Scientific evidence on how to manage multimorbidity is limited, but GPs have extensive practical experience with multimorbidity management.
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.
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.
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.
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.
comorbidity; focus groups; multimorbidity; patient-centredness; primary care; qualitative research
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.
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.
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.
Polypharmacy; Multimorbidity; General practitioner; Health services research
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.
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.
Primary care in Ireland.
Three focus groups were held in total, involving 13 GPs and seven pharmacists. Focus groups were recorded, transcribed, and analysed using the ‘framework’ approach.
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.
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.
chronic disease; general practice; multimorbidity; qualitative research
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
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.
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.
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.
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.
We wished to correlate multimorbidity with quality of life for elderly patients who
suffer from stable chronic diseases.
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.
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).
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.
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
Stable chronic diseases; Elderly; Aged; Multimorbidity; Quality of life
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.
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.
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.
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.
To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.
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.
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.
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.
Physicians' views and attitudes to elderly patients' participation in medical decision making.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Multimorbidity; Comorbidity; Chronic disease; Epidemiology; Prevalence
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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)].
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.
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.
Comorbidity; family practice; mortality; outcome assessment–health care; risk adjustment.
Multimorbidity, i.e., the presence of multiple diseases within one person, is a significant health-care problem for western societies: diagnosis, prognosis and treatment in the presence of of multiple diseases can be complex due to the various interactions between diseases. A literature review reveals that there is a variety of definitions that describe different concepts with respect to multimorbidity, both for the cause of multimorbidity as well as the implications of multimorbidity. To be able to aid computerized decision support systems within patient care, e.g. electronic clinical guidelines that can be personalized given the patient’s problems, these multimorbidity aspects need to be defined rigorously in a formal language. In this paper, we employ causal Bayesian networks to define and analyze a novel framework that can be used to model a spectrum of aspects related to multimorbidity. We conclude that this framework provides a solid basis for modeling interactions between multiple diseases.
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.
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.
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.
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.
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.
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.
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.
The above list of dominating chronic conditions and their combinations could present a pragmatic start for the development of needed guidelines related to multimorbidity.
To explore patients’ views and expectations regarding their first prescription for benzodiazepines (BZDs).
Qualitative study using semistructured interviews.
Patients were recruited from general practices in the regions of Ghent and Brussels in Belgium and were interviewed at home.
Fifteen family practice patients who had received prescriptions for BZDs for the first time.
Interviews were audiotaped and transcribed verbatim. Data were analyzed by themes using a phenomenologic approach.
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.
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.
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.
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.
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).
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.
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.
Cross-sectional studies; Elderly; Morbidity; Multimorbidity; Bangladesh
We sought to examine patients’ and providers’ views on the treatment of gout to better understand why management is suboptimal.
In-depth telephone interviews were conducted with gout patients (n=26) who initiated treatment with a urate-lowering drug (ULD) in the prior 6 months and with providers who care for gout patients (n=15). The interviews were audiotaped and transcribed verbatim. Using qualitative methods, results were analyzed and themes were identified. Interviews focused on the acute management, chronic management, and prevention and improvement strategies.
Providers viewed the majority of patients as having excellent relief with nonsteroidal anti-inflammatories, colchicine and glucocorticoids while some patients felt these medications were ineffective. Providers felt most patients had a good understanding of the rationale for ULD therapy and that patients responded well. Some patients felt ULDs triggered, worsened or had no impact on their disease. Most providers thought medication adherence was relatively good. Some patients reported discontinuing medications. Discontinuations were largely purposeful and due to clinical or financial concerns. Most providers thought their skills adequate to teach disease self-management behaviors. Patients requested more information and longer visit times.
Providers view gout as easily managed while patients report challenges and purposeful nonadherence.
medication use; gout treatment; medication adherence; qualitative
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.
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.
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.
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.
Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument.
A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status.
Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation.
Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words)
To explore with seniors what influences their choice of medication for
Qualitative study using semistructured in-depth interviews.
Interviews were conducted in patients’ homes in two cities in Nova
Seniors with a physician-confirmed diagnosis of osteoarthritis.
Interviews were audiotaped and transcribed verbatim. A grounded-theory
approach was used. Key words and phrases were identified independently by
all members of the research team who then collectively grouped the data into
Four themes emerged from discussions about medication choices: the role of
family physicians in influencing use of cyclooxygenase-2 inhibitors, the
effect of fear of making medication choices, the reasons for discontinuing
cyclooxygenase-2 inhibitors, and views on other information sources.
Distribution of free samples, family physicians’ recommendations, and fear
of side effects influenced seniors’ choices of osteoarthritis medications.
They claimed not to be influenced by direct-to-consumer advertising or the
fact that cyclooxygenase-2 inhibitors are more expensive than other classes
of drugs for osteoarthritis.
Because seniors’ choice of medications for osteoarthritis is often influenced
by physicians’ recommendations and distribution of free samples, further
research into how distribution of free samples affects medication choices in
family practice is needed.
Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects.
The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed.
The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.
Many patients with several concurrent medical conditions (multimorbidity) are seen in the primary care setting. A thorough understanding of outcomes associated with multimorbidity would benefit primary care workers of all disciplines. The purpose of this systematic review was to clarify the relationship between the presence of multimorbidity and the quality of life (QOL) or health-related quality of life (HRQOL) of patients seen, or likely to be seen, in the primary care setting.
Medline and Embase electronic databases were screened using the following search terms for the reference period 1990 to 2003: multimorbidity, comorbidity, chronic disease, and their spelling variations, along with quality of life and health-related quality of life. Only descriptive studies relevant to primary care were selected.
Of 753 articles screened, 108 were critically assessed for compliance with study inclusion and exclusion criteria. Thirty of these studies were ultimately selected for this review, including 7 in which the relationship between multimorbidity or comorbidity and QOL or HRQOL was the main outcome measure. Major limitations of these studies include the lack of a uniform definition for multimorbidity or comorbidity and the absence of assessment of disease severity. The use of self-reported diagnoses may also be a weakness. The frequent exclusion of psychiatric diagnoses and presence of potential confounding variables are other limitations. Nonetheless, we did find an inverse relationship between the number of medical conditions and QOL related to physical domains. For social and psychological dimensions of QOL, some studies reveal a similar inverse relationship in patients with 4 or more diagnoses.
Our findings confirm the existence of an inverse relationship between multimorbidity or comorbidy and QOL. However, additional studies are needed to clarify this relationship, including the various dimensions of QOL affected. Those studies must employ a clear definition of multimorbidity or comorbidity and valid ways to measure these concepts in a primary care setting. Pursuit of this research will help to better understand the impact of chronic diseases on patients.