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BACKGROUND: Although older adults with heart failure (HF) and multiple chronic conditions (MCC) frequently rely on caregivers for health management, digital health systems, such as patient portals and mobile apps, are designed for individual patients and often exclude caregivers. There is a need to develop approaches that integrate caregivers into care. This study tested the feasibility of the Social Convoy Palliative Care intervention (Convoy-Pal), a 12-week digital self-management program that includes assessment tools and resources for clinical palliative care, designed for both patients and their caregivers. METHODS: A randomized waitlist control feasibility trial involving patients over 65 years old with MCC who had been hospitalized two or more times for HF in the past 12 months and their caregivers. Descriptive statistics were used to evaluate recruitment, retention, missing data, self-reported social functioning, positive aspects of caregiving, and the acceptability of the intervention. RESULTS: Of 126 potentially eligible patients, 11 were ineligible and 69 were deceased. Of the 46 eligible patients, 31 enrolled in the trial. Although 48 caregivers were identified, only 15 enrolled. The average age was 76.3 years for patients and 71.6 years for caregivers, with most participants being non-Hispanic White. Notably, 4% did not have access to a personal mobile device or computer. Retention rates were 79% for intervention patients, 57% for intervention caregivers, and 60% for control participants. Only 4.6% of survey subscales were missing, aided by robust technical support. Intervention patients reported improved social functioning (SF-36: 64.6 ± 25.8 to 73.2 ± 31.3) compared to controls (64.6 ± 27.1 to 67.5 ± 24.4). Intervention caregivers also reported increased positive perceptions of caregiving (29.5 ± 5.28 to 35.0 ± 5.35) versus control caregivers (29.4 ± 8.7 to 28.0 ± 4.4). Waitlist control participants who later joined the Convoy-Pal program showed similar improvements. The intervention was well-rated for acceptability, especially regarding the information provided (3.96 ± .57 out of 5). CONCLUSIONS: Recruiting informal caregivers proved challenging. Nonetheless, Convoy-Pal retained patients and collected meaningful self-reported outcomes, showing potential benefits for both patients and caregivers. Given the importance of a patient and caregiver approach in palliative care, further research is needed to design digital tools that cater to multiple simultaneous users. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04779931. Date of registration: March 3, 2021.

Using data from Vietnamese-origin older immigrants/refugees in the Houston, Texas area, we assessed their overall health, chronic conditions, disability, depressive symptoms, and cognitive impairment, and examined the association between their chronic conditions and disability by comorbidity clusters. The mean age of the sample was 76 years old. The majority were married in fair/poor health with several chronic conditions and disabilities and lived with families in low-income households. Hypertension and arthritis were the most common health conditions, but cognitive impairment had the most significant impact on their disability. They experienced similar health conditions to other older Americans but had higher rates of depressive symptoms and cognitive impairment possibly due to cultural factors that may have delayed mental health treatment. Culturally and linguistically tailored services created by policymakers, healthcare professionals, and local social service agencies are recommended for the well-being of immigrants/refugees who migrated to the U.S. for a better life.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In VIII: clinical approaches, authors address the following themes: Evaluation, diagnosis and management I-toward a working diagnosis, Evaluation, diagnosis and management II-process steps, Interweaving integrative medicine and family medicine, Halfway-the art of clinical judgment, Seamless integration in family medicine-team-based care, Technology-uncovering stories from noise and Caring for patients with multiple long-term conditions. May readers recognise in these essays the uniqueness of a family medicine approach to care.

Background: Implementation research should assess the feasibility of scale up to bridge the evidence-practice gap for integrated care programs in the prevention and management of chronic conditions. Scalability assessment is the first critical step of scale up to determine the potential suitability of a promising health program to be adopted into routine practice and the fit of the program within local contexts. The Community Partnership Program (CPP), an integrated care intervention for older adults with diabetes and multiple chronic conditions, was designed at the outset with scale up in mind, and evaluated in an implementation-effectiveness randomized controlled trial across three Canadian provinces. The final phase of this program of research was to assess scalability and determine the critical factors and next steps for the development of a scale up plan. Methods: Multiple methods were used to assess the scalability of the CPP including collection and analysis of publicly available documents, synthesis of qualitative and quantitative evidence from studies of the CPP, semi-structured interviews with key informants, feedback and recommendations arising from working group meetings and knowledge exchange workshops to discuss and rate the scalability of the program. Data collection and analysis was informed by the Intervention Scalability Assessment Tool (ISAT); developed to support practitioners and policy makers in conducting systematic assessments of the suitability of health interventions for population scale-up in high-income countries. Results: Overall, the CPP received high scalability ratings from participants. A phased, horizontal implementation and scale up process was recommended, facilitating local adaptations, on-going program evaluation, and accumulation of evidence. Challenges to scale up were identified, including the need for further evidence of program effectiveness in other diverse settings and populations, and designated funding and adequate health human resources. Conclusions: Participants agreed the CPP meets the needs of many older adults with diabetes and multiple chronic conditions; however, they suggested further tailoring of the program to support different ethnocultural groups and targeting the CPP to older adults with higher needs. The scalability assessment process was a practical method to generate concrete strategies to facilitate the uptake of the CPP into practice. Trial registration: Clinical Trials.gov Identifier NCT03664583. Registration date: September 10, 2018. [ABSTRACT FROM AUTHOR]

Summary: We compared medication prescription and initiation proportions among high-risk Fracture Screening and Prevention Program patients with multiple chronic conditions. Patients with two conditions were more likely to receive prescriptions and initiate prescribed medication than those with none. Post hoc analysis showed that patients with ≥ 3 conditions were less likely to be prescribed and to initiate medication, compared to those with two conditions. Tailored interventions are important for improving post-fracture care outcomes. Purpose: To investigate the association between the number of chronic conditions and pharmacological treatment outcomes in high-risk patients who were screened through the Fracture Screening and Prevention Program (FSPP). Methods: A retrospective cohort study was employed to determine the association between the number of chronic conditions and treatment outcomes. All high-risk patients who were enrolled in the FSPP between June 1, 2017, and June 30, 2022, were included in the study. The number of self-reported chronic conditions available in the FSPP data was classified into four categories: (1) 0 condition; (2) 1 condition; (3) 2 conditions; and (4) ≥ 3 conditions. Multivariable logistic regression models were created with prescription and initiation as outcomes. Results: In total, 11,245 patients were identified as high-risk for future fracture. Patients with two chronic conditions demonstrated a 26% higher odds of receiving a medication prescription, and those with two chronic conditions and prescribed bone-active medication had a 57% increased odds of initiating the treatment compared to individuals without chronic conditions. No significant differences in medication prescription or initiation were seen in those with 1 or ≥ 3 chronic conditions compared to those without chronic conditions. In post hoc testing, we saw a 25–30% significantly lower odds of medication prescription and initiation in patients reporting ≥ 3 chronic conditions when compared to those who reported only two chronic conditions. Conclusion: The findings suggest that a large provincial secondary fracture prevention program resulted in higher odds of prescription and initiation of treatment in patients with two chronic conditions compared to those having no chronic conditions. Potential inequities in these treatment outcomes were found with a threshold of three or more chronic conditions. This highlights the need for tailored interventions and comprehensive support systems to improve fracture prevention outcomes for high-risk patients with multiple chronic conditions. [ABSTRACT FROM AUTHOR]

Background During coronavirus disease 2019 (COVID-19), people managing multiple chronic conditions (MCCs) experienced barriers to obtaining needed medications. The purposes of this paper are to (i) determine risk factors for difficulty obtaining medications during COVID-19, (ii) document reasons for the difficulty, and (iii) evaluate the impact on later physical and mental health outcomes. Method In a randomized controlled trial conducted in 2016–2021, 1969 adult primary care patients were surveyed about physical and mental health both before and during COVID-19. They reported their needs for medication during COVID-19 and any difficulty obtaining them. Reasons for difficulty accessing medications were tabulated descriptively. Logistic regression identified predictors of medication access difficulty. Multivariable linear regression modeled the relationship between access to medications and health outcomes, accounting for pre-COVID health. Results In total 13% of participants experienced difficulty accessing needed medications. Compared to the larger sample, those participants were younger, had more MCCs, and had lower income. They were more often female, unmarried, and were facing insecurities in housing, food, or finances (all P  < 0.004). Younger age and the presence of socioeconomic insecurity at baseline increased the odds of later difficulty accessing medications. Barriers to access included concerns about contracting COVID-19 (52%), physician or pharmacy inaccessibility (38%), and cost (26%). Adjusting for baseline health, difficulty accessing medications was associated with poorer health at follow up (P  = 0.001). Conclusion People with socioeconomic disadvantages experienced a disproportionate impact of difficulty obtaining medications and poorer health outcomes due to COVID-19. They may be at greater risk in the event of future pandemics and other societal disruptions. [ABSTRACT FROM AUTHOR]

PURPOSE: We performed a pragmatic, cluster randomized controlled trial of a comprehensive practice-level, multistage practice transformation intervention aiming to increase behavioral health integration in primary care practices and improve patient outcomes. We examined associations between completion of intervention stages and patient outcomes across a heterogeneous national sample of primary care practices. METHODS: Forty-two primary care practices across the United States with colocated behavioral health and 2,945 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint, and 2-year follow-up. We examined effects of intervention on patient health and primary care integration outcomes using multilevel mixed-effects models, controlling for baseline outcome measurements. RESULTS: No differences were found associated with the number of intervention stages completed and patient health outcomes including depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social participation, and physical function. However, the completion of each intervention stage was associated with increases in Practice Integration Profile domain scores and confirmed with modeling using multiple imputation for the following: workflow 3.5 (95% CI, 0.9 to 6.1), integration methods 4.6 (95% CI, 1.5 to 7.6), patient identification 2.9 (95% CI, 0.9 to 5.0), and total integration 2.7 (95% CI, 0.7 to 4.7). CONCLUSION: A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogeneous primary care practices treating patients with multiple chronic conditions when accounting for completion of intervention stages. Interventions that allow practices to flexibly improve care have the potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at the population level. [ABSTRACT FROM AUTHOR]

Patients with multimorbidity often require the concomitant use of multiple medications, presenting general practitioners (GPs) with the dilemma of assessing the benefits and risks due to complex and potential interactions between diseases and medications. This article takes one case of a multimorbid patient at a community health service center to illustrate and elucidate the process by which GP employs a medication decision-making framework for multimorbidity (MDMF). Furthermore, by examining the multi-stage goals set by Ariadne principle in the process of multimorbidity management, this article analyzes the key points and considerations for GPs in the assessment, communication, and making treatment plans, thereby offering reference to improve the quality of medication decision-making for patients with multimorbidity in the community.

Multimorbidity refers to an individual suffering from two or more chronic diseases simultaneously. Patients with multimorbidity refers often require the concurrent use of multiple medications, posing a challenge to community general practitioners in making scientific medication decisions. This paper analyzes the reasons and influencing factors that lead to the dilemmas in medication decision-making for patients with multimorbidity in the community. It also proposes a dynamic and comprehensive decision-making framework known as the Medication Decision-making for Multimorbidity Framework (MDMF). The framework consists of five stages in the process of community general practitioners treating patients with multimorbidity, which include "Health problems review""Comprehensive medication assessment""Shared decision-making""Medication therapy recording", and "Follow-up arrangement". The MDMF facilitates the development of individualized medication therapy for patients with multimorbidity by community general practitioners, but it also places certain demands on their capabilities. Therefore, it is recommended to provide training for community general practitioners centered on the MDMF, offer decision-making support, and implement reasonable incentives and supervision measures. This is expected to promote primary care institutions to provide patient-centered medication therapy, enhance its safety and efficacy, and alleviate the treatment burden on patients.

Background With the population aging, the number of patients with chronic diseases and disability is increasing, which brings a heavy burden on the medical system. While it is well established that comorbidity and disability are closely interconnected, there is a noticeable scarcity of studies addressing the relationship between different patterns of comorbidity and disability. Objective To explore the common comorbidity patterns and their associations with disability among the older adults in China taking Sichuan as an example. Methods A total of 501 older adults, aged 60 and above, were selected using quota sampling in Sichuan from August to Novermber 2022. Detailed data on chronic diseases, disability, and general demographics were collected. Comorbidity patterns among the older adults were identified using a two-step clustering method that combined self-organizing maps and K-Means. The association between patterns of comorbidity and disability was explored using a logistic regression model, employing the National Disability Assessment Scale for the Long-term Care issued by the National Healthcare Security Administration of China in 2021. Results In this survey, The prevalence of comorbidity 62.3% (312/501) and the prevalence of disability was 74.3% (372/501). We identified six comorbidity patterns: Arthritis/Rheumatism and Hypertension diseases, Cardiovascular and Metabolic diseases, Kidney and Arthritis/Rheumatism diseases, Cancer and Arthritis/Rheumatism diseases, Asthma, Hypertension, and Gastrointestinal diseases, Emotional/Mental and Memory-related diseases. The results of binomial logistic regression showed that the risk of disability was 6.3 times higher when people suffering from two or more chronic diseases at the same time (OR=6.3, 95%CI=3.9-10.3, P

Background With the acceleration of population aging in my country, the multiple chronic conditions in the elderly has become increasingly common. This not only seriously affects the quality of life of the elderly, but also places a heavy burden on families and society. Gansu is a province with a relatively high aging population in the northwest region, and it is urgent to pay attention to the multiple chronic conditions among the elderly. Objective In order to understand the current status and influencing factors of multiple chronic conditions among the elderly in Gansu Province, and provide a reference basis for the prevention, treatment and management of multiple chronic conditions in Gansu Province. Methods From 2023-07-15 to 2023-08-10, a multi-stage stratified random cluster sampling method was used to select 20 000 elderly people aged ≥60 years old in Gansu Province for a questionnaire survey. The questionnaire was designed by the research team itself and mainly investigated the prevalence of 15 common chronic diseases among the elderly, as well as their demographic characteristics and family circumstances. In the end, 19 038 valid questionnaires were collected, and the effective questionnaire recovery rate was 95.19%. Results The prevalence rate of chronic diseases among the elderly in Gansu Province was 74.78% (14 236/19 038), and the incidence rate of multiple chronic conditions was 38.97% (7 419/19 038). The top six chronic diseases with the highest prevalence were hypertension[9 693 (50.91%) ], arthritis or rheumatism[3 648 (19.16%) ], and heart disease[3 418 (17.95%) ], diabetes or elevated blood sugar[3 033 (15.93%) ], chronic lung disease[1 645 (8.64%) ], stroke[1 548 (8.13%) ]. Common comorbidity combination patterns are all related to hypertension. The top-ranked binary comorbidity pattern is hypertension + diabetes or elevated blood sugar[2 112 (11.09%) ], and the top-ranked ternary comorbidity pattern is hypertension + diabetes or elevated blood sugar + heart disease[532 (2.79%) ]. The results of multi-factor Logistic regression analysis showed that gender, age, ethnicity, pre-retirement occupation, spouse, number of children, relationship with children, self-rated health status, self-rated life satisfaction, and loneliness are influencing factors for the occurrence of multiple chronic conditions in the elderly (P

Introduction: Caregivers of patients with chronic diseases (PwCD) devote a substantial amount of energy to the care of their PwCD. This study aimed to review interventions fostering resilience in caregivers of PwCD. Methods: A systematic review of literature published either through databases Web of Science, PubMed, Scopus, Magiran, and SID or Google Scholar search engine was undertaken. The review was conducted according to the PRISMA review guidelines. Results: Ten studies were included in this review. Quantitative data provides empirical support for the advantages of psychoeducation, mindfulness-based intervention, cognitive behavioral therapy (CBT)-based intervention, and strengthening family coping resources approach, supportive-educational program based on COPE (Coping Orientation to Problems Experienced) model and commitment therapy. Seven out of ten included studies were randomized controlled trials (RCTs). Conclusion: The present review revealed that psychoeducation, mindfulness-based intervention, CBT-based intervention, strengthening family coping resources approach, supportive-educational Program based on COPE model, and commitment therapy may promote resilience amongst the caregivers of PwCD. Although, it remains unclear which specific intervention would be the most efficacious in improving resilience. Additional rigorous clinical trials are necessary to fortify the current limited evidence base for interventions targeting caregiver resilience.

Abstract Background Integrating behavioral health services in primary care is challenging; a toolkit approach to practice implementation can help. A recent comparative effectiveness randomized clinical trial examined the impact of a toolkit for improving integration on outcomes for patients with multiple chronic conditions. Some aspects of behavioral health integration improved; patient-reported outcomes did not. This report evaluates the implementation strategy (Toolkit) using Proctor’s (2011) implementation outcomes model. Methods Using data from the 20 practices randomized to the active (toolkit strategy) arm (education, redesign workbooks, online learning community, remote coaching), we identified 23 measures from practice member surveys, coach interviews, reports, and field logs to assess Toolkit acceptability, appropriateness, feasibility, and fidelity. A practice survey score was high (met expectations) if its average was ≥ 4 on a scale 1-5; all other data were coded dichotomously, with high = 1. Results Regarding acceptability, 74% (14) of practices had high scores for willingness of providers and staff to use the Toolkit and 68% (13) for quality improvement teams liking the Toolkit. For appropriateness, 95% (19) of practices had high scores for the structured process being a good match and 63% (12) for the Toolkit being a good match. Feasibility, measured by Toolkit prerequisites, was scored lower by site members at project end (e.g., provider leader available as champion: 53% of practices) compared to remote coaches observing practice teams (74%). For “do-ability,” coaches rated feasibility lower for practices (e.g., completion of workbook activities: 32%) than the practice teams (68%). Fidelity was low as assessed across seven measures, with 50% to 78% of practices having high scores across the seven measures. Conclusions Existing data from large trials can be used to describe implementation outcomes. The Toolkit was not implemented with fidelity in at least one quarter of the sites, despite being acceptable and appropriate, possibly due to low feasibility in the form of unmet prerequisites and Toolkit complexity. Variability in fidelity reflects the importance of implementation strategies that fit each organization, suggesting that further study on contextual factors and use of the Toolkit, as well as the relationship of Toolkit use and study outcomes, is needed. Trial registration ClinicalTrials.gov NCT02868983; date of registration: 08/15/2016.

Hypertension, type 2 diabetes mellitus (T2DM), and dyslipidemia are collectively referred to as the "three highs", which often coexist in the same individual. It significantly increases the risk of hospitalization, death, and relevant burdens for affected people. It is necessary to jointly control the risk and standardize the treatment of hypertension, T2DM and dyslipidemia. Primary healthcare institutions have become the main battlefield for the prevention and treatment of chronic diseases. Existing clinical evidence provides important insights into the prevention, treatment, and management of the "three highs", although norms, consensus, and guidelines for the co-management of the "three highs" in primary healthcare institutions at domestic and foreign are current not available. Four academic organizations led by Beijing Hypertension Association organized primary healthcare workers and invited experts and scholars from medical fields of cardiovascular diseases, endocrine, pharmacy, and public health services to participate in the consensus. Through widely soliciting clinical practice needs of primary healthcare workers, integrating and evaluating the evidence related to the prevention and treatment of the "three highs" in primary healthcare institutions, the consensus for primary healthcare in the prevention and treatment of the "three highs" including 21 opinions was developed after multiple rounds of discussions, revisions, and voting. The recommended opinions of this consensus aim to improve the awareness and ability of primary healthcare workers in the prevention and treatment of the "three highs", provide scientific strategic support, implement management with primary healthcare characteristics, and lay a solid foundation for comorbidity co-management.