Multimorbidity's many challenges

Fortin, Martin; Soubhi, Hassan; Hudon, Catherine; Bayliss, Elizabeth A.; Akker, Marjan van den

doi:10.1136/bmj.39201.463819.2c

Cited by 426 publications

(372 citation statements)

References 8 publications

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“…22 In addition, little is known about patients' perspectives. A review of 126 qualitative research papers on patients' experiences of the diagnosis and treatment of dementia 23 found very little evidence relating to the experiences of people diagnosed with dementia who have an accompanying comorbid condition.…”

Section: Dementia and Comorbiditymentioning

confidence: 99%

“…Most research on multimorbidity has been concerned with its effect on prevalence and physical functioning and its measurement, with little research investigating patient and carer preferences and experiences, the effect on processes of care or what constitutes 'best care' for these patients. 22,59 Moreover, qualitative research on dementia to date has tended to focus on the experience of living with dementia as a single disease. 23 This study sets out current research and knowledge about the impact of comorbidities on people diagnosed with dementia and what is known about their experiences of health care.…”

Section: Implications Of the Findingsmentioning

confidence: 99%

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Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Bunn

Burn

Goodman

et al. 2016

Health Serv Deliv Res

116

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BackgroundAmong people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.ObjectivesTo explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.DesignWe undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.ParticipantsThe study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.ResultsThe scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.ConclusionsSignificant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Dementia and Comorbiditymentioning

confidence: 99%

Section: Implications Of the Findingsmentioning

confidence: 99%

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Bunn

Burn

Goodman

et al. 2016

Health Serv Deliv Res

116

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“…Most PC patients present with multiple or comorbid conditions in a visit, 66 necessitating processes of sorting to identify and prioritize what conditions can and should be managed. Negotiation becomes an inevitable process to reach a common understanding on priorities and approaches in managing those conditions.…”

Section: Discussionmentioning

confidence: 99%

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

2013

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BACKGROUND: Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. OBJECTIVE: This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. DESIGN: Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n=24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. PARTICIPANTS: Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. KEY RESULTS: A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. CONCLUSIONS: The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

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“…constante incremento del número de pacientes con perfiles clínicos complejos debido a la presencia de enfermedades crónicas como consecuencia de la transición epidemiológica, representa un gran reto para su manejo clínico, así como para los sistemas de salud y para la investigación epidemiológica (3). En la actualidad, los pacientes con múltiples enfermedades crónicas son la regla más que la excepción, incluso en las unidades de cuidado primario (4).…”

Section: Multimorbidity: Conceptual Basis Epidemiological Models Andunclassified

Multimorbilidad: bases conceptuales, modelos epidemiológicos y retos de su medición

Fernández-Niño

Bustos-Vázquez

2016

biomedica

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Contribución de los autores:Ambos autores contribuyeron a la concepción y el diseño del ensayo, el análisis y la interpretación de las fuentes originales, así como a la redacción y la aprobación de la versión final. Multimorbilidad: bases conceptuales, modelos epidemiológicos y retos de su mediciónJulián A. Fernández-Niño 1 , Eduardo Bustos-Vázquez 2 1 Centro de Información para Decisiones en Salud Pública, Instituto Nacional de Salud Pública, Cuernavaca, México 2 Escuela de Salud Pública de México, Instituto Nacional de Salud Pública, Cuernavaca, México El incremento continuo de pacientes con perfiles clínicos complejos debidos a enfermedades crónicas ha favorecido el uso cada vez más extendido del término multimorbilidad. Es indispensable disponer de una medición apropiada de esta condición, dado que representa un reto para el manejo clínico de los pacientes, los sistemas de salud y la investigación epidemiológica. En este ensayo se revisan las propuestas conceptuales subyacentes a la medición de la multimorbilidad y se discuten los retos metodológicos involucrados, tomando como referencia las definiciones clásicas de comorbilidad, sus diferencias con el concepto de multimorbilidad y su papel en los estudios epidemiológicos, así como los distintos modelos conceptuales de los que se derivan las definiciones operativas y las estrategias de medición de dicha variable. Se pudo determinar que hay una brecha importante entre el desarrollo del concepto de multimorbilidad y las definiciones operativas, a pesar del significativo avance teórico que ha permitido trascender la concepción clásica de comorbilidad para llegar al concepto actual de multimorbilidad. Sin embargo, las estrategias de medición no se han desarrollado al mismo ritmo del concepto, por lo que se requieren nuevas propuestas metodológicas que permitan obtener información sobre su verdadero impacto en la salud de las personas y sus implicaciones para la salud pública.Palabras clave: comorbilidad, enfermedad crónica, modelos teóricos, estudios epidemiológicos, sesgo (epidemiología), envejecimiento. doi: http://dx.doi.org/10.7705/biomedica.v36i2.2710 Multimorbidity: conceptual basis, epidemiological models and measurement challengesThe growing number of patients with complex clinical profiles related to chronic diseases has contributed to the increasingly widespread use of the term 'multimorbidity'. A suitable measurement of this condition is essential to epidemiological studies considering that it represents a challenge for the clinical management of patients as well as for health systems and epidemiological investigations. In this context, the present essay reviews the conceptual proposals behind the measurement of multimorbidity including the epidemiological and methodological challenges it involves. We discuss classical definitions of comorbidity, how they differ from the concept of multimorbidity, and their roles in epidemiological studies. The various conceptual models that contribute to the operational definitions and strategies to measure this vari...

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Multimorbidity's many challenges

Cited by 426 publications

References 8 publications

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Primary Care Clinicians’ Recognition and Management of Depression: A Model of Depression Care in Real-World Primary Care Practice

Multimorbilidad: bases conceptuales, modelos epidemiológicos y retos de su medición

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