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      Critical review of multimorbidity outcome measures suitable for low-income and middle-income country settings: perspectives from the Global Alliance for Chronic Diseases (GACD) researchers


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          There is growing recognition around the importance of multimorbidity in low-income and middle-income country (LMIC) settings, and specifically the need for pragmatic intervention studies to reduce the risk of developing multimorbidity, and of mitigating the complications and progression of multimorbidity in LMICs. One of many challenges in completing such research has been the selection of appropriate outcomes measures. A 2018 Delphi exercise to develop a core-outcome set for multimorbidity research did not specifically address the challenges of multimorbidity in LMICs where the global burden is greatest, patterns of disease often differ and health systems are frequently fragmented. We, therefore, aimed to summarise and critically review outcome measures suitable for studies investigating mitigation of multimorbidity in LMIC settings.




          People with multimorbidity.

          Outcome measures

          Identification of all outcome measures.


          We present a critical review of outcome measures across eight domains: mortality, quality of life, function, health economics, healthcare access and utilisation, treatment burden, measures of ‘Healthy Living’ and self-efficacy and social functioning.


          Studies in multimorbidity are necessarily diverse and thus different outcome measures will be appropriate for different study designs. Presenting the diversity of outcome measures across domains should provide a useful summary for researchers, encourage the use of multiple domains in multimorbidity research, and provoke debate and progress in the field.

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          Most cited references61

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          Frailty in Older Adults: Evidence for a Phenotype

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            Modeling valuations for EuroQol health states.

            Paul Dolan (1997)
            It has become increasingly common for preference-based measures of health-related quality of life to be used in the evaluation of different health-care interventions. For one such measure, The EuroQol, designed to be used for these purposes, it was necessary to derive a single index value for each of the 243 health states it generates. The problem was that it was virtually impossible to generate direct valuations for all of these states, and thus it was necessary to find a procedure that allows the valuations of all EuroQol states to be interpolated from direct valuations on a subset of these. In a recent study, direct valuations were elicited for 42 EuroQol health states (using the time trade-off method) from a representative sample of the UK population. This article reports on the methodology that was adopted to build up a "tariff" of EuroQol values from this data. A parsimonious model that fits the data well was defined as one in which valuations were explained in terms of the level of severity associated with each dimension, an intercept associated with any move away from full health, and a term that picked up whether any dimension in the state was at its most severe level. The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for the states for which no direct observations exist.
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              Short form 36 (SF36) health survey questionnaire: normative data for adults of working age.

              To gain population norms for the short form 36 health survey questionnaire (SF36) in a large community sample and to explore the questionnaire's internal consistency and validity. Postal survey by using a booklet containing the SF36 and several other items concerned with lifestyles and illness. The sample was drawn from computerised registers of the family health services authorities for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire. 13,042 randomly selected subjects aged 18-64 years. Scores for the eight health dimensions of the SF36. The survey achieved a response rate of 72% (n = 9332). Internal consistency of the different dimensions of the questionnaire was high. Normative data broken down by age, sex, and social class were consistent with those from previous studies. The SF36 is a potentially valuable tool in medical research. The normative data provided here may further facilitate its validation and use.

                Author and article information

                BMJ Open
                BMJ Open
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                6 September 2020
                : 10
                : 9
                : e037079
                [1 ] departmentUCL Respiratory , University College London , London, UK
                [2 ] departmentFamily Medicine , McMaster University , Hamilton, Ontario, Canada
                [3 ] departmentDepartment of Clinical Pharmacy & Pharmacology , University Medical Center Groningen , Groningen, The Netherlands
                [4 ] departmentDeptartment of Global Public Health , Karolinska Institutet , Stockholm, Sweden
                [5 ] departmentDepartment of Food, Nutrition and Dietetics , Uppsala University , Uppsala, Sweden
                [6 ] departmentDepartment of Food Studies, Nutrition and Dietetics , Uppsala University , Uppsala, Sweden
                [7 ] departmentDeptartment of Global Public Health , Karolinska Institutet , Solna, Sweden
                [8 ] departmentInternational Maternal and Child Health Division, Department of Women’s and Children’s Health , Uppsala University , Uppsala, Sweden
                [9 ] departmentSchool of Medicine and Public Health , The University of Newcastle , Callaghan, New South Wales, Australia
                [10 ] Hunter Medical Research Institute , New Lambton, New South Wales, Australia
                [11 ] departmentRespiratory and Environmental Epidemiology , Woolcock Institute of Medical Research , Sydney, New South Wales, Australia
                [12 ] departmentDivision of Thoracic Medicine, Department of Internal Medicine , Taipei Medical University Shuang Ho Hospital , New Taipei City, Taiwan
                [13 ] departmentResearch , The George Institute for Global Health , New Delhi, India
                [14 ] departmentFaculty of Medicine , University of New South Wales , Sydney, New South Wales, Australia
                [15 ] Prasanna School of Public Health , Manipal, India
                [16 ] departmentCRONICAS Centre of Excellence in Chronic Diseases , Universidad Peruana Cayetano Heredia , Lima, Peru
                [17 ] departmentMedicine , University of Ibadan College of Medicine , Ibadan, Nigeria
                [18 ] departmentSchool of Nursing, Faculty of Health , York University , Toronto, Ontario, Canada
                [19 ] Universidad Autónoma de Madrid , Madrid, Spain
                [20 ] Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP) , Madrid, Spain
                [21 ] departmentCentro de Investigación en Red de Enfermedades Respiratorias (CIBERES) , Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
                [22 ] departmentDepartment of Population Health and Department of Medicine , NYU Langone Health , New York, New York, USA
                [23 ] departmentGlobal Health Research Center , Duke Kunshan University , Jiangsu, China
                [24 ] departmentMedicine , University of Cape Town , Cape town, South Africa
                Author notes
                [Correspondence to ] Professor John R Hurst; j.hurst@ 123456ucl.ac.uk
                Author information
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                : 17 January 2020
                : 28 April 2020
                : 18 July 2020
                Funded by: Global Alliance for Chronic Diseases;
                Award ID: NA
                Global Health
                Original research
                Custom metadata

                primary care,public health,statistics & research methods,clinical trials
                primary care, public health, statistics & research methods, clinical trials


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