%0 Journal Article %J Fam Pract %D 2009 %T Multimorbidity in primary care: developing the research agenda %A Mercer, Stewart W %A Smith, SM %A Wyke, Sally %A O'Dowd, T %A Watt, Graham C M %K Aged %K Chronic Disease %K Comorbidity %K Forecasting %K Great Britain %K Health Services Needs and Demand %K Humans %K International Cooperation %K Primary Health Care %K Quality Assurance, Health Care %X Multimorbidity - usually defined as the co-existence of two or more long-term conditions in an individual - is the norm rather than the exception in primary care patients1,2 and will become more prevalent as populations age.3,1 Multimorbidity cuts across the vertical paradigms in which most health research and policy is envisaged, supported and carried out, reflecting not only specialist interests in particular problems and diseases, but also the tendency of research to focus on easily defined issues. “Complicated” patients with multimorbidity are usually excluded from such research. Although complexity is under-represented in the research literature, it is common place in general medical practice, where the challenges are “horizontal”, integrating not only at the level of the clinical encounter, but also in the co-ordination of services to support patients with multiple problems. The challenge of carrying out research on multimorbidity is to reflect, investigate, inform and improve these aspects of generalist clinical practice. Given that multimorbidity is a challenge facing practitioners and patients alike it has attracted surprisingly little research interest.4 The research to date has largely focussed on analysis of the impact of multimorbidity on individuals and healthcare systems, with very few studies examining interventions to improve outcomes.5 One of ‘multimorbidity's many challenges’1 includes setting a research agenda to systematically begin to answer important practical issues in supporting people with multimorbidity. Given the scale and complexity of the task, the first difficulty is simply knowing where to start. In order to gather views from the academic primary care community on the research agenda in multimorbidity we held workshops in Ireland (July 2008) and Scotland (January 2009) under the aegis of the Society for Academic Primary Care and the Scottish School of Primary Care respectively. The workshops were attended by approximately 50 delegates, including patient representatives, primary care professionals, and academics; both explored issues of definition, outcome measures, studies and interventions. The common themes that emerged are outlined below. %B Fam Pract %V 26 %P 79-80 %8 2009 Apr %G eng %U http://fampra.oxfordjournals.org/content/26/2/79.long %N 2 %R 10.1093/fampra/cmp020 %0 Journal Article %J Cochrane Database Syst Rev %D 2012 %T Interventions for improving outcomes in patients with multimorbidity in primary care and community settings %A Smith, SM %A Soubhi, Hassan %A Fortin, M %A Hudon, Catherine %A O'Dowd, T %K Age Factors %K Chronic Disease %K Community Health Services %K Comorbidity %K Disease Management %K Humans %K Patient-Centered Care %K Primary Health Care %K Randomized Controlled Trials as Topic %K Risk Factors %K Treatment Outcome %X BACKGROUND: 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. OBJECTIVES: 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. SEARCH METHODS: 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. SELECTION CRITERIA: 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. DATA COLLECTION AND ANALYSIS: 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. MAIN RESULTS: 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. AUTHORS' CONCLUSIONS: 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. %B Cochrane Database Syst Rev %V 4 %P CD006560 %8 2012 %G eng %U http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006560.pub2/abstract;jsessionid=D2206ED1424E7EEAA91B88C4BA4F8E11.f03t01 %R 10.1002/14651858.CD006560.pub2 %0 Journal Article %J Br J Gen Pract %D 2010 %T GPs' and pharmacists' experiences of managing multimorbidity: a 'Pandora's box' %A Smith, SM %A O'Kelly, Siobhan %A O'Dowd, T %K Attitude of Health Personnel %K Chronic Disease %K Family Practice %K Humans %K Interprofessional Relations %K Ireland %K Pharmacists %K Physicians, Family %K Professional Practice %X BACKGROUND: Multimorbidity is defined as the occurrence of two or more chronic diseases in one individual. Patients with multimorbidity generally have poorer health and functioning and higher rates of attendance in primary care and specialty settings. AIM: To explore the views and attitudes of GPs and pharmacists managing patients with multimorbidity in primary care. DESIGN OF STUDY: Qualitative study using focus groups. SETTING: Primary care in Ireland. METHOD: Three focus groups were held in total, involving 13 GPs and seven pharmacists. Focus groups were recorded, transcribed, and analysed using the 'framework' approach. RESULTS: The predominant themes to emerge from the focus groups were: 1) the concept of multimorbidity and the link to polypharmacy and ageing; 2) health systems issues relating to lack to time, inter-professional communication difficulties, and fragmentation of care; 3) individual issues from clinicians relating to professional roles, clinical uncertainty, and avoidance; 4) patient issues; and 5) potential management solutions. CONCLUSION: This study provides information on the significant impact of multimorbidity from a professional perspective. It highlights potential elements of an intervention that could be designed and tested to achieve improvements in the management of multimorbidity, outcomes for individuals affected, and the experiences of those providing healthcare. %B Br J Gen Pract %V 60 %P 285-94 %8 2010 Jul %G eng %U http://bjgp.org/content/60/576/e285 %N 576 %R 10.3399/bjgp10X514756 %0 Journal Article %J Respir Med %D 2011 %T Chronic respiratory disease and multimorbidity: prevalence and impact in a general practice setting %A O'Kelly, Siobhan %A Smith, SM %A Lane, S %A Teljeur, C %A O'Dowd, T %K Adolescent %K Adult %K Aged %K Chronic Disease %K Comorbidity %K Cross-Sectional Studies %K Female %K General Practice %K Humans %K Ireland %K Lung Diseases %K Male %K Middle Aged %K Prevalence %K Socioeconomic Factors %K Urban Health Services %K Young Adult %X BACKGROUND: Multimorbidity is defined as two or more co-existing chronic conditions in an individual and is common in general practice. It is associated with poorer outcomes for patients. This study aimed to establish the prevalence of multimorbidity in patients with chronic respiratory disease in general practice and to describe its impact on health service use. METHODS: Cross-sectional study based in general practice in Dublin. Drug and disease code searches were performed to identify adult patients with a diagnosis of chronic respiratory disease. Medical records were reviewed for chronic respiratory diagnosis, other chronic conditions, demographic characteristics, General Practitioner (GP) and practice nurse utilisation rates, and numbers of medications. RESULTS: In a general practice population of 16,946 patients 3.9% had chronic respiratory disease and 60% of these had one or more co-existing chronic condition(s). GP and practice nurse utilisation rates, and number of medications were significantly higher among those with multimorbidity compared with those with respiratory disease alone. Multivariate analysis showed that increasing age and low socio-economic status were significantly associated with multimorbidity. CONCLUSION: The majority of patients with chronic respiratory disease have multimorbidity. Clinical guidelines based on single disease entities and outcomes are not as easy to implement and may not be as effective in this group. %B Respir Med %V 105 %P 236-42 %8 2011 Feb %G eng %U http://www.sciencedirect.com/science/article/pii/S0954611110003409 %N 2 %R 10.1016/j.rmed.2010.07.019