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
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* 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
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Publishe ’sNo e
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