What are the core predictors of ‘hassles’ among patients with multimorbidity in primary care? A cross sectional study

Our analysis explored the ‘hassles’ experienced by patients with multimorbidity, and examined predictors of ‘hassles’. The results show that the ‘hassles’ most frequently reported are related to lack of information about medical conditions, lack of information about treatment options, poor communication, and poor access to specialist care.

Increase in the number of conditions was associated with increase in the level of ‘hassles’ reported. Overall, five variables predicted more ‘hassles’: more long-term conditions, symptoms of anxiety and depression, younger age, being in paid employment, and not having a discussion with the GP in the last 12 months.

The study is essentially a replication of the earlier Parchman study [15]. The health care systems in the two settings (Greater Manchester, United Kingdom and South Texas, United States) are different, as were the populations included. For example, the patients in the US study were mostly male, and significantly younger (average age 50 vs. 70 years). This suggests that patient experience of hassles may be fairly common, even in different settings, and that different health care systems face common challenges.

Concerns must be raised by the response rate. The postal methods adopted for distribution of questionnaires provided an efficient way to collect relatively large amounts of information from patients, but this may have contributed to the response rate of 33 %. This response rate is consistent with those using postal surveys with patients in primary care [19‐21] and with large scale routine NHS surveys in primary care [22], but does leave the study vulnerable to bias in terms of the external validity of the results. For example, patients with more significant functional impacts of multimorbidity may have been less likely to respond. However, such bias may have less impact on examination of associations between variables, than on estimates of rates. It is also worth noting that, even if the rates of reporting of hassles were far lower in non-respondents, this would still mean that a significant proportion of patients report important problems in care, such as a ‘lack of information about my medical condition’ or ‘poor communication between different doctors or clinic’.

An implicit assumption of the current interests around ‘hassles’ is that greater numbers of long term conditions will lead to greater ‘hassles’, as patients will be required to manage more treatments, do more self-management, travel more, and receive more attention from services [11‐13]. This assumption was confirmed in the present study. To recruit patients through disease registers, this study focused on 5 conditions. It is possible that certain combinations of conditions are more prone to ‘hassles’. For example, some have distinguished between ‘discordant’ and ‘concordant’ conditions [23]. This work could be usefully replicated with other patient populations. At present, no consensus exists around appropriate typologies, and the present sample size was insufficient to explore such issues in depth.

This study is the first that we know of examining the predictors of ‘hassles’ in patients with multimorbidity in the United Kingdom.

These results support the findings of Parchman and colleagues, confirming greater ‘hassles’ in patients with multimorbidity (although they had compared those with single morbidity and multimorbidity) [15]. Other published studies have not explored wider predictors of ‘hassles’. However, one study by Bower and colleagues found few differences in patient experience of chronic illness care between those with single or multiple long term conditions, although the measure used was different [24].

Research evidence has shown that many older patients visit primary care with multimorbidity, and has highlighted the requirement to develop ways of improving health care services delivery to be responsive to the needs of these patients [25‐28]. The present work can contribute to developing such models, by identifying the key ‘hassles’ and those patient groups who are most at risk of that experience.

It is not clear whether the associations with depression and anxiety represent reporting issues or whether there is a clinically more important effect. It is possible that high levels of ‘hassles’ cause anxiety and depression symptoms, which would be implied by some of the qualitative work in this area. [29] A recent qualitative study reported that managing multimorbidity could lead to feelings of guilt and problems in relationships with others in the social network [13]. However, it is equally true that patients with depression may report more negatively on their experiences of care [30]. Exploring the causal mechanisms will be critical in developing new models and interventions to reduce ‘hassles’, as the implications are very different.

Although older patients are more likely to report multimorbidity, ‘hassles’ are not exclusive to the older population [25]. It is noteworthy that younger age was associated with high reports of ‘hassles’. Data on patient experience suggests that older people are generally more satisfied with services and complain less [31‐34]., so this may reflect a reporting issue. It is important to note that the age effect did not simply reflect greater flexibility of older, retired patients in terms of time for appointments, as the analysis also suggested that multimorbidity in the context of paid employment was independently associated with high level of ‘hassles’. In the United Kingdom, there is significant pressure for primary care practices to provide access outside normal hours [35‐37].

The frequency of discussions with a GP about long-term conditions (around 80 %) confirms previous work [21] and one interpretation of the findings is that a recent discussion with the GP might be important in reducing ‘hassles’. Certainly, recent discussions have highlighted the importance of continuity of care in multimorbidity [38].

In the United Kingdom, policy innovations such as care planning [39] or Year of Care [40] have been highlighted as methods of improving care for long-term conditions. Based broadly on the Chronic Care Model [41], the goal is to better support patients through individualised assessment of behaviour, collaborative goal setting, self-management support, and proactive follow-up. At present, most care planning is around single conditions [39, 40], and there may need to be modifications to take account of multimorbidity, such as those outlined recently in the Ariadne principles [42].

There has also been recent interest in developing models of consultation in primary care that have an explicit focus on reducing ‘hassles’, in line with what has been called ‘minimally disruptive medicine’ [10]. Care planning in multimorbidity could be used to enhance such care, although there is little evidence as yet on the effectiveness and cost-effectiveness of these new models of care [43], and their evaluation remains a priority [44].