Using Burden of Treatment as a Clinical Indicator of Barriers to Multimorbidity Management in Peru: A Mixed Methods Approach

摘要 在全世界，多人死亡的现象正在增加。在许多高收入国家，这是一种常态， 低收入和中等收入国家（LMIC）正朝着这个方向发展。 研究表明，多发性硬化症患者的临床结局更差。2部分原因是 他们经历了更高的治疗负担（BOT），这被定义为他们的医疗工作量-或 他们必须做的所有事情，以符合他们的医疗-影响他们的功能和福祉。 增加医疗工作量和BOT的众多因素之一是医疗保健的存在 与制度有关的障碍。在中低收入国家，医疗保健系统已经发展到治疗急性疾病，而不是管理 慢性的，因此充满了许多障碍，阻止成功的多morphology 1，2为了改善多项治疗的结果，建立以患者为中心的 干预措施尽量减少这些障碍。然而，这些变化的可持续实施需要使用 质量指标，其中之一是BOT。尽管一些患者报告的结局指标已被 虽然已确定在临床环境中测量BOT，但其在LMIC中的使用有限。在这项研究中，我们将评估 在秘鲁使用混合方法治疗多病患者的BOT。半结构化面试和 经验证的调查，治疗负担问卷（TBQ），将应用于不同医疗保健的患者 设置和地理区域。我们的首要目标是深入了解患者- 据报告，在秘鲁存在着多种经营管理的障碍，我们的目标是实现以下具体目标： 目的：1）使用BOT来识别和比较患者报告的多项管理障碍， 在秘鲁接受私人和公共保健部门护理的群体。2)用BOT来识别和比较 在不同地理区域接受治疗的患者中，患者报告的多药治疗障碍 在秘鲁。3)对患者进行半结构化访谈，以获得有关障碍的额外深入信息 到秘鲁的多企业管理。我们认为，本研究中使用的新方法具有重要意义。 推动全球多媒体领域的潜力。使用TBQ比较接受治疗的患者的BOT 不同类型的医疗保健和不同的地点将促进其作为医疗保健质量指标的使用。 此外，使用定性方法将使我们能够了解秘鲁存在哪些障碍， 它们被TBQ捕获。这种独特的方法将作为如何调整任务型问卷的一个模式 用于其他独特的医疗保健环境。使用可靠的工具来了解BOT之间的关系 和医疗保健系统-特别是那些在中低收入国家-有潜力提供一个基础， 集中干预，针对最繁重和最昂贵的方面，多产妇护理。 1

ABSTRACT Multimorbidity is increasing throughout the world. In many high-income countries (HICs), it is the norm rather than the exception, and low-and-middle-income countries (LMICs) are heading in this direction.1 Multiple studies have shown that patients with multimorbidity suffer from worse clinical outcomes.2 Part of this is due to the fact that they experience a higher burden of treatment (BOT), which is defined as how their healthcare workload - or all of the things they must do to comply with their medical treatment - affects their functionality and well-being. One of the many factors that increases healthcare workload and consequently BOT is the presence of healthcare system-related barriers. In LMICs, healthcare systems have evolved to treat acute conditions rather than manage chronic ones and consequently are replete with numerous barriers preventing successful multimorbidity management.1, 2 In order to improve outcomes in multimorbidity, it is crucial to create patient-centered interventions minimize these barriers. Sustainable implementation of these changes, however, requires the use of quality indicators, one of which is BOT. Although several patient-reported outcome measures have been identified to measure BOT in clinical settings, their use in LMICs has been limited. In this study, we will evaluate BOT in multimorbid patients in Peru using a mixed-methods approach. Both semi-structured interviews and a validated survey, the Treatment Burden Questionnaire (TBQ), will be applied to patients in different healthcare settings and geographic regions. Our overarching goal is to gain an in-depth understanding of what patient- reported barriers to multimorbidity management exist in Peru, and we aim to achieve the following specific objectives: 1) To use BOT to identify and compare patient-reported barriers to multimorbidity management in groups receiving care in private versus public healthcare sectors in Peru. 2) To use BOT to identify and compare patient-reported barriers to multimorbidity management in patients receiving care in different geographic regions in Peru. 3) To use semi-structured interviews with patients to gain additional, in-depth information about barriers to multimorbidity management in Peru. We believe that the novel approaches used in this study have significant potential to advance the field of global multimorbidity. The use of the TBQ to compare BOT in patients receiving different types of healthcare and in different locations will advance its use as an indicator of healthcare quality. Moreover, the use of qualitative methods will allow us to understand what barriers exist in Peru and how well they are captured by the TBQ. This unique approach will will serve as a model for how the TBQ can be adapted for use in other unique healthcare contexts. Using a reliable tool to understand the relationship between BOT and healthcare systems - particularly those in LMICs - has the potential to provide a foundation for patient- centered interventions that target the most burdensome and costly aspects of multimorbidity care. 1