Multimorbidity

Multimorbidity is defined ‘as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others’. (Boyd and Fortin, p453)1 Traditionally, medicine has taken a single disease approach to the management of chronic conditions.1 However, as Boyd and Fortin among others2 3 suggest, such an approach to disease management is becoming increasingly untenable as greater numbers of people present with multiple conditions. In fact, as Violan et al 4 highlight, multimorbidity is now considered the norm rather than exception in primary care patients and some, including Salisbury,3 acknowledge that managing multimorbidity is the most important task facing health services in developed countries.

Risk factors and prevalence

Prevalence estimates of multimorbidity vary from country to country. For example, recent research in Australia suggests that 25.5% of the population live with multimorbidity,5 while in Scotland the prevalence of multimorbidity is reported to be 23.2%,2  and in Ireland 45.3% of the population are reported to have multimorbidity.6 Indeed, prevalence rates of multimorbidity vary between subsets of different populations and are often found to be higher for those people who attend medical services. For example, Fortin and colleagues found that 90% patients in primary care in Canada had more than one condition,7 while in an Irish study, 66.2% of patients in primary care had multimorbidity.8

Although prevalence rates vary across populations and groups, it is clear that increasing numbers of people are developing multimorbidity. The rise in multimorbidity is due in part to improving technology, advancements in medicine and better health policies.9 In terms of risk factors however, research has shown that the most reliable predictor of multimorbidity is age. For example, one study found that the prevalence of two or more co-existing medical conditions in the age groups of 18–44 years, 45–64 years, and 65 years and older were, 68%, 95% and 99% respectively.7 While multimorbidity is positively correlated with age, it must be noted that it is not only the burden of older generations, as Agborsangaya et al 10 found that 70.2% of their sample under the age of 65 live with multimorbidity. Risk factors, including socioeconomic status, adverse childhood experiences,6 poor physical activity and risky health behaviours (eg, smoking) are also important contributors to multimorbidity.3

Impact

Living with multiple chronic conditions has debilitating physical, psychological, social and financial consequences for a person and their family. Specifically, multimorbidity increases the risk of engagement with healthcare providers (ie, hospitalisations), loss of physical functioning, depression, anxiety, polypharmacy and ultimately has an impact on a person’s health related quality of life (HRQoL).11 12 HRQoL is a health outcome measure which is an indicator of an individual’s overall well-being, and it is typically used to assess the effectiveness of interventions; it is therefore a predictor of treatment success and it is increasingly used to support ‘allocation decisions in the healthcare sector’.13 Research has shown unequivocally that chronic disease has a negative impact on HRQoL11 12; and it has been found that having multiple chronic conditions has an exponential impact on a person’s well-being.13 Therefore, there is an interaction effect rather than a cumulative effect of multimorbid chronic conditions on HRQoL.13 Due to the increasing prevalence of multimorbidity and the burden of living longer with these conditions, the aim of improving HRQoL for people with multimorbidity has now become central to the focus of health practitioners.14

Chronic pain and multimorbidity

Chronic pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage’ that persists for a period in excess of 3 months.15 Chronic pain is a major public health problem that can have debilitating physical, emotional, psychological and financial consequences for those individuals living with it.16–18 Prevalence estimates for chronic pain vary,12–14 19 20 however one recent study found that 35.5% of the Irish population were living with chronic pain.14

Chronic pain is highly correlated with multimorbidity, and consistently appears as one of the most common conditions in those identified as having multimorbidity.5 For example, in one Canadian study that examined the prevalence of disease-combinations, sixteen common disease pairs were identified, with chronic pain appearing in six of the combinations. Further, from the five most common disease triads identified in the same study, chronic pain was involved in three of these combinations.5 Boyd and Fortin1 noted that if a person had one chronic condition they were quite likely to also have another. Considering that over a third of the Irish population are reported to have chronic pain, and chronic pain is highly correlated with multimorbidity, it is important that research accounts for the relationship between the two.

Psychological interventions for multimorbidity and chronic pain

Cognitive–behavioural therapy (CBT) is frequently used when a psychological treatment is required as part of a multidisciplinary rehabilitative process for people with chronic conditions and has been employed widely, for example, with people who live with chronic pain.8–13 Although CBT-based treatments are effective with many disorders, this is not the case for all conditions.21 As a result, research has investigated the effects of other psychotherapeutic approaches.22–24 Recently, acceptance and commitment therapy (ACT) has gained support for improving HRQoL in people living with chronic conditions.23 24

Whereas CBT focuses on the reduction of symptom-related distress, ACT promotes ‘psychological flexibility’ (ie, the ability to engage with the present moment in a way that facilitates long term values). From the perspective of ACT, increasing psychological flexibility for a person with a chronic condition is a multistep process established by six core principles: acceptance of all experiences, both positive and negative; recognition of core personal values; committed action towards those values; psychological defusion; emphasis on the present moment; and sense of self as a context.25 ACT has been used as a psychological intervention to improve functioning and quality of life for people living with numerous chronic conditions, including depression,26 tinnitus,27 diabetes,28 cancer,29 post-traumatic stress30 and chronic pain.31

Indeed, a recent systematic review in the area of chronic pain32 found that ACT interventions were effective when compared with inactive treatment comparisons for improving physical functioning and reducing distress. Another systematic review of ACT in the context of chronic disease and long-term conditions found promising evidence to suggest ACT can be efficacious as a treatment in a number of ways, including disease self-management, despite the low number of high quality research studies using ACT as an intervention.33

ACT online

Traditionally, psychotherapeutic interventions, such as ACT, have been administered face-to-face when a client meets with a therapist. This face-to-face approach, however, is subject to numerous constraints including direct and indirect costs, high labour demands, long waiting lists, mobility and accessibility issues, and shortages in appropriately trained healthcare professionals.34 35 The provision of one-to-one therapy is therefore not currently feasible for wide-scale health interventions. To negate these limitations, researchers have begun to administer psychological interventions online.21 36–41 These programmes provide standardised psychological treatment over the internet and are promising in their cost-effectiveness and accessibility, as results have shown them to be efficacious.41 For example, one recent randomised controlled trial examined the effectiveness of an online ACT intervention for people living with chronic pain.42 Participants were randomly assigned to an online treatment group for 7 weeks, or to a control group that participated in a moderated online discussion forum. Results showed that participants in the experimental group demonstrated increased activity engagement and willingness to experience pain and reductions were found on measures of pain-related distress, anxiety and depression. Furthermore, these improvements were maintained at a 6-month follow-up.42

Experimental group

The treatment protocol is almost identical to that used in a previous study by Hayes et al examining the clinical and cost effectiveness of an internet-delivered ACT intervention for people living with chronic pain.35 The intervention was derived from an ACT treatment manual specifically devised for people with chronic pain44 and adapted for online dissemination. Hayes et al utilised other resources45–47 and a team of healthcare professionals, including physiotherapists and clinical psychologists who specialise in chronic conditions and ACT treatments to revise the material so that it was modified accordingly and was suitable for online delivery.35 Thus, the online ACT treatment designed by Hayes et al is a robust adaptation and has been adopted for the purposes of the current research.

Appropriate changes to the content were made, so that the ACT programme designed by Hayes et al can be used in the current study for people with multiple conditions rather than for chronic pain only. The core concepts, homework, metaphors and mindfulness exercises, have for the most part, not been altered in any way. The only amendments necessary to the Hayes et al. ACT treatment programme were to alter the content that referred to symptoms of chronic pain specifically to instead refer to living with multimorbidity.

The experimental treatment will consist of eight sessions over an 8-week period and will be hosted on the NUI Galway, Centre for Pain Research Website. The programme will be delivered via an interactive online platform, and will consist of information, homework assignments, relevant metaphors and mindfulness exercises. The focus of this treatment protocol is on increasing psychological flexibility by developing acceptance, present-focused awareness and engagement in values-based action. An overview of the treatment is provided in table 1.

Over the course of the trial, participants in the experimental group will receive an automated weekly email reminder to complete each session. Adherence to the intervention will be monitored through login data. There is no clinician contact, and the programme is self-guided, with researchers only contacting participants (by phone or email) to prompt them should they fall behind. If a participant wishes to discontinue their involvement they will be withdrawn from the intervention and this will be reported as attrition. Technical questions and other queries are answered by email by the research team.

Waiting list control group

The waiting list control group will continue with their usual care, and will be contacted by the research team to complete questionnaires at 8 weeks postallocation and at 3 months follow-up. They will then be offered the opportunity to use the online ACT intervention following the 3-month follow-up assessment.

Demographic and clinical information

Participants will be asked to provide details regarding age, gender, highest educational attainment, occupational status and relationship status as well as number and type of chronic conditions and duration of their conditions (including Body Mass Index) using a multimorbidity checklist. Some details about previous and current medical and alternative treatment will also be collected.

Brief Pain Inventory-Short form

The Brief Pain Inventory (BPI)-Short form48 is a 9-item instrument that measures the interference and severity of a person’s pain and the impact of their pain on their daily functioning, and is a standardised and widely used measurement tool for assessing chronic pain. The first eight items ask the person to provide demographic information, medicinal measures to alleviate pain symptoms, to identify locations of pain and to rate their pain severity from 1 to 10 (10 being the most severe pain) on a visual analogue scale over the past 24 hours. Item 9 is further divided into seven sub-items, examining interference with function. The subitems can then be grouped into those assessing physical functioning (ie, general activity, walking ability and working ability), those assessing psychological functioning (ie, mood, relations with other people and enjoyment of life) and one item investigating the extent to which pain affects sleep. The BPI has demonstrated good construct validity, adequate internal consistency,49 Cronbach’s alpha, α=0.88 and acceptable test-retest reliability.50

Twelve-Item Short Form Survey

The 12-Item Short Form Survey (SF-12) is a standardised instrument used as a measure of HRQoL.51 A shortened version of the SF-36,52 it reduces participant burden while still providing sub-scale scores across eight health domains (general health, physical functioning, emotional role limitation, physical role limitation, mental health, bodily pain, vitality and social functioning). It also produces two summary scores, a Mental Component Summary and a Physical Component Summary of HRQoL53 with lower scores on these scales representing lower quality of life. Both the overall score and the summary scores will be analysed, although the overall score will be the one of interest as primary outcome.

Acceptance and Action Questionnaire II

The original Acceptance and Action Questionnaire (AAQ)54 has been used extensively with chronic conditions,29 55 56 and the AAQ-II53 is widely used in measuring psychological inflexibility and experiential avoidance. The AAQ-II is a 7-item questionnaire, in which participants rate their responses to each item on a 1–7 scale in terms of how likely they are to accept or avoid aversive thoughts and feelings (1=‘never true’ and 7=‘always true’). The higher the participant scores overall, the greater the level of psychological flexibility. While there have been criticisms of the AAQ-II54 it has good content, construct, convergent and predictive validity,49 and satisfactory reliability.57

Chronic Pain Acceptance Questionnaire-8

The Chronic Pain Acceptance Questionnaire-8 (CPAQ-8)58—a shortened version of CPAQ53—is an 8-item questionnaire and is rated on a scale from 0 to 6 (0=‘never true’ and 6=‘always true’). The questionnaire contains two subscales; pain willingness and activity engagement which are summed to indicate overall acceptance of pain. The CPAQ-8 has been validated in various populations,59 60 has adequate to good reliability and consistency with Cronbach’s alpha coefficients ranging from 0.69 to 0.86 and good test–retest reliability with an overall score correlation of 0.81.61

Multimorbidity Illness Perceptions Scale

The Multimorbidity Illness Perceptions Scale (MULTIPleS)62 was developed to measure patient illness perceptions in the context of multimorbidity. Illness perceptions are a person’s thoughts and feelings about their disease. The MULTIPleS is a 22-item questionnaire. The respondent indicates their level of agreement with each item on a Likert scale; the first 16 item scores range from 0 to 3, where ‘0’ indicates that a person ‘strongly disagrees’ with an item and ‘3’ indicates that a person ‘strongly agrees’ with an item, and the remaining six items range from 0 to 5. Overall, the 22 items comprise five subscales; emotional representation, treatment burden, prioritising conditions, causal link and activity limitations. We will analyse the responses to the MULTIPleS across our three time points to assess for change overall or in these subscales. The MULTIPleS is relatively new - Gibbons et al 62 found that the scale provided a good fit to the Rasch model and demonstrated evidence of reliability and validity for each of the subscales.

Patient Health Questionnaire-9

The Patient Health Questionnaire-9 is a widely used measure of depression.63 Items relate to the criteria for depression in the Diagnostic and Statistical Manual of Mental Disorders (Version 5), and are scored on a 4-point Likert scale, ranging from 0 (‘not at all’) to 3 (‘nearly every day’). Higher scores indicate the person meets more of the symptom criteria, scores above 10 indicates moderate depression and scores above 15 indicates a clinical case of moderately severe depression. It has been used and validated with chronic condition populations.17

General Anxiety Disorder-7

The General Anxiety Disorder 7 (GAD-7) a validated and standardised measure, will be used to measure anxiety.64 The 7-item questionnaire presents items relating to how often over the past couple of weeks a person has felt bothered by the seven DSM V criteria symptoms of generalised anxiety disorder. Items are scored on 4-point Likert scales ranging from 0 ‘not at all’ to 3 ‘nearly every day’. A higher overall total score indicates greater symptom severity.

Client Services Receipt Inventory

The Client Services Receipt Inventory (CSRI)65 has been used widely in research examining the cost of chronic pain18 66 67 and has been shown to be a valid measure of frequency of health service use.68 Medication and health service use will be measured at baseline, post-treatment and follow-up, using a modified version of the CSRI. As medication use will most likely vary throughout the trial, change in medication use (including prescribed and over-the-counter medications) will be examined in post-treatment analysis.