Lise Lapointe

Prevalence of Multimorbidity Among Adults Seen in Family Practice

PURPOSE There are few valid data that describe the extent of multimorbidity in primary care patients. The purpose of this study was to estimate its prevalence in family practice patients by counting the number of chronic medical conditions and using a measure that considers the severity of these conditions, the Cumulative Illness Rating Scale (CIRS). METHODS The study was carried out in the Saguenay region (Québec, Canada) in 2003. The participation of adult patients from 21 family physicians was solicited during consecutive consultation periods. A research nurse reviewed medical records and extracted the data regarding chronic illnesses. For each chronic condition, a severity rating was determined in accordance with the CIRS scoring guidelines. RESULTS The sample consisted of 320 men and 660 women. Overall, 9 of 10 patients had more than 1 chronic condition. The prevalence of having 2 or more medical conditions in the 18- to 44-year, 45- to 64-year, and 65-year and older age-groups was, respectively, 68%, 95%, and 99% among women and 72%, 89%, and 97% among men. The mean number of conditions and mean CIRS score also increased significantly with age. CONCLUSIONS Whether measured by simply counting the number of conditions or using the CIRS, the prevalence of multimorbidity is quite high and increases significantly with age in both men and women. Patients with multimorbidity seen in family practice represent the rule rather than the exception.

Multimorbidity and quality of life in primary care: a systematic review

BackgroundMany patients with several concurrent medical conditions (multimorbidity) are seen in the primary care setting. A thorough understanding of outcomes associated with multimorbidity would benefit primary care workers of all disciplines. The purpose of this systematic review was to clarify the relationship between the presence of multimorbidity and the quality of life (QOL) or health-related quality of life (HRQOL) of patients seen, or likely to be seen, in the primary care setting.MethodsMedline and Embase electronic databases were screened using the following search terms for the reference period 1990 to 2003: multimorbidity, comorbidity, chronic disease, and their spelling variations, along with quality of life and health-related quality of life. Only descriptive studies relevant to primary care were selected.ResultsOf 753 articles screened, 108 were critically assessed for compliance with study inclusion and exclusion criteria. Thirty of these studies were ultimately selected for this review, including 7 in which the relationship between multimorbidity or comorbidity and QOL or HRQOL was the main outcome measure. Major limitations of these studies include the lack of a uniform definition for multimorbidity or comorbidity and the absence of assessment of disease severity. The use of self-reported diagnoses may also be a weakness. The frequent exclusion of psychiatric diagnoses and presence of potential confounding variables are other limitations. Nonetheless, we did find an inverse relationship between the number of medical conditions and QOL related to physical domains. For social and psychological dimensions of QOL, some studies reveal a similar inverse relationship in patients with 4 or more diagnoses.ConclusionsOur findings confirm the existence of an inverse relationship between multimorbidity or comorbidy and QOL. However, additional studies are needed to clarify this relationship, including the various dimensions of QOL affected. Those studies must employ a clear definition of multimorbidity or comorbidity and valid ways to measure these concepts in a primary care setting. Pursuit of this research will help to better understand the impact of chronic diseases on patients.

Relationship Between Multimorbidity and Health-Related Quality of Life of Patients in Primary Care

Previous studies about the association of multimorbidity and the health-related quality of life (HRQOL) in primary-care patients are limited because of their reliance on simple counts of diseases from a limited list of diseases and their failure to assess the severity of disease. We evaluated the association while taking into account the severity of the medical conditions based on the Cumulative Illness Rating Scale (CIRS) score, and controlling for potential confounders (age, sex, household income, education, self-perception of economic status, number of people living in the same dwelling, and perceived social support). We randomly selected 238 patients to construct quintiles of increasing multimorbidity (CIRS). Patients completed the 36-item Medical Outcomes study questionnaire (SF-36) to evaluate their HRQOL. Applying bivariate and multivariate linear regression analyses, we used the CIRS as either a continuous or a categorical (quintiles) variable. Use of the CIRS revealed a stronger association of HRQOL with multimorbidity than using a simple count of chronic conditions. Physical more than mental health deteriorated with increasing multimorbidity. Perceived social support and self-perception of economic status were significantly related to all scales of the SF-36 (p < 0.05). Increased multimorbidity adversely affected HRQOL in primary-care adult patients, even when confounding variables were controlled for.

Randomized Controlled Trials: Do They Have External Validity for Patients With Multiple Comorbidities?

PURPOSE Many randomized controlled trials (RCTs) exclude patients who have multiple comorbidities. The aim of this study was to illustrate the prevalence of comorbidities among patients followed up in primary care who would have met the inclusion criteria of selected RCTs focusing on treatment of a particular condition. We used hypertension as an example of a particular chronic condition. METHODS We used an existing database of 980 patients (660 women) that was representative of a population consulting primary care family doctors and that contained information about all chronic conditions. We randomly selected 5 RCTs that focused on patients with hypertension. The inclusion and exclusion criteria used in each of the 5 RCTs were applied (1 study at a time) to the patients in our database. The patients from our data set who met the inclusion criteria of a given RCT were considered eligible for that RCT. RESULTS Of the patients from our data set who were eligible for each of the RCTs, 89% to 100% had multiple chronic conditions. The mean number of chronic conditions of patients eligible for each RCT ranged from 5.5 ± 3.3 to 11.7 ± 5.3. CONCLUSIONS Results from this study suggest that RCTs targeting a chronic medical condition such as hypertension could find that, in a sample taken from family practice, most eligible patients have comorbid conditions. Whether these patients are sampled or excluded should be reported. Research results intended to be applied in medical practice should take the complex reality of effective treatment of these patients into consideration.

Psychological Distress and Multimorbidity in Primary Care

PURPOSE Psychological distress may decrease adherence to medical treatments and lead to poorer health outcomes of chronic diseases. The aim of this study was to evaluate the relationship between psychological distress and multimorbidity among patients seen in family practice after controlling for potential confounding variables and taking into account the severity of diseases. METHODS We evaluated 238 patients to construct quintiles of increasing multimorbidity based on the Cumulative Illness Rating Scale (CIRS), which is a comprehensive multimorbidity index that takes into account disease severity. Patients completed a psychiatric symptom questionnaire as a measurement of their psychological distress. In the first model of logistic regression analyses, we used the counted number of chronic diseases as the independent variable. In subsequent models, we used the quintiles of CIRS. RESULTS After adjusting for confounding factors, multimorbidity measured by a simple count of chronic diseases was not related to psychological distress (OR, 1.12; 95% CI, 0.97–1.29; P = .188), whereas multimorbidity measured by the CIRS remained significantly associated (OR, 1.67; 95% CI, 1.19–2.37; P = .002). The estimate risk of psychological distress by quintile of CIRS was as follows: Q1/2 = 1.0; Q3 = OR, 1.72; 95% CI, 0.53–5.86; Q4 = OR, 2.99; 95% CI, 1.01–9.74; Q5 = OR, 4.67; 95% CI, 1.61–15.16. CONCLUSIONS Psychological distress increased with multimorbidity when we accounted for disease severity. Clinicians should be aware of the possible presence of psychological distress, which can further complicate the comprehensive management of these complex patients.

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.