Knowledge Translation and Implementation, Research and Innovation, North York General Hospital, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
BMJ Open. 2019 Apr 3;9(4):e025009. doi: 10.1136/bmjopen-2018-025009.
To understand and effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.
A realist review.
Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.
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.
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.
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, programmes and ; (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.
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.
CRD42014014489.
了解有效的多慢性疾病管理干预措施如何影响 65 岁及以上老年人的健康结果。
现实主义综述。
电子数据库包括 Medline 和 Embase（从建库至 2017 年 12 月）；以及灰色文献。
我们考虑了任何研究（即实验准实验、观察性、定性和混合方法研究），只要它们提供数据来解释我们的方案理论和有效性综述（已发表）的结果。我们感兴趣的人群是患有两种或两种以上慢性疾病的老年人（年龄≥65 岁）。
我们使用现实主义和元叙述证据综合：不断发展的标准（RAMESES）质量和出版标准对我们的综合进行评估，旨在完善我们的方案理论，以便它们包含多个上下文机制结果配置，描述不同机制触发结果的方式。我们创建了一个 3 步综合过程，基于元人种学，将数据单元与文章分离，并从中得出解释性陈述。
106 篇文章对分析做出了贡献。我们改进了我们的方案理论，以解释老年人的多疾病管理：（1）具有最佳潜在影响的护理协调干预措施是基于团队的策略、计划和；（2）优化疾病优先级排序涉及确保临床医生与患者合作，确定哪些症状有问题以及原因，并探索双方都能接受的方案；（3）优化患者自我管理取决于患者的自我护理能力和程度，并确定患者需要什么来实现自我护理。
为了优化护理，需要从多个角度（患者、提供者和系统）考虑临床管理和患者自我管理。为了减轻多疾病管理的复杂性，患者专注于减轻症状和维持生活质量，而提供者则专注于对发病率和死亡率威胁最大的疾病。
CRD42014014489。
