Secondary analysis of data on comorbidity/multimorbidity: a call for papers

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.Journal of Comorbidity 2015;5(1):120–12

The Patient Centered Assessment Method (PCAM): integrating the social dimensions of health into primary care

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):110–11

A systematic review of motivational interviewing in healthcare: the potential of motivational interviewing to address the lifestyle factors relevant to multimorbidity

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. Journal of Comorbidity 2015;5(1):162–174

Stroke rehabilitation and patients with multimorbidity: a scoping review protocol

Stroke care presents unique challenges for clinicians, as most strokes occur in the context of other medical diagnoses. An assessment of capacity for implementing “best practice” stroke care found clinicians reporting a strong need for training specific to patient/system complexity and multimorbidity. With mounting patient complexity, there is pressure to implement new models of healthcare delivery for both quality and financial sustainability. Policy makers and administrators are turning to clinical practice guidelines to support decision-making and resource allocation. Stroke rehabilitation programs across Canada are being transformed to better align with the Canadian Stroke Strategy’s Stroke Best Practice Recommendations. The recommendations provide a framework to facilitate the adoption of evidence-based best practices in stroke across the continuum of care. However, given the increasing and emerging complexity of patients with stroke in terms of multimorbidity, the evidence supporting clinical practice guidelines may not align with the current patient population. To evaluate this, electronic databases and gray literature will be searched, including published or unpublished studies of quantitative, qualitative or mixed-methods research designs. Team members will screen the literature and abstract the data. Results will present a numerical account of the amount, type, and distribution of the studies included and a thematic analysis and concept map of the results. This review represents the first attempt to map the available literature on stroke rehabilitation and multimorbidity, and identify gaps in the existing research. The results will be relevant for knowledge users concerned with stroke rehabilitation by expanding the understanding of the current evidence.Journal of Comorbidity 2015;5(1):1–10

Abstracts of the 11th International Conference on Developmental Coordination Disorder (DCD11)

DCD11 – Developmental coordination disorder and other neurodevelopmental disorders: a focus on comorbidity; Toulouse, France, July 2-4, 2015Comorbidity refers to the presence of two or more disorders in the same person (especially DCD, dyslexia and attention deficit hyperactivity disorder in terms of developmental disorders). There has been growing interest in the presence of comorbidity in persons with neurodevelopmental disorders. Many recent studies suggest that up to half of all individuals diagnosed with a psychiatric or neurodevelopmental disorder have more than one condition. Comorbidity not only impacts patient outcomes but can also create a significant strain on both family and school life. It can also complicate diagnosis and healthcare organization. The 11th congress on DCD aimed to address some of the important issues surrounding comorbidity in neurodevelopmental disorders. Three main topics were covered during oral and poster presentations: (1) assessment and diagnostic criteria, (2) underlying processes, causal factors, and prognostic markers, and (3) intervention and management of DCD and associated disorders.Journal of Comorbidity 2015;5(2):32–109 

Care coordination of multimorbidity: a scoping study

Background: A key challenge in healthcare systems worldwide is the large number of patients who suffer from multimorbidity; despite this, most systems are organized within a single-disease framework. Objective: The present study addresses two issues: the characteristics and preconditions of care coordination for patients with multimorbidity; and the factors that promote or inhibit care coordination at the levels of provider organizations and healthcare professionals. Design: The analysis is based on a scoping study, which combines a systematic literature search with a qualitative thematic analysis. The search was conducted in November 2013 and included the PubMed, CINAHL, and Web of Science databases, as well as the Cochrane Library, websites of relevant organizations and a hand-search of reference lists. The analysis included studies with a wide range of designs, from industrialized countries, in English, German and the Scandinavian languages, which focused on both multimorbidity/comorbidity and coordination of integrated care. Results: The analysis included 47 of the 226 identified studies. The central theme emerging was complexity. This related to both specific medical conditions of patients with multimorbidity (case complexity) and the organization of care delivery at the levels of provider organizations and healthcare professionals (care complexity). Conclusions: In terms of how to approach care coordination, one approach is to reduce complexity and the other is to embrace complexity. Either way, future research must take a more explicit stance on complexity and also gain a better understanding of the role of professionals as a prerequisite for the development of new care coordination interventions. Journal of Comorbidity 2015;5(1):15–28

Coping with complexity: working beyond the guidelines for patients with multimorbidities

Primary care physicians believe they are delivering evidence-based care, understanding that adherence to evidence-based clinical guidelines results in tangible benefits in the populations for which they were developed. Unfortunately, most clinical guidelines are based on trial populations which are very different to primary care populations [1], and do not reflect the reality of multimorbidity in general practice [2–6]. Since patients with multimorbidity account for around eight in every 10 primary care consultations [7], it is unsurprising that many primary care physicians find managing these patients challenging. Additionally, current clinical guidelines do not provide guidance on how best to prioritize recommendations for individuals with multimorbidity, and may therefore result in over-treatment and polypharmacy, and a risk of overlooking patient preferences [2,8]. Journal of Comorbidity 2015;5(1):11–1

“You’re an expert in me”: the role of the generalist doctor in the management of patients with multimorbidity

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):132–13

Incorporating patient preferences in the management of multiple long-term conditions: is this a role for clinical practice guidelines?

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):122–13

Multimorbidity or polypharmacy: two sides of the same coin?

Polypharmacy, broadly defined as the chronic co-prescription of several drugs [1], has long been recognized as problematic. The greater the number of medicines a patient takes, the greater the risk of adverse effects of any one medicine, and the greater the risk of drug–drug interactions. Thus, polypharmacy is an accepted risk for poor health outcomes, including hospitalizations and mortality [2]. The number of drugs per patient (or polypharmacy) has come to be used as a measure of potentially hazardous professional behaviour, and is sometimes used in conjunction with the term ‘inappropriate prescribing’. Nonetheless, the prevalence of polypharmacy is rising inexorably [3]. This rise is driven, principally, by the rising prevalence of multimorbidity, i.e. the co-occurrence of two or more chronic long-term diseases or conditions in one patient [4]. The issue is compounded by clinical guidelines that advocate the use of several medicines in the management of individual diseases and their associated risk factors [5]. The result is a dilemma for prescribers: on the one hand there is the need to keep the number of medicines to a minimum, while on the other ensuring that the patient receives what evidence-based guidelines advocate as being in their best interest [6]. Journal of Comorbidity 2015;5(1):29–3