Objectives-To compare the practices of local research ethics committees and the time they take to obtain ethical approvalfor a multi-centre study. Design-A retrospective analysis of outcome of applications for a multi-centre study to local research ethics committees. Setting-Thirty-six local research ethics committees covering 38 district health authorities in England. Main measures-Response of chairmen and women, the time required to obtain approval, and questions asked in application forms. Results-We received replies from all 36 chairmen contacted: four (11 %o) granted their approval, and 32 (89%) required our proposal to be considered by their local research ethics committee. Three committees asked us to attend their meetings. The application was approved by all 36 local research ethics committees but the time to obtain ethical approval varied between six to 208 days. One third of the committees did not approve the project within three months, and three took longer than six months. There was considerable variation in the issues raised by local research ethics committees and none conformed exactly to the Royal College of Physicians' guidelines. Conclusion-Obtaining ethical approvalfor a multicentre study is time-consuming. There is much diversity in the practice of local research ethics committees. Our data support the recommendation for a central or regional review body of multi-centre studies which will be acceptable to all local research ethics committees.
The burden of multimorbidityThe focus of primary health care (PHC) in developed countries is now largely centred on the treatment and management of long-term or chronic diseases. Due to shared risk factors and interaction among diseases, chronic conditions are increasingly occurring in clusters. 1 In Canada, more than 50% of adults aged 65 years and older report having at least two chronic diseases. 2 The co-occurrence of multiple chronic diseases in an individual, or multimorbidity, is also understood to be the norm rather than the exception in PHC. 3 Multimorbidity is associated with reduced quality of life, limited functional status, polypharmacy, increased mortality, and high health care costs. 3 Deemed an "endless struggle" by PHC providers, multimorbidity is becoming more prevalent in younger patients and is no longer confined to elderly populations. 1,4 This phenomenon is pushing PHC providers and researchers alike to understand its multifaceted nature. A better understanding of the etiology behind multimorbidity can lead to a transformed clinical approach that will, in turn, be cost-saving in the long-run. To achieve this, three main components are necessary.
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