Lived experiences of multimorbidity: An interpretative meta-synthesis of patients', general practitioners' and trainees' perceptions

Development steps of multimodal exercise interventions for older adults with multimorbidity: A systematic review

Background and Aims

Multicomponent exercise interventions are recommended for older adults and for those with chronic diseases. While multiple programs have been tested, no one has yet explored how these programs were developed. This review set out to determine what development steps multicomponent exercise intervention studies that include older adults with multimorbidity have taken.

Methods

Systematic review and narrative synthesis.

Results

One hundred and thirty-eight studies meeting review criteria (Population: adults ≥60 years with multimorbidity; Intervention: exercise interventions with ≥2 components; Comparator: any considered; Outcome: any considered) were retrieved. Most studies (70%) do not report intervention development actions as suggested by available guidance. Notable deviations from recommendations include limited performance of systematic review of previously published evidence, lack of engagement with theory, and few examples of design then refine.

Conclusions

Exercise interventions for older adults with multimorbidity do not appear to follow best practice in terms of their developing. Disregard of development recommendations risks contributing to research redundancy and/or avoidable waste, as important steps that make sure the intervention is warranted, suitable for the population in question, and tested using optimal methods and outcome measures are overlooked.

Users' views on the use of a smartwatch app to collect daily symptom data in individuals with multiple long-term conditions (Multimorbidity): A qualitative study

Introduction

Long-term conditions are a major burden on health systems. One way to facilitate more research and better clinical care among patients with long-term conditions is to collect accurate data on their daily symptoms (patient-generated health data) using wearable technologies. Whilst evidence is growing for the use of wearable technologies in single conditions, there is less evidence of the utility of frequent symptom tracking in those who have more than one condition.

Aims

To explore patient views of the acceptability of collecting daily patient-generated health data for three months using a smartwatch app.

Methods

Watch Your Steps was a longitudinal study which recruited 53 patients to track over 20 symptoms per day for a 90-day period using a study app on smartwatches. Semi-structured interviews were conducted with a sub-sample of 20 participants to explore their experience of engaging with the app.

Results

In a population of older people with multimorbidity, patients were willing and able to engage with a patient-generated health data app on a smartwatch. It was suggested that to maintain engagement over a longer period, more 'real-time' feedback from the app should be available. Participants did not seem to consider the management of more than one condition to be a factor in either engagement or use of the app, but the presence of severe or chronic pain was at times a barrier.

Conclusion

This study has provided preliminary evidence that multimorbidity was not a major barrier to engagement with patient-generated health data via a smartwatch symptom tracking app.

Perceptions and experiences of living with and providing care for multimorbidity: A qualitative interview study

Background

Experiences of living with and seeking care for multimorbidity is a relatively under-researched field. By analysing experiences of people with multimorbidity, caregivers and care professionals, we can better understand the complex care needs of those with multimorbidity and identify improvements to care management. This paper reports findings from research that elicited the views of key stakeholders to inform future care practice and policy.

Aim

To elicit care recipient and care provider views to understand the care needs of those living with and seeking care for multimorbidity.

Method

A qualitative interview study using purposive sampling of those living with and providing care in multimorbidity.

Results

Increased support to those with multimorbidity and caregivers to navigate care systems was advocated. Establishing trusting care relationships featured prominently in participants accounts. Fragmented care, inadequate coordination and poor communication between care providers, were identified as system-wide challenges. There was agreement that integrated care models were needed, which delivered personalised care, such as shared decision-making, choice in care options and accessing services, and individualised care plans.

Conclusion

We found significant agreement among stakeholders on care need and management in multimorbidity. Understanding the experiences of those with multimorbidity, caregivers and care professionals, can inform future improvements in care management.

Ethical Dilemmas in Physicians’ Consultations with COPD Patients

Aim

This phenomenological study was aimed at exploring principal physicians’ (participants’) experience of attending to COPD patients and motivating their self-management, in light of the GOLD clinical guidelines of COPD therapy.

Methods

Interviews were conducted with nine physicians, who had referred patients to PR, five general practitioners (GPs) and four lung specialists (LSs). The interviews were recorded, transcribed, and analyzed through a process of deconstruction and reconstruction.

Results

The participants experienced several ethical dilemmas in being principal physicians of COPD patients and motivating their self-management; primarily in the balancing act of adhering to the Hippocratic Oath of promoting health and saving lives, while respecting their patients’ choice regarding non-adherence eg, by still smoking. It was also a challenge to deal with COPD as a nicotine addiction disease, deal with patients’ denial regarding the harm of smoking and in motivating patient mastery of the disease. The participants used various strategies to motivate their patients’ self-management such as active patient education, enhancing the patients’ inner motivation, by means of an interdisciplinary approach, involving the patients’ significant other when appropriate, and by proposing PR.

Conclusion

The findings indicate that being a principal physician of COPD patients and motivating their self-management is a balancing act, involving several dilemmas. Patients’ nicotine addiction and physicians’ ethical obligations are likely to create ethical dilemmas as the physician is obligated to respect the patients’ will, even though it contradicts what is best for the patient. The participants suggest strategies to motivate COPD patients’ self-management.

Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis

INTRODUCTION

Prescribing and medication use in palliative care is a multistep process. It requires systems coordination and is enacted through activities of patients, informal carers and professionals. This study compares practice to idealised descriptions of what should happen; identifying when, how and why process disturbances impact on quality and safety. Our objectives are to:Document an intended model (phase 1, scoping review).Refine the model with study of practice (phase 2, ethnography).Use the model to pinpoint 'hot' (viewed as problematic by participants) and 'cold' spots (observed as problematic by researchers) within or when patients move across three contexts-hospice, hospital and community (home).Create learning recommendations for quality and safety targeted at underlying themes and contributing factors.

METHODS AND ANALYSIS

The review will scope Ovid Medline, CINAHL and Embase, Google Scholar and Images-no date limits, English language only. The Population (palliative), Concept (medication use), Context (home, hospice, hospital) framework defines inclusion/exclusion criteria. Data will be extracted to create a model illustrating how processes ideally occur, incorporating multiple steps of typical episodes of prescribing and medication use for symptom control. Direct observations, informal conversations around acts of prescribing and medication use, and semistructured interviews will be conducted with a purposive sample of patients, carers and professionals. Drawing on activity theory, we will synthesise analysis of both phases. The analysis will identify when, how and why activities affect patient safety and experience. Generating a rich multivoiced understanding of the process will help identify meaningful targets for improvement.

ETHICS AND DISSEMINATION

Ethical approval granted by the Camden & Kings Cross NHS Regional Ethics Committee (21/LO/0459). A patient and public involvement (PPI) coinvestigator, a multiprofessional steering group and a PPI engagement group are working with the research team. Dissemination of findings is planned through peer-reviewed publications and a stakeholder (policymakers, commissioners, clinicians, researchers, public) report/dissemination event.

Mixed-methods study protocol: do national reporting and learning system medication incidents in palliative care reflect patient and carer concerns about medication management and safety?

INTRODUCTION

Approximately 20% of serious safety incidents involving palliative patients relate to medication. These are disproportionately reported when patients are in their usual residence when compared with hospital or hospice. While patient safety incident reporting systems can support professional learning, it is unclear whether these reports encompass patient and carer concerns with palliative medications or interpersonal safety.

AIM

To explore and compare perceptions of (un)safe palliative medication management from patient, carer and professional perspectives in community, hospital and hospice settings.

METHODS AND ANALYSIS

We will use an innovative mixed-methods study design combining systematic review searching techniques with cross-sectional quantitative descriptive analysis and interpretative qualitative metasynthesis to integrate three elements: (1) Scoping review: multiple database searches for empirical studies and first-hand experiences in English (no other restrictions) to establish how patients and informal carers conceptualise safety in palliative medication management. (2)Medication incidents from the England and Wales National Reporting and Learning System: identifying and characterising reports to understand professional perspectives on suboptimal palliative medication management. (3) Comparison of 1 and 2: contextualising with stakeholder perspectives.

PATIENT AND PUBLIC INVOLVEMENT

Our team includes a funded patient and public involvement (PPI) collaborator, with experience of promoting patient-centred approaches in patient safety research. Funded discussion and dissemination events with PPI and healthcare (clinical and policy) professionals are planned.

ETHICS AND DISSEMINATION

Prospective ethical approval granted: Cardiff University School of Medicine Research Ethics Committee (Ref 19/28). Our study will synthesise multivoiced constructions of patient safety in palliative care to identify implications for professional learning and actions that are relevant across health and social care. It will also identify changing or escalating patterns in palliative medication incidents due to the COVID-19 pandemic. Peer-reviewed publications, academic presentations, plain English summaries, press releases and social media will be used to disseminate to the public, researchers, clinicians and policy-makers.

Identification of the multimorbidity training needs of primary care professionals: Protocol of a survey

Current epidemiological situation has prompted the consideration of multimorbility (MM) as a prevalent condition, influenced by age, educational level and social support, related to unfavorable social and health determinants. Primary Care (PC) has a key role in its approach but further training of professionals in MM is required. The evidence on the effectiveness of training interventions in MM is still limited. Knowing the experiences, opinions and training needs of professionals is essential to enhance training interventions.

OBJECTIVES

Identify perceived training needs by PC health professionals (doctors and nurses) in MM and polypharmacy.

METHODS

Design: Cross-sectional study based on an online survey (anonymous-ad hoc questionnaire). Participants and recruitment: 384 doctors and nurses working in healthcare centers and out-of-hospital emergencies of the Spanish National Health System. Non-probabilistic convenience sampling via email addressed to Health Institutions, and social networks.

DATA

Demographic characteristics and professional profile data (close-ended and multiple-choice questions) will be collected. Open-ended questions will be used to identify training needs, difficulties and resources about MM; required skills to care patients with MM will be assessed using a 4-item ordinal scale.

ANALYSIS

Coding of data prior to analysis. Descriptive statistical analysis, participation and completion rates of the questionnaire and estimation of absolute and relative frequencies and 95% confidence intervals in close-ended questions. Content analysis with inductive methodology in open-ended questions. Ethics: Ethical approval, Online informed consent.

CONCLUSIONS

The identification of training needs of health professionals who care for patients with MM will be necessary data for developing highly effective training activities.

Trends in Risk of Limitations in Instrumental Activities of Daily Living Over Age in Older Persons With and Without Multiple Chronic Conditions

Background

To investigate trends over age by comorbidity status for the risk of limitations in individual activities of daily living for community-living older persons.

Methods

A longitudinal population-based study was conducted in 9,319 community-living Dutch persons aged 60 years and older. Self-reported multiple chronic conditions (MCC) and nine instrumental activities of daily livings (IADLs) were assessed in 15 studies of the Dutch National Care for the Elderly Program (TOPICS-MDS). Risks of limitations in IADLs, odds ratios (per 5 years), and rate ratios (per 5 years) were calculated with mixed logistic and negative binomial regression models with age as the underlying timescale, stratified by number of MCC (no, 1–2, ≥ 3 MCC), and corrected for confounders.

Results

At inclusion, the number of IADL limitations was highest for the “≥3 MCC” group (2.00 interquartile range [1.00–4.00]) and equal for “no MCC” or “1–2 MCC” (1.00 interquartile range [0.00–2.00]). Trends of individual IADLs depicted a higher risk in IADL limitation with increasing age over 2 years of follow-up, except for handling finances for the “no MCC” group. The longitudinal age effect on IADL limitations varied subject to MCC, being strongest for the “no MCC” group for most IADLs; grooming and telephone use were almost unaltered by age and MCC.

Conclusion

We observed a decline in IADL functioning with increasing age over 2 years of follow-up in persons with and without MCC. The impact of MCC on IADL decline varied per IADL activity.

Social support, social context and nonadherence to treatment in young senior patients with multimorbidity and polypharmacy followed-up in primary care. MULTIPAP Study

OBJECTIVE

To estimate the prevalence of nonadherence to treatment and its relationship with social support and social context in patients with multimorbidity and polypharmacy followed-up in primary care.

METHODS

This was an observational, descriptive, cross-sectional, multicenter study with an analytical approach. A total of 593 patients between 65-74 years of age with multimorbidity (≥3 diseases) and polypharmacy (≥5 drugs) during the last three months and agreed to participate in the MULTIPAP Study. The main variable was adherence (Morisky-Green). The predictors were social support (structural support and functional support (DUFSS)); sociodemographic variables; indicators of urban objective vulnerability; health-related quality of life (EQ-5D-5L-VAS & QALY); and clinical variables. Descriptive, bivariate and multivariate analyses with logistic regression models and robust estimators were performed.

RESULTS

Four out of ten patients were nonadherent, 47% had not completed primary education, 28.7% had an income ≤1050 €/month, 35% reported four or more IUVs, and the average perceived health-related quality of life (HRQOL) EQ-5D-5L-VAS was 65.5. The items that measure functional support, with significantly different means between nonadherent and adherent patients were receiving love and affection (-0.23; 95%CI: -0.40;-0.06), help when ill (-0.25; 95%CI: -0.42;-0.08), useful advice (-0.20; 95%CI: -0.37;-0.02), social invitations (-0.22; 95%CI:-0.44;-0.01), and recognition (-0.29; 95%CI:-0.50;-0.08). Factors associated with nonadherence were belonging to the medium vs. low tertile of functional support (0.62; 95%CI: 0.42;0.94), reporting less than four IUVs (0.69; 95%CI: 0.46;1.02) and higher HRQOL perception (0.98; 95%CI: 0.98;0.99).

CONCLUSIONS

Among patients 65-74 years of age with multimorbidity and polypharmacy, lower functional support was related to nonadherence to treatment. The nonadherence decreased in those patients with higher functional support, lower urban vulnerability and higher perceived health status according to the visual analog scale of health-related quality of life.

Changing conversations in primary care for patients living with chronic conditions: pilot and feasibility study of the ICAN Discussion Aid

PURPOSE

To pilot test the impact of the ICAN Discussion Aid on clinical encounters.

METHODS

A pre-post study involving 11 clinicians and 100 patients was conducted at two primary care clinics within a single health system in the Midwest. The study examined clinicians' perceptions about ICAN feasibility, patients' and clinicians' perceptions about encounter success, videographic differences in encounter topics, and medication adherence 6 months after an ICAN encounter.

RESULTS

39/40 control encounters and 45/60 ICAN encounters yielded usable data. Clinicians reported ICAN use was feasible. In ICAN encounters, patients discussed diet, being active and taking medications more. Clinicians scored themselves poorer regarding visit success than their patients scored them; this effect was more pronounced in ICAN encounters. ICAN did not improve 6-month medication adherence or lengthen visits.

CONCLUSION

This pilot study suggests that using ICAN in primary care is feasible, efficient and capable of modifying conversations. With lessons learned in this pilot, we are conducting a randomised trial of ICAN versus usual care in diverse clinical settings.

TRIAL REGISTRATION NUMBER

NCT02390570.

Social networks of patients with multimorbidity: a qualitative study of patients' and supporters' views

INTRODUCTION Multimorbidity impacts on patients' health and wellbeing, but relationships experienced within social networks can support people to live well. AIM This study sought to elicit the views of New Zealanders with multimorbidity about their social networks and the views of their nominated supporters. METHODS Ten patients with multimorbidity and their nominated supporters each independently recorded their views of the patient's social network on a five-concentric-circle template, indicating supporting role and importance to each patient. Sets of patients' and nominated supporters' templates were compared followed by comparing matched pairs of patient-supporter templates. Nominated supporters' views about the patients' networks and why they were nominated were collated. RESULTS Three patients nominated family members as supporters and seven nominated health professionals. Nominated family members identified a greater range of supporters than nominated health professionals. Nominated family members perceived that they played an integral role, whereas health professionals were less comfortable viewing relationships with patients in this way. Family members were not surprised to be nominated as supporters, and some described a considerable burden of care. Health professionals described themselves as coordinators of support and having positive relationships with patients. DISCUSSION Patients with multimorbidity have rich and diverse social networks. They view partners, family and health professionals as providing significant support. Family members are more aware of their role and have a deeper understanding of other network members than health professionals. Further research is needed on the use of social networks in clinical practice to support the health and wellbeing of those with multimorbidity.

Patients' experiences of coping with multiple chronic conditions: A meta-ethnography of qualitative work

Multiple chronic conditions (MCCs) pose a major and growing burden on the individuals' health. The ways in which people cope with their stresses related to their chronic conditions are significant to their health outcomes. This review sought to understand lived experiences of coping with MCCs by a meta-ethnography of qualitative studies. Twenty-six studies were identified in four electronic databases including PubMed, PsycINFO, EMBASE, and CINAHL that were searched from 1966 to 2017. A seven-step analytic method was used after a quality evaluation based on Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). The findings illustrated that experiences of coping with MCCs were interacted with (i) appraisals of MCCs, (ii) strategies to maintain a normal life, (iii) strategies to keep the spirits up, and (iv) coping in the social context. To sum up, this review provided a collection of narratives on coping with MCCs. The findings would help to recognize the high complexity experienced by these patients, also potentially offered a foundation for the design of a feasible intervention to more optimally highlight the demands of managing MCCs.

The Taxonomy of Everyday Self-management Strategies (TEDSS): A framework derived from the literature and refined using empirical data

OBJECTIVE

To extend our understanding of self-management by using original data and a recent concept analysis to propose a unifying framework for self-management strategies.

METHODS

Longitudinal interview data with 117 people with neurological conditions were used to test a preliminary framework derived from the literature. Statements from the interviews were sorted according to the predefined categories of the preliminary framework to investigate the fit between the framework and the qualitative data. Data on frequencies of strategies complemented the qualitative analysis.

RESULTS

The Taxonomy of Every Day Self-management Strategies (TEDSS) Framework includes five Goal-oriented Domains (Internal, Social Interaction, Activities, Health Behaviour and Disease Controlling), and two additional Support-oriented Domains (Process and Resource). The Support-oriented Domain strategies (such as information seeking and health navigation) are not, in and of themselves, goal focused. Instead, they underlie and support the Goal-oriented Domain strategies. Together, the seven domains create a comprehensive and unified framework for understanding how people with neurological conditions self-manage all aspects of everyday life.

CONCLUSIONS

The resulting TEDSS Framework provides a taxonomy that has potential to resolve conceptual confusion within the field of self-management science.

PRACTICE IMPLICATIONS

The TEDSS Framework may help to guide health service delivery and research.

The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting

BACKGROUND

Patients with multi-morbidity have complex care needs that often make healthcare delivery difficult and costly to manage. Current healthcare delivery is not tailored to the needs of patients with multi-morbidity, although multi-morbidity poses a heavy burden on patients and is related to adverse outcomes. Patient-centered care and co-creation of care are expected to improve outcomes, but the relationships among patient-centered care, co-creation of care, physical well-being, social well-being, and satisfaction with care among patients with multi-morbidity are not known.

METHODS

In 2017, a cross-sectional survey was conducted among 216 (of 394 eligible participants; 55% response rate) patients with multi-morbidity from eight primary care practices in Noord-Brabant, the Netherlands. Correlation and regression analyses were performed to identify relationships among patient-centered care, co-creation of care, physical well-being, social well-being, and satisfaction with care.

RESULTS

The mean age of the patients was 74.46 ± 10.64 (range, 47-94) years. Less than half (40.8%) of the patients were male, 43.3% were single, and 39.3% were less educated. Patient-centered care and co-creation of care were correlated significantly with patients' physical well-being, social well-being, and satisfaction with care (all p ≤ 0.001). Patient-centered care was associated with social well-being (B = 0.387, p ≤ 0.001), physical well-being (B = 0.368, p ≤ 0.001) and satisfaction with care (B = 0.425, p ≤ 0.001). Co-creation of care was associated with social well-being (B = 0.112, p = 0.006) and satisfaction with care (B = 0.119, p = 0.007).

CONCLUSIONS

Patient-centered care and co-creation of care were associated positively with satisfaction with care and the physical and social well-being of patients with multi-morbidity in the primary care setting. Making care more tailored to the needs of patients with multi-morbidity by paying attention to patient-centered care and co-creation of care may contribute to better outcomes.

Coping mediates the relationship between sense of coherence and mental quality of life in patients with chronic illness: a cross-sectional study

PURPOSE

The aim of the present study was to investigate relationships between sense of coherence, emotion-focused coping, problem-focused coping, coping efficiency, and mental quality of life (QoL) in patients with chronic illness. A model based on Lazarus' and Folkman's stress and coping theory tested the specific hypothesis: Sense of coherence has a direct and indirect effect on mental QoL mediated by emotion-focused coping, problem-focused coping, and coping efficiency in serial adjusted for age, gender, educational level, comorbidity, and economic status.

METHODS

The study used a cross-sectional and correlational design. Patients (n = 292) with chronic diseases (chronic heart failure, end-stage renal disease, multiple sclerosis, stroke, and Parkinson) completed three questionnaires and provided background data. Data were collected in 2012, and a serial multiple mediator model was tested using PROCESS macro for SPSS.

RESULTS

The test of the conceptual model confirmed the hypothesis. There was a significant direct and indirect effect of sense of coherence on mental QoL through the three mediators. The model explained 39% of the variance in mental QoL.

CONCLUSIONS

Self-perceived effective coping strategies are the most important mediating factors between sense of coherence and QoL in patients with chronic illness, which supports Lazarus' and Folkman's stress and coping theory.

Exploring the Validity of Developing an Interdisciplinarity Score of a Patient's Needs: Care Coordination, Patient Complexity, and Patient Safety Indicators

Despite the Affordable Care Act's push to improve the coordination of care for patients with multiple chronic conditions, most measures of coordination quality focus on a specific moment in the care process (e.g., medication errors or transfer between facilities), rather than patient outcomes. One possible supplementary way of measuring the care coordination quality of a facility would be to identify the patients needing the most coordination, and to look at outcomes for that group. This paper lays the groundwork for a new measure of care coordination quality by outlining a conceptual framework that considers the interaction between a patient's interdisciplinarity, biological susceptibility, and procedural intensity. Interdisciplinarity captures the degree of specialized medical expertise needed for a patient's care and will be an important measure to estimate the number of specialists a patient might see. We then develop a preliminary measure of interdisciplinarity and run tests linking interdisciplinarity to medical mistakes, as defined by Agency for Healthcare Research and Quality's Patient Safety Indicators. Finally, we use our preliminary measure to verify that interdisciplinarity is likely to be statistically different from existing measures of comorbidity, like the Charlson score. Future research will need to build upon our findings by developing a more statistically validated measure of interdisciplinarity.

Does the chronic care model meet the emerging needs of people living with multimorbidity? A systematic review and thematic synthesis

BACKGROUND

The Chronic Care Model (CCM) emerged in the 1990s as an approach to re-organize primary care and implement critical elements that enable it to proactively attend to patients with chronic conditions. The chronic care landscape has evolved further, as most patients now present with multiple chronic conditions and increasing psychosocial complexity. These patients face accumulating and overwhelming complexity resulting from the sum of uncoordinated responses to each of their problems. Minimally Disruptive Medicine (MDM) was proposed to respond to this challenge, aiming at improving outcomes that matter to patients with the smallest burden of treatment. We sought to critically appraise the extent to which MDM constructs (e.g., reducing patient work, improving patients' capacity) have been adopted within CCM implementations.

METHODS

We conducted a systematic review and qualitative thematic synthesis of reports of CCM implementations published from 2011-2016.

RESULTS

CCM implementations were mostly aligned with the healthcare system's goals, condition-specific, and targeted disease-specific outcomes or healthcare utilization. No CCM implementation addressed patient work. Few reduced treatment workload without adding additional tasks. Implementations supported patient capacity by offering information, but rarely offered practical resources (e.g., financial assistance, transportation), helped patients reframe their biography with chronic illness, or assisted them in engaging with a supportive social network. Few implementations aimed at improving functional status or quality of life, and only one-third of studies were targeted for patients of low socioeconomic status.

CONCLUSION

MDM provides a lens to operationalize how to care for patients with multiple chronic conditions, but its constructs remain mostly absent from how implementations of the CCM are currently reported. Improvements to the primary care of patients with multimorbidity may benefit from the application of MDM, and the current CCM implementations that do apply MDM constructs should be considered exemplars for future implementation work.

Perceived value of eHealth among people living with multimorbidity: a qualitative study

Background

The prevalence of multimorbidity is increasing, creating challenges for patients, healthcare professionals, and healthcare systems. Given that chronic disease management increasingly involves eHealth, it is useful to assess its perceived value among people with multimorbidity.

Objective

To explore challenges related to multimorbidity and patients’ perspectives on eHealth.

Design

Ten semi-structured interviews with adults, living with multimorbidity in Copenhagen, Denmark. Interviews focused on patient-experienced challenges, from challenges related to self-management to challenges experienced in the healthcare sector, as well as perceptions of eHealth. During interviews, participants were presented with pictures of different eHealth technologies. Data analysis followed the systematic text condensation approach.

Results

Participants experienced challenges in their daily lives, e.g. when practicing self-management activities, when navigating the healthcare sector, and when interacting with healthcare professionals. Patient-perceived value of eHealth varied, depending on their burden of illness and treatment: those with a greater burden had more positive perceptions of eHealth, and expressed more intention to use it. Participants with less complex disease patterns and less burdensome treatment regimens were more likely to perceive eHealth as something worthless and undesirable. Participants stressed that eHealth should only be introduced as an optional supplement.

Conclusions

eHealth can potentially address some patient-experienced challenges related to multimorbidity by promoting self-management, patient-centeredness, and access. However, patients’ needs and preferences vary and eHealth cannot substitute the personal interaction between patient and healthcare professionals. Our findings point to the importance of patient assessment and stratification to ensure appropriate use of eHealth.

The impact of socioeconomic status and multimorbidity on mortality: a population-based cohort study

OBJECTIVE

Multimorbidity (MM) is more prevalent among people of lower socioeconomic status (SES), and both MM and SES are associated with higher mortality rates. However, little is known about the relationship between SES, MM, and mortality. This study investigates the association between educational level and mortality, and to what extent MM modifies this association.

METHODS

We followed 239,547 individuals invited to participate in the Danish National Health Survey 2010 (mean follow-up time: 3.8 years). MM was assessed by using information on drug prescriptions and diagnoses for 39 long-term conditions. Data on educational level were provided by Statistics Denmark. Date of death was obtained from the Civil Registration System. Information on lifestyle factors and quality of life was collected from the survey. The main outcomes were overall and premature mortality (death before the age of 75).

RESULTS

Of a total of 12,480 deaths, 6,607 (9.5%) were of people with low educational level (LEL) and 1,272 (2.3%) were of people with high educational level (HEL). The mortality rate was higher among people with LEL compared with HEL in groups of people with 0-1 disease (hazard ratio: 2.26, 95% confidence interval: 2.00-2.55) and ≥4 diseases (hazard ratio: 1.14, 95% confidence interval: 1.04-1.24), respectively (adjusted model). The absolute number of deaths was six times higher among people with LEL than those with HEL in those with ≥4 diseases. The 1-year cumulative mortality proportions for overall death in those with ≥4 diseases was 5.59% for people with HEL versus 7.27% for people with LEL, and 1-year cumulative mortality proportions for premature death was 2.93% for people with HEL versus 4.04% for people with LEL. Adjusting for potential mediating factors such as lifestyle and quality of life eliminated the statistical association between educational level and mortality in people with MM.

CONCLUSION

Our study suggests that LEL is associated with higher overall and premature mortality and that the association is affected by MM, lifestyle factors, and quality of life.

The Knowledge, Awareness, and Practices of Portuguese General Practitioners Regarding Multimorbidity and its Management: Qualitative Perspectives from Open-Ended Questions

Multimorbidity's high prevalence and negative impact has made it a subject of worldwide interest. The main aim of this study was to access the Portuguese knowledge, awareness, and practices of general practitioners (GPs) regarding multimorbidity and its management, in order to aid in the development of interventions for improving outcomes in multimorbid patients in primary care. A web-based qualitative descriptive study was carried out in the first trimester of 2016 with primary care physicians working in two districts of the Centre region of Portugal. Open-ended questions were analysed via inductive thematic content analysis. GPs pointed out several difficulties and challenges while managing multimorbidity. Extrinsic factors were associated with the healthcare system logistics' management (consultation time, organization of care teams, clinical information) and society (media pressure, social/family support). Intrinsic factors related to the GP, patient, and physician-patient relationship were also stated. The most significant conclusion to emerge from this study is that although GPs perceived difficulties and challenges towards multimorbidity, they also have the tools to deal with them: the fundamental characteristics of family medicine. Also, the complex care required by multimorbid patients needs adequate consultation time, multidisciplinary teamwork, and more education/training.

Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid

BACKGROUND

The needs of the growing population of complex patients with multiple chronic conditions calls for a different approach to care. Clinical teams need to acknowledge, respect, and support the work that patients do and the capacity they mobilize to enact this work, and to adapt and self-manage. Tools that enable this approach to care are needed.

METHODS

Using user-centered design principles, we set out to create a discussion aid for use by patients, clinicians, and other health professionals during clinical encounters. We observed clinical encounters, visited patient homes, and dialogued with patient support groups. We then developed and tested prototypes in routine clinical practice. Then we refined a final prototype with extensive stakeholder feedback.

RESULTS

From this process resulted the ICAN Discussion Aid, a tool completed by the patient and reviewed during the consultation in which patients classified domains that contribute to capacity as sources of burden or satisfaction; clinical demands were also classified as sources of help or burden. The clinical review facilitated by ICAN generates hypotheses regarding why some treatment plans may be problematic and may not be enacted in the patient's situation.

CONCLUSION

We successfully created a discussion aid to elucidate and share insights about the capacity patients have to enact the treatment plan and hypotheses as to why this plan may or may not be enacted. Next steps involve the evaluation of the impact of the ICAN Discussion Aid on clinical encounters with a variety of health professionals and the impact of ICAN-informed treatment plans on patient-important outcomes.

Applying clinical guidelines in general practice: a qualitative study of potential complications

Background

Clinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners’ (GPs’) experiences with and reflections upon the consequences for general practice of applying multiple guidelines.

Methods

Qualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach.

Results

The GPs’ responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice ‘defensive medicine’. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life.

Conclusions

The GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs’ courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

Multimorbidity and the process of living with ongoing illness

OBJECTIVES

Living with two or more health conditions, or multimorbidity, is associated with higher rates of disability and lower quality of life. To overcome the challenges associated with multimorbidity, person-centred health care is essential. However, to provide person-centred health care, health professionals first need to understand how people with multiple health conditions experience their illness.

METHODS

Sixteen adult participants, with one or more health conditions, were recruited from hospital outpatient and community health services and interviewed twice. Qualitative data from interview transcripts and field notes were inductively analysed using constructivist grounded theory and life chart methods.

FINDINGS

'Living with ongoing illness' describes a process involving four interrelated experiences. Participants described, 'recognising something is not right,' 'working out what is wrong,' 'getting things under control' and 'getting on with life.' A case example is used to illustrate and compare the process across a participant's first and subsequent health conditions.

DISCUSSION

Participants with different health conditions shared similar illness experiences. Yet, the process of living with ongoing illness was unique and differed according to participants' health conditions and life context. By understanding the experiences, needs, and priorities of people with multimorbidity, health professionals can provide timely and relevant health care.