Research on patients with multiple health conditions: different constructs, different views, one voice

Technological advances, improvements in medical care and public health policies have resulted in a growing proportion of patients with multiple health conditions. The prevalence of multiple health conditions among individuals increases with age, is substantial among older adults, and will increase dramatically in coming years. This phenomenon has received growing interest in the most recent literature and has led to several – and often differing – conceptualizations.<p></p> The term “comorbidity” was originally defined by Feinstein as “any distinct additional clinical entity that has existed or may occur during the clinical course of a patient who has the index disease under study”. This definition places one disease in a central position and all other condition(s) as secondary, in that they may or may not affect the course and treatment of the index disease. Feinstein’s principle has been applied all too readily as if the effect of comorbidity was secondary or indeed negligible. In clinical research, individuals with a narrowly defined index condition and no major comorbidities are usually enrolled, leaving the majority of the patients seen in a typical family practice out in the cold. In clinical practice, management of the index condition invariably takes priority, with disjointed – if any – treatment plans developed for each of the comorbidities. This model of care is typical of delivery systems constructed around specialized care, where areas of expertise are defined around specific conditions and bodily systems [11]. Not surprisingly, clinical practice guidelines arising from that model of care lack pertinence for patients with multiple health conditions

Improving the health of people with multimorbidity: the need for prospective cohort studies

The dramatic rise in long-term conditions (LTCs) represents a major challenge for individuals, families, and health care systems worldwide. Due to the scale of this rise, the management of patients with LTCs largely falls within the domain of primary rather than secondary care, at least in countries with well-developed primary care systems. For example, in the UK, which has a comprehensive primary care system based around general practice (trained family physicians working in multidisciplinary teams) and funded by the National Health Service (NHS), primary care contacts account for around 90% of the total activity of the NHS, and patients with LTCs account for 80% of general practice consultations. Effective primary care and community-based management of people with LTCs is thus a top priority

General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland - a pilot prospective study using structural equation modelling

<b>Objective</b> The aim of this pilot prospective study was to investigate the relationships between general practitioners (GPs) empathy, patient enablement, and patient-assessed outcomes in primary care consultations in an area of high socio-economic deprivation in Scotland.<p></p> <b>Methods</b> This prospective study was carried out in a five-doctor practice in an area of high socio-economic deprivation in Scotland. Patients’ views on the consultation were gathered using the Consultation and Relational Empathy (CARE) Measure and the Patient Enablement Instrument (PEI). Changes in main complaint and well-being 1 month after the contact consultation were gathered from patients by postal questionnaire. The effect of GP empathy on patient enablement and prospective change in outcome was investigated using structural equation modelling.<p></p> <b>Results</b> 323 patients completed the initial questionnaire at the contact consultation and of these 136 (42%) completed and returned the follow-up questionnaire at 1 month. Confirmatory factor analysis confirmed the construct validity of the CARE Measure, though omission of two of the six PEI items was required in order to reach an acceptable global data fit. The structural equation model revealed a direct positive relationship between GP empathy and patient enablement at contact consultation and a prospective relationship between patient enablement and changes in main complaint and well-being at 1 month.<p></p> <b>Conclusion</b> In a high deprivation setting, GP empathy is associated with patient enablement at consultation, and enablement predicts patient-rated changes 1 month later. Further larger studies are desirable to confirm or refute these findings.<p></p> <b>Practice implications</b> Ways of increasing GP empathy and patient enablement need to be established in order to maximise patient outcomes. Consultation length and relational continuity of care are known factors; the benefit of training and support for GPs needs to be further investigate

Adapting clinical guidelines to take account of multimorbidity

Most people with a chronic condition have multimorbidity, but clinical guidelines almost entirely focus on single conditions. It will never be possible to have good evidence for every possible combination of conditions, but guidelines could be made more useful for people with multimorbidity if they were delivered in a format that brought together relevant recommendations for different chronic conditions and identified synergies, cautions, and outright contradictions. We highlight the problem that multimorbidity poses to clinicians and patients using guidelines for single conditions and propose ways of making them more useful for people with multimorbidity

Schizophrenia is associated with excess multiple physical-health comorbidities but low levels of recorded cardiovascular disease in primary care: cross-sectional study

<b>Objective</b> To assess the nature and extent of physical-health comorbidities in people with schizophrenia and related psychoses compared with controls. <p></p> <b>Design </b>Cross-sectional study. <p></p> <b>Setting </b>314 primary care practices in Scotland. <p></p> <b>Participants </b>9677 people with a primary care record of schizophrenia or a related psychosis and 1 414 701 controls. Main outcome measures Primary care records of 32 common chronic physical-health conditions and combinations of one, two and three or more physical-health comorbidities adjusted for age, gender and deprivation status. <p></p> <b>Results</b> Compared with controls, people with schizophrenia were significantly more likely to have one physical-health comorbidity (OR 1.21, 95% CI 1.16 to 1.27), two physical-health comorbidities (OR 1.37, 95% CI 1.29 to 1.44) and three or more physical-health comorbidities (OR 1.19, 95% CI 1.12 to 1.27). Rates were highest for viral hepatitis (OR 3.98, 95% CI 2.81 to 5.64), constipation (OR 3.24, 95% CI 3.00 to 4.49) and Parkinson's disease (OR 3.07, 95% CI 2.42 to 3.88) but people with schizophrenia had lower recorded rates of cardiovascular disease, including atrial fibrillation (OR 0.62, 95% CI 0.51 to 0.73), hypertension (OR 0.71, 95% CI 0.67 to 0.76), coronary heart disease (OR 0.75, 95% CI 0.61 to 0.71) and peripheral vascular disease (OR 0.83, 95% CI 0.71 to 0.97).<p></p> <b>Conclusions </b>People with schizophrenia have a wide range of comorbid and multiple physical-health conditions but are less likely than people without schizophrenia to have a primary care record of cardiovascular disease. This suggests a systematic under-recognition and undertreatment of cardiovascular disease in people with schizophrenia, which might contribute to substantial premature mortality observed within this patient group. <p></p&gt

How to design and evaluate interventions to improve outcomes for patients with multimorbidity

Multimorbidity is a major challenge for patients and healthcare providers. The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions. Here we present a consensus view from a group of international researchers working to improve care for people with multimorbidity to guide future studies of interventions. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems

The effects of mindfulness-based stress reduction program on the mental health of family caregivers: a randomized controlled trial

<b>Background</b> Caregivers of people with chronic conditions are more likely than non-caregivers to have depression and emotional problems. Few studies have examined the effectiveness of mindfulness-based stress reduction (MBSR) in improving their mental well-being. <p></p> <b>Methods</b> Caregivers of persons with chronic conditions who scored 7 or above in the Caregiver Strain Index were randomly assigned to the 8-week MBSR group (n = 70) or the self-help control group (n = 71). Validated instruments were used to assess the changes in depressive and anxiety symptoms, quality of life, self-efficacy, self-compassion and mindfulness. Assessments were conducted at baseline, post-intervention and at the 3-month follow-up. <p></p> <b>Results </b>Compared to the participants in the control group, participants in the MBSR group had a significantly greater decrease in depressive symptoms at post-intervention and at 3 months post-intervention (p < 0.01). The improvement in state anxiety symptoms was significantly greater among participants in the MBSR group than those of the control group at post-intervention (p = 0.007), although this difference was not statistically significant at 3 months post-intervention (p = 0.084). There was also a statistically significant larger increase in self-efficacy (controlling negative thoughts; p = 0.041) and mindfulness (p = 0.001) among participants in the MBSR group at the 3-month follow-up compared to the participants in the control group. No statistically significant group effects (MBSR vs. control) were found in perceived stress, quality of life or self-compassion. <p></p> <b>Conclusions </b>MBSR appears to be a feasible and acceptable intervention to improve mental health among family caregivers with significant care burden, although further studies that include an active control group are needed to make the findings more conclusive

Measurement of the Bottom-Strange Meson Mixing Phase in the Full CDF Data Set

We report a measurement of the bottom-strange meson mixing phase \beta_s using the time evolution of B0_s -> J/\psi (->\mu+\mu-) \phi (-> K+ K-) decays in which the quark-flavor content of the bottom-strange meson is identified at production. This measurement uses the full data set of proton-antiproton collisions at sqrt(s)= 1.96 TeV collected by the Collider Detector experiment at the Fermilab Tevatron, corresponding to 9.6 fb-1 of integrated luminosity. We report confidence regions in the two-dimensional space of \beta_s and the B0_s decay-width difference \Delta\Gamma_s, and measure \beta_s in [-\pi/2, -1.51] U [-0.06, 0.30] U [1.26, \pi/2] at the 68% confidence level, in agreement with the standard model expectation. Assuming the standard model value of \beta_s, we also determine \Delta\Gamma_s = 0.068 +- 0.026 (stat) +- 0.009 (syst) ps-1 and the mean B0_s lifetime, \tau_s = 1.528 +- 0.019 (stat) +- 0.009 (syst) ps, which are consistent and competitive with determinations by other experiments.Comment: 8 pages, 2 figures, Phys. Rev. Lett 109, 171802 (2012