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Puth MT, Weckbecker K, Schmid M, Münster E. Prevalence of multimorbidity in Germany: impact of age and educational level in a cross-sectional study on 19,294 adults. BMC Public Health 2017; 17:826. [PMID: 29047341 PMCID: PMC5648462 DOI: 10.1186/s12889-017-4833-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 10/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multimorbidity is one of the most important and challenging aspects in public health. Multimorbid people are associated with more hospital admissions, a large number of drug prescriptions and higher risks of mortality. As there is evidence that multimorbidity varies with age and socioeconomic disparity, the main objective aimed at determining age-specific prevalence rates as well as exploring educational differences relating to multimorbidity in Germany. METHODS This cross-sectional analysis is based on the national telephone health interview survey "German Health Update" (GEDA2012) conducted between March 2012 and March 2013 with nearly 20,000 adults. GEDA2012 provides information on 17 self-reported health conditions along with sociodemographic characteristics. Multimorbidity was defined as the occurrence of two or more chronic conditions in one individual at the same time. Descriptive statistical analysis was used to examine multimorbidity according to age and education, which was defined by the International Standard Classification of Education (ISCED 1997). RESULTS Overall, 39.6% (95% confidence interval (CI) 38.7%-40.6%) of the 19,294 participants were multimorbid and the proportion of adults with multimorbidity increased substantially with age: nearly half (49.2%, 95% CI 46.9%-51.5%) of the adults aged 50-59 years had already two or more chronic health conditions. Prevalence rates of multimorbidity differed considerably between the levels of education. Low-level educated adults aged 40-49 years were more likely to be multimorbid with a prevalence rate of 47.4% (95% CI 44.2%-50.5%) matching those of highly educated men and women aged about ten years older. CONCLUSIONS Our findings demonstrate that both, age and education are associated with a higher risk of being multimorbid in Germany. Hence, special emphasis in the development of new approaches in national public health and prevention programs on multimorbidity should be given to low-level educated people aged <65 years.
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Affiliation(s)
- Marie-Therese Puth
- Institute of General Practice and Family Medicine, University of Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany. .,Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany.
| | - Klaus Weckbecker
- Institute of General Practice and Family Medicine, University of Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Matthias Schmid
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Eva Münster
- Institute of General Practice and Family Medicine, University of Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
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Moriarty F, Cahir C, Bennett K, Hughes CM, Kenny RA, Fahey T. Potentially inappropriate prescribing and its association with health outcomes in middle-aged people: a prospective cohort study in Ireland. BMJ Open 2017; 7:e016562. [PMID: 29042380 PMCID: PMC5652466 DOI: 10.1136/bmjopen-2017-016562] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To determine the prevalence of potentially inappropriate prescribing (PIP) in a cohort of community-dwelling middle-aged people and assess the relationship between PIP and emergency department (ED) visits, general practitioner (GP) visits and quality of life (QoL). DESIGN Prospective cohort study. SETTING The Irish Longitudinal Study on Ageing (TILDA), a nationally representative cohort study of ageing. PARTICIPANTS Individuals aged 45-64 years recruited to TILDA who were eligible for the means-tested General Medical Services scheme and followed up after 2 years. EXPOSURE PIP was determined in the 12 months preceding baseline and follow-up TILDA data collection by applying the PRescribing Optimally in Middle-aged People's Treatments (PROMPT) criteria to participants' medication dispensing data. OUTCOME MEASURES At follow-up, the reported rates of ED and GP visits over 12 months (primary outcome) and the CASP-R12 (Control Autonomy Self-realisation Pleasure) measure of QoL (secondary outcome). ANALYSIS Multivariate negative binomial (rates) and linear regression (CASP-R12) models controlling for potential confounders. RESULTS At 2-year follow-up (n=808), PIP was detected in 42.9% by the PROMPT criteria. An ED visit was reported by 18.7% and 94.4% visited a GP (median 4 visits, IQR 2-6). Exposure to ≥2 PROMPT criteria was associated with higher rates of healthcare utilisation and lower QoL in unadjusted regression. However, in multivariate analysis, the associations between PIP and rates of ED visits (adjusted incidence rate ratio (IRR) 0.92, 95% CI 0.53 to 1.58), and GP visits (IRR 1.06, 95% CI 0.87 to 1.28), and CASP-R12 score (adjusted β coefficient 0.35, 95% CI -0.93 to 1.64) were not statistically significant. Numbers of medicines and comorbidities were associated with higher healthcare utilisation. CONCLUSIONS Although PIP was prevalent in this study population, there was no evidence of a relationship with ED and GP visits and QoL. Further research should evaluate whether the PROMPT criteria are related to these and other adverse outcomes in the general middle-aged population.
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Affiliation(s)
- Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitriona Cahir
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Carmel M Hughes
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
- Clinical and Practice Research Group, School of Pharmacy, Queen’s University Belfast, Belfast, Northern Ireland
| | - Rose Anne Kenny
- The Irish Longitundinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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353
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Lea SC, Watts KL, Davis NA, Panayiotou B, Bankart MJ, Arora A, Chambers R. The potential clinical benefits of medicines optimisation through comprehensive geriatric assessment, carried out by secondary care geriatricians, in a general practice care setting in North Staffordshire, UK: a feasibility study. BMJ Open 2017; 7:e015278. [PMID: 28963282 PMCID: PMC5640128 DOI: 10.1136/bmjopen-2016-015278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility and potential clinical benefits of medicines optimisation through comprehensive geriatric assessment (CGA) of frail patients with multiple conditions, by secondary care geriatricians in a general practice care setting. METHODS Seven general practitioner (GP) practices in one region of Stoke-on-Trent volunteered to take part. GPs selected patients (n=186) who were local permanent residents, at least 65 years old and on eight or more medications per day. Patients were sent a written invitation outlining the assessment purpose/format. Prior to patient assessments, primary care staff prepared packs detailing patient medical history, recent consultations, current medications, recent laboratory tests and social circumstances. One hour was allocated for the CGA per patient, with one of three geriatricians, to enable sufficient time to explore all relevant aspects. Assessment comprised a full history, thorough clinical examination, assessment of balance and mobility, mental function and information on home environment and support arrangements. After consultation, geriatricians made recommendations regarding further assessments, investigations or medication changes. Geriatricians entered their main findings and recommendations onto a standard template. RESULTS In total, 687 recommendations for changes in patients' medication regimens were made for 169 (91%) patients. In 17 (9%) patients there was no recommendation to alter medications. This resulted in an average of four alterations in medication per patient. The predominant changes to medications were to stop medications (34%) or to reduce the dosage (24%). Starting a new medication represented 18% of all the medication changes. Adherence rates to geriatrician medication recommendations were 72% at 6 months and 65% at 12 months. CONCLUSIONS CGA of older patients with complex needs, by geriatricians in a general practice care setting, is feasible. Our study demonstrated constructive collaboration between GPs and geriatricians from secondary care, suggesting further studies and clinical trials are feasible and have scope to yield beneficial outcomes.
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Affiliation(s)
- Simon Christian Lea
- Department of Research and Development, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Keira Louise Watts
- Department of Research and Development, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Nathan Ashley Davis
- Department of Research and Development, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Barnabas Panayiotou
- Primary Care, Stoke-on-Trent Clinical Commissioning Group, Stoke-on-Trent, UK
| | | | - Amit Arora
- Department of Elderly Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Ruth Chambers
- Primary Care, Stoke-on-Trent Clinical Commissioning Group, Stoke-on-Trent, UK
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Hersh LR, Beldowski K, Hajjar ER. Polypharmacy in the Geriatric Oncology Population. Curr Oncol Rep 2017; 19:73. [DOI: 10.1007/s11912-017-0632-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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355
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Nursing care needs and services utilised by home-dwelling elderly with complex health problems: observational study. BMC Health Serv Res 2017; 17:645. [PMID: 28899369 PMCID: PMC5596938 DOI: 10.1186/s12913-017-2600-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 09/06/2017] [Indexed: 11/20/2022] Open
Abstract
Background In Norway, as in many Western countries, a shift from institutional care to home care is taking place. Our knowledge is limited regarding which needs for nursing interventions patients being cared for in their home have, and how they are met. We aimed at assessing aspects of health and function in a representative sample of the most vulnerable home-dwelling elderly, to identify their needs for nursing interventions and how these needs were met. Methods In this observational study we included patients aged 75+ living in their own homes in Oslo, who received daily home care, had three or more chronic diagnoses, received daily medication, and had been hospitalized during the last year. Focused attention and cognitive processing speed were assessed with the Trail Making Test A (TMT-A), handgrip strength was used as a measure of sarcopenia, mobility was assessed with the “Timed Up-and-Go” test, and independence in primary activities of daily living by the Barthel Index. Diagnoses and medication were collected from electronic medical records. For each diagnosis, medication and functional impairment, a consensus group defined which nursing service that the particular condition necessitated. We then assessed whether these needs were fulfilled for each participant. Results Of 150 eligible patients, 83 were included (mean age 87 years, 25% men). They had on average 6 diagnoses and used 9 daily medications. Of the 83 patients, 61 (75%) had grip strength indicating sarcopenia, 27 (33%) impaired mobility, and 69 (83%) an impaired TMT-A score. Median amount of home nursing per week was 3.6 h (interquartile range 2.6 to 23.4). Fulfilment of pre-specified needs was >60% for skin and wound care in patients with skin diseases, observation of blood glucose in patients taking antidiabetic drugs, and in supporting food intake in patients with eating difficulties. Most other needs as defined by the consensus group were fulfilled in <10% of the patients. Conclusions We identified a very frail group of home-dwelling patients. For this group, resources for home nursing should probably be used in a more flexible and pro-active way to aim for preserving functional status, minimize symptom burden, and prevent avoidable hospitalisations.
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356
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Le Couteur DG, Wahl D, Naismith SL. Comorbidity and vascular cognitive impairment-no dementia (VCI-ND). Age Ageing 2017; 46:705-707. [PMID: 28481963 DOI: 10.1093/ageing/afx080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/26/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- David G Le Couteur
- Charles Perkins Centre, University of Sydney, Sydney, Australia
- Centre for Education and Research on Ageing and the Ageing and Alzheimers Research Institute, University of Sydney and Concord Hospital, Concord, Australia
| | - Devin Wahl
- Charles Perkins Centre, University of Sydney, Sydney,Australia
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357
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Olaya B, Moneta MV, Caballero FF, Tyrovolas S, Bayes I, Ayuso-Mateos JL, Haro JM. Latent class analysis of multimorbidity patterns and associated outcomes in Spanish older adults: a prospective cohort study. BMC Geriatr 2017; 17:186. [PMID: 28821233 PMCID: PMC5563011 DOI: 10.1186/s12877-017-0586-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 08/10/2017] [Indexed: 01/08/2023] Open
Abstract
Background This study sought to identify multimorbidity patterns and determine the association between these latent classes with several outcomes, including health, functioning, disability, quality of life and use of services, at baseline and after 3 years of follow-up. Methods We analyzed data from a representative Spanish cohort of 3541 non-institutionalized people aged 50 years old and over. Measures were taken at baseline and after 3 years of follow-up. Latent Class Analysis (LCA) was conducted using eleven common chronic conditions. Generalized linear models were conducted to determine the adjusted association of multimorbidity latent classes with several outcomes. Results 63.8% of participants were assigned to the “healthy” class, with minimum disease, 30% were classified under the “metabolic/stroke” class and 6% were assigned to the “cardiorespiratory/mental/arthritis” class. Significant cross-sectional associations were found between membership of both multimorbidity classes and poorer memory, quality of life, greater burden and more use of services. After 3 years of follow-up, the “metabolic/stroke” class was a significant predictor of lower levels of verbal fluency while the two multimorbidity classes predicted poor quality of life, problems in independent living, higher risk of hospitalization and greater use of health services. Conclusions Common chronic conditions in older people cluster together in broad categories. These broad clusters are qualitatively distinct and are important predictors of several health and functioning outcomes. Future studies are needed to understand underlying mechanisms and common risk factors for patterns of multimorbidity and to propose more effective treatments. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0586-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Beatriz Olaya
- Research, Innovation and Teaching Unit, Institut de Recerca Sant Joan de Déu, Carrer Dr. Antoni Pujadas, 42, Esplugues de Llobregat, 08830, Barcelona, Spain. .,Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain. .,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.
| | - Maria Victoria Moneta
- Research, Innovation and Teaching Unit, Institut de Recerca Sant Joan de Déu, Carrer Dr. Antoni Pujadas, 42, Esplugues de Llobregat, 08830, Barcelona, Spain.,Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Francisco Félix Caballero
- Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid, Madrid, Spain.,Department of Psychiatry, Instituto de Investigación Sanitaria Princesa (IP), Hospital Universitario de La Princesa, Madrid, Spain
| | - Stefanos Tyrovolas
- Research, Innovation and Teaching Unit, Institut de Recerca Sant Joan de Déu, Carrer Dr. Antoni Pujadas, 42, Esplugues de Llobregat, 08830, Barcelona, Spain.,Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Ivet Bayes
- Research, Innovation and Teaching Unit, Institut de Recerca Sant Joan de Déu, Carrer Dr. Antoni Pujadas, 42, Esplugues de Llobregat, 08830, Barcelona, Spain.,Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - José Luis Ayuso-Mateos
- Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Department of Psychiatry, Universidad Autónoma de Madrid, Madrid, Spain.,Department of Psychiatry, Instituto de Investigación Sanitaria Princesa (IP), Hospital Universitario de La Princesa, Madrid, Spain
| | - Josep Maria Haro
- Research, Innovation and Teaching Unit, Institut de Recerca Sant Joan de Déu, Carrer Dr. Antoni Pujadas, 42, Esplugues de Llobregat, 08830, Barcelona, Spain.,Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.,Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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358
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Hayek S, Ifrah A, Enav T, Shohat T. Prevalence, Correlates, and Time Trends of Multiple Chronic Conditions Among Israeli Adults: Estimates From the Israeli National Health Interview Survey, 2014-2015. Prev Chronic Dis 2017; 14:E64. [PMID: 28796598 PMCID: PMC5553352 DOI: 10.5888/pcd14.170038] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Chronic diseases constitute a major public health challenge. The prevalence of multiple chronic conditions (MCC) has increased. The objective of our study was to describe the prevalence, correlates, and time trends of MCC in the Israeli population and among the nation's 2 main population groups (Jewish and Arab). METHODS To describe the prevalence of correlates of MCC, we used data from the 2014-2015 Israeli National Health Interview Survey-III (INHIS-III). MCC was defined as having 2 or more of the following 10 self-reported physician-diagnosed chronic conditions: asthma, arthritis, cancer, diabetes, dyslipidemia, heart attack, hypertension, migraine, osteoporosis, or thyroid disease. For trend analysis, we used data from INHIS-I (2003-2004) and INHIS-II (2007-2010). Logistic regression was used for multivariate analysis. Estimates were weighted to the 2014 Israeli population. P for trend was calculated by using the Cochran-Armitage test for proportions. RESULTS In 2014-2015, the prevalence of MCC was 27.3% (95% confidence interval, 25.7%-28.8%). In multivariate analysis, MCC was associated with older age, female sex, a monthly household income of USD$3,000 or less, current and past smoking, and overweight or obesity. After adjusting for age, sex, income, smoking status, and body mass index, differences in MCC between Jewish and Arab populations disappeared. Dyslipidemia and hypertension were the most prevalent dyad among both men and women. Dyslipidemia, hypertension, and diabetes were the most prevalent triad among both men and women. The age-adjusted prevalence of MCC increased by 6.7% between 2003-2004 and 2014-2015. CONCLUSION With the increase in the prevalence of MCC, a comprehensive approach is needed to reduce the burden of chronic conditions. Of special concern are the groups most prone to MCC.
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Affiliation(s)
- Samah Hayek
- Israel Center for Disease Control, Israel Ministry of Health, Jerusalem, Israel.
| | - Anneke Ifrah
- Israel Center for Disease Control, Israel Ministry of Health, Jerusalem, Israel
| | - Teena Enav
- Israel Center for Disease Control, Israel Ministry of Health, Jerusalem, Israel
| | - Tamy Shohat
- Israel Center for Disease Control, Israel Ministry of Health, Jerusalem, Israel
- Department of Epidemiology and Preventive Medicine, Tel Aviv University, Tel Aviv, Israel
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Turner M, Fielding S, Ong Y, Dibben C, Feng Z, Brewster DH, Black C, Lee A, Murchie P. A cancer geography paradox? Poorer cancer outcomes with longer travelling times to healthcare facilities despite prompter diagnosis and treatment: a data-linkage study. Br J Cancer 2017; 117:439-449. [PMID: 28641316 PMCID: PMC5537495 DOI: 10.1038/bjc.2017.180] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/28/2017] [Accepted: 05/26/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Rurality and distance from cancer treatment centres have been shown to negatively impact cancer outcomes, but the mechanisms remain obscure. METHODS We analysed the impact of travel time to key healthcare facilities and mainland/island residency on the cancer diagnostic pathway (treatment within 62 days of referral, and within 31 days of diagnosis) and 1-year mortality using a data-linkage study with 12 339 patients. RESULTS After controlling for important confounders, mainland patients with more than 60 min of travelling time to their cancer treatment centre ((OR 1.42; 95% CI 1.25-1.61) and island dwellers (OR 1.32; 95% CI 1.09-1.59) were more likely to commence cancer treatment within 62 days of general practitioner (GP) referral and within 31 days of their cancer diagnosis compared with those living within 15 min. Island-dweller patients were more likely to have their diagnosis and treatment started on the same or next day (OR 1.72; 95% CI 1.31-2.25). Increased travelling time to a cancer treatment centre was associated with increased mortality to 1 year (30-59 min (HR 1.21; 95% CI 1.05-1.41), >60 min (HR 1.18; 95% CI 1.03-1.36), island dweller (HR 1.17; 95% CI 0.97-1.41). CONCLUSIONS Island dwelling and greater mainland travel burden was associated with more rapid cancer diagnosis and treatment following GP referral even after adjustment for advanced disease; however, these patients also experienced a survival disadvantage compared with those living nearer. Cancer services may need to be better configured to suit the different needs of dispersed populations.
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Affiliation(s)
- Melanie Turner
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Shona Fielding
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Yuhan Ong
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Chris Dibben
- School of Geosciences, Drummond Street, Edinburgh EH8 9XP, UK
| | - Zhiqianq Feng
- School of Geosciences, Drummond Street, Edinburgh EH8 9XP, UK
| | - David H Brewster
- Information Services Division, NHS National Services Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB, UK
| | - Corri Black
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Amanda Lee
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Peter Murchie
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
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Willis TA, West R, Rushforth B, Stokes T, Glidewell L, Carder P, Faulkner S, Foy R. Variations in achievement of evidence-based, high-impact quality indicators in general practice: An observational study. PLoS One 2017; 12:e0177949. [PMID: 28704407 PMCID: PMC5509104 DOI: 10.1371/journal.pone.0177949] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 05/05/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There are widely recognised variations in the delivery and outcomes of healthcare but an incomplete understanding of their causes. There is a growing interest in using routinely collected 'big data' in the evaluation of healthcare. We developed a set of evidence-based 'high impact' quality indicators (QIs) for primary care and examined variations in achievement of these indicators using routinely collected data in the United Kingdom (UK). METHODS Cross-sectional analysis of routinely collected, electronic primary care data from a sample of general practices in West Yorkshire, UK (n = 89). The QIs covered aspects of care (including processes and intermediate clinical outcomes) in relation to diabetes, hypertension, atrial fibrillation, myocardial infarction, chronic kidney disease (CKD) and 'risky' prescribing combinations. Regression models explored the impact of practice and patient characteristics. Clustering within practice was accounted for by including a random intercept for practice. RESULTS Median practice achievement of the QIs ranged from 43.2% (diabetes control) to 72.2% (blood pressure control in CKD). Considerable between-practice variation existed for all indicators: the difference between the highest and lowest performing practices was 26.3 percentage points for risky prescribing and 100 percentage points for anticoagulation in atrial fibrillation. Odds ratios associated with the random effects for practices emphasised this; there was a greater than ten-fold difference in the likelihood of achieving the hypertension indicator between the lowest and highest performing practices. Patient characteristics, in particular age, gender and comorbidity, were consistently but modestly associated with indicator achievement. Statistically significant practice characteristics were identified less frequently in adjusted models. CONCLUSIONS Despite various policy and improvement initiatives, there are enduring inappropriate variations in the delivery of evidence-based care. Much of this variation is not explained by routinely collected patient or practice variables, and is likely to be attributable to differences in clinical and organisational behaviour.
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Affiliation(s)
- Thomas A. Willis
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Tim Stokes
- Department of General Practice & Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Paul Carder
- West Yorkshire Research & Development, NHS Bradford Districts CCG, Douglas Mill, Bradford, United Kingdom
| | | | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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361
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McLean G, Hindle JV, Guthrie B, Mercer SW. Co-morbidity and polypharmacy in Parkinson's disease: insights from a large Scottish primary care database. BMC Neurol 2017; 17:126. [PMID: 28666413 PMCID: PMC5493890 DOI: 10.1186/s12883-017-0904-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Parkinson’s disease is complicated by comorbidity and polypharmacy, but the extent and patterns of these are unclear. We describe comorbidity and polypharmacy in patients with and without Parkinson’s disease across 31 other physical, and seven mental health conditions. Methods We analysed primary health-care data on 510,502 adults aged 55 and over. We generated standardised prevalence rates by age-groups, gender, and neighbourhood deprivation, then calculated age, sex and deprivation adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for those with PD compared to those without, for the prevalence, and number of conditions. Results Two thousand six hundred forty (0.5%) had Parkinson’s disease, of whom only 7.4% had no other conditions compared with 22.9% of controls (adjusted OR [aOR] 0.43, 95% 0.38–0.49). The Parkinson’s group had more conditions, with the biggest difference found for seven or more conditions (PD 12.1% vs. controls 3.9%; aOR 2.08 95% CI 1.84–2.35). 12 of the 31 physical conditions and five of the seven mental health conditions were significantly more prevalent in the PD group. 44.5% with Parkinson’s disease were on five to nine repeat prescriptions compared to 24.5% of controls (aOR 1.40; 95% CI 1.28 to 1.53) and 19.2% on ten or more compared to 6.2% of controls (aOR 1.90; 95% CI 1.68 to 2.15). Conclusions Parkinson’s disease is associated with substantial physical and mental co-morbidity. Polypharmacy is also a significant issue due to the complex nature of the disease and associated treatments.
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Affiliation(s)
- Gary McLean
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 9LX, UK
| | | | - Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 9LX, UK.
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Muche-Borowski C, Lühmann D, Schäfer I, Mundt R, Wagner HO, Scherer M. Development of a meta-algorithm for guiding primary care encounters for patients with multimorbidity using evidence-based and case-based guideline development methodology. BMJ Open 2017; 7:e015478. [PMID: 28645968 PMCID: PMC5734311 DOI: 10.1136/bmjopen-2016-015478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The study aimed to develop a comprehensive algorithm (meta-algorithm) for primary care encounters of patients with multimorbidity. We used a novel, case-based and evidence-based procedure to overcome methodological difficulties in guideline development for patients with complex care needs. STUDY DESIGN Systematic guideline development methodology including systematic evidence retrieval (guideline synopses), expert opinions and informal and formal consensus procedures. SETTING Primary care. INTERVENTION The meta-algorithm was developed in six steps:1. Designing 10 case vignettes of patients with multimorbidity (common, epidemiologically confirmed disease patterns and/or particularly challenging health care needs) in a multidisciplinary workshop.2. Based on the main diagnoses, a systematic guideline synopsis of evidence-based and consensus-based clinical practice guidelines was prepared. The recommendations were prioritised according to the clinical and psychosocial characteristics of the case vignettes.3. Case vignettes along with the respective guideline recommendations were validated and specifically commented on by an external panel of practicing general practitioners (GPs).4. Guideline recommendations and experts' opinions were summarised as case specific management recommendations (N-of-one guidelines).5. Healthcare preferences of patients with multimorbidity were elicited from a systematic literature review and supplemented with information from qualitative interviews.6. All N-of-one guidelines were analysed using pattern recognition to identify common decision nodes and care elements. These elements were put together to form a generic meta-algorithm. RESULTS The resulting meta-algorithm reflects the logic of a GP's encounter of a patient with multimorbidity regarding decision-making situations, communication needs and priorities. It can be filled with the complex problems of individual patients and hereby offer guidance to the practitioner. Contrary to simple, symptom-oriented algorithms, the meta-algorithm illustrates a superordinate process that permanently keeps the entire patient in view. CONCLUSION The meta-algorithm represents the back bone of the multimorbidity guideline of the German College of General Practitioners and Family Physicians. This article presents solely the development phase; the meta-algorithm needs to be piloted before it can be implemented.
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Affiliation(s)
- Cathleen Muche-Borowski
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Dagmar Lühmann
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Ingmar Schäfer
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Rebekka Mundt
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Hans-Otto Wagner
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Martin Scherer
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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363
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Gibson DS, Drain S, Kelly C, McGilligan V, McClean P, Atkinson SD, Murray E, McDowell A, Conway C, Watterson S, Bjourson AJ. Coincidence versus consequence: opportunities in multi-morbidity research and inflammation as a pervasive feature. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017. [DOI: 10.1080/23808993.2017.1338920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- David S. Gibson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Stephen Drain
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Catriona Kelly
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Victoria McGilligan
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Paula McClean
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Sarah D. Atkinson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Elaine Murray
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Andrew McDowell
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Caroline Conway
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Steven Watterson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
| | - Anthony J. Bjourson
- Northern Ireland Centre for Stratified Medicine, Altnagelvin Hospital Campus, Ulster University, Londonderry, UK
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364
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Ong GJ, Page A, Caughey G, Johns S, Reeve E, Shakib S. Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy. Pharmacol Res Perspect 2017; 5:e00321. [PMID: 28603638 PMCID: PMC5464348 DOI: 10.1002/prp2.321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 12/31/2022] Open
Abstract
It is not known how clinicians assess polypharmacy or the medication‐related characteristics that influence their assessment. The aim of this study was to examine the level of agreement between clinicians when assessing polypharmacy and to identify medication‐related characteristics that influence their assessment. Twenty cases of patients with varying levels of comorbidity and polypharmacy were used to examine clinician assessment of polypharmacy. Medicine‐related factors within the cases included Beers and STOPP Criteria medicines, falls‐risk medicines, drug burden index (DBI) medicines, medicines causing postural hypotension, and pharmacokinetic drug–drug interactions. Clinicians were asked to rate cases on the degree of polypharmacy, likelihood of harm, and potential for the medication list to be simplified. Inter‐rater reliability analysis, correlations, and multivariate logistic regression analyses were conducted to identify medicine factors associated with clinicians' assessment. Eighteen expert clinicians were recruited (69.2% response rate). Strong agreement was observed in clinicians' assessment of polypharmacy (intraclass correlation coefficients [ICC] = 0.94), likelihood to cause harm (ICC = 0.89), and ability to simplify medication list (ICC = 0.90). Multivariate analyses demonstrated number of medicines (P < 0.0001) and DBI scores (P = 0.047) were significantly associated with assessment of polypharmacy. Medicines associated with harm were significantly associated with the number of medicines (P = 0.01) and Beers criteria medicines (P = 0.003). Ability to simplify the medication regimen was significantly associated with number of medicines (P = 0.03) and medicines from the STOPP criteria (P = 0.018). Among clinicians, strong consensus exists with regard to assessment of polypharmacy, medication harm, and ability to simplify medications. Definitions of polypharmacy need to take into account not only the numbers of medicines but also potential for medicines to cause harm or be inappropriate, and validate them against clinical outcomes.
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Affiliation(s)
- Gao-Jing Ong
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia
| | - Amy Page
- School of Medicine and Pharmacology University of Western Australia Perth Australia
| | - Gillian Caughey
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia.,School of Pharmacy and Medical Sciences University of South Australia Adelaide South Australia Australia
| | - Sally Johns
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia
| | - Emily Reeve
- Cognitive Decline Partnership Centre Kolling Institute of Medical Research Sydney Medical School The University of Sydney New South Wales Australia.,Geriatric Medicine Research Unit Dalhousie University and Nova Scotia Health Authority 5955 Veterans' Memorial Lane Halifax Nova Scotia Canada
| | - Sepehr Shakib
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia.,Discipline of Pharmacology School of Medicine University of Adelaide North Terrace Adelaide South Australia Australia
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365
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Sadler E, Porat T, Marshall I, Hoang U, Curcin V, Wolfe CDA, McKevitt C. Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement. PLoS One 2017; 12:e0177102. [PMID: 28475606 PMCID: PMC5419597 DOI: 10.1371/journal.pone.0177102] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 04/22/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Stroke, like many long-term conditions, tends to be managed in isolation of its associated risk factors and multimorbidity. With increasing access to clinical and research data there is the potential to combine data from a variety of sources to inform interventions to improve healthcare. A 'Learning Health System' (LHS) is an innovative model of care which transforms integrated data into knowledge to improve healthcare. The objective of this study is to develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions, informed by a LHS, to improve long-term care for stroke survivors with multimorbidity. METHODS We used a stakeholder engagement study design informed by co-production principles to engage stakeholders, including service users, carers, general practitioners and other health and social care professionals, service managers, commissioners of services, policy makers, third sector representatives and researchers. Over a 10 month period we used a range of methods including stakeholder group meetings, focus groups, nominal group techniques (priority setting and consensus building) and interviews. Qualitative data were recorded, transcribed and analysed thematically. RESULTS 37 participants took part in the study. The concept of how data might drive intervention development was difficult to convey and understand. The engagement process led to four priority areas for needs for data and information being identified by stakeholders: 1) improving continuity of care; 2) improving management of mental health consequences; 3) better access to health and social care; and 4) targeting multiple risk factors. These priorities informed preliminary design interventions. The final choice of intervention was agreed by consensus, informed by consideration of the gap in evidence and local service provision, and availability of robust data. This shaped a co-produced decision support tool to improve secondary prevention after stroke for further development. CONCLUSIONS Stakeholder engagement to identify data-driven solutions is feasible but requires resources. While a number of potential interventions were identified, the final choice rested not just on stakeholder priorities but also on data availability. Further work is required to evaluate the impact and implementation of data-driven interventions for long-term stroke survivors.
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Affiliation(s)
- Euan Sadler
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- King’s Improvement Science, Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Talya Porat
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Iain Marshall
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Uy Hoang
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Vasa Curcin
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Charles D. A. Wolfe
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South London, King’s College Hospital NHS Foundation Trust and King’s College London, London, United Kingdom
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Christopher McKevitt
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South London, King’s College Hospital NHS Foundation Trust and King’s College London, London, United Kingdom
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
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366
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Megale RZ, Pollack A, Britt H, Latimer J, Naganathan V, McLachlan AJ, Ferreira ML. Management of vertebral compression fracture in general practice: BEACH program. PLoS One 2017; 12:e0176351. [PMID: 28472151 PMCID: PMC5417429 DOI: 10.1371/journal.pone.0176351] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 04/10/2017] [Indexed: 11/18/2022] Open
Abstract
Importance The pain associated with vertebral compression fractures can cause significant loss of function and quality of life for older adults. Despite this, there is little consensus on how best to manage this condition. Objective To describe usual care provided by general practitioners (GPs) in Australia for the management of vertebral compression fractures. Design, setting and participants Data from the Bettering the Evaluation And Care of Health (BEACH) program collected between April 2005 and March 2015 was used for this study. Each year, a random sample of approximately 1,000 GPs each recorded information on 100 consecutive encounters. We selected those encounters at which vertebral compression fracture was managed. Analyses of management options were limited to encounters with patients aged 50 years or over. Main outcome(s) and measure(s) i) patient demographics; ii) diagnoses/problems managed; iii) the management provided for vertebral compression fracture during the encounter. Robust 95% confidence intervals, adjusted for the cluster survey design, were used to assess significant differences between group means. Results Vertebral compression fractures were managed in 211 (0.022%; 95% CI: 0.018–0.025) of the 977,300 BEACH encounters recorded April 2005– March 2015. That provides a national annual estimate of 26,000 (95% CI: 22,000–29,000) encounters at which vertebral fractures were managed. At encounters with patients aged 50 years or over (those at higher risk of primary osteoporosis), prescription of analgesics was the most common management action, particularly opioids analgesics (47.1 per 100 vertebral fractures; 95% CI: 38.4–55.7). Prescriptions of paracetamol (8.2; 95% CI: 4–12.4) or non-steroidal anti-inflammatory drugs (4.1; 95% CI: 1.1–7.1) were less frequent. Non-pharmacological treatment was provided at a rate of 22.4 per 100 vertebral fractures (95% CI: 14.6–30.1). At least one referral (to hospital, specialist, allied health care or other) was given for 12.3 per 100 vertebral fractures (95% CI: 7.8–16.8). Conclusions and relevance The prescription of oral opioid analgesics remains the common general practice approach for vertebral compression fractures management, despite the lack of evidence to support this. Clinical trials addressing management of these fractures are urgently needed to improve the quality of care patients receive.
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Affiliation(s)
- Rodrigo Z. Megale
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
- * E-mail:
| | - Allan Pollack
- School of Public Health, Family Medicine Research Centre, The University of Sydney, Sydney, Australia
| | - Helena Britt
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jane Latimer
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Stdney, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, Australia
| | - Andrew J. McLachlan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, Australia
- Faculty of Pharmacy, The University of Sydney, Sydney, Australia
| | - Manuela L. Ferreira
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Stdney, Australia
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367
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Heart failure and multimorbidity in Australian general practice. JOURNAL OF COMORBIDITY 2017; 7:44-49. [PMID: 29090188 PMCID: PMC5556437 DOI: 10.15256/joc.2017.7.106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/14/2017] [Indexed: 11/10/2022]
Abstract
Background Heart failure (HF) is a serious condition that mostly affects older people. Despite the ageing population experiencing an increased prevalence of many chronic conditions, current guidelines focus on isolated management of HF. Objective To describe the burden of multimorbidity in patients with HF being managed in general practice in Australia. Design Data from the Bettering the Evaluation And Care of Health (BEACH) programme were used to determine (i) the prevalence of HF, (ii) the number of co-existing long-term conditions, and (iii) the most common disease combinations in patients with HF. The study was undertaken over fifteen, 5-week recording periods between November 2012 and March 2016. Results The dataset included a total of 25,790 general practitioner (GP) encounters with patients aged ≥45 years, collected by 1,445 GPs. HF had been diagnosed in 1,119 of these patients, a prevalence of 4.34% (95% confidence interval [CI] 3.99–4.68) among patients at GP encounters, and 2.08% (95% CI 1.87–2.29) when applied to the general Australian population overall. HF rarely occurred in isolation, with 99.1% of patients having at least one and 53.4% having six or more other chronic illnesses. The most common pair of comorbidities among active patients with HF was hypertension and osteoarthritis (43.4%). Conclusion Overall, one in every 20–25 GP encounters with patients aged ≥45 years in Australia is with a patient with HF. Multimorbidity is a typical presentation among this patient group and guidelines for general practice must take this into account.
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368
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Abstract
Multimorbidity and associated polypharmacy present a significant and increasing challenge to patients, carers and healthcare professionals.(1,2) While it is recognised that polypharmacy can be beneficial, there is considerable potential for harm, particularly through drug interactions, adverse drug events and non-adherence.(1) Such harms are amplified in people who are frail and who may require interventions to be tailored to their individual needs rather than strictly following guidance designed to manage single diseases. It is important to develop an approach that allows patients to make informed decisions and prioritise medicines for continuation or discontinuation, in order to maximise benefit and minimise harm.(1)The term 'deprescribing' has been suggested in recognition that the skills utilised in stopping medicines need to be as sophisticated as those used when initiating drug treatment.(3) Key to deprescribing, as with all medical interventions, is the active participation of the patient to ensure that their preferences and choices are taken into account. Particular care is needed when end-of-life considerations apply, so that treatment is optimised and the burden of taking medicines is minimised.(4) Although evidence is sparse, this article provides some practical observations on deprescribing.
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369
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Hillen JB, Vitry A, Caughey GE. Disease burden, comorbidity and geriatric syndromes in the Australian aged care population. Australas J Ageing 2017; 36:E14-E19. [DOI: 10.1111/ajag.12411] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jodie Belinda Hillen
- QUMPRC; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - Agnes Vitry
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - Gillian E Caughey
- QUMPRC; School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
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370
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Catalá-López F, Hutton B, Driver JA, Page MJ, Ridao M, Valderas JM, Alonso-Arroyo A, Forés-Martos J, Martínez S, Gènova-Maleras R, Macías-Saint-Gerons D, Crespo-Facorro B, Vieta E, Valencia A, Tabarés-Seisdedos R. Cancer and central nervous system disorders: protocol for an umbrella review of systematic reviews and updated meta-analyses of observational studies. Syst Rev 2017; 6:69. [PMID: 28376926 PMCID: PMC5379758 DOI: 10.1186/s13643-017-0466-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/23/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The objective of this study will be to synthesize the epidemiological evidence and evaluate the validity of the associations between central nervous system disorders and the risk of developing or dying from cancer. METHODS/DESIGN We will perform an umbrella review of systematic reviews and conduct updated meta-analyses of observational studies (cohort and case-control) investigating the association between central nervous system disorders and the risk of developing or dying from any cancer or specific types of cancer. Searches involving PubMed/MEDLINE, EMBASE, SCOPUS and Web of Science will be used to identify systematic reviews and meta-analyses of observational studies. In addition, online databases will be checked for observational studies published outside the time frames of previous reviews. Eligible central nervous system disorders will be Alzheimer's disease, anorexia nervosa, amyotrophic lateral sclerosis, autism spectrum disorders, bipolar disorder, depression, Down's syndrome, epilepsy, Huntington's disease, multiple sclerosis, Parkinson's disease and schizophrenia. The primary outcomes will be cancer incidence and cancer mortality in association with a central nervous system disorder. Secondary outcome measures will be site-specific cancer incidence and mortality, respectively. Two reviewers will independently screen references identified by the literature search, as well as potentially relevant full-text articles. Data will be abstracted, and study quality/risk of bias will be appraised by two reviewers independently. Conflicts at all levels of screening and abstraction will be resolved through discussion. Random-effects meta-analyses of primary observational studies will be conducted where appropriate. Parameters for exploring statistical heterogeneity are pre-specified. The World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for cancer outcomes. DISCUSSION Our study will establish the extent of the epidemiological evidence underlying the associations between central nervous system disorders and cancer and will provide a rigorous and updated synthesis of a range of important site-specific cancer outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016052762.
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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.
| | - 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
| | - Jane A Driver
- Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew J Page
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Manuel Ridao
- Instituto Aragonés de Ciencias de la Salud, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Zaragoza, Spain.,Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO-Salud Pública), Valencia, Spain
| | - José M Valderas
- Health Services and Policy Research Group, Exeter Collaboration for Academic Primary Care, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - 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-Spanish National Research Council (CSIC), Valencia, Spain
| | - Jaume Forés-Martos
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain
| | - Salvador Martínez
- Instituto de Neurociencias de Alicante, Universidad Miguel Hernández-Spanish National Research Council (UMH-CSIC), San Juan de Alicante, Spain
| | | | - Diego Macías-Saint-Gerons
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency (AEMPS), Madrid, Spain.,Department of Health Systems and Services, Unit of Medicines and Health Technologies, Pan American Health Organization (PAHO), Washington, DC, USA
| | - Benedicto Crespo-Facorro
- Department of Psychiatry, Hospital Marqués de Valdecilla, University of Cantabria/IDIVAL and CIBERSAM, Santander, Spain
| | - Eduard Vieta
- Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and CIBERSAM, Barcelona, Spain
| | - Alfonso Valencia
- Structural Biology and Biocumputing Programme, Spanish National Cancer Research Centre (CNIO), Madrid, Spain.,Life Sciences Department, Barcelona Supercomputing Center, Barcelona, Spain
| | - Rafael Tabarés-Seisdedos
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain.
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371
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Understanding the implementation and adoption of a technological intervention to improve medication safety in primary care: a realist evaluation. BMC Health Serv Res 2017; 17:196. [PMID: 28288634 PMCID: PMC5348746 DOI: 10.1186/s12913-017-2131-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/03/2017] [Indexed: 01/14/2023] Open
Abstract
Background Monitoring for potentially hazardous prescribing is increasingly important to improve medication safety. Healthcare information technology can be used to achieve this aim, for example by providing access to prescribing data through surveillance of patients’ electronic health records. The aim of our study was to examine the implementation and adoption of an electronic medicines optimisation system that was intended to facilitate clinical audit in primary care by identifying patients at risk of an adverse drug event. We adopted a sociotechnical approach that focuses on how complex social, organisational and institutional factors may impact upon the use of technology within work settings. Methods We undertook a qualitative realist evaluation of the use of an electronic medicines optimisation system in one Clinical Commissioning Group in England. Five semi-structured interviews, four focus groups and one observation were conducted with a range of stakeholders. Consistent with a realist evaluation methodology, the analysis focused on exploring the links between context, mechanism and outcome to explain the ways the intervention might work, for whom and in what circumstances. Results Using the electronic medicines optimisation system could lead to a number of improved patient safety outcomes including pre-emptively reviewing patients at risk of adverse drug events. The effective use of the system depended upon engagement with the system, the flow of information between different health professionals centrally placed at the Clinical Commissioning Group and those locally placed at individual general practices, and upon variably adapting work practices to facilitate the use of the system. The use of the system was undermined by perceptions of ownership, lack of access, and lack of knowledge and awareness. Conclusions The use of an electronic medicines optimisation system may improve medication safety in primary care settings by identifying those patients at risk of an adverse drug event. To fully realise the potential benefits for medication safety there needs to be better utilisation across primary care and with a wider range of stakeholders. Engaging with all potential stakeholders and users prior to implementation of such systems might allay perceptions that the system is owned centrally and increase knowledge of the potential benefits.
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372
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Johansson T, Flamm M, Sönnichsen A, Schuler J. Interventions to reduce inappropriate polypharmacy: Implications for research and practice. Maturitas 2017; 97:66-68. [DOI: 10.1016/j.maturitas.2016.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 11/16/2022]
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373
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van Wissen K, Thunders M, Mcbride-Henry K, Ward M, Krebs J, Page R. Cardiovascular disease and prediabetes as complex illness: People's perspectives. Nurs Inq 2017; 24. [DOI: 10.1111/nin.12177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kim van Wissen
- School of Nursing; Massey University; Wellington New Zealand
| | - Michelle Thunders
- School of Food and Nutrition; Massey University; Wellington New Zealand
| | - Karen Mcbride-Henry
- Postgraduate School of Nursing Midwifery and Health; Victoria University of Wellington; Wellington New Zealand
| | - Margaret Ward
- Endocrine, Diabetes and Research Centre; Capital and Coast District Health Board; Wellington New Zealand
| | - Jeremy Krebs
- Endocrine, Diabetes and Research Centre; Capital and Coast District Health Board; Wellington New Zealand
- Otago University; Dunedin New Zealand
| | - Rachel Page
- School of Food and Nutrition; Massey University; Wellington New Zealand
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374
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Prados-Torres D, Del Cura-González I, Prados-Torres A. [Towards a multimorbidity care model in Primary Care]. Aten Primaria 2017; 49:261-262. [PMID: 28089227 PMCID: PMC6875925 DOI: 10.1016/j.aprim.2016.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniel Prados-Torres
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Servicio Andaluz de Salud (SAS), Distrito Málaga/Guadalhorce, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España.
| | - Isabel Del Cura-González
- Unidad de Apoyo a la Investigación, Gerencia Asistencial de Atención Primaria, Madrid, España; REDISSEC ISCIII, Madrid, España
| | - Alexandra Prados-Torres
- REDISSEC ISCIII, Madrid, España; Instituto Aragonés de Ciencias de la Salud (IACS), Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
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375
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Neuner-Jehle S, Zechmann S, Grundmann Maissen D, Rosemann T, Senn O. Patient-provider concordance in the perception of illness and disease: a cross-sectional study among multimorbid patients and their general practitioners in Switzerland. Patient Prefer Adherence 2017; 11:1451-1458. [PMID: 28860728 PMCID: PMC5572955 DOI: 10.2147/ppa.s137388] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Multiple chronic health conditions are leading to multiple treatment procedures and polypharmacy. Prioritizing treatment according to patients' needs and preferences may be helpful for deprescribing. Thus, for improving health care, it is crucial for general practitioners (GPs) to perceive the chief complaints (CCs) of patients. The primary aim of this study was to investigate the patient-provider concordance of CCs and the secondary aim was to investigate the concordance between CCs and diagnosis, in a sample of Swiss multimorbid patients. MATERIALS AND METHODS A cross-sectional analysis based on a cluster randomized controlled trial (RCT) among 46 GPs, recruited between March 2015 to July 2016, and 334 multimorbid patients (≥60 years taking ≥5 drugs for at least 6 months) in Northern Switzerland was performed. CCs listed by GPs and by patients (n=128) were classified according to the International Classification of Primary Care, version 2 (ICPC-2) coding system on chapter and component level and defined as concordant if ICPC-2 codes of patients and GPs were identical. Concordance was classified into full, moderate or low, depending on the ranking of patients' CCs on GPs' list. As secondary outcome, we compared patients' CCs to GPs' diagnosis. Statistics included descriptive measures and a multivariate regression analysis of factors that are modifying concordance. RESULTS The mean age of patients was 76.9 (SD 8.1) years, where 38% were male, taking 7.9 (SD 2.6) drugs on the long term. The most frequent complaint was pain. Concordance of the CC was given in 101/128 (78.9%) on the ICPC-2 chapter level, whereby 86/128 (67.2%) showed full, 8/128 (6.3%) moderate and 7/128 (5.5%) low concordance; 27/128 (21.1%) were discordant. Concordance between CCs and diagnosis was 53.6%. Concordance increased with the intensity of the CC rated by patients (OR 1.48, CI 1.13-1.94, P<0.001). The younger age and higher intake of drugs were significantly associated with an increased concordance between CCs and diagnosis. CONCLUSION A majority of GPs perceive the CCs of the multimorbid patients correctly, but there is room for improvement.
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Affiliation(s)
- Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
- Correspondence: Stefan Neuner-Jehle, Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland, Tel +41 44 255 9855, Fax +41 44 255 9097, Email
| | - Stefan Zechmann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | | | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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376
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Mokienko A, Wangen KR. Disenrollment from general practitioners among chronic patients: a register-based longitudinal study of Norwegian claims data. BMC FAMILY PRACTICE 2016; 17:170. [PMID: 27978811 PMCID: PMC5159957 DOI: 10.1186/s12875-016-0571-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/02/2016] [Indexed: 11/19/2022]
Abstract
Background Norwegian general practitioners (GPs) consult on a variety of conditions with a mix of patient types. Patients with chronic diseases benefit from appropriate continuity of care and generally visit their GPs more often than the average patient. Our aim was to study disenrollment patterns among patients with chronic diseases in Norway, because such patterns could indicate otherwise unobserved GP quality. For instance, higher quality GPs could have both a greater share of patients with chronic diseases and lower disenrollment rates. Methods Data on 384,947 chronic patients and 3,974 GPs for the years 2009–2011 were obtained from national registers, including patient and GP characteristics, disenrollment data, and patient list composition. The birth cohorts from 1940 and 1970 (146,906 patients) were included for comparison. Patient and GP characteristics, comorbidity, and patient list composition were analyzed using descriptive statistics. Patients’ voluntary disenrollment was analyzed using logistic regression models. Results The GPs’ proportion of patients with a given chronic disease varied more than expected when the allocation was purely random. The proportions of patients with different chronic diseases were positively correlated, partly due to comorbidity. Patients tended to have lower disenrollment rates from GPs who had higher shares of patients with the same chronic disease. Disenrollment rates were generally lower from GPs with higher shares of patients with arthritis or depression, and higher from GPs who had higher shares of patients with diabetes type 1 and schizophrenia. This was the same in the comparison group. Conclusion Patients with a chronic disease appeared to prefer GPs who have higher shares of patients with the same disease. High shares of patients with some diseases were also negatively associated with disenrollment for all patient groups, while other diseases were positively associated. These findings may reflect the GPs’ general quality, but could alternatively result from the GPs’ specialization in particular diseases. The supportive findings for the comparison group make it more plausible that high shares of chronic patients could indicate GP quality.
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Affiliation(s)
- Anastasia Mokienko
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, Oslo, 0318, Norway.
| | - Knut Reidar Wangen
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, Oslo, 0318, Norway
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377
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Are care plans suitable for the management of multiple conditions? JOURNAL OF COMORBIDITY 2016; 6:103-113. [PMID: 29090181 PMCID: PMC5556452 DOI: 10.15256/joc.2016.6.79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 10/03/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Care plans have been part of the primary care landscape in Australia for almost two decades. With an increasing number of patients presenting with multiple chronic conditions, it is timely to consider whether care plans meet the needs of patients and clinicians. OBJECTIVES To review and benchmark existing care plan templates that include recommendations for comorbid conditions, against four key criteria: (i) patient preferences, (ii) setting priorities, (iii) identifying conflicts and synergies between conditions, and (iv) setting dates for reviewing the care plan. DESIGN Document analysis of Australian care plan templates published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. RESULTS Sixteen templates were reviewed. All of the care plan templates addressed patient preference, but this was not done comprehensively. Only three templates included setting priorities. None assisted in identifying conflicts and synergies between conditions. Fifteen templates included setting a date for reviewing the care plan. CONCLUSIONS Care plans are a well-used tool in primary care practice, but their current format perpetuates a single-disease approach to care, which works contrary to their intended purpose. Restructuring care plans to incorporate shared decision-making and attention to patient preferences may assist in shifting the focus back to the patient and their care needs.
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378
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Fraccaro P, Kontopantelis E, Sperrin M, Peek N, Mallen C, Urban P, Buchan IE, Mamas MA. Predicting mortality from change-over-time in the Charlson Comorbidity Index: A retrospective cohort study in a data-intensive UK health system. Medicine (Baltimore) 2016; 95:e4973. [PMID: 27787358 PMCID: PMC5089087 DOI: 10.1097/md.0000000000004973] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/29/2016] [Accepted: 09/06/2016] [Indexed: 01/02/2023] Open
Abstract
Multimorbidity is common among older people and presents a major challenge to health systems worldwide. Metrics of multimorbidity are, however, crude: focusing on measuring comorbid conditions at single time-points rather than reflecting the longitudinal and additive nature of chronic conditions. In this paper, we explore longitudinal comorbidity metrics and their value in predicting mortality.Using linked primary and secondary care data, we conducted a retrospective cohort study on adults in Salford, UK from 2005 to 2014 (n = 287,459). We measured multimorbidity with the Charlson Comorbidity Index (CCI) and quantified its changes in various time windows. We used survival models to assess the relationship between CCI changes and mortality, controlling for gender, age, baseline CCI, and time-dependent CCI. Goodness-of-fit was assessed with the Akaike Information Criterion and discrimination with the c-statistic.Overall, 15.9% patients experienced a change in CCI after 10 years, with a mortality rate of 19.8%. The model that included gender and time-dependent age, CCI, and CCI change across consecutive time windows had the best fit to the data but equivalent discrimination to the other time-dependent models. The absolute CCI score gave a constant hazard ratio (HR) of around 1.3 per unit increase, while CCI change afforded greater prognostic impact, particularly when it occurred in shorter time windows (maximum HR value for the 3-month time window, with 1.63 and 95% confidence interval 1.59-1.66).Change over time in comorbidity is an important but overlooked predictor of mortality, which should be considered in research and care quality management.
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Affiliation(s)
- Paolo Fraccaro
- Health eResearch Centre, Farr Institute for Health Informatics Research
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health
| | - Evangelos Kontopantelis
- Health eResearch Centre, Farr Institute for Health Informatics Research
- NIHR School for Primary Care Research, University of Manchester, Manchester
| | - Matthew Sperrin
- Health eResearch Centre, Farr Institute for Health Informatics Research
| | - Niels Peek
- Health eResearch Centre, Farr Institute for Health Informatics Research
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health
| | - Christian Mallen
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, United Kingdom
| | - Philip Urban
- Cardiovascular Department, Hôpital de La Tour, Geneva, Switzerland
| | - Iain E. Buchan
- Health eResearch Centre, Farr Institute for Health Informatics Research
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health
| | - Mamas A. Mamas
- Health eResearch Centre, Farr Institute for Health Informatics Research
- Keele Cardiovascular Research Group, Keele University Stoke-on-Trent and Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom
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379
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Buffel du Vaure C, Dechartres A, Battin C, Ravaud P, Boutron I. Exclusion of patients with concomitant chronic conditions in ongoing randomised controlled trials targeting 10 common chronic conditions and registered at ClinicalTrials.gov: a systematic review of registration details. BMJ Open 2016; 6:e012265. [PMID: 27678540 PMCID: PMC5051474 DOI: 10.1136/bmjopen-2016-012265] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To systematically assess registration details of ongoing randomised controlled trials (RCTs) targeting 10 common chronic conditions and registered at ClinicalTrials.gov and to determine the prevalence of (1) trial records excluding patients with concomitant chronic condition(s) and (2) those specifically targeting patients with concomitant chronic conditions. DESIGN Systematic review of trial registration records. DATA SOURCES ClinicalTrials.gov register. STUDY SELECTION All ongoing RCTs registered from 1 January 2014 to 31 January 2015 that assessed an intervention targeting adults with coronary heart disease (CHD), hypertension, heart failure, stroke/transient ischaemic attack, atrial fibrillation, type 2 diabetes, chronic obstructive pulmonary disease, painful condition, depression and dementia with a target sample size ≥100. DATA EXTRACTION From the trial registration records, 2 researchers independently recorded the trial characteristics and the number of exclusion criteria and determined whether patients with concomitant chronic conditions were excluded or specifically targeted. RESULTS Among 319 ongoing RCTs, despite the high prevalence of the concomitant chronic conditions, patients with these conditions were excluded in 251 trials (79%). For example, although 91% of patients with CHD had a concomitant chronic condition, 69% of trials targeting such patients excluded patients with concomitant chronic condition(s). When considering the co-occurrence of 2 chronic conditions, 31% of patients with chronic pain also had depression, but 58% of the trials targeting patients with chronic pain excluded patients with depression. Only 37 trials (12%) assessed interventions specifically targeting patients with concomitant chronic conditions; 31 (84%) excluded patients with concomitant chronic condition(s). CONCLUSIONS Despite widespread multimorbidity, more than three-quarters of ongoing trials assessing interventions for patients with chronic conditions excluded patients with concomitant chronic conditions.
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Affiliation(s)
- Céline Buffel du Vaure
- Faculté de Médecine, Département de médecine générale, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- METHODS Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris, France
| | - Agnès Dechartres
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- METHODS Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris, France
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Centre d'Epidémiologie Clinique, Paris, France
- French Cochrane Center, Paris, France
| | - Constance Battin
- METHODS Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris, France
| | - Philippe Ravaud
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- METHODS Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris, France
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Centre d'Epidémiologie Clinique, Paris, France
- French Cochrane Center, Paris, France
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Isabelle Boutron
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- METHODS Team, Epidemiology and Statistics Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris, France
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Centre d'Epidémiologie Clinique, Paris, France
- French Cochrane Center, Paris, France
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380
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Wallace E, McDowell R, Bennett K, Fahey T, Smith SM. Comparison of count-based multimorbidity measures in predicting emergency admission and functional decline in older community-dwelling adults: a prospective cohort study. BMJ Open 2016; 6:e013089. [PMID: 27650770 PMCID: PMC5051451 DOI: 10.1136/bmjopen-2016-013089] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Multimorbidity, defined as the presence of 2 or more chronic medical conditions in an individual, is associated with poorer health outcomes. Several multimorbidity measures exist, and the challenge is to decide which to use preferentially in predicting health outcomes. The study objective was to compare the performance of 5 count-based multimorbidity measures in predicting emergency hospital admission and functional decline in older community-dwelling adults attending primary care. SETTING 15 general practices (GPs) in Ireland. PARTICIPANTS n=862, ≥70 years, community-dwellers followed-up for 2 years (2010-2012). Exposure at baseline: Five multimorbidity measures (disease counts, selected conditions counts, Charlson comorbidity index, RxRisk-V, medication counts) calculated using GP medical record and linked national pharmacy claims data. PRIMARY OUTCOMES (1) Emergency admission and ambulatory care sensitive (ACS) admission (GP medical record) and (2) functional decline (postal questionnaire). STATISTICAL ANALYSIS Descriptive statistics and measure discrimination (c-statistic, 95% CIs), adjusted for confounders. RESULTS Median age was 77 years and 53% were women. Prevalent rates ranged from 37% to 91% depending on which measure was used to define multimorbidity. All measures demonstrated poor discrimination for the outcome of emergency admission (c-statistic range: 0.62, 0.65), ACS admission (c-statistic range: 0.63, 0.68) and functional decline (c-statistic range: 0.55, 0.61). Medication-based measures were equivalent to diagnosis-based measures. CONCLUSIONS The choice of measure may have a significant impact on prevalent rates. Five multimorbidity measures demonstrated poor discrimination in predicting emergency admission and functional decline, with medication-based measures equivalent to diagnosis-based measures. Consideration of multimorbidity in isolation is insufficient for predicting these outcomes in community settings.
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Affiliation(s)
- Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ronald McDowell
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Kathleen Bennett
- Population Health Sciences Division, Royal College of Surgeons of Ireland (RCSI), Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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381
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Morrison D, Agur K, Mercer S, Eiras A, González-Montalvo JI, Gruffydd-Jones K. Managing multimorbidity in primary care in patients with chronic respiratory conditions. NPJ Prim Care Respir Med 2016; 26:16043. [PMID: 27629064 PMCID: PMC5024357 DOI: 10.1038/npjpcrm.2016.43] [Citation(s) in RCA: 24] [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: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 01/15/2023] Open
Abstract
The term multimorbidity is usually defined as the coexistence of two or more chronic conditions within an individual, whereas the term comorbidity traditionally describes patients with an index condition and one or more additional conditions. Multimorbidity of chronic conditions markedly worsens outcomes in patients, increases treatment burden and increases health service costs. Although patients with chronic respiratory disease often have physical comorbidities, they also commonly experience psychological problems such as depression and anxiety. Multimorbidity is associated with increased health-care utilisation and specifically with an increased number of prescription drugs in individuals with multiple chronic conditions such as chronic obstructive pulmonary disease. This npj Primary Care Respiratory Medicine Education Section case study involves a patient in a primary care consultation presenting several common diseases prevalent in people of this age. The patient takes nine different drugs at this moment, one or more pills for each condition, which amounts to polypharmacy. The problems related with polypharmacy recommend that a routine medication review by primary care physicians be performed to reduce the risk of adverse effects of polypharmacy among those with multiple chronic conditions. The primary care physician has the challenging role of integrating all of the clinical problems affecting the patient and reviewing all medicaments (including over-the-counter medications) taken by the patient at any point in time, and has the has the key to prevent the unwanted consequences of polypharmacy. Multimorbid chronic disease management can be achieved with the use of care planning, unified disease templates, use of information technology with appointment reminders and with the help of the wider primary care and community teams.
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Affiliation(s)
- Deborah Morrison
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Karolina Agur
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stewart Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Andreia Eiras
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Rainha D. Amélia Family Health Unit, Porto, Portugal
| | - Juan I González-Montalvo
- Geriatrics Department, IdiPaz Research Institute Hospital Universitario La Paz, Universidad Autónoma de Madrid, School of Medicine, Madrid, Spain
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Sidorkiewicz S, Tran VT, Cousyn C, Perrodeau E, Ravaud P. Discordance Between Drug Adherence as Reported by Patients and Drug Importance as Assessed by Physicians. Ann Fam Med 2016; 14:415-21. [PMID: 27621157 PMCID: PMC5394381 DOI: 10.1370/afm.1965] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/27/2016] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Among patients on long-term medical therapy, we compared (1) patient and physician assessments of drug adherence and of drug importance and (2) drug adherence reported by patients with drug importance as assessed by their physicians. METHODS We recruited to the study patients receiving at least 1 long-term drug treatment from both hospital and ambulatory settings in France. We compared drug adherence reported by patients and drug importance assessed by physicians using Spearman correlation coefficients. Reasons for nonadherence were collected with open-ended questions and classified as intentional or unintentional. RESULTS Between April and August 2014, we recruited 128 patients taking 498 drugs. Patients and physicians showed only weak agreement in their assessments of drug adherence (r = -0.25; 95% CI, -0.37 to -0.11) and drug importance (r = 0.07; 95% CI, 0.00 to 0.13). We did not find any correlation between physician-assessed drug importance and patient-reported drug adherence (r = -0.04; 95% CI, -0.14 to 0.06). In all, 94 (18.9%) of the drugs that physicians considered important were not correctly taken by patients. Patients intentionally did not adhere to 26 (48.1%) of the drugs for which they reported reasons for nonadherence. CONCLUSIONS We found substantial discordance between patient and physician evaluations of drug adherence and drug importance. Nearly 20% of drugs considered important by physicians were not correctly taken by patients. These findings highlight the need for better patient-physician collaboration in drug treatment.
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Affiliation(s)
- Stéphanie Sidorkiewicz
- Department of General Medicine, Paris Descartes University, Paris, France METHODS Team, INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Centre, France
| | - Viet-Thi Tran
- METHODS Team, INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Centre, France Department of General Medicine, Paris Diderot University, Paris, France
| | - Cécile Cousyn
- Department of General Medicine, Paris Diderot University, Paris, France
| | - Elodie Perrodeau
- METHODS Team, INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Centre, France
| | - Philippe Ravaud
- METHODS Team, INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Centre, France French Cochrane Centre, Paris, France Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York
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383
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Lewis C, Wallace E, Kyne L, Cullen W, Smith SM. Training doctors to manage patients with multimorbidity: a systematic review. JOURNAL OF COMORBIDITY 2016; 6:85-94. [PMID: 29090179 PMCID: PMC5556450 DOI: 10.15256/joc.2016.6.87] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with multimorbidity (two or more chronic conditions) are now the norm in clinical practice, and place an increasing burden on the healthcare system. Management of these patients is challenging, and requires doctors who are skilled in the complexity of multiple chronic diseases. OBJECTIVE To perform a systematic review of the literature to ascertain whether there are education and training formats which have been used to train postgraduate medical doctors in the management of patients with multimorbidity in primary and/or secondary care, and which have been shown to improve knowledge, skills, attitudes, and/or patient outcomes. METHODS Overall, 75,110 citations were screened, of which 65 full-text articles were then independently assessed for eligibility by two reviewers, and two studies met the inclusion criteria for the review. RESULTS The two included studies implemented and evaluated multimorbidity workshops, and highlight the need for further research addressing the learning needs of doctors tasked with managing patients with multimorbidity in their daily practice. CONCLUSION While much has been published about the challenges presented to medical staff by patients with multimorbidity, published research regarding education of doctors to manage these problems is lacking. Further research is required to determine whether there is a need for, or benefit from, specific training for doctors to manage patients with multimorbidity. PROSPERO registration number: CRD42013004010.
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Affiliation(s)
- Cliona Lewis
- Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin, Ireland
| | | | | | - Walter Cullen
- School of Medicine, University College Dublin, Dublin, Ireland
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384
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van Hoof SJM, Spreeuwenberg MD, Kroese MEAL, Steevens J, Meerlo RJ, Hanraets MMH, Ruwaard D. Substitution of outpatient care with primary care: a feasibility study on the experiences among general practitioners, medical specialists and patients. BMC FAMILY PRACTICE 2016; 17:108. [PMID: 27506455 PMCID: PMC4979105 DOI: 10.1186/s12875-016-0498-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 07/21/2016] [Indexed: 01/17/2023]
Abstract
Background Reinforcing the gatekeeping role of general practitioners (GPs) by embedding specialist knowledge into primary care is seen as a possibility for stimulating a more sustainable healthcare system and avoiding unnecessary referrals to outpatient care. An intervention called Primary Care Plus (PC+) was developed to achieve these goals. The objective of this study is to gain insight into: (1) the content and added value of PC+ consultations according to stakeholders, and (2) patient satisfaction with PC+ compared to outpatient care. Methods A feasibility study was conducted in the southern part of the Netherlands between April 2013 and January 2014. Data was collected using GP, medical specialist and patient questionnaires. Patient characteristics and medical specialty data were collected through the data system of a GP referral department. Results GPs indicated that they would have referred 85.4 % of their PC+ patients to outpatient care in the hypothetical case that PC+ was not available. Medical specialists indicated that about one fifth of the patients needed follow-up in outpatient care and 75.9 % of the consultations were of added value to patient care. The patient satisfaction results appear to be in favour of PC+. Conclusion PC+ seems to be a feasible intervention to be implemented on a larger scale, because it has the potential to prevent unnecessary hospital referrals. PC+ will be evaluated on a larger scale regarding the effects on health outcomes, quality of care and costs (Triple Aim principle).
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Affiliation(s)
- Sofie J M van Hoof
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Marieke D Spreeuwenberg
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands. .,Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands.
| | - Mariëlle E A L Kroese
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jessie Steevens
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Ronald J Meerlo
- Primary Care Organisation Care In Development ZIO, Wilhelminasingel 81, 6221 BG, Maastricht, The Netherlands
| | - Monique M H Hanraets
- Department of Patient and Care, Academic Hospital Maastricht azM, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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385
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Lawton R, Heyhoe J, Louch G, Ingleson E, Glidewell L, Willis TA, McEachan RRC, Foy R. Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study. Implement Sci 2016; 11:113. [PMID: 27502590 PMCID: PMC4977705 DOI: 10.1186/s13012-016-0479-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background There are recognised gaps between evidence and practice in general practice, a setting posing particular implementation challenges. We earlier screened clinical guideline recommendations to derive a set of ‘high-impact’ indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. Here, we explore health professionals’ perceived determinants of adherence to these indicators, examining the degree to which determinants were indicator-specific or potentially generalisable across indicators. Methods We interviewed 60 general practitioners, practice nurses and practice managers in West Yorkshire, the UK, about adherence to four indicators: avoidance of risky prescribing; treatment targets in type 2 diabetes; blood pressure targets in treated hypertension; and anticoagulation in atrial fibrillation. Interview questions drew upon the Theoretical Domains Framework (TDF). Data were analysed using framework analysis. Results Professional role and identity and environmental context and resources featured prominently across all indicators whilst the importance of other domains, for example, beliefs about consequences, social influences and knowledge varied across indicators. We identified five meta-themes representing more general organisational and contextual factors common to all indicators. Conclusions The TDF helped elicit a wide range of reported determinants of adherence to ‘high-impact’ indicators in primary care. It was more difficult to pinpoint which determinants, if targeted by an implementation strategy, would maximise change. The meta-themes broadly underline the need to align the design of interventions targeting general practices with higher level supports and broader contextual considerations. However, our findings suggest that it is feasible to develop interventions to promote the uptake of different evidence-based indicators which share common features whilst also including content-specific adaptations.
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Affiliation(s)
- Rebecca Lawton
- School of Psychology, University of Leeds, Leeds, LS2 9JT, UK. .,Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
| | - Jane Heyhoe
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Gemma Louch
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Emma Ingleson
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Thomas A Willis
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Rosemary R C McEachan
- Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
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386
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Dale H, Lee A. Behavioural health consultants in integrated primary care teams: a model for future care. BMC FAMILY PRACTICE 2016; 17:97. [PMID: 27473414 PMCID: PMC4966805 DOI: 10.1186/s12875-016-0485-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 07/13/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Significant challenges exist within primary care services in the United Kingdom (UK). These include meeting current demand, financial pressures, an aging population and an increase in multi-morbidity. Psychological services also struggle to meet waiting time targets and to ensure increased access to psychological therapies. Innovative ways of delivering effective primary care and psychological services are needed to improve health outcomes. In this article we argue that integrated care models that incorporate behavioural health care are part of the solution, which has seldom been argued in relation to UK primary care. Integrated care involves structural and systemic changes to the delivery of services, including the co-location of multi-disciplinary primary care teams. Evidence from models of integrated primary care in the United States of America (USA) and other higher-income countries suggest that embedding continuity of care and collaborative practice within integrated care teams can be effective in improving health outcomes. The Behavioural Health Consultant (BHC) role is integral to this, working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing. Patients' needs for higher-intensity interventions to enable changes in behaviour and self-management are, therefore, more fully met within primary care. The role also increases accessibility of psychological services, delivers earlier interventions and reduces stigma, since psychological staff are seen as part of the core primary care service. Although the UK has trialled a range of approaches to integrated care, these fall short of the highest level of integration. A single short pilot of integrated care in the UK showed positive results. Larger pilots with robust evaluation, as well as research trials are required. There are clearly challenges in adopting such an approach, especially for staff who must adapt to working more collaboratively with each other and patients. Strong leadership is needed to assist in this, particularly to support organisations to adopt the shift in values and attitudes towards collaborative working. CONCLUSIONS Integrated primary care services that embed behavioural health as part of a multi-disciplinary team may be part of the solution to significant modern day health challenges. However, developing this model is unlikely to be straight-forward given current primary care structures and ways of working. The discussion, developed in this article, adds to our understanding of what the BHC role might consist off and how integrated care may be supported by such behavioural health expertise. Further work is needed to develop this model in the UK, and to evaluate its impact on health outcomes and health care utilisation, and test robustly through research trials.
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Affiliation(s)
- Hannah Dale
- NHS Fife, Department of Psychology, Lynebank Hospital, Halbeath Road, Dunfermline, KY11 4UW, UK.
- School of Medicine, Medical and Biological Sciences Building, University of St Andrews, North Haugh, St Andrews, Fife, KY16 9TF, UK.
| | - Alyssa Lee
- School of Medicine, Medical and Biological Sciences Building, University of St Andrews, North Haugh, St Andrews, Fife, KY16 9TF, UK
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387
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Li J, Green M, Kearns B, Holding E, Smith C, Haywood A, Cooper C, Strong M, Relton C. Patterns of multimorbidity and their association with health outcomes within Yorkshire, England: baseline results from the Yorkshire Health Study. BMC Public Health 2016; 16:649. [PMID: 27464646 PMCID: PMC4964308 DOI: 10.1186/s12889-016-3335-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 07/21/2016] [Indexed: 11/25/2022] Open
Abstract
Background Multimorbidity is increasingly being recognized as a serious public health concern. Research into its determinants, prevalence, and management is needed and as the risk of experiencing multiple chronic conditions increases over time, attention should be given to investigating the development of multimorbidity through prospective cohort design studies. Here we examine the baseline patterns of multimorbidity and their association with health outcomes for residents in Yorkshire, England using data from the Yorkshire Health Study. Methods Baseline data from the Yorkshire Health Study (YHS) was collected from 27,806 patients recruited between 2010 and 2012. A two-stage sampling strategy was implemented which first involved recruiting 43 general practice surgeries and then having them consent to mailing invitations to their patients to complete postal or online questionnaires. The questionnaire collected information on chronic health conditions, demographics, health-related behaviours, healthcare and medication usage, and a range of other health related variables. Descriptive statistics (chi-square and t tests) were used to examine associations between these variables and multimorbidity. Results In the YHS cohort, 10,332 participants (37.2 %) reported having at least two or more long-term health conditions (multimorbidity). Older age, BMI and deprivation were all positively associated with multimorbidity. Nearly half (45.7 %) of participants from the most deprived areas experienced multimorbidity. Based on the weighted sample, average health-related quality of life decreased with the number of health conditions reported; the mean EQ-5D score for participants with no conditions was 0.945 compared to 0.355 for participants with five or more. The mean number of medications used for those without multimorbidity was 1.81 (range 1-13, SD = 1.25) compared to 3.81 (range 1-14, SD = 2.44) for those with at least two long-term conditions and 7.47 (range 1-37, SD = 7.47) for those with 5+ conditions. Conclusion Patterns of multimorbidity within the Yorkshire Health Study support research on multimorbidity within previous observational cross-sectional studies. The YHS provides both a facility for participant recruitment to intervention trials, and a large population-based longitudinal cohort for observational research. It is planned to continue to record chronic conditions and other health related behaviours in future waves which will be useful for examining determinants and trends in chronic disease and multimorbidity.
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Affiliation(s)
- Jessica Li
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK. .,Public Health Section, ScHARR, Regent Court, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Mark Green
- Department of Geography & Planning, University of Liverpool, Liverpool, UK
| | - Ben Kearns
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Eleanor Holding
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Annette Haywood
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Strong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Clare Relton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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388
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Fox J, Pattison T, Wallace J, Pradhan S, Gaillemin O, Feilding E, Butler L, Vilches-Moraga A. Geriatricians at the front door: The value of early comprehensive geriatric assessment in the emergency department. Eur Geriatr Med 2016. [DOI: 10.1016/j.eurger.2016.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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389
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Iglay K, Hannachi H, Joseph Howie P, Xu J, Li X, Engel SS, Moore LM, Rajpathak S. Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Curr Med Res Opin 2016; 32:1243-52. [PMID: 26986190 DOI: 10.1185/03007995.2016.1168291] [Citation(s) in RCA: 259] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients with type 2 diabetes (T2DM) often have multiple comorbidities which may impact the selection of antihyperglycemic therapies. The purpose of this study was to quantify the prevalence and co-prevalence of common comorbidities. RESEARCH DESIGN AND METHODS A retrospective study was conducted using the Quintiles Electronic Medical Record database. Adult patients with T2DM who had ≥1 encounter from July 2014 to June 2015 (index period) with ≥1 year medical history available were included. The index date was defined as the most recent encounter date during the 1 year index period. MAIN OUTCOME MEASURES Comorbid conditions were assessed using all data available prior to and including the index date. Patient characteristics, laboratory measures, and comorbidities were summarized via descriptive analyses, overall and by subgroups of age (<65, 65-74, 75+ years) and gender. RESULTS Of the 1,389,016 eligible patients, 53% were female and the median age was 65 years. 97.5% of patients had at least one comorbid condition in addition to T2DM and 88.5% had at least two. The comorbidity burden tended to increase in older age groups and was higher in men than women. The most common conditions in patients with T2DM included hypertension (HTN) in 82.1%; overweight/obesity in 78.2%; hyperlipidemia in 77.2%; chronic kidney disease (CKD) in 24.1%; and cardiovascular disease (CVD) in 21.6%. The highest co-prevalence was demonstrated for the combination of HTN and hyperlipidemia (67.5%), followed by overweight/obesity and HTN (66.0%), overweight/obesity and hyperlipidemia (62.5%), HTN and CKD (22.4%), hyperlipidemia and CKD (21.1%), HTN and CVD (20.2%), hyperlipidemia and CVD (20.1%), overweight/obesity and CKD (19.1%) and overweight/obesity and CVD (17.0%). LIMITATIONS Limitations include the potential for misclassification/underreporting due to the use of diagnostic codes, drug codes, or laboratory measures for identification of medical conditions. CONCLUSIONS The vast majority of patients with T2DM have multiple comorbidities. To ensure a comprehensive approach to patient management, the presence of multimorbidity should be considered in the context of clinical decision making.
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Affiliation(s)
| | | | | | - Jinfei Xu
- a Merck & Co. Inc. , Kenilworth , NJ , USA
| | - Xueying Li
- a Merck & Co. Inc. , Kenilworth , NJ , USA
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390
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Mercer SW, Fitzpatrick B, Guthrie B, Fenwick E, Grieve E, Lawson K, Boyer N, McConnachie A, Lloyd SM, O'Brien R, Watt GCM, Wyke S. The CARE Plus study - a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis. BMC Med 2016; 14:88. [PMID: 27328975 PMCID: PMC4916534 DOI: 10.1186/s12916-016-0634-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/02/2016] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation. METHODS We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat. RESULTS Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11-0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86-£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028-0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue. CONCLUSIONS It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas. TRIAL REGISTRATION TRIAL REGISTRATION ISRCTN 34092919 , assigned 14/1/2013.
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Affiliation(s)
- Stewart W Mercer
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Bruce Guthrie
- Population Health Sciences Division, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Elisabeth Fenwick
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Eleanor Grieve
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Kenny Lawson
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Nicki Boyer
- Health Economics and Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Rosaleen O'Brien
- Institute of Applied Health, Glasgow Caledonian University, 4th Floor George Moore Building, Cowcaddens Road, Glasgow, Lanarkshire, G4 0BA, UK
| | - Graham C M Watt
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Sally Wyke
- Institute of Health and Wellbeing, University of Glasgow, 27 Bute Gardens, Glasgow, G12 8RS, UK
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391
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Skrove GK, Bachmann K, Aarseth T. Integrated care pathways—A strategy towards better care coordination in municipalities? A qualitative study. INTERNATIONAL JOURNAL OF CARE COORDINATION 2016. [DOI: 10.1177/2053434516649777] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction One of the main strategies in the Coordination Reform in Norway is implementing integrated care pathways. Most studies on integrated care pathways are conducted in hospital settings or across the hospital–primary care continuum. There are few studies on how such pathways are experienced in primary care. We have conducted a formative evaluation in a primary care setting. The research questions are “What assessments and understanding of integrated care pathways exist in primary care?” “To what extent do integrated care pathways appear as a suitable strategy to handle care coordination challenges from a primary care point of view?” Methods A total of 72 qualitative interviews with chief municipal executives and healthcare management from 36 municipalities in one county of Norway were conducted. Results Even though integrated care pathways were promoted as a strategy to accommodate the intentions of the Coordination Reform, the concept is perceived as diffuse and ambiguous among informants in our study. Only one of four municipalities reported use of integrated care pathways. Discussion Our empirical findings show that municipal management is skeptical and negatively minded to disease-specific integrated care pathways. However, they are positive towards patient-centered care pathways which are flexible, adaptable to individual needs and local conditions. We found that there is no golden strategy for handling challenges in care coordination in primary care. On the contrary, what our informants find as “appropriate” strategies vary and change, but the complexity in problem solving could never be reduced to enforce standardized diagnose-specific integrated care pathways.
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392
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Jones J, McBain H, Lamontagne-Godwin F, Mulligan K, Haddad M, Flood C, Thomas D, Simpson A. Severe mental illness and type 2 diabetes: using theory and research evidence to develop complex behaviour change interventions. J Psychiatr Ment Health Nurs 2016; 23:312-21. [PMID: 27307262 DOI: 10.1111/jpm.12311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 01/20/2023]
Affiliation(s)
- J Jones
- Centre for Mental Health Research, School of Health Sciences, City University London, UK
| | - H McBain
- Centre for Health Services Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
| | - F Lamontagne-Godwin
- Centre for Mental Health Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
| | - K Mulligan
- Centre for Health Services Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
| | - M Haddad
- Centre for Mental Health Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
| | - C Flood
- Centre for Mental Health Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
| | - D Thomas
- Centre for Mental Health Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
| | - A Simpson
- Centre for Mental Health Research, School of Health Sciences, City University London, UK.,East London NHS Foundation Trust, London, UK
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393
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Foy R, Leaman B, McCrorie C, Petty D, House A, Bennett M, Carder P, Faulkner S, Glidewell L, West R. Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016; 6:e010276. [PMID: 27178970 PMCID: PMC4874107 DOI: 10.1136/bmjopen-2015-010276] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing. DESIGN Trend, cross-sectional and longitudinal analyses of routinely recorded patient data. SETTING 111 primary care practices in Leeds and Bradford, UK. PARTICIPANTS We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse. MAIN OUTCOME MEASURES Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids. RESULTS Opioid prescribing in the adult population almost doubled for weaker opioids over 2005-2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31-3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75). CONCLUSIONS While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids.
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Affiliation(s)
- Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ben Leaman
- Calderdale Metropolitan Borough Council, Halifax, UK
| | - Carolyn McCrorie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Duncan Petty
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael Bennett
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Paul Carder
- Yorkshire & Humber Commissioning Support Unit, Bradford, UK
| | | | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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394
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Kydd A, Fleming A. What doctors need to know: Prescribing or not for the oldest old. Maturitas 2016; 90:9-16. [PMID: 27282788 DOI: 10.1016/j.maturitas.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
Given the global increase in the number of people over the age of 85, there is a growing body of work concerning this group, termed the oldest old. Much of this work is confined to the literature specialising in geriatrics and the more generic health care papers refer to 'older people' with little definition of what is meant by 'older'. Iatrogenesis (ill health caused by doctors) is a major issue and general practitioners (GPs) need practical help in prescribing for the oldest old. This paper presents a narrative review of the literature on prescribing and the oldest old. The results showed that all papers sourced referred to prescribing for the 'old' as those aged over 65, with only scant mention of oldest old. Yet prescribing for the oldest old involves clinical judgement and knowledge of the patient. It includes weighing up what will do good, cause no harm and is acceptable to the individual. GPs have to make treatment choices mostly in isolation from colleagues, during time-limited consultations and with few relevant guidelines on managing multi-morbidities in the oldest old. A major issue in prescribing for people over the age of 85 is that guidelines for diseases are based on trials with younger adults, outline the best practice for one disease in isolation (i.e. not in the presence of other diseases) and take little account of the interactions between the drugs used in managing several diseases in frail older people. There is a growing body of work, however, calling for specialist services for the oldest old.
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Affiliation(s)
- Angela Kydd
- School of Nursing Midwifery and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, United Kingdom.
| | - Anne Fleming
- School of Nursing Midwifery and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, United Kingdom
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395
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Li YT, Wang HHX, Liu KQL, Lee GKY, Chan WM, Griffiths SM, Chen RL. Medication Adherence and Blood Pressure Control Among Hypertensive Patients With Coexisting Long-Term Conditions in Primary Care Settings: A Cross-Sectional Analysis. Medicine (Baltimore) 2016; 95:e3572. [PMID: 27196458 PMCID: PMC4902400 DOI: 10.1097/md.0000000000003572] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hypertension is a typical example of long-term disease posing formidable challenges to health care. One goal of antihypertensive therapy is to achieve optimal blood pressure (BP) control and reduce co-occurring chronic conditions (multimorbidity). This study aimed to assess the influence of multimorbidity on medication adherence, and to explore the association between poor BP control and multimorbidity, with implications for hypertension management.A cross-sectional design with multistage sampling was adopted to recruit Chinese hypertensive patients attending general out-patient clinics from 3 geographic regions in Hong Kong. A modified systemic sampling methodology with 1 patient as a sampling unit was used to recruit consecutive samples in each general out-patient clinic. Data were collected by face-to-face interviews using a standardized protocol. Poor BP control was defined as having systolic BP/diastolic BP ≥130/80 mm Hg for those with diabetes or chronic kidney disease; and ≥140/90 mm Hg for others. Medication adherence was assessed by a validated Chinese version of the Morisky Medication Adherence Scale. A simple unweighted enumeration was adopted to measure the combinations of coexisting long-term conditions. Binary logistic regression analysis was conducted with medication adherence and multimorbidity as outcome variables, respectively, after controlling for effects of patient-level covariates.The prevalence of multimorbidity was 47.4% (95% confidence interval [CI] 45.4%-49.4%) among a total of 2445 hypertensive patients. The proportion of subjects having 0, 1, and ≥2 additional long-term conditions was 52.6%, 29.1%, and 18.3%, respectively. The overall rate of poor adherence to medication was 46.6%, whereas the rate of suboptimal BP control was 48.7%. Albeit the influence of multimorbidity on medication adherence was not found to be statistically significant, patients with poorly controlled BP were more likely to have multimorbidity (adjusted odds ratio 2.07, 95% CI 1.70-2.53, P < 0.001). Diabetes was the most prevalent concomitant long-term condition among hypertensive patients with poor BP control (38.6%, 95% CI 35.8-41.4 vs 19.7%, 95% CI 17.5-21.9 for patients with good BP control, P < 0.001).Multimorbidity was common among hypertensive patients, and was associated with poor BP control. Subjects with coexisting diabetes, heart disease, or chronic kidney disorder should receive more clinical attention to achieve better clinical outcomes.
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Affiliation(s)
- Yu Ting Li
- From the Community Research and Clinical Trials Unit, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, P.R. China (YTL); JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong (YTL, KQLL, GKYL, WMC, SMG); School of Public Health, Sun Yat-Sen University, Guangzhou, P.R. China (HHXW); and Centre for Health and Social Care Improvement, University of Wolverhampton, Wolverhampton, UK (RLC)
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Man MS, Chaplin K, Mann C, Bower P, Brookes S, Fitzpatrick B, Guthrie B, Shaw A, Hollinghurst S, Mercer S, Rafi I, Thorn J, Salisbury C. Improving the management of multimorbidity in general practice: protocol of a cluster randomised controlled trial (The 3D Study). BMJ Open 2016; 6:e011261. [PMID: 27113241 PMCID: PMC4854003 DOI: 10.1136/bmjopen-2016-011261] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION An increasing number of people are living with multimorbidity. The evidence base for how best to manage these patients is weak. Current clinical guidelines generally focus on single conditions, which may not reflect the needs of patients with multimorbidity. The aim of the 3D study is to develop, implement and evaluate an intervention to improve the management of patients with multimorbidity in general practice. METHODS AND ANALYSIS This is a pragmatic two-arm cluster randomised controlled trial. 32 general practices around Bristol, Greater Manchester and Glasgow will be randomised to receive either the '3D intervention' or usual care. 3D is a complex intervention including components affecting practice organisation, the conduct of patient reviews, integration with secondary care and measures to promote change in practice organisation. Changes include improving continuity of care and replacing reviews of each disease with patient-centred reviews with a focus on patients' quality of life, mental health and polypharmacy. We aim to recruit 1383 patients who have 3 or more chronic conditions. This provides 90% power at 5% significance level to detect an effect size of 0.27 SDs in the primary outcome, which is health-related quality of life at 15 months using the EQ-5D-5L. Secondary outcome measures assess patient centredness, illness burden and treatment burden. The primary analysis will be a multilevel regression model adjusted for baseline, stratification/minimisation, clustering and important co-variables. Nested process evaluation will assess implementation, mechanisms of effectiveness and interaction of the intervention with local context. Economic analysis of cost-consequences and cost-effectiveness will be based on quality-adjusted life years. ETHICS AND DISSEMINATION This study has approval from South-West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via final report, peer-reviewed publications and guidance to healthcare professionals, commissioners and policymakers. TRIAL REGISTRATION NUMBER ISRCTN06180958; Pre-results.
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Affiliation(s)
- Mei-See Man
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Cindy Mann
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter Bower
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Sara Brookes
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Bridie Fitzpatrick
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Bruce Guthrie
- Quality, Safety and Informatics Research Group, University of Dundee, Dundee, UK
| | - Alison Shaw
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Stewart Mercer
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Imran Rafi
- Clinical Innovation and Research, Royal College of General Practitioners, London, UK
| | - Joanna Thorn
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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397
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Meid AD, Quinzler R, Groll A, Wild B, Saum KU, Schöttker B, Heider D, König HH, Brenner H, Haefeli WE. Longitudinal evaluation of medication underuse in older outpatients and its association with quality of life. Eur J Clin Pharmacol 2016; 72:877-85. [DOI: 10.1007/s00228-016-2047-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/15/2016] [Indexed: 11/29/2022]
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398
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Towards increased visibility of multimorbidity research. JOURNAL OF COMORBIDITY 2016; 6:42-45. [PMID: 29090171 PMCID: PMC5556442 DOI: 10.15256/joc.2016.6.80] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 11/08/2022]
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399
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Williams JS, Egede LE. The Association Between Multimorbidity and Quality of Life, Health Status and Functional Disability. Am J Med Sci 2016; 352:45-52. [PMID: 27432034 DOI: 10.1016/j.amjms.2016.03.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/02/2016] [Accepted: 03/09/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Approximately 50% of adults have multimorbidity (MM) that is associated with greater disability, poorer quality of life (QOL) and increased psychological distress. This study assessed the association between MM and QOL, health status and functional disability in U.S. adults. METHODS Cross-sectional study of 23,789 patients from 2011 Medical Expenditure Panel Survey was conducted. Mean scores were calculated for QOL (physical component score [PCS] and mental component score [MCS]) and proportions for functional limitation (activities of daily living [ADL]; instrumental ADL [IADL] and physical functioning). Health status was assessed by depression and serious psychological distress. Regression models evaluated associations between MM and QOL, functional health status and functional limitations, while adjusting for confounders. RESULTS Approximately 53% of 45-64-year-olds and 84% of those ≥65-years-old had MM. In adjusted models, ≥3 conditions were significantly associated with poorer outcomes-PCS QOL (β = -9.15; 95% CI: -9.69 to -8.61), MCS QOL (β = -1.98; 95% CI: -2.43 to -1.52), ADL (odds ratio [OR] = 5.80; 95% CI: 2.27-14.8), IADL (OR = 3.99; 95% CI: 2.31-6.88) and physical functioning (OR = 16.8; 95% CI: 12.0-23.6) compared with 1-2 conditions. Depression (PCS QOL: β = -4.02; 95% CI: -4.89 to -3.15; MCS QOL: β = -12.5; 95% CI: -13.2 to -10.9; ADL: OR = 2.49; 95% CI: 1.65-3.76; IADL: OR = 2.65; 95% CI: 1.88-3.72; physical functioning: OR = 2.44; 95% CI: 1.99-2.99) and serious psychological distress (PCS QOL: β = -3.16; 95% CI: -4.30 to -2.03; MCS QOL: β = -11.8; 95% CI: -12.8 to -10.8; ADL: OR = 1.57; 95% CI: 0.95-2.60; IADL: OR = 1.13; 95% CI: 0.80-1.59 and physical functioning: OR = 1.41; 95% CI: 1.11-1.78) were significantly associated with adverse outcomes. CONCLUSIONS In this nationally representative sample of U.S. adults, MM was significantly associated with poorer QOL, functional health status and physical functioning, when adjusting for relevant confounders. A holistic view of the complexities associated with MM must dictate comprehensive care.
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Affiliation(s)
- Joni S Williams
- Department of Medicine, Center for Health Disparities Research, Medical University of South Carolina, Charleston, South Carolina; Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Leonard E Egede
- Department of Medicine, Center for Health Disparities Research, Medical University of South Carolina, Charleston, South Carolina; Division of General Internal Medicine and Geriatrics, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina.
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400
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Smith SM, Wallace E, O'Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2016; 3:CD006560. [PMID: 26976529 PMCID: PMC6703144 DOI: 10.1002/14651858.cd006560.pub3] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. OBJECTIVES To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. SEARCH METHODS We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. SELECTION CRITERIA Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. MAIN RESULTS We identified 18 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 12 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -2.23, 95% confidence interval (CI) -2.52 to -1.95). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence) although two studies that specifically targeted functional difficulties in participants had positive effects on functional outcomes with one of these studies also reporting a reduction in mortality at four year follow-up (Int 6%, Con 13%, absolute difference 7%). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. AUTHORS' CONCLUSIONS This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.
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Affiliation(s)
- Susan M Smith
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Emma Wallace
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Tom O'Dowd
- Trinity College Centre for Health SciencesDepartment of Public Health and Primary CareAdelaide and Meath Hosptials, Incorporating the National Children's HospitalTallaghtDublinIreland24
| | - Martin Fortin
- University of SherbrookeDepartment of Family MedicineUnite de Medicine de famille de Chicoutimi305, St‐Vallier ChicoutimiQuebecCanadaG7H 5H6
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