Multimorbidity

The National Press presents a simplistic explanation that it is the ageing population which accounts for rising health care demand. However, growth in the proportion of admissions aged 75+ in different specialties shows seemingly inexplicable very wide variation, and is characterized by non-linear and sometimes cyclic trends over time. Other studies have shown that age at first admission (for those aged 60+) increases in line with life expectancy. The question is posed regarding the role of infectious agents in these trends. Everyone will be well aware of the ageing population or the demographic shift and that the increase in admissions, A&E attendances and costs are often blamed on 'the ageing population'.

Background
Out of pocket expenditure (OOPE) on healthcare is related to the burden of illness and the number of chronic conditions a patient experiences, but the relationship of these costs to particular conditions and groups of conditions is less studied. This study examines the effect on OOPE of various morbidity groupings, and explores the factors associated with a ‘heavy financial burden of OOPE’ defined by an expenditure of over 10% of equivalised household income on healthcare.

Methods
Data were collected from 4,574 senior Australians using a stratified sampling procedure by age, rurality and state of residence. Natural clusters of chronic conditions were identified using cluster analysis and clinically relevant clusters based on expert opinion. We undertook logistic regression to model the probability of incurring OOPE, and a heavy financial burden; linear regression to explore the significant factors of OOPE; and two-part models to estimate the marginal effect of factors on OOPE.

Results
The mean OOPE in the previous three months was AU$353; and 14% of respondents experienced a heavy financial burden. Medication and medical service expenses were the major costs. Those who experienced cancer, high blood pressure, diabetes or depression were likely to report higher OOPE. Patients with cancer or diabetes were more likely than others to face a heavy burden of OOPE relative to income. Total number of conditions and some specific conditions predict OOPE but neither the clusters nor pairs of conditions were good predictors of OOPE.

Conclusions
Total number of conditions and some specific conditions predict both OOPE and heavy financial burden but particular comorbid groupings are not useful in predicting OOPE. Low-income patients pay a higher proportion of income than the well-off as OOPE for healthcare. Interventions targeting those who are likely to face severe financial burdens due to their health could address some of these differences.

Keywords: Costs; Financial stress; Long term conditions; Multimorbidity; Comorbidity; Disease cluster

Multimorbidity is prevalent, but its optimal quantification and associations with mortality rate and physical functioning in young through older adults are uncertain. We used data collected using the Short Form-36 in the Nurses' Health Study (enrollment started in 1976), Nurses' Health Study II (begun in 1989), and Health Professionals Follow-up Study (begun in 1986) to identify associations of a multimorbidity-weighted index (MWI) and common alternative indices with mortality and future physical functioning. We used Cox proportional hazard ratios to determine incident 10-year mortality and general linear models to obtain coefficients for the associations of MWI with 4-and 8-year physical functioning. At baseline, mean values for the 219,950 participants were 55.0 (standard deviation , 3.7) years for age; 3.8 (range, 0–51) for MWI; 2.7 (range, 0–23) for disease count, and 0.43 (range, 0–13) for Charlson Comorbidity Index (CCI). During follow-up, 23,709 deaths (10.8%) occurred. CCI, MWI, and disease count were 0 for 77%, 12%, and 19% of participants, respectively. When comparing persons in the highest quar-tiles with those in the lowest, the hazard ratios for mortality were 6.04 (95% confidence interval (CI): 6.00, 6.09; P for trend < 0.0001) for the MWI, 4.86 (95% CI: 4.81, 4.91; P for trend < 0.0001) for disease count, and 3.29 (95% CI: 3.26, 3.32; P for trend < 0.0001) for the CCI. For future physical functioning, MWI had the best model fit and explained the greatest variance. Multimorbidity has important associations with future physical functioning and mortality that are easily captured with a readily measured index. Among adults with chronic disease, multimorbidity (i.e., having multiple chronic conditions) is more common than having a single disease in isolation (1), and it is becoming increasingly recognized as its own entity rather than as comorbidity in the context of an index disease. Prior measures of multimor-bidity have been limited by disease inventory, adjustment for disease severity, generalizability to nonhospitalized (2) and younger and middle-aged adults (3), and disease clusters that may not be replicable in other populations (3). We recently developed and validated a multimorbidity-weighted index (MWI) that weights conditions by their concurrent impact on physical health–related quality of life in community-dwelling adults (4, 5). The MWI is easily assessed using simple disease inventories and to our knowledge is among the first indices to weight disease severity by an extensively validated and widely used health survey instrument for physical functioning (6, 7). Physical functioning is a universal patient-centered outcome consistent with values of patients' well-being (6, 8) and is also strongly associated with adverse health outcomes, including increased mortality risk, hospital readmission, and emergency department return visits (9, 10). Although the MWI weights disease severity by current physical functioning, its ability to predict mortality and future physical functioning is unknown. In the present study, our goal was to examine the associations of the MWI with mortality and future physical functioning and compare the performance of the MWI with those of 2 of the most frequently used alternatives: simple disease count and the Charlson Comorbidity

Multimorbidity is common in older persons. It is associated with higher disability, poor functional status, poor quality of life and higher mortality. This article highlights the extent of the problem and apparent inadequacy of comprehensive assessment and management strategies. Role of clinicians, patients and the systems to address multimorbidity is emphasized.

In the present qualitative, descriptive study, we explored Hong Kong community psychiatric nurses' (CPN) perceptions of using comprehensive physical health checks for service users diagnosed with severe mental illness (SMI). Research interviews were conducted with a purposive sample of 11 CPN in order to explore their perceptions about the use of the Health Improvement Profile (HIP) over a 1-year period. Interview data were analysed using inductive thematic analysis. The analysis revealed that the majority of CPN appreciated the comprehensive focus on the physical health of their clients and reported positive changes in their clinical practice. Many of them observed an increase in the motivation of their clients to improve their physical health, and also noted observable benefits in service users' well-being. The use of the HIP also helped the CPN identify implementation barriers, and highlighted areas of the tool that required modifications to suit the local cultural and clinical context. To our knowledge, this is the first study conducted in an Asian mental health service that explores nurses' views about using comprehensive health checks for people with SMI. The findings suggest that such approaches are viewed as being acceptable, feasible, and potentially beneficial in the community mental health setting. KEY WORDS: health behaviour change, health screening, physical health, severe mental illness.

Objective: This study aims: (1) to describe the pattern
and extent of multimorbidity and polypharmacy in UK
Biobank participants with chronic obstructive pulmonary
disease (COPD) and (2) to identify which comorbidities are
associated with increased risk of adverse drug reactions
(ADRs) resulting from polypharmacy.

Design: Cross-sectional.

Setting: Community cohort. Participants UK Biobank participants comparing self reported COPD (n=8317) with no COPD (n=494 323).
Outcomes Multimorbidity (≥4 conditions) and
polypharmacy (≥5 medications) in participants with COPD
versus those without. Risk of ADRs (taking ≥3 medications
associated with falls, constipation, urinary retention,
central nervous system (CNS) depression, bleeding or renal
injury) in relation to the presence of COPD and individual
comorbidities.

Results: Multimorbidity was more common in participants
with COPD than those without (17% vs 4%). Polypharmacy
was highly prevalent (52% with COPD taking ≥5
medications vs 18% in those without COPD). Adjusting
for age, sex and socioeconomic status, those with COPD
were significantly more likely than those without to be
prescribed ≥3 medications contributing to falls (OR 2.27,
95% CI 2.13 to 2.42), constipation (OR 3.42, 95% CI 3.10
to 3.77), urinary retention (OR 3.38, 95% CI 2.94 to 3.87),
CNS depression (OR 3.75, 95% CI 3.31 to 4.25), bleeding
(OR 4.61, 95% CI 3.35 to 6.19) and renal injury (OR
2.22, 95% CI 1.86 to 2.62). Concomitant cardiovascular
disease was associated with the greatest risk of taking ≥3
medications associated with falls/renal injury. Concomitant
mental health conditions were most strongly associated
with medications linked with CNS depression/urinary
retention/bleeding.

Conclusions: Multimorbidity is common in COPD
and associated with high levels of polypharmacy. Co-prescription
of drugs with various ADRs is common.
Future research should examine the effects on healthcare
outcomes of co-prescribing multiple drugs with similar
potential ADRs. Clinical guidelines should emphasise
assessment of multimorbidity and ADR risk.

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians.

Objectives: The objectives were to examine the association between multimorbid chronic disease and frequency of past 6 months emergency department (ED) visits, by sex, in a community sample of adults from North Florida (N = 7143). Methods: Data came from HealthStreet, a community engagement program at the University of Florida which uses the Community Health Worker Model to assess community member health conditions and concerns, and willingness to participate in health research. Using logistic regression, we estimated associations between multimorbid chronic disease and frequent ED use using sex as an effect modifier. Results: Multimorbid chronic disease was associated with frequent ED use overall, with a stronger association among men. Of the 7143 respondents, 14.4% were frequent ED users, 58.0% were female, and 61.5% were black non-Hispanic. Major findings included that women with 3+ chronic diseases were 2.49 (95% confidence interval, 1.7-3.6) times as likely as women without chronic diseases to report frequent ED use, compared with men with 3+ chronic diseases, who were 4.98 (95% confidence interval, 2.9-8.6) times as likely as men without chronic disease to report frequent ED use. Conclusions: Multimorbid chronic disease is very strongly associated with frequent ED use among all, but the association is especially strong among men. Future research is needed to further understand this association and its implication for health care.

• Physical health problems, especially cardiovascular disease and metabolic disorders are far more common in people with severe mental illness (SMI) than the general population. • While there are a considerable number of studies that have examined the physical health and health behaviours of people with SMI in Western countries, there have been few studies that have done this in Asia. What this paper adds to existing knowledge? • Unhealthy body mass index (BMI) values were observed in 44% of Thai service users diagnosed with schizophrenia despite desirable levels of exercise and relatively good diets being reported by the majority of participants. • Being prescribed two or more antipsychotics was significantly associated with greater body weight and a higher BMI than in people prescribed only one antipsychotic. What are the implications for practice? • Mental health professionals in Asia should be particularly aware of the additional risks of obesity that seem to be associated with antipsychotic polypharmacy when they are promoting the physical health of people with schizophrenia. Abstract Introduction: People with schizophrenia have worse physical health than the general population, and studies in developed countries demonstrate that their health behaviours are often undesirable. However, as no similar studies have been conducted in Asian countries with emerging healthcare systems, the physical health promotion challenges in these settings is unknown. Aim: To identify and explore relationships between cardiometabolic health risks, lifestyle and treatment characteristics in people with schizophrenia in Thailand. Method: This cross-sectional study reports the baseline findings from a physical health check programme using the Thai version of the Health Improvement Profile. Results: Despite desirable levels of exercise and relatively good diets being reported by most of the 105 service users, unhealthy body mass index values were observed in 44% of participants. A BMI>23 kg/m² and central obesity was found to be most likely in women. Being prescribed antipsychotic polypharmacy was significantly associated with a higher BMI than in people prescribed monotherapy. Implications for Practice: Mental health professionals in Asia should be aware of the additional risks of obesity that are associated with 1

Background Frailty is associated with older age and multimorbidity (two or more long-term conditions); however, little is known about its prevalence or effects on mortality in younger populations. This paper aims to examine the association between frailty, multimorbidity, specific long-term conditions, and mortality in a middle-aged and older aged population.

Multimorbidity is often considered a health problem of older people, but recent research shows that it is also prevalent among younger people. This thesis aimed to examine various aspects of multimorbidity among middle-aged people (45–64 years) using Canadian Longitudinal Study on Aging baseline data.

In the first manuscript, the prevalence of multimorbidity and its association with sociodemographic and lifestyle factors were examined. The prevalence of multimorbidity, defined as the coexisting three or more chronic conditions, was high among middle-aged people
(39.59%). Multivariate logistic regression showed that being older, female and low income were associated with multimorbidity. Alcohol intake was found to be protective against multimorbidity.

In the second manuscript, the association between multimorbidity and labour force participation was examined. Multivariate logistic regression showed that multimorbidity was associated with being retired and unemployed, but not the number of hours worked.

This thesis showed that multimorbidity is prevalent among middle-aged people. Preventive strategies targeted at this age group may prevent the negative consequences of multimorbidity.

Background: Multimorbidity is associated with higher mortality, but the relationship with cancer and cardiovascular mortality is unclear. The influence of demographics and type of condition on the relationship of multimorbidity with mortality remains unknown. We examine the relationship between multimorbidity (number/type) and cause of mortality and the impact of demographic factors on this relationship.

Background: COPD often occurs in the presence of co-morbidities which impact its presentation and management. Primary care patients usually have low self-efficacy in terms of disease knowledge and healthcare utilisation for their COPD.

Aims: The Activating Primary Care COPD Patients with Multi-morbidity (APCOM) pilot study aimed to empower patients with their COPD self-efficacy and overall health behaviour in general practices in Sydney, Australia.

Methods: This interventional study included patients aged 40 to 84 years with a spirometry diagnosis of COPD and at least one other co-morbidity. A self-management education program (SMEP) for COPD in the context of multi-morbidity, developed by the researchers, was tailored and delivered to the patients by trained practice nurses (PNs). Impact of the SMEP was assessed by Patient Activation Measure, COPD Knowledge Questionnaire, COPD Assessment Test, Multimorbidity Illness Perceptions Scale, Morisky Medication Adherence Scale and accuracy of inhaler technique. Qualitative evaluation of the SMEP was done by interviewing PNs, general physicians (GPs) and patients.

Results: Pre and post-test comparison of data from 44 patients who completed 6 months’ follow-up show significant improvement in patient activation (p<0.001), COPD knowledge (p<0.001), impact of COPD (p=0.012) and accuracy of inhaler technique (p=0.001). The qualitative interviews, currently being analysed, have yielded mostly positive feedback.

Conclusions: The study successfully increased self-efficacy of COPD patients and their overall health behaviour, forming an evidence base to test the SMEP in a future randomised controlled trial.

Aims & rationale: Understanding of chronic obstructive pulmonary disease (COPD) and uptake of relevant healthcare by patients is suboptimal, especially in primary care, further complicated by the presence of co-morbidities. This innovative pilot project aims to empower primary care COPD patients with multi-morbidity by improving their disease knowledge and self-efficacy through a practice nurse-delivered, tailored self-management intervention.

Methods: Potential participants (N=40) will be identified from Sydney general practices based on: i) age between 40 - 84 years, ii) COPD diagnosis ≤ 24 months, iii) presence of one or more co-morbidity and iv) history of smoking. Following an initial needs assessment, the self-management intervention based on Health Belief Model will be tailored by trained practice nurses and delivered to patients in subsequent one-to-one sessions. The intervention framework, which includes constructs from renowned self-care models, will involve active engagement of patients with strategies towards enhancing their COPD knowledge, self-management capacity and prioritisation of multiple chronic conditions. Impact of the intervention will be measured by pre and post-test outcome measures covering activation, knowledge, beliefs and self-efficacy regarding COPD and multi-morbidity. After a 6-month follow-up period, feasibility and sustainability of the intervention will be evaluated by qualitative feedback from participating healthcare providers.

Relevance to policy, research and/or practice needs: No prior study has focused on improving self-efficacy of recently-diagnosed COPD patients with multi-morbidity. The project seeks to motivate these patients to actively manage their COPD while effectively balancing other chronic conditions, which will lead to improved long-term health outcomes, better healthcare utilisation and enhanced patient-provider relationships.

Background: India's government is currently running several programs with a sole focus on women's health during their childbearing years. However, none of these programs incorporate the management of chronic health conditions during the reproductive span. This issue is an emerging public health concern; therefore, the present study aims to identify the patterns and correlates of multimorbidity among women in reproductive age groups in India. Methods: The study utilizes nationally-representative cross-sectional data from the Demographic and Health Survey on 661,811 women in the reproductive age group of 15-49 years. The study uses information on seven chronic morbidities, namely asthma, cancers, heart disease, diabetes, tuberculosis, hypertension, and thyroid disorder. Descriptive, bivariate, and multivariable techniques were utilized to accomplish the study objective. Results: The findings show that 17.4 and 3.5 per 100 women of reproductive age suffered from any one morbidity and multimorbidity, respectively. Hypertension, diabetes, and thyroid disorders were commonly occurring morbidities. The prevalence of having any one morbidity or multimorbidity increased with age. Variables like religion, wealth, parity, menopause, consumption of tobacco and alcohol, body mass index, and type of diet were found to be significantly related to the burden of multimorbidity. The prevalence of multimorbidity was found to be higher for women who belong to the Southern, Eastern, and NorthEastern regions of India. Conclusions: Findings suggest the importance of multimorbidity in the context of women of reproductive age. Inclusion of chronic disease management strategies with maternal and child health services needs to be taken into consideration by the program and policymakers. The annexation of social marketing approaches at the primary level of healthcare would assist policy-makers in educating Open Peer Review Reviewer Status

The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention. We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by...

Objective: To assess the prevalence, disease clusters, and patterns of multimorbidity using a novel 2-stage approach in middle-aged and older adults from the United Kingdom. Patients and Methods: Data on 36 chronic conditions from 502,643 participants aged 40 to 69 years with baseline measurements between March 13, 2006, and October 1, 2010, from the UK Biobank were extracted. We combined cluster analysis and association rule mining to assess patterns of multimorbidity overall and by age, sex, and ethnicity. A maximum of 3 clusters and 30 disease patterns were mined. Comparisons were made using lift as the main measure of association. Results: Ninety-five thousand seven hundred-ten participants (19%) had 2 or more chronic conditions. The first cluster included only myocardial infarction and angina (lift¼13.3), indicating that the likelihood of co-occurrence of these conditions is 13 times higher than in isolation. The second cluster consisted of 26 conditions, including cardiovascular, musculoskeletal, respiratory, and neurodegenerative diseases. The strongest association was found between heart failure and atrial fibrillation (lift¼23.6). Diabetes was at the center of this cluster with strong associations with heart failure, chronic kidney disease, liver failure, and stroke (lift>2). The third cluster contained 8 highly prevalent conditions, including cancer, hypertension, asthma, and depression, and the strongest association was observed between anxiety and depression (lift¼5.0). Conclusion: Conditions such as diabetes, hypertension, and asthma are the epicenter of disease clusters for multimorbidity. A more integrative multidisciplinary approach focusing on better management and prevention of these conditions may help prevent other conditions in the clusters. ª 2018 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2018;93(7):857-866

This chapter firstly provides an overview of multimorbidity as a complicated clinico-epidemiological, yet reductionist construct of multiple discreet disease(s) occurring in one individual. Current multimorbidity studies highlight taxonomic challenges about the actual nature of disease or chronic disease singly or in clusters and their underlying processes, and clinical practices. Multimorbidity is then viewed through the lens of systems medicine in the future, as multi-layered complex adaptive systems health care. Systems medicine is an interdisciplinary field of science which studies the nature and processes of complex systems of the biological sciences, as well as in information technology applied to medicine. Networks and psychoneuroimmunology and social phenomena form another " branch " of systems medicine. Nevertheless, clinico-epidemiological multi-morbidity, systems medicine and psychoneuroimmunology are very far apart in the literature with few intersecting research publications, despite commonality in the use of biomarkers and biometrics. As multimorbidity care will inevitably embrace new knowledge and technologies, it is important to improve personal-and population-centred care, rather than biomarker and biometrics reductionism. Opportunities must be embraced to transcend fragmented silos of knowledge and reductionistic care into integrated systems from biomarkers to clinical and population networks that help improve individual care.

Background: Multimorbidity is increasingly being recognized as a serious public health concern. Research into its determinants, prevalence, and management is needed and as the risk of experiencing multiple chronic conditions increases over time, attention should be given to investigating the development of multimorbidity through
prospective cohort design studies. Here we examine the baseline patterns of multimorbidity and their association
with health outcomes for residents in Yorkshire, England using data from the Yorkshire Health Study.

Methods: Baseline data from the Yorkshire Health Study (YHS) was collected from 27,806 patients recruited
between 2010 and 2012. A two-stage sampling strategy was implemented which first involved recruiting 43
general practice surgeries and then having them consent to mailing invitations to their patients to complete postal
or online questionnaires. The questionnaire collected information on chronic health conditions, demographics,
health-related behaviours, healthcare and medication usage, and a range of other health related variables. Descriptive statistics (chi-square and t tests) were used to examine associations between these variables and multimorbidity.

Results: In the YHS cohort, 10,332 participants (37.2 %) reported having at least two or more long-term health
conditions (multimorbidity). Older age, BMI and deprivation were all positively associated with multimorbidity. Nearly
half (45.7 %) of participants from the most deprived areas experienced multimorbidity. Based on the weighted sample, average health-related quality of life decreased with the number of health conditions reported; the mean EQ-5D score for participants with no conditions was 0.945 compared to 0.355 for participants with five or more. The mean number of medications used for those without multimorbidity was 1.81 (range 1-13, SD = 1.25) compared to 3.81 (range 1-14, SD = 2.44) for those with at least two long-term conditions and 7.47 (range 1-37, SD = 7.47) for those with 5+ conditions.

Conclusion: Patterns of multimorbidity within the Yorkshire Health Study support research on multimorbidity within previous observational cross-sectional studies. The YHS provides both a facility for participant recruitment to intervention trials, and a large population-based longitudinal cohort for observational research. It is planned
to continue to record chronic conditions and other health related behaviours in future waves which will be useful for examining determinants and trends in chronic disease and multimorbidity.

While scientific challenges raise relevant debates about the ethics of science, the scientific ethos, shattered by post-Mertonian studies, has received neither due attention nor further conceptualizations in view of the transition to knowledge society. On the contrary, in our investigation of Italian women scientists, it appears to have survived as a reference for scientists, even if the context has changed. Indeed, the ethos of scientists is no longer conceivable as exclusive, but is instead seen as open and dynamic in interaction with ...

Background: Multimorbidity can be defined as the presence of more than one chronic condition in an individual. Research on multimorbidity has predominantly focused on older adults and few studies have examined multimorbidity in middle-aged people. The objectives of this study were to: 1) examine the prevalence of multimorbidity among middle-aged Canadians; and 2) examine the association between lifestyle factors (smoking, alcohol intake, physical activity) and multimorbidity in this age group.

Methods: In this analysis of the Canadian Longitudinal Study on Aging (CLSA) baseline data, we extracted data from 29,841 participants aged 45-64 years from a database of 51,338 people aged 45-85 years. Self-reported data on 27 chronic physical health conditions were used to derive different multimorbidity definitions. We estimated the prevalence of 3+ to 5+ chronic physical health conditions in different subgroups for descriptive purposes. Multivariable logistic regression analyses were performed to determine the association between socio-demographic and lifestyle factors, and multimorbidity using a 3+ multimorbidity case definition.

Result: We found that 39.6% (99% CI 38.4-40.7) of participants had three or more chronic conditions with a mean number of chronic condition of 2.41 (99% CI 2.37-2.46). The prevalence of multimorbidity increased with age from 29.7% in the 45-49-year-old age group to 52% in individuals aged 60-64 years. The prevalence of 4+ and 5+ chronic conditions was 24.5 and 14.2% respectively. Analyses indicated that female sex and low income were associated with higher odds of multimorbidity, whereas daily or weekly alcohol intake were associated with lower odds of multimorbidity. Exercise was not associated with multimorbidity. Results were similar when analyses were conducted separately for women and men.

Conclusions: Multimorbidity is not limited to older adults, but is a common phenomenon among middle-aged people. Longitudinal research is needed to better understand the temporal relationship between lifestyle factors and multimorbidity.

Many mHealth technologies do not meet the needs of patients with complex chronic disease and disabilities (CCDDs) who are among the highest users of health systems worldwide. Furthermore, many of the development methodologies used in the creation of mHealth and eHealth technologies lack the ability to embrace users with CCDD in the specification process. This paper describes how we adopted and modified development techniques to create the electronic Patient-Reported Outcomes (ePRO) tool, a patient-centered mHealth solution to help improve primary health care for patients experiencing CCDD. This paper describes the design and development approach, specifically the process of incorporating qualitative research methods into user-centered design approaches to create the ePRO tool. Key lessons learned are offered as a guide for other eHealth and mHealth research and technology developers working with complex patient populations and their primary health care providers. Guided by user-cent...

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals ...

Objectives: To investigate the impact of gender on multimorbidity in northern Iran. Design: A cross-sectional analysis of the Golestan cohort data. Setting Golestan Province, Iran. Study population 49 946 residents (age 40–75 years) of Golestan Province, Iran. Main outcome measures: Researchers collected data related to multimorbidity, defined as co-existence of two or more chronic diseases in an individual, at the beginning of a representative cohort study which recruited its participants from 2004 to 2008. The researchers utilised simple and multiple Poisson regression models with robust variances to examine the simultaneous effects of multiple factors. Results Women had a 25.0% prevalence of multimorbidity, whereas men had a 13.4% prevalence (p&lt;0.001). Women of all age-groups had a higher prevalence of multimorbidity. Of note, multimorbidity began at a lower age (40–49 years) in women (17.3%) compared with men (8.6%) of the same age (p&lt;0.001). This study identified signific...

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for forward/backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previou...

The Hotel Study was initiated in Vancouver&#39;s Downtown East Side (DTES) neighborhood to investigate multimorbidity in homeless or marginally housed people. We evaluated the clinical effectiveness of existing, illness-specific treatment strategies and assessed the effectiveness of health care delivery for multimorbid illnesses. For context, we mapped the housing locations of patients presenting for 552,062 visits to the catchment hospital emergency department (2005-2013). Aggregate data on 22,519 apprehensions of mentally ill people were provided by the Vancouver Police Department (2009-2015). The primary strategy was a longitudinal cohort study of 375 people living in the DTES (2008-2015). We analysed mortality and evaluated the clinical and health service delivery effectiveness for infection with human immunodeficiency virus or hepatitis C virus, opioid dependence, and psychosis. Mapping confirmed the association between poverty and greater number of emergency visits related to ...

People with multimorbidity face a range of barriers in healthcare, and there is little knowledge about their challenges with regard to return-to-work (RTW). Rehabilitation coordinators, a new function in Swedish healthcare, support people in the RTW process. The present study had two aims: to explore what problems and barriers people with multimorbidity experience during their rehabilitation and RTW process and to explore in which domains the coordinators' support is perceived to be of importance. Methods: Interviews were conducted with 12 persons with multimorbidity who had contact with a rehabilitation coordinator during their sickness absence. Thematic analysis was guided by the case-management ecological model; this analysis was revised and adapted to the Swedish context. Results: The participants experienced problems in all domains of the model, namely: "the healthcare system", "the labor market and the workplace system", "the sickness insurance system", and "the personal system". Rehabilitation programs that did not accommodate combinations of diseases, social complexities and needs were felt to lead to worse symptoms, thus hindering rather than promoting RTW. An overall finding regarding support by coordinators is that interventions, regardless of domain, were felt to be valuable for people with multimorbidity. The coordinator was perceived to give most support by providing advice about and coordination with healthcare and employers. Sometimes the coordinator gave advice and coordination regarding the Social Insurance Agency, very occasionally the Public Employment Services. The coordinator gave least advice and coordination about social difficulties that hindered rehabilitation and RTW processes. Conclusion: People with multimorbidity perceive rehabilitation coordinator interventions as important in all domains investigated. Lack of advice and coordination, or rehabilitation programs that were not modified to the complexities of individual's circumstances, were associated with prolonged sickness absence, worse health, or social risk factors not being recognized.