Giving patients a voice for healthcare reform in Austria: the qualitative voice-study.

BACKGROUND: Inclusion of patients in healthcare service and system planning is an increasingly important tool to improve healthcare systems worldwide. In 2012, a focused healthcare reform was initiated in Austria to strengthen the primary care sector which is still underway in 2023. OBJECTIVE: The aim of this study was to assess the perceptions, desires, and needs of patients in terms of primary care as a necessary building block of the Austrian healthcare reform. METHODS: This study was designed as an exploratory qualitative study using semi-structured interviews between the years 2013 and 2018. Interviews with patients focused on positive and negative experiences with regard to general practice (GP) consultations and perceptions of the primary care system in general, as well as desires for improvement. Qualitative content analysis was used to analyse the material using the software atlas.ti. RESULTS: Altogether, 41 interviews were conducted with seven categories identified. These categories include organization and time management around consultation, access, and availability including opening hours, human and professional aspects of consultation, infrastructure and hygiene of the waiting room, healthcare system factors, as well as non-clinical/administrative staff. CONCLUSIONS: Appreciating and responding to patients' perceptions and needs, healthcare reform in Austria should include improvements regarding consultation/waiting time, coordination, and navigation in Primary Care. Successful healthcare reform has to include the patient voice.

Underlying motivations hampering Flemish primary care physicians from overcoming the barriers in osteoporosis care: an EMR-facilitated clinical reasoning study.

BACKGROUND: Over half of the European population aged minimum 65 years presents with at least two chronic diseases. Attention towards these diseases exhibits disparities, with limited primary care physician (PCP) attention for osteoporosis. This was confirmed in a previous integrated osteoporosis care (IOC) project in which notable difficulties to enlist PCPs arose. Consequently, this study was initiated in Flemish PCPs for in-depth analysis of underlying mechanisms hampering PCPs to fully commit to osteoporosis care. METHODS: A qualitative Electronic Medical Record (EMR)-facilitated clinical reasoning study was conducted. A semi-structured interview guide was employed to guide PCPs from reflections on their own patients to broader views regarding osteoporosis care. An inductive thematic analysis was performed using NVivo 12. RESULTS: Thirteen PCPs were interviewed. They stated that osteoporosis patients often had complex (medical) profiles. PCPs emphasised the ongoing necessity for prioritisation within this context. This leads to a competition for PCP attention during consultations at three levels: i. between acute versus preventive care; ii. between primary fracture prevention and other preventive services and iii. between secondary fracture prevention and other preventive services; spanning eight areas of competition: disease significance, perceived impact, PCP awareness, the patient agenda, PCP competence, PCP support, perceived patient burden, and efficiency of care provision. Applicability of these areas of competition differed between levels. CONCLUSION: The intricate context in which PCPs operate, creates a competition for PCP attention leading to a lack of attention for fracture prevention. To preserve efforts in fracture prevention, areas of competition should be systematically addressed. TRIAL REGISTRATION: Approval for the study has been provided by the Ghent University Hospital Ethics Committee (BC-09797).

Operationalizing the Chronic Care Model with Goal-Oriented Care.

The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.

Will the implementation process for goal-oriented primary care succeed? A qualitative study investigating five perceived attributes of goal-oriented care.

Throughout the western world, goal oriented care (GOC) is increasingly promoted as a strategy towards more person-centered, integrated care. The implementation of goal-oriented care not only takes place at the micro-level with individual primary care providers (PCPs) changing their approach, but also requires meso- and macro-level investment. In this study, we zoom in on experiences and actions of various meso- and macro-level actors that are actively engaged with implementing GOC, both within their organization or at the policy level. In-depth interviews were conducted with n = 23 actors from a variety of different organizations (governmental institutions, provider organizations, patient organizations, health/social care organizations, primary care zones/care councils, etc.), using a semi- interview guide inspired by realist interviewing. Three main drivers for implementation were identified: recognition, commitment and coordination. On top of that, results were interpreted through Rogers' Diffusion of Innovations (Dol) theory in which five attributes are discussed that contribute to or hinder implementation success. Our findings can help define actions to support and facilitate the implementation process of an innovation such as GOC.

Exploring readiness for implementing goal-oriented care in primary care using normalization process theory.

AIM: To use normalization process theory (NPT) to build a strategy for the implementation of goal-oriented care (GOC) in primary care in Flanders, Belgium. BACKGROUND: GOC is a possible approach to more coordinated and integrated care and tailors care to patients' personal life goals. The concept has gained interest among policy makers and researchers, but the main drivers for successful implementation are the primary healthcare professionals (PHCPs) who need to see added value of GOC in order to embed it into their daily practice. NPT, developed to understand the processes of implementing new ways of organizing care, offers a useful lens to understand adoption of GOC in primary care practice. METHOD: PHCPs (n = 131) who participated in a 2-hour community meeting on GOC were asked to complete the Normalization MeAsure Development survey. This 23-item survey is based on NPT and describes participants' views about how an intervention would impact their work, their expectations about it, and whether it could become a routine part of their work. FINDINGS: The NPT constructs coherence (sense-making work) and cognitive participation (relational work) showed positive tendency toward implementation of GOC. The participants had an initial understanding on GOC and there was much interest in supporting and start working with this approach. The other constructs collective action (operational work) and reflexive monitoring (appraisal work) will need further efforts to trigger implementation. A common ground is needed to integrate GOC as a common practice which can be achieved by intensive interprofessional collaboration.

Creating space to talk about patients' personal goals: experiences from primary care stakeholders.

BACKGROUND: To address the many challenges health systems and communities face, primary care is constantly searching for new strategies to improve quality of care. One of the strategies is to focus on patients' personal goals to direct the care process. To adopt an explicit focus on patients' personal goals, actions at different levels are required. As a first step in this process, this study aims to explore the experiences of primary care stakeholders (i.e., scholars, primary care providers, and policy makers) and develop a comprehensive understanding on the idea 'putting patients' goals first'. This will help to formulate suggestions about what these actions should include. METHOD: In this study, 41 primary care stakeholders participating in six focus groups between January 2020 and September 2020, were recruited via maximal variation purposive sampling. Data collection was done through an open-ended semi-structured interview guide. Focus groups were audio-recorded, transcribed verbatim, and analyzed following a phenomenological-hermeneutical philosophy of Lindseth and Norberg. RESULTS: All participants expressed a strong fundamental belief for putting patients' personal goals first. The primary care providers shared that they created space for patients' personal goals by letting them talk about their values and stories. They reported to integrate their medical expertise with patients' personal goals in order to develop a balanced relationship. In this context, they also talked about the importance of taking into account the perspectives of patients' significant others. Primary care providers also talked about how they used patients' personal goals as a guide in interprofessional collaboration. Scholars denoted that (future) care providers need more training to acquire competencies to discuss patients' personal goals. The providers and policy makers talked about organizational limitations in terms of time restrictions and the lack of registration systems to support a workflow oriented towards patients' personal goals. CONCLUSIONS: This study can be used to support the coherence of the development of different actions and strategies to get primary care stakeholders fully on board to support the adoption of patients' personal goals in care delivery at different levels. However, models of practice and policy plans are needed to work towards a person-centered integrated system.

Building an understanding of goal-oriented care through the experiences of people living with chronic conditions.

OBJECTIVE: To understand the concept of goal-oriented care (GOC) through the experiences of people with chronic conditions. METHOD: Interviews with people living with chronic conditions (n = 50) were analyzed in two ways. A deductive approach based on GOC attributes generated in a concept analysis on GOC: goal-elicitation, goal-setting, goal-evaluation, patients' context, and patients' needs and preferences. An inductive approach based on a thematic analysis using descriptive phenomenology. RESULTS: The phase of goal-elicitation was recognized by the participants, whereas goal-setting and goal-evaluation were experienced to a lesser extent. Regarding the underpinning attributes, mixed feelings were reported concerning the integration of the patient's context and the presence of their needs and preferences throughout the care process. The inductive analysis revealed specific attention to informing patients about their condition and treatment options and discussing goals in interprofessional collaboration. CONCLUSION: Goal-elicitation was already present and seems to be a good foundation for GOC. More attention should be given to goal-setting and goal-evaluation. PRACTICE IMPLICATIONS: Developing guidance by means of a workflow, tools, or questions might support people with chronic conditions and providers to underpin the entire care process with patients' personal goals.

On the same page? A qualitative study of shared mental models in an interprofessional, inter-organizational team implementing goal-oriented care.

Goal-oriented care is an approach to care delivery that uses patient-identified goals to drive care planning. Implementing goal-oriented care requires team members to cognitively shift the focus from "what is the matter" to "what matters to patients," and align their mental models of what it means to care for patients. Yet, no empirical studies of goal-oriented care apply evidence from the cognitive sciences, such as Shared Mental Model (SMM) theory. We conducted a qualitative case study of an interprofessional team that adopted goal-oriented care in Vermont, US (n = 18). Guided by SMM theory, we distinguished between task-related and team-related mental models. We used framework analysis and qualitative content analysis to determine mental model content and similarity. The most shared content areas were operationalizing goal-oriented care, engaging in formal and informal communication, taking a "whole-person" approach, taking a team approach, and building trusting relationships with patients and with other team members. Trust was the only construct that spanned both task and team mental model categories, highlighting the importance of both intra-team trust and provider-patient trust to the implementation of goal-oriented care. Team members developed SMMs through training, regular meetings, and interactions during care delivery. This study provides insight into the cognitive mechanisms that underlie team-based goal-oriented care delivery, which can be used to inform implementation, training content, and future research.

Psychosocial factors associated with health-related quality of life in patients with chronic disease: Results of a cross-sectional survey.

OBJECTIVE: The impact of various psychosocial factors (sense of coherence, illness perception, patient enablement, self-efficacy, health literacy, personality) is not fully understood across a wide range of chronic diseases, and in particular in patients with multimorbidity. As such, this study assessed the key psychosocial factors associated with impaired health-related quality of life (HRQoL) in patients with one or more chronic diseases based on cross-sectional data collected in Flanders (Belgium). METHODS: Cross-sectional data on 544 chronically ill patients were analysed. Multiple linear regression models were built to analyze the key psychosocial factors associated with HRQoL (EQ-5D-5Lindex as dependent factor). RESULTS: Overall, the strongest independently associated factor with HRQoL was illness perceptions (ß = -0.52, P < 0.001). In addition, sense of coherence (ß = 0.14, P = < 0.05) was independently positively associated with HRQoL. Moreover, after stratification for multimorbidity, the negative association of illness perceptions with HRQoL was stronger when multimorbidity is present compared to when it is absent (ß = -0.62, P < 0.001 vs ß = -0.38, P < 0.001). CONCLUSIONS: This study revealed interesting associations of the modifiable psychosocial factors of illness perceptions and sense of coherence with HRQoL in a population of chronically ill persons. Given that the burden of chronic diseases will rise in the next decades, designing and implementing interventions that enhance these psychosocial abilities of patients, especially illness perceptions in multimorbid patients, is needed in order to reduce the burden of chronic diseases in terms of impaired HRQoL.

Responding to vulnerable patients with multimorbidity: an interprofessional team approach.

BACKGROUND: People with multimorbidity, who may be more vulnerable to certain social determinants of health, often require care by an interprofessional primary healthcare (PHC) team that can tailor their approach to address the multiple and complex needs of this population. This paper describes how the needs of vulnerable patients experiencing multimorbidity are identified and provided care by innovative interprofessional PHC teams during an innovative one-hour consultation, outside of usual care. METHODS: This was a descriptive qualitative study. Forty-eight interviews were conducted with 20 allied healthcare professionals: (e.g., social work, pharmacy); 19 physicians (e.g., psychiatry, internal medicine, family medicine); and 9 decision makers. The thematic analysis was iterative using an individual and team approach to identify the main themes and exemplar quotations for illustration. RESULTS: Participants described patients with multimorbidity who were vulnerable as those experiencing major challenges accessing and navigating the healthcare system. Mental health issues were a major contributor to being vulnerable and often linked to common social determinants of health. Cultural factors were identified as potentially causing patients to be vulnerable. Participants articulated how the collaborative nature of the team generated new ideas and facilitated creative recommendations designed to meet the specific needs of each patient. CONCLUSIONS: This one-time consultation went beyond the assessment of a patient's multimorbidity by including a psycho-social-contextual understanding of vulnerability within the healthcare system. Findings may have important clinical and policy implications in the adoption and implementation of this approach and further assist vulnerable patients with multimorbidity in having their complex needs addressed.

Goal-oriented care for patients with chronic conditions or multimorbidity in primary care: A scoping review and concept analysis.

BACKGROUND: The healthcare system is faced by an ageing population, increase in chronic conditions and multimorbidity. Multimorbid patients are faced with multiple parallel care processes leading to a risk of fragmented care. These problems relate to the disease-oriented paradigm. In this paradigm the treatment goals can be in contrast with what patients value. The concept of goal-oriented care is proposed as an alternative way of providing care as meeting patients' goals could have potential benefits. Though, there is a need to translate this concept into tangible knowledge so providers can better understand and use the concept in clinical practice. The aim of this study is to address this need by means of a concept analysis. METHOD: This concept analysis using the method of Walker and Avant is based on a literature search in PubMed, Embase, Cochrane Library, PsychInfo, CINAHL, OTSeeker and Web of Science. The method provides eight iterative steps: select a concept, determine purpose, determine defining attributes, identify model case, identify additional case, identify antecedents and consequences and define empirical referents. RESULTS: The analysis of 37 articles revealed that goal-oriented care is a dynamic and iterative process of three stages: goal-elicitation, goal-setting, and goal-evaluation. The process is underpinned by the patient's context and values. Provider and patient preparedness are required to provide goal-oriented care. Goal-oriented care has the potential to improve patients' experiences and providers' well-being, to reduce costs, and improve the overall population health. The challenge is to identify empirical referents to evaluate the process of goal-oriented care. CONCLUSION: A common understanding of goal-oriented care is presented. Further research should focus on how and what goals are set by the patient, how this knowledge could be translated into a tangible workflow and should support the development of a strategy to evaluate the goal-oriented process of care.

The impact of multimorbidity patterns on health-related quality of life in the general population: results of the Belgian Health Interview Survey.

BACKGROUND: Chronic diseases and multimorbidity are a major cause of disease burden-for patients, caregivers, and society. Little is known however about potential interaction effects between specific disease combinations. Besides an additive effect, the presence of multiple conditions could also act synergistically or antagonistically regarding the impact on patients' health-related quality of life (HRQoL). The aim was to estimate the impact of coexisting chronic diseases on HRQoL of the adult general Belgian population. METHODS: The Belgian Health Interview Survey 2018 provided data on self-reported chronic conditions and HRQoL (EQ-5D-5L) for a nationally representative sample. Linear mixed models were used to analyze two-way and three-way interactions of disease combinations on HRQoL. RESULTS: Multimorbidity had a prevalence of 46.7% (≥ 2 conditions) and 29.7% (≥ 3 conditions). HRQoL decreased considerably with the presence of multiple chronic diseases. 14 out of 41 dyad combinations and 5 out of 13 triad combinations showed significant interactions, with a dominant presence of negative/synergistic effects. Positive/antagonistic effects were found in more subjective chronic diseases such as depression and chronic fatigue. Conditions appearing the most frequently in significant disease pair interactions were dorsopathies, respiratory diseases, and arthropathies. CONCLUSIONS: Diverse multimorbidity patterns, both dyads and triads, were synergistically or antagonistically associated with lower HRQoL. Tackling the burden of multimorbidity is needed, especially because most disease combinations affect each other synergistically, resulting in a greater reduction in HRQoL. Further knowledge about those multimorbidity patterns with a greater impact on HRQoL is needed to better understand disease burden beyond mortality and morbidity data.

Living with a chronic disease: insights from patients with a low socioeconomic status.

BACKGROUND: Little is known about how patients with low socioeconomic status (SES) experience their chronic disease, and how it impacts health-related quality of life (HRQoL). Compared to their more affluent counterparts, worse outcomes have been reported. A better understanding of the domains of HRQoL that are relevant to these specific populations is therefore needed. We explored the experiences of living with a chronic disease in low SES persons. METHODS: A qualitative interview study was performed in Flanders, Belgium. Semi-structured interviews were conducted in chronically ill patients, selected through purposive sampling. Interviews were audio-recorded and transcribed verbatim. Analysis followed an inductive and iterative approach. RESULTS: Fifteen patients were interviewed. Six major themes were identified: a heavy bag to carry, loss of autonomous life, inner and outer loneliness, emotional imbalance, unmet need for support, and coping strategies. Patients experienced their illness as an additional problem on top of all other problems (i.e. financial/social problems, traumatic life events). In general, the disease burden and non-disease burden were mutually reinforcing, resulting in greater dependency, greater risk of social isolation, greater psychological distress, and greater risk of impaired HRQoL. CONCLUSIONS: This study is the first to provide detailed insight into the experiences of living with a chronic disease in low SES persons. A conceptual model is proposed that can be used in daily clinical practice to raise awareness among clinicians and health care providers that the patient's needs go beyond the disease itself. Future research is needed to validate and test the model.

Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients' experience.

BACKGROUND: Patient-centred interventions to help patients with multimorbidity have had mixed results. AIM: To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work. DESIGN AND SETTING: Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada. METHOD: Patients aged 18-80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients' experiences of the intervention. RESULTS: A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (ß-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes. CONCLUSION: Overall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference's recommendations.

Hepatitis C in two general practices in Flanders, Belgium: is there a need to reconsider current screening recommendations?

Objectives: Hepatitis C virus (HCV) is a major cause of acute and chronic liver disease (e.g. cirrhosis and hepatocellular carcinoma). In Belgium, screening recommendations focus on risk groups. However, it is estimated that 50% of the infected patients are undiagnosed. This study assessed the prevalence of HCV in patients visiting two general practices in Flanders, Belgium. We revealed the associated risk factors and explored whether the current recommendations for HCV screening need to be reconsidered.Methods: A cross-sectional study in a non-urban practice in Lendelede and an urban community health center in Ghent, Belgium was performed. Patients for whom a blood test was required, were recruited for HCV screening. A patient survey assessed the associated risk factors.Results: There were 1112 patients included in the study. Nineteen patients were HCV Ab positive (1.71%) and eight were HCV RNA positive (0.72%). Five patients were unaware of their status. Using IV drugs, being born in the baby boom cohort and originating from a non-Belgian low-endemic country are significantly associated with HCV Ab positivity. Four of the 19 HCV Ab positive patients didn't meet any of the registered risk factors.Conclusions: This study confirms the problem of underdiagnosis of HCV, which is both related to the fact that not all risk groups are being screened and to the fact that patients are identified beyond the risk groups. These results, as well as the current changes in treatment options and their reimbursement, justify a reconsideration of the current recommendations for screening of HCV. To develop the most effective screening strategy in Flanders, further research is necessary.

Exploring the psychometric properties of the Working Alliance Inventory in general practice: a cross-sectional study.

BACKGROUND: The therapeutic alliance is a framework from psychology that describes three components: goals, tasks, and bond. The Working Alliance Inventory adapted for general practice (WAI-GP) measures the strength of the therapeutic alliance between the patient and the clinician, and it could be useful in both research and clinical settings. AIM: To determine if the patient score on WAI-GP can delineate the three components (goals, tasks, and bond), and to test concurrent validity with the Consultation and Relational Empathy (CARE) measure and the Patient Perception of Patient-Centredness (PPPC) measure. DESIGN & SETTING: A cross-sectional study took place in 12 general practice waiting rooms in Australia. METHOD: The research instruments included the 12-item WAI-GP (the patient version), the CARE and PPPC measures, plus a survey of demographics and reason for consultation. To perform a principal components factor analysis of the WAI-GP, this dataset was combined with an existing dataset. The Spearman rank correlation was used to determine concurrent validity between the WAI-GP and the CARE and PPPC measures. RESULTS: Participants (97-99%) reported a strong positive alliance after the consultation (average WAI-GP mean 4.27 ± 0.67 out of 5, n = 146). Factor analysis could not separate the three components (one factor, eigenvalue >1; Cronbach's α = 0.957; n = 281). Concurrent validity was supported by moderate correlations with the other measures (PPPC ρ = -0.51, P<0.005, CARE ρ = 0.56, P<0.005). CONCLUSION: Three components could not be identified, but the WAI-GP has a high internal consistency and concurrent validity with moderate correlations with the CARE and PPPC. A more diverse sample may better distinguish the three components leading to more specific feedback to clinicians on their consultation practices.

Goal-Oriented Care: A Catalyst for Person-Centred System Integration.

INTRODUCTION: Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation. DESCRIPTION: This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels. DISCUSSION: The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care. LESSONS LEARNED: By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift.

Health-related quality of life in patients with non-communicable disease: study protocol of a cross-sectional survey.

INTRODUCTION: Non-communicable diseases (NCDs) are associated with lower health-related quality of life (HRQoL). However, knowledge about those diseases and predictors with a greater impact on patients' HRQoL as well as knowledge on the complex relationship between HRQoL and comorbidities is lacking. The aim of this study is to assess the impact of NCDs on patients' HRQoL, with a focus on multimorbidity and socioeconomic status. METHODS AND ANALYSIS: A primary care-based cross-sectional study is conducted in Flanders (Belgium). Study participants (≥18 years) are medically diagnosed with at least one of the following diseases: cardiometabolic disorders, mental disorders and musculoskeletal disorders. A minimum of 50 general practitioners will participate to recruit participants (convenient sample) and a total of 531 patients will be enrolled (voluntary response sample). Each participant will complete a paper-based questionnaire to gather research outcomes. Statistical analyses will be performed using multiple linear regression models with HRQoL as main outcome parameter, adjusted for possible confounders. This study will generate new evidence on the key predictors of HRQoL in patients with NCDs, and particularly provide new insights in multimorbidity to improve the quality of care in primary care, to support patients' self-management and to allocate resources more effectively. ETHICS AND DISSEMINATION: The study has been approved by the Ethical Committee of Ghent University Hospital, Ghent, Belgium (reference number: B670201939629) prior to the beginning of the recruitment. Study results will be disseminated through peer-reviewed publications and conference presentations.

Prevalence of multimorbidity with frailty and associations with socioeconomic position in an adult population: findings from the cross-sectional HUNT Study in Norway.

OBJECTIVES: To explore prevalences and occupational group inequalities of two measures of multimorbidity with frailty. DESIGN: Cross-sectional study. SETTING: The Nord-Trøndelag Health Study (HUNT), Norway, a total county population health survey, 2006-2008. PARTICIPANTS: Participants older than 25 years, with complete questionnaires, measurements and occupation data were included. OUTCOMES: ≥2 of 51 multimorbid conditions with ≥1 of 4 frailty measures (poor health, mental illness, physical impairment or social impairment) and ≥3 of 51 multimorbid conditions with ≥2 of 4 frailty measures. ANALYSIS: Logistic regression models with age and occupational group were specified for each sex separately. RESULTS: Of 41 193 adults, 38 027 (55% female; 25-100 years old) were included. Of them, 39% had ≥2 multimorbid conditions with ≥1 frailty measure, and 17% had ≥3 multimorbid conditions with ≥2 frailty measures. Prevalence differences in percentage points (pp) with 95% confidence intervals of those in high versus low occupational group with ≥2 multimorbid conditions and ≥1 frailty measure were largest in women age 30 years, 17 (14 to 20) pp and 55 years, 15 (13 to 17) pp and in men age 55 years, 15 (13 to 17) pp and 80 years, 14 (9 to 18) pp. In those with ≥3 multimorbid conditions and ≥2 frailty measures, prevalence differences were largest in women age 30 years, 8 (6 to 10) pp and 55 years, 10 (8 to 11) ppand in men age 55 years, 9 (8 to 11) pp and 80 years, 6 (95% CI 1 to 10) pp. CONCLUSION: Multimorbidity with frailty is common, and social inequalities persist until age 80 years in women and throughout the lifespan in men. To manage complex multimorbidity, strategies for proportionate universalism in medical education, healthcare, public health prevention and promotion seem necessary.

Perspectives of specialists and family physicians in interprofessional teams in caring for patients with multimorbidity: a qualitative study.

BACKGROUND: Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings. METHODS: This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes. RESULTS: There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings. INTERPRETATION: Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.