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1.  GPs' considerations in multimorbidity management: a qualitative study 
The British Journal of General Practice  2012;62(600):e503-e510.
Background
Scientific evidence on how to manage multimorbidity is limited, but GPs have extensive practical experience with multimorbidity management.
Aim
To explore GPs’ considerations and main objectives in the management of multimorbidity and to explore factors influencing their management of multimorbidity.
Design and setting
Focus group study of Dutch GPs; with heterogeneity in characteristics such as sex, age and urbanisation.
Method
The moderator used an interview guide in conducting the interviews. Two researchers performed the analysis as an iterative process, based on verbatim transcripts and by applying the technique of constant comparative analysis. Data collection proceeded until saturation was reached.
Results
Five focus groups were conducted with 25 participating GPs. The main themes concerning multimorbidity management were individualisation, applying an integrated approach, medical considerations placed in perspective, and sharing decision making and responsibility. A personal patient–doctor relationship was considered a major factor positively influencing the management of multimorbidity. Mental-health problems and interacting conditions were regarded as major barriers in this respect and participants experienced several practical problems. The concept of patient-centredness overarches the participants’ main objectives.
Conclusion
GPs’ main objective in multimorbidity management is applying a patient-centred approach. This approach is welcomed since it counteracts some potential pitfalls of multimorbidity. Further research should include a similar design in a different setting and should aim at developing best practice in multimorbidity management.
doi:10.3399/bjgp12X652373
PMCID: PMC3381276  PMID: 22781998
comorbidity; focus groups; multimorbidity; patient-centredness; primary care; qualitative research
2.  General practitioners’ views on polypharmacy and its consequences for patient health care 
BMC Family Practice  2013;14:119.
Background
Multimorbidity is defined as suffering from coexistent chronic conditions. Multimorbid patients demand highly complex patient-centered care which often includes polypharmacy, taking an average of six different drugs per day. Adverse drug reactions, adverse drug events and medication errors are all potential consequences of polypharmacy. Our study aims to detect the status quo of the health care situation in Saxony’s general practices for multimorbid patients receiving multiple medications. We will identify the most common clinical profiles as well as documented adverse drug events and reactions that occur during the treatment of patients receiving multiple medications. We will focus on exploring the motives of general practitioners for the prescription of selected drugs in individual cases where there is evidence of potential drug-drug-interactions and potentially inappropriate medications in elderly patients. Furthermore, the study will explore general practitioners’ opinions on delegation of skills to other health professions to support medical care and monitoring of patients receiving multiple medications.
Methods/design
This is a retrospective cross sectional study using mixed methods. Socio-demographic data as well as diagnoses, medication regimens and clinically important events will be analyzed retrospectively using general practitioners documentation in patients’ records. Based on these data, short vignettes will be generated and discussed by general practitioners in qualitative telephone interviews.
Discussion
To be able to improve outpatient health care management for patients receiving multiple medications, the current status quo of care, risk factors for deficient treatment and characteristics of concerned patients must be investigated. Furthermore, it is necessary to understand the physicians’ decision making process regarding treatment.
doi:10.1186/1471-2296-14-119
PMCID: PMC3751821  PMID: 23947640
Polypharmacy; Multimorbidity; General practitioner; Health services research
3.  GPs' and pharmacists' experiences of managing multimorbidity: a ‘Pandora's box’ 
The British Journal of General Practice  2010;60(576):e285-e294.
Background
Multimorbidity is defined as the occurrence of two or more chronic diseases in one individual. Patients with multimorbidity generally have poorer health and functioning and higher rates of attendance in primary care and specialty settings.
Aim
To explore the views and attitudes of GPs and pharmacists managing patients with multimorbidity in primary care.
Design of study
Qualitative study using focus groups.
Setting
Primary care in Ireland.
Method
Three focus groups were held in total, involving 13 GPs and seven pharmacists. Focus groups were recorded, transcribed, and analysed using the ‘framework’ approach.
Results
The predominant themes to emerge from the focus groups were: 1) the concept of multimorbidity and the link to polypharmacy and ageing; 2) health systems issues relating to lack to time, inter-professional communication difficulties, and fragmentation of care; 3) individual issues from clinicians relating to professional roles, clinical uncertainty, and avoidance; 4) patient issues; and 5) potential management solutions.
Conclusion
This study provides information on the significant impact of multimorbidity from a professional perspective. It highlights potential elements of an intervention that could be designed and tested to achieve improvements in the management of multimorbidity, outcomes for individuals affected, and the experiences of those providing healthcare.
doi:10.3399/bjgp10X514756
PMCID: PMC2894403  PMID: 20594430
chronic disease; general practice; multimorbidity; qualitative research
4.  Consensus Validation of the FORTA (Fit fOR The Aged) List: A Clinical Tool for Increasing the Appropriateness of Pharmacotherapy in the Elderly 
Drugs & Aging  2013;31:131-140.
Background
Multimorbidity and polypharmacy represent a major problem for elderly patients; improvement of medication schemes is important and listing approaches (e.g. Beers list) are considered to be potentially useful.
Objectives
The aim of this study was to perform expert consensus validation of the FORTA (Fit fOR The Aged) List, a drug classification combining positive and negative labelling of drugs chronically prescribed to elderly patients.
Methods
A two-round Delphi procedure was conducted involving 20 experts, 17 geriatric internists and 3 geriatric psychiatrists from Germany and Austria, evaluating the labels assigned to 190 substances or substance groups. These labels ranged from A (indispensable), B (beneficial), C (questionable) to D (avoid), depending on the state of evidence for safety, efficacy and overall age-appropriateness. The experts were also requested to suggest additional substances and indication areas for assessment and possible inclusion in the FORTA List. A weighted (corrected) consensus coefficient was generated for each substance to reflect (1) agreement with the original label, and (2) distribution among raters’ labels.
Results
The overall consensus for all items and raters was 92 % (corrected). For 54/190 items (28.4 %), a unanimous response was achieved as to the original author-based FORTA label choice. Twenty-four substances (12.6 %) fell short of the consensus cutoff and were re-evaluated in a second round. This yielded confirmation of 171/190, or 90 %, of the original author-based FORTA labels. A total of 35 new substances were also accepted for the FORTA List. Drugs used for dementia and dementia syndromes provoked particular response heterogeneity.
Conclusion
The FORTA List now reflects a wider consensus among experts, increasing its validity for clinical use. It represents a tool to improve the quality of drug prescription in older patients by identifying both inappropriate and omitted drugs, and thus overtreatment and undertreatment. The validation of FORTA’s impact on clinical endpoints has yielded promising preliminary results, to be corroborated in ongoing larger trials.
Electronic supplementary material
The online version of this article (doi:10.1007/s40266-013-0146-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s40266-013-0146-0
PMCID: PMC3907693  PMID: 24353033
5.  Multimorbidity is common to family practice 
Canadian Family Physician  2005;51(2):245.
OBJECTIVE
Family physicians often have to care for patients with several concurrent chronic conditions (multimorbidity or comorbidity). Consequently, they need to inform themselves by reading indexed publications on multimorbidity. This study aimed to assess how well the concept of multimorbidity was covered in the medical literature. Objectives were first, to quantify the literature on multimorbidity (or comorbidity) and to compare the number of publications on it with the number of publications on three common chronic conditions (asthma, hypertension, and diabetes), and second, to describe the articles on multimorbidity.
DESIGN
Bibliometric study.
METHOD
We consulted MEDLINE for the reference period 1990 to the end of 2002. The term “multimorbidity” and its various spellings was used as the search term. Comorbidity, asthma, hypertension, and diabetes were searched for using their respective MeSH terms. For comparison purposes, prevalence data were taken from published sources. Abstracts of articles relating to multimorbidity were reviewed and their content analyzed.
MAIN OUTCOME MEASURES
Number and type of articles.
RESULTS
Multimorbidity has a prevalence of 60% among people aged 55 to 74. This prevalence is much higher than that of asthma (6.5%), hypertension (29.6%), and diabetes (8.7%). Few articles in the medical literature deal specifically with multimorbidity (or comorbidity), however. For each article on multimorbidity, there are 74 on asthma, 94 on hypertension, and 38 on diabetes. Content analysis of abstracts of articles on multimorbidity revealed a high proportion of epidemiologic studies (50.0%) followed by validation studies (22.4%) and opinion pieces (11.8%). The few experimental studies on multimorbidity were not done in primary care settings.
CONCLUSION
This study shows that the prevalence of multimorbidity is not matched by the number of indexed publications on it in the medical literature. To date, the number and diversity of articles on multimorbidity are both insufficient to provide scientific background for strong evidence-based care of patients affected by multiple concurrent chronic conditions. Research is needed to increase knowledge and understanding of this important clinical topic.
PMCID: PMC1472978  PMID: 16926936
6.  Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well? 
The British Journal of General Practice  2012;62(605):e821-e826.
Background
The consequences of multimorbidity include polypharmacy and repeated referrals for specialised care, which may increase the risk of adverse drug events (ADEs).
Aim
The objective of this study was to analyse the influence of multimorbidity, polypharmacy, and multiple referrals on the frequency of ADEs, as an indicator of therapeutic safety, in the context of a national healthcare system.
Design and setting
This was a multicentre, retrospective, observational study of 79 089 adult patients treated during 2008 in primary care centres.
Method
The explanatory patient variables sex, age, level of multimorbidity, polypharmacy, number of primary care physician visits, and number of different specialties attended were analysed. The response variable was the occurrence of ADEs. Logistic regression models were used to identify associations among the analysed variables.
Results
The prevalence of individuals with at least one ADE was 0.88%. Multivariate analysis identified the following variables as risk factors for the occurrence of ADE in descending order of effect size: multimorbidity level (odds ratio [OR]Veryhigh/Low = 45.26; ORHigh/Low = 17.58; ORModerate/Low = 4.25), polypharmacy (OR = 1.34), female sex (OR = 1.31), number of different specialties (OR = 1.20), and number of primary care physician visits (OR = 1.01). Age, however, did not show statistical significance (OR = 1.00; 95% confidence interval = 0.996 to 1.005).
Conclusion
The results of this study demonstrate that multimorbidity is strongly related to the occurrence of ADEs, insofar as it requires the intervention of multiple specialties and the prescription of multiple medications. Further research should shed light on the causal pathway between multimorbidity and increased risk of adverse events.
doi:10.3399/bjgp12X659295
PMCID: PMC3505415  PMID: 23211262
adverse drug event; healthcare system, national; multimorbidity, multiple; polypharmacy; referral, hospital
7.  Quality of Life and Multimorbidity of Elderly Outpatients 
Clinics (Sao Paulo, Brazil)  2009;64(1):45-50.
INTRODUCTION:
Substantial medical research has established an inverse relationship between quality of life and illness. However, there exists minimal evidence for such a connection in the context of stable and controlled diseases.
OBJECTIVE:
We wished to correlate multimorbidity with quality of life for elderly patients who suffer from stable chronic diseases.
METHODS:
We used a tool to evaluate quality of life, namely World Health Organization quality of life-BRIEF, together with a scale of multimorbidity known as the Cumulative Illness Rating Scale - Geriatric Version. Furthermore, the quality of life data were correlated with scores recorded on the Cumulative Illness Rating Scale - Geriatric Version, the number of drugs used, and individual perceptions of health and age.
RESULTS:
We studied 104 elderly patients who suffered from chronic diseases. The patients had exhibited neither acute events nor secondary complications, their cognition was intact, and they were functionally independent. The Cumulative Illness Rating Scale - Geriatric Version showed an inverse correlation with the physical domain (p= 0.008) and a tendency toward an inverse correlation with the psychological domain (p= 0.052). Self-perception of health showed a high correlation with the physical domain (p= 0.000), psychological domain (p= 0.000) and environmental domain (p= 0.000). The number of drugs used correlated only with the physical domain (p= 0.004). Age and social domain showed a tendency toward a positive correlation (p= 0.054).
DISCUSSION:
We uncovered an inverse relationship between quality of life and multimorbidity in a group of patients who suffered from stable chronic diseases, with no functional limitations, pain or complications. Our data suggest that a patient’s knowledge that they have a certain clinical condition changes their subjective assessment of quality of life in the related domain.
CONCLUSION:
The perceived quality of life of the sample was affected by multimorbidity in the physical domain, with a tendency toward commensurate effects in the psychological domain.
doi:10.1590/S1807-59322009000100009
PMCID: PMC2671977  PMID: 19142551
Stable chronic diseases; Elderly; Aged; Multimorbidity; Quality of life
8.  Patterns of ambulatory medical care utilization in elderly patients with special reference to chronic diseases and multimorbidity - Results from a claims data based observational study in Germany 
BMC Geriatrics  2011;11:54.
Background
In order to estimate the future demands for health services, the analysis of current utilization patterns of the elderly is crucial. The aim of this study is to analyze ambulatory medical care utilization by elderly patients in relation to age, gender, number of chronic conditions, patterns of multimorbidity, and nursing dependency in Germany.
Methods
Claims data of the year 2004 from 123,224 patients aged 65 years and over which are members of one nationwide operating statutory insurance company in Germany were studied. Multimorbidity was defined as the presence of 3 or more chronic conditions of a list of 46 most prevalent chronic conditions based on ICD 10 diagnoses. Utilization was analyzed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different physicians contacted for every single chronic condition and their most frequent triadic combinations. Main statistical analyses were multidimensional frequency counts with standard deviations and confidence intervals, and multivariable linear regression analyses.
Results
Multimorbid patients had more than twice as many contacts per year with physicians than those without multimorbidity (36 vs. 16). These contact frequencies were associated with visits to 5.7 different physicians per year in case of multimorbidity vs. 3.5 when multimorbidity was not present. The number of contacts and of physicians contacted increased steadily with the number of chronic conditions. The number of contacts varied between 35 and 54 per year and the number of contacted physicians varied between 5 to 7, depending on the presence of individual chronic diseases and/or their triadic combinations. The influence of gender or age on utilization was small and clinically almost irrelevant. The most important factor influencing physician contact was the presence of nursing dependency due to disability.
Conclusion
In absolute terms, we found a very high rate of utilization of ambulatory medical care by the elderly in Germany, when multimorbidity and especially nursing dependency were present. The extent of utilization by the elderly was related both to the number of chronic conditions and to the individual multimorbidity patterns, but not to gender and almost not to age.
doi:10.1186/1471-2318-11-54
PMCID: PMC3180370  PMID: 21914191
9.  Too complex and time-consuming to fit in! Physicians' experiences of elderly patients and their participation in medical decision making: a grounded theory study 
BMJ Open  2012;2(3):e001063.
Objective
To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.
Design
A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire.
Setting and participants
The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients.
Results
Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medical decision making. Two main categories were found: ‘being challenged’ by this patient group and ‘being a small part of the healthcare production machine’. Both categories were explained by the core category ‘lacking in time’. The reasons for the feeling of ‘being challenged’ were explained by the subcategories ‘having a feeling of incompetence’, ‘having to take relatives into consideration’ and ‘having to take cognitive decline into account’. The reasons for the feeling of ‘being a small part of the healthcare production machine’ were explained by the subcategories ‘at the mercy of routines’ and ‘inadequate remuneration system’, both of which do not favour elderly patients with multimorbidity.
Conclusions
Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medical decision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.
Article summary
Article focus
Physicians' views and attitudes to elderly patients' participation in medical decision making.
Key messages
Hospital care is not well adapted to elderly patients with multimorbidity as they are a highly complex patient group to take care of.
Taking care of elderly patients with multimorbidity often frustrates physicians by giving them a feeling of professional inadequacy.
Remuneration systems do not allow for necessary time for communication among medical professionals and between physicians and patients or relatives. Neither do these systems support the necessary integration of care.
Strengths and limitations of this study
The scope of the study, to the authors' knowledge, has not been clearly documented in earlier studies and is important to bear in mind when planning for future healthcare, especially as there will be a growing proportion of frail elderly people.
Qualitative research limits generalization.
The study was performed in a Swedish context.
doi:10.1136/bmjopen-2012-001063
PMCID: PMC3367145  PMID: 22654092
10.  Epidemiological strategies for adapting clinical practice guidelines to the needs of multimorbid patients 
Background
Clinical practice guidelines have been developed to improve the quality of health care. However, adherence to current monomorbidity-focused, mono-disciplinary guidelines may result in undesirable effects for persons with several comorbidities, in adverse interactions between drugs and diseases, conflicting management strategies, and polypharmacy. This is why new types of guidelines that address the problem of interacting medical interventions and conditions in multimorbid patients are needed.
Discussion
Previous research projects investigated patterns of multimorbidity and were able to identify combinations of the most prevalent chronic conditions, or clusters of comorbidities. These results represent potential methodological starting points for the development of guidelines that account for multimorbidity. The objective of these efforts is to identify frequent reasons for interactions and adverse events that may occur when the current type of guideline is rigorously applied in multimorbid patients.
Summary
The epidemiologic approaches described above may help guideline developers as a kind of check list of disease combinations that should systematically be considered during guideline development. Given the risk of worse outcomes in a huge group of vulnerable patients, researchers, guideline developers, and funding institutions should give first priority to the development of guidelines more appropriate for use in multimorbid persons.
doi:10.1186/1472-6963-13-352
PMCID: PMC3848618  PMID: 24041153
Clinical practice guideline; Multimorbidity; Chronic conditions
11.  Multimorbidity and comorbidity in the Dutch population – data from general practices 
BMC Public Health  2012;12:715.
Background
Multimorbidity is increasingly recognized as a major public health challenge of modern societies. However, knowledge about the size of the population suffering from multimorbidity and the type of multimorbidity is scarce. The objective of this study was to present an overview of the prevalence of multimorbidity and comorbidity of chronic diseases in the Dutch population and to explore disease clustering and common comorbidities.
Methods
We used 7 years data (2002–2008) of a large Dutch representative network of general practices (212,902 patients). Multimorbidity was defined as having two or more out of 29 chronic diseases. The prevalence of multimorbidity was calculated for the total population and by sex and age group. For 10 prevalent diseases among patients of 55 years and older (N = 52,014) logistic regressions analyses were used to study disease clustering and descriptive analyses to explore common comorbid diseases.
Results
Multimorbidity of chronic diseases was found among 13% of the Dutch population and in 37% of those older than 55 years. Among patients over 55 years with a specific chronic disease more than two-thirds also had one or more other chronic diseases. Most disease pairs occurred more frequently than would be expected if diseases had been independent. Comorbidity was not limited to specific combinations of diseases; about 70% of those with a disease had one or more extra chronic diseases recorded which were not included in the top five of most common diseases.
Conclusion
Multimorbidity is common at all ages though increasing with age, with over two-thirds of those with chronic diseases and aged 55 years and older being recorded with multimorbidity. Comorbidity encompassed many different combinations of chronic diseases. Given the ageing population, multimorbidity and its consequences should be taken into account in the organization of care in order to avoid fragmented care, in medical research and healthcare policy.
doi:10.1186/1471-2458-12-715
PMCID: PMC3490727  PMID: 22935268
Multimorbidity; Comorbidity; Chronic disease; Epidemiology; Prevalence
12.  Multimorbidity prevalence and patterns across socioeconomic determinants: a cross-sectional survey 
BMC Public Health  2012;12:201.
Background
Studies on the prevalence of multimorbidity, defined as having two or more chronic conditions, have predominantly focused on the elderly. We estimated the prevalence and specific patterns of multimorbidity across different adult age groups. Furthermore, we examined the associations of multimorbidity with socio-demographic factors.
Methods
Using data from the Health Quality Council of Alberta (HQCA) 2010 Patient Experience Survey, the prevalence of self reported multimorbidity was assessed by telephone interview among a sample of 5010 adults (18 years and over) from the general population. Logistic regression analyses were performed to determine the association between a range of socio-demographic factors and multimorbidity.
Results
The overall age- and sex-standardized prevalence of multimorbidity was 19.0% in the surveyed general population. Of those with multimorbidity, 70.2% were aged less than 65 years. The most common pairing of chronic conditions was chronic pain and arthritis. Age, sex, income and family structure were independently associated with multimorbidity.
Conclusions
Multimorbidity is a common occurrence in the general adult population, and is not limited to the elderly. Future prevention programs and practice guidelines should take into account the common patterns of multimorbidity.
doi:10.1186/1471-2458-12-201
PMCID: PMC3353224  PMID: 22429338
13.  Palliative care for the elderly - developing a curriculum for nursing and medical students 
BMC Geriatrics  2010;10:66.
Background
Delivering palliative care to elderly, dying patients is a present and future challenge. In Germany, this has been underlined by a 2009 legislation implementing palliative care as compulsory in the medical curriculum. While the number of elderly patients is increasing in many western countries multimorbidity, dementia and frailty complicate care. Teaching palliative care of the elderly to an interprofessional group of medical and nursing students can help to provide better care as acknowledged by the ministry of health and its expert panels.
In this study we researched and created an interdisciplinary curriculum focussing on the palliative care needs of the elderly which will be presented in this paper.
Methods
In order to identify relevant learning goals and objectives for the curriculum, we proceeded in four subsequent stages.
We searched international literature for existing undergraduate palliative care curricula focussing on the palliative care situation of elderly patients; we searched international literature for palliative care needs of the elderly. The searches were sensitive and limited in nature. Mesh terms were used where applicable. We then presented the results to a group of geriatrics and palliative care experts for critical appraisal. Finally, the findings were transformed into a curriculum, focussing on learning goals, using the literature found.
Results
The literature searches and expert feedback produced a primary body of results. The following deduction domains emerged: Geriatrics, Palliative Care, Communication & Patient Autonomy and Organisation & Social Networks. Based on these domains we developed our curriculum.
Conclusions
The curriculum was successfully implemented following the Kern approach for medical curricula. The process is documented in this paper. The information given may support curriculum developers in their search for learning goals and objectives.
doi:10.1186/1471-2318-10-66
PMCID: PMC2955033  PMID: 20854665
14.  The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. first results from the multicare cohort study 
Background
Multimorbidity is a phenomenon with high burden and high prevalence in the elderly. Our previous research has shown that multimorbidity can be divided into the multimorbidity patterns of 1) anxiety, depression, somatoform disorders (ADS) and pain, and 2) cardiovascular and metabolic disorders. However, it is not yet known, how these patterns are influenced by patient characteristics. The objective of this paper is to analyze the association of socio-demographic variables, and especially socio-economic status with multimorbidity in general and with each multimorbidity pattern.
Methods
The MultiCare Cohort Study is a multicentre, prospective, observational cohort study of 3.189 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Missing values have been imputed by hot deck imputation based on Gower distance in morbidity and other variables. The association of patient characteristics with the number of chronic conditions is analysed by multilevel mixed-effects linear regression analyses.
Results
Multimorbidity in general is associated with age (+0.07 chronic conditions per year), gender (-0.27 conditions for female), education (-0.26 conditions for medium and -0.29 conditions for high level vs. low level) and income (-0.27 conditions per logarithmic unit). The pattern of cardiovascular and metabolic disorders shows comparable associations with a higher coefficient for gender (-1.29 conditions for female), while multimorbidity within the pattern of ADS and pain correlates with gender (+0.79 conditions for female), but not with age or socioeconomic status.
Conclusions
Our study confirms that the morbidity load of multimorbid patients is associated with age, gender and the socioeconomic status of the patients, but there were no effects of living arrangements and marital status. We could also show that the influence of patient characteristics is dependent on the multimorbidity pattern concerned, i.e. there seem to be at least two types of elderly multimorbid patients. First, there are patients with mainly cardiovascular and metabolic disorders, who are more often male, have an older age and a lower socio-economic status. Second, there are patients mainly with ADS and pain-related morbidity, who are more often female and equally distributed across age and socio-economic groups.
Trial registration
ISRCTN89818205
doi:10.1186/1472-6963-12-89
PMCID: PMC3348059  PMID: 22471952
15.  Comparing measures of multimorbidity to predict outcomes in primary care: a cross sectional study 
Family Practice  2012;30(2):172-178.
Background.
An increasing proportion of people are living with multiple health conditions, or ‘multimorbidity’. Measures of multimorbidity are useful in studies of interventions in primary care to take account of confounding due to differences in case-mix.
Objectives.
Assess the predictive validity of commonly used measures of multimorbidity in relation to a health outcome (mortality) and a measure of health service utilization (consultation rate).
Methods.
We included 95372 patients registered on 1 April 2005 at 174 English general practices included in the General Practice Research Database. Using regression models we compared the explanatory power of six measures of multimorbidity: count of chronic diseases from the Quality and Outcomes Framework (QOF); Charlson index; count of prescribed drugs; three measures from the John Hopkins ACG software [Expanded Diagnosis Clusters count (EDCs), Adjusted Clinical Groups (ACGs), Resource Utilisation Bands (RUBs)].
Results.
A model containing demographics and GP practice alone explained 22% of the uncertainty in consultation rates. The number of prescribed drugs, ACG category, EDC count, RUB category, QOF disease count, or Charlson index increased this to 42%, 37%, 36%, 35%, 30%, and 26%, respectively. Measures of multimorbidity made little difference to the fit of a model predicting 3-year mortality. Nonetheless, Charlson index score was the best performing measure, followed by the number of prescribed drugs.
Conclusion.
The number of prescribed drugs is the most powerful measure for predicting future consultations and the second most powerful measure for predicting mortality. It may have potential as a simple proxy measure of multimorbidity in primary care.
doi:10.1093/fampra/cms060
PMCID: PMC3604888  PMID: 23045354
Comorbidity; family practice; mortality; outcome assessment–health care; risk adjustment.
16.  Prevalence estimates of multimorbidity: a comparative study of two sources 
Background
Published prevalence studies on multimorbidity present diverse data collection methods, sources of data, targeted age groups, diagnoses considered and study populations, making the comparability of prevalence estimates questionable. The objective of this study was to compare prevalence estimates of multimorbidity derived from two sources and to examine the impact of the number of diagnoses considered in the measurement of multimorbidity.
Methods
Prevalence of multimorbidity was estimated in adults over 25 years of age from two separate Canadian studies: a 2005 survey of 26,000 respondents randomly selected from the general population and a 2003 study of 980 patients from 21 family practices. We estimated the prevalence of multimorbidity based on the co-occurrence of ≥ 2 and ≥ 3 diseases of the seven diseases listed in the general population survey. For primary care patients, we also estimated multimorbidity prevalence using an open list of chronic diseases.
Results
Prevalence estimates were considerably higher for each age group in the primary care sample than in the general population. For primary care patients, the number of chronic diseases considered for estimates resulted in large differences, especially in younger age groups. The prevalence of multimorbidity increased with age in both study populations.
Conclusions
The prevalence of multimorbidity was substantially lower when estimated in a general population than in a family practice-based sample and was higher when the number of conditions considered increased.
doi:10.1186/1472-6963-10-111
PMCID: PMC2907759  PMID: 20459621
17.  Multimorbidity patterns of and use of health services by Swedish 85-year-olds: an exploratory study 
BMC Geriatrics  2013;13:120.
Background
As life expectancy continues to rise, more elderly are reaching advanced ages (≥80 years). The increasing prevalence of multimorbidity places additional demands on health-care resources for the elderly. Previous studies noted the impact of multimorbidity on the use of health services, but the effects of multimorbidity patterns on health-service use have not been well studied, especially for very old people. This study determines patterns of multimorbidity associated with emergency-room visits and hospitalization in an 85-year-old population.
Methods
Health and living conditions were reported via postal questionnaire by 496 Linköping residents aged 85 years (189 men and 307 women). Diagnoses of morbidity were reviewed in patients’ case reports, and the local health-care register provided information on the use of health services. Hierarchical cluster analysis was applied to evaluate patterns of multimorbidity with gender stratification. Factors associated with emergency-room visits and hospitalization were analyzed using logistic regression models.
Results
Cluster analyses revealed five clusters: vascular, cardiopulmonary, cardiac (only for men), somatic–mental (only for men), mental disease (only for women), and three other clusters related to aging (one for men and two for women). Heart failure in men (OR = 2.4, 95% CI = 1–5.7) and women (OR = 3, 95% CI = 1.3–6.9) as a single morbidity explained more variance than morbidity clusters in models of emergency-room visits. Men's cardiac cluster (OR = 1.6; 95% CI = 1–2.7) and women's cardiopulmonary cluster (OR = 1.7, 95% CI = 1.2–2.4) were significantly associated with hospitalization. The combination of the cardiopulmonary cluster with the men’s cardiac cluster (OR = 1.6, 95% CI = 1–2.4) and one of the women’s aging clusters (OR = 0.5, 95% CI = 0.3–0.8) showed interaction effects on hospitalization.
Conclusion
In this 85-year-old population, patterns of cardiac and pulmonary conditions were better than a single morbidity in explaining hospitalization. Heart failure was superior to multimorbidity patterns in explaining emergency-room visits. A holistic approach to examining the patterns of multimorbidity and their relationships with the use of health services will contribute to both local health care policy and geriatric practice.
doi:10.1186/1471-2318-13-120
PMCID: PMC3840694  PMID: 24195643
Multimorbidity; 85-year-old; Emergency-room visit; Hospitalization
18.  Prevalence of multimorbidity according to the deprivation level among the elderly in the Basque Country 
BMC Public Health  2013;13:918.
Background
Multimorbidity is clearly a major challenge for healthcare systems. However, currently, its magnitude and impact on healthcare expenditures is still not well known. The objective of this paper is to present an overview of the prevalence of multimorbidity by deprivation level in the elderly population of the Basque Country.
Methods
We conducted a cross-sectional analysis that included all the inhabitants of the Basque Country aged 65 years and over (N = 452,698). This was based on data from primary care electronic medical records, hospital admissions, and outpatient care databases, for a 4-year period. The health problems of the patients were identified from their diagnoses and prescriptions. Multimorbidity was defined as the presence of two or more chronic diseases out of a list of 47 of the most important and common chronic conditions consistent with the literature. In addition, we explored socio-economic and demographic variables such as age, sex, and deprivation level.
Results
Multimorbidity was found in 66.13% of the population aged 65 and over and increases with age until 80 years. The prevalence of multimorbidity was higher in deprived (69.94%) than better-off (60.22%) areas. This pattern of differences between the most and least disadvantaged areas was observed in all age groups and more marked in female (70.96-59.78%) than in male (68.54-60.86%) populations. In almost all diseases studied (43 out of 47), 90% of patients had been diagnosed with at least one other illness. It was also frequent the coexistence of mental and physical health problems in the same person and the presence of multiple physical diseases is higher in patients with mental disease than in the rest of population (74.97% vs. 58.14%).
Conclusion
Multimorbidity is very common among people over 65 years old in the Basque Country, particularly in unfavourable socioeconomic environments. Given the ageing population, multimorbidity and its consequences should be taken into account in healthcare policy, organization of care and medical research. Administrative health databases are readily available sources of a range of information that can be useful for such purposes.
doi:10.1186/1471-2458-13-918
PMCID: PMC3852493  PMID: 24088559
Multimorbidity; Chronic diseases; Elderly; Aged; 80 and over; Inequalities
19.  Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany 
BMC Public Health  2011;11:101.
Background
Growing interest in multimorbidity is observable in industrialized countries. For Germany, the increasing attention still goes still hand in hand with a small number of studies on multimorbidity. The authors report the first results of a cross-sectional study on a large sample of policy holders (n = 123,224) of a statutory health insurance company operating nationwide. This is the first comprehensive study addressing multimorbidity on the basis of German claims data. The main research question was to find out which chronic diseases and disease combinations are specific to multimorbidity in the elderly.
Methods
The study is based on the claims data of all insured policy holders aged 65 and older (n = 123,224). Adjustment for age and gender was performed for the German population in 2004. A person was defined as multimorbid if she/he had at least 3 diagnoses out of a list of 46 chronic conditions in three or more quarters within the one-year observation period. Prevalences and risk-ratios were calculated for the multimorbid and non-multimorbid samples in order to identify diagnoses more specific to multimorbidity and to detect excess prevalences of multimorbidity patterns.
Results
62% of the sample was multimorbid. Women in general and patients receiving statutory nursing care due to disability are overrepresented in the multimorbid sample. Out of the possible 15,180 combinations of three chronic conditions, 15,024 (99%) were found in the database. Regardless of this wide variety of combinations, the most prevalent individual chronic conditions do also dominate the combinations: Triads of the six most prevalent individual chronic conditions (hypertension, lipid metabolism disorders, chronic low back pain, diabetes mellitus, osteoarthritis and chronic ischemic heart disease) span the disease spectrum of 42% of the multimorbid sample. Gender differences were minor. Observed-to-expected ratios were highest when purine/pyrimidine metabolism disorders/gout and osteoarthritis were part of the multimorbidity patterns.
Conclusions
The above list of dominating chronic conditions and their combinations could present a pragmatic start for the development of needed guidelines related to multimorbidity.
doi:10.1186/1471-2458-11-101
PMCID: PMC3050745  PMID: 21320345
20.  Self-rated health in multimorbid older general practice patients: a cross-sectional study in Germany 
BMC Family Practice  2014;15:1.
Background
With increasing life expectancy the number of people affected by multimorbidity rises. Knowledge of factors associated with health-related quality of life in multimorbid people is scarce. We aimed to identify the factors that are associated with self-rated health (SRH) in aged multimorbid primary care patients.
Methods
Cross-sectional study with 3,189 multimorbid primary care patients aged from 65 to 85 years recruited in 158 general practices in 8 study centers in Germany. Information about morbidity, risk factors, resources, functional status and socio-economic data were collected in face-to-face interviews. Factors associated with SRH were identified by multivariable regression analyses.
Results
Depression, somatization, pain, limitations of instrumental activities (iADL), age, distress and Body Mass Index (BMI) were inversely related with SRH. Higher levels of physical activity, income and self-efficacy expectation had a positive association with SRH. The only chronic diseases remaining in the final model were Parkinson’s disease and neuropathies. The final model accounted for 35% variance of SRH. Separate analyses for men and women detected some similarities; however, gender specific variation existed for several factors.
Conclusion
In multimorbid patients symptoms and consequences of diseases such as pain and activity limitations, as well as depression, seem to be far stronger associated with SRH than the diseases themselves. High income and self-efficacy expectation are independently associated with better SRH and high BMI and age with low SRH.
Trial registration
MultiCare Cohort study registration:ISRCTN89818205.
doi:10.1186/1471-2296-15-1
PMCID: PMC3923097  PMID: 24387712
Quality of life; Self-assessment; Chronic disease; Depression; Pain; Functionally- impaired elderly; General practice
21.  Prevalence and Patterns of Multimorbidity among Elderly People in Rural Bangladesh: A Cross-sectional Study 
Data on multimorbidity among the elderly people in Bangladesh are lacking. This paper reports the prevalence and distribution patterns of multimorbidity among the elderly people in rural Bangladesh. This cross-sectional study was conducted among persons aged ≥60 years in Matlab, Bangladesh. Information on their demographics and literacy was collected through interview in the home. Information about their assets was obtained from a surveillance database. Physicians conducted clinical examinations at a local health centre. Two physicians diagnosed medical conditions, and two senior geriatricians then evaluated the same separately. Multimorbidity was defined as suffering from two or more of nine chronic medical conditions, such as arthritis, stroke, obesity, signs of thyroid hypofunction, obstructive pulmonary symptoms, symptoms of heart failure, impaired vision, hearing impairment, and high blood pressure. The overall prevalence of multimorbidity among the study population was 53.8%, and it was significantly higher among women, illiterates, persons who were single, and persons in the non-poorest quintile. In multivariable logistic regression analyses, female sex and belonging to the non-poorest quintile were independently associated with an increased odds ratio of multimorbidity. The results suggest that the prevalence of multimorbidity is high among the elderly people in rural Bangladesh. Women and the non-poorest group of the elderly people are more likely than men and the poorest people to be affected by multimorbidity. The study sheds new light on the need of primary care for the elderly people with multimorbidity in rural Bangladesh.
PMCID: PMC3190372  PMID: 21957680
Cross-sectional studies; Elderly; Morbidity; Multimorbidity; Bangladesh
22.  Multimorbidity Patterns in the Elderly: A New Approach of Disease Clustering Identifies Complex Interrelations between Chronic Conditions 
PLoS ONE  2010;5(12):e15941.
Objective
Multimorbidity is a common problem in the elderly that is significantly associated with higher mortality, increased disability and functional decline. Information about interactions of chronic diseases can help to facilitate diagnosis, amend prevention and enhance the patients' quality of life. The aim of this study was to increase the knowledge of specific processes of multimorbidity in an unselected elderly population by identifying patterns of statistically significantly associated comorbidity.
Methods
Multimorbidity patterns were identified by exploratory tetrachoric factor analysis based on claims data of 63,104 males and 86,176 females in the age group 65+. Analyses were based on 46 diagnosis groups incorporating all ICD-10 diagnoses of chronic diseases with a prevalence ≥ 1%. Both genders were analyzed separately. Persons were assigned to multimorbidity patterns if they had at least three diagnosis groups with a factor loading of 0.25 on the corresponding pattern.
Results
Three multimorbidity patterns were found: 1) cardiovascular/metabolic disorders [prevalence female: 30%; male: 39%], 2) anxiety/depression/somatoform disorders and pain [34%; 22%], and 3) neuropsychiatric disorders [6%; 0.8%]. The sampling adequacy was meritorious (Kaiser-Meyer-Olkin measure: 0.85 and 0.84, respectively) and the factors explained a large part of the variance (cumulative percent: 78% and 75%, respectively). The patterns were largely age-dependent and overlapped in a sizeable part of the population. Altogether 50% of female and 48% of male persons were assigned to at least one of the three multimorbidity patterns.
Conclusion
This study shows that statistically significant co-occurrence of chronic diseases can be subsumed in three prevalent multimorbidity patterns if accounting for the fact that different multimorbidity patterns share some diagnosis groups, influence each other and overlap in a large part of the population. In recognizing the full complexity of multimorbidity we might improve our ability to predict needs and achieve possible benefits for elderly patients who suffer from multimorbidity.
doi:10.1371/journal.pone.0015941
PMCID: PMC3012106  PMID: 21209965
23.  First benzodiazepine prescriptions 
Canadian Family Physician  2007;53(7):1200-1201.
OBJECTIVE
To explore patients’ views and expectations regarding their first prescription for benzodiazepines (BZDs).
DESIGN
Qualitative study using semistructured interviews.
SETTING
Patients were recruited from general practices in the regions of Ghent and Brussels in Belgium and were interviewed at home.
PARTICIPANTS
Fifteen family practice patients who had received prescriptions for BZDs for the first time.
METHOD
Interviews were audiotaped and transcribed verbatim. Data were analyzed by themes using a phenomenologic approach.
MAIN FINDINGS
Patients had asked their physicians for “something” because they thought they were in serious distress and needed help. They seemed to feel a conflict between the need for medication and the negative connotations surrounding BZD use. Patients used 2 strategies to justify consumption of BZDs: maximizing their problems and minimizing use. Patients knew very little about the medication and did not ask about it. Their expectations regarding continued use were vague, even though they seemed to be aware of the risk of psychological dependency and conditioning mechanisms. Patients did not actively ask for nonpharmacologic alternatives, but when they were offered them, their attitudes toward them were generally positive.
CONCLUSION
First-time BZD users ask for help with distress, but place the responsibility for solving their problems on their family physicians. Even when short-term users were aware of the concept of psychological dependency, they did not feel the need for more information. Physicians should develop communication strategies to persuade their patients that they take the patients’ problems seriously even though consultations do not always end with prescriptions. It is important that doctors clearly explain the risks and benefits of starting BZD treatment and set limits from the start. This will help doctors manage first-time BZD users more effectively and will help patients avoid chronic use.
PMCID: PMC1949305  PMID: 17872818
24.  Treatment Considerations for Elderly and Frail Patients With Neuropathic Pain 
Mayo Clinic Proceedings  2010;85(3 Suppl):S26-S32.
Currently, an estimated 38 million individuals 65 years or older live in the United States, and more than 11 million of these individuals are 80 years or older. Older people are at high risk of neuropathic pain because many diseases that cause neuropathic pain increase in incidence with age. Depending on their underlying health, older adults with neuropathic pain may have to cope with multiple coexisting diseases, polypharmacy, and impaired functional ability. The objective of this article is to review how aging and frailty affect the treatment of older adults with neuropathic pain. Specific topics reviewed include the complexity of treatment decisions in older patients due to aged heterogeneity, multimorbidity, and polypharmacy; selection of treatment in an effort to maximize patients' functional abilities in addition to relieving their pain; more careful dosing (usually lower) and monitoring of pharmacotherapy relative to younger patients due to age-related changes in pharmacokinetics and pharmacodynamics; and underrepresentation of older adults in clinical trials of neuropathic pain treatments, which further compromises physicians' ability to make informed treatment decisions.
doi:10.4065/mcp.2009.0646
PMCID: PMC2844008  PMID: 20194145
25.  Co- and multimorbidity patterns in primary care based on episodes of care: results from the German CONTENT project 
Background
Due to technological progress and improvements in medical care and health policy the average age of patients in primary care is continuously growing. In equal measure, an increasing proportion of mostly elderly primary care patients presents with multiple coexisting medical conditions. To properly assess the current situation of co- and multimorbidity, valid scientific data based on an appropriate data structure are indispensable. CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) is an ambitious project in Germany to establish a system for adequate record keeping and analysis in primary care based on episodes of care. An episode is defined as health problem from its first presentation by a patient to a doctor until the completion of the last encounter for it. The study aims to describe co- and multimorbidity as well as health care utilization based on episodes of care for the study population of the first participating general practices.
Methods
The analyses were based on a total of 39,699 patients in a yearly contact group (YCG) out of 17 general practices in Germany for which data entry based on episodes of care using the International Classification of Primary Care (ICPC) was performed between 1.1.2006 and 31.12.2006. In order to model the relationship between the explanatory variables (age, gender, number of chronic conditions) and the response variables of interest (number of different prescriptions, number of referrals, number of encounters) that were applied to measure health care utilization, we used multiple linear regression.
Results
In comparison to gender, patients' age had a manifestly stronger impact on the number of different prescriptions, the number of referrals and number of encounters. In comparison to age (β = 0.043, p < 0.0001), multimorbidity measured by the number of patients' chronic conditions (β = 0.51, p < 0.0001) had a manifestly stronger impact the number of encounters for the observation period. Moreover, we could observe that the number of patients' chronic conditions had a significant impact on the number of different prescriptions (β = 0.226, p < 0.0001) as well as on the number of referrals (β = 0.3, p < 0.0001).
Conclusion
Documentation in primary care on the basis of episodes of care facilitates an insight to concurrently existing health problems and related medical procedures. Therefore, the resulting data provide a basis to obtain co- and multimorbidity patterns and corresponding health care utilization issues in order to understand the particular complex needs caused by multimorbidity.
doi:10.1186/1472-6963-8-14
PMCID: PMC2244601  PMID: 18205916

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