Better management of patients with multimorbidity

Roland, Martín; Paddison, Charlotte

doi:10.1136/bmj.f2510

Cited by 136 publications

(105 citation statements)

References 24 publications

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“…Time constraints because of competing demands during primary care visits may play a major role, namely a focus on acute medical management of the patient's chronic conditions or disabilities. 6,15,[18][19][20][21] Physical limitations, both in getting to physicians' offices and within physicians' offices, such as getting on the examination table, have also been identified as potentially influencing screening practices for women with disabilities. 8,[22][23][24][25] Physicians' "self-identified lack of confidence" (in appropriately treating patients with disabilities) has been noted in the literature.…”

Section: Explanation and Comparison With Other Studiesmentioning

confidence: 99%

Screening for cervical cancer in women with disability and multimorbidity: a retrospective cohort study in Ontario, Canada

et al. 2014

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Background: People with disability, multiple chronic conditions or both may experience challenges in accessing primary care. We aimed to determine the association between appropriate cervical cancer screening and level of disability among women eligible for screening in Ontario and the influence of relevant sociodemographic and health-related variables, including level of morbidity (measured by number of chronic conditions), on screening. Methods:We used multiple linked databases, including 2 waves of the Canadian Community Health Survey (2005 and 2007/08). Of the 22 824 women included in the study, 7600 reported some level of disability. We used Ontario Health Insurance Plan fee codes to identify appropriate cervical cancer screening.Results: Compared with women without disability, women with disability were older, less educated, had lower income and had more chronic conditions (36.2% had at least 2 conditions v. 8.4% of women without disability). Women with no disability and no chronic conditions were more frequently screened appropriately than those with severe disability and 2 or more chronic conditions (64.5% v. 39.8%). In multivariable logistic regression analysis, age, rurality, education, marital status and household income were each independently associated with cervical cancer screening. There was a significant interaction between level of morbidity and level of disability. Women with a higher level of disability were less likely to be screened than women with lower level of disability as their level of morbidity increased. Conclusion:The rate of screening for cervical cancer is low among women with both disability and multimorbidity. Policymakers should note these results as they work toward improving cancer screening rates for an aging population with complex medical needs. AbstractCMAJ OPEN, 2(4) E241

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Section: Explanation and Comparison With Other Studiesmentioning

confidence: 99%

Screening for cervical cancer in women with disability and multimorbidity: a retrospective cohort study in Ontario, Canada

et al. 2014

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“…The important role of the generalist physician to take a holistic overview of patients on multiple medications has been acknowledged [5,6,28]. Patients with co-morbidities may be prescribed BP lowering medication to treat other conditions, e.g.…”

Section: Discussionmentioning

confidence: 99%

“…prostatism, Parkinson's, depression or cardiac conditions, and a regular holistic medication review is advised. In the face of a multiplicity of single disease guidelines, an evolving evidence-based clinical decision-making requires judgement and treatment has to consider patient circumstances and preferences [5,6,28]. Additionally, there is further scope for the development of clinical systems to aid decision-making in the care of elderly patients with multiple medications and co-morbidities [5,6,29].…”

Section: Discussionmentioning

confidence: 99%

118older People Remain on Blood Pressure Agents Despite Being Hypotensive Resulting in Increased Mortality and Hospital Admission

et al. 2017

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Background: the use of antihypertensive medication in older people in order to prevent cardiovascular events is well established. The use of such agents has been encouraged by incentive schemes in the United Kingdom including the Quality and Outcomes Framework. In addition, many guidelines recommend good blood pressure (BP) control in the elderly. However, in older people antihypertensives can cause adverse effects related to hypotension. Aim: the aim of this study was to assess the prevalence of low BP and impact on outcomes, particularly in the presence of antihypertensive treatment, in a primary care population of older people. Design: a retrospective observational cohort study in people over the age of 70 years registered with primary care providers in Kent. Results: a total of 11,167 patients over 70 years old were analysed, 6,373 female (57%). Systolic blood pressure (SBP) was below 120 mmHg in 1,297 people (844 on antihypertensives), below 110 mmHg in 474 (313 on antihypertensives) and below 100 mmHg in 128 (89 on antihypertensives). Hypotension was independently associated with mortality, acute kidney injury and hospital admission.Conclusions: the results demonstrate that low SBP is associated with adverse events, it is possible that the pursuit of BP control at a population level may lead to over-treatment in certain groups of patients. This may result in an increased incidence of adverse events particularly in older people.

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“…196 Our review would add to this by suggesting that building confidence in medicines management and promoting functional ability in people living with dementia and their carers is reliant on multiple contexts that allow clinicians to base assessment on familiarity with the patient's (and carer's) story, priorities and needs. Longer consultations are needed for patients with the 'cumulative complexity' of multiple chronic conditions and for those less able to articulate their priorities and needs, 197 both of which apply to people with dementia and diabetes.…”

Section: Care Pathwaysmentioning

confidence: 99%

Managing diabetes in people with dementia: a realist review

Bunn

Goodman

Jones

et al. 2017

Health Technol Assess

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BackgroundDementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.ObjectivesTo identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.DesignRealist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.ParticipantsTwenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.Data sourcesThe following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing – UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).ResultsWe included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context–mechanism–outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.LimitationsThere is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.ConclusionsThis review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.Study registrationThis study is registered as PROSPERO CRD42015020625.FundingThe NIHR HTA programme.

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Better management of patients with multimorbidity

Abstract: Martin Roland and Charlotte Paddison call for greater emphasis on continuity of care and clinical judgment to improve the experience of patients with multiple conditions

Cited by 136 publications

References 24 publications

Screening for cervical cancer in women with disability and multimorbidity: a retrospective cohort study in Ontario, Canada

Screening for cervical cancer in women with disability and multimorbidity: a retrospective cohort study in Ontario, Canada

118older People Remain on Blood Pressure Agents Despite Being Hypotensive Resulting in Increased Mortality and Hospital Admission

Managing diabetes in people with dementia: a realist review

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