2012 Review of 62 Studies on Health & Wellness American Journal of Health Promotion
Multimorbidity in primary care: a systematic review of prospective cohort studies
Abstract
Background Primary care increasingly deals with patients with multimorbidity, simply relevant prove-based interventions are scarce. Cognition most multimorbidity over fourth dimension is required to inform the development of effective interventions.
Aim This review identifies prospective cohort studies of multimorbidity in principal intendance to determine: their nature, scope and central findings; the methodologies used; and gaps in noesis.
Design Systematic review.
Method Studies were identified by searching electronic databases, reviewing citations, and writing to authors. Searches were limited to adult populations with no restrictions on publication appointment or linguistic communication. In total, 996 articles were identified and screened.
Results Of the 996 manufactures, vi detailing 5 completed prospective cohort studies were selected as appropriate. Iii of the studies were undertaken in the Us and ii in The Netherlands; none was nationally representative. The principal focus of the studies was: healthcare utilisation and/or costs (n = 3); patients' concrete functioning (n = 1); and run a risk factors for developing multimorbidity (due north = i). The atmospheric condition that were included varied widely. The findings of these studies showed that multimorbidity increased healthcare costs (due north = 2), inpatient admission (northward = i), decease rates (north = 1), and service apply (n = 3), and reduced physical functioning (due north = 1). I study identified psychosocial risk factors for multimorbidity. No report used random sampling, sample sizes were relatively small (414–3745 patients at baseline), and study duration was relatively short (one–4 years). No study focused on prevalence, treatment use, patient safety, service models, cultural or socioeconomic factors, and patient experience, and no written report nerveless qualitative data.
Conclusion Few longitudinal studies based in master care have investigated multimorbidity. Farther large, long-term prospective studies are required to inform healthcare commissioning, planning, and commitment.
- chronic disease
- multimorbidity
- main care
- review
INTRODUCTION
The dramatic rise in long-term conditions presents a significant challenge to healthcare systems worldwide.1 Primary intendance is key to the management of patients with long-term conditions2,3 but, in the main, takes a single-illness approach,4 fifty-fifty though multimorbidity — the co-occurrence of two or more long-term conditions within an private — is common.5–eight
Despite the high prevalence of multimorbidity, the prove base for interventions is extremely limited.ix,10 An important precursor to developing effective interventions is knowledge almost multimorbidity over time in 'real-life' primary care settings. Prospective cohort studies are the about robust way to observe 'real-life' issues over time.11 They have fewer potential sources of bias than retrospective and case–command studies, and yield true incidence and relative gamble compared with randomised trial information that, due to strict eligibility for the trial, low recruitment levels, or large numbers of people refusing consent, often accept restricted generalisability. As such, prospective accomplice studies are the 'aureate standard' for studying and describing the natural history and development of morbidity, likewise as the development and implementation of prognostic models of care.12
Although reviews of the bear upon of multimorbidity have been undertaken,13 there are no published reviews of cohort studies on multimorbidity in primary care. This commodity reports the findings of a systematic review of prospective accomplice studies of multimorbidity in primary care. The aims were to determine:
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the nature, scope and key findings of the published studies;
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the methodologies used in the studies; and
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any gaps in noesis.
METHOD
Inclusion and exclusion criteria
Multimorbidity was defined as an individual having two or more weather condition, without a specific index status beingness specified. Studies with a prospective, longitudinal design, whose main focus was multimorbidity in adults in primary intendance settings, were included. There were no restrictions on publication engagement or language of the full paper, but an abstract in English had to exist bachelor. As prospective cohort studies are the 'gold standard' for conducting such enquiry, retrospective studies, cross-sectional report designs, evaluation studies, randomised controlled trials and intervention studies, studies that recruited only children anile <18 years, and those whose principal focus was neither multimorbidity nor main care information and/or settings were excluded.
How this fits in
Multimorbidity is condign the norm, rather than the exception, in primary care, only evidence-based interventions are scarce. Equally knowledge of the furnishings of multimorbidity over time is a necessary precursor to developing effective interventions, a systematic review of prospective accomplice studies of multimorbidity in principal care was carried out. Out of 996 manufactures identified, only six manufactures from five completed studies were plant that were relevant; although the studies identified provide useful information, they as well demonstrate meaning gaps in cognition. To program future healthcare services and treatment guidelines for those with multimorbidity, a meliorate understanding of the personal experience, handling, and health service use, equally well equally the psychological, physical, and social factors that influence multimorbidity over time, is needed.
Search strategy
The following databases were searched; the corresponding start appointment is given in parentheses:
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PubMed (1960);
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Medline (1950);
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PsycINFO (1887);
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CINAHL (1982);
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the CSA Conference Papers Index (1982);
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the Index to Scientific and Technical Proceedings (via ISI Web of Science) (1990); and
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BioMedCentral (BMC) periodical report protocols (2000).
In addition, hand searches of key journals (Family unit Practice, BMC Health Services Research, BMC Public Health, Chronic Illness, Periodical of Clinical Epidemiology) were carried out for the 12 months preceding the kickoff of this review. All searches were carried out by i researcher on 23 March 2010. Experts in the field of multimorbidity were as well contacted to help identify relevant studies; they carried out hand searches of reference lists in included studies in an attempt to identify other relevant studies.
A mixture of Medical Subject area Headings (MeSH) and key words were used to search PubMed and Medline; headings and key words for CINAHL; descriptors, key words and methodology terms for PsycINFO; and topics and keywords for ISI Web of Science. Other databases including the CSA Conference Papers Index and the BMC journals database rely on keyword searches. The exact search terms for selected databases are shown in Table 1. As comorbidity and multimorbidity are not consistently divers in the literature, articles using either term were searched for and included.
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Tabular array 1
Search terms used in primary databases
Multiple searches were performed via PubMed to identify relevant papers prior to, and after, the introduction of key MeSH terms. The term 'accomplice studies' was just introduced as a MeSH term in 1989 and 'comorbidity' in 1990; to find articles prior to those dates the study used dissimilar search terms, such every bit the MeSH terms 'follow-up studies' or 'prospective studies' instead of 'accomplice studies', and variations of the keywords 'comorbid' and 'multimorbid' in the championship or abstract.
Information extraction and analysis
All citations (title and abstract) were screened by two different reviewers. If either reviewer could non confidently include or exclude the newspaper based on the abstract or commendation, the full paper was obtained. In total, 27 papers were read in full. All authors contributed to the double screening practise. If there was a disagreement about whether a paper should be included or excluded, it was read past 1 or more additional reviewers and an agreement was reached through give-and-take. A information extraction sheet was used independently by two reviewers and compared for consistency; again, whatever disagreements were resolved through give-and-take.
The study adhered to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement to ensure our review was of skillful quality.
RESULTS
Eight prospective cohort studies on multimorbidity in primary intendance settings that were described in nine papers were identified from a total of 996 articles. Three protocol papers14–16 were excluded, leaving six papers, which related to five divide cohort studies (Figure i).17–22
Nature and scope of studies
Written report aims
Iii studies19,21,22 focused on healthcare utilisation and/or costs, simply also included some patient outcomes (severity of affliction,22 new morbidity,nineteen and mortality22). One report focused solely on patient outcomes (concrete reject),20 while some other (written up in two papers17,18) looked at psychosocial risk factors. Full details are given in Table ii.
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Theoretical or conceptual frameworks
Two papers explicitly described a theoretical or conceptual framework for the report.eighteen,20 Van den Akker et al's 2006 paper18 drew on a theory of general disease susceptibility; Bayliss et al's analyses20 were based on a conceptual interaction between long-term conditions and the 'psychosocial environs' that impacted on concrete wellbeing. The aim was to assistance clinical decision making and the management of physical decline past informing a generic chronic care model for patients with multimorbidities; implicitly, this relates to the cost to the healthcare organization. The model implicit in Van den Akker et al'southward 200117 paper focused on psychosocial, likewise every bit illness, factors impacting on the evolution of multimorbidity.
In the remaining three studies, no conceptual model was stated or implied. The impetus for these studies appeared to be to investigate the relationship between multimorbidity and resources use.nineteen,21,22
Written report location
Three studies were conducted in the US20–22 and ii in The Netherlands17,eighteen (Table three). None of the cohorts were multicountry merely they were restricted to a single region of The Netherlands,17–19 3 urban Usa cities,twenty and the geographical expanse served by a single US primary care practice.21,22
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Key overall study findings
2 studies (three papers) reported run a risk factors for the course of multimorbidity, including the type of disease20 and psychosocial characteristics.17,18 Van den Akker et al17,18 identified psychosocial risk factors — negative life events, an external health locus of control, and a social network of less than five people — for developing multimorbidity,17 which may predominantly apply in conditions that do not have a known common pathophysiological origin.xviii
I study20 found that certain combinations of chronic conditions — for case, chronic respiratory illness (CRD), congestive heart failure (CHF), and diabetes — presented a greater risk for physical decline than others, and some combinations — such equally CRD and osteoarthritis — resulted in higher patient consultation rates.19
Three studies reported that patients with multimorbidities had college healthcare utilisation19,21,22 than those with only a single status. Increasing multimorbidity predicted higher healthcare charges in an outpatient setting and an increased likelihood of inpatient admission or decease.21,22
One study suggested that a simple count of prescribed medications might have the greatest predictive validity for healthcare utilisation and costs, and diagnosis-based measures might be best for predicting 1-year mortality; withal all measures had poor to modest predictive validity.23
No study had health inequalities or socioeconomic status as its major focus. Perkins et al's study21 did compare the bear on of patients' income, sex, age, and indigenous origin on multimorbidity using five different measures of it; contradictory results were plant, depending on the mensurate used.
Methodologies used
Study blueprint and methods
Table 3 describes the methods used in the v studies. Studies varied widely in: their eligibility criteria for inclusion in the accomplice; how multimorbidity was measured; which outcomes were assessed; the type of primary care setting/patient selection procedures used; and the type of data that were nerveless.
Pick of primary intendance settings and patients
None of the studies randomly selected primary intendance settings or GPs, then randomly selected patients. They recruited a volunteer sample of practices,20 GPs who had taken role in a previous study,xix practices registered on a database,eighteen,19 or used a convenience sample of patients.21,22 The studies recruited between 1 and 15 practices. Between four and 42 GPs participated in three studies (four articles);17–19,22 225 GPs participated in another;20 and one did not state how many GPs took part.21 One report included all eligible patients from the report practices,nineteen one written report (written upwardly in ii articles) randomly sampled patients (the method of randomisation was non stated),17,xviii while the others used convenience samples.20–22
Four studies had a potentially biased sample due to: loss to followup;20 patient not-response;17,xviii the study inclusion/exclusion criteria;17 or the method of sampling patients.17,18,20–22 Table iii shows the characteristics of those patients excluded or lost due to non-response or attrition.
Multimorbidity definitions and measures
All studies operationalised multimorbidity as 2 ore more conditions within a patient, just not all express the atmospheric condition to those that are long-term and the studies varied in the list of conditions that could be included. Only three of the studies (iv articles) provided a clear definition.17,18,20,22
Ii studies included people with less than one of five19 or six20 specific chronic diseases. In Schellevis et al's19 study, it is not clear why the specific diseases were chosen; Bayliss et alxx chose loftier-prevalence conditions that frequently appear in the research literature on multimorbidity or chronic affliction direction. 3 studies (four articles) had broader inclusion criteria with few limitations on which conditions were included.17,18,21,22 Table 3 provides details of definitions and how multimorbidity was operationalised.
Sample size
None of the papers justified sample size. Cohort sizes ranged from 414 to 3745 patients at baseline and from 413 to 3551 patients at follow-upward (Table 3). However, not all patients in the cohorts had, or developed, multimorbidity. One written report did not state how many patients had multimorbidity,21 the number was relatively small in three studies (4 manufactures) (n = 216,22 due north = 268,19 and n = 30517,eighteen), and i study had a larger number (due north = 686).xx This meant that analyses by sub-grouping or sub-population (for example, type of status, type of disease susceptibility, age, or deprivation level) were not possible or had very limited statistical power.
Patient follow-up
Four of the studies (five manufactures)17–xix,21,22 carried out principal research; 3 analysed routinely collected data.19,21,22 Two papers17,eighteen drew on the same longitudinal dataset to carry out unlike analyses. One20 carried out a secondary assay of 4-year follow-up information, which had been nerveless in 1990 (some fourteen years previously), equally part of a longitudinal study called the Medical Outcomes Written report. Tabular array 3 shows, in particular for each study, the information that were gathered and from which sources they derived. The range of outcomes measured was limited, with studies mainly appearing to rely on routinely nerveless information.19
The study follow-upwards times ranged from 1–4 years, with four of the five studies following patients for 12–24 months.17–19,21,22 One of the studies had simply one follow-upward point.20
Retention rates varied betwixt 70% and 100% of the sample, depending on the follow-upward methods; follow-up past record extraction resulted in little or no attrition.19,21,22 Loss to follow-upward contributed to the sample being unrepresentative in one study.20
Inclusion criteria and screening procedures
All studies — except that by Perkins et al,21 which sampled on the basis of age — focused on identifying patients with clinically determined diagnoses of diseases; one also included cocky-reported diagnoses.20 Patients were identified by a variety of ways including: dr. reports verified by study clinical staff and through a patient questionnaire;twenty searches of an electronic database;17,18 a GP search of records;19 or patient attendance at the practise during a specific time period.xix,21,22 Further details of the inclusion criteria are given in Table 3.
Give-and-take
Summary
This review identified 5 cohort studies of multimorbidity in chief care; these derived from two countries (The netherlands and the US). Substantial variation occurred in the conditions included. Multimorbidity predicted increased health service use and costs, bloodshed rates, and reduced physical office. Psychosocial run a risk factors for multimorbidity included negative life events, external health locus of control, and modest social networks, which may be most of import in conditions that lack a mutual pathophysiological origin. Although these pioneering studies offer valuable insights, important gaps were likewise identified: none of the studies focused on mental illness and multimorbidity, or the interaction with socioeconomic deprivation, and patients' views were notably absent. Methodologically, a clear conceptual framework was not always apparent and no study used random sampling of general practices and patients.
Strengths and limitations
The main limitation of whatsoever systematic review is the difficulty in ensuring that all of the relevant literature has been identified. This was maximised by combining a variety of search strategies. Abstracts were required to be in English, which could have excluded potentially relevant papers, however only 2 papers originally identified did not fulfil this criterion. The absenteeism of consistent indexing in databases due to the lack of a key indexing term for 'multimorbidity' posed a difficulty, so comorbidity — which is often used synonymously — was searched for and variations of these search terms were used.23
Comparison with existing literature
Every bit far as the authors are aware, this is the starting time systematic review on this topic. The inconsistency in defining and measuring multimorbidity has been reported by others.23,24 Retrospective and cross-sectional studies support the findings on healthcare utilisation and costs, mortality, and physical performance.6,8,25,26 Since conducting this review, ii other relevant cohort studies take been identified; one on the influence of multimorbidity on cognition in an aging population in one region of Holland,27 and the other on the bear on of multimorbidity (as measured by the Ambulatory Care Group case mix system) on option of main care provider in two practices in 1 canton of Sweden.28 However, these two recently published papers do not alter our conclusions or the implications for future research outlined below.
Implications for research
The studies identified tended to exist limited in scope and size, with questionable generalisability relating to issues of sampling, inclusion criteria, patient attrition and not-response. Causal pathways, prognostic factors, treatment use, patient safety, service models, quality of care, and patient perceptions and experiences were not well documented. A demand to focus on socioeconomic factors in time to come cohort studies is important equally retrospective and prevalence studies in Kingdom of the netherlands,eight Scotland,29 England,9 and Ireland25,26 all suggest a significant link between low socioeconomic condition and the corporeality and brunt of multimorbidity. Future research must also explore the longitudinal links betwixt mental affliction and multimorbidity, given the growing testify on their interconnectedness.29,30 Longitudinal studies on multimorbidity in principal care have important gaps in knowledge. A fuller understanding of personal experience, treatment burden and health service use, likewise equally the psychological, concrete, and social factors that influence multimorbidity over time is needed.
Acknowledgments
Nosotros would similar to thank the six international experts in multimorbidity research who sent us information regarding studies.
Notes
Funding
This systematic review was funded by a Scottish School of Primary Intendance Visiting Professor Award (grant number: 63124). The funders had no part in the study design, data collection and assay, decision to publish, or preparation of the manuscript.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have alleged no competing interests.
- Received September half dozen, 2011.
- Revision received September 27, 2011.
- Accustomed November 15, 2011.
- © British Journal of Full general Practice 2012
Source: https://bjgp.org/content/62/597/e297
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