Challenges of managing people with multimorbidity in today’s healthcare systems

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas. General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity

Evaluation of Primary Care Transformation in Scotland - Summary of findings from an independent programme of research by the University of Edinburgh:Executive Summary - National Scottish GP Survey 2023

Background: A national survey of GPs in Scotland’s working life and views on the new GP contract was conducted in late 2023/early 2024 and compared with a similar survey in Scotland in 2018. The characteristics of respondents and their practices in 2023 and 2018 were very similar, allowing a direct comparison. In both years, the surveys were broadly representative of all GPs in Scotland. Key Findings: Compared with survey findings in 2018:➢ Years in practice, and current employment models were similar but sessions worked per week, and holiday taken per year by GPs were both significantly lower in 2023.➢ There was a significant overall improvement in GPs positive work attributes in 2023 but work pressure was significantly higher and negative work attributes and work satisfactionwere unchanged.➢ Cluster Quality Leads’ (CQLs) and Practice Quality Leads’ (PQLs) views on cluster working were largely unchanged, with approximately 80% reporting insufficient support. However, other GPs (non-CQL/PQLs) showed some significant improvements in their views on clusters, especially on their understanding of quality improvement.➢ On average, GPs felt that only 8.5% of their previous clinical work was now delegated to MDT staff, but felt that around a fifth (22.4%) of their current work could safely be delegated (if there were sufficient MDT staff). ➢ Although GPs in the 2023 survey were generally positive about the expansion of the MDT only a third overall reported that had reduced their workload.➢ Only 1 in 20 GPs in the 2023 survey thought that the new contract had improved the care of elderly patients with multimorbidity, or improved the care of younger deprived patientswith multimorbidity.➢ Significantly fewer GPs reported giving longer consultations for complex patients in 2023 than in 2018 (39.8% versus 52.2%, respectively).➢ Significantly more GPs reported that their practices were trying to recruit GPs (35.8% versus 30.5% in 2018) and had been trying to recruit for longer (42% > 12 months versus 30.9% in 2018).➢ GPs in the 2023 survey felt that NHS services in their local areas had significantly worsenedin the last 12 months, that practice workload was higher, and the long-term sustainability of the practices was worse compared with the 2018 survey.➢ Significantly more GPs in 2023 were planning to reduce their hours and leave direct patient care in the next 5 years. In those below 55 years of age, significantly more planned to reduce their hours, leave direct patient care, and leave medical work entirely in 2023 compared with 2018. The biggest difference was in planning to reduce hours (42% of all GPs in 2023 versus 35% in 2018).ConclusionsAlthough there have been some improvements in GPs views on some aspects of working life and the new GP contract in Scotland, most aspects have remained the same and some have worsened since 2018. GPs appear to be responding by reducing or planning to reduce their workload or leave direct patient care, which is a worrying picture given the GP recruitment difficulties reported

Multimorbidity: Technical Series on Safer Primary Care

No abstract available

Challenges of managing people with multimorbidity in today's healthcare systems

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas. General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity.Publisher PDFPeer reviewe

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

'Learning together': Sharing international experience on new models of primary care

No abstract available

Acceptability of mindfulness from the perspective of stroke survivors and caregivers: a qualitative study

Background: Depression is very common among stroke survivors with estimated prevalence rates of approximately 33% among stroke survivors, but treatment options are limited. Mindfulness-Based Stress Reduction (MBSR) is an effective treatment for depression generally, but benefits in stroke patients are unclear. The aim of this study was to determine the feasibility of delivering MBSR to stroke survivors and their caregivers in the community. We conducted a study to gain views of MBSR as a potential treatment option among stroke survivors and their caregivers in the community. Methods: Participants were recruited from an urban community in Scotland (UK) using newspaper adverts, social media and support groups run by health charities. A 2-h MBSR taster session was delivered by two experienced mindfulness instructors, followed by focus group sessions with all participants on their user experience and suggestions for MBSR modifications for stroke survivors. The focus group sessions were audio recorded and transcribed verbatim. Transcript data were analysed thematically using the framework approach. Results: The study sample consisted of 28 participants (16 females); there were 21 stroke survivors (11 females) and 7 caregivers (5 females). The median age for participants was 60 years. Most participants described the MBSR taster session as a positive experience. The main challenge reported was trying to maintain focus and concentration throughout the MBSR session. Some participants expressed reservations about the duration of standard mindfulness course sessions, suggesting a preference for shorter sessions. The potential for achieving better control over negative thoughts and emotions was viewed as a potential facilitator for future MBSR participation. Participants suggested having an orientation session prior to starting an 8-week course as a means of developing familiarity with the MBSR instructor and other participants. Conclusion: It was feasible to recruit 21 stroke survivors and 7 caregivers for MBSR taster sessions in the community. A shorter MBSR session and an orientation session prior to the full course are suggestions for potential MBSR modifications for stroke survivors, which needs further research and evaluation

Using normalisation process theory to understand barriers and facilitators to implementing mindfulness-based stress reduction for people with multiple sclerosis

Objectives: To study barriers and facilitators to implementation of mindfulness-based stress reduction for people with multiple sclerosis. Methods: Qualitative interviews were used to explore barriers and facilitators to implementation of mindfulness-based stress reduction, including 33 people with multiple sclerosis, 6 multiple sclerosis clinicians and 2 course instructors. Normalisation process theory provided the underpinning conceptual framework. Data were analysed deductively using normalisation process theory constructs (coherence, cognitive participation, collective action and reflexive monitoring). Results: Key barriers included mismatched stakeholder expectations, lack of knowledge about mindfulness-based stress reduction, high levels of comorbidity and disability and skepticism about embedding mindfulness-based stress reduction in routine multiple sclerosis care. Facilitators to implementation included introducing a pre-course orientation session; adaptations to mindfulness-based stress reduction to accommodate comorbidity and disability and participants suggested smaller, shorter classes, shortened practices, exclusion of mindful-walking and more time with peers. Post-mindfulness-based stress reduction booster sessions may be required, and objective and subjective reports of benefit would increase clinician confidence in mindfulness-based stress reduction. Discussion: Multiple sclerosis patients and clinicians know little about mindfulness-based stress reduction. Mismatched expectations are a barrier to participation, as is rigid application of mindfulness-based stress reduction in the context of disability. Course adaptations in response to patient needs would facilitate uptake and utilisation. Rendering access to mindfulness-based stress reduction rapid and flexible could facilitate implementation. Embedded outcome assessment is desirable

Mindfulness-based interventions for mental well-being among people with multiple sclerosis: a systematic review and meta-analysis of randomised controlled trials

Objective: Impairment of mental well-being (anxiety, depression, stress) is common among people with multiple sclerosis (PwMS). Treatment options are limited, particularly for anxiety. The aim of this study was to update our previous systematic review (2014) and evaluate via meta-analysis the efficacy of mindfulness-based interventions (MBIs) for improving mental well-being in PwMS. Methods: Systematic searches for eligible randomised controlled trials (RCTs) were carried out in seven major databases (November 2017, July 2018), using medical subject headings and key words. Studies were screened, data extracted, quality appraised and analysed by two independent reviewers, using predefined criteria. Study quality was assessed using the Cochrane Collaboration risk of bias tool. Mental well-being was the primary outcome. Random effects model meta-analysis was performed, with effect size reported as standardised mean difference (SMD). Results: Twelve RCTs including 744 PwMS were eligible for inclusion in the systematic review, eight had data extractable for meta-analysis; n=635. Ethnicity, socioeconomic status, comorbidity and disability were inconsistently reported. MBIs varied from manualised to tailored versions, lasting 6–9 weeks, delivered individually and via groups, both in person and online. Overall SMD for mental well-being (eight studies) was 0.40 (0.28–0.53), p<0.01, I2=28%; against active comparators only (three studies) SMD was 0.17 (0.01–0.32), p<0.05, I2 =0%. Only three adverse events were reported. Conclusions: MBIs are effective at improving mental well-being in PwMS. More research is needed regarding optimal delivery method, cost-effectiveness and comparative-effectiveness

Enhancing research quality and reporting: why the Journal of Comorbidity is now publishing study protocols

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