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Objectives: To compare the effect of a 6-month community-based intervention with that of usual care on quality of life, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with type 2 diabetes mellitus (T2DM) and 2 or more comorbidities., Design: Multisite, single-blind, parallel, pragmatic, randomized controlled trial., Setting: Four communities in Ontario, Canada., Participants: Community-dwelling older adults (≥65) with T2DM and 2 or more comorbidities randomized into intervention (n = 80) and control (n = 79) groups (N = 159)., Intervention: Client-driven, customized self-management program with up to 3 in-home visits from a registered nurse or registered dietitian, a monthly group wellness program, monthly provider team case conferences, and care coordination and system navigation., Measurements: Quality-of-life measures included the Physical Component Summary (PCS, primary outcome) and Mental Component Summary (MCS, secondary outcome) scores of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12). Other secondary outcome measures were the Generalized Anxiety Disorder Scale, Center for Epidemiologic Studies Depression Scale (CES-D-10), Summary of Diabetes Self-Care Activities (SDSCA), Self-Efficacy for Managing Chronic Disease, and healthcare costs., Results: Morbidity burden was high (average of eight comorbidities). Intention-to-treat analyses using analysis of covariance showed a group difference favoring the intervention for the MCS (mean difference = 2.68, 95% confidence interval (CI) = 0.28-5.09, P = .03), SDSCA (mean difference = 3.79, 95% CI = 1.02-6.56, P = .01), and CES-D-10 (mean difference = -1.45, 95% CI = -0.13 to -2.76, P = .03). No group differences were seen in PCS score, anxiety, self-efficacy, or total healthcare costs., Conclusion: Participation in a 6-month community-based intervention improved quality of life and self-management and reduced depressive symptoms in older adults with T2DM and comorbidity without increasing total healthcare costs., (© 2017 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Background The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty. Methods A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models. Results The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively). Conclusion In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients. [ABSTRACT FROM AUTHOR]

Background: Adverse childhood experiences (ACEs) are associated with multimorbidity in adulthood. This link may be mediated by psychosocial and biological factors, but evidence is lacking. The current study evaluates this mediation model. Method: We analyzed data from the Canadian Longitudinal Study of Aging (N = 27 170 community participants). Participants were 45–85 years at recruitment, when allostatic load and social engagement data were collected, and 3 years older at follow-up, when ACEs and multimorbidity data were collected. Structural equation modeling was used to test for mediation in the overall sample, and in sex- and age-stratified subsamples, all analyses adjusted for concurrent lifestyle confounds. Results: In the overall sample, ACEs were associated with multimorbidity, directly, β = 0.12 (95% confidence interval 0.11–0.13) and indirectly. Regarding indirect associations, ACEs were related to social engagement, β = −0.14 (−0.16 to −0.12) and social engagement was related to multimorbidity, β = −0.10 (−0.12 to −0.08). ACEs were related to allostatic load, β = 0.04 (0.03–0.05) and allostatic load was related to multimorbidity, β = 0.16 (0.15–0.17). The model was significant for males and females and across age cohorts, with qualifications in the oldest stratum (age 75–85). Conclusions: ACEs are related to multimorbidity, directly and via social engagement and allostatic load. This is the first study to show mediated pathways between early adversity and multimorbidity in adulthood. It provides a platform for understanding multimorbidity as a lifespan dynamic informing the co-occurrence of the varied disease processes represented in multimorbidity. [ABSTRACT FROM AUTHOR]

Background: The Coronavirus Disease-2019 (COVID-19) pandemic has created a spectrum of adversities that have affected older adults disproportionately. This paper examines older adults with multimorbidity using longitudinal data to ascertain why some of these vulnerable individuals coped with pandemic-induced risk and stressors better than others - termed multimorbidity resilience. We investigate pre-pandemic levels of functional, social and psychological forms of resilience among this sub-population of at-risk individuals on two outcomes - self-reported comprehensive pandemic impact and personal worry.Methods: This study was conducted using Follow-up 1 data from the Canadian Longitudinal Study on Aging (CLSA), and the Baseline and Exit COVID-19 study, conducted between April and December in 2020. A final sub-group of 9211 older adults with two or more chronic health conditions were selected for analyses. Logistic regression and Generalized Linear Mixed Models were employed to test hypotheses between a multimorbidity resilience index and its three sub-indices measured using pre-pandemic Follow-up 1 data and the outcomes, including covariates.Results: The multimorbidity resilience index was inversely associated with pandemic comprehensive impact at both COVID-19 Baseline wave (OR = 0.83, p < 0.001, 95% CI: [0.80,0.86]), and Exit wave (OR = 0.84, p < 0.001, 95% CI: [0.81,0.87]); and for personal worry at Exit (OR = 0.89, p < 0.001, 95% CI: [0.86,0.93]), in the final models with all covariates. The full index was also associated with comprehensive impact between the COVID waves (estimate = - 0.19, p < 0.001, 95% CI: [- 0.22, - 0.16]). Only the psychological resilience sub-index was inversely associated with comprehensive impact at both Baseline (OR = 0.89, p < 0.001, 95% CI: [0.87,0.91]) and Exit waves (OR = 0.89, p < 0.001, 95% CI: [0.87,0.91]), in the final model; and between these COVID waves (estimate = - 0.11, p < 0.001, 95% CI: [- 0.13, - 0.10]). The social resilience sub-index exhibited a weak positive association (OR = 1.04, p < 0.05, 95% CI: [1.01,1.07]) with personal worry, and the functional resilience measure was not associated with either outcome.Conclusions: The findings show that psychological resilience is most pronounced in protecting against pandemic comprehensive impact and personal worry. In addition, several covariates were also associated with the outcomes. The findings are discussed in terms of developing or retrofitting innovative approaches to proactive coping among multimorbid older adults during both pre-pandemic and peri-pandemic periods. [ABSTRACT FROM AUTHOR]

Background: Researchers often use survey data to study the effect of health and social variables on physician use, but how self-reported physician use compares to administrative data, the gold standard, in particular within the context of multimorbidity and functional limitations remains unclear. We examine whether multimorbidity and functional limitations are related to agreement between self-reported and administrative data for physician use.Methods: Cross-sectional data from 52,854 Ontario participants of the Canadian Community Health Survey linked to administrative data were used to assess agreement on physician use. The number of general practitioner (GP) and specialist visits in the previous year was assessed using both data sources; multimorbidity and functional limitation were from self-report.Results: Fewer participants self-reported GP visits (84.8%) compared to administrative data (89.1%), but more self-reported specialist visits (69.2% vs. 64.9%). Sensitivity was higher for GP visits (≥90% for all multimorbidity levels) compared to specialist visits (approximately 75% for 0 to 90% for 4+ chronic conditions). Specificity started higher for GP than specialist visits but decreased more swiftly with multimorbidity level; in both cases, specificity levels fell below 50%. Functional limitations, age and sex did not impact the patterns of sensitivity and specificity seen across level of multimorbidity.Conclusions: Countries around the world collect health surveys to inform health policy and planning, but the extent to which these are linked with administrative, or similar, data are limited. Our study illustrates the potential for misclassification of physician use in self-report data and the need for sensitivity analyses or other corrections. [ABSTRACT FROM AUTHOR]

Self-reported health is a common measure predictive of morbidity and mortality among adults. Many factors are known to be associated with self-reported health including the number of chronic conditions (i.e., multimorbidity). While the association between self-reported health and morbidity and mortality has been well-established, the factors that shape the relationship with self-reported health (e.g., modify and mediate) are poorly understood. Further, it is unknown why some older adults, despite having high numbers of chronic conditions, continue to rate their health positively. This is known as the well-being paradox. This mixed methods research study was designed to address these knowledge gaps. The objectives of the proposed research are to (1) determine what factors shape the relationship between multimorbidity and self-reported health and how they do so; (2) describe the ways that older adults define and perceive their individual health; and (3) explain the well-being paradox. Informed by a multimorbidity resilience framework, the quantitative component of research will analyze Canadian Longitudinal Study on Aging data while the qualitative component will collect and analyze interview data from 12 to 20 community-dwelling older adults using a case study design. Findings from this study have the potential to inform and advance future health intervention programs or services aimed at improving health-related quality of life for community-dwelling older adults. [ABSTRACT FROM AUTHOR]

Background: Identification of those who are most at risk of developing specific patterns of disease across different populations is required for directing public health policy. Here, we contrast prevalence and patterns of cross-national disease incidence, co-occurrence and related risk factors across population samples from the U.S., Canada, England and Ireland.Methods: Participants (n = 62,111) were drawn from the US Health and Retirement Study (n = 10,858); the Canadian Longitudinal Study on Ageing (n = 36,647); the English Longitudinal Study of Ageing (n = 7938) and The Irish Longitudinal Study on Ageing (n = 6668). Self-reported lifetime prevalence of 10 medical conditions, predominant clusters of multimorbidity and their specific risk factors were compared across countries using latent class analysis.Results: The U.S. had significantly higher prevalence of multimorbid disease patterns and nearly all diseases when compared to the three other countries, even after adjusting for age, sex, BMI, income, employment status, education, alcohol consumption and smoking history. For the U.S. the most at-risk group were younger on average compared to Canada, England and Ireland. Socioeconomic gradients for specific disease combinations were more pronounced for the U.S., Canada and England than they were for Ireland. The rates of obesity trends over the last 50 years align with the prevalence of eight of the 10 diseases examined. While patterns of disease clusters and the risk factors related to each of the disease clusters were similar, the probabilities of the diseases within each cluster differed across countries.Conclusions: This information can be used to better understand the complex nature of multimorbidity and identify appropriate prevention and management strategies for treating multimorbidity across countries. [ABSTRACT FROM AUTHOR]

Introduction: Increasing multimorbidity is often associated with declining physical functioning, with some studies showing a disproportionate impact on functioning when mental health conditions are present. More research is needed because most multimorbidity studies exclude mental health conditions. Objectives: This study aims to improve our understanding of the association between functional limitation and multimorbidity, including a comparison of those with multimorbidity that includes versus excludes mental health conditions. Methods: This is a population-based, cross-sectional analysis of data from The Canadian Longitudinal Study on Aging. Functional limitation was defined as the presence of any of 14 activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Multimorbidity, measured by the number of chronic conditions, included mood and anxiety disorders. Logistic regression explored the association between multimorbidity (with and without mental health conditions) and functional limitation. Factor analysis identified common condition clusters to help understand clinical complexity in those with mood/anxiety disorders and the potential influences on functional limitation. Results: There were 51,338 participants, with a similar proportion of men and women (49% versus 51%) and 42% age 65 years or older. Fifteen percent (15%) had no chronic conditions and 17% had 5+. Ten percent (10%) reported at least one ADL or IADL limitation. Odds ratios (ORs) for functional limitation increased with multimorbidity and were generally higher for those with versus without mental health conditions (e.g., ORs from 1 to 5+ chronic conditions increased 1.9 to 15.8 for those with mood/anxiety disorders versus 1.8 to 10.2 for those without). Factor analysis showed that mood/anxiety conditions clustered with somatic conditions (e.g., migraines, bowel/gastrointestinal disorders). Conclusion: This study found higher odds of functional limitation for those with multimorbidity that included versus excluded mental health conditions, at all levels of multimorbidity. It highlights the need for concurrent management of mental and physical comorbidities to prevent functional limitations and future decline. This approach is aligned with the NICE clinical assessment and management guidelines for people with multimorbidity. [ABSTRACT FROM AUTHOR]

Background: This study explores how socio-demographic and health factors shape the relationship between multimorbidity and one-year acute care service use (i.e., hospital, emergency department visits) in older adults in Ontario, Canada.Methods: We linked multiple cycles (2005-2006, 2007-2008, 2009-2010, 2011-2012) of the Canadian Community Health Survey (CCHS) to health administrative data to create a cohort of adults aged 65 and older. Administrative data were used to estimate one-year service use and to identify 12 chronic conditions used to measure multimorbidity. We examined the relationship between multimorbidity and service use stratified by a range of socio-demographic and health variables available from the CCHS. Logistic and Poisson regressions were used to explore the association between multimorbidity and service use and the role of socio-demographic factors in this relationship.Results: Of the 28,361 members of the study sample, 60% were between the ages of 65 and 74 years, 57% were female, 72% were non-immigrant, and over 75% lived in an urban area. Emergency department visits and hospitalizations consistently increased with the level of multimorbidity. This study did not find strong evidence of moderator or interaction effects across a range of socio-demographic factors. Stratified analyses revealed further patterns, with many being similar for both services - e.g., the odds ratios were higher at all levels of multimorbidity for men, older age groups, and those with lower household income. Rurality and immigrant status influenced emergency department use (higher in rural residents and non-immigrants) but not hospitalizations. Multimorbidity and the range of socio-demographic variables remained significant predictors of service use in the regressions.Conclusions: Strong evidence links multimorbidity with increased acute care service use. This study showed that a range of factors did not modify this relationship. Nevertheless, the factors were independently associated with acute care service use, pointing to modifiable risk factors that can be the focus of resource allocation and intervention design to reduce service use in those with multimorbidity. The study's results suggest that optimizing acute care service use in older adults requires attention to both multimorbidity and social determinants, with programs that are multifactorial and integrated across the health and social service sectors. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity, the co-existence of 2+ (or 3+) chronic diseases in an individual, is an increasingly common global phenomenon leading to reduced quality of life and functional status, and higher healthcare service use and mortality. There is an urgent need to develop and test new models of care that incorporate the components of multimorbidity interventions recommended by international organizations, including care coordination, interdisciplinary teams, and care plans developed with patients that are tailored to their needs and preferences. Purpose: To determine the effectiveness of a 6-month, community-based, multimorbidity intervention compared to usual home care services for community-dwelling older adults (age 65+ years) with multimorbidity (3+ chronic conditions) that were newly referred to and receiving home care services. Methods: A pragmatic, parallel, two-arm randomized controlled trial evaluated the intervention, which included in-home visits by an interdisciplinary team, personal support worker visits, and monthly case conferences. The study took place in two sites in central Ontario, Canada. Eligible and consenting participants were randomly allocated to the intervention and control group using a 1:1 ratio. The participants, statistician/analyst, and research assistants collecting assessment data were blinded. The primary outcome was the Physical Component Summary (PCS) score of the 12-Item Short-Form health survey (SF-12). Secondary outcomes included the SF-12 Mental Component Summary (MCS) score, Center for Epidemiological Studies of Depression (CESD-10), Generalized Anxiety Disorder (GAD-7), Self-Efficacy for Managing Chronic Disease, and service use and costs. Analysis of covariance (ANCOVA) tested group differences using multiple imputation to address missing data, and non-parametric methods explored service use and cost differences. Results: 59 older adults were randomized into the intervention (n = 30) and control (n = 29) groups. At baseline, groups were similar for the primary outcome and number of chronic conditions (mean of 8.6), but the intervention group had lower mental health status. The intervention was cost neutral and no significant group differences were observed for the primary outcome of PCS from SF-12 (mean difference: −4.94; 95% CI: −12.53 to 2.66; p = 0.20) or secondary outcomes. Conclusion: We evaluated a 6-month, self-management intervention for older adults with multimorbidity. While the intervention was cost neutral in comparison to usual care, it was not found to improve the PCS from SF-12 or secondary health outcomes. Recruitment and retention challenges were significant obstacles limiting our ability to assess intervention effectiveness. Yet, the intervention was grounded in internationally-endorsed recommendations and implemented in a practice setting (home care) viewed as a key upstream resource fostering independence in older adults. These features collectively support the identification of ways to recruit/retain older adults and test alternative implementation strategies for interventions that are based on sound principles of multimorbidity management. [ABSTRACT FROM AUTHOR]

The International Multimorbidity Symposium was held in November 2019 at Western University to achieve three main objectives: to discuss progress and findings from various jurisdictions; to facilitate collaboration through group discussion to identify strategies to move multimorbidity research forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnership. This event included keynote presentations, elevator pitch presentations and breakout sessions and there was a total of 35 attendees from eight countries, representing diverse disciplines and training levels. The overall themes arising from the event were: the importance of integrating the study and management of multimorbidity from both the primary care and public health perspectives; meaningful engagement and collaboration with patients and caregivers to understand key dimensions of multimorbidity; the considerable benefit of collaborative international partnerships; and the need to spread and scale innovations for health care systems that can better respond to the complex needs of patients and caregivers who are living with multimorbidity. Finally, it was well-acknowledged among the attendees that expanding the collaboration and discussion among international colleagues via in-person and virtual events will be important to move multimorbidity research forward. [ABSTRACT FROM AUTHOR]

Objective: To examine agreement between administrative and self-reported data on the number of and constituent chronic conditions (CCs) used to measure multimorbidity. Study Design and Setting: Cross-sectional self-reported survey data from four Canadian Community Health Survey waves were linked to administrative data for residents of Ontario, Canada. Agreement for each of 12 CCs was assessed using kappa (κ) statistics. For the overall number of CCs, perfect agreement was defined as agreement on both the number and constituent CCs. Jackknife methods were used to assess the impact of individual CCs on perfect agreement. Results: The level of chance-adjusted agreement between self-report and administrative data for individual CCs varied widely, from κ = 5.5% (inflammatory bowel disease) to κ = 77.5% (diabetes), and there was no clear pattern on whether using administrative data or self-reported data led to higher prevalence estimates. Only 26.9% of participants had perfect agreement on the number and constituent CCs; 10.6% agreed on the number but not constituent CCs. The impact of each CC on perfect agreement depended on both the level of agreement and the prevalence of the individual CC. Conclusion: Our results show that measuring agreement on multimorbidity is more complex than for individual CCs and that even small levels of individual condition disagreement can have a large impact on the agreement on the number of CCs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To explore how different frameworks and categories of chronic conditions impact multimorbidity (defined as two or more chronic conditions) prevalence estimates and associations with patient‐important functional outcomes. DESIGN: Baseline data from a population‐based cohort study. SETTING: National sample of Canadians. PARTICIPANTS: A total of 51 338 community‐living adults, aged 45 to 85 years. MAIN OUTCOME MEASURES: Chronic conditions from three commonly recognized frameworks were categorized as: (1) diseases, (2) risk factors, or (3) symptoms. Estimates of multimorbidity prevalence were compared among frameworks by age and sex. Separate weighted logistic regression models were used to explore the impact of the different frameworks and categories of chronic conditions on odds ratios (ORs) for multimorbidity for four patient‐important functional outcomes: disability, social participation restriction, and self‐rated physical and mental health. RESULTS: One framework included diseases and risk factors, and two frameworks included diseases, risk factors, and symptoms. The prevalence of multimorbidity differed among the frameworks, ranging from 33.5% to 60.6% having two or more chronic conditions. Including risk factors in frameworks increased prevalence estimates, while including symptoms increased prevalence estimates and associations with most patient‐important outcomes. The two frameworks that included symptoms had the largest ORs for associations with disability, social participation restriction, and self‐rated physical health but not self‐rated mental health. Similar results were found when we compared ORs for patient‐important outcome for multimorbidity based on three subframeworks: one including diseases only, one including diseases and risk factors, and one including diseases, risk factors, and symptoms. CONCLUSIONS: Including risk factors appeared to increase only the prevalence of multimorbidity without significantly altering relationships to outcomes. The inclusion of symptoms increased prevalence and associations with patient‐important outcomes. These findings underscore the importance of considering not only the number, but also the category, of conditions included in multimorbidity frameworks, as simply counting the number of diagnoses may reduce sensitivity to outcomes that are important to individuals. J Am Geriatr Soc 67:1632–1640, 2019 [ABSTRACT FROM AUTHOR]

The demand for home care services is increasing, yet the literature describing the clinical characteristics of community-dwelling individuals with a history of stroke who receive home care is limited. In this retrospective, cross-sectional, population-level study, data were sourced from home care recipients aged 65+ who had a routine assessment using the Resident Assessment Instrument for Home Care (RAI-HC) in Ontario between January 2007 and December 2011. The RAI-HC contains several health status indicators and validated health index scales. The association of a history of stroke on health status was assessed through a series of logistic regression models, adjusted for age, sex, and number of comorbidities. Sex differences were also explored. A change in odds of ≥25% was considered to indicate a clinically important finding. From the home care data (N = 319,694), 56,909 individuals had a stroke diagnosis, with approximately 86% diagnosed with ≥3 chronic conditions. A stroke diagnosis was associated with a higher risk of limitations or impairments with communication, locomotion, continence, activities of daily living, and cognitive performance. A clinically meaningful difference was not observed for symptoms of depression. Few sex differences were observed. In an effort to support the development of effective home and community-based care programs, research is needed to understand differences in community-dwelling versus institutional populations. Community-dwelling individuals with a history of stroke show higher levels of impairment and limitations compared with those without, suggesting areas where home care resources could be improved to help manage the chronic effects of stroke. [ABSTRACT FROM AUTHOR]

Aims: This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs.Methods: This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services.Results: There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities.Conclusions: Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning. [ABSTRACT FROM AUTHOR]

Background: Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization. Methods: This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts). Results: Nearly all, 96.3%, had at least one comorbid condition, while 18.4% had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8%), and arthritis (66.2%). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity. Conclusions: Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community. [ABSTRACT FROM AUTHOR]

Background: Promoting the collection and use of health related outcome measures (HROM) in daily practice has long been a goal for improving and assessing the effectiveness of care provided to patients. However, there has been a lack of consensus on what criteria to use to select outcomes or instruments, particularly in the context of primary health care settings where patients present with multiple concurrent health conditions and interventions are whole-health and person-focused. The purpose of this proposed study is to undertake a formal consensus exercise to establish criteria for selecting HROM (including patient-reported (PRO or PROM), observer-reported (ObsR)), clinician-reported (ClinRO) and performance related outcomes (PerfO) for use in shared decision-making, or in assessing, screening or monitoring health status in primary health care settings. Methods: A Delphi consensus online survey will be developed. Criteria for the Delphi panel participants to consider were selected from a targeted literature search. These initial criteria (n = 35) were grouped into four categories within which items will be presented in the Delphi survey, with the option to suggest additional items. Panel members invited to participate will include primary health care practitioners and administrators, policy-makers, researchers, and experts in HROM development; patients will be excluded. Standard Delphi methodology will be employed with an expectation of at least 3 rounds to achieve consensus (75% agreement). As the final list of criteria for selecting HROM emerges, panel members will be asked to provide opinions about potential weighting of items. The Delphi survey was approved by the Ethics Committee in the Faculty of Health Sciences at McMaster University. Discussion: Previous literature establishing criteria for selecting HROM were developed with a focus on patient reported outcomes, psychological/ behavioural outcomes or outcomes for minimum core outcome sets in clinical trials. Although helpful, these criteria may not be applicable and feasible for application in a primary health care context where patients with multi-morbidity and complex interventions are typical and the constraints of providing health services differ from those in research studies. The findings from this Delphi consensus study will address a gap for establishing consensus on criteria for selecting HROM for use across primary health care settings. [ABSTRACT FROM AUTHOR]