title: Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review.
abstract: The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on 'comorbidity' (i.e. the 'index disease' approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on 'multi-morbidity' (i.e. multiplicity of problems) and 'morbidity burden' (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.
authors.affiliation: a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Ricci-Cabello
authors.affiliation: b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.|c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.
authors.forename: Concepció
authors.initials: C
authors.lastname: Violán
authors.affiliation: b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.|c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.|d Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain.
authors.forename: Quinti
authors.initials: Q
authors.lastname: Foguet-Boreu
authors.affiliation: e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK.
authors.forename: Luke T A
authors.initials: LT
authors.lastname: Mounce
authors.affiliation: a Nuffield Department of Primary Care Health Sciences , University of Oxford , Oxford , UK.|b Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) , Barcelona , Spain.|c Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès) , Spain.|e Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter , Exeter , UK.|f CIBER en Epidemiologia y Salud P blica (CIBERESP) , Barcelona , Spain.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Valderas
mesh_terms: D035843:Biomedical Research; D015897:Comorbidity; D003266:Continuity of Patient Care; D006291:Health Policy; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D018802:Patient-Centered Care; D012720:Severity of Illness Index
keywords: Multi-morbidity; comorbidity; health services needs and demand; primary care; quality of healthcare; scoping review