Quality of Care for Patients with Multimorbidity

Abstract

Multimorbidity, the presence of multiple chronic conditions in one person, is a major challenge for healthcare systems worldwide. Fragmentation and lack of reliable evidence are among the main obstacles for healthcare providers, making the care of patients with multimorbidity vulnerable to quality deficits. As overburdened patients are more likely to be less compliant and have a poorer experience of care, treatment burden is an important aspect of quality of care for this patient group. Inadequate application of clinical guidelines and quality metrics designed for single conditions can adversely affect the quality of care. Standardised quality measures that take account of multimorbidity are needed to assess the current state of health care. So far, however, there are none available for Germany. This thesis comprises three studies designed to gain insight into the quality of care for patients with multimorbidity and their experience of care. The research employed a mixed-methods approach and addressed the following objectives: (1) developing quality indicators and a measurement framework for the management of multimorbidity, (2) exploring patients’ perspectives on the quality of care through focus groups; and (3) creating a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and determining its validity.

The development of the quality indicator set was informed by a systematic literature review of guidelines and quality metrics, which resulted in the identification of 81 recommendations and six relevant metrics. The results of the focus group supported most of the quality aspects found in the literature, and four new ones emerged. These were used to create new quality indicators, which were then assessed by an independent multidisciplinary expert panel. In a two-stage nominal group consensus process, the panel selected a set of 25 indicators. A conceptual framework was developed to visualise and organise quality measurement for multimorbidity covering three layers of multilevel influences on quality of care. Another main outcome is the German adaptation of the MTBQ, a brief tool to assess treatment burden in patients with multimorbidity. A robust and well-established methodology was utilised for translation and minor changes were made to the obtained version in order to ensure cross-cultural validity. The analysis showed robust face validity, acceptable reliability, a single-factor structure and good construct validity.

These findings present the first standardised instruments to assess the quality of care for multimorbidity in the German health care system. The importance of including the patient perspective in quality assessment is underlined by the involvement of patients at multiple stages of the research process. Further empirical validation is needed before the indicators can be used to evaluate standard care. The MTBQ holds potential as an outcome measure in future clinical trials, and its effectiveness as a tool in clinical practice should be examined in the future. Both instruments offer a promising solution to the limitations of disease-specific measures of quality of care that fail to address the complexity of multimorbidity.