Effect of multimorbidity on health service utilisation and health care experiences
Elinor Millar 1 , James Stanley 1 , Jason Gurney 1 , Jeannine Stairmand 1 , Cheryl Davies 2 , Kelly Semper 1 , Anthony Dowell 3 , Ross Lawrenson 4 , Dee Mangin 5 , Diana Sarfati 1
+ Author Affiliations
- Author Affiliations
1 Cancer and Chronic Conditions (C3) Research Group, University of Otago, Wellington, New Zealand
2 Tu Kotahi Asthma Trust, Lower Hutt, New Zealand
3 Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
4 University of Waikato, Hamilton, New Zealand
5 Department of Family Medicine, McMaster University, Ontario, Canada
Correspondence to: Elinor Millar, Cancer and Chronic Conditions (C3) Research Group, University of Otago, Wellington, New Zealand. Email: elinor.millar@gmail.com
Journal of Primary Health Care 10(1) 44-53 https://doi.org/10.1071/HC17074
Published: 29 March 2018
Journal Compilation © Royal New Zealand College of General Practitioners 2018.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Abstract
INTRODUCTION: Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians.
AIM: To understand the experiences of people with multimorbidity in the NZ health care system.
METHODS: A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey.
RESULTS: Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population.
DISCUSSION: Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.
KEYWORDS: Multimorbidity; comorbidity; health care utilisaiton; long term conditions; primary care; secondary care; care coordination; health care access
References
[1] Ministry of Health. Health loss in New Zealand 1990–2013: a report from New Zealand Burden of Diseases, Injuries and Risk Factors Study. Wellington: Ministry of Health; 2016.[2] Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012; 380 37–43.
| Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.Crossref | GoogleScholarGoogle Scholar |
[3] Ministry of Health. Health and Independence Report 2015. The Director-General of Health’s Annual Report on the State of Health. Wellington: Ministry of Health; 2015.
[4] Davis P, Lay-Yee R, Fitzjohn J, et al. Co-morbidity and health outcomes in three Auckland hospitals. N Z Med J. 2002; 115 211–5.
[5] Walker AE. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn. 2007; 3 202–18.
| Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia.Crossref | GoogleScholarGoogle Scholar |
[6] Salisbury C, Johnson L, Purdy S, et al. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011; 61 e12–21.
| Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study.Crossref | GoogleScholarGoogle Scholar |
[7] Fortin M, Bravo G, Hudon C, et al. Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res. 2006; 15 83–91.
| Relationship between multimorbidity and health-related quality of life of patients in primary care.Crossref | GoogleScholarGoogle Scholar |
[8] Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012; 307 2493–4.
| Designing health care for the most common chronic condition—multimorbidity.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC38XhtVCkurfJ&md5=42abbbfe72070559a0a31669165af569CAS |
[9] Duguay C, Gallagher F, Fortin M. The experience of adults with multimorbidity: a qualitative study. J Comorb. 2014; 4 11–21.
| The experience of adults with multimorbidity: a qualitative study.Crossref | GoogleScholarGoogle Scholar |
[10] Clarke LH, Bennett EV, Korotchenko A. Negotiating vulnerabilities: how older adults with multiple chronic conditions interact with physicians. Can J Aging. 2014; 33 26–37.
| Negotiating vulnerabilities: how older adults with multiple chronic conditions interact with physicians.Crossref | GoogleScholarGoogle Scholar |
[11] Adeniji C, Kenning C, Coventry PA, et al. What are the core predictors of ‘hassles’ among patients with multimorbidity in primary care? A cross sectional study. BMC Health Serv Res. 2015; 15 255
| What are the core predictors of ‘hassles’ among patients with multimorbidity in primary care? A cross sectional study.Crossref | GoogleScholarGoogle Scholar |
[12] Bonney A, Magee C, Pearson R. Cross-sectional survey of older patients’ views regarding multidisciplinary care for chronic conditions in general practice. Aust J Prim Health. 2014; 20 27–33.
| Cross-sectional survey of older patients’ views regarding multidisciplinary care for chronic conditions in general practice.Crossref | GoogleScholarGoogle Scholar |
[13] Schoen C, Osborn R, Squires D, et al. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff (Millwood). 2011; 30 2437–48.
| New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated.Crossref | GoogleScholarGoogle Scholar |
[14] Bayliss EA, Edwards AE, Steiner JF, et al. Processes of care desired by elderly patients with multimorbidities. Fam Pract. 2008; 25 287–93.
| Processes of care desired by elderly patients with multimorbidities.Crossref | GoogleScholarGoogle Scholar |
[15] May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ. 2009; 339 b2803
| We need minimally disruptive medicine.Crossref | GoogleScholarGoogle Scholar |
[16] Haggerty JL. Ordering the chaos for patients with multimorbidity. BMJ. 2012; 345 e5915
| Ordering the chaos for patients with multimorbidity.Crossref | GoogleScholarGoogle Scholar |
[17] Corser W, Dontje K. Self-management perspectives of heavily comorbid primary care adults. Prof Case Manag. 2011; 16 6–15.
| Self-management perspectives of heavily comorbid primary care adults.Crossref | GoogleScholarGoogle Scholar |
[18] de Heer HD, Balcazar HG, Morera OF, et al. Barriers to care and comorbidities along the U.S.-Mexico border. Public Health Rep. 2013; 128 480–8.
| Barriers to care and comorbidities along the U.S.-Mexico border.Crossref | GoogleScholarGoogle Scholar |
[19] Signal L, Semper K, Stairmand J, et al. A walking stick in one hand and a chainsaw in the other: patients’ perspectives of living with multimorbidity. N Z Med J. 2017; 130 65
[20] Schoenberg NE, Bardach SH, Manchikanti KN, et al. Appalachian residents’ experiences with and management of multiple morbidity. Qual Health Res. 2011; 21 601–11.
| Appalachian residents’ experiences with and management of multiple morbidity.Crossref | GoogleScholarGoogle Scholar |
[21] McKinlay E, Graham S, Horrill P. Culturally and linguistically diverse patients’ views of multimorbidity and general practice care. J Prim Health Care. 2015; 7 228–35.
[22] Stokes T, Tumilty E, Doolan-Noble F, et al. Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study. BMC Fam Pract. 2017; 18 51
| Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.Crossref | GoogleScholarGoogle Scholar |
[23] Stanley J, Sarfati D. The new measuring multimorbidity index predicted mortality better than Charlson and Elixhauser indices among the general population. J Clin Epidemiol. 2017; 92 99–110.
| The new measuring multimorbidity index predicted mortality better than Charlson and Elixhauser indices among the general population.Crossref | GoogleScholarGoogle Scholar |
[24] Ministry of Health. Content Guide 2014/15 New Zealand Health Survey. Wellington: Ministry of Health; 2015.
[25] Gulliford M, Cowie L, Morgan M. Relational and management continuity survey in patients with multiple long-term conditions. J Health Serv Res Policy. 2011; 16 67–74.
| Relational and management continuity survey in patients with multiple long-term conditions.Crossref | GoogleScholarGoogle Scholar |
[26] Parchman ML, Noel PH, Lee S. Primary care attributes, health care system hassles, and chronic illness. Med Care. 2005; 43 1123–9.
| Primary care attributes, health care system hassles, and chronic illness.Crossref | GoogleScholarGoogle Scholar |
[27] Bayliss EA, Ellis J, Steiner J, et al. Initial validation of an instrument to identify barriers to self-management for persons with co-morbidities. Chronic Illn. 2005; 1 315–20.
| Initial validation of an instrument to identify barriers to self-management for persons with co-morbidities.Crossref | GoogleScholarGoogle Scholar |
[28] Salmond CE, Crampton P. Development of New Zealand’s deprivation index (NZDep) and its uptake as a national policy tool. Can J Public Health. 2012; 103 S7–11.
[29] Davis K, Stremikis K, Squires D, et al. Mirror, mirror on the Wall, 2014 Update: how the U.S. health care system compares internationally. New York: Commonwealth Fund; 2014.
[30] Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J. 2017; 130 23–38.
[31] Sorondo B, Allen A, Fathima S, et al. Patient portal as a tool for enhancing patient experience and improving quality of care in primary care practices. EGEMS (Wash DC). 2017; 4 1262.
[32] Goldzweig CL, Shekelle PG, Towfigh AA, et al. Secure messaging between providers and patients, and patients’ access to their own medical record. Washington DC: Department of Veterans Affairs; 2012.
[33] Bayliss EA, Ellis JL, Steiner JF. Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities. Ann Fam Med. 2007; 5 395–402.
| Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities.Crossref | GoogleScholarGoogle Scholar |
[34] Mishra SI, Gioia D, Childress S, et al. Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions. Health Soc Work. 2011; 36 249–58.
| Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions.Crossref | GoogleScholarGoogle Scholar |
[35] Schäfer I, Hansen H, Schon G, et al. The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the multicare cohort study. BMC Health Serv Res. 2012; 12 89
| The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the multicare cohort study.Crossref | GoogleScholarGoogle Scholar |
[36] Lawson KD, Mercer SW, Wyke S, et al. Double trouble: the impact of multimorbidity and deprivation on preference-weighted health related quality of life a cross sectional analysis of the Scottish Health Survey. Int J Equity Health. 2013; 12 67
| Double trouble: the impact of multimorbidity and deprivation on preference-weighted health related quality of life a cross sectional analysis of the Scottish Health Survey.Crossref | GoogleScholarGoogle Scholar |
[37] Ministry of Health. Care Plus 2017 [updated 10-03-2017]. Wellington: Ministry of Health; 2017. [cited 2017 July 17]. Available from: http://www.health.govt.nz/our-work/primary-health-care/primary-health-care-subsidies-and-services/care-plus.
[38] Kuluski K, Gill A, Naganathan G, et al. A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers. BMC Fam Pract. 2013; 14 133
| A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers.Crossref | GoogleScholarGoogle Scholar |
[39] Zulman DM, Kerr EA, Hofer TP, et al. Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients. J Gen Intern Med. 2010; 25 408–14.
| Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients.Crossref | GoogleScholarGoogle Scholar |
[40] Morris RL, Sanders C, Kennedy AP, et al. Shifting priorities in multimorbidity: a longitudinal qualitative study of patient’s prioritization of multiple conditions. Chronic Illn. 2011; 7 147–61.
| Shifting priorities in multimorbidity: a longitudinal qualitative study of patient’s prioritization of multiple conditions.Crossref | GoogleScholarGoogle Scholar |
[41] Sevick MA, Trauth JM, Ling BS, et al. Patients with complex chronic diseases: perspectives on supporting self-management. J Gen Intern Med. 2007; 22 438–44.
| Patients with complex chronic diseases: perspectives on supporting self-management.Crossref | GoogleScholarGoogle Scholar |
[42] Health Care Home Collaborative. Health Care Home 2017. Wellington: CompassHealth. Available from: http://www.healthcarehome.org.nz/
[43] Cowie L, Morgan M, White P, et al. Experience of continuity of care of patients with multiple long-term conditions in England. J Health Serv Res Policy. 2009; 14 82–7.
| Experience of continuity of care of patients with multiple long-term conditions in England.Crossref | GoogleScholarGoogle Scholar |
[44] Mazor KM, Clauser BE, Field T, et al. A demonstration of the impact of response bias on the results of patient satisfaction surveys. Health Serv Res. 2002; 37 1403–17.
| A demonstration of the impact of response bias on the results of patient satisfaction surveys.Crossref | GoogleScholarGoogle Scholar |
