PT - JOURNAL ARTICLE AU - Monika Kastner AU - Leigh Hayden AU - Geoff Wong AU - Yonda Lai AU - Julie Makarski AU - Victoria Treister AU - Joyce Chan AU - Julianne H Lee AU - Noah M Ivers AU - Jayna Holroyd-Leduc AU - Sharon E Straus TI - Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review AID - 10.1136/bmjopen-2018-025009 DP - 2019 Apr 01 TA - BMJ Open PG - e025009 VI - 9 IP - 4 4099 - http://bmjopen.bmj.com/content/9/4/e025009.short 4100 - http://bmjopen.bmj.com/content/9/4/e025009.full SO - BMJ Open2019 Apr 01; 9 AB - Objectives To understand how and why effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.Design A realist review.Data sources Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.Eligibility criteria for selecting studies We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.Analysis We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.Results 106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, disease management programmes and case management; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients’ capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.Conclusions To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.PROSPERO registration number CRD42014014489.