Journal of Comorbidity

1

Authors: Francesca Colombo, Manuel García-Goñi, Christoph Schwierz

Erratum to: Colombo F, García-Goñi M, Schwierz C. Addressing multimorbidity to improve healthcare and economic sustainability. J Comorbidity 2016;6(1):21−27. doi: 10.15256/joc.2016.6.74. The first sentence of the Acknowledgements section should read, 'The opinions expressed in this paper are the responsibility of the authors and do not necessarily reflect those of the OECD, the European Commission or its member countries.' Journal of Comorbidity 2016;6(1):33 The original article can be found at: http://dx.doi.org/10.15256/joc.2016.6.74

3

Authors: Sarah Dennis

Multimorbidity is the co-occurrence of two or more diseases in an individual without a defining index disease [1,2]. In developed countries, the prevalence of multimorbidity has been estimated from both general practice and population data [3,4]. Data from general practices in Scotland found that 23% of patients had multimorbidity [3], whereas the prevalence of multimorbidity in Québec, Canada, was 46–51% in the general practice population and 10–13% in the general population aged over 24 years [4]. Australian data indicate that almost 40% of people aged over 44 years have multimorbidity, and this proportion increases to around 50% of those aged 65–74 years and to 70% of those aged 85 and over [5]. Data from a study of Australian general practice activity reported prevalence estimates for the most common combinations of chronic conditions [6]. Of the 12 most common combinations, the majority included conditions that can be positively impacted by physiotherapy interventions, such as low back pain [7], arthritis [8], chronic obstructive pulmonary disease [9], cardiac disease [10] and type 2 diabetes [11]. However, for some of these conditions, the uptake and access to physiotherapy interventions was suboptimal, especially in the primary care setting, due to poor referral from general practitioners (GPs) [12,13] and/or restricted access to physiotherapy associated with workforce shortages, as well as high cost to the patient for private consultation. Journal of Comorbidity 2016;6(2):50–52

3

Authors: Susan M. Smith, Joanne Reeve, Jane Gunn, Nathan R. Hill, Martin Fortin, Catherine A. O'Donnell, Marjan van den Akker, Joanne Protheroe, Stewart W. Mercer

The Journal of Comorbidity and the Society for Academic Primary Care (SAPC) are pleased to announce an exciting new partnership aimed at strengthening collaborations and enhancing opportunities among primary care professionals with an interest in comorbidity and multimorbidity. The Journal of Comorbidity and SAPC share a mutual goal to improve the management and care of patients by making clinical and research information and perspectives available to a global network of healthcare professionals. This new partnership will be an invaluable contribution to expanding the research platform for discussions and the scholarly exchange of knowledge, ideas, and research on comorbidity and multimorbidity. Journal of Comorbidity 2016;6(2):73–75

4

Authors: Hilde D.P. Luijks, Antoine L.M. Lagro-Janssen, Chris van Weel

The ageing population is marked by an increase in chronic health problems, raising concerns over the feasibility of healthcare systems and their financial capabilities [1,2]. A central point here is the growing rate of multimorbidity, i.e. the coexistence of multiple chronic conditions in a given individual [3]. The concept of multimorbidity conflicts with the ‘single-disease model’, around which healthcare, medicine and health research are traditionally organized. This model has dominated healthcare, research and education for so long that it is only recently that multimorbidity is being presented as a demographic feature. Multimorbidity requires a paradigm shift away from this single-disease model of patient management; a shift that is now increasingly recognized and adopted, albeit at a slow pace. However, the reality in primary healthcare is already somewhat different. Primary healthcare, in its comprehensive approach to all health problems in all individuals at all disease stages and phases of life, has a long experience in dealing with individuals experiencing a range of health problems [4], including chronic health problems as reported in the literature [5–7]. These reports indicate that multimorbidity is substantial, with about a third of the (primary healthcare) population affected; this prevalence is in line with those reported in more recent studies from other countries [8–12]. Journal of Comorbidity 2016;6(2):46–49

7

Authors: Francesca Colombo, Manuel García-Goñi, Christoph Schwierz

Patients with multimorbidity are responsible for more than half of all healthcare utilization, challenging the healthcare budgets of all European nations. Although the European Union is showing signs of a fragile economic recovery, achieving sustainable growth will depend on delivering a combination of fiscal responsibility, structural reforms, and improved efficiency. Addressing the challenges of multimorbidity and providing more effective, affordable, and sustainable care, has climbed the political agenda at a global, European, and national level. Current healthcare systems are poorly adapted to cope with the challenges of patients with multimorbidity. Little is known about the epidemiology and natural history of multimorbidity; the evidence base is weak; clinical guidelines are not always relevant to this population; and financing and delivery systems have not evolved to adequately measure and reward quality and performance. Pockets of innovation are, however, beginning to emerge. In Spain, for example, the ongoing economic crisis has forced regional governments to deliver substantial efficiency savings and, with this in mind, integrated care programmes have been introduced across the country for people with chronic disease and multimorbidity. Early results suggest that formalized integrated care for patients with multimorbidity improves their perceptions of care coordination, reduces hospital and emergency admissions and readmissions, and reduces average costs per capita. Such innovations require meaningful investments at a national level – something that is now supported within the framework of the European Union’s Stability and Growth Pact. Journal of Comorbidity 2016;6(1):21–27 An erratum to this article can be found here: http://dx.doi.org/10.15256/joc.2016.6.77

7

Authors: comorbidity, integrated care, multimorbidity, patient satisfaction, qualitative research, user involvement

Background: The prevalence of multiple comorbid chronic conditions, or multimorbidity, is increasing. Care provided to people with multimorbidity is often fragmented, incomplete, inefficient and ineffective. As part of a research and development project focusing on improving care, we sought to involve patients with multimorbidity in the development process. Objective: To identify opportunities for improving care by understanding how patients from a Danish University Hospital experience care coordination. Design: Qualitative semi-structured interviews with 14 patients with multimorbidity. Results: Patients with multimorbidity described important concerns about care that included: 1) disease-centered, rather than patient-centered, care; 2) lack of attention to comorbidities and patient preferences and needs; and 3) involvement of numerous healthcare providers with limited care coordination. Poor continuity of care resulted in lack of treatment for complex problems such as pain and mental health issues, medication errors, adverse events and a feeling of being lost in the system. Receiving care from generalists (e.g., general practitioners and healthcare professionals at prevention centers) and having a care coordinator seemed to improve patients’ experience of continuity and coordination of care. Suggestions for service improvements when providing care for people with multimorbidity included using care coordinators, longer consultation times, consultations specifically addressing follow-up on prescribed medications and shifting the focus of care from disease states to patients’ overall health status. Conclusions: A need exists for a reorganization of care delivery for people with multimorbidity that focuses on improved care coordination and puts patient preferences at the center of care. Journal of Comorbidity 2016;6(2):95–102

8

Authors: Eva H. DuGoff , Karen Bandeen-Roche , Gerard F. Anderson

Background: Continuity of care is a basic tenant of primary care practice. However, the evidence on the importance of continuity of care for older adults with complex conditions is mixed. Objective: To assess the relationship between measurement of continuity of care, number of chronic conditions, and health outcomes. Design: We analyzed data from a cohort of 1,600 US older adults with diabetes and ≥1 other chronic condition in a private Medicare health plan from July 2010 to December 2011. Multivariate regression models were used to examine the association of baseline continuity (the first 6 months) and the composite outcome of any emergency room use or inpatient hospitalization occurring in the following 12-month period. Results: After adjusting for baseline covariates, high known provider continuity (KPC) was associated with an 84% (adjusted odds ratio 0.16; 95% confidence interval 0.09–0.26) reduction in the risk of the composite outcome. High KPC was significantly associated with a lower risk of the composite outcome among individuals with ≥6 conditions. However, the usual provider of care and continuity of care indices were not significantly related with the composite outcome in the overall sample or in those with ≥6 conditions. Conclusion: The relationship between continuity of care and adverse outcomes depends on the measure of continuity of care employed. High morbidity patients are more likely to benefit from continuity of care interventions as measured by the KPC, which measures the proportion of a patient’s visits that are with the same providers over time. Journal of Comorbidity 2016;6(2):65–72

9

Authors: Robert G. Maunder, Lesley Wiesenfeld, Sian Rawkins, Jamie Park

Background: Psychiatric syndromes are complicated by comorbidity and other factors that burden patients, making guideline-informed psychiatric care challenging, and negatively affecting outcome. A comprehensive intake tool could improve the quality of care. Existing tools to quantify these characteristics do not identify specific complications and may not be sensitive to phenomena that are common in psychiatric outpatients. Objective: To develop a practical inventory to capture observations related to complex care in psychiatric outpatients and quantify the overall burden of complicating factors. Design: We developed a checklist inventory through literature review and clinical experience. The inventory was tested and compared with related measures in a cross-sectional study of 410 consenting outpatients at the time of initial assessment. Results: The summed score of inventory checklist items was significantly correlated with patient-assessed measures of distress (K10, r=0.36) and function (WHODAS 2.0, r=0.31), and physician-assessed measures of function (GAF, r=−0.42), number of psychiatric diagnoses [F(df3)=33.6], and most complex diagnosis [F(df3)=37.4]. In 53 patients whose assessment was observed by two clinicians, inter-rater reliability was acceptable for both total inventory score (intraclass correlation, single measures = 0.74) and agreement on specific items (mean agreement score = 90%). Conclusions: The Psychiatric C4 Inventory is a reliable instrument for psychiatrists that captures information that may be useful for quality improvement and resource planning. It demonstrates convergent validity with measures of patient distress, function, and complexity. Further tests of validity and replication in other settings are warranted. Journal of Comorbidity 2016;6(2):56–64

10

Authors: Cliona Lewis, Emma Wallace, Lorraine Kyne, Walter Cullen, Susan M. Smith

Background: Patients with multimorbidity (two or more chronic conditions) are now the norm in clinical practice, and place an increasing burden on the healthcare system. Management of these patients is challenging, and requires doctors who are skilled in the complexity of multiple chronic diseases. Objective: To perform a systematic review of the literature to ascertain whether there are education and training formats which have been used to train postgraduate medical doctors in the management of patients with multimorbidity in primary and/or secondary care, and which have been shown to improve knowledge, skills, attitudes, and/or patient outcomes. Methods: Overall, 75,110 citations were screened, of which 65 full-text articles were then independently assessed for eligibility by two reviewers, and two studies met the inclusion criteria for the review. Results: The two included studies implemented and evaluated multimorbidity workshops, and highlight the need for further research addressing the learning needs of doctors tasked with managing patients with multimorbidity in their daily practice. Conclusion: While much has been published about the challenges presented to medical staff by patients with multimorbidity, published research regarding education of doctors to manage these problems is lacking. Further research is required to determine whether there is a need for, or benefit from, specific training for doctors to manage patients with multimorbidity. PROSPERO registration number: CRD42013004010. Journal of Comorbidity 2016;6(2):85–94