Managing patients with multimorbidity: systematic review of interventions in primary care and community settings.
Managing patients with multimorbidity: systematic review of interventions in primary care and community settings.
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DOI：
10.1136/bmj.e5205
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发表时间：
2012-09-03
期刊：
影响因子：
--
通讯作者：
O'Dowd T
中科院分区：
文献类型：
--
作者：
Smith SM;Soubhi H;Fortin M;Hudon C;O'Dowd T
目的 确定旨在改善初级保健和社区环境中多病患者结局的干预措施的有效性。设计系统审查。数据来源 Medline、Embase、CINAHL、CAB Health、Cochrane 对照试验中央登记册、有效性审查摘要数据库以及 Cochrane EPOC（有效实践和护理组织）登记册（搜索于 2011 年 4 月更新）。资格标准 随机对照试验、对照临床试验、研究前后对照以及中断时间序列分析，报告改善初级保健和社区环境中多病患者结局的干预措施。多重发病被定义为同一个人患有两种或多种慢性病。结果包括任何经过验证的身体或心理健康和心理社会状态的衡量标准，包括生活质量结果、福祉以及残疾或功能状态的衡量标准。还包括对患者和提供者行为的衡量，包括药物依从性、卫生服务的利用、服务的可接受性和成本。数据选择 两名评审员独立评估研究的资格、提取数据并评估研究质量。由于参与者和干预措施的异质性，无法对结果进行荟萃分析，因此对纳入研究的结果进行了叙述性综合。结果 确定了 10 项研究，检查了总计 3407 名患有多种疾病的患者的一系列复杂干预措施。所有试验均为随机对照试验，偏倚风险较低。两项研究描述了对患有特定合并症的患者的干预措施。其余八项研究重点关注多发病，通常针对老年患者。很少考虑社会经济剥夺的影响。所有研究都涉及多个组成部分的复杂干预措施。在这 10 项研究中，有 6 项研究的主要内容是对护理服务组织的改变，通常是通过病例管理或加强多学科团队合作。在其余四项研究中，干预措施主要以患者为导向。总体而言，结果好坏参半，有改善处方和药物依从性的趋势。结果表明，很难改善该人群的治疗结果，但针对共病情况下的特定危险因素或多发病的功能困难进行干预可能会更有效。尽管一些研究中处方和风险因素管理的改进可能会带来潜在的重要成本节省，但没有包括经济分析。结论 尽管多重病的患病率及其对患者和医疗保健系统的影响，但关于多重病患者护理的证据仍然有限。迄今为止的干预措施效果好坏参半，但如果针对风险因素或特定的功能困难可能会更有效。需要明确识别患有多种疾病的患者，并制定具有成本效益且针对性强的干预措施，以改善健康结果。
Objective To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Design Systematic review. Data sources Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011). Eligibility criteria Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs. Data selection Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out. Results 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings. Conclusions Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.
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影响因子：
6.7
作者：
Krska, J;Cromarty, JA;Seymour, DG
通讯作者：
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