Journal of Comorbidity

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Authors: Tit Albreht, Mariana Dyakova, François Schellevis, Stephan Van den Broucke

Erratum to: Albreht T, Dyakova M, Schellevis FG, Van den Broucke S. Many diseases, one model of care? J Comorbidity 2016;6(1):12−20. doi: 10.15256/joc.2016.6.73. The received and accepted dates for this article were incorrectly published as Jan 4, 2015 and Jan 25, 2015, respectively, instead of Jan 4, 2016 and Jan 25, 2016, respectively. The original article has now been updated to reflect the correct submission and acceptance dates. Journal of Comorbidity 2016;6(1):34 The original article can be found at: http://dx.doi.org/10.15256/joc.2016.6.73

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Authors: Boris Azaïs, John Bowis, Matthias Wismar

Multimorbidity is a major public health challenge that is rising up the political and health agenda at an accelerated rate. Although the prevalence of multimorbidity increases with age, more than half of the population with multimorbidity are under the age of 65 years [1], with social deprivation a key determinant of multimorbidity in young and middle-aged adults [2,3]. From an individual’s perspective, multimorbidity reduces life expectancy [4–6], decreases physical functioning and quality of life [7], and increases the risk of depression and other mental health disorders [3]. From a healthcare provider’s perspective, multimorbidity is associated with increased health service use, a high risk of emergency and other hospital admissions, high rates of polypharmacy, and spiralling costs [8]. Current health systems, which are typically built around a single-disease framework, are poorly adapted to cope with patients with multimorbidity, who typically experience fragmented healthcare services, leading to potentially inefficient and ineffective care. It is increasingly clear that we need to change our perspective on multimorbidity in order to address it as a specific condition that requires tailored solutions and approaches. The urgent need to tackle multimorbidity in a more strategic, holistic, and cost-effective manner was evident at the 18th European Health Forum Gastein, a leading annual health policy event in the European Union (EU), held in the autumn of 2015. This Forum attracted policymakers, clinicians, health service managers, patients, and a broad range of other stakeholders, all of whom were invited to attend a session entitled “Facing the Challenge of Multimorbidity”. Journal of Comorbidity 2016;6(1):1–3

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Authors: Carolyn A. Chew-Graham, Jill Rasmussen, Neal Maskrey

Managing elderly patients with multimorbidity can be challenging to clinicians, particularly those in primary care. We discuss the complexities and challenges in this editorial. Introducing Alice Alice is 82 years old. She has type 2 diabetes mellitus and is on metformin – she only takes one 500 mg tablet twice a day as she “can’t stand” the abdominal discomfort and loose stools if she takes more, even though the general practitioner (GP) has told her she should take one with each meal. She takes levothyroxine, has asthma (which is managed with a Seretide® inhaler) and hypertension (which is controlled with ramipril). For the pain in her knees and feet, which the GP says is due to “wear and tear”, she takes paracetamol regularly, but does not feel it works – and it might not, given the recent paper in the Lancet [1] – so she uses a rubefacient, which makes her feel better. She was recently diagnosed with atrial fibrillation and, after much deliberation, agreed to start rivaroxaban. A year ago, Alice was given simvastatin by one of the practice nurses after having a blood pressure check, but often wonders why she needs to take this; and because the instructions are to take at night, Alice often forgets to take it. Journal of Comorbidity 2016;6(2):53–55

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Authors: Aline Ramond-Roquin, Martin Fortin

The number of people living with comorbidity, multimorbidity, or multiple chronic conditions, hereafter referred to as “multimorbidity” (see Box 1) [1,2], has become the norm rather than the exception in healthcare. In developed countries, approximately one in four adults have at least two chronic conditions [3,4], and over half of older adults have three or more [5]. Although the prevalence of multimorbidity increases with age, many studies have reported high rates of multimorbidity even among younger adults [6]. Multimorbidity negatively impacts patient outcomes, including physical and psychological functioning, quality of life, and life expectancy [7,8]. It also complicates treatment and increases healthcare utilization and costs [9–11]. Despite representing a large – and growing – proportion of adults seen in primary care today, there is a major gap in our understanding of how best to address, meet, and satisfy the complex care needs of patients with multimorbidity [11]. The traditional single-disease model of care does not work for them, and multimorbidity should definitively not be considered as the simple juxtaposition of independent conditions [12,13]. Fortunately though, interest in multimorbidity is growing worldwide, and has become a healthcare and research priority [14,15]. An international community interested in multimorbidity research has recently emerged and become organized through different activities, such as the creation of the Journal of Comorbidity, a weblog that hosts and supports the exchanges from the International Research Community on Multimorbidity [16], the organization of an international forum [17] at the North American Primary Care Research Group (NAPCRG) congress, and the publication of an “ABC of Multimorbidity” [1]. Journal of Comorbidity 2016;6(2):42–45

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Authors: Stanimir Hasardzhiev, Luís Mendão, Wolfram Nolte, Bert Aben, Karin Kadenbach

The patient’s experience of their own healthcare is an important aspect of care quality that has been shown to improve clinical and other outcomes. Very little is currently known about patient experience in the management of multimorbidity, although preliminary evidence suggests that it may be poor. Individuals with multimorbidity report better experiences of care when they are knowledgeable and involved in the decision-making, when their care is well coordinated, and communication is good. A greater focus on disease prevention, stronger collaboration between health and social care services, and the provision of more integrated care for people with mental and physical health problems would also help to improve the patient experience. Advocacy groups can amplify the patient voice and improve access to care, as well as provide information and support to patients and their families. Patients have an important role in preventing multimorbidity and improving its management, and should be involved in the development of health policies and the delivery of healthcare services. Inequalities in access to quality healthcare must also be addressed. Journal of Comorbidity 2016;6(1)28–32

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Authors: Michelle L.A. Nelson, Elizabeth Hanna, Stephen Hall, Michael Calvert

Background: Approximately 80% of people who survive a stroke have on average five other conditions and a wide range of psychosocial issues. Attention to biopsychosocial issues has led to the identification of ‘complex patients’. No single definition of ‘patient complexity’ exists, therefore applied health researchers seek to understand ‘patient complexity’ as it relates to a specific clinical context. Objective: To understand how ‘patient complexity’ is conceptualized by clinicians, and to position the findings within the existing literature on patient complexity. Methods: A qualitative descriptive approach was utilized. Twenty-three rehabilitation clinicians participated in four focus groups. Results: Five elements of patient complexity were identified: medical/functional issues, social determinant factors, social/family support, personal characteristics, and health system factors. Using biopsychosocial factors to identify complexity results in all patients being complex; operationalization of the definition led to the identification of systemic elements. A disconnect between acute, inpatient rehabilitation and community services was identified as a trigger for increased complexity. Conclusions: Patient complexity is not a dichotomous state. If applying existing complexity definitions, all patients are complex. This study extends the understanding by suggesting a structural element of complexity from manageable to less manageable complexity based on ability to discharge. Journal of Comorbidity 2016;6(2):35–41

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Authors: Rokas Navickas, Vesna-Kerstin Petric, Andrea B. Feigl, Martin Seychell

Multimorbidity, which is defined as the co-occurrence of two or more chronic conditions, has moved onto the priority agenda for many health policymakers and healthcare providers. Patients with multimorbidity are high utilizers of healthcare resources and are some of the most costly and difficult-to-treat patients in Europe. Preventing and improving the way multimorbidity is managed is now a key priority for many countries, and work is at last underway to develop more sustainable models of care. Unfortunately, this effort is being hampered by a lack of basic knowledge about the aetiology, epidemiology, and risk factors for multimorbidity, and the efficacy and cost-effectiveness of different interventions. The European Commission recognizes the need for reform in this area and has committed to raising awareness of multimorbidity, encouraging innovation, optimizing the use of existing resources, and coordinating the efforts of different stakeholders across the European Union. Many countries have now incorporated multimorbidity into their own healthcare strategies and are working to strengthen their prevention efforts and develop more integrated models of care. Although there is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems. In low- to middle-income countries, which are facing the double burden of infectious and chronic diseases, integration of care will require capacity building, better quality services, and a stronger evidence base. Journal of Comorbidity 2016;6(1):4–11

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Authors: Tit Albreht, Mariana Dyakova, François Schellevis, Stephan Van den Broucke

This article has been corrected. See J Comorbidity 2016;6(1):33. http://dx.doi.org/joc.2016.6.78. Patients with multiple chronic conditions (multimorbidity) have complex and extensive health and social care needs that are not well served by current silo-based models of care. A lack of integration between care providers often leads to fragmented, incomplete, and ineffective care, leaving many patients overwhelmed and unable to navigate their way towards better health outcomes. In planning for the future, healthcare policies and models of care are required that cater for the complex needs of patients with multimorbidity and that deliver coordinated care that is patient-centred and focused on disease prevention, multidisciplinary teamwork and shared decision-making, and on empowering patients to self-manage. Salient lessons can be learnt from the work undertaken at a European and national level to develop care models in cancer and diabetes – two complex and often co-occurring conditions requiring coordinated long-term care. Innovative work is also underway in many European countries aimed at improving the integration of care for people with multimorbidity, resulting in more efficient and cost-effective health outcomes. This article reviews some of the most innovative programmes that have been initiated across and within Europe with the aim of improving the way care is delivered to people with complex and multiple long-term conditions. This work provides a foundation upon which to build better, more effective models of care for people with multimorbidity. Journal of Comorbidity 2016;6(1):12–20

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Authors: Tara Sampalli, Robert Dickson, Jill Hayden, Lynn Edwards, Arun Salunkhe

Individuals with multimorbidity have complex care needs along with significant impacts to their functional health and quality of life. Recent evidence-based and experience-based explorations have revealed the importance of patient perspectives and functional health management in improving care delivery and health outcomes for individuals with multimorbidity. The impact of managing multimorbidity is evident at multiple levels of healthcare – the individual, the provider, and the system. Our local experience dealing with these challenges has led to the development of a functional health model that includes patient perspectives in care delivery within the Integrated Chronic Care Service (ICCS) of the health authority in Nova Scotia. In this paper, we present a discussion of the challenges, guiding models, and service-level transformations that have been integrated into care delivery at the ICCS to meet the healthcare needs of people with multiple health conditions. We describe our redesign strategies for care team planning, treatment approach, and patient inclusion. Journal of Comorbidity 2016;6(2):76–84

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Authors: Marjan van den Akker, Jane Gunn, Stewart W. Mercer, Martin Fortin, Susan M. Smith

Despite the high proportion and growing number of people with comorbidity/multimorbidity, clinical trials often exclude this group, leading to a limited evidence base to guide policy and practice for these individuals [1–5]. This evidence gap can potentially be addressed by secondary analysis of studies that were not originally designed to specifically examine comorbidity/multimorbidity, but have collected information from participants on co-occurring conditions. For example, secondary data analysis from randomized controlled trials may shed light on whether there is a differential impact of interventions on people with comorbidity/multimorbidity. Furthermore, data regarding comorbidity/multimorbidity can often be obtained from registration networks or administrative data sets.

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Authors: David Haslam

It is not often that a single patient successfully symbolizes almost every important trend in modern medicine, but one particular man achieved this in a solitary consultation. He was a patient in my general practice. He was 77 years old – exemplifying the ageing population, and had only lived in my area for 3 or 4 years – exemplifying an increasingly mobile population. I knew him well and saw him often – combining an aspiration for continuity, and increasing consultation rates in primary care. He had prostate cancer, but he also had hypertension, diabetes, coronary artery disease, macular degeneration, hyperlipidaemia, an arthritic right hip, and, hardly surprisingly, depression. This was multimorbidity par excellence. Journal of Comorbidity 2015;5(1):132–134

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Authors: Rebekah Pratt, Carina Hibberd, Isobel M. Cameron, Margaret Maxwell

Background: Social dimensions of health are known to contribute to what is often termed “patient complexity”, which is particularly common among patients with multimorbidity. Health-care professionals require tools to help them identify and manage these aspects of patient needs. Objectives: To examine: (i) the Patient Centered Assessment Method (PCAM), a tool for assessing patient complexity in ways that are sensitive to the biopsychosocial dimensions of health, in primary care settings in Scotland; (ii) the impact of the PCAM on referral patterns and its perceived value; and (iii) the PCAM’s perceived applicability for use in a complex patient population. Design: Two studies are described: (i) a mixed-methods prospective cohort study of the implementation of the PCAM in primary care clinics; and (ii) a qualitative exploratory study that evaluated the value of the PCAM in a complex patient population. Results: Use of the PCAM did not impact patient satisfaction or perception of practitioners’ empathy, but it did increase both the number of onward referrals per referred patient (9–12%) and the proportion of referrals to non-medical services addressing psychological, social, and lifestyle needs. Nurses valued the PCAM, particularly its ability to help them address psychological and social domains of patients’ lives, and found it to be highly relevant for use in populations with known high complexity. Conclusions: The PCAM represents a feasible approach for assessing patient needs with consideration to the social dimensions of health, and allows practitioners to refer patients to a broader range of services to address patient complexity. Journal of Comorbidity 2015;5(1):110–119

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Authors: Charlotte E. Young, Frances M. Boyle, Katie S. Brooker, Allyson J. Mutch

Background: Clinical practice guidelines provide an evidence-based approach to managing single chronic conditions, but their applicability to multiple conditions has been actively debated. Incorporating patient-preference recommendations and involving consumers in guideline development may enhance their applicability, but further understanding is needed. Objectives: To assess guidelines that include recommendations for comorbid conditions to determine the extent to which they incorporate patient-preference recommendations; use consumer-engagement processes during development, and, if so, whether these processes produce more patient-preference recommendations; and meet standard quality criteria, particularly in relation to stakeholder involvement. Design: A review of Australian guidelines published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Document analysis of guidelines examined the presence of patient-preference recommendations and the consumer-engagement processes used. The Appraisal of Guidelines for Research and Evaluation instrument was used to assess guideline quality. Results: Thirteen guidelines were reviewed. Twelve included at least one core patient-preference recommendation. Ten used consumer-engagement processes, including participation in development groups (seven guidelines) and reviewing drafts (ten guidelines). More extensive consumer engagement was generally linked to greater incorporation of patient-preference recommendations. Overall quality of guidelines was mixed, particularly in relation to stakeholder involvement. Conclusions: Guidelines do incorporate some patient-preference recommendations, but more explicit acknowledgement is required. Consumer-engagement processes used during guideline development have the potential to assist in identifying patient preferences, but further research is needed. Clarification of the consumer role and investment in consumer training may strengthen these processes. Journal of Comorbidity 2015;5(1):122–131

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Authors: Kylie J. McKenzie, David Pierce, Jane M. Gunn

Internationally, health systems face an increasing demand for services from people living with multimorbidity. Multimorbidity is often associated with high levels of treatment burden. Targeting lifestyle factors that impact across multiple conditions may promote quality of life and better health outcomes for people with multimorbidity. Motivational interviewing (MI) has been studied as one approach to supporting lifestyle behaviour change. A systematic review was conducted to assess the effectiveness of MI in healthcare settings and to consider its relevance for multimorbidity. Twelve meta-analyses pertinent to multimorbidity lifestyle factors were identified. As an intervention, MI has been found to have a small-to-medium statistically significant effect across a wide variety of single diseases and for a range of behavioural outcomes. This review highlights the need for specific research into the application of MI to determine if the benefits of MI seen with single diseases are also present in the context of multimorbidity.

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Authors: Emma L. Healey, Clare Jinks, Valerie A. Tan, Carolyn A. Chew-Graham, Sarah A. Lawton, Elaine Nicholls, Andrew G. Finney, Mark Porcheret, Vince Cooper, Martyn Lewis, Krysia S. Dziedzic, Simon Wathall, Christian D. Mallen

Background: Long-term conditions (LTCs) are important determinants of quality of life and healthcare expenditure worldwide. Whilst multimorbidity is increasingly the norm in primary care, clinical guidelines and the delivery of care remain focused on single diseases, resulting in poorer clinical outcomes. Osteoarthritis, and anxiety and/or depression frequently co-occur with other LTCs, yet are seldom prioritized by the patient or clinician, resulting in higher levels of disability, poorer prognosis, and increased healthcare costs. Objective: To examine the feasibility and acceptability of an integrated approach to LTC management, tackling the under-diagnosis and under-management of osteoarthritis-related pain and anxiety and/or depression in older adults with other LTCs in primary care. Design: The ENHANCE study is a pilot stepped-wedge cluster randomized controlled trial to test the feasibility and acceptability of a nurse-led ENHANCE LTC review consultation for identifying, assessing, and managing joint pain, and anxiety and/or depression in patients attending LTC reviews. Specific objectives (process evaluation and research outcomes) will be achieved through a theoretically informed mixed-methods approach using participant self-reported questionnaires, a medical record review, an ENHANCE EMIS template, qualitative interviews, and audio recordings of the ENHANCE LTC review. Discussion: Success of the pilot trial will be measured against the level of the primary care team engagement, assessment of training delivery, and degree of patient recruitment and retention. Patient satisfaction and treatment fidelity will also be explored. ISRCTN registry number: 12154418. Journal of Comorbidity 2015;5(1):135–149

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Authors: Susan M. Smith, Stewart W. Mercer, Jane Gunn, Marjan van den Akker, Martin Fortin

The Journal of Comorbidity was launched in 2011 and has since become established as a high-quality journal that publishes open-access, peer-reviewed articles, with a focus on advancing the clinical management of patients with comorbidity/multimorbidity. To further enhance research quality and reporting of studies in this field, the journal is now offering authors the opportunity to publish a summary of their study protocols – a move designed to generate interest and raise awareness in ongoing clinical research and to enable researchers to detail their methodologies in order that replication by scientific peers is possible. Journal of Comorbidity 2014;4(1):55−57

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Authors: Elizabeth A. Bayliss, Liza M. Reifler, Chan Zeng, Deanna B McQuillan, Jennifer L Ellis, John F Steiner

Background: Cancer patients with cardiovascular and other comorbidities are at concurrent risk of multiple adverse outcomes. However, most treatment decisions are guided by evidence from single-outcome models, which may be misleading for multimorbid patients. Objective: We assessed the interacting effects of cancer, cardiovascular, and other morbidity burdens on the competing outcomes of cancer mortality, serious cardiovascular events, and other-cause mortality. Design: We analyzed a cohort of 6,500 adults with initial cancer diagnosis between 2001 and 2008, SEER 5-year survival ≥26%, and a range of cardiovascular risk factors. We estimated the cumulative incidence of cancer mortality, a serious cardiovascular event (myocardial infarction, coronary revascularization, or cardiovascular mortality), and other-cause mortality over 5 years, and identified factors associated with the competing risks of each outcome using cause-specific Cox proportional hazard models. Results: Following cancer diagnosis, there were 996 (15.3%) cancer deaths, 328 (5.1%) serious cardiovascular events, and 542 (8.3%) deaths from other causes. In all, 4,634 (71.3%) cohort members had none of these outcomes. Although cancer prognosis had the greatest effect, cardiovascular and other morbidity also independently increased the hazard of each outcome. The effect of cancer prognosis on outcome was greatest in year 1, and the effect of other morbidity was greater in individuals with better cancer prognoses. Conclusion: In multimorbid oncology populations, comorbidities interact to affect the competing risk of different outcomes. Quantifying these risks may provide persons with cancer plus cardiovascular and other comorbidities more accurate information for shared decision-making than risks calculated from single-outcome models. Journal of Comorbidity 2014:4(1):29–36

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Authors: Diane E. Arnold-Reed, Tom Brett, Lakkhina Troeung, Jasmine O'Neill, Rupert Backhouse, Max K. Bulsara

Background: Multimorbidity, the co-existence of two or more (2+) long-term conditions in an individual, is common among problem drug abusers. Objective: To delineate the patterns, multimorbidity prevalence, and disease severity in patients enrolled in a community-based primary care methadone maintenance treatment (MMT) programme. Design: This was a retrospective cohort study (n=274). The comparator group consisted of mainstream primary care patients. Electronic medical record assessment was performed using the Cumulative Illness Rating Scale. Results: Prevalence of multimorbidity across 2+ domains was significantly higher within the MMT sample at 88.7% (243/274) than the comparator sample at 51.8% (142/274), p<0.001. MMT patients were seven times more likely to have multimorbidity across 2+ domains compared with mainstream patients (OR 7.29, 95% confidence interval 4.68–11.34; p<0.001). Prevalence of multimorbidity was consistently high across all age groups in the MMT cohort (range 87.8–100%), while there was a positive correlation with age in the comparator cohort (r=0.29, p<0.001). Respiratory, psychiatric, and hepatic–pancreatic domains were the three most common domains with multimorbidity. Overall, MMT patients (mean±SD, 1.97±0.43) demonstrated significantly higher disease severity than mainstream patients (mean±SD, 1.18±0.78), p<0.001. Prevalence of moderate disease severity observed in the <45-year MMT age group was 50% higher than the ≥45-year comparator age group. Conclusions: Prevalence of multimorbidity and disease severity in MMT patients was greater than in the age- and sex-matched comparators. Patients with a history of drug abuse require co-ordinated care for treatment of their addiction, and to manage and prevent chronic illnesses. Community-based programmes delivered through primary care help fulfil this need. Journal of Comorbidity 2014;4(1):46–54

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Authors: Cynthia Duguay, Frances Gallagher, Martin Fortin

Background: Findings from several countries indicate that the prevalence of multimorbidity is very high among clients of primary healthcare. A deeper understanding of patients’ experiences from their own perspective can greatly enrich any intervention to help them live as well as possible with multimorbidity. Objective: To describe the fundamental structure of adults’ experience with multimorbidity. Design: A phenomenological study was undertaken to describe the experiences of 11 adults with multimorbidity. These adults participated in two semi-structured interviews, the content of which was rigorously analyzed. Results: At the core of the study participants’ multimorbidity experience are the impression of aging prematurely, difficulties with self-care management, and issues with access to the healthcare system, which contribute to the problem’s complexity. Despite these issues, participants with multimorbidity report attempting to take control of their situation and adjusting to daily living. Conclusions: The description of this experience, through the systemic vision of participants, provides a better understanding of the realities experienced by people with multimorbidity. Journal of Comorbidity 2014;4(1):11–21

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Authors: Rafael Tabarés-Seisdedos, Jose M. Valderas

Research on comorbidity and multimorbidity is finally receiving the attention it deserves, particularly considering the magnitude and impact they have on health and the delivery of healthcare [1,2]. Numerous studies have demonstrated that individuals with Down’s syndrome, Parkinson’s disease, schizophrenia, diabetes, anorexia nervosa, Alzheimer’s disease, allergy related diseases, multiple sclerosis or Huntington’s disease (among other health problems) are protected against many forms of cancer, including solid tumors, smoking-related tumors and prostate cancer. This apparent anti-cancer effect, which we have termed inverse cancer comorbidity, has been observed in many serious CNS and immune disorders, and is the subject of active research [3–5]. Journal of Comorbidity 2013;3(1):1–3

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Authors: Jose M. Valderas

The report “Multiple Chronic Conditions: A Strategic Framework,” which was developed by the U.S. Department of Health & Human Services (HSS), has identified as one of the key goals for improving health and the provision of healthcare for people with multiple chronic conditions “to increase clinical, community and patient-centered research.” In their linked commentary of this special journal issue, Parekh and Goodman identify and consider the potential impact of a number of related research initiatives supported by the National Institutes of Health and the Agency for Health Research and Quality, particularly focusing on two very specific areas: behavioral medicine and secondary analyses of available datasets. In this paper, I comment on both documents and discuss the opportunities offered by the current approaches and highlight related research needs; in particular, the need for an improved and expanded conceptual model of healthcare for people with multimorbidity, and the need for further exploration of the use of multimorbidity-relevant outcomes as part of usual clinical practice. Journal of Comorbidity 2013;3(2):41–44

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Authors: José Almirall, Martin Fortin

Background: Consensus on terminology for multiple diseases is lacking. Because of the clinical relevance and social impact of multiple concurrent diseases, it is important that concepts are clear. Objective: To highlight the diversity of terms in the literature referring to the presence of multiple concurrent diseases/conditions and make recommendations. Design: A bibliometric analysis of English-language publications indexed in the MEDLINE database from 1970 to 2012 for the terms comorbidity, multimorbidity, polymorbidity, polypathology, pluripathology, multipathology, and multicondition, and a review of definitions of multimorbidity found in English-language publications indexed from 1970 to 2012 in the MEDLINE and SCOPUS databases. Results: Comorbidity was used in 67,557 publications, multimorbidity in 434, and the other terms in three to 31 publications. At least 144 publications used the term comorbidity without referring to an index disease. Thirteen general definitions of multimorbidity were identified, but only two were frequently used (91% of publications). The most frequently used definition (48% of publications) was “more than one or multiple chronic or long-term diseases/conditions”. Multimorbidity was not defined in 51% of the publications using the term. Conclusions: Comorbidity was overwhelmingly used to describe any clinical entity coexisting with an index disease under study. Multimorbidity was the term most frequently used when no index disease was designated. Several definitions of multimorbidity were found. However, most authors using the term did not define it. The use of clearly defined terms in the literature is recommended until a general consensus on the terminology of multiple coexistent diseases is reached. Journal of Comorbidity 2013;3(1):4–9

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Authors: Efrat Shadmi

Disadvantaged populations are disproportionately affected by multiple chronic conditions (MCCs), yet few studies examine the prevalence, outcomes, or effectiveness of MCC interventions in minority and socioeconomically deprived individuals and populations. An important first step in understanding MCCs, not only in such diverse population groups, but also in the general population as a whole, is to broaden the definition and scope of MCC measurement, to encompass more than the simple additive effect of clinical conditions, and to include a wide range of health and health-related aspects that interact and make up the full spectrum of multimorbidity. Only with the use of a comprehensive MCC measurement can some of the differences between the disadvantaged populations be adequately detected. Better understanding of the disparities in access to high quality health and healthcare for persons with MCCs can help guide policy and practice aimed at the prevention and amelioration of the effects of MCCs among disadvantaged groups. Indeed, disparity in MCC populations has been identified as a key goal of the U.S. Department of Health and Human Services’ Strategic Framework on MCCs. The aim of the present paper is to describe current knowledge on disparities in the population of persons with MCCs and to guide efforts for the prevention and management of MCCs in disadvantaged populations. Journal of Comorbidity 2013;3(2):45–50

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Authors: Anand K. Parekh, Richard A. Goodman

Among the 21st century’s major emerging health issues, one of the most critical is the increasing prevalence of individuals with comorbidities, or multiple chronic conditions (MCCs), and the myriad challenges this poses for public health, healthcare, social services, and other sectors. Given the increasing prevalence of individuals with MCCs and the paramount role of MCCs as a healthcare cost driver, in 2008 the U.S. Department of Health and Human Services (HHS) launched an initiative to strengthen efforts by the HHS to address the effects of MCCs on health status, quality of life, and cost. In this paper, we first provide an overview of the HHS initiative with a particular focus on the approach used in developing the initiative’s centerpiece, the HHS Strategic Framework on Multiple Chronic Conditions; we next describe progress in implementing one of the framework’s four major goal areas (Goal 4) on facilitating research to fill knowledge gaps about, and interventions and systems to benefit, individuals with MCCs; and we conclude by suggesting additional potential priorities for research on MCCs. Although considerable research on MCCs has been reported over the past decade, the HHS Strategic Framework’s goal on research provides a set of priority areas and a plan for systematically strengthening the evidence and information foundation necessary to address the challenges of MCCs in the USA. More broadly, the Strategic Framework provides a roadmap to help improve coordination between HHS operating divisions and enhance collaboration with external stakeholders to improve the quality of life for those with MCCs. Journal of Comorbidity 2013;3(2)22–29

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Authors: Kate Shankland, Peter Kirkbride, Anne-Marie Bourke, James Price, Lucy Walkington, Sarah Danson

Background: An Acute Oncology Service (AOS) is paramount to providing timely and improved pathways of care for patients who are admitted to hospital with cancer-related problems or suspected cancer. Objective: To establish an AOS pilot study to decide how best to implement such a service locally. Methods: The AOS, which included collaboration between the oncology and palliative care teams at the Northern General Hospital in Sheffield, UK, ensured that the majority of oncology patients in the region received timely assessment by an oncologist if they became acutely unwell as a result of their cancer or its treatment. The AOS consisted of a thrice-weekly ward round, and daily telephone advice service. Results: We report on patient data during the first 12 months of the pilot study. Delivery of the AOS enhanced communication between the services and provided inter-professional education and support, resulting in earlier oncological team involvement in the management of patients with cancer admitted under other teams, as well as provision of advice to patients and their caregivers and families. Provision of the AOS shortened the mean length of hospital stay by 6 days. Two case studies are presented to illustrate the typical challenges faced when managing these patients. Conclusions: Establishment of the AOS enabled effective collaboration between the oncology and other clinical teams to provide a rapid and streamlined referral pathway of patients to the AOS. Locally, this process has been supported by the development of acute oncology protocols, which are now in use across the local cancer network. Journal of Comorbidity 2012;2(1):10–17