Exploring The Management Burdens Faced By Patients With Multimorbidities in Primary Care: Systematic review and Cross Sectional Study

Student thesis: Master of Philosophy


Background: A major problem in service delivery in primary care is that services are set up for patients with single long term conditions, whereas many older patients have more than one condition (called 'multimorbidity'). Qualitative research suggests that some patients with multimorbidity experience 'management burdens' in their care, including multiple appointments, poor co-ordination, and conflicting treatment recommendations. However, there is limited quantitative evidence on the management burdens that patients experience, or factors predicting management burdens. Aims and Objective: To determine which management burdens are reported by patients with multimorbidity in primary care, and what factors predict greater level of management burden. Methods: The study used two main methods: a systematic review and a cross sectional study.A systematic review was conducted by searching the following electronic databases: Medline, EMBASE, and CINAHL. Searches of organisational websites such as the National Institute for Health and Care Excellence (NICE), the Department of Health (DoH), and the Centre for Disease Control and Prevention (CDC) were also conducted for, together with "Zetoc" journal updates. Articles were included if they were written in English and published between 2000 to April 2014. An empirical study on management burdens was conducted using a cross sectional design, involving mailing questionnaires to 1460 patients with multimorbidity identified from the disease registers in general practice. The aim was to understand what management burdens are routinely reported by patients with multimorbidity, to test whether greater levels of multimorbidity predicted more management burdens and to explore the factors that predict management burdens in patients with multimorbidity. Data were analysed using descriptive statistics and regression modelling. Results: Ten studies were included in the systematic review, of which five were quantitative and the rest were qualitative. In general, the result suggested that patients with multimorbidity experience more management burdens compared to those with single conditions. The commonly reported issues were problems relating to access to primary care, interpersonal communication between patients and the healthcare provider, continuity and coordination of care, and a lack of support for self-management and issues relating to impact of care on their normal life. In the empirical study, 486 patients with multimorbidity returned the survey (33% response rate). The management burdens most often reported by patients related to lack of information about conditions and treatment options, poor communication among health professionals, and poor access to specialist care. There was a significant positive relationship between numbers of conditions, and reports of greater number of management burdens. In multivariate analysis, 5 variables predicted more management burdens: 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.Conclusion: There is evidence that patient with greater levels of multimorbidity experienced greater levels of management burdens. Further analysis of these factors may suggest what new models of service delivery might improve the experience of patients with multimorbidity.
Date of Award1 Aug 2017
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorPeter Bower (Supervisor)


  • Long term conditions
  • Comorbidity
  • Multimorbidity
  • Primary care
  • Management burden
  • Hassles

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