Marie-Eve Poitras

A Systematic Review of Prevalence Studies on Multimorbidity: Toward a More Uniform Methodology

PURPOSE We sought to identify and compare studies reporting the prevalence of multimorbidity and to suggest methodologic aspects to be considered in the conduct of such studies. METHODS We searched the literature for English- and French-language articles published between 1980 and September 2010 that described the prevalence of multimorbidity in the general population, in primary care, or both. We assessed quality of included studies with a modified version of the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Results of individual prevalence studies were adjusted so that they could be compared graphically. RESULTS The final sample included 21 articles: 8 described studies conducted in primary care, 12 in the general population, and 1 in both. All articles were of good quality. The largest differences in prevalence of multimorbidity were observed at age 75 in both primary care (with prevalence ranging from 3.5% to 98.5% across studies) and the general population (with prevalence ranging from 13.1% to 71.8% across studies). Apart from differences in geographic settings, we identified differences in recruitment method and sample size (primary care: 980–60,857 patients; general population: 1,099–316,928 individuals), data collection, and the operational definition of multimorbidity used, including the number of diagnoses considered (primary care: 5 to all; general population: 7 to all). This last aspect seemed to be the most important factor in estimating prevalence. CONCLUSIONS Marked variation exists among studies of the prevalence of multimorbidity with respect to both methodology and findings. When undertaking such studies, investigators should carefully consider the specific diagnoses included and their number, as well as the operational definition of multimorbidity.

Measuring Patients’ Perceptions of Patient-Centered Care: A Systematic Review of Tools for Family Medicine

PURPOSE Patient-centered care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify and compare instruments, subscales, or items assessing patients’ perceptions of patient-centered care in family medicine. METHODS We conducted a systematic literature review using the MEDLINE, Embase, and Cochrane databases covering 1980 through April 2009, with a specific search strategy for each database. The search strategy was supplemented with searching by hand and expert suggestions. We looked for articles meeting all of the following criteria: (1) describing self-administered instruments measuring patient perceptions of patient-centered care; (2) reporting quantitative or psychometric results of development or validation; (3) being relevant to an ambulatory family medicine context. The quality of each article retained was assessed using a modified version of the Standards for Reporting of Diagnostic Accuracy. Instrument’ items were mapped to dimensions of a patient-centered care conceptual framework. RESULTS Of the 3,045 articles identified, 90 were examined in detail, and 26, covering 13 instruments, met our inclusion criteria. Two instruments (5 articles) were dedicated to patient-centered care: the Patient Perception of Patient-Centeredness and the Consultation Care Measure, and 11 instruments (21 articles) included relevant subscales or items. CONCLUSIONS The 2 instruments dedicated to patient-centered care address key dimensions but are visit-based, limiting their applicability for the study of care processes over time, such as chronic illness management. Relevant items from the 11 other instruments provide partial coverage of the concept, but these instruments were not designed to provide a specific assessment of patient-centered care.

Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity

BackgroundClinical guidelines have been the subject of much criticism in primary care literature partly due to potential conflicts in their implementation among patients with multiple chronic conditions. We assessed the relevance of selected Canadian clinical guidelines on chronic diseases for patients with comorbidity and examined their quality.MethodsWe selected 16 chronic medical conditions according to their frequency of occurrence, complexity of treatment, and pertinence to primary care. Recent Canadian clinical guidelines (2004 - 2009) on these conditions, published in English or French, were retrieved. We assessed guideline relevance to the care of patients with comorbidity with a tool developed by Boyd and colleagues. Quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.ResultsRegarding relevance, 56.2% of guidelines addressed treatment for patients with multiple chronic conditions and 18.8% addressed the issue for older patients. Fifteen guidelines (93.8%) included specific recommendations for patients with one concurrent condition; only three guidelines (18.8%) addressed specific recommendations for patients with two comorbid conditions and one for more than two concurrent comorbid conditions. Quality of the evaluated guidelines was good to very good in four out of the six domains measured using the AGREE instrument. The domains with lower mean scores were Stakeholder Involvement and Applicability.ConclusionsThe quality of the Canadian guidelines examined is generally good, yet their relevance for patients with two or more chronic conditions is very limited and there is room for improvement in this respect.

Enablement in health care context: a concept analysis

RATIONALE, AIMS AND OBJECTIVES The enablement process is defined as a professional intervention aiming to recognize, support and emphasize the patients capacity to have control over her or his health and life. The purpose of this article was to study the enablement concept through a concept analysis in the health care context to identify: (1) its attributes and (2) its antecedents and consequents. METHOD A concept analysis was performed according to the method of Rodgers. The literature was reviewed from 1980 to June 2008, using search strategies adapted to the databases Cinahl, Medline, Embase, PsycInfo and Social Works Abstract, and hand searching. All articles contributing to a deeper understanding of the concept were included. The analysis was carried out according to a thematic analysis procedure, as described by Miles & Huberman. RESULTS The search identified 1305 citations. After in-depth assessment of 148 potentially eligible citations, 61 articles were included in the review. Five articles were added with hand searching. Sixty-seven per cent of these articles were related to nursing. The attributes of the enablement concept included: contribution to the therapeutic relationship; consideration of the person as a whole; facilitation of learning; valorization of the persons strengths; implication and support to decision making; and broadening of the possibilities. CONCLUSION These attributes could be used as a basis for other studies on enablement. Conceptual and empirical work is still needed to better position this concept among others such as patient-centred care, shared decision making and patients participation.

The relationship between literacy and multimorbidity in a primary care setting

BackgroundMultimorbidity is now acknowledged as a research priority in primary care. The identification of risk factors and people most at risk is an important step in guiding prevention and intervention strategies. The aim of this study was to examine the relationship between literacy and multimorbidity while controlling for potential confounders.MethodsParticipants were adult patients attending the family medicine clinic of a regional health centre in Saguenay (Quebec), Canada. Literacy was measured with the Newest Vital Sign (NVS). Multimorbidity was measured with the Disease Burden Morbidity Assessment (DBMA) by self-report. Information on potential confounders (age, sex, education and family income) was also collected. The association between literacy (independent variable) and multimorbidity was examined in bivariate and multivariate analyses. Two operational definitions of multimorbidity were used successively as the dependent variable; confounding variables were introduced into the model as potential predictors.ResultsOne hundred three patients (36 men) 19–83 years old were recruited; 41.8% had completed 12 years of school or less. Forty-seven percent of patients provided fewer than four correct answers on the NVS (possible low literacy) whereas 53% had four correct responses or more. Literacy and multimorbidity were associated in bivariate analyses (p < 0.01) but not in multivariate analyses, including age and family income.ConclusionThis study suggests that there is no relationship between literacy and multimorbidity when controlling for age and family income.

Family physician enabling attitudes: a qualitative study of patient perceptions

BackgroundFamily physicians frequently interact with people affected by chronic diseases, placing them in a privileged position to enable patients to gain control over and improve their health. Soliciting patients’ perceptions about how their family physician can help them in this process is an essential step to promoting enabling attitudes among these health professionals. In this study, we aimed to identify family physician enabling attitudes and behaviours from the perspective of patients with chronic diseases.MethodsWe conducted a descriptive qualitative study with 30 patients, 35 to 75 years of age presenting at least one common chronic disease, recruited in primary care clinics in two regions of Quebec, Canada. Data were collected through in-depth interviews and were analyzed using thematic analysis.ResultsFamily physician involvement in a partnership was perceived by participants as the main attribute of enablement. Promoting patient interests in the health care system was also important. Participants considered that having their situation taken into account maximized the impact of their physician’s interventions and allowed the legitimization of their feelings. They found their family physician to be in a good position to acknowledge and promote their expertise, and to help them maintain hope.ConclusionsFrom the patient’s perspective, their partnership with their family physician is the most important aspect of enablement.

Validation of the disease burden morbidity assessment by self-report in a French-speaking population

BackgroundThe Disease Burden Morbidity Assessment (DBMA) is a self-report questionnaire used to estimate the disease burden experienced by patients. The aim of this study was to test and to measure the properties of the French translation of the DBMA (DBMA-Fv).MethodsThe original version of the DBMA was translated into French (Canadian) and first assessed during cognitive interviews. In the validation study, patients recruited during consecutive consultation periods completed the DBMA-Fv questionnaire while they were in the waiting room of a primary care setting (T1). Participants completed the same questionnaire mailed to their home two weeks later (T2). Concomitant validity of the DBMA-Fv was assessed using the Cumulative Illness Rating Scale (CIRS). Patient medical records were reviewed to verify chronic diseases and past medical history.ResultsNinety-seven patients were recruited and 85 (88%) returned the mailed questionnaires; 5 (5.9%) were incomplete. DBMA-Fv scores of the 80 participants with a complete questionnaire at T2 ranged from 0 to 30 (median 5.5, mean 7.7, SD = 7.0). Test-retest reliability of the DBMA-Fv was high (ICC: 0.86, 95% CI: 0.79-0.92). The DBMA-Fv and the CIRS correlated moderately at T1 (r = 0.46, 95% CI: 0.26 - 0.62, p < 0.01) and T2 (r = 0.56, 95% CI: 0.38 - 0.70, p < 0.01). The mean (SD) sensitivity of patient reports of a condition in relation to chart review at T2 was 73.9 (8.4) (range 62.5% to 90%). The overall mean (SD) specificity was 92.2 (6.7) (range 77.6% to 98.6%).ConclusionsThe DBMA-Fvs properties are similar to its English counterpart as to its median sensitivity and specificity compared to chart reviews. It correlated moderately with an established index of multimorbidity. A high percentage of patients were able to complete the test correctly as a mail questionnaire and it showed high test-retest reliability.

The Patient Enablement Instrument-French version in a family practice setting: a reliability study

BackgroundPatient enablement can be defined as the extent to which a patient is capable of understanding and coping with his or her health issues. This concept is linked to a number of health outcomes such as self-management of chronic diseases and quality of life. The Patient Enablement Instrument (PEI) was designed to measure this concept after a medical consultation. The instrument, in its original form and its translations into several languages, has proven to be reliable and valid. The purpose of this study was to evaluate the reliability of the French version of the PEI (PEI-Fv) in a family practice setting.MethodsOne hundred and ten participants were recruited in a family medicine clinic in the Saguenay region of Quebec (Canada). The PEI-Fv was completed twice, immediately after consultation with a physician (T1) and 2 weeks after the consultation (T2). The internal consistency of the tool was assessed with Cronbachs α and test-retest reliability by intraclass correlation coefficient.ResultsThe mean score for the PEI-Fv was 5.06 ± 3.97 (95% confidence interval [CI]: 4.30-5.81) at T1 and 4.63 ± 3.90 (95% CI: 3.82-5.44) at T2. Cronbachs α was high at T1 (α1 = 0.93; 95% CI: 0.91-0.95) and T2 (α2 = 0.93; 95% CI: 0.91-0.95). The intraclass correlation coefficient was 0.62 (95% CI: 0.48-0.74), indicating a moderate test-retest reliability.ConclusionsThe internal consistency of the PEI-Fv is excellent. Test-retest reliability was moderate to good. Test-retest reliability should be examined in further studies at a less than 2-week interval to reduce maturation bias. This instrument can be used to measure enablement after consultation in a French-speaking family practice setting.

Primary care nursing activities with patients affected by physical chronic disease and common mental disorders: A qualitative descriptive study

AIMS AND OBJECTIVES To describe nursing activities in primary care with patients affected by physical chronic disease and common mental disorders. BACKGROUND Patients in primary care who are affected by physical chronic disease and common mental disorders such as anxiety and depression require care and follow-up based on their physical and mental health condition. Primary care nurses are increasingly expected to contribute to the care and follow-up of this growing clientele. However, little is known about the actual activities carried out by primary care nurses in providing this service in the Province of Quebec (Canada). METHODS A qualitative descriptive study was conducted. Data were obtained through semistructured individual interviews with 13 nurses practising among patients with physical chronic disease in seven Family Medicine Groups in Quebec (Canada). RESULTS Participants described five activity domains: assessment of physical and mental health condition, care planning, interprofessional collaboration, therapeutic relationship and health promotion. CONCLUSION The full potential of primary care nurses is not always exploited, and some activities could be improved. Evidence for including nurses in collaborative care for patients affected by physical chronic disease and common mental disorders has been shown but is not fully implemented in Family Medicine Groups. Future research should emphasise collaboration among mental health professionals, primary care nurses and family physicians in the care of patients with physical chronic disease and common mental disorders. RELEVANCE TO CLINICAL PRACTICE Primary care nurses would benefit from gaining more knowledge about common mental disorders and from identifying the resources they need to contribute to managing them in an interdisciplinary team.

How to report professional practice in nursing? A scoping review

BackgroundNursing professional practice in different contexts of care has been widely described in evidence-based literature. Currently, there is no consensus on a common structure for these descriptions. Understanding and comparing similar practices is made difficult by the varying nature of descriptions provided in scientific literature. Purpose of the study: 1) to report research methods found in the scientific literature that were used to describe the practice of different health professionals; 2) to report on the main concepts used to describe the practice of these health professionals; 3) to propose a structure for the description of the practice in nursing.MethodsA scoping review following a five-stage approach: 1) identifying the research question; 2) identifying relevant studies; 3) selecting studies; 4) charting data; 5) reporting results. The Medline, CINAHL, psychARTICLES, psyCRITIQUES, psycEXTRA, Psychology and Behavioral Science Collection and psycINFO databases were searched. Each study was analyzed and extracted data were classified by categories and structures used to describe the health professional practices.ResultsForty-nine studies were included. In these studies, quantitative, qualitative or mixed methods were used to describe professional practice in different health disciplines. Three major concepts were reported most frequently in describing professional practice: roles, domains and activities. The concepts varied greatly among authors. We found that to define roles or to characterize a professional practice, activities must be described and organized on the basis of different domains.ConclusionsA promising structure for describing nursing professional practice is proposed by the authors of this review. The structure facilitates the accurate description of all domains and activities performed by nurses in different contexts of practice, and will contribute to the development of knowledge about nursing practice in different contexts based on shared concepts.