Christiane Muth

Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies.

Introduction Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care. Methods Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa  = 0.86). Results We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions. Conclusions Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.

Case Management for Depression by Health Care Assistants in Small Primary Care Practices: A Cluster Randomized Trial

Context Few studies have evaluated whether health care assistants can improve care for depressed patients. Contribution Patients who were randomly assigned to receive telephone case management by health care assistants reported slightly greater improvements in depression symptoms, better adherence to antidepressant therapies, and more favorable assessments of the quality of their care than did patients randomly assigned to receive usual care. Implication Telephone case management facilitated by health care assistants may be a feasible mechanism for small primary care practices to improve care of their patients with depression. The Editors Depression causes a substantial disease burden (1) and is responsible for annual health care costs of about

The Ariadne principles: how to handle multimorbidity in primary care consultations

83.1 billion in the United States (2, 3). Most patients with depression are treated in primary care (46). Collaborative care can improve depression outcomes by providing decision support and clinical information for family physicians, as well as self-management support and follow-up for patients. However, evidence regarding collaborative depression care stems mostly from academic or managed care settings in the United States (711). In these trials, family physicians generally relied on mental health case managers and decision support from mental health specialists (12). Case management is a patient-centered element of collaborative care that may be effective in primary care (13). It comprises systematic tracking of patients, support for continuing the treatment, and taking action in the case of nonadherence or lack of improvement (14). Collaborative depression care has generally yielded positive results in diverse primary care settings (7). The IMPACT (Improving MoodPromoting Access to Collaborative Treatment) trial found that care managers who were supervised by psychiatrists and who provided education and support for medication adherence reduced depression symptoms in older patients (15). Dietrich and colleagues (16) found that telephone support, provided by a trained, centrally based mental health care manager who was supervised by a psychiatrist, improved depression symptoms. Dobscha and colleagues (17) evaluated a primary care decision-support team for depression (comprising a psychiatrist and a mental health nurse) and found improved care processes but no differences in depression symptoms (17), possibly because of less intensive follow-up of patients. Small, isolated primary care settings often have limited resources (18). In the United States, 26% of primary care practices are solo practices or 2-person partnerships, in which extensive collaborative models would be difficult to implement, and 22% are located in rural areas with limited access to mental health specialists (19). Health care assistants are established professionals in primary care settings. They have less training than U.S. physician assistants or nurse practitioners, who provide first-contact care, and need not be college graduates (20). In Germany, health care assistants have 3 years of on-the-job training. They are mainly responsible for administrative tasks in general practice but provide basic clinical procedures (21). Health care assistants are a potentially important resource for enhancing patient care in primary care settings (20). Our aim was to evaluate whether case management by a practice-based health care assistant can reduce depression symptoms and improve the process of care for patients with major depression in small primary care practices. Methods We designed a pragmatic, cluster randomized, controlled trial that used practice as the unit of randomization to avoid contamination (22). The institutional review board of Goethe University Frankfurt am Main, Frankfurt am Main, Germany, approved the study protocol on 25 April 2005 (23). We used written consent procedures for family physicians and patients. We recruited practices between February 2005 and May 2005 and patients between May 2005 and July 2006. We carried out the intervention between June 2005 and August 2007. We completed the last follow-up for study patients in September 2007. Setting and Participants After calculating the sample size (24), we informed all 1600 family physicians registered with the medical association of the state of Hesse, Germany (mandatory registration), about the trial and invited them by mail to participate in information meetings. As the registration list presents only names and addresses, we checked inclusion criteria only for those who participated in the meetings. We stopped recruiting when 74 practices had enrolled, even though more practices were interested in participating. Inclusion criteria for the practices were acceptance of all major health plans (90% of patients are covered by this type of insurance) (25); provision of a primary care service, according to the definition of Starfield and colleagues (26); and management by a family physician. Patients were screened on special dates and referred to the trial by the family physician in the primary care practice. Inclusion criteria for patients were diagnosis of major depression with indication for any antidepressive treatment, age 18 to 80 years, access to a private telephone, ability to give informed consent, and ability to communicate in German. The diagnosis of major depression was based on a score of more than 9 points and a categorical diagnosis in the Patient Health Questionnaire-9 (PHQ-9) (27), and was confirmed by the family physician by using the checklists in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and International Classification of Diseases, Tenth Edition. New patients were double-screened with the same procedure within 2 weeks. Exclusion criteria were confirmed pregnancy, severe alcohol or illicit drug consumption, or acute suicidal ideation assessed by the family physician. Randomization and Interventions The data safety and monitoring board stratified the practices according to the size of the city and performed computer-based randomization. Patient random assignment status was nested within the practice status. The data safety and monitoring board was responsible for allocation concealment by keeping the randomization results in a secure database. Because of the practice staff training required for the behavioral intervention, patients, health care assistants, family physicians, and researchers were not blinded to assignment once the trial was started. We designed our case management intervention in accordance with the Chronic Care Model (28, 29), which emphasizes proactive support for the patient by the entire practice team. We trained 1 health care assistant from each practice assigned to the intervention group in 2 workshops (an 11-hour and a 6-hour workshop). This interactive training included information on depression, communication skills, telephone monitoring, and behavioral activation for the patient (3032). The health care assistants contacted their patients by telephone twice a week in the first month and than once a month for the following 11 months. They monitored depression symptoms and adherence to medication by using the Depression Monitoring List (33). Health care assistants also encouraged patients to follow self-management activities, such as medication adherence and activation for pleasant or social activities. The assistants provided this information to the family physician in a structured report that stratified the urgency of the contact by a robot scheme. Family physicians in both the intervention and control groups received training on evidence-based depression treatment guidelines (34). During the trial, other forms of disease or case management programs were uncommon in Germany (35). No study practice carried out case management for any other diseases. Outcomes and Follow-up Self-rating questionnaires were handed out to the patients at baseline and at 6 and 12 months after baseline. Patients filled in the questionnaires at home and sent them back to the practice. We collected the questionnaires in the practices and collected data from patient records (number of family physician and specialist contacts, hospitalization, and prescribed medication). Research staff carried out data input and management (36). Serious adverse events were reported to the data safety and monitoring board. Clinical Outcomes The primary outcome was depression symptoms, which we assessed by using the primary carevalidated PHQ-9 (37). Each item is scored from 0 (not at all) to 3 (nearly every day), for a total score that ranges from 0 to 27 (high scores indicate more severe depression). We assessed response (50% improvement in PHQ-9 score) and remission status (PHQ-9 score<5) as secondary outcomes. We also report data for the following secondary outcomes: quality of life, patient assessment of chronic illness care, and medication adherence. We measured health-related quality of life by using the Medical Outcomes Study Short Form 36 (SF-36) (38, 39) and the EuroQol-5D (40). The SF-36 allows the calculation of scores for physical health and mental health (range, 0 to 100; higher scores indicate better status). The EuroQol-5D is a generic instrument that measures health-related quality of life with a visual analogue scale (range, 0 to 100; higher ratings indicate higher quality of life). We determined the number of physical comorbid conditions by counting the documented diagnoses from different diagnostic groups listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and International Classification of Diseases, Tenth Edition, excluding all psychiatric diagnoses in the patient record. We assessed severity of chronic physical diseases by using the Chronic Disease Score, on the basis of prescription data from the patient record (41). Process-of-Care Outcomes We assessed the number of family physician and mental health specialist contacts, as well as prescriptions for ant

Multimorbidity's research challenges and priorities from a clinical perspective: The case of ‘Mr Curran’

Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.Please see related article: http://www.biomedcentral.com/1741-7015/12/222.

The Systematic Guideline Review: Method, rationale, and test on chronic heart failure

ABSTRACT Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patients needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.

Guideline recommended treatments in complex patients with multimorbidity.

BackgroundEvidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources – especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development – the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF).MethodsA systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline.ResultsOf 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) – the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer.ConclusionThe systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines.

Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)

New evidence is reassuring, but every patient is different

Pilot study to test the feasibility of a trial design and complex intervention on PRIoritising MUltimedication in Multimorbidity in general practices (PRIMUMpilot)

Patients with multimorbidity have complex health needs but, due to the current traditional disease-oriented approach, they face a highly fragmented form of care that leads to inefficient, ineffective, and possibly harmful clinical interventions. There is limited evidence on available integrated and multidimensional care pathways for multimorbid patients. An expert consensus meeting was held to develop a framework for care of multimorbid patients that can be applied across Europe, within a project funded by the European Union; the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). The experts included a diverse group representing care providers and patients, and included general practitioners, family medicine physicians, neurologists, geriatricians, internists, cardiologists, endocrinologists, diabetologists, epidemiologists, psychologists, and representatives from patient organizations. Sixteen components across five domains were identified (Delivery of Care; Decision Support; Self Management Support; Information Systems and Technology; and Social and Community Resources). The description and aim of each component are described in these guidelines, along with a summary of key characteristics and relevance to multimorbid patients. Due to the lack of evidence-based recommendations specific to multimorbid patients, this care model needs to be assessed and validated in different European settings to examine specifically how multimorbid patients will benefit from this care model, and whether certain components have more importance than others.

Strategies to Improve Medication Adherence in Older Persons: Consensus Statement from the Senior Italia Federanziani Advisory Board

Objective To improve medication appropriateness and adherence in elderly patients with multimorbidity, we developed a complex intervention involving general practitioners (GPs) and their healthcare assistants (HCA). In accordance with the Medical Research Council guidance on developing and evaluating complex interventions, we prepared for the main study by testing the feasibility of the intervention and study design in a cluster randomised pilot study. Setting 20 general practices in Hesse, Germany. Participants 100 cognitively intact patients ≥65 years with ≥3 chronic conditions, ≥5 chronic prescriptions and capable of participating in telephone interviews; 94 patients completed the study. Intervention The HCA conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision-support system (CDSS), the GPs discussed medication intake with patients and adjusted their medication regimens. The control group continued with usual care. Outcome measures Feasibility of the intervention and required time were assessed for GPs, HCAs and patients using mixed methods (questionnaires, interviews and case vignettes after completion of the study). The feasibility of the study was assessed concerning success of achieving recruitment targets, balancing cluster sizes and minimising drop-out rates. Exploratory outcomes included the medication appropriateness index (MAI), quality of life, functional status and adherence-related measures. MAI was evaluated blinded to group assignment, and intra-rater/inter-rater reliability was assessed for a subsample of prescriptions. Results 10 practices were randomised and analysed per group. GPs/HCAs were satisfied with the interventions despite the time required (35/45 min/patient). In case vignettes, GPs/HCAs needed help using the CDSS. The study made no patients feel uneasy. Intra-rater/inter-rater reliability for MAI was excellent. Inclusion criteria were challenging and potentially inadequate, and should therefore be adjusted. Outcome measures on pain, functionality and self-reported adherence were unfeasible due to frequent missing values, an incorrect manual or potentially invalid results. Conclusions Intervention and trial design were feasible. The pilot study revealed important limitations that influenced the design and conduct of the main study, thus highlighting the value of piloting complex interventions. Trial registration number ISRCTN99691973; Results.

International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

Poor adherence to treatment regimens has long been recognized as a substantial roadblock to achieving better outcomes for patients. Non-adherence to medications affects the quality and length of life and has been associated with negative health outcomes and increasing healthcare costs. The problem of non-adherence is particularly troublesome in older patients who are affected by multiple chronic diseases and for this reason receive multiple treatments. To date, no single intervention strategy has been shown to be effective in improving adherence across all patients, conditions, and settings. Between September and October 2014, a group of experts in geriatrics, pharmacology, epidemiology, and public health applied a modified RAND appropriateness method to reach a consensus on the possible best interventions to improve adherence in older individuals. Seven interventions were identified, classified based on their target (patient, therapy, and public health/society): (1) Comprehensive Geriatric Assessment, (2) patient (and caregiver) education to improve patient empowerment, (3) optimization of treatment, (4) use of adherence aids, (5) physician and other healthcare professionals’ education, (6) adherence assessment, (7) facilitating access to medicine by service integration. For each intervention, experts assessed (a) target population, (b) health professionals potentially involved in the intervention, (c) strategies/instruments needed for implementation, and (d) time of the intervention. Interventions that target adherence must combine different approaches targeting the complex aspects of older adults in a holistic approach. Tackling non-adherence, with its complexity, requires a multi-stakeholder patient-centred approach acting in a defined framework of interactions in which the different players may provide different services but are integrated with one another.