Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.
ABSTRACT Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions for multimorbidity.
To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual.
We searched MEDLINE, EMBASE, CINAHL, CAB Health, AMED, HealthStar, The Cochrane Central Register of Controlled Trials (CENTRAL), the EPOC Register and the Database of Abstracts of Reviews of Effectiveness (DARE), and the EPOC Register in April 2011.
We considered randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series analyses (ITS) reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. The outcomes included any validated measure of physical or mental health, psychosocial status including quality of life outcomes, well-being, and measures of disability or functional status. We also included measures of patient and provider behaviour including measures of medication adherence, utilisation of health services, and acceptability of services and costs.
Two review authors independently assessed studies for eligibility, extracted data, and assessed study quality. Meta-analysis of results was not possible so we carried out a narrative synthesis of the results from the included studies.
Ten studies examining a range of complex interventions for patients with multimorbidity were identified. All were RCTs and there was low risk of bias. Two of the nine studies focused on specific co-morbidities. The remaining studies focused on multimorbidity, generally in older patients. All studies involved complex interventions with multiple elements. In six of the ten studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, the interventions were predominantly patient oriented. Overall the results were mixed with a trend towards improved prescribing and medication adherence. The results indicate that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors or functional difficulties in patients with co-morbid conditions or multimorbidity may be more effective. Cost data were limited with no economic analyses included, though the improvements in prescribing and risk factor management in some studies provided potentially significant cost savings.
This review highlights the paucity of research into interventions to improve outcomes for multimorbidity with the focus to date being on co-morbid conditions or multimorbidity in older patients. The limited results suggest that interventions to date have had mixed effects but have shown a tendency to improve prescribing and medication adherence, particularly if interventions can be targeted at risk factors or specific functional difficulties in people with co-morbid conditions or multimorbidity. There is a need for clear definitions of participants, consideration of appropriate outcomes, and further pragmatic studies based in primary care settings.
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ABSTRACT: To describe factors associated with multimorbidity in community-dwelling older adults; to determine if a simple measure of multimorbidity predicts death over 5 years; and to assess if any effect of multimorbidity on mortality is independent of key covariates. Analysis of an existing population-based cohort study. Cox proportional hazards models were constructed for time to death. Manitoba. A total of 1751 community-dwelling adults aged 65 and older were interviewed and followed for 5 years. Age, sex, marital status, living arrangement, education, Mini-Mental State Examination (MMSE) score, Center for Epidemiologic Studies Depression Scale score, and the Older Americans Resource and Services Multidimensional Functional Assessment Questionnaire score were recorded for each participant. Multimorbidity was defined based on a simple list of common health complaints and diseases, followed by an open-ended question about other problems. These were summed and the scores ranged from 0 to 16. Death and time of death were determined during the 5-year interval by death certificate, administrative data, or proxy report. Multimorbidity was more prevalent in women; older age groups; and those with lower educational levels, lower MMSE scores, more depressive symptoms, and higher levels of disability. Multimorbidity was a predictor of mortality in unadjusted models (hazard ratio 1.09, 95% CI 1.05 to 1.12). In models adjusting for age, sex, education, marital status, living arrangement, and Center for Epidemiologic Studies Depression Scale and MMSE scores, this effect persisted (hazard ratio 1.04, 95% CI 1.00 to 1.08). However, after adjusting for functional status, the effect of multimorbidity was no longer significant. Multimorbidity predicts 5-year mortality but the effect might be mediated by disability.Canadian family physician Medecin de famille canadien 05/2014; 60(5):e272-80. · 1.19 Impact Factor
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