Patient-Centred Innovations for Persons with Multimorbidity: funded evaluation protocol

International guideline comparison of lifestyle management for acute coronary syndrome and type 2 diabetes mellitus: A rapid review

Acute coronary syndrome (ACS) is a life-threatening condition, with ACS-associated morbidity and mortality causing substantial human and economic challenges to the individual and health services. Due to shared disease determinants, those with ACS have a high risk of comorbid Type 2 diabetes mellitus (T2DM). Despite this, the two conditions are managed separately, duplicating workload for staff and increasing the number of appointments and complexity of patient management plans. This rapid review compared current ACS and T2DM guidelines across Australia, Canada, Europe, Ireland, New Zealand, the UK, and the USA. Results highlighted service overlap, repetition, and opportunities for integrated practice for ACS-T2DM lifestyle management across diet and nutrition, physical activity, weight management, clinical and psychological health. Recommendations are made for potential integration of ACS-T2DM service provision to streamline care and reduce siloed care in the context of the health services for ACS-T2DM and similar comorbid conditions.

Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses

BACKGROUND

Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched).

METHODS

Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls.

RESULTS

There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]).

INTERPRETATION

Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods.

ONTARIO

ClinicalTrials.gov : 104191.

Responding to vulnerable patients with multimorbidity: an interprofessional team approach

Background

People with multimorbidity, who may be more vulnerable to certain social determinants of health, often require care by an interprofessional primary healthcare (PHC) team that can tailor their approach to address the multiple and complex needs of this population. This paper describes how the needs of vulnerable patients experiencing multimorbidity are identified and provided care by innovative interprofessional PHC teams during an innovative one-hour consultation, outside of usual care.

Methods

This was a descriptive qualitative study. Forty-eight interviews were conducted with 20 allied healthcare professionals: (e.g., social work, pharmacy); 19 physicians (e.g., psychiatry, internal medicine, family medicine); and 9 decision makers. The thematic analysis was iterative using an individual and team approach to identify the main themes and exemplar quotations for illustration.

Results

Participants described patients with multimorbidity who were vulnerable as those experiencing major challenges accessing and navigating the healthcare system. Mental health issues were a major contributor to being vulnerable and often linked to common social determinants of health. Cultural factors were identified as potentially causing patients to be vulnerable. Participants articulated how the collaborative nature of the team generated new ideas and facilitated creative recommendations designed to meet the specific needs of each patient.

Conclusions

This one-time consultation went beyond the assessment of a patient’s multimorbidity by including a psycho-social-contextual understanding of vulnerability within the healthcare system. Findings may have important clinical and policy implications in the adoption and implementation of this approach and further assist vulnerable patients with multimorbidity in having their complex needs addressed.

Effect of an interprofessional small-group communication skills training incorporating critical incident approaches in an acute care and rehabilitation clinic specialized for spinal cord injury and disorder

AIM

To investigate the impact of site-specific inter-professional small-group communication skills training (CST) that incorporates critical incident approaches to learning on patient satisfaction with communication.

SETTING

Rehabilitation clinic specialized for spinal cord injury/disorder (SCI/D).

METHODS

Retrospective observational cohort study design using patient and health-professional self-report data. Data for patient satisfaction with communication were collected in 2014 (existing records) and each year from 2015 to 2021 (post-program; volunteers) using the MECON survey.

RESULTS

Fifteen basic (n = 161 participants), 16 refresher (n = 84), and five short (n = 17) CST seminars were conducted. Overall, 262 employees (105 physicians, 63 nurses, 36 physio- and occupational therapists, and 58 others) participated; 92 participants (response rate 37.6%) responded to feedback surveys. They rated the seminars positive concerning the alternation between theory, discussion, and practical exercise in 91.3%, and rated the length of the training ideal in 80.2%. Post-program patient satisfaction overall increased from 83.1% (confidence interval (CI) 2.6%) to 90% (CI 0.8%; R2 = 0.776; p= 0.004). It was higher in specific communication-related topics: "receiving information" (81.1%, CI 3.1-90.2%, CI 1.0%; p = 0.003), "being able to bring in concerns" (83%, CI 1.0-90.8%; R2 = 0.707; p = 0.009) and "being treated with respect" (89.4%, CI 2.6-94.4%, CI 0.8%; R2 = 0.708; p = 0.004).

PRACTICE IMPLICATIONS

Inter-professional CST is feasible and well accepted by professionals from various professional groups. During seven years of continuous training, independent patient ratings of satisfaction with professional communication have improved significantly. Participants attest to the training's high credibility and usefulness in everyday life.

One year follow-up and exploratory analysis of a patient-centered interdisciplinary care intervention for multimorbidity

Context

Interventions for people with multimorbidity have obtained mixed results. We aimed to document the long-term effect of an intervention for people with multimorbidity.

Methods

284 patients (18-80 years) presenting three or more chronic conditions were recruited from seven family medicine groups in the Saguenay-Lac St-Jean region, Quebec, Canada. The patient-centered intervention was based on motivational approach and self-management support. Outcomes were evaluated in a one-year pre-post study design with questionnaires that included the Health Education Questionnaire (heiQ), the Self-Efficacy for Managing Chronic Diseases, the Veteran RAND-12 Health Survey (VR-12), the EuroQoL 5-Domains questionnaire, the Kessler six item Psychological Stress Scale, and measures of smoking habit, physical activity, healthy eating and alcohol consumption. Subgroup analyses by age, number of conditions, sex, and income were also conducted.

Results

The heiQ domain of emotional wellbeing improved significantly. Improvement was also observed for the VR-12 and the K6. Among the health behaviours, only healthy eating was improved. Subgroup analyses in this exploratory study suggest that younger patients, those with lower number of chronic conditions or higher incomes may respond better in relation to self-management, health status and health behaviours.

Conclusion

One year after the intervention, participants significantly improved a variety of outcomes. Subgroup analyses suggest that younger patients, those with lower number of chronic conditions or higher incomes may respond better in relation to self-management, health status and health behaviours. This suggests that future interventions should be tailored to patients' characteristics including age, sex, income and number of conditions.

Obesity management in primary care: systematic review exploring the influence of therapeutic alliance

PURPOSE

To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care.

METHOD

Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present.

RESULTS

From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care.

CONCLUSIONS

We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

Evaluating the implementation of interdisciplinary patient-centred care intervention for people with multimorbidity in primary care: a qualitative study

OBJECTIVE

A patient-centred care interdisciplinary pragmatic intervention to support self-management for patients with multimorbidity was implemented in one region of Quebec, Canada. This embedded study aimed to evaluate the process of implementation.

DESIGN

A descriptive qualitative study was conducted in 2016-2017 using semistructured individual interviews. The Consolidated Framework for Implementation Research (CFIR) was used to guide the data coding, analysis and reporting of the findings.

SETTING

The study took place in seven Family Medicine Groups in one region (Saguenay-Lac-Saint-Jean) of Quebec, Canada.

PARTICIPANTS

Ten managers (including two family physicians) and 19 healthcare professionals (HCPs), nurses, kinesiologists, nutritionists and a respiratory therapist, were interviewed.

RESULTS

Many key elements within the five CFIR domains were identified as impacting the implementation of the intervention : (1) intervention characteristics-evidence strength and quality, design quality and packaging, relative advantage and complexity; (2) outer setting-patients' needs and resources, external policies and incentives; (3) inner setting-structural characteristics, networks and communication, culture, compatibility, readiness for implementation and leadership engagement; (4) characteristics of the managers and HCPs-knowledge and belief about the intervention; (5) process-planning, opinion leaders, formally appointed internal implementation leaders, reflecting and evaluating.

CONCLUSION

This study revealed the organisational and contextual aspects of the implementation based on different and complementary perspectives. With the growing demand for interdisciplinary teams in primary care, we believe that our insights will be helpful for practices, researchers, and policymakers interested in the implementation of disease prevention and management programmes for people with multiple chronic conditions in primary care.

TRIAL REGISTRATION NUMBER

NCT02789800.

Prevalence of multimorbidity in adults with cancer, and associated health service utilization in Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

The majority of people with cancer have at least one other chronic health condition. With each additional chronic disease, the complexity of their care increases, as does the potential for negative outcomes including premature death. In this paper, we describe cancer patients' clinical complexity (i.e., multimorbidity; MMB) in order to inform strategic efforts to improve care and outcomes for people with cancer of all types and commonly occurring chronic diseases.

METHODS

We conducted a population-based, retrospective cohort study of adults diagnosed with cancer between 2003 and 2013 (N = 601,331) identified in Ontario, Canada healthcare administrative data. During a five to 15-year follow-up period (through March 2018), we identified up to 16 co-occurring conditions and patient outcomes for the cohort, including health service utilization and death.

RESULTS

MMB was extremely common, affecting more than 91% of people with cancer. Nearly one quarter (23%) of the population had five or more co-occurring conditions. While we saw no differences in MMB between sexes, MMB prevalence and level increased with age. MMB prevalence and type of co-occurring conditions also varied by cancer type. Overall, MMB was associated with higher rates of health service utilization and mortality, regardless of other patient characteristics, and specific conditions differentially impacted these rates.

CONCLUSIONS

People with cancer are likely to have at least one other chronic medical condition and the presence of MMB negatively affects health service utilization and risk of premature death. These findings can help motivate and inform health system advances to improve care quality and outcomes for people with cancer and MMB.

Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients' experience

Background

Patient-centred interventions to help patients with multimorbidity have had mixed results.

Aim

To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.

Design and setting

Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.

Method

Patients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention.

Results

A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.

Conclusion

Overall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.

Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial

PURPOSE

To measure the effectiveness of a 4-month interdisciplinary multifaceted intervention based on a change in care delivery for patients with multimorbidity in primary care practices.

METHODS

A pragmatic randomized controlled trial with a mixed-methods design in patients aged 18 to 80 years with 3 or more chronic conditions from 7 family medicine groups (FMGs) in Quebec, Canada. Health care professionals (nurses, nutritionists, kinesiologists) from the FMGs were trained to deliver the patient-centered intervention based on a motivational approach and self-management support. Primary outcomes: self-management (Health Education Impact Questionnaire); and self-efficacy.

SECONDARY OUTCOMES

health status, quality of life, and health behaviors. Quantitative analyses used multi-level mixed effects and generalized linear mixed models controlling for clustering within FMGs. We also conducted in-depth interviews with patients, family members, and health care professionals.

RESULTS

The trial randomized 284 patients (144 in intervention group, 140 in control group). The groups were comparable. After 4 months, the intervention showed a neutral effect for the primary outcomes. There was significant improvement in 2 health behaviors (healthy eating with odds ratios [OR] 4.36; P = .006, and physical activity with OR 3.43; P = .023). The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results.

CONCLUSIONS

Quantitatively, this intervention showed a neutral effect on the primary outcomes and substantial improvement in 2 health behaviors as secondary outcomes. Qualitatively, the intervention was evaluated as positive. The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.

Understanding patient outcomes to develop a multimorbidity adapted patient-reported outcomes measure: a qualitative description of patient and provider perspectives

Background

Multimorbidity is a complex health situation that requires interventions tailored to patient needs; the outcomes of such interventions are difficult to evaluate. The purpose of this study was to describe the outcomes of patient-centred interventions for people with multimorbidity from the patients’ and healthcare providers’ perspectives.

Methods

This study followed a qualitative descriptive design. Nine patients with multimorbidity and 18 healthcare professionals (nurses, general practitioners, nutritionists, and physical and respiratory therapists), participating in a multimorbidity-adapted intervention in primary care were recruited. Data were collected using semi-structured interviews with 12 open-ended questions. Triangulation of disciplines among interviewers, research team debriefing, data saturation assessment and iterative data collection and analysis ensured a rigorous research process.

Results

Outcome constructs described by participants covered a wide range of themes and were grouped into seven outcome domains: Health Management, Physical Health, Functional Status, Psychosocial Health, Health-related Behaviours, General Health and Health Services. The description of constructs by stakeholders provides valuable insight on how outcomes are experienced and worded by patients.

Conclusion

Participants described a wide range of outcome constructs, which were relevant to and observable by patients and were in line with the clinical reality. The description provides a portrait of multimorbidity-adapted intervention outcomes that are significant for the selection and development of clinical research outcome measures.

Advancing cross-national planning and partnership: Proceedings from the International Multimorbidity Symposium 2019

The International Multimorbidity Symposium was held in November 2019 at Western University to achieve three main objectives: to discuss progress and findings from various jurisdictions; to facilitate collaboration through group discussion to identify strategies to move multimorbidity research forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnership. This event included keynote presentations, elevator pitch presentations and breakout sessions and there was a total of 35 attendees from eight countries, representing diverse disciplines and training levels. The overall themes arising from the event were: the importance of integrating the study and management of multimorbidity from both the primary care and public health perspectives; meaningful engagement and collaboration with patients and caregivers to understand key dimensions of multimorbidity; the considerable benefit of collaborative international partnerships; and the need to spread and scale innovations for health care systems that can better respond to the complex needs of patients and caregivers who are living with multimorbidity. Finally, it was well-acknowledged among the attendees that expanding the collaboration and discussion among international colleagues via in-person and virtual events will be important to move multimorbidity research forward.

Perspectives of specialists and family physicians in interprofessional teams in caring for patients with multimorbidity: a qualitative study

BACKGROUND

Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings.

METHODS

This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes.

RESULTS

There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings.

INTERPRETATION

Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.

Patients, caregivers and health-care professionals' experience with an interdisciplinary intervention for people with multimorbidity in primary care: A qualitative study

Background

Multimorbidity challenges the health‐care system and requires innovative approaches. In 2015, a 4‐month patient‐centred interdisciplinary pragmatic intervention was implemented in primary care with the aim of supporting self‐management for patients with multimorbidity.

Objective

To explore the perceptions and experiences of health‐care professionals, patients and their caregivers with a 4‐month patient‐centred interdisciplinary pragmatic intervention in primary care.

Design

A descriptive, qualitative study using semi‐structured interviews was conducted.

Setting and participants

A purposive sample of 30 participants was recruited from seven family medicine groups including patients, caregivers and health‐care professionals (HCPs). Interviews were analysed using Thorne's interpretive description approach.

Results

Findings were grouped into the benefits and challenges of participating in the intervention. The programme allowed patients to adopt realistic and adapted objectives; to customize interventions to the patient's reality; and to help patients gain confidence, improve their knowledge, skills and motivation to manage their condition. Interprofessional collaboration eased the exchange of information via team meetings and electronic medical records. Challenges were related to collaboration, communication, coordination of work and integration of newly relocated HCPs mainly due to part‐time assignments and staff turnover. HCPs part‐time schedules limited their availability and hindered patients’ follow‐up.

Discussion and conclusion

This intervention was useful and rewarding from the HCPs, patients and caregivers’ perspective. However, to ensure the success of this complex interdisciplinary intervention, implementers and managers should anticipate organizational barriers such as availability and time management of relocated HCPs.

Prevalence, characteristics, and patterns of patients with multimorbidity in primary care: a retrospective cohort analysis in Canada

BACKGROUND

Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed.

AIM

To determine the prevalence, characteristics, and patterns of patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care.

DESIGN AND SETTING

A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database.

METHOD

Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations.

RESULTS

Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased.

CONCLUSION

This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.

Chronic disease prevention and management programs in primary care: Realist synthesis of 6 programs in Quebec

OBJECTIVE

To identify the mechanisms associated with success and failure of chronic disease prevention and management (CDPM) programs, as well as their key contexts.

DESIGN

Realist synthesis.

SETTING

Six primary care CDPM programs funded between 2011 and 2013 in Quebec.

PARTICIPANTS

Patients, health providers, program leaders, and other stakeholders involved in CDPM programs.

METHODS

A collaborative research process was implemented, involving representatives from the executive and advisory committees: researchers, health care providers, decision makers, and patients and families. Leaders were asked to provide all documents related to their programs to the research team. The documents were selected depending on their relevance and rigour. The thematic analysis of each program consisted of identifying the outcomes and mechanisms, as well as the specific contexts associated with these outcomes. Results for each program were validated by its leader before synthesizing the results of all programs together.

MAIN FINDINGS

A total of 108 documents (eg, grant applications, scientific reports) were collected from the programs. Positive and negative outcomes were observed at the patient, health care provider, and health care system levels. Four main mechanism categories were associated with outcomes: patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners. The main contextual factors that influenced the successes of these mechanisms were related to patients (multimorbidity, involvement of family caregivers), to health care providers (professional training, culture of interprofessional collaboration, mobilization of family physician), and to health care organizations (coordination between services, history of collaboration between partners, funding).

CONCLUSION

This study confirms the essential role of patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners when caring for patients with chronic diseases. It constitutes a relevant contribution for stakeholders involved in primary care transformation and should be used to inform the sustainability and scaling up of CDPM programs.

Social Vulnerability in Patients with Multimorbidity: A Cross-Sectional Analysis

BACKGROUND

Social aspects play an important role in individual health and should be taken into consideration in the long-term care for people with multimorbidity.

PURPOSES

To describe social vulnerability, to examine its correlation with the number of chronic conditions, and to investigate which chronic conditions were significantly associated with the most socially vulnerable state in patients with multimorbidity.

METHODS

Cross-sectional analysis from the baseline data of the Patient-Centred Innovations for Persons with Multimorbidity (PACEinMM) Study. Participants were patients attending primary healthcare settings in Quebec, Canada. A social vulnerability index was applied to identify social vulnerability level. The index value ranges from 0 to 1 (1 as the most vulnerable). Spearman's rank correlation coefficient was calculated for the correlation between the social vulnerability index and the number of chronic conditions. Logistic regression was applied to investigate which chronic conditions were independently associated with the most socially vulnerable state.

RESULTS

There were 301 participants, mean age 61.0 ± 10.5, 53.2% female. The mean number of chronic health conditions was 5.01 ± 1.82, with the most common being hyperlipidemia (78.1%), hypertension (69.4%), and obesity (54.2%). The social vulnerability index had a median value of 0.13 (range 0.00⁻0.78). There was a positive correlation between the social vulnerability index and the number of chronic conditions (r = 0.24, p < 0.001). Obesity, depression/anxiety, and cardiovascular diseases were significantly associated with the most socially vulnerable patients with multimorbidity.

CONCLUSIONS

There was a significant correlation between social vulnerability and the total number of chronic conditions, with depression/anxiety, obesity, and cardiovascular diseases being the most related to social vulnerability.

What are the effective elements in patient-centered and multimorbidity care? A scoping review

BACKGROUND

Interventions to improve patient-centered care for persons with multimorbidity are in constant growth. To date, the emphasis has been on two separate kinds of interventions, those based on a patient-centered care approach with persons with chronic disease and the other ones created specifically for persons with multimorbidity. Their effectiveness in primary healthcare is well documented. Currently, none of these interventions have synthesized a patient-centered care approach for care for multimorbidity. The objective of this project is to determine the particular elements of patient-centered interventions and interventions for persons with multimorbidity that are associated with positive health-related outcomes for patients.

METHOD

A scoping review was conducted as the method supports the rapid mapping of the key concepts underpinning a research area and the main sources and types of evidence available. A five-stage approach was adopted: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting results. We searched for interventions for persons with multimorbidity or patient-centered care in primary care. Relevant studies were identified in four systematic reviews (Smith et al. (2012;2016), De Bruin et al. (2012), and Dwamena et al. (2012)). Inductive analysis was performed.

RESULTS

Four systematic reviews and 98 original studies were reviewed and analysed. Elements of interventions can be grouped into three main types and clustered into seven categories of interventions: 1) Supporting decision process and evidence-based practice; 2) Providing patient-centered approaches; 3) Supporting patient self-management; 4) Providing case/care management; 5) Enhancing interdisciplinary team approach; 6) Developing training for healthcare providers; and 7) Integrating information technology. Providing patient-oriented approaches, self-management support interventions and developing training for healthcare providers were the most frequent categories of interventions with the potential to result in positive impact for patients with chronic diseases.

CONCLUSION

This scoping review provides evidence for the adaption of patient-centered interventions for patients with multimorbidity. Findings from this scoping review will inform the development of a toolkit to assist chronic disease prevention and management programs in reorienting patient care.

Examining the prevalence and patterns of multimorbidity in Canadian primary healthcare: a methodologic protocol using a national electronic medical record database

In many developed countries, the burden of disease has shifted from acute to long-term or chronic diseases – producing new and broader challenges for patients, healthcare providers, and healthcare systems. Multimorbidity, the coexistence of two or more chronic diseases within an individual, is recognized as a significant public health and research priority. This protocol aims to examine the prevalence, characteristics, and changing burden of multimorbidity among adult primary healthcare (PHC) patients using electronic medical record (EMR) data. The objectives are two-fold: (1) to measure the point prevalence and clusters of multimorbidity among adult PHC patients; and (2) to examine the natural history and changing burden of multimorbidity over time among adult PHC patients. Data will be derived from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The CPCSSN database contains longitudinal, point-of-care data from EMRs across Canada. To identify adult patients with multimorbidity, a list of 20 chronic disease categories (and corresponding ICD-9 codes) will be used. A computational cluster analysis will be conducted using a customized computer program written in JAVA. A Cox proportional hazards analysis will be used to model time-to-event data, while simultaneously adjusting for provider- and patient-level predictors. All analyses will be conducted using STATA SE 13.1. This research is the first of its kind using a pan-Canadian EMR database, which will provide an opportunity to contribute to the international evidence base. Future work should systematically compare international research using similar robust methodologies to determine international and geographical variations in the epidemiology of multimorbidity.