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1.  Transforming primary healthcare by including the stakeholders involved in delivering care to people living in poverty: EQUIhealThY study protocol 
Background
Ensuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations.
Methods/design
This study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decision-making role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews.
Discussion
The proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty.
doi:10.1186/1472-6963-13-92
PMCID: PMC3610178  PMID: 23497400
Participatory research; Poverty; Primary care; Photovoice; Knowledge transfer
2.  Implementing a knowledge application program for anxiety and depression in community-based primary mental health care: a multiple case study research protocol 
Background
Anxiety and depressive disorders are increasingly recognized as a health care policy priority. Reducing the treatment gap for common mental disorders requires strengthening the quality of primary mental health care. We developed a knowledge application program designed to improve the organization and delivery of care for anxiety and depression in community-based primary mental health care teams in Quebec, Canada. The principal objectives of the study are: to implement and evaluate this evidence-based knowledge application program; to examine the contextual factors associated with the selection of local quality improvement strategies; to explore barriers and facilitators associated with the implementation of local quality improvement plans; and to study the implementation of local quality monitoring strategies.
Methods
The research design is a mixed-methods prospective multiple case study. The main analysis unit (cases) is composed of the six multidisciplinary community-based primary mental health care teams, and each of the cases has identified at least one primary care medical clinic interested in collaborating with the implementation project. The training modules of the program are based on the Chronic Care Model, and the implementation strategies were developed according to the Promoting Action on Research Implementation in Health Services conceptual framework.
Discussion
The implementation of an evidence-based knowledge application program for anxiety and depression in primary care aims to improve the organization and delivery of mental health services. The uptake of evidence to improve the quality of care for common mental disorders in primary care is a complex process that requires careful consideration of the context in which innovations are introduced. The project will provide a close examination of the interplay between evidence, context and facilitation, and contribute to the understanding of factors associated with the process of implementation of interventions in routine care. The implementation of the knowledge application program with a population health perspective is consistent with the priorities set forth in the current mental health care reform in Quebec. Strengthening primary mental health care will lead to a more efficient health care system.
doi:10.1186/1748-5908-8-26
PMCID: PMC3614908  PMID: 23497399
Depression; Anxiety disorders; Primary care; Quality of care; Quality improvement; Mental health care; Quality indicators; Knowledge application
3.  Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial 
Background
Chronic diseases represent a major challenge for health care and social services. A number of people with chronic diseases require more services due to characteristics that increase their vulnerability. Given the burden of increasingly vulnerable patients on primary care, a pragmatic intervention in four Family Medicine Groups (primary care practices in Quebec, Canada) has been proposed for individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain) who are frequent users of hospital services. The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program. The goals of this study are to: (1) analyze the implementation of the intervention in the participating practices in order to determine how the various contexts have influenced the implementation and the observed effects; (2) evaluate the proximal (self-efficacy, self-management, health habits, activation and psychological distress) and intermediate (empowerment, quality of life and health care use) effects of the intervention on patients; (3) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention.
Methods/Design
The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders (Family Medicine Group and health centre management, Family Medicine Group practitioners, patients and their families, health centre or community partners). The data will be obtained through individual and group interviews, project documentation reviews and by documenting the intervention. Evaluation of the effects on patients will be based on a pragmatic randomized before-after experimental design with a delayed intervention control group (six months). Economic analysis will include cost-effectiveness and cost-benefit analysis.
Discussion
The integration of a case management intervention delivered by nurses and self-management group support into primary care practices has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care. Decision-makers, managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practices in the region and elsewhere.
Trial Registration
NCT01719991
doi:10.1186/1472-6963-13-49
PMCID: PMC3601974  PMID: 23391214
Chronic diseases; Primary care; Family Medicine Group; Frequent users; Case management; Self-management; Primary care nursing; Services integration
4.  Family physician enabling attitudes: a qualitative study of patient perceptions 
BMC Family Practice  2013;14:8.
Background
Family physicians frequently interact with people affected by chronic diseases, placing them in a privileged position to enable patients to gain control over and improve their health. Soliciting patients’ perceptions about how their family physician can help them in this process is an essential step to promoting enabling attitudes among these health professionals. In this study, we aimed to identify family physician enabling attitudes and behaviours from the perspective of patients with chronic diseases.
Methods
We conducted a descriptive qualitative study with 30 patients, 35 to 75 years of age presenting at least one common chronic disease, recruited in primary care clinics in two regions of Quebec, Canada. Data were collected through in-depth interviews and were analyzed using thematic analysis.
Results
Family physician involvement in a partnership was perceived by participants as the main attribute of enablement. Promoting patient interests in the health care system was also important. Participants considered that having their situation taken into account maximized the impact of their physician’s interventions and allowed the legitimization of their feelings. They found their family physician to be in a good position to acknowledge and promote their expertise, and to help them maintain hope.
Conclusions
From the patient’s perspective, their partnership with their family physician is the most important aspect of enablement.
doi:10.1186/1471-2296-14-8
PMCID: PMC3556105  PMID: 23305144
Power (psychology); Enablement; Patient-centred care; Family practice; Primary health care; Chronic disease
5.  The relationship between literacy and multimorbidity in a primary care setting 
BMC Family Practice  2012;13:33.
Background
Multimorbidity is now acknowledged as a research priority in primary care. The identification of risk factors and people most at risk is an important step in guiding prevention and intervention strategies. The aim of this study was to examine the relationship between literacy and multimorbidity while controlling for potential confounders.
Methods
Participants were adult patients attending the family medicine clinic of a regional health centre in Saguenay (Quebec), Canada. Literacy was measured with the Newest Vital Sign (NVS). Multimorbidity was measured with the Disease Burden Morbidity Assessment (DBMA) by self-report. Information on potential confounders (age, sex, education and family income) was also collected. The association between literacy (independent variable) and multimorbidity was examined in bivariate and multivariate analyses. Two operational definitions of multimorbidity were used successively as the dependent variable; confounding variables were introduced into the model as potential predictors.
Results
One hundred three patients (36 men) 19–83 years old were recruited; 41.8% had completed 12 years of school or less. Forty-seven percent of patients provided fewer than four correct answers on the NVS (possible low literacy) whereas 53% had four correct responses or more. Literacy and multimorbidity were associated in bivariate analyses (p < 0.01) but not in multivariate analyses, including age and family income.
Conclusion
This study suggests that there is no relationship between literacy and multimorbidity when controlling for age and family income.
doi:10.1186/1471-2296-13-33
PMCID: PMC3388951  PMID: 22536833
6.  Validation of the disease burden morbidity assessment by self-report in a French-speaking population 
Background
The Disease Burden Morbidity Assessment (DBMA) is a self-report questionnaire used to estimate the disease burden experienced by patients. The aim of this study was to test and to measure the properties of the French translation of the DBMA (DBMA-Fv).
Methods
The original version of the DBMA was translated into French (Canadian) and first assessed during cognitive interviews. In the validation study, patients recruited during consecutive consultation periods completed the DBMA-Fv questionnaire while they were in the waiting room of a primary care setting (T1). Participants completed the same questionnaire mailed to their home two weeks later (T2). Concomitant validity of the DBMA-Fv was assessed using the Cumulative Illness Rating Scale (CIRS). Patient medical records were reviewed to verify chronic diseases and past medical history.
Results
Ninety-seven patients were recruited and 85 (88%) returned the mailed questionnaires; 5 (5.9%) were incomplete. DBMA-Fv scores of the 80 participants with a complete questionnaire at T2 ranged from 0 to 30 (median 5.5, mean 7.7, SD = 7.0). Test-retest reliability of the DBMA-Fv was high (ICC: 0.86, 95% CI: 0.79-0.92). The DBMA-Fv and the CIRS correlated moderately at T1 (r = 0.46, 95% CI: 0.26 - 0.62, p < 0.01) and T2 (r = 0.56, 95% CI: 0.38 - 0.70, p < 0.01). The mean (SD) sensitivity of patient reports of a condition in relation to chart review at T2 was 73.9 (8.4) (range 62.5% to 90%). The overall mean (SD) specificity was 92.2 (6.7) (range 77.6% to 98.6%).
Conclusions
The DBMA-Fv's properties are similar to its English counterpart as to its median sensitivity and specificity compared to chart reviews. It correlated moderately with an established index of multimorbidity. A high percentage of patients were able to complete the test correctly as a mail questionnaire and it showed high test-retest reliability.
doi:10.1186/1472-6963-12-35
PMCID: PMC3305524  PMID: 22333434
7.  Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity 
BMC Family Practice  2011;12:74.
Background
Clinical guidelines have been the subject of much criticism in primary care literature partly due to potential conflicts in their implementation among patients with multiple chronic conditions. We assessed the relevance of selected Canadian clinical guidelines on chronic diseases for patients with comorbidity and examined their quality.
Methods
We selected 16 chronic medical conditions according to their frequency of occurrence, complexity of treatment, and pertinence to primary care. Recent Canadian clinical guidelines (2004 - 2009) on these conditions, published in English or French, were retrieved. We assessed guideline relevance to the care of patients with comorbidity with a tool developed by Boyd and colleagues. Quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.
Results
Regarding relevance, 56.2% of guidelines addressed treatment for patients with multiple chronic conditions and 18.8% addressed the issue for older patients. Fifteen guidelines (93.8%) included specific recommendations for patients with one concurrent condition; only three guidelines (18.8%) addressed specific recommendations for patients with two comorbid conditions and one for more than two concurrent comorbid conditions. Quality of the evaluated guidelines was good to very good in four out of the six domains measured using the AGREE instrument. The domains with lower mean scores were Stakeholder Involvement and Applicability.
Conclusions
The quality of the Canadian guidelines examined is generally good, yet their relevance for patients with two or more chronic conditions is very limited and there is room for improvement in this respect.
doi:10.1186/1471-2296-12-74
PMCID: PMC3146414  PMID: 21752267
8.  The Patient Enablement Instrument-French version in a family practice setting: a reliability study 
BMC Family Practice  2011;12:71.
Background
Patient enablement can be defined as the extent to which a patient is capable of understanding and coping with his or her health issues. This concept is linked to a number of health outcomes such as self-management of chronic diseases and quality of life. The Patient Enablement Instrument (PEI) was designed to measure this concept after a medical consultation. The instrument, in its original form and its translations into several languages, has proven to be reliable and valid. The purpose of this study was to evaluate the reliability of the French version of the PEI (PEI-Fv) in a family practice setting.
Methods
One hundred and ten participants were recruited in a family medicine clinic in the Saguenay region of Quebec (Canada). The PEI-Fv was completed twice, immediately after consultation with a physician (T1) and 2 weeks after the consultation (T2). The internal consistency of the tool was assessed with Cronbach's α and test-retest reliability by intraclass correlation coefficient.
Results
The mean score for the PEI-Fv was 5.06 ± 3.97 (95% confidence interval [CI]: 4.30-5.81) at T1 and 4.63 ± 3.90 (95% CI: 3.82-5.44) at T2. Cronbach's α was high at T1 (α1 = 0.93; 95% CI: 0.91-0.95) and T2 (α2 = 0.93; 95% CI: 0.91-0.95). The intraclass correlation coefficient was 0.62 (95% CI: 0.48-0.74), indicating a moderate test-retest reliability.
Conclusions
The internal consistency of the PEI-Fv is excellent. Test-retest reliability was moderate to good. Test-retest reliability should be examined in further studies at a less than 2-week interval to reduce maturation bias. This instrument can be used to measure enablement after consultation in a French-speaking family practice setting.
doi:10.1186/1471-2296-12-71
PMCID: PMC3143930  PMID: 21736729
9.  Nurses joining family doctors in primary care practices: perceptions of patients with multimorbidity 
BMC Family Practice  2010;11:84.
Background
Among the strategies used to reform primary care, the participation of nurses in primary care practices appears to offer a promising avenue to better meet the needs of vulnerable patients. The present study explores the perceptions and expectations of patients with multimorbidity regarding nurses' presence in primary care practices.
Methods
18 primary (health) care patients with multimorbidity participated in semi-directed interviews, in order to explore their perceptions and expectations in regard to the involvement of nurses in primary care practices. Interviews were audio-recorded and transcribed. After reviewing the transcripts, the principal investigator and research assistants performed thematic analysis independently and reached consensus on the retained themes.
Results
Patients with multimorbidity were open to the participation of nurses in primary care practices. They expected greater accessibility, for both themselves and for new patients. However, the issue of shared roles between nurses and doctors was a source of concern. Many patients held the traditional view of the nurse's role as an assistant to the doctor in his or her various duties. In general, participants said they were confident about nurses' competency but expressed concern about nurses performing certain acts that their doctor used to, notwithstanding a close collaboration between the two professionals.
Conclusion
Patients with multimorbidity are open to the involvement of nurses in primary care practices. However, they expect this participation to be established using clear definitions of professional roles and fields of practice.
doi:10.1186/1471-2296-11-84
PMCID: PMC2987912  PMID: 21050443
10.  At the interface of community and healthcare systems: a longitudinal cohort study on evolving health and the impact of primary healthcare from the patient's perspectiv 
Background
Massive efforts in Canada have been made to renew primary healthcare. However, although early evaluations of initiatives and research on certain aspects of the reform are promising, none have examined the link between patient assessments of care and health outcomes or the impacts at a population level. The goal of this project is to examine the effect of patient-centred and effective primary healthcare on the evolution of chronic illness burden and health functioning in a population, and in particularly vulnerable groups: the multi-morbid and the poor.
Methods/Design
A randomly selected cohort of 2000 adults aged 25 to 75 years will be recruited within the geographic boundaries of four local healthcare networks in Quebec. At recruitment, cohort members will report on socio-demographic information, functional health and healthcare use. Two weeks, 12 months and 24 months after recruitment, cohort participants will complete a self-administered questionnaire on current health and health behaviours in order to evaluate primary healthcare received in the previous year.
The dependent variables are calculated as change over time of functional health status, chronic illness burden, and health behaviours. Dimensions of patient-centred care and clinical processes are measured using sub-scales of validated instruments. We will use Poisson regression modelling to estimate the incidence rate of chronic illness burden scores and structural equation modelling to explore relationships between variables and to examine the impact of dimensions of patient-centred care and effective primary healthcare.
Discussion
Results will provide valuable information for primary healthcare clinicians on the course of chronic illness over time and the impact on health outcomes of accessible, patient-centred and effective care. A demonstration of impact will contribute to the promotion of continuous quality improvement activities at a clinical level. While considerable advances have been made in the management of specific chronic illnesses, this will make a unique contribution to effective care for persons with multiple morbidities. Furthermore, the cohort and data architecture will serve as a research platform for future projects.
doi:10.1186/1472-6963-10-258
PMCID: PMC2940881  PMID: 20815880
11.  Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity 
Annals of family medicine  2010;8(2):170-177.
We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other’s goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.
doi:10.1370/afm.1056
PMCID: PMC2834724  PMID: 20212304 CAMSID: cams1140
Primary health care; multimorbidity; community of practice; interprofessional practice; collective learning; complex adaptive systems
12.  Multimorbidity's many challenges 
BMJ : British Medical Journal  2007;334(7602):1016-1017.
Time to focus on the needs of this vulnerable and growing population
doi:10.1136/bmj.39201.463819.2C
PMCID: PMC1871747  PMID: 17510108
13.  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
14.  Comorbidity and glycemia control among patients with type 2 diabetes in primary care 
Reports on the relationship between comorbidity and glycemia control in diabetic patients are conflicting and the method of measuring comorbidity varies widely among studies. The aim of the present study was to evaluate the relationship between diabetes control and comorbidity, taking into account all comorbidities and their severity, in a primary care setting. We performed a retrospective descriptive study based on chart review of 96 randomly selected type 2 diabetic patients. Comorbidity was measured with the cumulative illness rating scale (CIRS), an exhaustive comorbidity index. Diabetes was considered as controlled if the mean value of two measurements of glycosylated hemoglobin A (HbA1c) was less than 7%. Taking diabetes control as the dependent variable, its relationship with the CIRS score, age, sex, diabetes duration, and diabetes-related complications was explored. Diabetes control was not significantly related with the CIRS score, age, sex or diabetes severity. Diabetes duration was the only variable significantly related to diabetes control. Our study suggests that comorbidity measured with the CIRS in patients with type 2 diabetes is not a factor that prevents the achievement of a good glycemia control.
PMCID: PMC3052715  PMID: 21437154
glycemia control; type 2 diabetes mellitus; comorbidity; primary care
15.  Relationship between multimorbidity and physical activity: Secondary analysis from the Quebec health survey 
BMC Public Health  2008;8:304.
Background
Abundant literature supports the beneficial effects of physical activity for improving health of people with chronic diseases. The relationship between multimorbidity and physical activity levels, however, has been little evaluated. The purpose of the current exploratory study was to examine the relationship between a) multimorbidity and physical activity levels, and b) long-term limitations on activity, self-rated general health, psychological distress, and physical activity levels for each sex in adults, after age, education, income, and employment factors were controlled for.
Methods
Data from the Quebec Health Survey 1998 were used. The sample included 16,782 adults 18–69 yr of age. Independent variables were multimorbidity, long-term limitations on activity, self-rated general health, and psychological distress. The dependent variable was physical activity levels. Links between the independent and dependent variables were assessed separately for men and women with multinomial regressions while accounting for the survey sampling design and household clustering.
Results
About 46% of the participants were men. Multimorbidity was not associated with physical activity levels for either men or women. Men and women with long-term limitations on activity and with poor-to-average self-rated general health were less likely to be physically active. No relationship between psychological distress and physical activity was found for men. Women with high levels of psychological distress were less likely to be physically active.
Conclusion
Multimorbidity was not associated with physical activity levels in either sex, when age, education, income, and employment factors were controlled for. Long-term limitations on activity and poor-to-average self-rated general health seem related to a reduction in physical activity levels for both sexes, whereas psychological distress was associated with a reduction in physical activity levels only among women. Longitudinal studies using a comorbidity or multimorbidity index to account for severity of the chronic diseases are needed to replicate the results of this exploratory study.
doi:10.1186/1471-2458-8-304
PMCID: PMC2542369  PMID: 18775074
16.  Single risk factor interventions to promote physical activity among patients with chronic diseases 
Canadian Family Physician  2008;54(8):1130-1137.
ABSTRACT
OBJECTIVE
To provide a summary of evidence on the effectiveness of interventions to promote physical activity among patients affected by at least 1 chronic disease. The interventions studied were each targeted at a single risk factor.
DATA SOURCES
MEDLINE, CINAHL, and EMBASE were searched from 1966 to 2006 using 2 sets of search terms. First we searched using physical activity or physical fitness or exercise and health care or primary care or primary health care or family practice or medical office or physician’s office and health promotion or health education or counselling. Then we used physical activity or exercise and diabetes or hyperlipidemia or hypertension or obesity or cardiovascular disease or pulmonary disease or risk factor or comorbidity and health promotion or health education or counselling or prescription.
STUDY SELECTION
We chose randomized controlled trials or trials with a controlled quasi-experimental design that evaluated single risk factor interventions to promote physical activity among adult patients in primary care settings who were affected by at least 1 chronic disease, that reported participation in physical activity as a primary outcome, and that were published in English or French.
SYNTHESIS
Of the 4858 articles found, 62 were assessed, and 3 were selected. Two studies concluded that the interventions evaluated had no effect on level of physical activity. The other reported a positive short-term effect with use of an intensive intervention that was based on the theory of planned behaviour and integrated nurses into the general practitioner counseling process.
CONCLUSION
There is insufficient evidence to assess the effectiveness of single risk factor interventions to promote physical activity among patients affected by at least 1 chronic disease in primary care settings. Of 3 studies, only 1 reported a short-term positive effect.
PMCID: PMC2515256  PMID: 18697975
17.  Chronic musculoskeletal conditions and comorbidities in primary care settings 
Canadian Family Physician  2008;54(1):74-75.
RÉSUMÉ
OBJECTIFS
Estimer la prévalence des conditions musculo-squelettiques chroniques en première ligne. Parmi les patients atteints de ces conditions, estimer le nombre moyende comorbidités, ainsi que la prévalence des maladies chroniques pouvant se détériorer avec la prise d’anti-inflammatoires non stéroïdiens (AINS).
DEVIS
Analyse secondaire de données collectées dans une étude sur la prévalence de la multimorbidité.
CONTEXTE
Vingt-et-une pratiques de médecine familiale dans la région du Saguenay au Québec.
PARTICIPANTS
Plan d’échantillonnage à 2 niveaux, soit les médecins de famille et leur clientèle sollicitée pendant des périodes consécutives de consultation.
PRINCIPAUX PARAMÈTRES MESURÉS
Proportion de patients ayant des conditions musculo-squelettiques chroniques et, dans ce sous-échantillon, le nombre moyen de comorbidités et la proportion de patients atteints de maladies chroniques (hypertension, maladies cardio-vasculaires, maladies rénales et ulcères d’estomac ou reflux) pouvant se détériorer avec la prise d’AINS.
RÉSULTATS
La banque de données comprenait 980 patients dont l’âge moyen était 56 ans. La prévalence des conditions musculo-squelettiques chroniques s’élevait à 58%pour l’ensemble de l’échantillon. Parmi les patients atteints de ces conditions, le nombre de comorbidités variait de 0 à 11 pour une moyenne de 4. Environ 49% des patients avaient de l’hypertension, 31% des maladies cardiaques, 31% des troubles urinaires ou maladies du rein et 17% des ulcères d’estomac ou du reflux. Finalement, 70% des patients avec des conditions musculo-squelettiques chroniques présentaient au moins une comorbidité parmi les 4 énumérées.
CONCLUSION
Plus de la moitié des patients qui consultent en première ligne ont des conditions musculo-squelettiques chroniques. Le nombre moyen de comorbidités parmi ces patients est élevé et plusieurs présentent des comorbidités qui peuvent se détériorer avec l’usage d’AINS. Le médecin de famille doit donc demeurer vigilant avec l’utilisation des AINS dans cette clientèle.
PMCID: PMC2293320  PMID: 18208959
18.  Multimorbidity and quality of life: a closer look 
Background
The presence of multiple chronic conditions is associated with lower health related quality of life (HRQOL). Disease severity also influences HRQOL. To analyse the effects of all possible combinations of single diseases along with their severity on HRQOL seems cumbersome. Grouping diseases and their severity in specific organ domains may facilitate the study of the complex relationship between multiple chronic conditions and HRQOL. The goal of this study was to analyse impaired organ domains that affect the most HRQOL of patients with multiple chronic conditions in primary care and their possible interactions.
Methods
We analysed data from 238 patients recruited from the clientele of 21 family physicians. We classified all chronic conditions along with the measure of their severity into the 14 organ domains of the Cumulative Illness Rating Scale (CIRS). Patients also completed the 36-item Medical Outcomes Study questionnaire (SF-36). One-way analyses of variance were performed to study the relationship between the severity score for each CIRS domain and both physical component summary (PCS) and mental component summary (MCS) of HRQOL. Two-way analyses of variance were conducted to investigate the significance of possible organ domains interactions. Variables involved in significant bivariate relationships or interactions were candidates for inclusion in a multivariate model. Five additional variables were included in the multivariate model because of their possible confounding effect: perceived social support, age, education, perceived economic status and residual CIRS.
Results
Significant differences in the PCS (p < 0.01) were found in 12 of the 14 CIRS organ domains. A significant difference in MCS was found only in the Psychiatric domain. In the multivariate analysis for the PCS, the CIRS domains Musculoskeletal, Neurological, and Psychiatric, had an independent direct impact on PCS while the Upper gastrointestinal, Vascular, Cardiac and Respiratory domains were involved in interactions. A multivariate model was not necessary for the mental component.
Conclusion
Vascular, Upper gastrointestinal and Musculoskeletal systems have strong negative effects on HRQOL. Among combinations of systems, the respiratory and cardiac combination is of particular concern because of a synergistic negative effect. This study paves the way for a future study with a bigger sample that could yield a model of wider generalizability.
doi:10.1186/1477-7525-5-52
PMCID: PMC2042974  PMID: 17683600
19.  Perceived conflict in the couple and chronic illness management: Preliminary analyses from the Quebec Health Survey 
BMC Family Practice  2006;7:59.
Background
The quality of the relationship with the spouse/partner appears crucial among patients with multiple chronic conditions where illness management is complex and multifaceted. This study draws on data from the Quebec Health Survey (QHS) to examine, among patients with one or more chronic conditions, the relation between marital status, the perceived conflict with the spouse/partner, and what the patients do to manage their illness as well as how they perceive their health.
Methods
Data from the QHS 1998 were used. The sample included 7547 coupled adults who had one or more chronic health problems lasting more than 6 months. Independent variables included marital status, perceived conflict with the spouse/partner, and the number of chronic conditions. Illness management was defined broadly as a measure of the patient's efforts at self-care and an illness status indicator, including visits to the generalist and the specialist, the use of telephone health line in the last 12 months, self-rated general health, mental health, and a measure of psychological distress. Linkages between the independent variables and illness management were assessed for males and females separately with logistic regressions, while accounting for the survey sampling design and household clustering.
Results
Female patients who did not live with their partner and had never been married were more likely to report a negative perception of their general health and a higher psychological distress than those who were married. Perceived conflict with the partner was linked to a negative perception of mental health and a higher psychological distress among both men and women. Compared to patients with only one chronic condition, males who reported more than one chronic condition were more likely to have consulted a generalist prior to the survey and used the telephone health line, whereas females were more likely to have consulted a specialist. Both males and females with more than one chronic condition were more likely to have a negative perception of their general health and mental health.
Conclusion
The study provides a useful preliminary measure of the importance of living arrangements and the quality of the couple relationship in chronic illness management broadly conceived as a measure of the patient's efforts at self-care and an illness status indicator. Results of this study prod us to examine more closely, within longitudinal designs, the influence of living arrangements and the presence of conflict in the couple on chronic illness management as well as the modifying effect of gender on these associations.
doi:10.1186/1471-2296-7-59
PMCID: PMC1629014  PMID: 17052336
20.  Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life 
Background
Measures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL.
Methods
We used data on chronic diseases and on the SF-36 questionnaire assessing HRQOL of 238 adult primary care patients who participated in a previous study. We extracted all the diagnoses for every patient from chart review to score the CIRS, the FCI and the Charlson. Data for potential confounders (age, sex, self-perceived economic status and self-perceived social support) were also collected. We calculated the Pearson correlation coefficients (r) of the SF-36 scores with the three measures of multimorbidity, as well as the coefficient of determination, R2, while controlling for confounders.
Results
The r values for the CIRS (range: -0.55 to -0.18) were always higher than those for the FCI (-0.47 to -0.10) and Charlson (-0.31 to -0.04) indices. The CIRS explained the highest percent of variation in all scores of the SF-36, except for the Mental Component Summary Score where the variation was not significant. Variations explained by the FCI were significant in all scores of SF-36 measuring physical health and in two scales evaluating mental health. Variations explained by the Charlson were significant in only three scores measuring physical health.
Conclusion
The CIRS is a better choice as a measure of multimorbidity than the FCI and the Charlson when HRQOL is the outcome of interest. However, the FCI may provide a good option to evaluate the physical aspect of HRQOL for the ease in its administration and scoring. The Charlson index may not be recommended as a measure of multimorbidity in studies related to either physical or mental aspects of HRQOL.
doi:10.1186/1477-7525-3-74
PMCID: PMC1310518  PMID: 16305743
21.  Access to health care 
Canadian Family Physician  2005;51(11):1503.
OBJECTIVE
To explore access to health care for patients presenting with multiple chronic conditions and to identify barriers and factors conducive to access.
DESIGN
Qualitative study with focus groups.
SETTING
Family practice unit in Chicoutimi (Saguenay), Que.
PARTICIPANTS
Twenty-five male and female adult patients with at least four chronic conditions but no cognitive disorders or decompensating conditions.
METHODS
For this pilot study, only three focus group discussions were held.
MAIN FINDINGS
The main barriers to accessing follow-up appointments included long waits on the telephone, automated telephone-answering systems, and needing to attend at specific times to obtain appointments. The main barriers to specialized care were long waiting times and the need to get prescriptions and referrals from family physicians. Factors reported conducive to access included systematic callbacks and the personal involvement of family physicians. Good communication between family physicians and specialists was also perceived to be an important factor in access.
CONCLUSION
Systematic callbacks, family physicians’ personal efforts to obtain follow-up visits, and better physician-specialist communication were all suggested as ways to improve access to care for patients with multiple chronic conditions.
PMCID: PMC1479488  PMID: 16926944
22.  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
23.  Multimorbidity and quality of life in primary care: a systematic review 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1477-7525-2-51
PMCID: PMC526383  PMID: 15380021
24.  Assessing enablement in clinical practice: a systematic review of available instruments 
Rationale, aims and objectives
Enablement is an intervention by which the health care provider recognizes, promotes and enhances patients' ability to control their health and life. An abundant health literature suggests that enablement is associated with good outcomes. In this review, we aimed at identifying and comparing instruments that assess enablement in the health care context.
Method
We conducted a systematic literature review using Medline, Embase, Cochrane, Cinahl and PsycINFO databases, 1980 through March 2009, with specific search strategy for each database. Citations were included if they reported: (1) development and/or validation of an instrument; (2) evaluation of enablement in a health care context; and (3) quantitative results following administration of the instrument. The quality of each main retained citation was assessed using a modified version of the Standards for Reporting of Diagnostic Accuracy.
Results
Of 3135 citations identified, 53 were retrieved for detailed evaluation. Four articles were included. Two instruments were found: the Patient Empowerment Scale (PES) and the Empowering Speech Practices Scale (ESPS). Both instruments assessed enablement in hospital setting, one from the inpatient's perspective (PES) and the other from both perspectives (ESPS).
Conclusion
Two instruments assess enablement in hospital setting. No instrument is currently available to assess enablement in an ambulatory care context.
doi:10.1111/j.1365-2753.2009.01332.x
PMCID: PMC3023028  PMID: 20727059
empowerment; enablement; instruments; professional practice; questionnaires; systematic review
25.  Managing patients with multimorbidity: systematic review of interventions in primary care and community settings 
Objective To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings.
Design Systematic review.
Data sources Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011).
Eligibility criteria Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs.
Data selection Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out.
Results 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings.
Conclusions Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.
doi:10.1136/bmj.e5205
PMCID: PMC3432635  PMID: 22945950

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