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Background Older adults with multimorbidity represent a growing segment of the population. Metrics to assess quality, safety and effectiveness of care can support policy makers and healthcare providers in addressing patient needs. However, there is a lack of valid measures of quality of care for this population. In the MULTIqual project, 24 general practitioner (GP)-reported and 14 patient-reported quality indicators for the healthcare of older adults with multimorbidity were developed in Germany in a systematic approach. This study aimed to select, validate and pilot core sets of these indicators. Methods In a cross-sectional observational study, we collected data in general practices (n = 35) and patients aged 65 years and older with three or more chronic conditions (n = 346). One-dimensional core sets for both perspectives were selected by stepwise backward selection based on corrected item-total correlations. We established structural validity, discriminative capacity, feasibility and patient-professional agreement for the selected indicators. Multilevel multivariable linear regression models adjusted for random effects at practice level were calculated to examine construct validity. Results Twelve GP-reported and seven patient-reported indicators were selected, with item-total correlations ranging from 0.332 to 0.576. Fulfilment rates ranged from 24.6 to 89.0%. Between 0 and 12.7% of the values were missing. Seventeen indicators had agreement rates between patients and professionals of 24.1% to 75.9% and one had 90.7% positive and 5.1% negative agreement. Patients who were born abroad (− 1.04, 95% CI = − 2.00/ − 0.08, p = 0.033) and had higher health-related quality of life (− 1.37, 95% CI = − 2.39/ − 0.36, p = 0.008), fewer contacts with their GP (0.14, 95% CI = 0.04/0.23, p = 0.007) and lower willingness to use their GPs as coordinators of their care (0.13, 95% CI = 0.06/0.20, p p = 0.002) and were less willing to use their GP to coordinate their care (0.16, 95% CI = 0.10/0.21, p Conclusions The quality indicator core sets are the first brief measurement tools specifically designed to assess quality of care for patients with multimorbidity. The indicators can facilitate implementation of treatment standards and offer viable alternatives to the current practice of combining disease-related metrics with poor applicability to patients with multimorbidity.

In den Notaufnahmen wachst die Arbeitsbelastung durch Patienten ohne medizinischen Notfall. Unterstutzungsangebote aus dem ambulanten Sektor haben sich noch nicht ausreichend etabliert. Um festzustellen, inwieweit es sich bei Patienten in Notaufnahmen um echte medizinische Notfalle handelt, sollen Patienten mit mindestens 2 und solche mit maximal 1 chronischen Erkrankung verglichen werden. Zudem sollen Einflussfaktoren auf die vorherige Inanspruchnahme ambulanter Strukturen identifiziert werden. Die Studienklientel stammt aus der Querschnittsstudie „PiNo-Nord“. In 5 Notaufnahmen wurden zwischen 10/2015 und 07/2016 alle „nicht sofort“ oder „nicht sehr dringend“ Behandlungsbedurftigen interviewt. Die Datenanalyse erfolgte explorativ und mithilfe multivariater logistischer Regression. Die 293 Patienten mit ≥2 chronischen Erkrankungen stellten verglichen mit den 847 Patienten mit max. 1 chronischen Erkrankung etwa genauso haufig einen medizinischen Notfall dar. Konsultationsanlasse (und Entlassungsdiagnosen) waren v. a. Traumata am Bewegungsapparat (33 %, n = 293 vs. 42 %, n = 847) oder der Haut (11 %, n = 293 vs. 13 %, n = 847). In beiden Gruppen spielten die haus- oder facharztliche Versorgung sowie diagnostische oder Behandlungsmoglichkeiten fur das Aufsuchen der Notaufnahme selten eine Rolle. Starkste Pradiktoren fur eine vorherige ambulante Behandlung waren langere Beschwerdedauer, subjektiv hohe Behandlungsdringlichkeit, mindestens zwei chronische Erkrankungen und eine den Bewegungsapparat betreffende Konsultation. In beiden Patientengruppen wurde kein Anhaltspunkt fur unnotiges Aufsuchen der Notaufnahme gefunden. Zum grosten Teil werden vorab ambulante Strukturen genutzt und die Notaufnahme nur bei tatsachlichem medizinischen Notfall aufgesucht.

Background Among other factors, the patients’ consultation reasons and GPs’ spectrum of services determine the process and outcome of the medical treatment. So far, however, there has been little information on differences in reasons for consultation and GPs’ services between urban and rural areas. Our study’s goal was thus to investigate these factors in relation to the regional location of GPs’ practices. Methods We conducted a cross-sectional observational study based on standardised GP interviews in a quota sampling design. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban area, environs, rural area) and stratified proportionally to the population size. Differences in the number of reasons for consultation and services were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the German federal states and administrative districts. Differences in individual consultation reasons and services were identified by logistic regression via stepwise forward and backward selection. Results Primary care practices in 34 of the 37 selected administrative districts (91.9%) were represented in the dataset. In total, 211 GPs were personally interviewed. On average, GPs saw 344 patients per month with a slightly higher number of patients in rural areas. They reported 59.1 ± 15.4 different reasons for consultation and 30.3 ± 3.9 different services. There was no statistically significant regional variation in the number of different consultation reasons, but there was a broader service spectrum by rural GPs (ß = − 1.42; 95% confidence interval − 2.75/− 0.08; p = 0.038) which was statistically explained by a higher level of medical training. Additionally, there were differences in the frequency of individual consultation reasons and services between rural and urban areas. Conclusion GPs in rural areas performed more frequently services usually provided by medical specialists in urban areas. This might be caused by a low availability of specialists in rural areas. The association between medical training and service spectrum might imply that GPs compensate the specific needs of their patients by completing advanced medical training before or after setting up a medical practice. Trial registration The study was registered in ClinicalTrials.gov (NCT02558322).

Wir untersuchten bei alteren, multimorbiden Patienten den Gebrauch von verschreibungspflichtigen und nicht verschreibungspflichtigen Schmerzmitteln (OTC, „over the counter“) und damit verbundene Risiken. Insbesondere uber deren kombinierten Einsatz ist in Deutschland wenig bekannt. Der Schmerzmittelgebrauch wurde in den Baselinedaten (2008/2009) der MultiCare-Kohorte mit primararztlich versorgten alteren multimorbiden Patienten untersucht (Trial registration: ISRCTN89818205). Berucksichtigt wurden Opioide, andere Analgetika und Antipyretika sowie nichtsteroidale Antirheumatika. Gebrauch von OTC-Praparaten, Dosierungen, Doppelmedikation und Interaktionen wurden fur Acetylsalicylsaure, Diclofenac, (Dex)Ibuprofen, Naproxen und Paracetamol untersucht. Von 3189 multimorbiden 65- bis 85-jahrigen Patienten gaben 1170 Patienten an, innerhalb der letzten 3 Monate mindestens ein Schmerzmittel eingenommen zu haben (36,7 %). Mindestens ein OTC-Schmerzmittel nahmen 289 Patienten (24,7 % von 1170) ein. Doppelmedikation mit wirkstoffgleichen Praparaten erfolgte in 86 Fallen, von diesen regelmasig in 15 Fallen. In 2 Fallen wurde durch Doppelmedikation die maximale Tagesdosis an Diclofenac uberschritten. In 235 Fallen nahmen Patienten parallel einen potenziell klinisch relevanten interagierenden Wirkstoff ein. In 43 Fallen (18,3 %) Fallen war ein OTC-Schmerzmittel, meist Ibuprofen, beteiligt. Uber ein Drittel der alteren Patienten nahm regelmasig oder bei Bedarf Schmerzmittel ein. Trotz des relativ hohen Gebrauchs von OTC-Schmerzmitteln ist der Anteil an Doppelmedikationen, Uberdosierungen und Interaktionen durch OTC-Praparate gering.

Allgemein wird angenommen, dass chronische Krankheiten und insbesondere Multimorbiditat das Risiko fur Pflegebedurftigkeit erhohen. Dennoch ist bisher fur Deutschland nicht systematisch untersucht worden, welche chronischen Krankheiten wie mit Pflegebedurftigkeit zusammenhangen. Die Untersuchung erfolgte auf der Basis von Abrechnungsdaten der Gmunder ErsatzKasse 2006. Einschlusskriterien waren: Alter ≥ 65 Jahre, mindestens eine von 46 Diagnosen in mindestens 3 Quartalen sowie eine Pflegestufe (n = 8678). Eine Vergleichsgruppe wurde gebildet mit n = 114.962. Berechnet wurden: Pravalenzunterschiede, relative Risiken sowie – mittels nominaler Regression – Einflussfaktoren auf die Pflegebedurftigkeit. Nur wenige Krankheiten (Demenz, Harninkontinenz, Zustand nach Schlaganfall und Herzinsuffizienz) weisen hohe Pravalenzen bei den Pflegebedurftigen (> 20 %) und zugleich grose Pravalenzunterschiede im Vergleich zu den Nichtpflegebedurftigen auf. Diese Daten sind essenziell fur eine Optimierung der medizinischen Versorgung von pflegebedurftigen Menschen. Weiterhin erforschungsbedurftig ist, uber welche Mechanismen die wenigen pflegespezifischen Krankheiten Behinderung und Gebrechlichkeit und damit Pflegebedurftigkeit verursachen.

Background Chronic conditions are the most common themes in doctor-patient communication, especially for older patients with multimorbidity and their GPs. Former quantitative studies identified a variety of socio-demographic and health-related factors which were associated with the (dis-)agreement between medical records and patient self-reported diseases. The aim of this qualitative study was to identify reasons for disagreement regarding illnesses between patients and their GPs. Methods We conducted three focus groups with GPs (n = 15) and three focus groups with multimorbid patients aged 65 to 85 (n = 21). The participants were recruited from the MultiCare Cohort Study. Focus groups were audiotaped and transcribed verbatim. The transcripts of the focus groups were analysed using the qualitative content analysis according to Mayring. Categories were determined deductively and inductively. Results The analysis revealed seven themes concerning reasons for disagreement regarding illnesses between patients and their GPs: problems with communication and cooperation between health care professionals, disease management by the GP and the patient, the documentation behaviour of the GP, communication challenges between GP and patient, differences in the understanding of a disease between GP and patient, the prioritization and rating of diseases by GP and patient and obliviousness, repression and avoidance by the patient. Conclusions For older patients with multimorbidity, our study demonstrated that there is a need to enhance the cooperation between GPs, specialists and outpatient care, a demand to improve doctor-patient communication and a need for interventions to increase patients’ knowledge of diseases. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0286-x) contains supplementary material, which is available to authorized users.

Background Growing interest in multimorbidity is observable in industrialized countries. For Germany, the increasing attention still goes still hand in hand with a small number of studies on multimorbidity. The authors report the first results of a cross-sectional study on a large sample of policy holders (n = 123,224) of a statutory health insurance company operating nationwide. This is the first comprehensive study addressing multimorbidity on the basis of German claims data. The main research question was to find out which chronic diseases and disease combinations are specific to multimorbidity in the elderly. Methods The study is based on the claims data of all insured policy holders aged 65 and older (n = 123,224). Adjustment for age and gender was performed for the German population in 2004. A person was defined as multimorbid if she/he had at least 3 diagnoses out of a list of 46 chronic conditions in three or more quarters within the one-year observation period. Prevalences and risk-ratios were calculated for the multimorbid and non-multimorbid samples in order to identify diagnoses more specific to multimorbidity and to detect excess prevalences of multimorbidity patterns. Results 62% of the sample was multimorbid. Women in general and patients receiving statutory nursing care due to disability are overrepresented in the multimorbid sample. Out of the possible 15,180 combinations of three chronic conditions, 15,024 (99%) were found in the database. Regardless of this wide variety of combinations, the most prevalent individual chronic conditions do also dominate the combinations: Triads of the six most prevalent individual chronic conditions (hypertension, lipid metabolism disorders, chronic low back pain, diabetes mellitus, osteoarthritis and chronic ischemic heart disease) span the disease spectrum of 42% of the multimorbid sample. Gender differences were minor. Observed-to-expected ratios were highest when purine/pyrimidine metabolism disorders/gout and osteoarthritis were part of the multimorbidity patterns. Conclusions The above list of dominating chronic conditions and their combinations could present a pragmatic start for the development of needed guidelines related to multimorbidity.

Background Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects. Methods/Design The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed. Discussion The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.