Pauline Boeckxstaens

James Mackenzie Lecture 2011: multimorbidity, goal-oriented care, and equity

![][1] Today we face an important demographic and epidemiological transition, confronting us with the challenge of non-communicable diseases (NCDs), which occur more and more in the context of multimorbidity. In the next decade, multimorbidity will become the rule, no longer the exception: 50% of the those aged ≥65 years have at least three chronic conditions, whereas 20% of the ≥65-year group have at least five chronic conditions.1 In the case of COPD, for example, more than half of the patients have at least one comorbid disease.2 In recent years, not only Western countries, but also developing countries started with ‘chronic disease management-programmes’ to improve care. The design of those programmes include most frequently: strategies for case-finding, protocols describing what should be done and by whom, the importance of information and empowerment of the patient, and the definition of process- and outcome-indicators that may contribute to the monitoring of care. Wagner has described the different components of the Chronic Care Model (CCM) as developed in the context of primary health care.3 The CCM has inspired policy makers and providers all over the world and is widely accepted in the US and Canada, Europe, and Australia. Taking into account the epidemiological transition, we are faced with the question: ‘How will this approach work in a situation of multimorbidity’? Let us illustrate this with a patient from our general practice, we call her ‘Jennifer’ (Box 1). #### Box 1. Jennifer Jennifer is 75 years old. Fifteen years ago she lost her husband. She has been a patient at the practice for 15 years now. During these 15 years she has been through a difficult medical history: hip replacement surgery for osteoarthritis, hypertension, type 2 diabetes, and COPD. She lives independently at home, with some help from her youngest daughter, Elisabeth. I visit her regularly … [1]: /embed/graphic-1.gif

The relationship of multimorbidity with disability and frailty in the oldest patients: A cross-sectional analysis of three measures of multimorbidity in the BELFRAIL cohort

Abstract Background: Ageing people show increasing morbidity, dependence and vulnerability. Objectives: To compare the relationships of different measures of multimorbidity with dependence (operationalized as disability) and vulnerability (operationalized as frailty). Method: A cross-sectional analysis within the BELFRAIL cohort (567 subjects aged ≥ 80). Multimorbidity was measured using a disease count (DC), the Charlson comorbidity index (CCI) and the cumulative illness rating scale (CIRS), respectively. Associations with disability (based on activities of daily living) and frailty (defined by the Fried frailty criteria) were assessed using bivariable and multivariable analyses. Net reclassification improvement (NRI) values were calculated to compare the abilities of the DC, CCI and CIRS to identify patients with disability or frailty. Results: Disability was associated with the DC (crude odds ratio, OR: 2.1; 95% confidence interval, CI: 1.4–3.4), CCI (crude OR: 1.8; 95% CI: 1.2–2.7) and CIRS (crude OR: 4.0; 95% CI: 2.5–6.5); only the association with CIRS was independent of age, sex, chronic inflammation, impaired cognition and frailty (adjusted OR: 3.2; 95% CI: 1.7–5.8). Frailty was associated with CCI (crude OR: 2.4; 95% CI: 1.2–4.6) and CIRS (crude OR: 2.6; 95% CI: 1.3–5.3); adjusted for age, sex, chronic inflammation, impaired cognition and disability. These associations were not statistically significant. The NRIs demonstrated a similar ability of the DC, CCI, and CIRS to identify patients with disability or frailty, respectively. Conclusion: The associations of different measures of multimorbidity with disability and frailty differ but their ability to identify patients with disability or frailty is similar. Generally, multimorbidity scores incompletely reflect dependence and vulnerability in this age group.

Chronic Disease Management Programmes: an adequate response to patients’ needs?

Background  Inspired by American examples, several European countries are now developing disease management programmes (DMPs) to improve the quality of care for patients with chronic diseases. Recently, questions have been raised whether the disease management approach is appropriate to respond to patient‐defined needs.

Multimorbidity measures were poor predictors of adverse events in patients aged ≥80 years: a prospective cohort study

OBJECTIVES To assess and compare the ability of two measures of multimorbidity and a simple disease count (DC) to predict health outcomes in a population of patients aged ≥80 years. STUDY DESIGN AND SETTING A prospective, observational, and population-based cohort study including 567 individuals [3.0 years (standard deviation ± 0.25) follow-up]. RESULTS Of the patients, 37.6% were reported with five or more diseases. Multimorbidity was measured by means of a modified Charlson comorbidity index [mCCI; median score, 5 (range, 4-15)], Cumulative Illness Rating Scale [CIRS; median score, 4 (range, 1-11)], and a simple DC of 22 selected chronic conditions [median score, 4 (range, 0-13)]. All measures were independently related to mortality [adjusted hazard ratio (HR) mCCI, 2.5 (confidence interval {CI}: 1.5, 4.1); CIRS, 2.1 (CI: 1.4, 3.2); DC, 2.1 (CI: 1.4, 3.2)] and hospitalization [adjusted HR DC, 2.3 (CI: 1.7, 3.1); mCCI, 2.1 (CI: 1.5, 3.0), CIRS, 1.9 (CI: 1.5, 2.6)] but not to functional decline. Areas under the curve for mortality and hospitalization were all below 0.70. Net reclassification improvements did not indicate that any one measure provided a significant benefit over the others. CONCLUSION In this population, the mCCI, CIRS, and unweighted DC predicted mortality and hospitalization but not functional decline. There is no clear advantage of using one measure over another.

A practice-based analysis of combinations of diseases in patients aged 65 or older in primary care

BackgroundMost evidence on chronic diseases has been collected for single diseases whereas in reality, patients often suffer from more than one condition. There is a growing need for evidence-based answers to multimorbidity, especially in primary care settings where family doctors (FD’s) provide comprehensive care for a high variety of chronic conditions. This study aimed to define which disease and problem combinations would be most relevant and useful for the development of guidelines to manage multimorbidity in primary care.MethodsA practice-based cross sectional analysis of clinicians’ chart reviews in 543 patients aged over 65 registered within two family practices in Ghent, Belgium. Main outcome measures were prevalence of disease and problem combinations and association strengths.ResultsThe prevalence of multimorbidity (Cumulative Illness Rating Scale >1) in the study sample is 82.6%. The most prevalent combination is hypertension-osteoarthritis (132/543). Moderate to strong associations (Yules Q > 0.50) are reported for 14 combinations but the corresponding prevalences are mostly below 5%. More than half of these associations show a contribution of a psychiatric problem or a social problem.ConclusionsThis study confirms the high prevalence of multimorbidity in patients aged over 65 in primary care. Hypertension-osteoarthritis is defined as a frequent combination however 94% of these patients have more than two disorders. The low prevalence of specific combinations, the high prevalence of psychiatric and social problems and the general complexity of multimorbidity will hamper the usefulness of randomized trials or guidelines at practice level. There is a need to explore new paradigms for addressing multimorbidity.

Chronic obstructive pulmonary disease and comorbidities through the eyes of the patient.

Patient’s attitudes and illness beliefs have shown to be of great importance in chronic obstructive pulmonary disease (COPD). As former qualitative research has mainly focused on patients with end-stage COPD, who are recruited within hospital or pulmonary rehabilitation settings, and excluding patients with disabling comorbidities, this study specifically aims to explore the perspectives of patients with COPD and comorbidities in primary care. This study was designed as a qualitative, explorative study using open patient interviews. The study was conducted at three primary care practices, East Flanders, Belgium. A total number of seven patients, diagnosed with COPD and given a minimum score of 2 on the Charlson Comorbidity Index were included. In-depth interviews were recorded and transcribed verbatim. Thematic analysis was deductive using NVivo software. Researchers’ triangulation was performed. Participants show high adaptation capabilities and report quite positively about their functional status, with an emphasis on social participation and partnership. Knowledge of the causes and consequences of COPD appears rather limited, and participants predominantly show an external locus of control in relation to the reported factors influencing the disease and strategies for self-management. Patients with COPD with comorbidity integrate their illness and symptoms into their lives. However, a lack of knowledge and education may leave them more anxious and more dependent on health care than necessary. Our results indicate that health care workers should adopt a positive approach toward patient’s functioning and empower and inform their patients. We believe that chronic care for patients with COPD should provide personalized rehabilitation taking into account individual patient characteristics and self-management and coping attitudes. We believe that there is a generic core to be identified, which can tackle both COPD and comorbidities. Further research is mandatory to develop these generic programs focusing on patients with complicated needs. Primary care can provide the setting for exploration.

Empowering patients to determine their own health goals

In this issue of the European Journal of General Practice , we fi nd papers on two subjects: respiratory tract diseases and multi-morbidity. Both belong to the very core of our job as family doctors. Multi-morbidity is undoubtedly the biggest challenge of the coming decades. Twenty to 40% of patients aged over 65 have more than fi ve chronic diseases and, in patients over 75, multi-morbidity is the rule rather than the exception (1). A recent large epidemiological study on the global burden of disease shows that increasing numbers of people are suff ering from several disorders that cause disability but not mortality as they grow older (2). Most of these people live at home and will count on family medicine for their day-to-day care. How one provides high quality care to this complex group of patients, is currently the subject of debate on many large international fora (3 – 9). One thing is clear: the classical problem and diseaseoriented medical model does not fi t anymore. This model was ideally suited to understand and manage acute and curable illnesses, and was very important for clinical research. It enabled us to build evidence for eff ective management of single diseases and develop evidence based guidelines for clinical practice. However, when confronted with a patient with multiple diseases, the value of such guidelines is reduced for several reasons. A recent review of fi ve NICE clinical guidelines (type-2 diabetes mellitus, secondary prevention for people with myocardial infarction, osteoarthritis, chronic obstructive pulmonary disease and depression) showed that they accounted poorly for co-morbidity (10,11). A 79-year old woman with osteoporosis, osteoarthritis, type 2 diabetes mellitus, hypertension and chronic obstructive pulmonary disease — not an uncommon combination — will have to take 12 diff erent medications daily and follow 14 non-pharmacological recommendations according to the cumulative guidelines for each separate disease (12). This is practically a full-time job. Guidelines can also be confl icting; e.g. corticosteroids are recommended in case of an exacerbation of COPD, but will disturb diabetes control. Moreover, the evidence on management of chronic diseases is generally based on clinical trials with strict inclusion criteria for which patients with other diseases are often excluded. This is illustrated by the study by Fortin et al., (13) who reviewed the medical records of 980 family practice patients and found that almost all patient eligible for an RCT on hypertension had co-morbid conditions and would be excluded. Finally, a disease or problem oriented approach focuses mainly on biomedical targets. Management of diabetes, for example, focuses on the levels of HbA1c, and the management of COPD focuses on an optimal FEV1. However, what if the patient simply wants enough breath to be able to walk to the supermarket in the morning? Maybe she does not care so much about her 10% risk of dying from a cardiovascular disease within 10 years if it means that today she has to take several pills that may cause signifi cant side eff ects? The paper in this issue of the European Journal of General Practice by Vos et al. (pp. 117 – 122) illustrates some of these points. It confi rms the high prevalence of multi-morbidity in old age, and it shows that self-rated health is lower when people have severe headache or back pain among their problems. Headache and low back pain are understandably very annoying to the patient, but from a purely biomedical point of view these complaints may be looked at as rather trivial — because they are not life threatening — and, therefore, receive less attention in a disease-focused care plan. Research on multi-morbidity will often not even take into account these more trivial disorders and only focus on the well established chronic diseases. However, from a patientcentred point of view any disorder that aff ects the patient ’ s functional status and quality of life is important. In the clinical management of patients with multimorbidity, an orientation of care towards the individual European Journal of General Practice, 2013; 19: 75–76

A High Sense of Coherence as Protection Against Adverse Health Outcomes in Patients Aged 80 Years and Older

PURPOSE We set out to assess whether a high sense of coherence (SOC) protects from adverse health outcomes in patients aged 80 years and older who have multiple chronic diseases. METHODS A population-based prospective cohort study in 29 primary care practices throughout Belgium included 567 individuals aged 80 years and older. We plotted the highest tertile of SOC scores in Kaplan-Meier curves representing 3-year mortality and time to first hospitalization. Using Cox proportional hazard regression analyses and multiple logistic regression analyses adjusted for sociodemographic characteristics, depression, cognition, disability, and multimorbidity we examined the relationship between SOC and mortality, hospitalization, and decline in performance of activities of daily living (ADL). RESULTS Subjects with high SOC scores showed a higher cumulative survival than others (Log rank = 0.004) independent of other prognostic characteristics (adjusted hazard ratio 0.62 (95% CI, 0.38–1.00), P = .049). For ADL decline, a high SOC was shown to be protective, and this effect tended to be independent from the covariates under study (adjusted odds ratio 0.56 (95% CI, 0.31–1.0), P = .05). CONCLUSION Even very elderly persons with high SOC scores were shown to have lower mortality rates and less functional decline. These effects were independent of multimorbidity, depression, cognition, disability, and sociodemographic characteristics.

Should we keep on measuring multimorbidity

Based on recent studies and in this journal, Bernardini and Fracchia report a disillusion and even a substantial uselessness of multimorbidity tools. In the light of a continuously increasing incidence of chronic diseases and continuously increasing numbers of patients with multimorbidity, this may seem remarkable.

Treating sarcopenia in clinical practice: where are we now?

Sarcopenia – or the loss of muscle mass, strength and function with ageing – represents an important health issue of the twenty-first century because of its devastating effects in addition to an increased prevalence of aged people. The devastating health effects of sarcopenia are multiple: an increased falls risk, a decreased physical ability and quality of life and an independent increase of all-cause mortality. Although the ultimate remedy for sarcopenia yet has to be found, some interventions have proven their merit and might be of practical use in clinical practice, especially for geriatricians, who deal most with sarcopenia. This review intends to summarize the current therapeutic interventions, their proposed mechanism of action as well as their clinical value. The results of our review highlight the importance of exercise (50% resistance training, 50% endurance training), nutrition (25–30 g proteins with essential amino acids every meal and long-chain ω-3 fatty acids) and limitation of alcohol and smoking. In addition, studies also suggest a place for vitamin D (aim serum levels >30 ng/L), testosterone (aim serum levels >300 ng/dL) and creatine (15–20 g/d for five days, thereafter 3–5 g/d). In conclusion, although more studies are needed to elucidate the exact effectiveness and safety of many sarcopenia interventions, the current evidence already provides clinically useful information, which might benefit the patient with (pre-)sarcopenia.