What makes stroke rehabilitation patients complex? Clinician perspectives and the role of discharge pressure

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):35–4

Integrated multimorbidity management in primary care: why, what, how, and how to?

The epidemic of multimorbidityPolicymakers regard “the epidemic of multimorbidity” as the greatest threat to the sustainability of healthcare systems. They believe the solution is “integrated care”, “The search to connect the healthcare system (acute, primary medical and skilled) with other human service systems (e.g. long-term care, education and vocational and housing services) in order to improve outcomes (clinical, satisfaction, and efficiency)” [1]. This definition includes key characteristics of complex adaptive systems. People act as agents who evolve in their characteristics and behaviours over time. These agents constantly learn and adapt in real time to changing contexts. These systems display emergent dynamic non-linear behaviours resulting from ongoing iterative feedback amongst their agents.Emergent outcomes do not have linear “cause and effect” relationships and can best be understood in hindsight. Emergent behaviours are highly sensitive to context; consequently, the “same” approach used by different agents in different contexts will not produce the same outcomes. Agents navigate toward mutually agreed outcomes by constantly adapting to evolving changes within the context of local constraints [2].A complex adaptive system approach overcomes many of the dysfunctions in the current health systems, in particular the fragmentation of patient care [3]. Overcoming fragmentation requires continuous adaptation to changing circumstances – a constant challenge for patients, health professionals, community service providers, and policymakers.How can the already overburdened primary healthcare services achieve these goals?To address the complex challenge, we first must reflect on three key questions:What is health?What is disease?What is multimorbidity?  Journal of Comorbidity 2016;6(2):114–11

Considering the healthcare needs of older people with multimorbidity: managing Alice

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 AliceAlice 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):53–5

Towards increased visibility of multimorbidity research

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):42–4

A qualitative interpretation of challenges associated with helping patients with multiple chronic diseases identify their goals

Background: Patients with multiple chronic diseases are usually treated according to disease-specific guidelines, with outcome measurements focusing mostly on biomedical indicators (e.g. blood sugar levels or lung function). However, for multimorbidity, a goal-oriented approach focusing on the goals defined by the individual patient, may be more suitable. Despite the clear theoretical and conceptual advantages of including patient-defined goals in clinical decision-making for multimorbidity, it is not clear how patients define their goals and which aspects play a role in the process of defining them. Objective: To explore goal-setting in patients with multimorbidity. Design: Qualitative analysis of interviews with 19 patients diagnosed with chronic obstructive pulmonary disease and comorbidities. Results: Patients do not naturally present their goals. Their goals are difficult to elicit, even when different interviewing techniques are used. Four underlying hypotheses which may explain this finding were identified from the interviews: (1) patients cannot identify with the concept of goal-setting; (2) goal-setting is reduced due to acceptation; (3) actual stressors predominate over personal goal-setting; and (4) patients may consider personal goals as selfish. Conclusions: Our findings advocate for specific attention to provider skills and strategies that help patients identify their personal goals. The hypotheses on why patients may struggle with defining goals may be useful to prompt patients in this process and support the development of a clinical method for goal-oriented care.Journal of Comorbidity 2016;6(2):120–12

Relationship between continuity of care and adverse outcomes varies by number of chronic conditions among older adults with diabetes

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):65–7

The Journal of Comorbidity affiliates with the Society for Academic Primary Care

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):73–7

Training doctors to manage patients with multimorbidity: a systematic review

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

Facing the challenge of multimorbidity

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–

Managing multimorbidity: how can the patient experience be improved?

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)28–3