TY - JOUR T1 - Managing patients with multimorbidity: systematic review of interventions in primary care and community settings JF - BMJ Y1 - 2012 A1 - Smith, SM A1 - Soubhi, Hassan A1 - Fortin, M A1 - Hudon, Catherine A1 - O'Dowd, T AB - OBJECTIVE: To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011). ELIGIBILITY CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs. DATA SELECTION: Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out. RESULTS: 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings. CONCLUSIONS: Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes. VL - 345 UR - http://www.bmj.com/content/345/bmj.e5205 ER - TY - JOUR T1 - Interventions for improving outcomes in patients with multimorbidity in primary care and community settings JF - Cochrane Database Syst Rev Y1 - 2012 A1 - Smith, SM A1 - Soubhi, Hassan A1 - Fortin, M A1 - Hudon, Catherine A1 - O'Dowd, T KW - Age Factors KW - Chronic Disease KW - Community Health Services KW - Comorbidity KW - Disease Management KW - Humans KW - Patient-Centered Care KW - Primary Health Care KW - Randomized Controlled Trials as Topic KW - Risk Factors KW - Treatment Outcome AB - 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. VL - 4 UR - http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006560.pub2/abstract;jsessionid=D2206ED1424E7EEAA91B88C4BA4F8E11.f03t01 ER - TY - JOUR T1 - Interventions for improving outcomes in patients with multimorbidity in primary care and community settings JF - Cochrane Database of Systematic Reviews Y1 - 2016 A1 - Smith, SM A1 - Wallace, E A1 - O'Dowd, T A1 - Fortin, M KW - Age Factors KW - Chronic Disease [therapy] KW - Community Health Services KW - Comorbidity KW - Disease Management KW - Humans[checkword] KW - Patient-Centered Care [methods] KW - Primary Health Care KW - Randomized Controlled Trials as Topic KW - Risk Factors KW - Treatment Outcome SN - 1465-1858 UR - http://dx.doi.org/10.1002/14651858.CD006560.pub3 IS - 3 ER - TY - JOUR T1 - Improving the external validity of clinical trials: the case of multiple chronic conditions JF - Journal of Comorbidity Y1 - 2013 A1 - Fortin, M A1 - Smith, SM KW - clinical trials KW - Comorbidity KW - external validity KW - internal validity KW - multimorbidity KW - multiple chronic conditions AB - The U.S. Department of Health and Human Services vision and strategic framework on multiple chronic conditions(MCCs) incorporates recommendations designed to facilitate research that will improve our knowledge about interventions and systems that will benefit individuals with MCCs (or multimorbidity). The evidence base supporting the management of patients with MCCs will be built through intervention trials specifi cally designed to address multimorbidity and identifi cation of MCCs in participants across the clinical trial range. This article specifically focuses on issues relating to external validity with specifi c reference to trials involving patients with MCCs. The exclusion of such patients from clinical trials has been well documented. Randomized control trials (RCTs) are considered the “gold standard” of evidence, but may have drawbacks in relation to external validity, particularly in relation to multimorbidity. It may, therefore, be necessary to consider a broader range of research methods that can provide converging evidence on intervention effects to address MCCs. Approaches can also be taken to increase the usefulness of RCTs in general for providing evidence to inform multimorbidity management. Additional improvements to RCTs would include better reporting of inclusion and exclusion criteria and participant characteristics in relation to MCCs. New trials should be considered in terms of how they will add to the existing evidence base and should inform how interventions may work in different settings and patient groups. Research on treatments and interventions for patients with MCCs is badly needed. It is important that this research includes patient-centered measures and that generalizability issues be explicitly addressed. VL - 3 UR - http://jcomorbidity.com/index.php/test/article/view/27 IS - 2 ER - TY - JOUR T1 - How to design and evaluate interventions to improve outcomes for patients with multimorbidity JF - Journal of Comorbidity Y1 - 2013 A1 - Smith, SM A1 - Bayliss, EA A1 - Mercer, Stewart W A1 - Gunn, J A1 - Vestergaard, M A1 - Wyke, Sally A1 - Salisbury, C A1 - Fortin, M KW - Comorbidity KW - Family Practice KW - interventions KW - multimorbidity AB - Multimorbidity is a major challenge for patients and healthcare providers. The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions. Here we present a consensus view from a group of international researchers working to improve care for people with multimorbidity to guide future studies of interventions. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems VL - 3 UR - http://jcomorbidity.com/index.php/test/article/view/21 IS - 1 ER - TY - Generic T1 - An International Perspective on Designing Interventions For Multimorbidity in Primary Care. The Multiple Chronic Conditions Research Network, AHRQ, 23 April 2013, Maryland. USA Y1 - 2013 A1 - Smith, SM A1 - Soubhi, Hassan A1 - Fortin, M A1 - Hudon, Catherine A1 - O'Dowd, T UR - http://www.hrbcentreprimarycare.ie/ppt/SMSmith_webinar.ppt ER -