Living with complexity; marshalling resources: a systematic review and qualitative meta-synthesis of lived experience of mental and physical multimorbidity

Opportunities and challenges in utilizing community assets to extend chronic care management in podoconiosis endemic areas: Evidence from Northwestern Ethiopia

Community-based chronic care intervention is important in the control and prevention of lifelong conditions such as podoconiosis and similar 'intensive disease management' neglected tropical diseases (NTDs). Despite a call for such interventions, few efforts have been made to identify opportunities and challenges related to their implementation. Employing a qualitative approach, this study explored the possibility of engaging community actors, physical places and networks to promote chronic care management in rural Ethiopia. We gathered data from affected individuals, community members, local leaders, health professionals and community health workers between April and May 2022. The study revealed that affected individuals, family members, religious leaders, traditional leaders, and health professionals have the potential to extend chronic care management in rural areas. Houses, churches, schools, and healthcare facilities are suitable venues at which to perform interventions. Strong community solidarity and political will are vital to chronic care interventions, while lack of understanding about chronic conditions, financial constraints, and limited resources at healthcare facilities could pose challenges. Using community assets has great promise for expanding chronic care management with minimal costs and efforts in under resourced areas. Achieving this will require a successful plan to coordinate the collaboration among the agents and settings.

Living With and Beyond Cancer With Comorbid Conditions: Qualitative Insights to Understand Psychosocial Support Needs

INTRODUCTION

There is a pressing need to understand and explore the complex experiences and psychosocial support needs of people LWBC-CM and their informal caregivers, to inform survivorship and supportive care interventions.

METHODS

In-depth qualitative interviews were conducted with people LWBC-CM and their informal caregivers in Scotland, invited via primary care. One-to-one, face-to-face interviews were conducted with informed consent exploring experiences of symptoms, psychosocial support needs and interactions with health services. Interviews were transcribed and analysed using a thematic approach.

RESULTS

Forty-one people LWBC-CM and twenty-three informal caregivers were interviewed. Four themes were identified: the Physical and Psychological Impact of Cancer and Comorbidity, Dominant Storie-Prioritising Conditions and Making Sense of Illness, Navigating Health Services and Treatments and Caring for People with Complex Health Conditions. Type and severity of conditions mediated people's experiences and daily living. Complex fatigue-fatigue arising from a number of health conditions-dominated symptomology. Participants navigated multiple appointments and complex medication regimes. Patients identified the need for acknowledgement of other chronic conditions and for streamlined care provision. Mutual caring and social isolation were also identified as part of the caring relationship.

CONCLUSIONS

There is a mandate to address the psychosocial support needs of people LWBC-CM, and their informal carers, given the burden of treatment for cancer survivors with moderate to severe complex conditions as they navigate health services.

PATIENT OR PUBLIC CONTRIBUTION

A patient representative has been involved in all stages of the study from development of the application through study design, commenting on documentation, analysis of transcripts and writing the manuscript. They are included as an author on the manuscript.

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.

An exploratory randomised trial investigating feasibility, potential impact and cost effectiveness of link workers for people living with multimorbidity attending general practices in deprived urban communities

BACKGROUND

Social prescribing link workers are non-health or social care professionals who connect people with psychosocial needs to non-clinical community supports. They are being implemented widely, but there is limited evidence for appropriate target populations or cost effectiveness. This study aimed to explore the feasibility, potential impact on health outcomes and cost effectiveness of practice-based link workers for people with multimorbidity living in deprived urban communities.

METHODS

A pragmatic exploratory randomised trial with wait-list usual care control and blinding at analysis was conducted during the COVID 19 pandemic (July 2020 to January 2021). Participants had two or more ongoing health conditions, attended a general practitioner (GP) serving a deprived urban community who felt they may benefit from a one-month practice-based social prescribing link worker intervention.. Feasibility measures were recruitment and retention of participants, practices and link workers, and completion of outcome data. Primary outcomes at one month were health-related quality of life (EQ-5D-5L) and mental health (HADS). Potential cost effectiveness from the health service perspective was evaluated using quality adjusted life years (QALYs), based on conversion of the EQ-5D-5L and ICECAP-A capability index to utility scoring.

RESULTS

From a target of 600, 251 patients were recruited across 13 general practices. Randomisation to intervention (n = 123) and control (n = 117) was after baseline data collection. Participant retention at one month was 80%. All practices and link workers (n = 10) were retained for the trial period. Data completion for primary outcomes was 75%. There were no significant differences identified using mixed effects regression analysis in EQ-5D-5L (MD 0.01, 95% CI -0.07 to 0.09) or HADS (MD 0.05, 95% CI -0.63 to 0.73), and no cost effectiveness advantages. A sensitivity analysis that considered link workers operating at full capacity in a non-pandemic setting, indicated the probability of effectiveness at the €45,000 ICER threshold value for Ireland was 0.787 using the ICECAP-A capability index.

CONCLUSIONS

While the trial under-recruited participants mainly due to COVID-19 restrictions, it demonstrates that robust evaluations and cost utility analyses are possible. Further evaluations are required to establish cost effectiveness and should consider using the ICE-CAP-A wellbeing measure for cost utility analysis.

REGISTRATION

This trial is registered on ISRCTN.

TITLE

Use of link workers to provide social prescribing and health and social care coordination for people with complex multimorbidity in socially deprived areas.

TRIAL ID

ISRCTN10287737. Date registered 10/12/2019. Link: https://www.isrctn.com/ISRCTN10287737.

Service innovations for people with multiple long-term conditions: reflections of a rapid evaluation team

Background

People living with multiple long-term conditions represent a significant concern for National Health Service policy and practice, and their care is a major theme in the 2019 National Health Service Long Term Plan. The Birmingham RAND and Cambridge Rapid Evaluation Centre team has undertaken a thematic synthesis of the 10 evaluations it has conducted from 2018 to 2023, exploring the needs, priorities and implications for people with multiple long-term conditions.

Objectives

The aims for this overarching study were to: (1) build a body of learning about service innovations in primary and community settings for people of all ages with multiple long-term conditions, focused on questions that matter most to people with multimorbidity; and (2) develop methodological insights about how rapid evaluation can be used to inform the scoping, testing and implementation of service innovations for people with multiple long-term conditions.

Design

The focus on multiple long-term conditions came from a Birmingham RAND and Cambridge Rapid Evaluation Centre prioritisation process undertaken in 2018 using James Lind Alliance methods. Cross-analysis of the findings from the 10 individual rapid evaluations was supplemented by (1) building aspects of multimorbidity into the design of later evaluations; (2) interviewing national and regional stakeholders (n=19) working in or alongside integrated care systems; (3) undertaking a rapid review of evidence on remote monitoring for people with multiple long-term conditions (19 papers included); and (4) testing overall insights with organisations representing patients and carers through a patient, public and professional engagement workshop with 10 participants plus members of the research team.

Results

While living with multiple long-term conditions is common and is the norm for people over the age of 50 using health and care services, it is not often a focus of health service provision or innovation, nor of research and evaluation activity. We discuss six themes emerging from the totality of the study: (1) our health system is mainly organised around single conditions and not multiple long-term conditions; (2) research calls and studies usually focus on single conditions and associated services; (3) building opportunities for engaged, informed individuals and carers and improved self-management; (4) the importance of measures that matter for patients and carers; (5) barriers to developing and implementing service innovations for people with multiple long-term conditions; and (6) what is needed to make patients with multiple long-term conditions a priority in healthcare planning and delivery.

Limitations

Care of people with multiple long-term conditions was not the principal focus of several of the rapid evaluations. While this was a finding in itself, it limited our learning about designing and implementing, as well as methodological approaches to evaluating, service innovations for people with multiple long-term conditions.

Conclusions

Through a thematic analysis of the portfolio of evaluations, we have deduced a set of suggested implications for how the needs of people with multiple long-term conditions can be better embedded in policy, research and practice.

Future work

Areas of uncertainty related to the care of people with multiple long-term conditions should be further explored, including developing and testing measures of patient experience of (un)co-ordinated care across settings, and interrogating the experience of health and care staff when working with people with multiple long-term conditions, to understand what works.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR134284) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information.

Shaping research for people living with co-existing mental and physical health conditions: A research priority setting initiative from the United Kingdom

INTRODUCTION

Those with severe and enduring mental ill health are at greater risk of long-term physical health conditions and have a reduced life expectancy as a result. Multiple factors compound this health inequality, and the need for setting research priorities in this area is highlighted with physical and mental healthcare services being separate, and limited multimorbidity research.

METHODS

The aim of this exercise was to work in partnership with healthcare professionals and carers, family, friends and individuals with lived experience of both mental and physical health conditions, to set research priorities to help people with mental health conditions to look after their physical health. The exercise was guided by the James Lind Alliance approach. For this, a steering group was set up, two surveys were completed and a final priority workshop was conducted.

RESULTS

This priority setting exercise guided by people's needs and lived experience has produced a set of well-defined research topics. Initially, 555 research questions were suggested in the first survey, which were refined to 54 questions for the second survey. A priority setting workshop was then conducted to get the final 10 priorities.

CONCLUSIONS

Taking these topics forward to improve services and treatment for both mental and physical ill health may in turn improve physical health and lessen the reduced life expectancy of those living with mental ill health.

PATIENT OR PUBLIC CONTRIBUTION

This work was completed in collaboration with people who have lived experience of mental ill health and physical health conditions, as well as carers, family and friends. Their contribution has been significant for this work from piloting surveys, amending language used and educating the researchers and contributing to this paper. The initial work was completed with a steering group and continued with surveys and workshops.

Managing Complexity: Black Older Adults With Multimorbidity

BACKGROUND AND OBJECTIVES

Black older adults have higher rates of multimorbidity and receive less effective multimorbidity support than their white counterparts. Yet little is known about the experiences of Black older adults with multimorbidity that may be at the heart of those disparities and which are central to interventions and improving care for this population. In this study, we aimed to conceptualize the multimorbidity management (MM) experience for Black older adults.

RESEARCH DESIGN AND METHODS

As part of a larger study on Black older adults' multimorbidity and physician empathy, we conducted in-depth qualitative interviews with 30 Black older adults living in a large midwestern city in the United States aged 65 years and older with self-reported multimorbidity. We used grounded theory analysis to distill findings into a core conceptual category as well as component domains and dimensions.

RESULTS

"Managing complexity" emerged as the core category to describe MM in our sample. Managing complexity included domains of "social context," "daily logistics," "care time," and "care roles."

DISCUSSION AND IMPLICATIONS

We discuss how managing complexity is distinct from patient complexity and how it is related to cumulative inequality and precarity. Study findings have potential implications for intervention around provider education and empathy as well as for enabling agency of Black older adults with MM.

An interpretative phenomenological analysis of the lived experience of people with multimorbidity in low- and middle-income countries

People living with multimorbidity (PLWMM) have multiple needs and require long-term personalised care, which necessitates an integrated people-centred approach to healthcare. However, people-centred care may risk being a buzzword in global health and cannot be achieved unless we consider and prioritise the lived experience of the people themselves. This study captures the lived experiences of PLWMM in low- and middle-income countries (LMICs) by exploring their perspectives, experiences, and aspirations.We analysed 50 semi-structured interview responses from 10 LMICs across three regions-South Asia, Latin America, and Western Africa-using an interpretative phenomenological analysis approach.The bodily, social, and system experiences of illness by respondents were multidirectional and interactive, and largely captured the complexity of living with multimorbidity. Despite expensive treatments, many experienced little improvements in their conditions and felt that healthcare was not tailored to their needs. Disease management involved multiple and fragmented healthcare providers with lack of guidance, resulting in repetitive procedures, loss of time, confusion, and frustration. Financial burden was exacerbated by lost productivity and extreme finance coping strategies, creating a vicious cycle. Against the backdrop of uncertainty and disruption due to illness, many demonstrated an ability to cope with their conditions and navigate the healthcare system. Respondents' priorities were reflective of their desire to return to a pre-illness way of life-resuming work, caring for family, and maintaining a sense of independence and normalcy despite illness. Respondents had a wide range of needs that required financial, health education, integrated care, and mental health support.In discussion with respondents on outcomes, it appeared that many have complementary views about what is important and relevant, which may differ from the outcomes established by clinicians and researchers. This knowledge needs to complement and be incorporated into existing research and treatment models to ensure healthcare remains focused on the human and our evolving needs.

Caring for high-need patients

OBJECTIVE

We aimed to explore the construct of "high need" and identify common need domains among high-need patients, their care professionals, and healthcare organizations; and to describe the interventions that health care systems use to address these needs, including exploring the potential unintended consequences of interventions.

METHODS

We conducted a modified Delphi panel informed by an environmental scan. Expert stakeholders included patients, interdisciplinary healthcare practitioners (physicians, social workers, peer navigators), implementation scientists, and policy makers. The environmental scan used a rapid literature review and semi-structured interviews with key informants who provide healthcare for high-need patients. We convened a day-long virtual panel meeting, preceded and followed by online surveys to establish consensus.

RESULTS

The environmental scan identified 46 systematic reviews on high-need patients, 19 empirical studies documenting needs, 14 intervention taxonomies, and 9 studies providing construct validity for the concept "high need." Panelists explored the construct and terminology and established that individual patients' needs are unique, but areas of commonality exist across all high-need patients. Panelists agreed on 11 domains describing patient (e.g., social circumstances), 5 care professional (e.g., communication), and 8 organizational (e.g., staffing arrangements) needs. Panelists developed a taxonomy of interventions with 15 categories (e.g., care navigation, care coordination, identification and monitoring) directed at patients, care professionals, or the organization. The project identified potentially unintended consequences of interventions for high-need patients, including high costs incurred for patients, increased time and effort for care professionals, and identification of needs without resources to respond appropriately.

CONCLUSIONS

Care for high-need patients requires a thoughtful approach; differentiating need domains provides multiple entry points for interventions directed at patients, care professionals, and organizations. Implementation efforts should consider outlined intended and unintended downstream effects on patients, care professionals, and organizations.

Sociocultural and patient-health care professional related factors influencing self-management of multiethnic patients with multimorbidities: A thematic synthesis

Self-management is critical for the general well-being and disease management of individuals with multimorbidities. A better understanding of sociocultural and patient-professional level factors affecting self-management can be valuable for designing individual and community-based strategies to promote optimal self-management. The purpose of this review was to explore sociocultural and patient-health care professional related factors affecting self-management among patients with multimorbidities. A metasynthesis was conducted. Literature was searched in PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 21 qualitative studies published from January 2010-March 2023 were critically appraised and reviewed. Thematic synthesis was used for analysis and eight descriptive and three analytical themes were generated. The analytical themes illustrated that personal and structural vulnerabilities, social and family struggles, and fragmented interpersonal relationships with health care professionals affect health care access, navigation, and self-management of individuals with multimorbidities. Engagement in self-management for individuals with multiple chronic conditions is hampered by under-resourced community and health care environments, structural vulnerabilities, familial and interpersonal conflicts, and disjointed relationships. There is a dire need to ensure optimal community resources to support individuals to address and navigate complexities associated with accessing care and effectively managing their illnesses.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada

BACKGROUND

There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18-64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets.

METHODS

Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546).

FINDINGS

There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions.

CONCLUSIONS

Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.

Interventions and management on multimorbidity: An overview of systematic reviews

BACKGROUND

Multimorbidity poses an immense burden on the healthcare systems globally, whereas the management strategies and guidelines for multimorbidity are poorly established. We aim to synthesize current evidence on interventions and management of multimorbidity.

METHODS

We searched four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews). Systematic reviews (SRs) on interventions or management of multimorbidity were included and evaluated. The methodological quality of each SR was assessed by the AMSTAR-2 tool, and the quality of evidence on the effectiveness of interventions was assessed by the grading of recommendations assessment, development and evaluation (GRADE) system.

RESULTS

A total of 30 SRs (464 unique underlying studies) were included, including 20 SRs of interventions and 10 SRs summarizing evidence on management of multimorbidity. Four categories of interventions were identified: patient-level interventions, provider-level interventions, organization-level interventions, and combined interventions (combining the aforementioned two or three- level components). The outcomes were categorized into six types: physical conditions/outcomes, mental conditions/outcomes, psychosocial outcomes/general health, healthcare utilization and costs, patients' behaviors, and care process outcomes. Combined interventions (with patient-level and provider-level components) were more effective in promoting physical conditions/outcomes, while patient-level interventions were more effective in promoting mental conditions/outcomes and psychosocial outcomes/general health. As for healthcare utilization and care process outcomes, organization-level and combined interventions (with organization-level components) were more effective. The challenges in the management of multimorbidity at the patient, provider and organizational levels were also summarized.

CONCLUSION

Combined interventions for multimorbidity at different levels would be favored to promote different types of health outcomes. Challenges exist in the management at the patient, provider, and organization levels. Therefore, a holistic and integrated approach of patient-, provider- and organization- level interventions is required to address the challenges and optimize care of patients with multimorbidity.

"A reinstilled hope that they can change": Facilitator perspectives on a self-care and health promotion peer group program for veterans

Introduction

This study assessed the relevance, value, and effectiveness of "Taking Charge of My Life and Health" (TCMLH), a patient wellbeing peer group program for U.S. veterans focused on empowering them to identify what really matters in their lives and to work toward health goals that align with their mission, aspirations, or purpose in life. The potential of TCMLH to empower veterans to engage in self-care behaviors, make health behavior changes, and participate in health care decision making is important, as veterans are more likely than the general population to suffer from multiple chronic conditions that require ongoing self-management.

Methods

We conducted individual semi-structured interviews with 19 TCMLH facilitators serving in eight U.S. Veteran's Health Administration medical centers. Data were analyzed using an inductive approach to identify salient themes in facilitators' experiences.

Results

Facilitators reported that TCMLH participants demonstrated positive attitude changes (e.g., greater confidence and hope) and behavior changes (e.g., making healthcare appointments and implementing self-care practices) by program completion. Further, findings show that mindful awareness practices, the peer group setting, Whole Health assessment tools, and goal setting tools were perceived as the most impactful program elements leading to positive health behavior change.

Conclusion

Overall, findings suggest that this non-clinical peer group program can enhance patient wellbeing, and that there are certain program elements of TCMLH that are driving key attitudinal and behavioral changes.

"I wouldn't survive it, as simple as that": Syndemic vulnerability among people living with chronic non-communicable disease during the COVID-19 pandemic

The co-occurrence of COVID-19, non-communicable diseases and socioeconomic disadvantage has been identified as creating a syndemic: a state of synergistic epidemics, occurring when co-occurring health conditions interact with social conditions to amplify the burden of disease. In this study, we use the concept of illness management work to explore the impact of the COVID-19 pandemic on the lives of people living with, often multiple, chronic health conditions in a range of social circumstances. In-depth interviews were conducted between May and July 2020 with 29 participants living in a city in North East England. Qualitative data provide unique insights for those seeking to better understand the consequences for human life and wellbeing of the interacting social, physical and psychological factors that create syndemic risks in people's lives. Among this group of people at increased vulnerability to harm from COVID-19, we find that the pandemic public health response increased the work required for condition management. Mental distress was amplified by fear of infection and by the requirements of social isolation and distancing that removed participants' usual sources of support. Social conditions, such as poor housing, low incomes and the requirement to earn a living, further amplified the work of managing everyday life and risked worsening existing mental ill health. As evidenced by the experiences reported here, the era of pandemics will require a renewed focus on the connection between health and social justice if stubborn, and worsening health and social inequalities are to be addressed or, at the very least, not increased.

Self-efficacy in disadvantaged communities: Perspectives of healthcare providers and clients

OBJECTIVE

Most chronic disease self-management interventions emphasise the integral role of self-efficacy in achieving behaviour change. We explored the applicability of this model in a low-income setting, from the perspective of both patients and clinicians.

METHODS

Interviews with multimorbid patients and their health providers at two rural community health centres in Victoria, Australia. We used a phenomenological methodology, exploring themes of confidence to manage health, outcome expectations and goals.

RESULTS

Many assumptions in which the self-efficacy model is grounded did not apply to this population. Past experiences and resource constraints, especially poverty and healthcare access, influenced confidence, expectations and the ability to achieve desired outcomes.

DISCUSSION

The focus of traditional self-management support on individual behaviour change disadvantages rural low-income patients, who face barriers related to life experience and resource constraints. For this group, self-management support needs to return to its roots, moving away from a narrow conception of behaviour change and reinstating the role of 'support' into 'self-management support' interventions. Health providers working in rural low-income settings should recognise the limits inherent in self-efficacy focussed interventions and think broadly about engaging with their clients in whatever way supports them to find a life with meaning and purpose.

Integration of primary palliative care into geriatric care from the Indian perspective

The rising trend in the ageing population alongside social, cultural, and economic changes poses a major threat to the health care system in the country. Elderly population have dynamic and complex health care needs, are debilitated by the progressive chronic life-threatening diseases, and live a compromised quality of life. Palliative care, with its multifaceted approach, can provide respite to the elderly population. A decentralized approach in which palliative care is provided by the local community will ensure seamless continuity of care and care at an affordable cost. General practitioners or family physicians play a vital role in delivering primary palliative care to the elderly population in the community. An integrating primary palliative-geriatric care model will ensure that care is provided in alignment with the patients' and their families' wishes along the trajectory of the life-threatening illness and at the patients' preferred place. However, delivering primary palliative care in the community can be riddled with challenges at various levels, such as identification of patients in need of palliative care, interpersonal communication, addressing patients' and caregivers' needs, clarity in roles and responsibilities between general practitioner and family physicians and specialist palliative care teams, coordination of services with specialists, and lack of standard guidelines for palliative care referral. Various geriatric-palliative care models have been tested over the years, such as delivering palliative and end-of-life care for disease-specific conditions at specified care settings (home or hospice) and provision of care by different specialist palliative care teams and general practitioners or family physicians. Akin to the aforementioned models, the National Health Program in the country envisages to strengthen the integration of geriatric and palliative care. The integrated geriatric-palliative care model will ensure continuity of care, equitable distribution of service, impeccable inter-sectoral collaboration and care at an affordable cost.

Total uncertainty: a systematic review and thematic synthesis of experiences of uncertainty in older people with advanced multimorbidity, their informal carers and health professionals

OBJECTIVES

uncertainty pervades the complex illness trajectories experienced by older adults with multimorbidity. Uncertainty is experienced by older people, their informal carers and professionals providing care, yet is incompletely understood. We aimed to identify and synthesise systematically the experience of uncertainty in advanced multimorbidity from patient, carer and professional perspectives.

DESIGN

systematic literature review of published and grey qualitative literature from 9 databases (Prospero CRD 42021227480).

PARTICIPANTS

older people with advanced multimorbidity, and informal carers/professionals providing care to this group. Exclusion criteria: early multimorbidity, insufficient focus on uncertainty.

ANALYSIS

weight-of-evidence assessment was used to appraise included articles. We undertook thematic synthesis of multi-perspective experiences and response to uncertainty.

RESULTS

from 4,738 unique search results, we included 44 articles relating to 40 studies. 22 focused on patient experiences of uncertainty (n = 460), 15 on carer experiences (n = 197), and 19 on health professional experiences (n = 490), with 10 exploring multiple perspectives. We identified a shared experience of 'Total Uncertainty' across five domains: 'appraising and managing multiple illnesses'; 'fragmented care and communication'; 'feeling overwhelmed'; 'uncertainty of others' and 'continual change'. Participants responded to uncertainty by either active (addressing, avoiding) or passive (accepting) means.

CONCLUSIONS

the novel concept of 'Total Uncertainty' represents a step change in our understanding of illness experience in advanced multimorbidity. Patients, carers and health professionals experienced uncertainty in similar domains, suggesting a shared understanding is feasible. The domains of total uncertainty form a useful organising framework for health professionals caring for older adults with multimorbidity.

The lived experience of severe mental illness and long-term conditions: a qualitative exploration of service user, carer, and healthcare professional perspectives on self-managing co-existing mental and physical conditions

BACKGROUND

People with severe mental illness (SMI), such as schizophrenia, have higher rates of physical long-term conditions (LTCs), poorer health outcomes, and shorter life expectancy compared with the general population. Previous research exploring SMI and diabetes highlights that people with SMI experience barriers to self-management, a key component of care in long-term conditions; however, this has not been investigated in the context of other LTCs. The aim of this study was to explore the lived experience of co-existing SMI and LTCs for service users, carers, and healthcare professionals.

METHODS

A qualitative study with people with SMI and LTCs, their carers, and healthcare professionals, using semi-structured interviews, focused observations, and focus groups across the UK. Forty-one interviews and five focus groups were conducted between December 2018 and April 2019. Transcripts were coded by two authors and analysed thematically.

RESULTS

Three themes were identified, 1) the precarious nature of living with SMI, 2) the circularity of life with SMI and LTCs, and 3) the constellation of support for self-management. People with co-existing SMI and LTCs often experience substantial difficulties with self-management of their health due to the competing demands of their psychiatric symptoms and treatment, social circumstances, and access to support. Multiple long-term conditions add to the burden of self-management. Social support, alongside person-centred professional care, is a key facilitator for managing health. An integrated approach to both mental and physical healthcare was suggested to meet service user and carer needs.

CONCLUSION

The demands of living with SMI present a substantial barrier to self-management for multiple co-existing LTCs. It is important that people with SMI can access person-centred, tailored support for their LTCs that takes into consideration individual circumstances and priorities.

Multimorbidity in patients living with and beyond cancer: protocol for a scoping review

INTRODUCTION

The number of people living with and beyond cancer is increasing rapidly. Many of them will experience ongoing physical or psychological sequelae as a result of their original cancer diagnosis or comorbidities arising from risk factors common to cancers and other long-term conditions. This poses the complex problem of managing cancer as a 'chronic' illness along with other existing comorbidities. This scoping review aims to map the literature available on multimorbidity in patients living with and beyond cancer, to explore, quantify and understand the impact of comorbid illnesses to inform work around cancer care in UK primary care settings.

METHODS AND ANALYSIS

This review will be guided by Joanna Briggs Institute Reviewer's manual for scoping reviews. A systematic literature search using Medical Subject Heading and text words related to cancer survivors and multimorbidity will be performed in MEDLINE, CINAHL, Embase and Web of Science, from 1990. Results will be described in a narrative style, reported in extraction tables and diagrams, and where appropriate in themes and text.

ETHICS AND DISSEMINATION

The scoping review will undertake secondary analysis of published literature; therefore, ethics committee approval is not required. Results will be disseminated through a peer-reviewed scientific journal and presented in relevant conferences. The scoping review will inform understanding of the burden of multimorbidity for cancer survivors, thus allow families, practitioners, clinicians and researchers to take the steps necessary to improve patient-centred care.

Primary care for people with severe mental illness and comorbid obstructive airways disease: a qualitative study of patient perspectives with integrated stakeholder feedback

OBJECTIVES

To explore patient and stakeholder perspectives on primary respiratory care for people with severe mental illness (SMI) and comorbid obstructive airways disease (OAD).

DESIGN

Qualitative, semistructured qualitative interviews were undertaken with a purposive sample of people with a diagnosis of SMI (bipolar illness, schizophrenia, affective disorder with psychosis) and comorbid asthma or chronic obstructive pulmonary disease. Transcribed data were analysed using an interpretive phenomenological approach. Study results were discussed with stakeholders.

SETTING

Eight UK general practices.

PARTICIPANTS

16 people aged 45-75 years, with SMI and comorbid asthma or chronic obstructive pulmonary disease, were interviewed. Twenty-one people, four with lived experience of SMI and seventeen health/social care/third sector practitioners, participated in discussion groups at a stakeholder event.

RESULTS

Participants described disability and isolation arising from the interplay of SMI and OAD symptoms. Social support determined ease of access to primary care. Self-management of respiratory health was not person-centred as practitioners failed to consider individual needs and health literacy. Participants perceived smoking cessation impossible without tailored support. Less than half of the practices facilitated personalised access to timely primary care and continuity. Overall, there was a reliance on urgent care if service adaptations and social support were lacking. The stakeholder group expressed concern about gaps in care, the short-term funding of community organisations and fear of loss of benefits. Potential solutions focused on supported navigation of care pathways, relational continuity, individual and community asset building and the evolving social prescriber role.

CONCLUSION

This study suggests that despite UK guidelines and incentives to optimise physical healthcare, primary care fails to consistently deliver integrated biopsychosocial care for patients with SMI and OAD. Collaborative, personalised care that builds social capital and tailors support for self-management is needed, alongside service-level interventions to enhance access to healthcare for patients with comorbid SMI and OAD.

Environmental Influences on Life Satisfaction and Depressive Symptoms Among Older Adults With Multimorbidity: Path Analysis Through Loneliness in the Canadian Longitudinal Study on Aging

BACKGROUND AND OBJECTIVES

More older adults with multimorbidity are aging in place than ever before. Knowing how the environment affects their mental well-being could enhance the efficacy of age-friendly interventions for multimorbidity resilience. With reference to the Transdisciplinary Neighborhood Health Framework, we construct and examine a priori models of environmental influences on life satisfaction and depressive symptoms.

RESEARCH DESIGN AND METHODS

Baseline and follow-up data (after 3 years) were drawn from the Canadian Longitudinal Study on Aging to identify a subsample (n = 14,301) of participants aged at least 65 years with at least 2 chronic diseases. Path analysis examined sociobehavioral attributes (i.e., social support, social participation, walking) and loneliness as primary and secondary mediators, controlling for age, sex, education, and outcomes during baseline.

RESULTS

Good model fit was found (TFI = 1.00; CFI = 1.00; RMSEA < 0.001; SRMR < 0.001). The total effects of housing quality (rtotal = 0.08, -0.07) and neighborhood cohesion (rtotal = 0.03, -0.06) were weak but statistically significant in the expected direction. The mediators explained 21%-31% of the total effects of housing quality and 67%-100% of the total effects of neighborhood cohesion. Loneliness mediated 27%-29% of these environmental influences on mental well-being, whereas walking mediated a mere 0.4%-0.9% of the total effects. Walking did not explain the relationship between housing quality and mental well-being.

DISCUSSION AND IMPLICATIONS

Data supported a priori pathways from environment to mental well-being through sociobehavioral attributes and loneliness. If these pathways from neighborhood cohesion to life satisfaction reflect causal effects, community-based age-friendly interventions should focus on enhancing neighborhood cohesion to mitigate loneliness among multimorbid older adults for their mental well-being.

Keeping in balance on the multimorbidity tightrope: A narrative analysis of older patients' experiences of living with and managing multimorbidity

Primary care management of patients with multimorbidity in the UK is underpinned by clinical guidelines, quality standards and measurable targets which govern practices of risk management and disease control. There is concern that standardised approaches may not always be appropriate for older patients living with multimorbidity. Using a narrative approach, we elicited the voices of older people living with multiple conditions in order to rethink chronicity, and consider what their accounts might mean for reconfiguring care practices. Within an ethnographic study of multimorbidity and polypharmacy, we conducted in-depth interviews, based on the Biographical Narrative Interpretive Method, with 24 participants aged 65 to 94. Participants were recruited from three general practices in England. All had two or more chronic conditions and were prescribed ten or more medicines. Our analysis draws on Bakhtinian theory, tracing the multiple ways in which participants voiced living with multimorbidity. In this paper, we focus on 'keeping in balance' which emerged as a key meta-conceptualisation across our dataset. Adopting the metaphor of the 'multimorbidity tightrope' we explore the precarity of patients' experiences and show their struggle to create coherence from within a deeply ambiguous living situation. We consider how and to what extent participants' narrative constructions co-opt or resist normative biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients' voices and values may sometimes be at odds with those promoted within professional guidelines. Narrative approaches may offer significant potential for reorienting healthcare towards enabling patients to live a flourishing life, even when facing significant adversity.

The (failed) promise of multimorbidity: chronicity, biomedical categories, and public health

Multimorbidity has become an increasingly prominent lens through which public health focuses on the 'burden' of ill health in ageing populations, with the promise of a more upstream and holistic approach. We use a situational analysis (drawing on documentary analysis and interviews with service providers, policy actors and people living with multiple conditions) in south London, UK, to explore what this lens brings into focus, and what it obscures. Local initiatives mobilised the concept of multimorbidity in initiatives for integrating health care systems and for commissioning for prevention as well as care. However, as the latest of a series of historical attempts to address system fragmentation, these initiatives generated more complexity, and a system orientated to constant transformation, rather than repair or restoration. Service providers and patients continued to struggle to navigate the system. Dominant policy and practice narratives framed patient self-management as the primary route for addressing individualised risk factors on a trajectory to multimorbidity, whereas the narratives of those living with multiple conditions were more oriented to a relational model of health. The findings suggest possibilities and limitations for leveraging the concept of multimorbidity for public health. In this field, the promise arose from its potential to make spaces for a focus on populations, not patients with discrete diseases. Realising this promise, however, was limited by the inherent tensions of biomedical nosologies, which separate discrete diseases within individual bodies, and from epidemiological approaches that reify the socio-material contexts of failing health as risks for individuals.

Pilot randomized controlled trial Protocol: Life context-informed pre-visit planning to improve care plans for primary care patients with multiple chronic conditions including diabetes

Background

Multimorbidity is common, and care is impacted by patient life context. Effective, efficient interventions to improve patient-centered outcomes such as perceived treatment burden are limited. There is a need for interventions that integrate patient contextual information into primary care encounters to improve such outcomes. Patient life context is a multitude of factors that influence a patient’s life and healthcare, including social determinants of health and broader elements such as family and work demands.

Methods

This pilot randomized controlled trial (RCT) protocol will compare standard pre-visit planning to context-informed pre-visit planning that incorporates the patient’s life context, for patients with diabetes plus other chronic comorbid conditions. Primary outcomes include measures of trial protocol and intervention feasibility and acceptability: physician study and visit perceived burden, patient satisfaction, and patient, physician and staff experience with the trial. Additional measurements of intervention impact include: initial estimates of effect size on patient treatment burden and other patient-oriented outcomes, change in glycemic control, and other intermediate medical outcomes.

Discussion

This intervention is novel as it collects patient life context information using a direct person-to-person approach, allows physicians to review the information prior to patient arrival at the clinic and, where appropriate, incorporate it when negotiating treatment plans, and is longitudinal, summarizing evolving contextual information over time. This pilot RCT has the potential to demonstrate trial protocol and intervention feasibility and acceptability, and estimate effect size on patient and provider outcomes, to inform for a future, definitive RCT.

Trial Registration: This trial was registered at ClinicalTrials.gov prior to patient enrollment: NCT04568382

Exploring the facilitators, barriers, and strategies for self-management in adults living with severe mental illness, with and without long-term conditions: A qualitative evidence synthesis

BACKGROUND

People living with severe mental illness (SMI) have a reduced life expectancy by around 15-20 years, in part due to higher rates of long-term conditions (LTCs) such as diabetes and heart disease. Evidence suggests that people with SMI experience difficulties managing their physical health. Little is known, however, about the barriers, facilitators and strategies for self-management of LTCs for people with SMI.

AIM

To systematically review and synthesise the qualitative evidence exploring facilitators, barriers and strategies for self-management of physical health in adults with SMI, both with and without long-term conditions.

METHODS

CINAHL, Conference Proceedings Citation Index- Science, HMIC, Medline, NICE Evidence and PsycInfo were searched to identify qualitative studies that explored barriers, facilitators and strategies for self-management in adults with SMI (with or without co-morbid LTCs). Articles were screened independently by two independent reviewers. Eligible studies were purposively sampled for synthesis according to the richness and relevance of data, and thematically synthesised.

RESULTS

Seventy-four articles met the inclusion criteria for the review; 25 articles, reporting findings from 21 studies, were included in the synthesis. Seven studies focused on co-morbid LTC self-management for people with SMI, with the remaining articles exploring self-management in general. Six analytic themes and 28 sub-themes were identified from the synthesis. The themes included: the burden of SMI; living with co-morbidities; beliefs and attitudes about self-management; support from others for self-management; social and environmental factors; and routine, structure and planning.

CONCLUSIONS

The synthesis identified a range of barriers and facilitators to self-management, including the burden of living with SMI, social support, attitudes towards self-management and access to resources. To adequately support people with SMI with co-morbid LTCs, healthcare professionals need to account for how barriers and facilitators to self-management are influenced by SMI, and meet the unique needs of this population.

Self-Management in Older Pakistanis Living With Multimorbidity in East London

In this article, we explore how older British Pakistani people experience multimorbidity (defined as the coexistence of two or more medical conditions) and engage with self-management within the context of their life histories and relationships. We conducted biographical narrative interviews in Urdu and/or English with 15 first-generation Pakistani migrants living with multimorbidity, at their homes in East London. Our analysis showed that the triadic construct of family, faith, and health was central to how participants made sense of their lives, constituting notions of "managing" in the context of multimorbidity. For Pakistani patients, the lived experience of health was inseparable from a situated context of family and faith. Our findings have implications for existing public health strategies of self-management, underpinned by neoliberal discourses that focus on individual responsibility and agency. Health care provision needs to better integrate the importance of relationships between family, faith, and health when developing services for these patients.

Multimorbidity and its effect on perceived burden, capacity and the ability to self-manage in a low-income rural primary care population: A qualitative study

INTRODUCTION

Multimorbidity is increasing in prevalence, especially in low-income settings. Despite this, chronic conditions are often managed in isolation, potentially leading to burden-capacity imbalance and reduced treatment adherence. We aimed to explore, in a low-income population with common comorbidities, how the specific demands of multimorbidity affect burden and capacity as defined by the Cumulative Complexity Model.

MATERIALS AND METHODS

Qualitative interviews with thirteen rural community health centre patients in Victoria, Australia. Participants were aged between 47-72 years and reported 3-10 chronic conditions. We asked about perceived capacity and burden in managing health. The Theory of Patient Capacity was used to analyse capacity and Normalisation Process Theory to analyse burden. All data specifically associated with the experience of multimorbidity was extracted from each burden and capacity domain.

RESULTS

The capacity domains of biography, resource mobilisation and work realisation were important in relation to multimorbidity. Conditions causing functional impairment (e.g. chronic pain, depression) interacted with physical, psychological and financial capacity, leading to biographical disruption and an inability to realise treatment and life work. Despite this, few people had a treatment plan for these conditions. Participants reported that multimorbidity affected all burden domains. Coherence and appraisal were especially challenging due to condition interactions, with clinicians providing little guidance.

DISCUSSION

The capacity and burden deficits highlighted by participants were not associated with any specific diagnosis, but were due to condition interactions, coupled with the lack of health provider support to navigate interactions. Physical, psychological and financial capacities were inseparable, but rarely addressed or understood holistically. Understanding and managing condition and treatment interactions was a key burden task for patients but was often difficult, isolating and overwhelming. This suggests that clinicians should become more aware of linkages between conditions, and include generic, synergistic or cross-disciplinary approaches, to build capacity, reduce burden and encourage integrated chronic condition management.

Adults' experience of living with multimorbidity: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to synthesize the qualitative research literature on the experiences of adults living with multimorbidity.

INTRODUCTION

Persons living with two or more chronic health conditions, known as multimorbidity, is a global health problem in countries of all income levels. Multimorbidity presents an ever-increasing resource and financial burden for health care systems and similarly challenges those living with multiple health conditions because of the complexity of their health and treatment requirements. Overall, persons with multimorbid conditions experience a high risk of mortality and a lower quality of life. Understanding the adult experience of multimorbidity is important for creating and implementing health care that meets the needs of individuals living with the burden of multiple chronic health conditions.

INCLUSION CRITERIA

The systematic review will include published peer-reviewed and unpublished English-language studies from 2000 to 2020 that provide qualitative evidence of adults' (18+ years of age) experiences of living with multimorbidity.

METHODS

CINAHL with full text, Cochrane, MEDLINE, Embase, PsycINFO, Consumer Health Database, Scopus, and ScienceDirect journals and books will be searched. Reference lists of included studies will also be cross-checked with search outcomes to identify additional studies. Sources of gray literature will also be searched for unpublished studies. The critical appraisal of selected studies and the extraction of data will be independently undertaken by two reviewers using JBI methods. The findings will be pooled using meta-aggregation to produce comprehensive synthesized findings. A ConQual Summary of Findings will also be presented.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020152038.

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes

OBJECTIVES

There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes.

METHODS

We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the Journal of Comorbidity between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment.

RESULTS

Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases.

CONCLUSIONS

We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.

Games of uncertainty: the participation of older patients with multimorbidity in care planning meetings - a qualitative study

BACKGROUND

Active patients lie at the heart of integrated care. Although interventions to increase the participation of older patients in care planning are being implemented in several countries, there is a lack of knowledge about the interactions involved and how they are experienced by older patients with multimorbidity. We explore this issue in the context of care-planning meetings within Norwegian municipal health services.

METHODS

This qualitative study drew on direct observations of ten care-planning meetings and an interview with each patient right after the meeting. Following a stepwise-deductive induction approach, the analysis began inductively and then considered the interactions through the lens of game theory.

RESULTS

The care-planning interactions were influenced by uncertainty about the course of the disease and how to plan service delivery. In terms derived from game theory, the imaginary and unpredictable player 'Nature' generated uncertainty in the 'game' of care planning. The 'players' assessed this uncertainty differently, leading to three patterns of game. 1) In the 'game of chance', patients viewed future events as random and uncontrollable; they felt outmatched by the opponent Nature and became passive in their decision-making. 2) In the 'competitive game', participants positioned themselves on two opposing sides, one side perceiving Nature as a significant threat and the other assigning it little importance. The two sides negotiated about how to accommodate uncertainty, and the level of patient participation varied. 3) In the 'coordination game', all participants were aligned, either in viewing themselves as teammates against Nature or in ascribing little importance to it. The level of patient participation was high.

CONCLUSIONS

In care planning meetings, the level of patient participation may partly be associated with how the various actors appraise and respond to uncertainty. Dialogue on uncertainty in care-planning interventions could help to increase patient participation.

Life goes on… Patient perspectives on having a cancer diagnosis and other comorbid diseases: A qualitative study

OBJECTIVES

Due to a growing population with both cancer and chronic diseases, we explored patients' experiences of living with a cancer diagnosis and comorbidities, the possible effects on everyday living and management of comorbidities.

METHODS

Semi-structured interviews were conducted during 2016 with 15 patients in Denmark, with finished cancer treatment and preexisting comorbidities. Analysis was performed by Systematic Text Condensation.

RESULTS

Symptoms which disrupted everyday function were given attention, regardless of the disease from which the symptoms originated. The awareness of cancer and comorbidities constituted an inverse process over time. Most patients perceived cancer as being transient, whereas experiences of comorbidities varied from ignorance to worry. Most patients reported maintaining their chronic illness consultations with their general practitioner as before cancer.

CONCLUSION

Patients prioritized an everyday life with normal chores highly in contrast to paying attention to diseases. Disruptive symptoms, rather than specific diseases, took up patients' attention. Cancer did not change the patients' attendance at chronic care consultations. General practitioners should focus on maintaining the patient's functional level in everyday life. Further, they should continue to prioritize the chronic care management, as this might increase the patients' own view of the importance of self-management.

Community assets and multimorbidity: A qualitative scoping study

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ISRCTN10287737;Pre-results.

Meta-ethnography in healthcare research: a guide to using a meta-ethnographic approach for literature synthesis

BACKGROUND

Qualitative synthesis approaches are increasingly used in healthcare research. One of the most commonly utilised approaches is meta-ethnography. This is a systematic approach which synthesises data from multiple studies to enable new insights into patients' and healthcare professionals' experiences and perspectives. Meta-ethnographies can provide important theoretical and conceptual contributions and generate evidence for healthcare practice and policy. However, there is currently a lack of clarity and guidance surrounding the data synthesis stages and process.

METHOD

This paper aimed to outline a step-by-step method for conducting a meta-ethnography with illustrative examples.

RESULTS

A practical step-by-step guide for conducting meta-ethnography based on the original seven steps as developed by Noblit & Hare (Meta-ethnography: Synthesizing qualitative studies.,1998) is presented. The stages include getting started, deciding what is relevant to the initial interest, reading the studies, determining how the studies are related, translating the studies into one another, synthesising the translations and expressing the synthesis. We have incorporated adaptations and developments from recent publications. Annotations based on a previous meta-ethnography are provided. These are particularly detailed for stages 4-6, as these are often described as being the most challenging to conduct, but with the most limited amount of guidance available.

CONCLUSION

Meta-ethnographic synthesis is an important and increasingly used tool in healthcare research, which can be used to inform policy and practice. The guide presented clarifies how the stages and processes involved in conducting a meta-synthesis can be operationalised.

Prioritizing social identities: Patients' perspective on living with multimorbidity

OBJECTIVE

This article explores experiences of people with multimorbidity, and attempts to advance understandings of the complexity of living with multimorbidity outside the medical encounter in a social identity theoretical framework.

METHOD

This is a qualitative study using individual semi-structured interviews among nine persons living with multimorbidity. The interviews are analysed inductively according to thematic content analysis.

RESULTS

The emerging themes are: 1) Impact on daily life, 2) Professional life and 3) Capacity for handling multimorbidity. People with multimorbidity experience physical limitations and psychological distress, which limits their ability to maintain social relations and affiliation to the labour market. Accordingly, they are challenged in their ability to retain a sense of normal everyday life, which is mediated by their capacity for handling multimorbidity.

DISCUSSION

Multimorbidity may compromise various social identities. The complexity of living with multimorbidity is increased by an aspiration to maintain valued social identities in order to preserve a coherent sense of self and a normal everyday life. This study suggests an increased focus on individual priorities and values outside the medical encounter, and argues in favour of recognizing the conflicts that people experience as they try to balance multimorbidity with other important aspects of their daily lives.

Meikirch model: new definition of health as hypothesis to fundamentally improve healthcare delivery

The unrelenting rise in healthcare costs over the past 50 years has caused policymakers to respond. Their reactions have led to a gradual economic transformation of medicine. As a result, detailed billing, quality controls, financial incentives, savings targets and digitalisation are now putting increasing pressures on the nursing and medical staff. In addition, the humanity of care of the patient–doctor and/or patient–nurse interactions has been cast aside to a great extent. Therefore, the immaterial side of care has been neglected or even removed from these relationships. These changes are now perceived as intolerable by most health workers and patients. Yet healthcare costs are still rising. This paper presents a hypothesis that should enable healthcare systems to respond more effectively. It proposes the introduction of the Meikirch model, a new comprehensive definition of health. The Meikirch model takes human nature fully into account, including health and disease. The inclusion of the individual potentials, the social surroundings and the natural environment leads to the concept of health as a complex adaptive system (CAS). Care for such a definition of health requires medical organisations to change from top–down management to bottom–up leadership. Such innovations are now mature and ready for implementation. They require a long-term investment, a comprehensive approach to patient care and new qualifications for leadership. The Meikirch model reads: ‘To be healthy a human individual must be able to satisfy the demands of life. For this purpose, each person disposes of a biologically given and a personally acquired potential, both of which are closely related to the social surroundings and the natural environment. The resulting CAS enables the individual to unfold a personal identity and to develop it further until death. Healthcare has the purpose to empower each individual to fully realize optimal health’.This hypothesis postulates that the new definition of health will further develop healthcare systems in such a way that better health results at lower costs.

The evolution of an evidence based intervention designed to improve prescribing and reduce polypharmacy in older people with multimorbidity and significant polypharmacy in primary care (SPPiRE)

Introduction

By the time an intervention is ready for evaluation in a definitive RCT the context of the evidence base may have evolved. To avoid research waste, it is imperative that intervention design and evaluation is an adaptive process incorporating emerging evidence and novel concepts. The aim of this study is to describe changes that were made to an evidence based intervention at the protocol stage of the definitive RCT to incorporate emerging evidence.

Methods

The original evidence based intervention, a GP delivered web guided medication review, was modified in a five step process:Identification of core components of the original intervention.Literature review.Modification of the intervention.Pilot study.Final refinements. A framework, developed in public health research, was utilised to describe the modification process.

Results

The population under investigation changed from older people with a potentially inappropriate prescription (PIP) to older people with significant polypharmacy, a proxy marker for complex multimorbidity. An assessment of treatment priorities and brown bag medication review, with a focus on deprescribing were incorporated into the original intervention. The number of repeat medicines was added as a primary outcome measure as were additional secondary patient reported outcome measures to assess treatment burden and attitudes towards deprescribing.

Conclusions

A framework was used to systematically describe how and why the original intervention was modified, allowing the new intervention to build upon an effective and robustly developed intervention but also to be relevant in the context of the current evidence base.

Renegotiating dimensions of the self: A systematic review and qualitative evidence synthesis of the lived experience of self-managing rheumatoid arthritis

Background

As chronic illnesses, such as rheumatoid arthritis (RA), place an increased burden on health‐care systems, the ability of individuals to self‐manage these diseases is crucial.

Objective

To identify and synthesize the lived experience of self‐management described by adults living with RA.

Design

A systematic search of five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and ASSIA) was undertaken to identify relevant studies. Data were extracted and quality‐assessed using CASP guidelines. A meta‐synthesis was conducted based on Thomas and Harden's thematic synthesis approach.

Results

The search identified 8423 publications. After removing duplicates, 6527 records remained of which 32 studies met the inclusion criteria. Quality of studies was moderate to high, yet a considerable lack of reflection on researcher bias was evident. Our analysis identified 28 dimensions of self‐management RA across six domains: (a) cognitive‐emotional, (b) behavioural, (c) social, (d) environmental, (e) physical and (f) technological. Cognitive‐emotional experiences dominated the analysis. Renegotiating ‘the self’ (self‐concept, self‐esteem, self‐efficacy) was a key focus of self‐management among individuals with RA.

Conclusion

Our findings highlight the focus of ‘the self’ as a central concern in the self‐management of RA. Standardized self‐management programmes may primarily focus on disease management and daily functioning. However, we suggest that personal biographies and circumstances should move to the fore of self‐management support.

Registration

PROSPERO International Prospective Register of Systematic Reviews 2018: CRD42018100450.

Patient or Public Contribution

Patient and public involvement was not explicit in this review. However, three authors provided a patient perspective on the self‐management of arthritis and autoimmune disease.

A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK

BACKGROUND

The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff.

METHODS

We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis.

RESULTS

We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems.

CONCLUSIONS

Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.

General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research

Background

General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care.

Methods

Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies.

Results

Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk.

Conclusions

GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient’s unique circumstances, and useable knowledge of each individual’s capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.

Patient Work and Their Contexts: Scoping Review

Background

Having patients self-manage their health conditions is a widely promoted concept, but many patients struggle to practice it effectively. Moreover, few studies have analyzed the nature of work required from patients and how such work fits into the context of their daily life.

Objective

This study aimed to review the characteristics of patient work in adult patients. Patient work refers to tasks that health conditions impose on patients (eg, taking medications) within a system of contextual factors.

Methods

A systematic scoping review was conducted using narrative synthesis. Data were extracted from PubMed, Excerpta Medica database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO, including studies from August 2013 to August 2018. The included studies focused on adult patients and assessed one or more of the following: (1) physical health–related tasks, (2) cognitive health–related tasks, or (3) contextual factors affecting these tasks. Tasks were categorized according to the themes that emerged: (1) if the task is always visible to others or can be cognitive, (2) if the task must be conducted collaboratively or can be conducted alone, and (3) if the task was done with the purpose of creating resources. Contextual factors were grouped according to the level at which they exert influence (micro, meso, or macro) and where they fit in the patient work system (the macroergonomic layer of physical, social, and organizational factors; the mesoergonomic layer of household and community; and the microergonomic triad of person-task-tools).

Results

In total, 67 publications were included, with 58 original research articles and 9 review articles. A variety of patient work tasks were observed, ranging from physical and tangible tasks (such as taking medications and visiting health care professionals) to psychological and social tasks (such as creating coping strategies). Patient work was affected by a range of contextual factors on the micro, meso, or macro levels. Our results indicate that most patient work was done alone, in private, and often imposing cognitive burden with low amounts of support.

Conclusions

This review sought to provide insight into the work burden of health management from a patient perspective and how patient context influences such work. For many patients, health-related work is ever present, invisible, and overwhelming. When researchers and clinicians design and implement patient-facing interventions, it is important to understand how the extra work impacts one’s internal state and coping strategy, how such work fits into daily routines, and if these changes could be maintained in the long term.

Setting the research agenda for living with and beyond cancer with comorbid illness: reflections on a research prioritisation exercise

BACKGROUND

People living with and beyond cancer are more likely to have comorbid conditions and poorer mental and physical health, but there is a dearth of in-depth research exploring the psychosocial needs of people experiencing cancer and comorbid chronic conditions. A patient partnership approach to research prioritisation and planning can ensure outcomes meaningful to those affected and can inform policy and practice accordingly, but can be challenging.

METHODS

We aimed to inform priorities for qualitative inquiry into the experiences and support needs of people living with and beyond cancer with comorbid illness using a partnership approach. A three-step process including a patient workshop to develop a consultation document, online consultation with patients, and academic expert consultation was carried out. The research prioritisation process was also appraised and reflected upon.

RESULTS

Six people attended the workshop, ten responded online and eight academic experts commented on the consultation document. Five key priorities were identified for exploration in subsequent qualitative studies, including the diagnostic journey, the burden of symptoms, managing medications, addressing the needs of informal carers, and service provision. Limitations of patient involvement and reflections on procedural ethics, and the challenge of making measurable differences to patient outcomes were discussed.

CONCLUSIONS

Findings from this research prioritisation exercise will inform planned qualitative work to explore patients' experiences of living with and beyond cancer with comorbid illness. Including patient partners in the research prioritisation process adds focus and relevance, and feeds into future work and recommendations to improve health and social care for this group of patients. Reflections on the consultation process contribute to a broadening of understanding the field of patient involvement.

Informational Practices of Postacute Brain Injury Patients During Personal Recovery: Qualitative Study

BACKGROUND

The effects of brain injury, structural damage, or the physiological disruption of brain function last far beyond initial clinical treatment. Self-tracking and management technologies have the potential to help individuals experiencing brain injury in their personal recovery-helping them to function at their best despite ongoing symptoms of illness. However, current self-tracking technologies may be unsuited for measuring the interconnected, nonlinear ways in which brain injury manifests.

OBJECTIVE

This study aimed to investigate (1) the current informational practices and sensemaking processes used by postacute brain injury patients during personal recovery and (2) the potential role of quality-of-life instruments in improving patient awareness of brain injury recovery, advocacy, and involvement in care used outside the clinical context. Our objective was to explore the means of improving awareness through reflection that leads to compensatory strategies by anticipating or recognizing the occurrence of a problem caused by impairment.

METHODS

We conducted a qualitative study and used essentialist or realist thematic analysis to analyze the data collected through semistructured interviews and questionnaires, 2 weeks of structured data collection using brain injury-specific health-related quality of life instrument, quality of life after brain injury (QoLIBRI), and final interviews.

RESULTS

Informational practices of people with brain injury involve data collection, data synthesis, and obtaining and applying the insights to their lifestyles. Participants collected data through structured tools such as spreadsheets and wearable devices but switched to unstructured tools such as journals and blogs as changes in overall progress became more qualitative in nature. Although data collection helped participants summarize their progress better, the lack of conceptual understanding made it challenging to know what to monitor or communicate with clinicians. QoLIBRI served as an education tool in this scenario but was inadequate in facilitating reflection and sensemaking.

CONCLUSIONS

Individuals with postacute brain injury found the lack of conceptual understanding of recovery and tools for making sense of their health data as major impediments for tracking and being aware of their personal recovery. There is an urgent need for a better framework for recovery and a process model for choosing patient-generated health data tools that focus on the holistic nature of recovery and improve the understanding of brain injury for all stakeholders involved throughout recovery.

Cost-related nonadherence to medicines in people with multiple chronic conditions

BACKGROUND

Multimorbidity is common and frequently associated with medicine nonadherence. Although cost is a common reason for nonadherence, very little research has quantified cost-related nonadherence (CRNA) to medicines specifically in people with multimorbidity, the prevalence of CRNA for different conditions nor the impact of cost when prioritising treatment between conditions.

OBJECTIVE

To determine the extent of CRNA in people with multimorbidity and the patient characteristics associated with these behaviours.

DESIGN AND SETTING

People reporting two or more chronic conditions responding to a rapid response module regarding prescription drug affordability fielded between January 1 and June 30 2016 in the Canadian Community Health Survey, a cross-sectional household survey.

METHODS

Ordinal logistic regression, adjusted for key sociodemographic, clinical and treatment related variables, of weighted population estimates of self-reported CRNA within one group of conditions, across multiple groups of conditions, or no CRNA.

RESULTS

10.2% of 8420 Canadians with multimorbidity reported CRNA. The majority (61%) reported CRNA within one group of conditions, especially respiratory (16%) and mental health disorders (17%). CRNA was more common in younger adults, people without employer or association drug insurance plans, poorer health status, more chronic conditions, and increased out-of-pocket prescription costs. Having no prescription insurance was associated with a higher probability of CRNA across multiple groups of conditions.

CONCLUSIONS

People with multimorbidity primarily forego medicines because of cost within one group of conditions. However, those without drug insurance extended these behaviours to multiple condition groups. Further work is needed to determine how people prioritise the conditions and treatments that are foregone because of cost, and how to best incorporate this information into treatment plans.

Multimorbidity and care dependence in older adults: a longitudinal analysis of findings from the 10/66 study

BACKGROUND

In an ageing world facing an epidemic of chronic diseases, there is great interest in the burden of multimorbidity on individuals and caregivers, yet no studies have examined the longitudinal association between multimorbidity and care dependence in low and middle income countries. Mental and cognitive disorders are associated with dependence but little is known about their role in the pathway to dependence in the context of multimorbidity. This study aims to determine (1) the association of multimorbidity with the onset of care dependence in older adults, accounting for mortality and controlling for sociodemographic factors, and (2) the independent effects of physical multimorbidity, mental and cognitive disorders.

METHODS

A population-based cohort study of people aged 65 years and older in six countries in Latin America, and China. Data on chronic conditions and sociodemographic factors were collected at baseline. Multimorbidity was ascertained as a count of up to 15 mental, cognitive and physical health conditions. Dependence was ascertained through informant interviews at baseline and follow-up. We used competing risk regression to assess the association between multimorbidity and the onset of care dependence, acknowledging the possibility of dependence-free death. We also assessed the independent effects of physical multimorbidity and depression, anxiety and dementia individually.

RESULTS

12,965 participants, with no needs for care at baseline, were followed up for a median of 3.0-4.9 years. Each unit increase in multimorbidity count increased the cumulative risk of dependence by 20% in the fully adjusted model. Age was the only variable to confound this relationship. Physical multimorbidity was associated with only a modest increased risk of care dependence. Dementia, depression and anxiety were independently associated with incident care dependence at every level of physical multimorbidity, and depression and anxiety attenuated the effect of physical multimorbidity.

CONCLUSION

Multimorbidity consistently predicts care dependence with little variation between countries. Physical multimorbidity imparts a lower risk than multimorbidity with mental and cognitive disorders included. Mental and cognitive disorders independently increase the risk of care dependence. Comprehensive and holistic assessment of disorders of body, brain and mind can help to identify older people at high risk of care dependence.

Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review

OBJECTIVES

To understand how and why effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.

DESIGN

A realist review.

DATA SOURCES

Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.

ANALYSIS

We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.

RESULTS

106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, disease management programmes and case management; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients' capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.

CONCLUSIONS

To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.

PROSPERO REGISTRATION NUMBER

CRD42014014489.