Multimorbidity and consultation time: a systematic review

RESEARCH ARTICLE Open Access Mul imo bidi y and consul a ion ime: a sys ema ic e iew Ana Ca olina Reis Tadeu 1* , Inês Rosendo Ca alho e Sil a Cae ano 1,2 , Inês Jo ge de Figuei edo 1,3,4 and Luiz Miguel San iago 1,5,6 Abs ac Backg ound: Mul imo bidi y (MM) is one o he majo challenges heal h sys ems cu en ly ace. Managemen o ime leng h o a medical consul a ion wi h a pa ien wi h MM is a ma e o conce n o doc o s. Me hods: A sys ema ic e iew was pe o med o desc ibe he impac o MM on he a e age ime o a medical consul a ion conside ing he P e e ed Repo ing I ems o Sys ema ic Re iew and Me a-analyses (PRISMA) guidelines. The sys ema ic online sea ches o he Embase and PubMed da abases we e unde aken, om Janua y 2000 o Augus 2018. The s udies we e independen ly sc eened by wo e iewe s o decide which ones me he inclusion c i e ia. (Kappa = 0.84 and Kappa = 0.82). Di e ing opinions we e sol ed by a hi d pe son. This sys ema ic e iew included people wi h MM c i e ia as pa icipan s ( wo o mo e ch onic condi ions in he same indi idual). The ype o ou come included was explici ly de ined – he leng h o medical appoin men s wi h pa ien s wi h MM. Any s a egies aiming o analyse he impac o MM on he a e age consul a ion ime we e conside ed. The leng h o ime o medical appoin men o pa ien s wi hou MM was he compa a o c i e ia. Expe imen al and obse a ional s udies we e included. Resul s: O 85 a icles iden i ied, only 1 obse a ional s udy was included, showing a clea end o pa ien s wi h MM o ha e longe consul a ions han pa ien s wi hou MM c i e ia (p< 0.001). Conclusions: Mo e s udies a e equi ed o be e assess alloca ion leng h- ime o pa ien s wi h MM and o measu e o he cha ac e is ics like doc o s’wo kload. Keywo ds: Mul imo bidi y, Medical appoin men , Quali y o heal hca e, Consul a ion leng h Backg ound Mul imo bidi y (MM) is de ined by he Eu opean Gen- e al P ac ice Resea ch Ne wo k as “any combina ion o ch onic disease wi h a leas one o he disease (acu e o ch onic) o biopsychosocial ac o (associa ed o no ) o soma ic isk ac o ”[1]. This is some imes simpli ied o, “ he simul aneous occu ence o wo o mo e ch onic diseases in he same indi idual”[2]. MM is now one o he main challenges aced by heal h sys ems a an in e - na ional le el and occupies a conside able pa o he daily ac i i y o Gene al P ac i ione s/Family Doc o s (GPs/FMs) a ound he wo ld [3–6]. Wi h an e e -ageing wo ld popula ion, MM and i s consequences, a e becoming a majo issue in public heal h and p ima y ca e. Acco ding o Uni ed Na ions da a [7,8], Eu ope has he la ges pe cen age o popula- ion aged 60 o o e (25%) [7]. In 2015 he numbe o people in he wo ld aged 60 yea s and olde was 901 mil- lion [8]. I is p ojec ed ha in 2030 his igu e will ise o 1.4 billion (a 56% inc ease since 2015) and s and a 2.1 billion in 2050 [8]. Se e al s udies ha e shown ha he e is a signi ican associa ion be ween age [2] and he p e alence o MM, mos na ional heal h sys ems no © The Au ho (s). 2020 Open Access This a icle is licensed unde a C ea i e Commons A ibu ion 4.0 In e na ional License, which pe mi s use, sha ing, adap a ion, dis ibu ion and ep oduc ion in any medium o o ma , as long as you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons licence, and indica e i changes we e made. The images o o he hi d pa y ma e ial in his a icle a e included in he a icle's C ea i e Commons licence, unless indica ed o he wise in a c edi line o he ma e ial. I ma e ial is no included in he a icle's C ea i e Commons licence and you in ended use is no pe mi ed by s a u o y egula ion o exceeds he pe mi ed use, you will need o ob ain pe mission di ec ly om he copy igh holde . To iew a copy o his licence, isi h p://c ea i ecommons.o g/licenses/by/4.0/. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed in a c edi line o he da a. * Co espondence: ca olina. . [email protected] 1 Facul y o Medicine, Uni e si y o Coimb a, Coimb a, Po ugal Full lis o au ho in o ma ion is a ailable a he end o he a icle Tadeu e al. BMC Family P ac ice (2020) 21:152 h ps://doi.o g/10.1186/s12875-020-01219-5 being p epa ed o able o cope wi h his apid ageing wi h many demands [5,6]. MM educes li e expec ancy and quali y o li e (QoL) [5]. Howe e , QoL can inc ease i he quali y o ca e (QoC) imp o es [9], and his can equi e addi ional consul a ion ime. So, i is impe a i e o hink abou he mos co ec app oach o pa ien s wi h MM in o de o maximize he QoC p o ided by he Heal h Se ices (HS), and so ensu e a be e quali y o li e. GPs/FMs medical eam ace a ious di icul ies in ca ing o a pa ien wi h MM like lack o esou ces; con- sul a ion ime es ic ions [10]; lack o in e disciplina y ca e/ eams; inadequa e pa ien suppo (la gely elying on communi y-based suppo se ices); inadequa e ools (guidelines a e d awn up s ic ly o speci ic diseases and no o he MM pa ien ); he a i ude o he pa ien (o en discou aged and poo ly engaged) [4,11]. In o ma ion abou he leng h- ime o a consul a ion wi h a pa ien wi h MM is essen ial o be e o ganize and deli e heal hca e. To ou knowledge, no p e ious e iew has summa ized da a ela ed o: Wha is he im- pac o ha ing MM on he medical consul a ion?; and Is he a e age leng h- ime consul a ion wi h a pa ien wi h MM longe han o a pa ien wi hou MM?. Me hods A sys ema ic e iew was pe o med conside ing he P e- e ed Repo ing I ems o Sys ema ic Re iew and Me a- Analyses (PRISMA) guidelines o sys ema ic e iews and me a-analysis, no ollowing any e iew p o ocol. This esea ch p oposal has been submi ed o and app o ed by he Facul y o Medicine a he Uni e si y o Coimb a. Eligibili y c i e ia The PICO model has been ollowed o de ine he ques- ion and allow he mos e ec i e li e a u e sea ch. The popula ion (P) was de ined as people wi h MM. The mos widely used de ini ion o MM was used, which is he coexis ence o wo o mo e ch onic condi ions in he same indi idual [2]. The Wo ld Heal h O ganiza ion (WHO) de ini ion o ch onic disease was adop ed, namely, heal h p oblems ha equi e ongoing ca e o e a long pe iod o ime (yea s o decades) [12]. As in e en ions (I) any s a egies aiming o analyse he impac o MM on he a e age consul a ion ime we e conside ed. The leng h o ime o medical appoin - men o pa ien s wi hou MM was he compa a o c i- e ion (C). As ou come (O), i was expec ed o explici ly de ine he leng h- ime o medical appoin men s wi h pa- ien s wi h MM. Expe imen al and obse a ional s udies we e included. S udies which did no speci y he ime spen on medical appoin men s we e excluded. In o ma ion sou ces and sea ch s a egy The sys ema ic online sea ches we e implemen ed using combina ions o keywo ds in he ollowing elec onic da abases: he Embase and PubMed da abases, om Janua y 1, 2000 un il Augus 31, 2018, an 18-yea ime pe iod, o ind pe inen s udies. The au ho s belie e ha he mos eliable way o assess consul a ion ime is h ough compu e ized clinical eco ds, which we e e y sca ce be o e 2000. The sea ch wi hin he Embase da abase used he ol- lowing combina ion o keywo ds: (‘mul iple ch onic con- di ions’/exp. OR’mul iple ch onic condi ions’)AND (‘consul a ion ime’OR ((‘consul a ion’/exp. OR consul - a ion) AND (‘ ime’/exp. OR ime))); (‘mul iple ch onic condi ions’/exp. OR ‘mul iple ch onic condi ions’)AND (‘p ima y heal h ca e’/exp. OR ‘p ima y heal h ca e’) AND (‘ ime’/exp. OR ime); ‘consul a ion’/exp. AND ‘mul iple ch onic condi ions’/exp./mj; ‘mul iple ch onic condi ions’/exp. AND (‘ ime’/exp. OR’a e age’/exp. OR ‘consul a ion’/exp). Fo he PubMed da abase he combi- na ions o keywo ds we e: “Ch onic Disease/epidemiolo- gy”[Mesh] AND ((“ e e al and consul a ion”[MeSH Te ms] OR (“ e e al”[All Fields] AND “consul a io- n”[All Fields]) OR “ e e al and consul a ion”[All Fields] OR “consul a ion”[All Fields]) AND (“ ime”[MeSH Te ms] OR “ ime”[All Fields])). The sea ch was limi ed o pape s in English, Po u- guese, Spanish and F ench published in in e na ionally- ecognized pee - e iewed jou nals o ensu e he eliabil- i y o he da a. No o he limi s we e imposed du ing his s age o he s udy. Re e ences in he iden i ied li e a u e we e scanned o u he li e a u e when i was ound app op ia e o suppo wo k decisions. Da a ex ac ion and quali y assessmen The po en ially ele an s udies con aining quan i a i e consul a ion ime da a we e selec ed in wo s ages. Fi s , he i les and abs ac s quo ed in he li e a u e sea ch we e independen ly sc eened by wo e iewe s ( he i s and hi d co-au ho s o his wo k) o decide which ones o accep , mee ing he inclusion c i e ia (Kappa = 0.84). Those no mee ing he inclusion c i e ia we e excluded. Di e ing opinions on a s udy’s inclusion we e esol ed by a hi d pe son ( he second co-au ho o his wo k). Secondly, he esea che s independen ly ead and ana- lysed he in eg i y o he ma ching s udies and ied o each an ag eemen conce ning eligibili y (Kappa = 0.82). Those no mee ing he inclusion c i e ia we e excluded. Di e ing opinions on a s udy’s inclusion we e esol ed by a hi d pe son ( he second co-au ho o his wo k). The quali y and isk o bias o he included s udies was assessed using he Newcas le-O awa Scale (NOS), mo e p ecisely, he Newcas le-O awa scale adap ed o c oss- sec ional s udies [13]. The NOS is widely used and Tadeu e al. BMC Family P ac ice (2020) 21:152 Page 2 o 8 ecommended by he Coch ane Collabo a ion [14], and he au ho s ound i sui able o he pu pose o his wo k. This ool assesses h ee aspec s o a s udy: he selec ion o he sample; he compa abili y o he g oups; and he ou come (assessmen o ou come and s a is ical es ). I is composed o 7 i ems and classi ies he s udy in 4 possible le els: Ve y good (9–10 poin s), Good (7–8 poin s), Sa is ac o y (5–6 poin s) and Unsa is ac o y (0– 4 poin s). Any disag eemen was esol ed h ough consensus. This sys ema ic e iew was conduc ed using Co i- dence 13, he s anda d p oduc ion pla o m used o Coch ane e iews, which was used o he da a and eco ds managemen . Ou comes and s a is ical analysis The pa ien s we e spli in o wo g oups, hose wi h and hose wi hou MM, and he ela i e equencies we e calcula ed. The esul s we e analysed using he chi- squa e dis ibu ion es . Resul s S udy selec ion As desc ibed in Fig. 1, he elec onic da abase sea ches s a ed wi h 85 po en ially eligible e e ences (16 in PubMed and 59 in Embase). O hese, 5 we e duplica es and we e hus excluded and 31 we e conside ed i ele an based on a e iew o he i le and abs ac . The emaining s udies we e ully ead, analysed and assessed o eligibili y; 36 we e hen excluded due o unsa is ac o y ou come [3,16–49], 5 due o unsui able s udy design [50–54], 4 due o unsui able pa ien popu- la ion [11,55–57], 2 due o inadequa e language [58,59] and 1 o unsa is ac o y se ing [60]. In he end, 1 s udy was included [61]. S udy cha ac e is ics and quali y The main ele an ea u es and ou pu s o he s udy we e ex ac ed o he pu pose o his sys ema ic e iew and a e summa ized in Table 1. The included s udy was conduc ed be ween 2008 and 2009 in Denma k, o e 12 mon hs. I in ol ed 404 gen- e al p ac i ione s (GPs) pa icipan s and a o al o 8236 con ac s. I included pa ien s aged 40 yea s o mo e, g ouped as hose wi hou any ch onic condi ion and hose wi h one, wo, h ee o mo e ch onic condi ions. Du ing he s udy pe iod, he GPs comple ed a one- page egis a ion o m o each o hei pa ien con ac s. O he a ious i ems ha we e egis e ed, he ones ele- an o his e iew we e in o ma ion on ch onic diseases and leng h- ime o consul a ion. Quali y assess- men esul , pe o med as desc ibed in me hodology, is p esen ed in Table 2. The quali y o he s udy was conside ed sa is ac o y (sco e 6 ou o a maximum sco e Fig. 1 PRISMA Flow Diag am [15]–Li e a u e sea ch and selec ion p ocess o s udies included Tadeu e al. BMC Family P ac ice (2020) 21:152 Page 3 o 8 Table 1 Summa y o s udy’s cha ac e is ics Au ho Yea o s udy Coun y Design Numbe o pa icipan s Popula ion (inclusion c i e ia) Se ing Me hod o da a collec ion Ou comes measu ed Au ho ’s conclusions Mo h e al 2008–2009 Denma k C oss- sec ional 404 GPs, 8236 con ac s Pe sons aged 40 yea s o mo e Gene al p ac ice Regis a ion o m comple ed by GP abou all pa ien c on ac s on one andomly assigned da e du ing he s udy pe iod. - Leng h o consul a ion ime, ch onic disease, eason o appoin men , diagnosis, numbe o addi ional psychosocial p oblems aised by he pa ien du ing he consul a ion, di icul y ound wi h consul a ion o he consul a ion, e e al o specialized ca e, and whe he a nu se could ha e eplaced he GP. - GPs ound consul a ions wi h pa ien s su e ing om ch onic condi ions o be mo e di icul han hose wi h pa ien s wi hou ch onic disease (p< 0.001). GP Gene al P ac i ione Tadeu e al. BMC Family P ac ice (2020) 21:152 Page 4 o 8 o 10), i s main weakness being in he compa abili y sec ion. Resul s o s udy Table 3shows he ela ionship be ween he leng h o consul a ion ime and he ype o pa ien (wi h and wi h- ou MM). The e is a clea signi ican end o pa ien s wi h MM o ha e longe consul a ions han pa ien s wi hou MM (p<0.001). Mo e han 25% o MM pa ien s had a consul a ion leng h- ime o a leas 16 min while mo e han 75% o he pa ien s wi hou MM had a consul a ion leng h- ime unde 15 min. Leng h- ime consul a ion on bo h ypes o pa ien s is mo e equen ly be ween 6 and 15 min. The e is a signi ican di e ence, howe e , in he pe cen age o pa ien s wi h MM equi ing mo e ime han pa ien s wi hou MM c i e ia. Discussion Main indings The p esen sys ema ic e iew sough o ind ou i he a e age consul a ion ime spen on pa ien s wi h MM is longe han ha spen on pa ien s who do no mee he MM c i e ia. I could only iden i y one s udy [61], unde aken in Denma k, in which he consul a ion ime was logged as a unc ion o he numbe o ch onic dis- eases. This s udy e ealed a endency o consul a ions o ake longe o pa ien s wi h MM han o hose wi h- ou MM. Howe e , he s udy was no di ec ly aimed a answe ing his ques ion and i did no ake con ounding ac o s in o accoun . In addi ion, i does no desc ibe he calcula ion o de e mine he sample size o he s udy and i could be inaccu a e o s udy his speci ic ou come s ill i answe s he posed ques ion. Compa ison wi h exis ing li e a u e The small numbe o publica ions in he li e a u e on his subjec shows ha mo e s udies should be designed o in es iga e he impac o MM on he consul a ion leng h- ime. I is i al o analyse his issue in o de o manage esou ces so ha hey mee he ac ual need, and o ensu e he se ices p o ided by heal h se ices, na- ional o p i a e, a e app op ia e. I will hus be possible o gua an ee be e quali y heal h se ices and ou comes o hese pa ien s. In ac , MM is abou a pa ien wi h mo e han wo ch onic diseases o one ch onic disease wi h biopsychosocial ac o (associa ed o no ) o som- a ic isk ac o , so illness being included and no only abou he speci ic su e ances [1,11]. In s udies wi h calcula ed size popula ion ep esen- a i e andom samples i is impo an ha accu a e me hods a e used o measu e he ealleng h- imeo a consul a ion using app op ia e ools. Con ounding ac o s mus be elimina ed as he ime spen on adminis a i e wo k. Only di ec obse a ion using ideo eco ding has been p o en o ob ain accu a e alues when measu ing he du a ion o consul a ions [62], which could be a p ocedu e ha mi iga es many o he e o s p e iously men ioned. I is essen ial o iden i y be o ehand any possible con ounding ac o s inhe en o he pa ien s ( o example, hea ing di i- cul y, educa ion le el, age, socio-economic le el), in- he en o he doc o (in pa icula , a change in beha iou due o he pa icipa ion in he esea ch s udy –Haw ho ne e ec [63]), and inhe en o he consul a ion/ins i u ion ( o example, gli ches in com- pu e sys ems, o ganiza ion o necessa y in o ma ion in he heal h in o ma ics eco ds, coding e o s, ele- phone call in e up ions). The ime los sea ching o in o ma ion in consul a ion, he iendliness o clinical in o ma ics and he ime spen on eco ds a e also is- sues o be s udied and hough o [64,65]. Heal h de- e minan s a e ac o s o be s udied in such a MM popula ion o be e heal h and social ou comes [66]. The da a analysis mus be e alua ed using objec i e alida ed labo a o y me hods and, i possible, i should be a blind assessmen . S a is ical es s used o analyse he da a mus be app op ia e and clea ly desc ibed. Measu es o associa ion, including con idence in e als and he P alue, mus be p esen ed. Table 3 Leng h o consul a ion ime and ype o pa ien (wi h and wi hou MM c i e ia) Leng h o consul a ion ime No MM (n) % MM (n) % p- alue < 5 min 293 11.7 96 7.7 p< 0.001 6–15 min 1686 67.3 804 64.9 16–30 min 485 19.4 314 25.3 > 30 min 42 1.7 25 2.0 To al 2506 100 1239 100 Table 2 Quali y o s udy - Newcas le-O awa Scale adap ed o c oss-sec ional s udies Au ho Selec ion Compa abili y Ou come To al sco e Powe Rep esen a i eness o he sample Sample size Non- esponden s Asce ainmen o exposu e ( isk ac o ) Compa abili y o subjec s in di e en ou come g oups on he basis o design o analysis. Assessmen o ou come S a is ical es Mo h e al * - (b) * ** - (c) * * 6 Sa is ac o y * - sco e o 1 poin ; ** - sco e o 2 poin s; (b) –Calcula ion no epo ed; (c) –Da a/ esul s no adjus ed o all ele an con ounde s no p o ided C oss-sec ional S udies: Ve y Good S udies (9–10 poin s); Good S udies (7–8 poin s); Sa is ac o y S udies (5–6 poin s); Unsa is ac o y S udies (0 o 4 poin s) Tadeu e al. BMC Family P ac ice (2020) 21:152 Page 5 o 8 Fu he conside a ions The QoL o MM pa ien s can inc ease i he quali y o QoC imp o es, so he imp o emen o he quali y o se ices p o ided by he HS is an impo an ma e . Pa ien s wi h MM equi e mo e medical esou ces and longe consul a ion leng h. Medical eams need o be in e disciplina y and guidelines d awn up o speci ic diseases need o be imp o ed o MM pa ien s. HS need o p o ide good pa ien suppo and o acqui e knowledge o deal wi h o en discou aged and poo ly engaged pa ien s. The app op ia e leng h o a consul a ion o a pa ien wi h MM needs o be aken in o accoun o be e o ganize and deli e heal hca e, aking in o accoun ha he equency o consul ing and he numbe o p oblems o dis- cuss a e signi ican ly highe in he pa ien s wi h MM [67]. S eng hs and limi a ions The main limi a ion o his sys ema ic e iew was he di icul y in ensu ing ha all he ele an li e a u e was included. E en hough he esea ch used wo o he main da abases –PubMed and Embase – he e could be o he ele an ma e ial in g ey li e a u e, no aken in o accoun in he p esen wo k o ensu e he eliabili y o he da a. The sca ci y o he li e a u e ha was ound was a limi a ion o his e iew. The one publica ion ound, besides no di ec ly answe ing ou ques ion, also does no ake con ounding ac o s in o accoun , and does no desc ibe he calcula ion o de e mine he sample size o he s udy. Howe e , i does highligh he ele ance o he subjec ma e . The au ho s belie e ha he lack o ecogni ion o MM and agile pa ien s in he clinical managemen o pa ien s is also one o he easons why scien i ic esea ch has paid less a en ion o MM. Conclusions This impac o MM on he du a ion o a consul a ion has ha dly been s udied, his sys ema ic e iew shows. A endency o consul a ions o pa ien s wi h MM o ake longe han hose wi hou MM was ound in he only one s udy wi h “sa is ac o y”quali y which me he inclusion c i e ia. So mo e esea ch is needed o acqui e mo e in o ma- ion on his subjec , impo an o deal no only wi h diseases bu wi h he pe son su e ing om MM o consul a ion mus ha e he adequa e leng h du a ion o enable doc o s and s ake-holde s wi h a p ope quan i i- ca ion o he ime and associa ed cos s. I a longe consul a ion ime is con i med, i will be impo an o e hink and adap GPs’lis s o pa ien s in o de o achie e be e medical ca e p o iding agendas wi h speci ic imes and alloca ing enough ime o all he equi ed asks. Abb e ia ions MM: Mul imo bidi y; QoL: Quali y o li e; QoC: Quali y o ca e; GP: Gene al P ac i ione ; PRISMA: P e e ed Repo ing I ems o Sys ema ic Re iew and Me a-analyses; HS: Heal h Se ice; WHO: Wo ld Heal h O ganiza ion Acknowledgemen s Helena Dona o, MD o he aluable con ibu ion in he li e a u e sea ch. Au ho s’con ibu ions ACRT: Da a ex ac ion, da a examina ion, ea men o da a, w i ing o manusc ip and i s scien i ic c i icism as well as app o al. IRCSC: Da a ex ac ion, da a examina ion, ea men o da a, w i ing o manusc ip and i s scien i ic c i icism as well as app o al. IJF: Da a examina ion, ea men o da a, w i ing o manusc ip and i s scien i ic c i icism as well as app o al. LMS: Da a ga he ing and analysis, and manusc ip w i ing, scien i ic e ision and app o al. All au ho s ha e ead and app o ed he inal manusc ip . Funding No unding o sponso ship was ecei ed o his s udy o publica ion o his a icle. A ailabili y o da a and ma e ials Ma e ials can be assessed upon eques . E hics app o al and consen o pa icipa e This s udy has been app o ed by he Pedagogic Council o he Facul y o Medicine o he Uni e si y o Coimb a and i s Dean. Consen o publica ion No applicable. Compe ing in e es s No au ho s a es inancial and non- inancial compe ing in e es s o his wo k. Au ho de ails 1 Facul y o Medicine, Uni e si y o Coimb a, Coimb a, Po ugal. 2 USF Coimb a Cen o, Coimb a, Po ugal. 3 ACeS Dão La ões, Coimb a, Po ugal. 4 Facul y o Heal h Sciences, Uni e si y o Bei a In e io , Co ilhã, Po ugal. 5 Gene al P ac ice/Family P ac ice clinic o he Facul y o Medicine o Uni e si y o Coimb a, Coimb a, Po ugal. 6 Cen e o Heal h and In es iga ion s udies o he Uni e si y o Coimb a (CEISUC), Coimb a, Po ugal. Recei ed: 10 Oc obe 2019 Accep ed: 12 July 2020 Re e ences 1. Le Res e JY, Nabbe P, Manceau B, Lygidakis C, Doe C, Lingne H, e al. 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