Advancing multimorbidity management in primary care: a narrative review

The Chinese version of patient experience with treatment and self-management (PETS vs. 2.0): translation and validation in patients with multimorbidity in primary care in Hong Kong

BACKGROUND

Validated and comprehensive tools to measure treatment burden are needed for healthcare professionals to understand the treatment burden of patients in China. The study aimed to translate and validate the Chinese version of Patient Experience with Treatment and Self-management (PETS vs. 2.0) in patients with multimorbidity in primary care.

METHODOLOGY

The translation process of the 60-item PETS vs. 2.0 followed the Functional Assessment of Chronic Illness Therapy (FACIT) Translation, Formatting, and Testing Guidelines. Computer-assisted assessments were conducted in adult primary care patients with multimorbidity from three general out-patient clinics in Hong Kong. A sample of 502 patients completed the assessments from July to December 2023. Internal reliability was examined using Cronbach's alphas for each domain of the PETS vs. 2.0. Concurrent validity was assessed through the correlations between different domains of PETS vs. 2.0 with established measures including quality of life, frailty, and depression. Confirmatory Factor Analysis (CFA) with maximum likelihood method was carried out to assess the construct validity.

RESULTS

The mean age of participants was 64.9 years old and 56.2% were female. Internal consistency reliability was acceptable (alpha ≥ 0.70) for most domains. Higher scores of PETS domains were significantly correlated with worse quality of life, higher level of frailty, and more depressive symptoms (p < 0.05). In CFA, after setting the covariances on the error variances, the adjusted model revealed an acceptable model fit (χ2/df = 1.741; root mean square error of approximation (RMSEA) = 0.038; standardized root mean square residual (SRMR) = 0.058; comparative fit index (CFI) = 0.911; Tucker-Lewis Index (TLI) = 0.903). All standardized factor loadings were 0.30 or above. Significant positive correlations between the latent factors were found for all factor pairs (correlation coefficient < 0.8).

CONCLUSIONS

The Chinese version of PETS vs. 2.0 is a reliable and valid tool for assessing the perceived treatment burden in patients with multimorbidity in primary care. All domains and items in the original questionnaires were retained.

Mapping multimorbidity progression among 190 diseases

BACKGROUND

Current clustering of multimorbidity based on the frequency of common disease combinations is inadequate. We estimated the causal relationships among prevalent diseases and mapped out the clusters of multimorbidity progression among them.

METHODS

In this cohort study, we examined the progression of multimorbidity among 190 diseases among over 500,000 UK Biobank participants over 12.7 years of follow-up. Using a machine learning method for causal inference, we analyzed patterns of how diseases influenced and were influenced by others in females and males. We used clustering analysis and visualization algorithms to identify multimorbidity progress constellations.

RESULTS

We show the top influential and influenced diseases largely overlap between sexes in chronic diseases, with sex-specific ones tending to be acute diseases. Patterns of diseases that influence and are influenced by other diseases also emerged (clustering significance Pau > 0.87), with the top influential diseases affecting many clusters and the top influenced diseases concentrating on a few, suggesting that complex mechanisms are at play for the diseases that increase the development of other diseases while share underlying causes exist among the diseases whose development are increased by others. Bi-directional multimorbidity progress presents substantial clustering tendencies both within and across International Classification Disease chapters, compared to uni-directional ones, which can inform future studies for developing cross-specialty strategies for multimorbidity. Finally, we identify 10 multimorbidity progress constellations for females and 9 for males (clustering stability, adjusted Rand index >0.75), showing interesting differences between sexes.

CONCLUSION

Our findings could inform the future development of targeted interventions and provide an essential foundation for future studies seeking to improve the prevention and management of multimorbidity.

Primary healthcare service delivery for older people with progressive multimorbidity in low- and middle-income countries: a systematic review

Ensuring primary healthcare (PHC) accessibility to older people with multimorbidity is vital in preventing unnecessary health deterioration. However, older people ≥50 y of age in low- and middle-income countries (LMICs) face challenges in effectively accessing and utilizing PHC. A systematic review was conducted adopting the Andersen-Newman theoretical framework for health services utilization to assess evidence on factors that affect access to PHC by older people. This framework predicts that a series of factors (predisposing, enabling and need factors) influence the utilization of health services by people in general. Seven publications were identified and a narrative analytical method revealed limited research in this area. Facilitating factors included family support, closeness to the PHC facility, friendly service providers and improved functional status of the older people. Barriers included long distance and disjointed PHC services, fewer health professionals and a lack of person-centred care. The following needs were identified: increasing the number of health professionals, provision of PHC services under one roof and regular screening services. There is a need for more investment in infrastructure development, coordination of service delivery and capacity building of service providers in LMICs to improve access and utilization of PHC services for older people.

My Wellbeing Journal: Development of a communication and goal-setting tool to improve care for older adults with chronic conditions and multimorbidity

BACKGROUND

Chronic conditions and multimorbidity, the presence of two or more chronic conditions, are increasingly common in older adults. Effective management of chronic conditions and multimorbidity in older adults requires a collaborative and person-centred approach that considers the individual's goals, preferences and priorities. However, ensuring high-quality personalised care for older adults with multimorbidity can be challenging due to the complexity of their care needs, limited time and a lack of patient preparation to discuss their personal goals and preferences with their healthcare team.

OBJECTIVE

To codesign a communication and goal-setting tool, My Wellbeing Journal, to support personalised care planning for older adults with chronic conditions and multimorbidity.

DESIGN

We drew on an experience-based codesign approach to develop My Wellbeing Journal. This article reports on the final end-user feedback, which was collected via an online survey with older adults and their carers.

SETTING AND PARTICIPANTS

Older adults with chronic conditions, multimorbidity and informal carers living in Australia. Personalised care planning was considered in the context of primary care.

RESULTS

A total of 88 participants completed the online survey. The survey focused on participants' feedback on the tool in terms of effectiveness, efficiency, satisfaction and errors encountered. This feedback resulted in modifications to My Wellbeing Journal, which can be used during clinical encounters to facilitate communication, goal setting and progress tracking.

DISCUSSION AND CONCLUSIONS

Clinicians and carers can use the tool to guide discussions with older adults about their care planning and help them set realistic goals that are meaningful to them. The findings of this study could be used to inform the development of recommendations for healthcare providers to implement person-centred, goal-oriented care for older adults with chronic conditions and multimorbidity.

PATIENT OR PUBLIC CONTRIBUTION

Older adults living with chronic conditions and multimorbidity and their carers have contributed to the development of a tool that has the potential to significantly enhance the experience of personalised care planning. Their direct involvement as collaborators has ensured that the tool is optimised to meet the standards of effectiveness and usability.

Utilization of Primary Healthcare Services in Patients with Multimorbidity According to Their Risk Level by Adjusted Morbidity Groups: A Cross-Sectional Study in Chamartín District (Madrid)

Patients with multimorbidity have increased and more complex healthcare needs, posing their management a challenge for healthcare systems. This study aimed to describe their primary healthcare utilization and associated factors. A population-based cross-sectional study was conducted in a Spanish basic healthcare area including all patients with chronic conditions, differentiating between having multimorbidity or not. Sociodemographic, functional, clinical and service utilization variables were analyzed, stratifying the multimorbid population by the Adjusted Morbidity Groups (AMG) risk level, sex and age. A total of 6036 patients had multimorbidity, 64.2% being low risk, 28.5% medium risk and 7.3% high risk. Their mean age was 64.1 years and 63.5% were women, having on average 3.5 chronic diseases, and 25.3% were polymedicated. Their mean primary care contacts/year was 14.9 (7.8 with family doctors and 4.4 with nurses). Factors associated with primary care utilization were age (B-coefficient [BC] = 1.15;95% Confidence Interval [CI] = 0.30-2.01), female sex (BC = 1.04; CI = 0.30-1.78), having a caregiver (BC = 8.70; CI = 6.72-10.69), complexity (B-coefficient = 0.46; CI = 0.38-0.55), high-risk (B-coefficient = 2.29; CI = 1.26-3.32), numerous chronic diseases (B-coefficient = 1.20; CI = 0.37-2.04) and polypharmacy (B-coefficient = 5.05; CI = 4.00-6.10). This study provides valuable data on the application of AMG in multimorbid patients, revealing their healthcare utilization and the need for a patient-centered approach by primary care professionals. These results could guide in improving coordination among professionals, optimizing multimorbidity management and reducing costs derived from their extensive healthcare utilization.

Designing Telemedicine for Older Adults With Multimorbidity: Content Analysis Study

BACKGROUND

Telemedicine is a potential option for caring for older adults with multimorbidity. There is a need to explore the perceptions about telemedicine among older adults with multimorbidity to tailor it to the needs of older adults with multiple chronic conditions.

OBJECTIVE

This study aims to explore the perceptions about telemedicine among older patients with multimorbidity.

METHODS

A qualitative study was conducted using semistructured interviews. The interview questions examined older adults' perspectives about telemedicine, including their expectations regarding telemedicine services and the factors that affect its use. Thematic analysis was performed using NVivo (version 12; Lumivero). The study was reported using the Standards for Reporting Qualitative Research guidelines.

RESULTS

In total, 29 patients with multimorbidity-21 (72%) female patients and 8 (28%) male patients with a mean age of 69 (SD 10.39) years-were included. Overall, 4 themes and 7 subthemes emerged: theme 1-perceived benefit of telemedicine among older adults with multimorbidities, theme 2-appropriate use of telemedicine for multimorbid care, theme 3-telemedicine system catering to the needs of older patients, and theme 4-respect patients' decision to decline to use telemedicine.

CONCLUSIONS

Telemedicine for older adults with multimorbidity should focus on those with stable conditions. This can help increase access to care for those requiring continuous condition monitoring. A structured telemedicine program and patient-centered services can help increase patient acceptance of telemedicine. However, health care providers must accept the limitations of older patients that may prevent them from receiving telemedicine services.

Embedding a multiple health condition approach across NHS Greater Manchester

Here, we present two real-world examples of how a prioritised, person-centred, multiple health condition approach - also termed a multimorbidity approach - has been applied to long-term condition management in general practice in Greater Manchester. The first example is the implementation of targeted multiple health condition reviews via a population health management approach across general practice in the City of Manchester. The second example is the development of a person-centred risk stratification tool, focused on unmet cardiovascular need, called 'CVNeed'. This tool provides a unique approach to highlighting the highest unmet need and, thus, the largest return on investment to the system from proactive efforts. These examples demonstrate how a person-centred, multiple health condition approach to long-term condition management, enabled by data intelligence to drive prioritisation of clinical need, can help to address longstanding health inequalities and unwarranted variation in health outcomes. This work also highlights the potential for integrated care systems (ICS) to work collaboratively to tackle health inequalities at a system, locality and neighbourhood level, thus making significant strides toward achieving the vision set out in the Greater Manchester Integrated Care Partnership (ICP) Strategy.

A fuzzy based dietary clinical decision support system for patients with multiple chronic conditions (MCCs)

Due to the multifaceted nature of Multiple Chronic Conditions (MCCs), setting a diet for these patients is complicated and time-consuming. In this study, a clinical decision support system based on fuzzy logic was modeled and evaluated to aid dietitians in adjusting the diet for patients with MCCs. Mamdani fuzzy logic with 1144 rules was applied to design the model for MCCs patients over 18 years who suffer from one or more chronic diseases, including obesity, diabetes, hypertension, hyperlipidemia, and kidney disease. One hundred nutrition records from three nutrition clinics were employed to measure the system's performance. The findings showed that the diet set by nutritionists had no statistically significant difference from the diet recommended by the fuzzy model (p > 0.05), and there was a strong correlation close to one between them. In addition, the results indicated a suitable model performance with an accuracy of about 97%. This system could adjust the diet with high accuracy as well as humans. In addition, it could increase dietitians' confidence, precision, and speed in setting the diet for MCCs patients.

Osteoporosis care through an Integrated, People-Centred Health Services framework lens: a hybrid qualitative analysis of international patient experiences

OBJECTIVES

Globally, patients with osteoporosis have unmet needs in terms of care accessibility, patient-centredness and care comprehensiveness. The WHO developed the Integrated, People-Centred Health Services (IPCHS) framework to reorient and integrate healthcare systems using 5 interdependent strategies and 20 substrategies. Patients' perspectives with regard to these strategies are poorly understood. We sought to relate patient-experienced gaps in osteoporosis care to the IPCHS strategies and identify key strategies to guide osteoporosis care reforms.

DESIGN, SETTING AND PARTICIPANTS

Qualitative online study of the experiences of international patients with osteoporosis.

PROCEDURE

Two researchers conducted semi-structured interviews in English, Dutch, Spanish and French that were recorded and transcribed verbatim. Patients were categorised according to their countries' healthcare systems (universal, public/private and private) and fracture status. A hybrid (sequential theory-driven and data-driven) analysis was performed, with the IPCHS framework used for the theory-driven analysis.

RESULTS

Thirty-five patients (33 women) from 14 countries participated. Twenty-two patients had universal healthcare and 18 had experienced fragility fractures. Prioritised substrategies overlapped among healthcare systems, with reported shortcomings related primarily to 'empowering and engaging individuals and families' and 'coordinating care' (at varying levels). Patients with all healthcare types prioritised 'reorienting care', with different substrategies prioritised. Patients with private healthcare called for 'improving funding and reforming payment systems'. Substrategy prioritisation did not differ between those receiving primary and secondary fracture prevention.

CONCLUSION

Patients' experiences with osteoporosis care are universal. Given the current care gaps and associated patient burdens, policymakers should make osteoporosis a(n) (inter)national health priority. Integrated osteoporosis care reforms should focus on patient-reported experiences with and be guided by priorities in IPCHS strategies, taking into account the healthcare system context.

The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

Utilization and out-of-pocket expenses of primary care among the multimorbid elderly in China: A two-part model with nationally representative data

Background

Multimorbidity has become an essential public health issue that threatens human health and leads to an increased disease burden. Primary care is the prevention and management of multimorbidity by providing continuous, comprehensive patient-centered services. Therefore, the study aimed to investigate the determinants of primary care utilization and out-of-pocket expenses (OOPE) among multimorbid elderly to promote rational utilization of primary care and reduce avoidable economic burdens.

Methods

The study used data from CHARLS 2015 and 2018, which included a total of 4,384 multimorbid elderly aged 60 and above. Guided by Grossman theory, determinants such as education, gender, marriage, household economy, and so on were included in this study. A two-part model was applied to evaluate primary care utilization and OOPE intensity in multimorbid populations. And the robustness testing was performed to verify research results.

Results

Primary care visits rate and OOPE indicated a decline from 2015 to 2018. Concerning primary outpatient care, the elderly who were female (OR = 1.51, P < 0.001), married (OR = 1.24, P < 0.05), living in rural areas (OR = 1.77, P < 0.001) and with poor self-rated health (OR = 2.23, P < 0.001) had a significantly higher probability of outpatient utilization, whereas those with middle school education (OR = 0.61, P < 0.001) and better household economy (OR = 0.96, P < 0.001) had a significantly less likelihood of using outpatient care. Rural patients (β = -0.72, P < 0.05) may have lower OOPE, while those with better household economy (β = 0.29, P < 0.05; β = 0.58, P < 0.05) and poor self-rated health (β = 0.62, P < 0.001) occurred higher OOPE. Regarding primary inpatient care, adults who were living in rural areas (OR = 1.48, P < 0.001), covered by Urban Employee Basic Medical Insurance (UEBMI) or Urban Rural Basic Medical Insurance (URBMI) (OR = 2.46, P < 0.001; OR = 1.81, P < 0.001) and with poor self-rated health (OR = 2.30, P < 0.001) had a significantly higher probability of using inpatient care, whereas individuals who were female (OR = 0.74, P < 0.001), with middle school education (OR = 0.40, P < 0.001) and better household economy (OR = 0.04, P < 0.001) had a significantly lower tendency to use inpatient care. Significantly, more OOPE occurred by individuals who were women (β = 0.18, P < 0.05) and with better household economy (β = 0.40, P < 0.001; β = 0.62, P < 0.001), whereas those who were covered by URBMI (β = -0.25, P < 0.05) and satisfied with their health (β = -0.21, P < 0.05) had less OOPE.

Conclusion

To prompt primary care visits and reduce economic burden among subgroups, more policy support is in need, such as tilting professional medical staff and funding to rural areas, enhancing awareness of disease prevention among vulnerable groups and so on.