Erratum to: Addressing multimorbidity to improve healthcare and economic sustainability

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):33The original article can be found at: http://dx.doi.org/10.15256/joc.2016.6.7

Multimorbidity and the primary healthcare perspective

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):46–4

Multimorbidity: What do we know? What should we do?

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):4–1

Secondary prevention of chronic health conditions in patients with multimorbidity: what can physiotherapists do?

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):50–5

Meeting the needs of a complex population: a functional health- and patient-centered approach to managing multimorbidity

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):76–8

Many diseases, one model of care?

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):12–2

Erratum to: Many diseases, one model of care?

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):34The original article can be found at: http://dx.doi.org/10.15256/joc.2016.6.7

Development of the C4 Inventory: a measure of common characteristics that complicate care in outpatient psychiatry

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):56–6

Addressing multimorbidity to improve healthcare and economic sustainability

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):21–27An erratum to this article can be found here: http://dx.doi.org/10.15256/joc.2016.6.7

Are care plans suitable for the management of multiple conditions?

Background: Care plans have been part of the primary care landscape in Australia for almost two decades. With an increasing number of patients presenting with multiple chronic conditions, it is timely to consider whether care plans meet the needs of patients and clinicians. Objectives: To review and benchmark existing care plan templates that include recommendations for comorbid conditions, against four key criteria: (i) patient preferences, (ii) setting priorities, (iii) identifying conflicts and synergies between conditions, and (iv) setting dates for reviewing the care plan. Design: Document analysis of Australian care plan templates published from 2006 to 2014 that incorporated recommendations for managing comorbid conditions in primary care. Results: Sixteen templates were reviewed. All of the care plan templates addressed patient preference, but this was not done comprehensively. Only three templates included setting priorities. None assisted in identifying conflicts and synergies between conditions. Fifteen templates included setting a date for reviewing the care plan. Conclusions: Care plans are a well-used tool in primary care practice, but their current format perpetuates a single-disease approach to care, which works contrary to their intended purpose. Restructuring care plans to incorporate shared decision-making and attention to patient preferences may assist in shifting the focus back to the patient and their care needs.Journal of Comorbidity 2016;6(2):103–11