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BACKGROUND: Although mobile health (mHealth) apps are increasingly being used to support patients with multiple chronic conditions (multimorbidity), most mHealth apps experience low interaction and eventual abandonment. To tackle this engagement issue, when developing an mHealth program, it is important to understand the social-behavioral factors that affect patients' use behavior.OBJECTIVE: The aim of this study was to explore the social and behavioral factors contributing to patients' use behavior of an mHealth app called the electronic Patient-Reported Outcome (ePRO). The ePRO app supports goal-oriented care delivery in interdisciplinary primary care models.METHODS: A descriptive qualitative study was used to analyze interview data collected for a larger mixed methods pragmatic trial. The original 15-month trial was conducted in 6 primary care teams across Ontario, Canada, between 2018 and 2019. The eligibility criteria for patients were being aged ≥60 years with ≥10 visits within the previous 12 months of study enrollment. For this analysis, patients were classified as long-term or short-term users based on their length of use of the ePRO app during the trial. The Social Cognitive Theory by Bandura was used to categorize social-behavioral factors that contributed to patients' decision to continue or discontinue using the app.RESULTS: The patient-provider relationship emerged as a key factor that shaped patients' experiences with the app and subsequent decision to continue using the app. Other factors that contributed to patients' decision to continue using the app were personal and social circumstances, perceived usefulness, patients' previous experience with goal-related behaviors, and confidence in one's capability. There was an overlap of experience between long- and short-term app users but, in general, long-term users perceived the app to be more useful and their goals to be more meaningful than short-term app users. This observation was complicated by the fact that patient health-related goals were dynamic and changed over time.CONCLUSIONS: Complex patients' use behavior of a goal-supporting mHealth app is shaped by an array of sociobehavioral factors that can evolve. To tackle this dynamism, there should be an emphasis on creating adaptable health technologies that are easily customizable by patients and able to respond to their changing contexts and needs.TRIAL REGISTRATION: ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954.

Background: Patients with multimorbidity often experience treatment burden as a result of fragmented, specialist-driven healthcare. The ‘family doctor team’ is an emerging service model in China to address the increasing need for high-quality routine primary care. Objective: To explore the extent to which treatment burden was associated with healthcare needs and patients’ experiences. Methods: Multi-site surveys were conducted in primary care facilities in Guangdong province, southern China. Interviewer-administered questionnaires were used to collect data from patients (N=2,160) who had ≥two clinically-diagnosed long-term conditions (multimorbidity) and had ≥one clinical encounter in the past 12 months since enrolment registration with the family doctor team. Patients’ experiences and treatment burden were measured using a previously-validated, Chinese version of the Primary Care Assessment Tool (PCAT) and the Treatment Burden Questionnaire, respectively. Results: The mean age of patients was 61.4 years and slightly over half were females. Patients who had a family doctor team as the primary source of care reported significantly higher PCAT scores (mean difference 7.2 points, p

Background Goal-oriented care is being adopted to deliver person-centered primary care to older adults with multimorbidity and complex care needs. Although this model holds promise, its implementation remains a challenge. Digital health solutions may enable processes to improve adoption; however, they require evaluation to determine feasibility and impact. Objective This study aims to evaluate the implementation and effectiveness of the electronic Patient-Reported Outcome (ePRO) mobile app and portal system, designed to enable goal-oriented care delivery in interprofessional primary care practices. The research questions driving this study are as follows: Does ePRO improve quality of life and self-management in older adults with complex needs? What mechanisms are likely driving observed outcomes? Methods A multimethod, pragmatic randomized controlled trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrollment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the midpoint and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data were analyzed using qualitative description and framework analysis methods. Results Recruitment challenges resulted in fewer sites and participants than expected; of the 176 target, only 142 (80.6%) patients were identified as eligible to participate because of lower-than-expected provider participation and fewer-than-expected patients willing to participate or perceived as ready to engage in goal-setting. Of the 142 patients approached, 45 (32%) participated. Patients set a variety of goals related to self-management, mental health, social health, and overall well-being. Owing to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however, the intervention group, ePRO plus usual care (mean 15.28, SD 18.60) demonstrated a nonsignificant decrease in quality of life (t24=−1.20; P=.24) when compared with usual care only (mean 21.76, SD 2.17). The ethnographic data reveal a complex implementation process in which the meaningfulness (or coherence) of the technology to individuals’ lives and work acted as a key driver of adoption and tool appraisal. Conclusions This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinical settings, dynamic goal-oriented care process, and readiness of provider and patient participants. Trial Registration ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954

Faced with ageing populations in which multimorbidity is the norm rather than the exception,1 governments around the world are seeking to integrate health and social care systems in an attempt to meet the triple aim of improving the individual experience of care, improving the health of populations, and reducing costs.2 In this issue, Dambha-Miller and colleagues undertook a qualitative study exploring the views of key stakeholders on drivers and barriers of integrated primary care and social services, and opportunities for successful implementation.3 Thirty-seven interviews were conducted across England with GPs, nurses, social care staff, commissioners, local government officials, voluntary and private sector workers, patients, and carers. They report that integration is progressing slowly. The drivers and barriers of integration identified were similar to those found in other settings. Drivers included groups of like-minded individuals supported by good leadership, expanded interface roles to bridge gaps between systems, and co-location of services. Barriers included structural and interdisciplinary tension between professions, organisational self-interest, and challenges in record-sharing. They conclude that a systems-wide approach to health and social care integration is required to go beyond local and professional level change, and that such macro policy-level initiatives are necessary …

BackgroundSocial prescribing involving primary care-based ‘link workers’ is a key UK health policy that aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to the desired impact and outcomes.AimTo explore the implementation process of such an approach in practice.Design and settingQualitative process evaluation of the ‘Deep End’ Links Worker Programme (LWP) over a 2-year period, in seven general practices in deprived areas of Glasgow.MethodThe study used thematic analysis to identify the extent of LWP integration in each practice and the key factors associated with implementation. Analysis was informed by normalisation process theory (NPT).ResultsOnly three of the seven practices fully integrated the LWP into routine practice within 2 years, based on the NPT constructs of coherence, cognitive participation, and collective action. Compared with ‘partially integrated practices’, ‘fully integrated practices’ had better shared understanding of the programme among staff, higher staff engagement with the LWP, and were implementing all aspects of the LWP at patient, practice, and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations.ConclusionEven in a well-resourced government-funded programme, the majority of practices involved had not fully integrated the LWP within the first 2 years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a ‘quick fix’ for mitigating health inequalities in deprived areas.

Background There is limited quantitative research on the effect of physician attire on patient–physician relationships. This study aimed to measure the influence of Japanese family physicians’ attire on the “human” aspects of medical care in terms of patient-perceived relational empathy. Methods This was a multicenter, prospective, controlled trial conducted in primary clinics in Japan. We explored the effects of family physician attire (white coat vs. casual attire) on patient-perceived empathy. Family physicians were allocated to alternate weeks of wearing a white coat or casual attire during consultations. Patients’ perceptions of physician empathy were evaluated using the self-rated Japanese Consultation and Relational Empathy (CARE) Measure. We used a linear mixed model to analyze the CARE Measure scores, adjusting for cluster effects of patients nested within doctor, age, and sex of patients, and doctors’ sex and years of clinical experience. We used the same method with Bonferroni adjustment to analyze patient sex differences in perceived empathy. Results A total of 632 patients of seven family physicians were allocated to white coat-wearing consultations (n = 328), and casual attire-wearing consultations (n = 304). There was no difference in CARE Measure scores between white coat and casual primary care consultations overall (p = 0.162). Subgroup analysis of patient sex showed that CARE Measure scores of male patients were significantly higher in the Casual group than in the White coat group (adjusted p-value = 0.044). There was no difference in female patient scores between White coat and Casual groups (adjusted p-value = 1.000). Conclusions This study demonstrated that physician attire (white coat or casual attire) in a primary care setting did not affect patient-perceived relational empathy overall. However, male patients of physicians wearing casual attire reported higher physician empathy. Although empathy cannot be reduced to simple variables such as attire, white coats may have a negative effect on patients, depending on the context. Family physicians should choose their attire carefully. Trial registration Japanese University Hospital Medical Information Network (UMIN-ICDR). Clinical Trial identifier number UMIN000037687 (Registered August 14, 2019, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000042749). The study was prospectively registered.

Objectives The Links Worker Programme is a primary care-based social prescribing initiative in Glasgow, Scotland, targeting patients with complex needs in areas of high socioeconomic deprivation. The programme aims to improve wellbeing by connecting patients to appropriate community resources. This study explored the utility of Self-Determination Theory in understanding the reported impacts of the intervention. Methods Thematic analysis of semi-structured interviews with 12 patients (34–64 years, six female) referred to Community Links Practitioners using Self-Determination Theory as a framework. Impact was assessed from participants’ description of their personal circumstances before and after interaction with the Community Links Practitioner. Results Four patients described no overall change in daily life, two described slight improvement and six described moderate or major improvement. Improvers described satisfaction of the three psychological needs identified in Self-Determination Theory: relatedness, competence and autonomy. This often related to greater participation in community activities and sense of competence in social interaction. Patients who benefitted most described a change towards more intrinsic regulation of behaviour following the intervention. Conclusions Understanding the impact of this social prescribing initiative was facilitated by analysis using Self-Determination Theory. Self-Determination Theory may therefore be a useful theoretical framework for the development and evaluation of new interventions in this setting.

Background Comorbidity of musculoskeletal (MSK) and mental health (MH) problems is common but challenging to treat using conventional approaches. Integration of conventional with complementary approaches (CAM) might help address this challenge. Integration can aim to transform biomedicine into a new health paradigm or to selectively incorporate CAM in addition to conventional care. This study explored professionals’ experiences and views of CAM for comorbid patients and the potential for integration into UK primary care. Methods We ran focus groups with GPs and CAM practitioners at three sites across England and focus groups and interviews with healthcare commissioners. Topics included experience of co-morbid MSK-MH and CAM/integration, evidence, knowledge and barriers to integration. Sampling was purposive. A framework analysis used frequency, specificity, intensity of data, and disconfirming evidence. Results We recruited 36 CAM practitioners (4 focus groups), 20 GPs (3 focus groups) and 8 commissioners (1 focus group, 5 interviews). GPs described challenges treating MSK-MH comorbidity and agreed CAM might have a role. Exercise- or self-care-based CAMs were most acceptable to GPs. CAM practitioners were generally pro-integration. A prominent theme was different understandings of health between CAM and general practitioners, which was likely to impede integration. Another concern was that integration might fundamentally change the care provided by both professional groups. For CAM practitioners, NHS structural barriers were a major issue. For GPs, their lack of CAM knowledge and the pressures on general practice were barriers to integration, and some felt integrating CAM was beyond their capabilities. Facilitators of integration were evidence of effectiveness and cost effectiveness (particularly for CAM practitioners). Governance was the least important barrier for all groups. There was little consensus on the ideal integration model, particularly in terms of financing. Commissioners suggested CAM could be part of social prescribing. Conclusions CAM has the potential to help the NHS in treating the burden of MSK-MH comorbidity. Given the challenges of integration, selective incorporation using traditional referral from primary care to CAM may be the most feasible model. However, cost implications would need to be addressed, possibly through models such as social prescribing or an extension of integrated personal commissioning. Electronic supplementary material The online version of this article (10.1186/s12906-018-2349-8) contains supplementary material, which is available to authorized users.

BackgroundThe concept of GP clusters is derived from 'quality circles' in general practice in Europe and Canada. GP clusters commenced across Scotland in 2016 to improve the quality of care of local populations.AimTo determine GPs' views on clusters, and the robustness of bespoke questions about them.Design & settingA cross-sectional national survey of work satisfaction of GPs in Scotland took place, which was conducted in July 2018–October 2018.MethodAn analysis of bespoke questions on GP clusters was undertaken. The questions were completed by quality leads (QLs) and all other GPs in a nationally representative sample of GPs.ResultsIn total, 2456 responses were received from 4371 GPs (56.4%). QLs reported that clusters were meeting regularly, and were friendly and well organised but not always productive. Support for cluster activity (data, health intelligence, analysis, quality improvement methods, advice, leadership, and evaluation) was suboptimal. Factor analysis identified two separate constructs (cluster meetings [CMs] and cluster support [CS]), which were minimally influenced (70%) reported no positive changes in various aspects of quality improvement. Factor analysis of these items indicated two constructs (cluster knowledge and engagement [CKE] and cluster quality improvement [CQI]), which were minimally affected by GP and practice characteristics.ConclusionGP clusters are ‘up and running’ in Scotland but are at an early stage in terms of perceived impact and appear to be in need of more support in order to improve quality of care. The bespoke questions developed on clusters have robust construct validity, suitable for future surveys.

ObjectivesThe UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced.Design and settingComparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation.Participants2048 GPs in Scotland and 879 GPs in England.Main outcome measuresFour intentions to reduce work participation (5-point scales: 1=‘none’, 5=‘high’): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1=‘extremely dissatisfied’, 7=‘extremely satisfied’); job stressors (5-point-scale: 1=‘no pressure’, 5=‘high pressure); positive and negative job attributes (5-point scales: 1=‘strongly disagree’, 5=‘strongly agree’).ResultsCompared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=−0.52; 95% CI −0.64 to −0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=−0.32; 95% CI −0.42 to −0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=−0.37; 95% CI −0.47 to −0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=−0.2; 95% CI −0.28 to −0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes.ConclusionFollowing the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.

PurposeThis is an ongoing prospective cohort aiming to examine the biopsychosocial health profiles and predictors of health outcomes of older patients with multimorbidity in primary care in Hong Kong.ParticipantsFrom April 2016 to October 2017, 1077 patients aged 60+ years with at least two chronic diseases were recruited in four public primary care clinics in the New Territories East Region of Hong Kong.Findings to dateAfter weighting, the patients had 4.1 (1.8) chronic conditions and 2.5 (1.9) medications on average; 37% forgot taking medication sometimes; 71% rated their health as fair or poor; 17% were frail; 73% reported one (21%) or two or more (52%) body pain areas; 62% were overweight/obese; 23% reported chewing difficulty, 18% reported incontinence; 36% had current stage 1/2 hypertension; 38% had handgrip strength below the cut-off; 10% screened positive in sarcopenia; 17% had mild or severer cognitive impairment; 17% had mild to severe depression; 16% had mild to severe anxiety; 50% had subthreshold to severe insomnia; 28% indicated being lonely; 12% needed help in at least one out of the five daily functions and the EuroQoL-5-Dimensions-5-Level index score was 0.81 (0.20) and its Visual Analogue Scale (VAS) score was 67.6 (14.6). In the past 12 months, 17% were hospitalised, 92% attended general outpatient clinics, 70% attended specialist outpatient clinics and 10% used elderly daycare centre services, the median out-of-pocket health cost was HK$1000 (US$150). Female and male patients showed significant differences in many biopsychosocial health aspects.Future plansWith assessments and clinical data, the cohort can be used for understanding longitudinal trajectories of biopsychosocial health profiles of Chinese older patients with multimorbidity in primary care. We are also initially planning cohort studies on factors associated with various health outcomes, as well as quality of life and healthcare use.Cohort registration numberChiCTR-OIC-16008477

ObjectivePatients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost-effectiveness of the 3D intervention, which was developed to improve the system of care.DesignEconomic evaluation conducted alongside a pragmatic cluster-randomised trial.SettingGeneral practices in three centres in England and Scotland.Participants797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care.InterventionThe 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments.Primary and secondary outcome measuresThe primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs accrued by both participants and carers, and deaths) in a cost–consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses.ResultsVery small increases were found in both QALYs (adjusted mean difference 0.007 (−0.009 to 0.023)) and costs (adjusted mean difference £126 (£−739 to £991)) in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was £18 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY (55.8% at £30 000 per QALY).ConclusionsThe small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal.Trial registration numberISCRTN06180958

Objectives CARE Plus is a primary-care-based complex intervention for patients with multimorbidity living in areas of high socioeconomic deprivation. This study explores patients’ experience of the intervention and whether self-determination theory is useful to understand reported impacts. Method Thematic analysis of semistructured interviews of 14 participants conducted during a randomised controlled trial of CARE Plus. Improvement in wellbeing in daily lives following CARE Plus was estimated from participants’ accounts of their experiences of the intervention. Findings Participants valued the CARE Plus consultations irrespective of perceived improvements. Six participants reported changes in wellbeing that improved daily life, three reported slight improvement (not impacting daily life) and five no improvement. Evidence of satisfaction of the three major self-determination theory psychological needs – relatedness, competence and autonomy – was prominent in the accounts of those experiencing improved wellbeing in daily life; this group also spoke in ways congruent with more self-determined motivational regulation. These changes were not evident in those with little or no improvement in wellbeing. Discussion This study suggests self-determination theory has utility in understanding the impact of CARE Plus on patients and may be a useful theory to inform development of future interventions to improve outcomes for patients with multimorbidity.

PurposeMultimorbidity is a challenge for health systems globally. New models of care are urgently needed to better manage patients with multimorbidity. However, there is no agreed framework to support development and reporting of models of care for multimorbidity and their evaluation.MethodsWe used a literature search to identify models of care for multimorbidity. We developed a framework to describe these models. We illustrate the application of the framework by identifying the focus and gaps in current models of care, and by describing the evolution of models over time.ResultsThe framework describes each model in terms of its theoretical basis and target population (the foundations of the model), and elements of care implemented to deliver the model. We categorised elements of care into three types: (a) clinical focus; (b) organisation of care; (c) support for model delivery. Application of the framework identified a limited use of theory in model development and a strong focus on some patient groups (elderly, high users) more than others (younger patients, deprived populations). We identified changes in elements over time, with a decrease in models implementing home care, and an increase in models offering extended appointments.ConclusionsBy encouraging greater clarity about underpinning theory and target population, and categorising the wide range of potentially important elements of an intervention to improve care for patients with multimorbidity, the framework may have utility in the development and reporting of models of care. This will help ensure the effective development of the currently limited evidence base.

Background: Chronic migraine is common but there is limited knowledge on associated comorbidities. Objectives: To examine mental and physical comorbidities in chronic migraine and the influence of socioeconomic status in a large, nationally representative dataset. Design: Analysis of cross-sectional primary healthcare data from 1,468,404 adults in Scotland. Chronic migraine, 31 other physical conditions, and seven mental health conditions we examined. Prevalence rates were standardized by age groups, sex, and socioeconomic deprivation, and adjusted odds ratio (aOR) and 95% confidence intervals (CI) calculated for those with chronic migraine compared with those without. Results: Chronic migraine patients had more conditions, with the biggest difference found for five or more conditions (chronic migraine 11.7% vs. controls 4.9%; aOR 3.00; 95% CI 2.78–3.22). Twenty-five of the 31 physical conditions were significantly more prevalent in the chronic migraine group. The biggest difference was for chronic pain (aOR 4.33; 95% CI 4.12–4.55). For mental health conditions, the biggest differences were for anxiety (aOR 2.95; 95% CI 2.76–31.5) and depression (aOR 2.94; 95% CI 2.81–3.08). Increasing deprivation was associated with more severe and complex comorbidity (five or more conditions), and with more combined mental and physical comorbidity in the chronic migraine group. Conclusions In a large nationally representative sample in primary care, comorbidity was most common in those with chronic migraine compared with standardized controls, and this was exacerbated by living in areas of higher deprivation.

Background Empathy is widely regarded as being key to effective consultation in general practice. The Consultation and Relational Empathy (CARE) Measure is a widely used and well-validated patient-rated measure in English. A Japanese version of the CARE Measure has undergone preliminary validation, but its ability to differentiate between individual doctors has not been established. The current study sought to investigate the reliability of the Japanese version of the CARE Measure in terms of discrimination between doctors. Methods We conducted secondary analysis of a dataset involving 252 patients assessed by nine attending General Practitioners. The intra-cluster correlation coefficient was evaluated as an index of the reliability of the Japanese version of the CARE Measure for discriminating between doctors. With a criterion of intra-cluster correlation coefficient = 0.8, we conducted a decision (D) study using generalizability theory to determine the required number of patients for reliable CARE Measure estimates. Results The ability of the CARE Measure to discriminate between doctors increased with the number of patients assessed per doctor. A sample size of 38 or more patients provided an average intra-cluster correlation coefficient of 0.8. Conclusions The Japanese CARE Measure appears to reliably discriminate between doctors with a feasible number of patient-ratings per doctor. Further studies involving larger numbers of doctors with a multicenter analysis are required to confirm the results of the current study, which was conducted at a single institution.

Recent editorials in the SJPHC have highlighted some of the challenges facing general practice (GP) and primary care across Europe (such as multimorbidity and widening health inequalities) [1], as ...

Healthcare systems across the world are facing common challenges relating to changing demographics, and in particular ageing populations. In the UK multimorbidity is a key common denominator in frailty in older people, and health inequalities in younger age groups.1,2 There is substantial divergence in how the four nations of the UK are responding to this challenge.3 In this editorial we describe the Scottish approach to primary care transformation and how better evidence to support transformation can be generated in countries undergoing healthcare reforms. The Scottish Government has recently embarked on an ambitious journey to transform the health and social care system, with primary care at the heart of this.4,5 Numerous new models of primary care are currently being piloted, and an evaluation is being undertaken by the Scottish School of Primary Care (a consortium of Scottish universities with a strong track record in academic primary care). Following the abolition of the Quality and Outcomes Framework in Scotland in 2016, a new Scottish GP contract will be rolled out in 2018 and will include a fresh approach to quality improvement with a requirement for GP practices to work in Quality Clusters. The clusters are expected to lead both healthcare quality improvement focused on local needs, and the engagement of GPs in the wider integration agenda.6 These radical changes in Scotland are underpinned …

BackgroundSocial prescribing is a collaborative approach to improve inter-sectoral working between primary health care and community organisations. The Links Worker Programme (LWP) is a social prescribing initiative in areas of high deprivation in Glasgow, Scotland, that is designed to mitigate the negative impacts of the social determinants of health.AimTo investigate issues relevant to implementing a social prescribing programme to improve inter-sectoral working to achieve public health goals.Design and settingQualitative interview study with community organisation representatives and community links practitioners (CLPs) in LWP areas.MethodAudiorecordings of semi-structured interviews with 30 community organisation representatives and six CLPs were transcribed verbatim and analysed thematically.ResultsParticipants identified some benefits of collaborative working, particularly the CLPs’ ability to act as a case manager for patients, and their position in GP practices, which operated as a bridge between organisations. However, benefits were seen to flow from new relationships between individuals in community organisations and CLPs, rather than more generally with the practice as a whole. Challenges to the LWP were related to capacity and funding for community organisations in the context of austerity. The capacity of CLPs was also an issue given that their role involved time-consuming, intensive case management.ConclusionAlthough the LWP appears to be a fruitful approach to collaborative case management, integration initiatives such as social prescribing cannot be seen as ‘magic bullets’. In the context of economic austerity, such approaches may not achieve their potential unless funding is available for community organisations to continue to provide services and make and maintain their links with primary care.

Purpose: The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation.\ud \ud Methods: We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP’s empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups.\ud \ud Results: In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727).\ud \ud Conclusions: In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.

The Journal of Comorbidity is pleased to announce that it has extended its society collaborations by forming another important partnership with the North American Primary Care Research Group (NAPCRG), a renowned multidisciplinary organization for primary care researchers based in North America and beyond. The new partnership reflects an ongoing commitment of both the Journal of Comorbidity and NAPCRG to strengthen and broaden their ties with the primary care community and to foster the dissemination of innovative research in the field of comorbidity and multimorbidity. The partnership marks a celebration of the contribution of NAPCRG and its global members to conducting and reporting high-quality research on comorbidity/multimorbidity over the past 10 years. NAPCRG has been instrumental in growing awareness and developing the field of comorbidity/multimorbidity through various workshops, seminars, and plenaries at its annual meetings held in North America. Furthermore, in 2007, NAPCRG helped organize a meeting funded by the Canadian Institutes of Health on the theme of multimorbidity; attended by over 30 participants from eight countries, this led to the creation of the International Research Community on Multimorbidity (IRCMo) [1]. IRCMo now has almost 1,000 subscribers who are connected through a blog that showcases the most recent developments and publications on comorbidity/multimorbidity research. IRCMo also publishes regular updates on publications that are particularly important in terms of capacity building in research. Journal of Comorbidity 2017;7(1):114–116

Background ‘Social prescribing’ can be used to link patients with complex needs to local (non-medical) community resources. The ‘Deep End’ Links Worker Programme is being tested in general practices serving deprived populations in Glasgow, Scotland. Objectives To assess the implementation and impact of the intervention at patient and practice levels. Methods Study design: Quasi-experimental outcome evaluation with embedded theory-driven process evaluation in 15 practices randomized to receive the intervention or not. Complex intervention: Comprising a practice development fund, a practice-based community links practitioner (CLP), and management support. It aims to link patients to local community organizations and enhance practices’ social prescribing capacity. Study population: For intervention practices, staff and adult patients involved in referral to a CLP, and a sample of community organization staff. For comparison practices, all staff and a random sample of adult patients. Sample size: 286 intervention and 484 comparator patients. Outcomes: Primary patient outcome is health-related quality of life (EQ-5D-5L). Secondary patient outcomes include capacity, depression/anxiety, self-esteem, and healthcare utilization. Practice outcome measures include team climate, job satisfaction, morale, and burnout. Outcomes measured at baseline and 9 months. Processes: Barriers and facilitators to implementation of the programme and possible mechanisms through which outcomes are achieved. Analysis plan: For outcome, intention-to-treat analysis with differences between groups tested using mixed-effects regression models. For process, case-study approach with thematic analysis. Discussion This evaluation will provide new evidence about the implementation and impact of social prescribing by general practices serving patients with complex needs living in areas of high deprivation.

Background Multimorbidity is common in patients living in areas of high socioeconomic deprivation and is associated with poor quality of life, but the reasons behind this are not clear. Exploring the ‘everyday life work’ of patients may reveal important barriers to self-management and wellbeing. Objective To investigate the relationship between the management of multimorbidity and ‘everyday life work’ in patients living in areas of high socioeconomic deprivation in Scotland, as part of a programme of work on multimorbidity and deprivation. Design Qualitative study: individual semi-structured interviews of 14 patients (8 women and 6 men) living in deprived areas with multimorbidity, exploring how they manage. Analysis was continuous and iterative. We report the findings in relation to everyday life work. Results The in-depth analysis revealed four key themes: (i) the symbolic significance of everyday life work to evidence the work of being ‘normal’; (ii) the usefulness of everyday life work in managing symptoms; (iii) the impact that mental health problems had on everyday life work; and (iv) issues around accepting help for everyday life tasks. Overall, most struggled with the amount of work required to establish a sense of normalcy in their everyday lives, especially in those with mental–physical multimorbidity. Conclusions Everyday life work is an important component of self-management in patients with multimorbidity in deprived areas, and is commonly impaired, especially in those with mental health problems. Interventions to improve self-management support for patients living with multimorbidity may benefit from an understanding of the role of everyday life work.

The Journal of Comorbidity is pleased to announce a new partnership with the Scottish School of Primary Care (SSPC). The SSPC is a virtual school comprising all Scottish academic departments with significant primary care research output. This currently includes the Universities of Aberdeen, Dundee, Edinburgh, Glasgow, Stirling, and St. Andrew’s. This is the second important partnership that the journal has formed to strengthen ties with professional primary care networks with an interest in comorbidity and multimorbidity research. It is anticipated that this new collaboration will increase the journal’s reach and help cultivate research, discussion, and knowledge about comorbidity and multimorbidity. The Scottish School of Primary Care Since its inception in 2000, the SSPC has established a reputation for research excellence, attracting new research funding to Scottish universities. The school aims to support the development of a sustainable, equitable, high-quality primary care service that meets the needs of the people of Scotland. Working towards this vision, the SSPC’s current strategic objectives are to: Inform key stakeholders by collating relevant available national and international evidence, as well as actively contributing to the growing evidence base Support the continuing growth of academic primary care in Scotland Promote Scottish academic primary care internationally. Journal of Comorbidity 2017;7(1):112–113

Background Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation. Methods We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30–65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat. Results Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11–0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86–£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028–0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue. Conclusions It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas. Trial registration Trial registration: ISRCTN 34092919, assigned 14/1/2013. Electronic supplementary material The online version of this article (doi:10.1186/s12916-016-0634-2) contains supplementary material, which is available to authorized users.

Introduction As an increasing number of people are living with more than 1 long-term condition, identifying effective interventions for the management of multimorbidity in primary care has become a matter of urgency. Interventions are challenging to evaluate due to intervention complexity and the need for adaptability to different contexts. A process evaluation can provide extra information necessary for interpreting trial results and making decisions about whether the intervention is likely to be successful in a wider context. The 3D (dimensions of health, drugs and depression) study will recruit 32 UK general practices to a cluster randomised controlled trial to evaluate effectiveness of a patient-centred intervention. Practices will be randomised to intervention or usual care. Methods and analysis The aim of the process evaluation is to understand how and why the intervention was effective or ineffective and the effect of context. As part of the intervention, quantitative data will be collected to provide implementation feedback to all intervention practices and will contribute to evaluation of implementation fidelity, alongside case study data. Data will be collected at the beginning and end of the trial to characterise each practice and how it provides care to patients with multimorbidity. Mixed methods will be used to collect qualitative data from 4 case study practices, purposively sampled from among intervention practices. Qualitative data will be analysed using techniques of constant comparison to develop codes integrated within a flexible framework of themes. Quantitative and qualitative data will be integrated to describe case study sites and develop possible explanations for implementation variation. Analysis will take place prior to knowing trial outcomes. Ethics and dissemination Study approved by South West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via a final report, peer-reviewed publications and practical guidance to healthcare professionals, commissioners and policymakers. Trial registration number ISRCTN06180958.

Multimorbidity increases with age and is generally more common in women, but little is known about sex effects on the “typology” of multimorbidity. We have characterized multimorbidity in a large nationally representative primary care dataset in terms of sex in ten year age groups from 25 years to 75 years and over, in a cross-sectional analysis of multimorbidity type (physical-only, mental-only, mixed physical and mental; and commonest conditions) for 1,272,685 adults in Scotland. Our results show that women had more multimorbidity overall in every age group, which was most pronounced in the 45–54 years age group (women 26.5% vs. men 19.6%; difference 6.9 (95% CI 6.5 to 7.2). From the age of 45, physical-only multimorbidity was consistently more common in men, and physical-mental multimorbidity more common in women. The biggest difference in physical-mental multimorbidity was found in the 75 years and over group (women 30.9% vs. men 21.2%; difference 9.7 (95% CI 9.1 to 10.2). The commonest condition in women was depression until the age of 55 years, thereafter hypertension. In men, drugs misuse had the highest prevalence in those aged 25–34 years, depression for those aged 35–44 years, and hypertension for 45 years and over. Depression, pain, irritable bowel syndrome and thyroid disorders were more common in women than men across all age groups. We conclude that the higher overall prevalence of multimorbidity in women is mainly due to more mixed physical and mental health problems. The marked difference between the sexes over 75 years especially warrants further investigation. © 2016 by the authors; licensee MDPI, Basel, Switzerland.

The Journal of Comorbidity and the Society for Academic Primary Care (SAPC) are pleased to announce an exciting new partnership aimed at strengthening collaborations and enhancing opportunities among primary care professionals with an interest in comorbidity and multimorbidity. The Journal of Comorbidity and SAPC share a mutual goal to improve the management and care of patients by making clinical and research information and perspectives available to a global network of healthcare professionals. This new partnership will be an invaluable contribution to expanding the research platform for discussions and the scholarly exchange of knowledge, ideas, and research on comorbidity and multimorbidity. Journal of Comorbidity 2016;6(2):73–75

Background\ud Empathic patient-centred care is central to high quality health encounters. The Consultation and Relational Empathy (CARE) Measure is a patient-rated experience measure of the interpersonal quality of healthcare encounters. The measure has been extensively validated and is widely used by doctors in primary care but has not been validated in nursing. This study assessed the validity and reliability of the CARE Measure in routine nurse consultations in primary care.\ud \ud Methods\ud Seventeen nurses from nine general medical practices located in three Scottish Health Boards participated in the study. Consecutive patients (aged 16 years or older) were asked to self-complete a questionnaire containing the CARE Measure immediately after their clinical encounter with the nurse. Statistical analysis included Spearman’s correlation and principal component analysis (construct validity), Cronbach’s alpha (internal consistency), and Generalisability theory (inter-rater reliability).\ud \ud Results\ud A total of 774 patients (327 male and 447 female) completed the questionnaire. Almost three out of four patients (73 %) felt that the CARE Measure items were very important to their current consultation. The number of ‘not applicable’ responses and missing values were low overall (5.7 and 1.6 % respectively). The mean CARE Measure score in the consultations was 45.9 and 48 % achieved the maximum possible score of 50. CARE Measure scores correlated in predicted ways with overall satisfaction and patient enablement in support of convergent and divergent validity. Factor analysis found that the CARE Measure items loaded highly onto a single factor. The measure showed high internal consistency (Cronbach’s alpha coefficient = 0.97) and acceptable inter-rater reliability (G = 0.6 with 60 patients ratings per nurse). The scores were not affected by patients’ age, gender, self-perceived overall health, living arrangements, employment status or language spoken at home.\ud \ud Conclusions\ud The CARE Measure has high face and construct validity, and internal reliability in nurse consultations in primary care. Its ability to discriminate between nurses is sufficient for educational and quality improvement purposes.

Background Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. Methods Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. Results We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs’ capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. Conclusions This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0322-1) contains supplementary material, which is available to authorized users.

The Consultation and Relational Empathy (CARE) Measure is a validated patient-rated measure of consultation quality in the UK.To provide preliminary evidence of the reliability and validity of a Chinese version of the CARE Measure in a primary care setting in Hong Kong.Following translation, back-translation and pilot testing, a Chinese version of the CARE Measure was developed and tested on 253 unselected primary care patients in Hong Kong.The Chinese-CARE Measure was regarded by patients as being relevant to their consultations, with on average only 5.5% of patients rating the items as not important (range 3.6-10.2% for individual items), suggesting high acceptability and face validity. This was also supported by the relatively low number of 'not applicable' responses recorded for the measure (average 8.2%, range 0.4-21.7% for individual items). Internal reliability was high (Cronbach's alpha 0.962) and was reduced by the removal of any of the 10 items, and homogeneity was indicated by high corrected item-total correlations (0.786-0.876). Factor analysis showed a single solution for the Chinese-CARE Measure items with high item loadings (0.821-0.891). Construct validity was further supported by significant hypothesized relationships with other variables (patient enablement and patient satisfaction). Consultation length and continuity of care were independent predictors of Chinese-CARE Measure score in stepwise multiple regression analysis but together explained10% of variation in CARE score.These preliminary data support the reliability and validity of the Chinese version of the CARE Measure in primary care in Hong Kong.

PURPOSE The inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates. METHODS A questionnaire study was carried out on 3,044 National Health Ser- vice (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affl uent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health vari- ables, and a range of factors relating to quality of care. RESULTS Compared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more long- term illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was signifi cantly lower in the most deprived areas. Patients in the most deprived areas had more prob- lems to discuss (especially psychosocial), yet clinical encounter length was gener- ally shorter. GP stress was higher and patient enablement was lower in encoun- ters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation. CONCLUSIONS The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.

Aim: To translate the Consultation and Relational Empathy (CARE) Measure into Croatian and validate the Croatian version of the questionnaire.\ud Methods: A cross-sectional study was conducted in July\ud 2011 in 8 general practices (GP) in Croatia. Following two\ud stages of translation, back-translation, and pilot testing, the Croatian version of the CARE was tested on 568 consecutive patients.\ud Results: Face validity was high, the number of missing\ud values was low (9%), and the internal consistency (Cronbach’s alpha) was 0.77. A principal component analysis of 10 CARE Measure items extracted two components with\ud eigenvalues >1. These two components explained 43.6%\ud of the total instrument variance.\ud Conclusion: The Croatian version of the CARE Measure\ud had acceptable reliability and face validity, but its intended component structure was not reproduced and further research is needed to understand its dimensionality.

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas. General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity. Publisher PDF

Background Visual impairment is common in older people and the presence of additional health conditions can compromise health and rehabilitation outcomes. A small number of studies have suggested that comorbities are common in visual impairment; however, those studies have relied on self-report and have assessed a relatively limited number of comorbid conditions. Methods We conducted a cross-sectional analysis of a dataset of 291,169 registered patients (65-years-old and over) within 314 primary care practices in Scotland, UK. Visual impairment was identified using Read Code ever recorded for blindness and/or low vision (within electronic medical records). Prevalence, odds ratios (from prevalence rates standardised by stratifying individuals by age groups (65 to 69 years; 70 to 74; 75 to 79; 80 to 84; and 85 and over), gender and deprivation quintiles) and 95% confidence intervals (95% CI) of 37 individual chronic physical/mental health conditions and total number of conditions were calculated and compared for those with visual impairment to those without. Results Twenty seven of the 29 physical health conditions and all eight mental health conditions were significantly more likely to be recorded for individuals with visual impairment compared to individuals without visual impairment, after standardising for age, gender and social deprivation. Individuals with visual impairment were also significantly more likely to have more comorbidities (for example, five or more conditions (odds ratio (OR) 2.05 95% CI 1.94 to 2.18)). Conclusions Patients aged 65 years and older with visual impairment have a broad range of physical and mental health comorbidities compared to those of the same age without visual impairment, and are more likely to have multiple comorbidities. This has important implications for clinical practice and for the future design of integrated services to meet the complex needs of patients with visual impairment, for example, embedding depression and hearing screening within eye care services. Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0181-7) contains supplementary material, which is available to authorized users.