The global burden of multimorbidity – or the co-existence of two or more chronic conditions in the same person – is greatest in low-income and middle-income countries (LMICs). Hence, pragmatic intervention studies are urgently needed to reduce the risk of developing multimorbidity and mitigate its complications in LMICs.
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Selecting appropriate outcomes measures for such studies, however, present a major challenge to researchers. In a report, authors affiliated with the Global Alliance for Chronic Diseases (GACD) present a summary of outcome measures suitable for research studies on mitigation of multimorbidity in LMIC settings (Hurst et al. 2020).
Relevant data and information for this report were collected through a survey among the GACD multimorbidity working group. Potential outcome measures multimorbidity studies in LMICs were then distilled by the writing committee (the authors) into categories through consensus discussion.
As a result, eight domains of outcome measures suitable for multimorbidity interventions in LMICs have been identified. Criteria for suitability included ease of measurement (i.e. availability of data, availability of local translations and cost), generalisability (i.e. applicability of the outcome across diverse populations within and between LMIC settings) and statistical considerations (the feasibility of demonstrating a clinically significant change).
Mortality: Death is the final common outcome for all individuals and is therefore considered an ‘essential’ core outcome measure.
Quality of life: Health-related quality of life (HRQoL) instruments measure multidimensional wellbeing and functioning. QoL is useful not only as an outcome marker, but also as an input factor into formulating clinical management.
Function: Using multidimensional indices of function (e.g. WHO Disability Assessment Schedule 2.0, or WHODAS 2.0) to assess functional deficits or disabilities and frailty.
Health economics: Cost-effectiveness of any intervention is an important consideration. The different costs to be included in cost-effectiveness analysis depend on the perspective that is taken (e.g. the healthcare payer, the society, the patient, or the family).
Healthcare access and utilisation: Multimorbidity is associated with repeated care seeking, resulting in multiple interactions with healthcare settings through outpatient and inpatient admissions. Access to medicines listed on the WHO Essential Medications list would provide another metric, as would recommendations on attention to comorbidity and pharmacological interactions in treatment guidelines.
Treatment burden: Assessing treatment burden is a priority in order to achieve better quality healthcare, but such work is not easy. This requires multidimensional measures that are tailored to the medical condition(s), health system(s) and cultural background.
Measures of ‘Healthy Living’: These include many aspects of health and wellbeing, such as diet, physical activity including sedentary behaviour, tobacco and alcohol consumption, developing health literacy, maintaining good hygiene and sanitation.
Self-efficacy and social functioning: Social determinants of health such as age, gender, education level and socioeconomic status, affect how an individual is able to look after their health conditions (self-efficacy) and interact in society with other individuals leading a fulfilling life (social functioning).
"Studies in multimorbidity are necessarily diverse and thus different outcome measures will be appropriate for different study designs," the authors point out. "Presenting the diversity of outcome measures across domains should provide a useful summary for researchers, encourage the use of multiple domains in multimorbidity research, and provoke debate and progress in the field."