Future of multimorbidity research: How should understanding of multimorbidity inform health system design?

Public Health Reviews

Volumn 33, Issue 2, 2011, Pages 451-474

  Boyd, Cynthia M ^a   Fortin, Martin ^b  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b UNIVERSITÉ DE SHERBROOKE   (Canada)

Author keywords

Aging; Chronic conditions; Comorbidity; Health system; Healthcare; Multimorbidity

Indexed keywords

AGING; CHRONIC DISEASE; COMORBIDITY; COST UTILITY ANALYSIS; CULTURAL FACTOR; DISABILITY; DISEASE ASSOCIATION; EDUCATIONAL STATUS; EMPLOYMENT STATUS; FAMILY CENTERED CARE; FUNCTIONAL STATUS; HEALTH BEHAVIOR; HEALTH CARE NEED; HEALTH CARE SYSTEM; HEALTH CARE UTILIZATION; HUMAN; INTERPERSONAL COMMUNICATION; MORTALITY; NEEDS ASSESSMENT; PATIENT ASSESSMENT; PATIENT PREFERENCE; PRACTICE GUIDELINE; PRIMARY HEALTH CARE; PRIORITY JOURNAL; QUALITY OF LIFE; REVIEW; RISK BENEFIT ANALYSIS; SOCIAL CLASS; SOCIAL SUPPORT; WELLBEING;

EID: 84862194470     PISSN: 03010422     EISSN: 21076952     Source Type: Journal    
DOI: None     Document Type: Review

References (143)

1. Anderson G, Horvath J. Chronic conditions: Making the case for ongoing care. Baltimore (MD): Partnership for Solutions; December 2002.
2. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005;3:223-8. (Pubitemid 40806715)
3. Fortin M, Hudon C, Haggerty J, Akker M, Almirall J. Prevalence estimates of multimorbidity: A comparative study of two sources. BMC Health Serv Res.10:111.
4. Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity's many challenges. BMJ. 2007;334:1016-7. (Pubitemid 46808438)
5. U.S. Department of Health and Human Services. Multiple Chronic Conditions - A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington (DC): USDoHaH; 2010.
6. McGann PE. Comorbidity in heart failure in the elderly. Clin Geriatr Med. 2000;16:631-48. (Pubitemid 30641713)
7. Patrick L, Knoefel F, Gaskowski P, Rexroth D. Medical comorbidity and rehabilitation efficiency in geriatric inpatients. J Am Geriatr Soc. 2001;49:1471-7. (Pubitemid 33051397)
8. Concato J, Horwitz RI, Feinstein AR, Elmore JG, Schiff SF. Problems of comorbidity in mortality after prostatectomy. JAMA. 1992;267:1077-82.
9. Satariano WA. Aging, comorbidity, and breast cancer survival: An epidemiologic view. Adv Exp Med Biol. 1993;330:1-11. (Pubitemid 23202988)
10. Yancik R, Havlik RJ, Wesley MN, Ries L, Long S, Rossi WK, Edwards BK. Cancer and comorbidity in older patients: A descriptive profile. Ann Epidemiol. 1996;6:399-412. (Pubitemid 26372528)
11. Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, van den Bos GA. Causes and consequences of comorbidity: A review. J Clin Epidemiol. 2001;54:661-74. (Pubitemid 32594852)
12. Fillenbaum GG, Pieper CF, Cohen HJ, Cornoni-Huntley JC, Guralnik JM. Comorbidity of five chronic health conditions in elderly community residents: Determinants and impact on mortality. J Gerontol A Biol Sci Med Sci. 2000;55:M84-9. (Pubitemid 30165501)
13. McGee D, Cooper R, Liao Y, Durazo-Arvizu R. Patterns of comorbidity and mortality risk in blacks and whites. Ann Epidemiol. 1996;6:381-5. (Pubitemid 26375173)
14. Satariano WA, Ragland DR. The effect of comorbidity on 3-year survival of women with primary breast cancer. Ann Intern Med. 1994;120:104-10. (Pubitemid 24027550)
15. Yancik R, Wesley MN, Ries LA, Havlik RJ, Edwards BK, Yates JW. Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA. 2001;285:885-92. (Pubitemid 32171549)
16. Yancik R, Wesley MN, Ries LA, Havlik RJ, Long S, Edwards BK, Yates JW. Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study. Cancer. 1998;82:2123-34. (Pubitemid 28240818)
17. Guralnik JM, LaCroix AZ, Abbott RD, Berkman LF, Satterfield S, Evans DA, Wallace RB. Maintaining mobility in late life. I. Demographic characteristics and chronic conditions. Am J Epidemiol. 1993;137:845-57. (Pubitemid 23149663)
18. Fried LP, Bandeen-Roche K, Kasper JD, Guralnik JM. Association of comorbidity with disability in older women: The Women's Health and Aging Study. J Clin Epidemiol. 1999;52:27-37. (Pubitemid 29064271)
19. Cornoni-Huntley JC, Foley DJ, Guralnik JM. Co-morbidity analysis: A strategy for understanding mortality, disability and use of health care facilities of older people. Int J Epidemiol. 1991;20Suppl1:S8-17.
20. Ettinger WH, Davis MA, Neuhaus JM, Mallon KP. Long-term physical functioning in persons with knee osteoarthritis from NHANES. I: Effects of comorbid medical conditions. J Clin Epidemiol. 1994;47:809-15. (Pubitemid 24236263)
21. Verbrugge LM, Lepkowski JM, Imanaka Y. Comorbidity and its impact on disability. Milbank Q. 1989;67:450-84. (Pubitemid 20232414)
22. Fortin M, Bravo G, Hudon C, Lapointe L, Almirall J, Dubois MF, Vanasse A. Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res. 2006;15:83-91. (Pubitemid 43097589)
23. Parekh AK, Barton MB. The challenge of multiple comorbidity for the US health care system. JAMA. 303:1303-4.
24. Menotti A, Mulder I, Nissinen A, Giampaoli S, Feskens EJ, Kromhout D. Prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10-year all-cause mortality: The FINE study (Finland, Italy, Netherlands, Elderly). J Clin Epidemiol. 2001;54:680-6. (Pubitemid 32594853)
25. Safford MM, Allison JJ, Kiefe CI. Patient complexity: More than comorbidity. The vector model of complexity. J Gen Intern Med. 2007;22Suppl3:382-90. (Pubitemid 350172453)
26. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. 2005;294:716-24. (Pubitemid 41159291)
27. Grau L, Kovner C. Comorbidity, age, and hospital use among elderly Medicare patients. J Aging Health. 1991;3:352-67.
28. Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic disease. J Chron Dis. 1970;23:455-68.
29. Piette JD, Kerr EA. The impact of comorbid chronic conditions on diabetes care. Diabetes Care. 2006;29:725-31. (Pubitemid 44115387)
30. Weiss CO, Boyd CM, Yu Q, Wolff JL, Leff B. Patterns of prevalent major chronic disease among older adults in the United States. JAMA. 2007;298:1160-2. (Pubitemid 47403117)
31. Boyd CM, Leff B, Wolff JL, et al. Informing Clinical Practice Guideline Development and Implementation: Prevalence of Co-existing Conditions Among Adults with Coronary Heart Disease. J Am Geriatr Soc. 2010;In Press.
32. Boyd C, Leff B, Weiss C, Wolff J, Clark R, Richards T. Full report: Clarifying multimorbidity to improve targeting and delivery of clinical services for Medicaid populations. Center for Health Care Strategies, Inc.; 2010.
33. van den Akker M, Buntinx F, Knottnerus JA. Comorbidity or multimorbidity: What's in a name? Eur J Gen Pract. 1996;2:65-70.
34. Boyd CM, Ritchie CS, Tipton EF, Studenski SA, Wieland D. From bedside to bench: Summary from the American Geriatrics Society/National Institute on Aging Research conference on comorbidity and multiple morbidity in older adults. Aging Clin Exp Res. 2008;20:181-8.
35. Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: Implications for understanding health and health services. Ann Fam Med. 2009;7:357-63.
36. Agency for Healthcare Research and Quality. Optimizing prevention and healthcare management for the complex patient (R21). Services DoHaH, ed., 2007.
37. Sales AE, Tipton EF, Levine DA, Houston TK, Kim Y, Allison J, Kiefe CI. Are co-morbidities associated with guideline adherence? The MI-Plus study of Medicare patients. J Gen Intern Med. 2009;24:1205-10.
38. Boyd CM, Weiss CO, Halter J, Han KC, Ershler WB, Fried LP. Framework for evaluating disease severity measures in older adults with comorbidity. J Gerontol A Biol Sci Med Sci. 2007;62:286-95. (Pubitemid 47065726)
39. Uijen AA, van de Lisdonk EH. Multimorbidity in primary care: Prevalence and trend over the last 20 years. Eur J Gen Pract. 2008;14Suppl1:28-32.
40. Taylor AW, Price K, Gill TK, et al. Multimorbidity - not just an older person's issue. Results from an Australian biomedical study. BMC Public Health.10:718.
41. Marengoni A, Rizzuto D, Wang HX, Winblad B, Fratiglioni L. Patterns of chronic multimorbidity in the elderly population. J Am Geriatr Soc. 2009;57:225-30.
42. Marengoni A, von Strauss E, Rizzuto D, Winblad B, Fratiglioni L. The impact of chronic multimorbidity and disability on functional decline and survival in elderly persons. A community-based, longitudinal study. J Intern Med. 2009;265:288-95.
43. Marengoni A, Winblad B, Karp A, Fratiglioni L. Prevalence of chronic diseases and multimorbidity among the elderly population in Sweden. Am J Public Health. 2008;98:1198-200. (Pubitemid 351947989)
44. Metsemakers JF, Hoppener P, Knottnerus JA, Kocken RJ, Limonard CB. Computerized health information in The Netherlands: a registration network of family practices. Br J Gen Pract. 1992;42:102-6.
45. van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: Prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51:367-75. (Pubitemid 28223302)
46. Schellevis FG, van der Velden J, van de Lisdonk E, van Eijk JT, van Weel C. Comorbidity of chronic diseases in general practice. J Clin Epidemiol. 1993;46:469-73. (Pubitemid 23194269)
47. Fuchs Z, Blumstein T, Novikov I, Walter-Ginzburg A, Lyanders M, Gindin J, et al. Morbidity, comorbidity, and their association with disability among community-dwelling oldest-old in Israel. J Gerontol A Biol Sci Med Sci. 1998;53:M447-55. (Pubitemid 28524564)
48. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269-76. (Pubitemid 35332510)
49. Schneider KM, O'Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States' Medicare population. Health Qual Life Outcomes. 2009;7:82.
50. Kronick RG, Bella M, Gilmer TP, Somers SA. The faces of Medicaid II: Recognizing the care needs of people with multiple chronic conditions. Hamilton (NJ): Center for Health Care Strategies, Inc.; 2007.
51. van der Lee JH, Mokkink LB, Grootenhuis MA, Heymans HS, Offringa M. Definitions and measurement of chronic health conditions in childhood: A systematic review. JAMA. 2007;297:2741-51. (Pubitemid 47001100)
52. Guralnik JM. Assessing the impact of comorbidity in the older population. Ann Epidemiol. 1996;6:376-80. (Pubitemid 26372525)
53. Fortin M, Dubois MF, Hudon C, Soubhi H, Almirall J. Multimorbidity and quality of life: A closer look. Health Qual Life Outcomes. 2007;5:52.
54. Newman AB, Boudreau RM, Naydeck BL, Fried LF, Harris TB. A physiologic index of comorbidity: Relationship to mortality and disability. J Gerontol A Biol Sci Med Sci. 2008;63:603-9.
55. Peters-Klimm F, Kunz CU, Laux G, Szecsenyi J, Muller-Tasch T. Patient - and provider-related determinants of generic and specific health-related quality of life of patients with chronic systolic heart failure in primary care: A cross-sectional study. Health Qual Life Outcomes.8:98.
56. Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: A systematic review. Health Qual Life Outcomes. 2004;2:51.
57. Fultz NH, Ofstedal MB, Herzog AR, Wallace RB. Additive and interactive effects of comorbid physical and mental conditions on functional health. J Aging Health. 2003;15:465-81. (Pubitemid 36897372)
58. Wolff JL, Boult C, Boyd C, Anderson G. Newly reported chronic conditions and onset of functional dependency. J Am Geriatr Soc. 2005;53:851-5. (Pubitemid 41656932)
59. Bayliss EA, Bosworth HB, Noel PH, Wolff JL, Damush TM, McIver L. Supporting self-management for patients with complex medical needs: Recommendations of a working group. Chronic illness. 2007;3:167-75. (Pubitemid 47613186)
60. Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care desired by elderly patients with multimorbidities. Fam Pract. 2008;25:287-93.
61. Bayliss EA, Ellis JL, Steiner JF. Seniors' self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures. J Clin Epidemiol. 2009;62:550-7.
62. Bayliss EA, Ellis JL, Steiner JF. Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities. Ann Fam Med. 2007;5:395-402. (Pubitemid 47535969)
63. Bayliss EA, Ellis JL, Steiner JF. Subjective assessments of comorbidity correlate with quality of life health outcomes: Initial validation of a comorbidity assessment instrument. Health Qual Life Outcomes. 2005;3:51.
64. Bayliss EA, Ellis JL, Steiner JF, Main DS. Initial validation of an instrument to identify barriers to self-management for persons with co-morbidities. Chronic illness. 2005;1:315-20.
65. Townsend A, Hunt K, Wyke S. Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use. BMJ. 2003;327:837.
66. Wolff JL, Roter DL. Hidden in plain sight: Medical visit companions as a resource for vulnerable older adults. Arch Intern Med. 2008;168:1409-15. (Pubitemid 352008422)
67. Gerteis M, Edgeman-Levitan S, Daley J. Through the patient's eyes. Understanding and promoting patient-centered care. San Francisco (CA): Jossey-Bass; 1993.
68. Bull SA, Hu XH, Hunkeler EM, Lee JY, Ming EE, Markson LE, Fireman B. Discontinuation of use and switching of antidepressants: influence of patient-physician communication. JAMA. 2002;288:1403-9. (Pubitemid 35025915)
69. DiMatteo M. Social Suppor and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23:207-18. (Pubitemid 38365280)
70. Partnership for Solutions. Burden on family caregivers. Available from URL: http://www.partnershipforsolutions.org/problem/burden.html (Accessed 23 December 2010).
71. Partnership for Solutions. Survey reveals americans' concerns about living with chronic conditions and desire for elected officials to take action to improve care. Available from URL: http://www.partnershipforsolutions.org/ statistics/perceptions.html (Accessed 23 December 2010).
72. Travis SS, Kao HF, Acton GJ. Helping family members manage medication administration hassles. J Psychosoc Nurs Ment Health Serv. 2005;43:13-5. (Pubitemid 41704352)
73. Vickrey BG, Mittman BS, Connor KI, Pearson ML, Della Penna RD, Ganiats TG, et al. The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med. 2006;145:713-26. (Pubitemid 351650351)
74. Campaign for Better Care. The case for better care. Available from URL: http://www.nationalpartnership.org/site/DocServer/Fact-Sheet-1--The-Problem.pdf? docID=6202 (Accessed, 23 December 2010).
75. Institute for Patient- and Family-Centered Care. Advancing the practice of patient- and family- centered care how to get started... http://www.ipfcc. org/pdf/getting-started.pdf (Accessed 11 February 2011)
76. Wolff JL, Roter DL. Family caregivers, patients, and physicians. J Gen Intern Med.25:487; author reply 488.
77. Boult C, Wieland GD. Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through". JAMA.304:1936-43.
78. Boyd CM, Boult C, Shadmi E, Griswold M, Leff B, Brager R, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47:697-704. (Pubitemid 350156066)
79. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-23. (Pubitemid 23034809)
80. Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. 2001;38:666-71. (Pubitemid 33131567)
81. Librero J, Peiro S, Ordinana R. Chronic comorbidity and outcomes of hospital care: Length of stay, mortality, and readmission at 30 and 365 days. J Clin Epidemiol. 1999;52:171-9. (Pubitemid 29148427)
82. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370:173-84. (Pubitemid 47049724)
83. Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-7. (Pubitemid 24289708)
84. Tinetti ME, Fried T. The end of the disease era. Am J Med. 2004;116:179-85. (Pubitemid 38121675)
85. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511-44.
86. Lucas GM, Chaudhry A, Hsu J, Woodson T, Lau B, Olsen Y, et al. Clinic-based treatment of opioid-dependent HIV-infected patients versus referral to an opioid treatment program: A randomized trial. Ann Intern Med.152:704-11.
87. Kinder LS, Katon WJ, Ludman E, et al. Improving depression care in patients with diabetes and multiple complications. J Gen Intern Med. 2006;21: 1036-41. (Pubitemid 44337731)
88. Katon W, Lin EH, Von Korff M, et al. Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: the design of the TEAMcare study. Contemp Clin Trials.31: 312-322.
89. Bogner HR, de Vries HF. Integration of depression and hypertension treatment: a pilot, randomized controlled trial. Ann Fam Med. 2008;6: 295-301.
90. Vargas RB, Mangione CM, Asch S, Russo J, Simon G, Lin EH, et al. Can a chronic care model collaborative reduce heart disease risk in patients with diabetes? J Gen Intern Med. 2007;22: 215-222. (Pubitemid 47308823)
91. Lucas GM, Mullen BA, Weidle PJ, Hader S, McCaul ME, Moore RD. Directly administered antiretroviral therapy in methadone clinics is associated with improved HIV treatment outcomes, compared with outcomes among concurrent comparison groups. Clin Infect Dis. 2006;42:1628-35.
92. Boyd CM, Shadmi E, Conwell LJ, Griswold M, Leff B, Brager R, Sylvia M, Boult C. A pilot test of the effect of guided care on the quality of primary care experiences for multimorbid older adults. J Gen Intern Med. 2008;23:536-42.
93. Mead N, Bower P. Patient-centred consultations and outcomes in primary care: A review of the literature. Patient Educ Couns. 2002;48:51-61. (Pubitemid 36151681)
94. Stewart M, Brown J, Weston W, Freeman T. Patient-centred medicine: transforming the clinical method. 2nd ed. United Kingdom: Radcliffe Medical Press; 2003.
95. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: Is there enough time for prevention? Am J Public Health. 2003;93:635-41. (Pubitemid 36790885)
96. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209-14. (Pubitemid 40806713)
97. Grumbach K, Coffman J. Physicians and nonphysician clinicians: complements or competitors? JAMA. 1998;280:825-6. (Pubitemid 28406761)
98. Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med. 2000;160:1825-33. (Pubitemid 30418821)
99. Archer SL, Greenlund KJ, Casper ML, Rith-Najarian S, Croft JB. Associations of community-based health education programs with food habits and cardiovascular disease risk factors among Native Americans with diabetes: The inter-tribal heart project, 1992 to 1994. J Am Diet Assoc. 2002;102:1132-5. (Pubitemid 40434140)
100. Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, Blumenthal D. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22Suppl3:391-5. (Pubitemid 350172457)
101. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994;120:999-1006. (Pubitemid 24169279)
102. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA. 1999;281:613-20. (Pubitemid 29098061)
103. Naylor MD, McCauley KM. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. J Cardiovasc Nurs. 1999;14:44-54.
104. Coleman EA, Grothaus LC, Sandhu N, Wagner EH. Chronic care clinics: A randomized controlled trial of a new model of primary care for frail older adults. J Am Geriatr Soc. 1999;47:775-83. (Pubitemid 29326005)
105. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: The care transitions measure. Med Care. 2005;43:246-55. (Pubitemid 40353908)
106. Wieland D. The Program of All-Inclusive Care for the Elderly PACE. In: Schulz R NL, Rockwood K, Sprott R, (editors). The Encyclopedia of Aging 4th ed. New York (NY): Springer: 2006. p.973-5.
107. Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. Potential unintended consequences due to medicare's "no pay for errors rule"? A randomized controlled trial of an educational intervention with internal medicine residents. J Gen Intern Med.25:1097-101.
108. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: Lessons from a flawed performance measure. Ann Intern Med. 2008;149:29-32.
109. Wachter RM, Foster NE, Dudley RA. Medicare's decision to withhold payment for hospital errors: The devil is in the details. Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources. 2008;34:116-23.
110. Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev. 2006;63:135-57. (Pubitemid 43344149)
111. Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: Results from a systematic review of the literature and methodological issues. Int J Qual Health Care. 2000;12:133-42. (Pubitemid 30262229)
112. Wolff JL, Roter DL, Given B, Gitlin LN. Optimizing patient and family involvement in geriatric home care. J Healthc Qual. 2009;31:24-33.
113. Mitnick S, Leffler C, Hood VL. Family caregivers, patients and physicians: Ethical guidance to optimize relationships. J Gen Intern Med. 25:255-60.
114. Soubhi H, Fortin M, Hudon C. Perceived conflict in the couple and chronic illness management: Preliminary analyses from the Quebec Health Survey. BMC Fam Pract. 2006;7:59.
115. Scholle SH, Torda P, Peikes D, Han E, Genevro J. Engaging patients and families in the medical home. Rockville (MD): Agency for Healthcare Research and Quality; 2010.
116. Institute for Patient-Centered and Family-Centered Care. Available from URL: http://www.ipfcc.org/ (Accessed 27 April 2011).
117. Boyd CM, Darer, J, Fried LP, Boult C, Wu AW. The challenges of following clincial practice guidelines in older patients with multiple comorbid conditions. J Am Geriatr Soc. 2003;51:S220.
118. Vitry AI, Zhang Y. Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions. Med J Aust. 2008;189:360-5.
119. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2001;2005:1-56.
120. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905-15.
121. Brown AF, Mangione CM, Saliba D, Sarkisian CA. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51:S265-80. (Pubitemid 36535105)
122. Kent DM, Hayward RA. Limitations of applying summary results of clinical trials to individual patients: The need for risk stratification. JAMA. 2007;298:1209-12. (Pubitemid 47403108)
123. Kent DM, Kitsios G. Against pragmatism: on efficacy, effectiveness and the real world. Trials. 2009;10:48.
124. Fabbri L, Boyd CM, Boschetto P, et al. How to deal with multiple comorbidities in guideline development: An official ATS/ERS Workshop Report. Manuscript submitted for publication. 2010.
125. Boyd C. AHRQ R21 Improving Clinical Practice Guidelines for Complex Patients. Agency for Healthcare Research and Quality.
126. Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: Summary of a conference conducted by the Society of General Internal Medicine. J Gen Intern Med. 2007;22:1206-11. (Pubitemid 47038048)
127. Higashi T, Wenger NS, Adams JL, Fung C, Roland M, McGlynn EA, et al. Relationship between number of medical conditions and quality of care. N Engl J Med. 2007;356:2496-504. (Pubitemid 46919775)
128. Shadmi E, Boyd CM, Hsiao CJ, Sylvia M, Schuster AB, Boult C. Morbidity and older persons' perceptions of the quality of their primary care. J Am Geriatr Soc. 2006;54:330-4.
129. Min LC, Wenger NS, Fung C, Chang JT, Ganz DA, Higashi T, et al. Multimorbidity is associated with better quality of care among vulnerable elders. Med Care. 2007;45:480-8.
130. Chang JT, Hays RD, Shekelle PG, MacLean CH, Solomon DH, Reuben DB, et al. Patients' global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144:665-72. (Pubitemid 46780651)
131. Fung CH, Setodji CM, Kung FY, Keesey J, Asch SM, Adams J, McGlynn EA. The relationship between multimorbidity and patients' ratings of communication. J Gen Intern Med. 2008;23:788-93.
132. National Quality Forum. Multiple Chronic Conditions Measurement Framework. Available from URL: http://www.qualityforum.org/Projects/Multiple- Chronic-Conditions-Measurement-Framework.aspx (Accessed 27 April 2011).
133. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington (DC): National Academy Press; 2001.
134. Ganz DA, Wenger NS, Roth CP, Kamberg CJ, Chang JT, MacLean CH, et al. The effect of a quality improvement initiative on the quality of other aspects of health care: the law of unintended consequences? Med Care. 2007;45:8-18.
135. Wenger NS, Solomon DH, Roth CP, MacLean CH, Saliba D, Kamberg CJ, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003;139:740-7.
136. Pham HH, Schrag D, O'Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356:1130-9. (Pubitemid 46425597)
137. Boyd CM, Boult C, Shadmi E, Leff B, Brager R, Dunbar L, et al. Guided Care for Multimorbid Older Adults. Gerontologist. 2007;47:697-704. (Pubitemid 350156066)
138. Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): A new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54:1136-41. (Pubitemid 43992554)
139. Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors: A randomized controlled trial. JAMA. 2007;298:2623-33. (Pubitemid 350254954)
140. Freund T, Kayling F, Miksch A, Szecsenyi J, Wensing M. Effectiveness and efficiency of primary care based case management for chronic diseases: rationale and design of a systematic review and meta-analysis of randomized and non-randomized trials. BMC Health Serv Res.10:112.
141. Freund T, Wensing M, Mahler C, Gensichen J, Erler A, Beyer M, et al. Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol. Implement Sci.5:70.
142. Soubhi H, Bayliss EA, Fortin M, Hudon C, van den Akker M, Thivierge R, et al. Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity. Ann Fam Med.8:170-7.
143. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's "retooling for an aging America" report. J Am Geriatr Soc. 2009;57:2328-37.