Hassan Soubhi

Managing patients with multimorbidity : systematic review of interventions in primary care and community settings

Objective To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Design Systematic review. Data sources Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011). Eligibility criteria Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs. Data selection Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out. Results 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings. Conclusions Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.

Multimorbidity's many challenges

Time to focus on the needs of this vulnerable and growing population

Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life

BackgroundMeasures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL.MethodsWe used data on chronic diseases and on the SF-36 questionnaire assessing HRQOL of 238 adult primary care patients who participated in a previous study. We extracted all the diagnoses for every patient from chart review to score the CIRS, the FCI and the Charlson. Data for potential confounders (age, sex, self-perceived economic status and self-perceived social support) were also collected. We calculated the Pearson correlation coefficients (r) of the SF-36 scores with the three measures of multimorbidity, as well as the coefficient of determination, R2, while controlling for confounders.ResultsThe r values for the CIRS (range: -0.55 to -0.18) were always higher than those for the FCI (-0.47 to -0.10) and Charlson (-0.31 to -0.04) indices. The CIRS explained the highest percent of variation in all scores of the SF-36, except for the Mental Component Summary Score where the variation was not significant. Variations explained by the FCI were significant in all scores of SF-36 measuring physical health and in two scales evaluating mental health. Variations explained by the Charlson were significant in only three scores measuring physical health.ConclusionThe CIRS is a better choice as a measure of multimorbidity than the FCI and the Charlson when HRQOL is the outcome of interest. However, the FCI may provide a good option to evaluate the physical aspect of HRQOL for the ease in its administration and scoring. The Charlson index may not be recommended as a measure of multimorbidity in studies related to either physical or mental aspects of HRQOL.

Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other’s goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Relationship between multimorbidity and physical activity: secondary analysis from the Quebec health survey.

BackgroundAbundant literature supports the beneficial effects of physical activity for improving health of people with chronic diseases. The relationship between multimorbidity and physical activity levels, however, has been little evaluated. The purpose of the current exploratory study was to examine the relationship between a) multimorbidity and physical activity levels, and b) long-term limitations on activity, self-rated general health, psychological distress, and physical activity levels for each sex in adults, after age, education, income, and employment factors were controlled for.MethodsData from the Quebec Health Survey 1998 were used. The sample included 16,782 adults 18–69 yr of age. Independent variables were multimorbidity, long-term limitations on activity, self-rated general health, and psychological distress. The dependent variable was physical activity levels. Links between the independent and dependent variables were assessed separately for men and women with multinomial regressions while accounting for the survey sampling design and household clustering.ResultsAbout 46% of the participants were men. Multimorbidity was not associated with physical activity levels for either men or women. Men and women with long-term limitations on activity and with poor-to-average self-rated general health were less likely to be physically active. No relationship between psychological distress and physical activity was found for men. Women with high levels of psychological distress were less likely to be physically active.ConclusionMultimorbidity was not associated with physical activity levels in either sex, when age, education, income, and employment factors were controlled for. Long-term limitations on activity and poor-to-average self-rated general health seem related to a reduction in physical activity levels for both sexes, whereas psychological distress was associated with a reduction in physical activity levels only among women. Longitudinal studies using a comorbidity or multimorbidity index to account for severity of the chronic diseases are needed to replicate the results of this exploratory study.

Interprofessional learning in the trenches: fostering collective capability.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value – caring for patients – to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

Toward an Ecosystemic Approach to Chronic Care Design and Practice in Primary Care

Despite the increasing prevalence of chronic conditions and multimorbidities, the essential attributes of the structure and delivery of primary care continue to be defined in terms of disease-specific approaches and acute conditions. Effective improvements will require alternative ways of thinking about chronic care design and practice. This essay argues for an ecosystemic understanding of chronic care founded on a communal and a dynamic view of the response of the patient, family, and health professionals to chronic illness. The communal view highlights the cocreative nature of the response to illness and the need to integrate the skills and resources of all the participants; what and how the participants learn in the course of the illness become central to chronic care. The dynamic view draws attention to the unfolding of illness management activities over time and to the need to engage the illness at specific time points or recurring time intervals that have the potential for important change in the experience of the participants. Chronic care would then include design for community, with an emphasis on the patient and family as necessary participants in the health care team. It would also include design for emergent learning and practice whereby health professionals go beyond standardization of care processes to develop new ways to harness the participants’ imagination and learn from the changing experience of illness. Health professionals would also learn to cultivate trust, communal engagement, and openness to experimentation that facilitate collective learning, and help sharpen the participants’ responsiveness to the emergent.

Perceived conflict in the couple and chronic illness management: Preliminary analyses from the Quebec Health Survey

BackgroundThe quality of the relationship with the spouse/partner appears crucial among patients with multiple chronic conditions where illness management is complex and multifaceted. This study draws on data from the Quebec Health Survey (QHS) to examine, among patients with one or more chronic conditions, the relation between marital status, the perceived conflict with the spouse/partner, and what the patients do to manage their illness as well as how they perceive their health.MethodsData from the QHS 1998 were used. The sample included 7547 coupled adults who had one or more chronic health problems lasting more than 6 months. Independent variables included marital status, perceived conflict with the spouse/partner, and the number of chronic conditions. Illness management was defined broadly as a measure of the patients efforts at self-care and an illness status indicator, including visits to the generalist and the specialist, the use of telephone health line in the last 12 months, self-rated general health, mental health, and a measure of psychological distress. Linkages between the independent variables and illness management were assessed for males and females separately with logistic regressions, while accounting for the survey sampling design and household clustering.ResultsFemale patients who did not live with their partner and had never been married were more likely to report a negative perception of their general health and a higher psychological distress than those who were married. Perceived conflict with the partner was linked to a negative perception of mental health and a higher psychological distress among both men and women. Compared to patients with only one chronic condition, males who reported more than one chronic condition were more likely to have consulted a generalist prior to the survey and used the telephone health line, whereas females were more likely to have consulted a specialist. Both males and females with more than one chronic condition were more likely to have a negative perception of their general health and mental health.ConclusionThe study provides a useful preliminary measure of the importance of living arrangements and the quality of the couple relationship in chronic illness management broadly conceived as a measure of the patients efforts at self-care and an illness status indicator. Results of this study prod us to examine more closely, within longitudinal designs, the influence of living arrangements and the presence of conflict in the couple on chronic illness management as well as the modifying effect of gender on these associations.

Professionalism in Medicine

Jill Thistlethwaite and John Spencer have authored a thoughtful, well documented book that will satisfy everyone interested in what professionalism means and what it calls for in a doctor. The chapters that drew my rapt attention were the first, the second, the fifth, and the last. Not that the other eight chapters were less engaging or informative. Readers will find countless bits – some tantalizing in their brevity, others highly instructive in their details – on law and ethics, professional and patient relationships, autonomy, competence and cultural diversity, lifelong learning, self-care, and teaching and assessing professionalism. By the end of the book, readers will have a comprehensive view of what is needed in a professional: a compelling ensemble of attributes and behaviors that surely requires a lifetime of practice. Setting the basis of what is meant by professionalism, the opening chapter presents medical professionalism as the foundation of medicine’s contract with society. In exchange for the principled application of knowledge and skills in the best interest of patients, doctors gain autonomy, freedom to self-regulate, and considerable social status. Understandably, there are all the ingredients for both reverence and contempt, but also for periods of intense scrutiny of what may pass as monopoly and elitism. Examining the developments in both the UK and North America, the authors go on to explain what helped catalyzed thinking in medical professionalism, particularly in the last ten years or so. I savored reading the second chapter as it took me through the history of the concept starting with Hippocrates. What better way to learn about professionalism than in understanding its origins and evolution. Box 2.2 on p. 25 for example, presents a delightful view of important dates in the professionalization of medicine: from 1511 with the institution of license to practice to 1858 with the establishment of rights to the profession to selfregulate relatively freely from lay and government control – a highly questioned freedom in the new millennium, reported the authors in the preceding chapter, since both the profession and society must now clearly understand the elements of professionalism. The fifth chapter examines communication within teams and the value that interprofessional education may bring to clinical practice. Interestingly enough, clinical practice is the site for encounters with the expertise of multiple professionals, but also with uncertainty, ill defined problems, knowledge and ignorance, empathy and cynicism, cooperation and competition, altruism and selfishness, all human attributes in a highly humane endeavor: caring for the sick. Can the encounters of these attributes be regulated by the social contracts that define the professions? Can the elaboration of medical professionalism reduce or increase conflicts in interprofessional practice? Journal of Interprofessional Care, March 2010; 24(2): 213–216