Society (634 papers; 0.7%) and Obesity Surgery (588 papers; 0.7%) published the largest number of papers. 168 countries were involved in the production of papers. The global productivity ranking was headed by the United States (37624 papers), followed by the United Kingdom (7355 papers), Germany (6899 papers) and Canada (5706 papers). Twenty authors who published 100 or more papers were identified; the most prolific authors were affiliated with Harvard Medical School, State University of New York Upstate Medical University, National Taiwan Normal University and China Medical University. The 50 most cited papers ("citation classics" with at least 1000 citations) were published in 20 journals, led by JAMA Psychiatry (11 papers) and JAMA (10 papers). The most cited papers provided contributions focusing on methodological aspects (e.g. Charlson Comorbidity Index, Elixhauser Comorbidity Index, APACHE prognostic system), but also important studies on chronic diseases (e.g. epidemiology of mental disorders and its correlates by the U.S. National Comorbidity Survey, Fried's frailty phenotype or the management of obesity). CONCLUSIONS Ours is the first analysis of global scientific research in comorbidity and multimorbidity. Scientific production in the field is increasing worldwide with research leadership of Western countries, most notably, the United States.
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Affiliation(s)
- Ferrán Catalá-López
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain
- Fundación Instituto de Investigación en Servicios de Salud, Valencia, Spain
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Adolfo Alonso-Arroyo
- Department of History of Science and Documentation, University of Valencia, Valencia, Spain
- Unidad de Información e Investigación Social y Sanitaria-UISYS, University of Valencia and Spanish National Research Council (CSIC), Valencia, Spain
| | - Matthew J. Page
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Rafael Tabarés-Seisdedos
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain
| | - Rafael Aleixandre-Benavent
- Unidad de Información e Investigación Social y Sanitaria-UISYS, University of Valencia and Spanish National Research Council (CSIC), Valencia, Spain
- Ingenio-Spanish National Research Council (CSIC) and Universitat Politécnica de Valencia (UPV), Valencia, Spain
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345
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McKinlay E, Young J, Gray B. General practice and patients’ views of the social networks of patients with multimorbidity. J Prim Health Care 2018; 10:258-266. [DOI: 10.1071/hc17050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
ABSTRACT
INTRODUCTION
For patients with multimorbidity to live well, they need the support of not only health professionals but family, friends and organisations. These social networks provide support, potentially enabling the formation of a Community of Clinical Practice approach to multimorbidity care.
AIM
This study aimed to explore general practice knowledge of the social networks of patients with multimorbidity.
METHODS
Social network maps were completed by both patients and general practice. The social network maps of 22 patients with multimorbidity were compared with corresponding social network maps completed by general practice staff.
RESULTS
In 60% (13/22) of the patients, general practice staff held a high or moderate knowledge of individual patients’ social networks. Information on social networks was recalled from staff memory and not systematically recorded in patients’ electronic health records.
DISCUSSION
Social network information is not routinely collected, recorded or used by general practice to understand the support available to patients with multimorbidity. General practice could take an active role in coordinating social network supporters for certain patient groups with complex multimorbidity. For these groups, there is value in systematically recording and regularly updating their social network information for general practice to use as part of a coordinated Community of Clinical Practice.
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346
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Choosing a medication brand: Excipients, food intolerance and prescribing in older people. Maturitas 2018; 107:103-109. [DOI: 10.1016/j.maturitas.2017.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/01/2017] [Indexed: 11/18/2022]
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Jones J, Jones GD, Thacker M, Faithfull S. Physical activity interventions are delivered consistently across hospitalized older adults but multimorbidity is associated with poorer rehabilitation outcomes: A population-based cohort study. J Eval Clin Pract 2017; 23:1469-1477. [PMID: 28990265 DOI: 10.1111/jep.12833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/05/2017] [Accepted: 08/07/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older adults live with multimorbidity including frailty and cognitive impairment often requiring hospitalization. While physical activity interventions (PAIs) are a normal rehabilitative treatment, their clinical effect in hospitalized older adults is uncertain. OBJECTIVE To observe PAI dosing characteristics and determine their impact on clinical performance parameters. DESIGN A single-site prospective observational cohort study in an older persons' unit. SUBJECTS Seventy-five older persons' unit patients ≥65 years. INTERVENTION PAI; therapeutic contact between physiotherapy clinician and patient. MEASUREMENTS Parameters included changes in activities-of-daily-living (Barthel Index), handgrip strength, balance confidence, and gait velocity, measured between admission and discharge (episode). Dosing characteristics were PAI temporal initiation, frequency, and duration. Frailty/cognition status was dichotomized independently per participant yielding 4 subgroups: frail/nonfrail and cognitively-impaired/cognitively-unimpaired. RESULTS Median (interquartile range) PAI initiation occurred after 2 days (1-4), frequency was 0.4 PAIs per day (0.3-0.5), and PAI duration per episode was 3.75 hours (1.8-7.2). All clinical parameters improved significantly across episodes: grip strength median (interquartile range) change, 2.0 kg (0.0-2.3) (P < .01); Barthel Index, 5 (3-8) (P < .01); gait velocity, 0.06 m.∙s-1 (0.06-0.16) (P < .01); and balance confidence, -3 (-6 to -1) (P < .01). Physical activity intervention dosing remained consistent within subgroups. While several moderate to large associations between amount of PAIs and change in clinical parameters were observed, most were within unimpaired subgroups. CONCLUSIONS PAI dosing is consistent. However, while clinical changes during hospital episodes are positive, more favourable responses to PAIs occur if patients are nonfrail/cognitively-unimpaired. Therefore, to deliver a personalized rehabilitation approach, adaptation of PAI dose based on patient presentation is desirable.
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Affiliation(s)
- Jacky Jones
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Michael Thacker
- Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre of Human and Aerospace Physiological Sciences, Faculty of Life Sciences and Medicine, Kings College London, London, UK.,Allied Health Sciences, School for Health and Social Care, London South Bank University, London, UK
| | - Sara Faithfull
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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348
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Vermunt NP, Harmsen M, Elwyn G, Westert GP, Burgers JS, Olde Rikkert MG, Faber MJ. A three-goal model for patients with multimorbidity: A qualitative approach. Health Expect 2017; 21:528-538. [PMID: 29193557 PMCID: PMC5867317 DOI: 10.1111/hex.12647] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2017] [Indexed: 02/06/2023] Open
Abstract
Background To meet the challenge of multimorbidity in decision making, a switch from a disease‐oriented to a goal‐oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed. Objective This study aimed to develop conceptual descriptions of goal‐oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity. Method Qualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis. Results Clinicians distinguished disease‐ or symptom‐specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. “Fundamental goals” are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations. Conclusion Based on the perspectives of clinicians, we expanded the concept of goal‐oriented care by identifying a three‐level goal hierarchy. This model could facilitate collaborative goal‐setting for patients with multiple long‐term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice.
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Affiliation(s)
- Neeltje P Vermunt
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,The Dutch Council for Health and Society (Raad voor Volksgezondheid en Samenleving, RVS), The Hague, The Netherlands
| | - Mirjam Harmsen
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Glyn Elwyn
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA.,Cochrane Institute for Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Gert P Westert
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jako S Burgers
- Family Medicine Department, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands.,Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Marcel G Olde Rikkert
- Radboud University Medical Center/Radboudumc Alzheimer Center, Nijmegen, The Netherlands
| | - Marjan J Faber
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Lloyd HM, Pearson M, Sheaff R, Asthana S, Wheat H, Sugavanam TP, Britten N, Valderas J, Bainbridge M, Witts L, Westlake D, Horrell J, Byng R. Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care. Health Res Policy Syst 2017; 15:98. [PMID: 29166917 PMCID: PMC5700670 DOI: 10.1186/s12961-017-0263-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable ‘blue print’ mean that services are ‘experimenting’ with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings. Methods Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations. Results Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.
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Affiliation(s)
- Helen M Lloyd
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom.
| | - Mark Pearson
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom.,Health Services & Policy Research, University of Exeter Collaboration for Academic Primary Care, APEx, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Rod Sheaff
- School of Law, Criminology and Government, University of Plymouth, Portland Villas, Plymouth, Devon, PL4 8AA, United Kingdom
| | - Sheena Asthana
- School of Law, Criminology and Government, University of Plymouth, Portland Villas, Plymouth, Devon, PL4 8AA, United Kingdom
| | - Hannah Wheat
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Thava Priya Sugavanam
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Nicky Britten
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom.,Health Services & Policy Research, University of Exeter Collaboration for Academic Primary Care, APEx, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Jose Valderas
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom.,Health Services & Policy Research, University of Exeter Collaboration for Academic Primary Care, APEx, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Michael Bainbridge
- Primary Care Development Somerset Clinical Commissioning Group, Working Together to Improve Health and Wellbeing, Wynford House, Lufton Way, Yeovil, Somerset, BA22 8HR, United Kingdom
| | - Louise Witts
- South West Academic Health Science Network, Pynes Hill Court, Pynes Hill, Exeter, EX2 5AZ, United Kingdom
| | - Debra Westlake
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Jane Horrell
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Richard Byng
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
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Stokes J, Man MS, Guthrie B, Mercer SW, Salisbury C, Bower P. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. Ann Fam Med 2017; 15:570-577. [PMID: 29133498 PMCID: PMC5683871 DOI: 10.1370/afm.2150] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/09/2017] [Accepted: 06/15/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Multimorbidity challenges health systems globally. New models of care are urgently needed to better manage patients with multimorbidity; however, there is no agreed framework for designing and reporting models of care for multimorbidity and their evaluation. METHODS Based on findings from a literature search to identify models of care for multimorbidity, we developed a framework to describe these models. We illustrate the application of the framework by identifying the focus and gaps in current models of care, and by describing the evolution of models over time. RESULTS Our framework describes each model in terms of its theoretical basis and target population (the foundations of the model) and of the elements of care implemented to deliver the model. We categorized elements of care into 3 types: (1) clinical focus, (2) organization of care, (3) support for model delivery. Application of the framework identified a limited use of theory in model design and a strong focus on some patient groups (elderly, high users) more than others (younger patients, deprived populations). We found changes in elements with time, with a decrease in models implementing home care and an increase in models offering extended appointments. CONCLUSIONS By encouragin greater clarity about the underpinning theory and target population, and by categorizing the wide range of potentially important elements of an intervention to improve care for patients with multimorbidity, the framework may be useful in designing and reporting models of care and help advance the currently limited evidence base.
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Affiliation(s)
- Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom .,Centre for Health Economics, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Mei-See Man
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Bruce Guthrie
- Quality, Safety and Informatics Research Group, University of Dundee, Dundee, United Kingdom
| | - Stewart W Mercer
- General Practice and Primary Care, Institute for Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
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