Increasing primary care comorbidity: a conceptual research and practice framework.

Purpose: To present a "contrasting perspectives" conceptual framework reflecting the typically strained experiences of many comorbid adults now interacting with primary care clinicians across the world. Background: More comorbidity-related needs are presented to primary care clinicians during typically shorter office-based health care encounters. The overall perceptual differences between many comorbid consumers and health care clinicians and systems in many countries are likely to worsen. Conclusions: Conceptual implications are discussed for primary care researchers testing interventions and attempting to influence the outcomes of increasingly comorbid primary care adults. Implications for Nursing Research and Practice: Three strategies are offered for researchers and clinicians considering how to include elements of comorbidity into their prospective primary care study interventions and care delivery processes. Keywords: comorbidity; primary care; chronic illness; multimorbidity As adults live longer to develop multiple chronic health conditions, the growing phenomenon of comorbidity (also referred to as medical complexity, multimorbidity, or multiple chronic conditions) has been increasingly noted by primary care clinicians and researchers (Conwell & Boult, 2008; Dickinson et al., 2008; Diederichs, Berger, & Bartels, 2011; Parekh & Barton, 2010; Sevick et al., 2007). For primary care specialists in most countries, the fullest conceptualization of how comorbidity is typically experienced by adults is still incomplete because of the lack of cogent frameworks reflecting their health care experiences (Corser & Dontje, 2011; Karlamangla et al., 2007; U.S. Department of Health and Human Services, 2010). Our overall understanding of the more appropriate conceptual approaches to take toward comorbidity in primary care settings has continued to be hampered by two factors. First, most comorbidity research to date has been conducted with hospital patients (Bayliss, Ellis, & Steiner, 2009; Corser & Dontje, 2011). Second, comorbidity methods have been largely derived from mortality or adverse event outcome models that may now be less pertinent to most adults now surviving longer with multiple comorbid conditions (Baldwin, Klabunde, Green, Barlow, & Wright, 2006; Diederichs et al., 2011; Lash et al., 2007). Our need for an improved conceptual understanding of comorbidity has been clear because comorbid adults frequently consume significantly greater rates of office-based, hospital, and emergency department services, albeit in a fairly nonlinear manner (Corser & Dontje, 2011; Decker, Schappert, & Sisk, 2009; Machlin, 2009; Schoen, Osborn, How, Doty, & Peugh, 2009; Struijs, Baan, Schellevis, Westert, & van den Bos, 2006). Although health care policy makers in most developed countries have identified these trends, the optimal conceptual approaches for studying this growing stratum of surviving adults have proven to be evasive (Bott, Kapp, Johnson, & Magno, 2009; Charlson, Charlson, Briggs, & Hollenberg, 2007; Diederichs et al., 2011; Nikolova, Demers, Beland, & Giroux, 2011; Robert Wood Johnson Foundation, 2010; Valderas, Starfield, Sibbald, Salisbury, & Roland, 2009). The development of conceptually grounded primary care interventions for many adults with comorbid conditions will prove integral for the improvement of health outcomes (Bayliss et al., 2007; Boult et al., 2011; Boyd et al., 2010; Chess, Krentzman, & Charde, 2007). At the same time, experts have agreed that the methodological challenges now imposed on primary care researchers attempting to study the extremely varied experiences of many comorbid adults have become more complex (Bayliss et al., 2009; Boyd et al., 2010; Charlson et al., 2007; Noel et al., 2007; Ravenscroft, 2010; Safford, Allison, & Kiefe, 2007; Schoen et al., 2009; Starfield, Lemke, Herbert, Pavlovich, & Anderson, 2005). …