The EGPRN new concept of multimorbidity in General Practice. The

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Research projects,
information, reports
projekty badawcze –
informacje, raporty
Keywords:
The EGPRN new concept of multimorbidity
in General Practice. The Polish study
Słowa kluczowe:
Nowa koncepcja wielochorobowości według Europejskiej Sieci
Naukowej Lekarzy Rodzinnych. Badania polskie
multimorbidity, general
practice, epidemiology
wielochorobowość,
medycyna rodzinna,
epidemiologia
Medical College, Nicolaus Copernicus
University, Toruń, Poland
S. Czachowski, MD, PhD
[email protected]
Department of General Practice,
Université de Bretagne Occidentale,
Brest, France
J.Y. Le Reste, MD, [email protected]
P. Nabbe
J. Deriennic
Department of English, Nicolaus
Copernicus University, Torun, Poland
A. Sowińska, PhD, [email protected]
University of Zagreb, Croatia
D. Lazic, MD PhD
Associazione Italiana Medici di Famiglia
(AIMEF), Bologna, Italy
C. Lygidakis, MD
Allegemein Medizin Hochschule
Hannover, Hannover, Germany
H. Lingner, MD
University of Plovdiv, Bulgaria
R. Assenova, MD
The Greek Association of General Practitioners (ELEGEIA), Thessaloniki, Greece
S. Argyriadou, MD
Allegemein Medizin Hochschule
Göttingen, Göttingen, Germany
C. Doerr, MD
Vigo University, Vigo, Spain
A. Claveria, MD
IDIAP Jordi GOL Unitat de Support
a la Recerca, Barcelona, Spain
M. Munoz, MD
VU University Medical Center,
Amsterdam, The Netherlands
H. Van Marvijk, MD, PhD
Department of Public Health, Université
de Bretagne Occidentale, Brest, France
C. Lietard, PhD
Department of Primary and
Interdisciplinary Care, Faculty
of Medicine and Health Sciences,
Universiteit Antwerpen, Belgium
P. Van Royen, MD, PhD
CORRESPONDENCE ADDRESS:
Dr n. med. Sławomir Czachowski
ul. Grabowa 10, 87-100 Toruń
[email protected]
mobile +48 605427566
RECEIVED: 18.11.2013
ACCEPTED: 05.12.2013
Czachowski S, Le Reste JY, Sowińska A, Nabbe P, Lazic D, Lygidakis C,
Lingner H, Assenova R, Argyriadou S, Doerr C, Claveria A,
Deriennic J, Munoz M, Van Marvijk H, Lietard C, Van Royen P
Abstract: Introduction. Multimorbidity, according to the World Health Organization, exists when patients
suffer from two or more chronic conditions. General practitioners (GPs) consider this concept inaccurate for
the holistic approach to the patient. The European General Practitioners Research Network (EGPRN) prepared
a new definition of multimorbidity, which was next translated into European languages. Aim. To introduce
the forward and backward translation of the English definition of multimorbidity into the Polish language.
Design and Setting. Forward translation of the English definition of multimorbidity into Polish and backward
translation in Toruń, Poland. Method. Delphi procedure: 30 GPs were asked to rank the translation from 1
(absolutely disagree) to 9 (fully agree) and to explain each rank under 7. Result. 83% of 30 GPs agreed on
the translation. 25 gave 7 points or more on the scale and 5 assessed the translation as below 7 points. The
consensus was achieved after the first round although several linguistic corrections were suggested. After
considering all remarks, the final version was sent to the EGPRN study scientific board. Discussion. GPs in
Poland use officially the ICD-10 coding system which does not always fit in primary care. The new definition
is based on a broad spectrum of factors which impact the patient’s condition. It is a challenge for Polish GPs
to accept the new definition. Conclusion. The new definition is closely related to primary care and can be
useful in Long Term Care.
Streszczenie:
Wstęp. Wielochorobowość (MM), według Światowej Organizacji Zdrowia (WHO),
występuje w przypadku zaistnienia dwóch lub więcej chorób przewlekłych. Europejska Sieć Naukowa
Lekarzy Rodzinnych (EGPRN) uważa tę definicję za nieadekwatną w zakresie holistycznego podejścia wobec
pacjenta. EGPRN przygotowała nową definicję MM, która została przetłumaczona na różne języki Europy.
Cel. Przedstawienie polskiej wersji definicji MM po zwrotnym tłumaczeniu z języka angielskiego. Metoda
i miejsce badania. Tłumaczenie definicji MM z języka angielskiego na polski wraz z tłumaczeniem zwrotnym.
Miejsce tłumaczenia: Uniwersytet Mikołaja Kopernika w Toruniu. Materiał i metodyka. Wykorzystano
metodę Delphi. 20 lekarzy rodzinnych oceniało tłumaczenie w skali od 1 (całkowicie nie zgadzam się) do 9
(całkowicie zgadzam się), z prośbą o komentarz, jeśli ocena była poniżej 7. Wyniki. 83% lekarzy rodzinnych
zaakceptowało tłumaczenie. 25 badanych wyceniło proces na 7 punktów i więcej, a 5 osób oceniło tłumaczenie
poniżej 7. Konsensus został osiągnięty po pierwszej rundzie Delphi, jakkolwiek zasugerowano kilkanaście
poprawek lingwistycznych. Po uwzględnieniu wszystkich uwag, ostateczną wersję polskiego tłumaczenia
wysłano do komitetu naukowego EGPRN. Dyskusja. Lekarze rodzinni w Polsce stosują formalnie ICD-10 do
kodowania chorób, który to model nie zawsze jest dostosowany do pracy w podstawowej opiece zdrowotnej.
Nowa definicja uwzględnia szerokie spectrum czynników wpływających na stan pacjenta. Nowa definicja MM
jest wyzwaniem dla lekarzy rodzinnych w Polsce. Wniosek. Nowa definicja MM jest ściśle związana z pracą
w podstawowej opiece zdrowotnej i może być użyteczna w zakresie opieki długoterminowej.
(Probl Med Rodz 2014;3(43):77–80)
Introduction
Multimorbidity is a challenging concept for
General Practice and it is important to clarify
its definition throughout Europe. The concept
was first established in 1976 in Germany and
remained restricted to German publications
for 14 years1. Between 1976 and 1990 only 72
PROBLEMY MEDYCYNY RODZINNEJ, MARCH 2014, VOL. XV, No. 3
articles had multimorbidity within their content and 66 out of them were written in German. Since 1990, the multimorbidity concept
has got an international interest, although it
was an addition to the notion of co-morbidity2.
Comorbidity was defined as any disease or
risk factors that could interact with one main
disease with the effect of deterioration3. The
77
Research projects, information, reports
projekty badawcze – informacje, raporty
World Health Organization (WHO) has defined multimorbidity as a state where people are affected by two
or more chronic conditions4. The tendency was to look
at all conditions in one individual that could impact on
that individual’s global health status. The word “condition” in that case was not clear enough for practical purposes and could have evoked many interpretations.
Multimorbidity could be the main problem in the
context of the increasing prevalence of chronic illness
in an ageing population across Europe and all developed countries. It is closely related to a global functional
patient’s centred view, which is a core competency of
General Practice as defined, for instance, by the World
Organization of National Colleges, Academies and Academic Associations of Family Physicians (WONCA)5.
Multimorbidity could help modelling and restructuring health care with a view to provide greater support
for the patient: a new health care challenge6. It is also an
important concept when applied to patients, as it gives
an overview of all the factors that could lead to frailty7.
Frailty is a new concept formulated to help GPs to identify decompensating patients, especially in Long Term
Care. The link between multimorbidity and frailty has
already been discussed8.
The European General Practice Research Network
(EGPRN) workgroup has emphasized the necessity of
a new definition of multimorbidity. The new definition,
which would be understandable and usable for further
collaborative epidemiologic research, could advance
methodological and instrumental research in primary
care throughout Europe. It would support the development of primary care epidemiology with respect to
patient’s oriented health9. It would help researchers in
general practice investigate the complexity of patients’
conditions and their overall impact on patients’ health.
This definition of multimorbidity could be an additional
tool for the identification of frail patients with the aim to
prevent decompensation.
A research team including 8 European national
research groups all active within the EGPRN has created
a research community in order to clarify the multimorbidity concept for Family Medicine throughout Europe.
Their first hypothesis was that researchers should
have established what constituted a multimorbid patient
within their research using clear inclusion criteria. The
review of the scientific literature (published between
01/01/1990 and 12/31/2010) according to PRISMA
guidelines10 could lead the way to a clearer definition.
Having identified 416 abstracts and selected 68 out of
78
them, 54 articles were included and revealed 1631 criteria11. These criteria’s analysis led to the following definition (see Table III).
The second hypothesis of the EGPRN research group
was that GPs could use a concept of multimorbidity that
differs from those of other specialists. They are justified
in doing so because they appear to be more in line with
the patient’s expectations about chronic illnesses like
depression12. Qualitative research throughout Europe
could then lead to the identification of new concepts for
multimorbidity. In order to do that the translation into
each native language had to be undertaken using a Delphi procedure13 in each participating country.
Research question
What is the forward and backward translation of the
English definition of multimorbidity into the Polish
language?
Method
The forward and backward translation of the original
English definition has been done using a Delphi consensus procedure. First, two translators (one medical and one
official translator) were asked to translate the definition
from English into Polish. The next stage was to send the
English definition of multimorbidity and its translation
into Polish by email to 30 Polish GPs from all over Poland.
Those GPs were known to be English-speaking experts
and to be involved in research activity. Each participant
was contacted separately to avoid contamination, which is
the basic methodology for Delphi procedure.
All experts were then asked to assess the equivalence
of the translations on the scale from 1 (absolutely no
agreement) to 9 (full agreement) and had to write down
their remarks and opinions for each rank under 7. Consensus was defined as at least 70 % of the participants
rating 7 or above the consensual definition. Once the
consensual definition in Polish had been established
two other translators did a backward translation from
Polish into English and send it for agreement to the scientific committee of the study.
Results
Thirty GPs (15 males and 15 females) participated
in the study. All participants had a good or very good
command of English and most of them were involved
in research activity (see Table I). 25 (83%) voted at least
7 points or higher for agreement and 5 wrote negative
assessment, below 7 (17%) points. The high consensus
over the translation allowed to stop making another
round of Delphi procedure (see Table II).
Table I. Participants of the Polish translation procedure
Polish participants
Number
Average age
Average number of years in practice as a GP
Average number of English publications
Average number of other publications
Gender
Male
15
45.2
12.6
1.7
4.2
Female
15
42.1
11.8
1.7
4.2
Table II. Achieved agreement among Polish GPs using Delphi method
Statement Round 1 N=30 Round 2 Round 3 Result Round
Nb CP (%) Nb CP Nb CP
(%)
(%)
1
30
83
A
A A
A Accepted
1
2
30
83
A
A A
A Accepted
1
3
30
83
A
A A
A Accepted
1
Nb: Number of participants’ comments for accepted or rejected statement.
CP: Consensus percentage (number of votes equal or above 7) for accepted
statement, should be above 70% to be accepted.
A: Accepted (no further round).
Minor linguistic alterations were proposed by the
experts who accepted the translation (gave more than 7
points). These concerned mainly two concepts: “somatic”
and “weakness”, and did not change the whole structure
of definition of multimorbidity (see Table III).
Table III. Changes proposed by Polish participants
Notion
“somatic”
Proposed changes
Two experts (GP 2, 26) suggested removing the word
“somatic” from the Polish definition on the grounds that
it was not considered a medical condition by some GPs.
“weakness” Two experts indicated the need to specify the term
“weakness” as “handicap” (“upośledzenie”) (GP 21) or
“a bad state of mind” (“złe samopoczucie”) (GP 17).
The remarks were next considered by the Polish
research team (SC, AS) and the following translation of
the definition of multimorbidity was finally proposed:
Wielochorobowość jest definiowana jako jakiekolwiek połączenie choroby przewlekłej z przynajmniej
jeszcze jedną chorobą (ostrą lub przewlekłą) lub z czynnikami bio-psycho-społecznymi (związanymi z nią lub
nie) lub z czynnikami ryzyka.
Jakikolwiek czynnik bio-psycho-społeczny, czynnik
ryzyka, sieć społeczna, obciążenie chorobami, korzystanie z opieki zdrowotnej i strategie radzenia sobie przez
pacjenta mogą funkcjonować jako modyfikatory.
Wielochorobowość może modyfikować wyniki zdrowotne i prowadzić do zwiększonej niepełnosprawności
lub obniżenia jakości życia lub osłabienia.
The Polish team and the experts agreed that these
statements best reflect the cultural values in the Polish translation of the definition of multimorbidity
(see Table IV).
Finally, the backward translation was accepted by the
scientific committee of the study (PvR, HM, JYLR, PN,
CL) and the leaders of the national groups during the
EGPRN meeting in Antwerp in October, 2012. No further changes were required.
Table IV. The original English definition and the back translation
of the final Polish version
Polish final version translated
into English
English original version
Multimorbidity is defined as any
combination of a chronic disease
with at least one more disease
(acute or chronic) or with biopsycho-social factors (related to
it or not), or with risk factors.
Multimorbidity is defined as
any combination of chronic
disease with at least one other
disease (acute or chronic) or
biopsychosocial factor (associated
or not) or somatic risk factor.
Any bio-psycho-social factor,
any risk factor, the social
network, the burden of diseases,
using health services, and the
patient’s coping strategies may
function as modifiers.
Any biopsychosocial factor, any
somatic risk factor, the social
network, the burden of diseases,
the health care consumption and
the patient’s coping strategies
may function as modifiers (of
the effects of multimorbidity).
Multimorbidity may modify
health results and lead to
an increased disability or
a decreased quality of life, or
weakness.
Multimorbidity may modify
the health outcomes and lead
to an increased disability or
a decreased quality of life or
frailty. Discussion
The study is a consecutive stage of the EGPRN project which aims to provide a comprehensive definition
of multimorbidity throughout Europe. The literature
review led to a new definition, which is usable for further research stages14.
The main finding of the study is the Polish translation of the English definition of multimorbidity and its
English backward translation. The translation makes
provision for the cultural background in which GPs
cope with problems in their practices, and forces the
holistic approach to the patient.
Family medicine was implemented in Poland in 1994.
Under communism Polish GPs were not familiar with
the holistic approach, and the medical language that
would reflect mental or social aspects of the patient’s
health was virtually non-existent. The only coding sys-
79
tem that GPs used was ICD-10 in which the bio-psycho-social model of treatment is not considered. The
Polish experiences were thus very limited15. Since the
notions, such as frailty or social network are missing from the Polish medical literature finding the
right expressions and assessing the equivalence of
the translations posed a great challenge. In the light
of an increasing number of elderly patients and Polish migrants across Europe16 introducing the Polish
translation of the new definition of multimorbidity is
a necessary and relevant step.
The GPs’ preference for “weakness” rather than
“frailty” may possibly be explained by the focus on why
people are weak rather than why they lack a social network and feel frail. The attribute “somatic” (risk factor)
was also omitted in the Polish translation of the definition on the grounds of not being a medical “condition”
and not really an illness. The study has shown that a psychosocial impact on the patient, which encompasses
thoughts, emotions, and behaviours, wasn’t anticipated
enough by Polish GPs, despite a strong presence in the
world literature17.
A limitation of this study is a relatively low number
of publications by the participating GPs. However, it
should be observed that General Practice is new in
Poland and so there are few publishers in General
Practice. The introduction of a new concept of multimorbidity in Poland, which is currently missing, is
an important implication of the study as it improves
Polish GPs’ awareness of multimorbid patients. It
can also play a role in Long-Term Care when considering the management of chronic patients18.
Conclusions
The Polish national team has finalized the Polish version
of the published English definition of multimorbidity.
The implementation of the new definition is
intended to help Polish GPs to identify multimorbid patients. It is also important for Long-Term Care
Physicians as well as policy makers to plan an optimal
management of patients, and to lower the burden of
multimorbidity19.
The Polish translation enables the research team to
proceed to the next step, which is qualitative research,
in order to find the added value by GPs in the concept of multimorbidity. This will be achieved by using
a grounded theory analysis and a deductive analysis
from the translated definition of multimorbidity. Then
an International Classification Primary Care code will
be put forward to the ICPC committee of the WONCA20
for further implementation into databases.
Acknowledgement
We thank all Polish GPs who participated in the Delphi procedure.
Ethical issues
The Ethical Committee of the Kujavian-Pomeranian
Doctor’s Chamber Nr 35/KB/2012 has accepted the
project.
Competing Interest statement
All Authors assure that they have no competing
interest with this article.
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