Background Inspired by American examples, several European countries are now developing disease management programmes (DMPs) to improve the quality of care for patients with chronic diseases. Recently, questions have been raised whether the disease management approach is appropriate to respond to patient-defined needs.

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KEY MESSAGE:Patients with multiple chronic diseases, patients with disability and frail patients represent partly overlapping but distinct • groups. Multimorbidity, measured by the cumulative illness rating scale, is independently associated with disability, but not withDiff erent measures of multimorbidity show similarly limited ability to identify patients with disability or frailty. • ABSTRACT Background : Ageing people show increasing morbidity, dependence and vulnerability. Objectives : To compare the relationships of diff erent measures of multimorbidity with dependence (operationalized as disability) and vulnerability (operationalized as frailty). Method : A cross-sectional analysis within the BELFRAIL cohort (567 subjects aged Ն 80). Multimorbidity was measured using a disease count (DC), the Charlson comorbidity index (CCI) and the cumulative illness rating scale (CIRS), respectively. Associations with disability (based on activities of daily living) and frailty (defi ned by the Fried frailty criteria) were assessed using bivariable and multivariable analyses. Net reclassifi cation improvement (NRI) values were calculated to compare the abilities of the DC, CCI and CIRS to identify patients with disability or frailty. Results : Disability was associated with the DC (crude odds ratio, OR: 2.1; 95% confi dence interval, CI: 1.4 -3.4), CCI (crude OR: 1.8; 95% CI: 1.2 -2.7) and CIRS (crude OR: 4.0; 95% CI: 2.5 -6.5); only the association with CIRS was independent of age, sex, chronic infl ammation, impaired cognition and frailty (adjusted OR: 3.2; 95% CI: 1.7 -5.8). Frailty was associated with CCI (crude OR: 2.4; 95% CI: 1.2 -4.6) and CIRS (crude OR: 2.6; 95% CI: 1.3 -5.3); adjusted for age, sex, chronic infl ammation, impaired cognition and disability. These associations were not statistically signifi cant. The NRIs demonstrated a similar ability of the DC, CCI, and CIRS to identify patients with disability or frailty, respectively.Conclusion : The associations of diff erent measures of multimorbidity with disability and frailty diff er but their ability to identify patients with disability or frailty is similar. Generally, multimorbidity scores incompletely refl ect dependence and vulnerability in this age group.

PURPOSEWe set out to assess whether a high sense of coherence (SOC) protects from adverse health outcomes in patients aged 80 years and older who have multiple chronic diseases.METHODS A population-based prospective cohort study in 29 primary care practices throughout Belgium included 567 individuals aged 80 years and older. We plotted the highest tertile of SOC scores in Kaplan-Meier curves representing 3-year mortality and time to first hospitalization. Using Cox proportional hazard regression analyses and multiple logistic regression analyses adjusted for sociodemographic characteristics, depression, cognition, disability, and multimorbidity we examined the relationship between SOC and mortality, hospitalization, and decline in performance of activities of daily living (ADL).RESULTS Subjects with high SOC scores showed a higher cumulative survival than others (Log rank = 0.004) independent of other prognostic characteristics (adjusted hazard ratio 0.62 (95% CI, 0.38-1.00), P = .049). For ADL decline, a high SOC was shown to be protective, and this effect tended to be independent from the covariates under study (adjusted odds ratio 0.56 (95% CI, 0.31-1.0), P = .05).CONCLUSION Even very elderly persons with high SOC scores were shown to have lower mortality rates and less functional decline. These effects were independent of multimorbidity, depression, cognition, disability, and sociodemographic characteristics.

Patient's attitudes and illness beliefs have shown to be of great importance in chronic obstructive pulmonary disease (COPD). As former qualitative research has mainly focused on patients with end-stage COPD, who are recruited within hospital or pulmonary rehabilitation settings, and excluding patients with disabling comorbidities, this study specifically aims to explore the perspectives of patients with COPD and comorbidities in primary care. This study was designed as a qualitative, explorative study using open patient interviews. The study was conducted at three primary care practices, East Flanders, Belgium. A total number of seven patients, diagnosed with COPD and given a minimum score of 2 on the Charlson Comorbidity Index were included. In-depth interviews were recorded and transcribed verbatim. Thematic analysis was deductive using NVivo software. Researchers' triangulation was performed. Participants show high adaptation capabilities and report quite positively about their functional status, with an emphasis on social participation and partnership. Knowledge of the causes and consequences of COPD appears rather limited, and participants predominantly show an external locus of control in relation to the reported factors influencing the disease and strategies for self-management. Patients with COPD with comorbidity integrate their illness and symptoms into their lives. However, a lack of knowledge and education may leave them more anxious and more dependent on health care than necessary. Our results indicate that health care workers should adopt a positive approach toward patient's functioning and empower and inform their patients. We believe that chronic care for patients with COPD should provide personalized rehabilitation taking into account individual patient characteristics and self-management and coping attitudes. We believe that there is a generic core to be identified, which can tackle both COPD and comorbidities. Further research is mandatory to develop these generic programs focusing on patients with complicated needs. Primary care can provide the setting for exploration.