Multimorbidity a concept for family medicine within Europe
22 January 2016
UZA, Auditorium Kinsbergen (route 12) - Wilrijkstraat 10 - 2650 Edegem
Jean Yves Le Reste
Prof P. Van Royen, Prof C. Liétard & H. Van Marwijk
PhD defence Jean Yves Le Reste - Faculty of Medicine and Health Sciences
Multimorbidity is a concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of Family Medicine and its core competencies. However, the definition of multimorbidity and its subsequent operationalization were unclear. There was a great lack of data about what multimorbidity was and what its usefulness could be. For the World Health Organization people with multimorbidity are 'people being affected by two or more chronic health conditions'.
The WHO highlighted the need for research and practice to take into account complexity and that multimorbidity was an efficient concept to understand and then manage complexity. However the word 'condition' was broad but not that manifest for research or practical purpose. 'Conditions' has lead to numerous interpretations and gave great diversities for the inclusion of patients in research. Multimorbidity is a very challenged concept for Family Medicine.
A lack of knowledge is persistent for the usefulness of the concept of multimorbidity in family medicine. Some authors linked Multimorbidity with cost of care, health related quality of life, depression, frailty, patient’s complexity… The links with complexity could be of high interest for the implementation of usable recommendations in practice. The European General Practice Research Network (EGPRN) was concerned with the concept of Multimorbidity and constituted a research group to produce, translate and check the accuracy of a comprehensive definition of multimorbidity. The management of that research group was one of the challenges of this thesis.
The research question of this thesis was: How can we better formulate the concept of Multimorbidity, translate and validate it (conceptualization) for academic researchers and for European Family Physicians? What research could be issued from that reformulated concept?
The first study aim was to produce a comprehensive definition of multimorbidity. The method was a systematic review of literature involving eight EGPRN national teams. The databases searched were Pubmed, Embase and Cochrane (1990-2010). Only articles containing descriptions of multimorbidity criteria were selected for inclusion. The multi-national team undertook a methodic data extraction, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.
The results identified 416 documents, selected 68 abstracts, included 54 articles and found 132 definitions with 1631 different criteria. These criteria were aggregated into 11 themes which led to the following definition:
- Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or bio-psychosocial factor (associated or not) or somatic risk factor. Any bio-psychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption and the patient’s coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty.
- This first study produced a comprehensive definition of multimorbidity. The resulting improvements in the management of multimorbidity, and its usefulness in Long-Term Care and in Family Medicine, will have to be assessed in future studies.
- The second study objective was to translate that comprehensive definition into European languages and to validate the semantic, conceptual and cultural homogeneity of the translations for further research. The method was a forward backward translation of the EGPRN’s definition of multimorbidity followed by a Delphi consensus procedure assessment, a backward translation and a cultural check for all translations. This design was achieved to ensure the homogeneity of the translations in their national context. Consensus was defined as 70 % of the scores being higher than 6. Delphi rounds were repeated in each country until a consensus was reached.
- The results were drawn by 229 European medical expert FPs that participated in the study. Ten consensual translations of the EGPRN comprehensive definition of multimorbidity were achieved.
- This second study produced a comprehensive definition of multimorbidity available in English and ten European languages for further collaborative research in FM and long-term care.
- The third study objective was to explore how European Family Physicians (FPs) perceived and worked with this concept of multimorbidity and whether they would add new themes to it. The method was qualitative survey using focus groups or semi structured interviews as data collection techniques with a purposive sample of practicing FPs from each country. Data collection continued in each country until saturation was reached. Analysis was undertaken using a grounded theory based method. In each national team, the analysis was carried out by four researchers, working independently on the coded data and pooling them afterwards. Finally, an international team of 10 researchers pooled the axial and selective coding of all the national teams to check the concept of multimorbidity and highlight emerging themes.
- The results highlighted the maximal variation and saturation of the sample that were reached in each country with 211 FPs selected for inclusion. The 11 themes which describe multimorbidity in the EGPRN definition were identified in each country. Two additional themes emerged from this survey: the use of the Wonca’s core competencies of FM and the dynamics of the doctor-patient relationship in detecting and managing Multimorbidity.
- The third study underlined that European FPs recognized the enhanced concept of multimorbidity and added the two previously mentioned themes. These results open new perspectives regarding the dealing with complexity through the use of the concept of Multimorbidity in FM. It also highlighted the complexity of the concept of multimorbidity and its main weakness: what is the burden of multimorbidithy that needs an intervention from carers? This issue leaded to a need for simplification.
- The fourth study wanted to achieve a research agenda in order to detail new paths for the simplification of the concept in FM. The research question was: What research themes help our understanding of the concept of multimorbidity in family medicine?
- The method was a nominal group design by e-mail with a purposive panel of 15 experts in the field of multimorbidity coming from three groups of researchers: the EGPRN working group, the Threads and Yarns multimorbidity group and academic researchers in the field of multimorbidity from Polish, UK and Dutch universities. The Nominal group followed four phases: ideas generation phase, ideas recording phase, evaluation and analysis phase and a prioritization phase. A research agenda was established with 6 topics and 11 themes with their corresponding designs. The highest priorities were given to the following topics: measure of Multimorbidity and to the impact of Multimorbidity. Reverse methods starting from the outcomes of multimorbidity to lead to the useful variables in the pragmatic concept for research on multimorbidity, should also be used to simplify the concept.
- Using a step-by-step careful research process this thesis created a European research team to design its research protocol.
- The systematic review of literature showed a huge amount of different definitions (132 different definitions) and a great diversity in those definitions (with 1631 distinct single criteria). The comprehensive definition of the concept of multimorbidity issued from the systematic literature review was a relevant step.
- The translations of the concept were finalized for Bulgarian, Castellan, Catalan, Croatian, French, Galician, German, Greek, Italian and Polish.
- The qualitative studies confirmed the concept for FPs and added two modificators of Multimorbidity with the Wonca’s core competencies of FM and the doctor-patient relationship dynamics as a help to detect and manage multimorbidity.
- The research agenda focused future research needs on the measurement of multimorbidity and its impact on patient. It also enhanced the need for the simplification of this concept using a pragmatic approach to determine the useful variables of the concept on its outcomes and its link to complexity.