Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review

Monika Kastner, Leigh Hayden, Geoff Wong, Yonda Lai, Julie Makarski, Victoria Treister, Joyce Chan, Julianne H Lee, Noah M Ivers, Jayna Holroyd-Leduc, Sharon E Straus, Monika Kastner, Leigh Hayden, Geoff Wong, Yonda Lai, Julie Makarski, Victoria Treister, Joyce Chan, Julianne H Lee, Noah M Ivers, Jayna Holroyd-Leduc, Sharon E Straus

Abstract

Objectives: To understand how and why effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.

Design: A realist review.

Data sources: Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.

Eligibility criteria for selecting studies: We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.

Analysis: We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.

Results: 106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, disease management programmes and case management; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients' capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.

Conclusions: To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.

Prospero registration number: CRD42014014489.

Keywords: chronic disease management; complex interventions; multimorbidity; older adults; realist review.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Flow of article selection for the Realist Review.
Figure 2
Figure 2
Framework of optimised disease prioritization in multimorbidity management. A simplified overarching programme theory of identifying factors (conceptualised as barriers and facilitators) that need to be considered by patients and providers when trying to optimise disease prioritization.
Figure 3
Figure 3
Framework of optimised multimorbidity management. A simplified overarching programme theory identifying factors (conceptualised as barriers and facilitators) that need to be considered when trying to optimise multimorbidity management from the patient, provider and system perspective.

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Source: PubMed

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