Poster Abstracts

Comparison of comorbidity status and eligibility to participate in navigation intervention projects in an elderly patient population in Brandenburg

Dr. Kathrin Gödde¹; Susanne Schulze¹; Sandra Wendlandt²; Oliver Schäfer³; Prof. Dr. Christine Holmberg¹

¹Brandenburg Medical School Theodor Fontane; ²Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin; ³University Hospital of Brandenburg an der Havel

Background: Coordination of care can be challenging for patients in the fragmented German healthcare system, especially for elderly patients and patients with comorbidities. Therefore, a variety of care coordination interventions have been developed and evaluated in Germany that often focus on single diseases. Here, we want to investigate to which degree eligibility to participate in these care interventions overlaps in patients with multimorbidity.

Methods: We performed an internet and literature search to identify care coordination interventions in Germany. Additionally, we performed a secondary analysis of routine data from 2022 of an elderly patient population (>65 years) from a hospital in Brandenburg to investigate the comorbidity status. Finally, we will compare diagnosis-related inclusion criteria of the identified studies with patient comorbidity data to identify the number of projects these patients would be eligible for.

Results: The internet and literature search identified 32 care interventions that mainly focused on single diseases (e.g. stroke, diabetes) or disease groups (e.g. cardiovascular diseases). The sample patients (N=8059) were on average 77.8 years old (SD = 7.88 years), had 1.4 hospital stays in 2022 (SD = 0.99) and 49.6 % were female. Further analyses of eligibility overlap will be presented for this population.

Conclusion: Expected results will give insights about the eligibility overlap to participate in coordination of care interventions for patients with multimorbidity and could therefore support a resourceful implementation of such interventions.

Network of Doctors for Multimorbidity and Diabetes – The NOMAD Intervention: Protocol for feasibility trial of multidisciplinary team conferences for people with diabetes and multimorbidity

Stine Jorstad Bugge^1,2,3, Daniel Pilsgaard Henriksen^1,2,3, Per Damkier^2,3 , Martin Torp Rahbek^2,4, Karoline Schousboe^1,3, Mette Juel Rothmann^1,3, Marianne Kjær Poulsen^1,3, Camilla Hansen¹, Subagini Nagarajah^3,5, Per Bruno Jensen^3,5, Sofie Lock Johanson^3,6, Vasiliki Panou^3,6, Ida Ransby Schneider^3,7, Charlotte Gjørup Pedersen^8,9, Jonas Dahl Andersen^10,11, Jørgen Hangaard^1,3, Ann-Dorthe Olsen Zwisler^3,7,12

¹Steno Diabetes Centre Odense, Odense University Hospital, Odense, Denmark; ²Department of Pharmacology, Odense University Hospital, Odense, Denmark; ³Department of Clinical Research, University of Southern Denmark, Odense, Denmark; ⁴Department of Public Health, University of Southern Denmark, Odense, Denmark; ⁵Department of Nephrology, Odense University Hospital, Odense, Denmark; ⁶Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark; ⁷Department of Cardiology, Odense University Hospital, Odense, Denmark; ⁸Steno Diabetes Centre Aarhus, Aarhus university Hospital, Aarhus, Denmark;⁹Department of Public Health, Aarhus University, Aarhus, Denmark; ¹⁰Steno Diabetes Centre Northern Jutland, Aalborg University Hospital, Aalborg, Denmark; ¹¹Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; ¹²REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark

Background: Prevalence of diabetes and coexisting multimorbidity rises worldwide. Providing evidence-based, coherent and patient-centred care for multimorbid patients pose challenges in healthcare systems, which typically deliver disease-specific care. We propose an intervention comprising multidisciplinary team conferences (MDTs). The MDT consists of medical specialists in five specialities meeting biweekly to discuss multimorbid patients. This protocol describes a study aiming to feasibility test MDTs designed to coordinate care and improve quality of life for people with diabetes and multimorbidity.

Methods: A mixed-methods one-arm feasibility test of the MDT. Feasibility will be assessed through prospectively collected data. We will explore patient perspectives through patient-reported outcomes (PROs) and assess feasibility of electronic questionnaires. Feasibility outcomes are recruitment, PRO completion, technical difficulties, MDT impact and clinician preparation time. During 17 months we recruit up to 112 participants. Results are reported narratively and with descriptive statistics. The study will precede a future large-scale randomised trial.

Discussion: Multidisciplinary approaches focusing on better management of multimorbid diabetic patients may improve functional status, quality of life and health outcomes. Multimorbidity and diabetes are highly prevalent in our healthcare system, but we lack solid evidence-based approaches to patient-centred care for these patients. This study represents initial steps towards building such evidence. The concept can be efficiency tested in a randomised setting, if found feasible to intervention providers and receivers. If not, we will have gained experience on how to manage diabetes and multimorbidity and organisational aspects, which together may generate hypotheses for further research on multimorbidity care.

Care model for patients with complicated multimorbidity (CIM2) – preliminary results of a pilot RCT study

Sanne Lykke Lundstrøm¹; Barbara Ann Barrett²; Iben Charlotte Aamann¹; Anne Frølich^{2 1}

¹NSR Hospital & Bispebjerg- and Frederiksberg Hospital; ²NSR Hospital

Background: Managing care for patients with complex multimorbidity demands an integrated, patient-focused approach, yet organizing healthcare services for such cases continues to pose significant challenges. In response, our team developed the ""complex intervention for multimorbidity"" (CIM), which we have since advanced to CIM2 following a feasibility study. The effectiveness of CIM in delivering comprehensive care has been recognized, culminating in its incorporation into the 2022-2024 agreement between Danish Regions and the Danish Organization of General Practitioners.

Aim: Our study aims to evaluate CIM2 through a pilot Randomized Controlled Trial (RCT), detailing our experiences in recruiting practices and patients, and sharing early findings.

Methods: We recruited fourteen general practices from two Danish regions, randomly assigning them to either the CIM2 intervention or a control group. The intervention group received special training to offer patient-centered care through extended consultations for patients with complex health conditions. Data were collected at baseline, 6, and 12 months, including interviews with both patients and healthcare professionals.

Results: Early findings, based on patient assessments and questionnaires, alongside descriptions of the recruitment process, indicate CIM2's potential to improve care quality for patients with complicated multimorbidity.

Conclusion: This pilot RCT of CIM2 represents a significant step towards enhancing patient-centered, integrated care, contributing to better healthcare outcomes for individuals with complex needs. Our findings offer insights into the initial effectiveness of the CIM2 model and its contribution to ongoing efforts to improve care for this challenging patient group.

Addressing multimorbidity with a local, personalized care management approach - Insights from the randomized controlled LoChro-trial

Gloria Metzner; Lukas Maximilian Horstmeier; Sebastian Voigt-Radloff; Erik Farin-Glattacker

Section of Health Care Research and Rehabilitation Research, Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg

Background: Multimorbidity presents a challenge for modern healthcare. Several care approaches have been developed, but often focused on single diseases.

Objective: This study assessed the effectiveness of a new local, personalized care-approach (LoChro-Care) for patients with multiple chronic diseases in comparison to usual care (control group, CG).

Method: The randomized controlled trial included 524 participants (aged 65+). LoChro-Care consists of a structured assistance to enhance patients’ self-management in coordination their supportive network, provided by trained chronic care managers for 12 months (intervention group, IG). Patients’ functional health was assessed using the WHODAS, depressive symptoms by the PHQ-9, and patients’ degree of multimorbidity with the weighted index by Tooth et al. (2008). Data analyses was conducted with linear-mixed-models.

Results: The results indicate no significant difference between IG and CG (WHODAS: p=.52; PHQ-9: p=.65). In both groups, the functional (WHODAS: b=11.04, p < .001) and mental health status (PHQ-9: b=4.82, p=.02) significantly worsened over time. Patients’ degree of multimorbidity was a significant predictor for this decline in functional (WHODAS: b=1.59, p < .001) and mental health (PHQ-9: b=.91, p < .001) in both groups.

Discussion: Results did not reveal any significant improvements of LoChro-Care over usual care. One potential explanation might be that our sample was already highly burdened so that self-management support alone could not succeed in improving health status. Future supportive care approaches should reach patients earlier and proactively provide case management strategies.

Understanding the scope of deprescribing in a shared decision setting: A subanalysis of the COFRAIL Study

Veronika Bencheva¹; Matthias Gogolin¹; Prof. Sven Schmiedl¹; Prof. Achim Mortsiefer¹; Prof. Stefan Wilm²; Anja Wollny³; Eva Drewelow³; Manuela Ritzke³; Prof. Attila Altiner⁴; Prof. Andrea Icks²; Jens Abraham⁵; Birgitt Wiese⁶; Prof. Petra Thürmann¹

¹University of Witten/Herdecke; ²Heinrich-Heine-University Düsseldorf ; ³University Medical Centre Rostock; ⁴Heidelberg University; ⁵Martin Luther University Halle-Wittenberg; ⁶Hannover Medical School

Introduction: Multimorbidity and polypharmacy frequently correlate with negative outcomes such as adverse drug effects, falls and hospitalizations. Implementing deprescribing into the treatment regimen may lead to minimizing these outcomes.

Method: In the COFRAIL study (a clusterRCT) 114 general practitioners (GPs) and 623 frail (Rockwood scale 5-7), elderly ( ≥ 70 years) outpatients with polypharmacy ( ≥ 5 drugs/d) were enrolled. The intervention consisted of 3 family conferences (FK), where deprescribing was conducted utilizing a manual developed for this study. In this subanalysis, we obtained the medication plans of a randomly selected group of patients within the intervention group (IG) before and after the 1st and 2nd FK and analysed them focusing on documented medication adjustments in the medication regimes.

Results: The analysis involved n = 177 IG patients of whom medication plans were available with a mean age of 83.4 ± 5.9 years (68% females) who received 10.4 ± 3.9 drugs. In the IG 2.4 ± 2.1 medications per patient were deprescribed, resulting in a significant (p < 0.001) reduction of 1.4 ± 2.0 drugs per patient. Furthermore, in 0.8 ± 1.0 drugs per patient dosages were reduced. The most frequently deprescribed drugs were those for the treatment of gout, statins and proton-pump inhibitors with withdrawal rates of 55%, 45%, and 31%, respectively.

Conclusion: This subanalysis enhanced our understanding of treatment patterns and clinical decision-making processes in the target group by showing different deprescribing potentials for the observed medication groups. It may be used in developing future treatment strategies.

An educational intervention on multimorbidity and polypharmacy: Assessment of 5 editions of the eMULTIPAP course

Francisca Leiva-Fernández¹; Marcos Castillo-Jiménez²; Aída Moreno-Juste³; Josefa Bujalance-Zafra⁴; Antonio Gimeno-Miguel⁵; Isabel Del Cura-González⁶; Juan Antonio López-Rodríguez⁷; Paula Ara-Bardají⁸; MULTIPAP Group

¹Multiprofessional Teaching Unit of Community and Family Care. Málaga-Guadalhorce Health District. Málaga, Spain.Group C-08 Biomedical Research Institute of Málaga(IBIMA).RICAPPS, ISCIII.; ²Dept of Pharmacology and Paediatrics,School of Medicine,University of Malaga.Group C-08 Biomedical Research Institute of Málaga(IBIMA).Primary Care Health Centre Campillos, Northern Málaga Integrated Healthcare Area, Andalusian Health Service. Spain ; ³EpiChron Research Group, IACS, IIS Aragón, Miguel Servet University Hospital. San Pablo Primary Care Health Centre, Aragon Health Service (SALUD), Zaragoza, Spain. RICAPPS, ISCIII; ⁴Group C-08 Biomedical Research Institute of Málaga (IBIMA), Málaga, Spain. Primary Care Health Centre Victoria, Health District Málaga-Guadalhorce, Andalusian Health Service, Málaga, Spain; ⁵EpiChron Research Group, IACS, IIS Aragón, Miguel Servet University Hospital, 50009 Zaragoza, Spain. RICAPPS, ISCIII.; ⁶Research Unit, Primary Care Assistance Management, Madrid Health Service. Dept of Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University. IIS Gregorio Marañon(IiSGM). RICAPPS, ISCIII. Madrid, Spain; ⁷Research Unit,Primary Care Assistance Management,Madrid Health Service.Dept of Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University. IiSGM .RICAPPS,ISCIII. Ricardos General Health Center,Madrid Health Service. Spain; ⁸EpiChron Research Group, IACS, IIS Aragón, Miguel Servet Univesity Hospital. Zaragoza, Spain. RICAPPS, ISCIII.francisca.leiva.sspa@juntadeandalucia.es Malaga ES Distrito Sanitario Malaga-Guadalhorce

Multimorbidity (MM) is a widespread problem and it poses unsolved issues like the healthcare professionals’ training. A training curriculum has been proposed, but it has not been sufficiently explored in a clinical context. The eMULTIPAP course was first developed as part of the MULTIPAP complex intervention, applied through a pragmatic controlled, cluster randomized clinical trial to general practitioners (GP) and his/her patients with MM with 12 months follow-up. It has also been applied in other research context and usual practice conditions. The eMULTIPAP course is based on problem-based learning, constructivism and Ariadne principles, which its main objective is to review the international recommendations for dealing with MM and polymedication in primary care, minimizing as far as possible the safety problems for the patient. It has been assessed according to the Kirkpatrick model, considering 4 levels of evaluation: Reaction, Learning, Behaviour and Results. The results have shown high student satisfaction, knowledge improvement and high applicability of learning with more motivation to consider MM in the clinical practice all over the five editions. It has also been related with an improvement in the Medication Appropriateness Index at 6 months and at 12 months. The contents have been adapted according to the students' suggestions, which has been reflected in learning gains. We conclude that the eMULTIPAP course generates significant changes in GP’s learning, enhancing clinical practice in multimorbidity scenarios. These results have been published in a report in Spanish: ISBN 978-84-09-53990-1

Primary healthcare nurses as facilitators for the participation and self-care of patients with complex chronic conditions. Barriers and enablers

Marcus Heumann¹; Dr. Gundula Röhnsch²; Dr. Edurne Zabaleta-del-Olmo³; Prof. Dr. Beatriz Rosana Gonçalves de Oliveira Toso⁴; Prof. Dr. Ligia Giovanella⁵; Prof. Dr. Kerstin Hämel¹

¹Bielefeld University; ²Freie Universität Berlin; ³Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol I Gurina (IDIAPJGol); ⁴Western Paraná State University—UNIOESTE; ⁵National School of Public Health, Fundação Oswaldo Cruz

Background: Offering person-centred care for patients with complex chronic conditions challenges healthcare systems worldwide. Strong multiprofessional primary healthcare (PHC) can contribute by addressing the multiple social and health needs of patients with chronic conditions and multimorbidity. PHC nurses are increasingly responsible for chronic care and participation support in models of team-based care. It is therefore important to strengthen their abilities to support patient participation and self-care.

Aim: To identify barriers and enablers PHC nurses face when supporting the participation of patients with complex chronic conditions.

Method: We conducted interviews with 34 practicing PHC nurses and 23 key informants in Brazil, Germany, and Spain. The data were analysed from a cross-country perspective using thematic coding.

Results: Four categories for barriers and enablers emerged. They refer to (1) nurses’ ability to build “bonds” with patients and foster trusting relationships; (2) their approach to strengthening the resources for self-care in patients’ families; (3) in how far nurses’ engagement towards patient participation is supported by other professions in the PHC team; and (4) to what extent nurses are facilitated to engage in participation support by their work environment, e.g., technical infrastructure and time to have conversations with patients.

Conclusion: PHC nurses are challenged to address the support needs of patients with complex chronic conditions and engage in patient participation and self-care, as these patients and their families are often overwhelmed by the complexity of chronic care. PHC nurses also see chances for tailored healthcare provision through the participation of patients with complex chronic conditions.

Prevalence of multimorbidity and needs for intervention in people aged 65 and older in the nationwide study 'Gesundheit 65+'

Dr. Judith Fuchs; Dr. Beate Gaertner

Robert Koch Institute

Introduction: Multimorbidity (MM) is one of the most important and challenging aspects in public health and is associated with physical and mental health disorders, frailty, hospital admissions and polypharmacy.

Methods: 'Gesundheit 65+' is a population-based longitudinal epidemiological study on the health situation of people aged 65 years and older in Germany. Based on two-stage stratified random sampling from 128 local population registries 3,694 individuals participated in the baseline survey (response 30.9%) between June 2021 and April 2022 (47.9% women, mean age 78.8 years). MM was defined as the presence of 2 or more diseases and health problems (yes vs. no) from a list of 11 chronic diseases and health problems (self-reported 12-month prevalence of hypertension, coronary heart disease, stroke, hypercholesterolemia, diabetes, chronic bronchitis, osteoarthritis, osteoporosis, lower back complaints or other chronic back complaints, depression and life-time cancer).

Results: Overall, 48.9% of the participants were multimorbid, women more often (53.6%, CI 50.4-56.8) than men (43.0%, CI 39.7-46.4) and the prevalence was significantly higher in older individuals. Women and men with MM reported significantly more often poorer self-rated health, hospital admission in the last 12 month and the use of 5 and more prescribed medications (polypharmacy) than participants without MM. Furthermore, women with MM reported loneliness more often.

Conclusion: MM is highly prevalent in older people and is associated with ageing. In addition to the general recommendations to promote a healthy lifestyle (e.g., sufficient exercise, balanced diet), interventions in multimorbid individuals should also address loneliness and polypharmacy.

The impact of adverse childhood experiences on multimorbidity: a systematic review and meta-analysis

Dr. Dhaneesha Senaratne; Dr. Bhushan Thakkar; Prof. Blair Smith; Prof. Tim Hales; Dr. Louise Marryat; Prof. Lesley Colvin

University of Dundee

Background: Adverse childhood experiences (ACEs) are potentially stressful events or environments that occur before the age of 18. They are implicated in the aetiology of long-term health outcomes, including multimorbidity. In this systematic review and meta-analysis we aimed to aggregate the current evidence linking ACEs and multimorbidity.

Methods: We searched seven databases from inception to 20 July 2023 (PROSPERO: CRD42023389528). We selected studies with adverse events having occurred during childhood (< 18 years) and an assessment of multimorbidity in adulthood (≥ 18 years). Studies that only assessed adverse events in adulthood or health outcomes in childhood were excluded. Risk of bias was assessed using the ROBINS-E tool. We performed meta-analysis of prevalence and dose-response meta-analysis for quantitative data synthesis.

Results: From 15,586 records, 25 studies were eligible for inclusion (372,162 participants). The prevalence of exposure to ≥ 1 ACE was 48.1% (95% CI 33.4-63.1%). The prevalence of multimorbidity was 34.5% (95% CI 23.4-47.5%). Eight studies provided sufficient data for dose-response meta-analysis (197,981 participants). There was a significant dose-dependent relationship between ACE exposure and multimorbidity (p < 0.001), with every additional ACE contributing a 12.9% (95% CI 7.9-17.9%) increase in the odds for multimorbidity. However, there was heterogeneity among the included studies (I2 = 76.9%, Cochran Q = 102, p < 0.001).

Discussion: This systematic review and meta-analysis demonstrates a dose-dependent relationship between ACEs and multimorbidity across a large number of participants. It builds on an extensive body of literature that shows an association between ACEs and poor long-term health outcomes.

Clustering multimorbid disease trajectories in disease-space and time

Nikolaj Normann Holm; Dr. Thao Minh Le; Prof. Anne Frølich; Prof. Ove Andersen; Helle Gybel Juul-Larsen; Anders Stockmarr; Prof. Svetha Venkatesh

Technical University of Denmark

Nationwide clustering analyses have previously been employed to highlight multimorbidity patterns, which can be used as a basis for focused interventions. Historically, such analyses have utilized cross-sectional data, neglecting the temporal dynamics influencing multimorbidity progression.

We introduce a novel, deep learning approach for temporal disease-based clustering, where clusters are formed from disease portfolios arising around the same stages in life. The approach relies on a longitudinal dataset of chronic diseases, possibly derived from electronic health records.

We evaluated our approach on a dataset containing the entire adult Danish population of chronic heart disease (HD) patients in 1995-2015, comprising 766,596 individuals. We utilized algorithmic diagnoses for 15 chronic diseases, targeting diagnoses from primary and secondary healthcare sectors.

We demonstrate how the spatiotemporal clusters obtained from our model can provide a novel understanding of the development of multimorbidity over time. The presence of high cholesterol, osteoporosis and dementia were pivotal in characterizing the separate clusters arising at different stages in life in the HD population. Our analysis of patient transitions among clusters unveiled three main trajectory pathways. One path featured respiratory multimorbidity, which was typical for heart failure patients. Another was complicated by hypertension and diabetes, while a third pathway was characterized by early multimorbidity and high cholesterol, typical for ischemic heart disease patients. Our findings illustrate the advantages of conducting temporal cluster analyses on multimorbidity, which can facilitate targeted early-stage interventions.

The proposed approach is versatile and does not require conditioning on a specific disease, such as HD.

Clusters of Chronic Diseases in the Danish Population

Dr. Anders Stockmarr PhD¹; Prof. Anne Frølich PhD²

¹Technical University of Denmark; ²University of Copenhagen

With the aging of European populations, clusters of individuals with chronic conditions are a way of mapping the structure of the population that in the future will challenge our heaths sectors, and who will experience a lifetime with more pressure from chronic conditions, challenging their Quality of Life. From algorithmic diagnoses of the entire Danish population, we discuss properties of clusters of individuals, and techniques to create these. This includes detailed studies of co-occurrences of diseases, sociodemography, general health, and challenges with common clustering mechanisms.

Usage of machine learning in multimorbidity research: protocol for a scoping review

Danny Anthonimuthu¹; Ole Hejlesen; Ann-Dorthe Olsen Zwisler; Flemming Witt Udsen

¹Aalborg university

Background: Multimorbidity, the presence of multiple chronic conditions, poses global healthcare challenges, leading to increased mortality, reduced quality of life, and higher costs. The burden of multimorbidity is expected to worsen if no effective intervention is taken. Machine learning has the potential to assist in addressing these challenges by providing advanced analysis for disease prediction, treatment development, and clinical strategies.

Objective: This paper represents the protocol of a scoping review, which aims to identify and explore the current literature concerning the utilization of machine learning for multimorbidity patients. Furthermore, the scoping review will also explore the available literature in investigating the usability and interface aspects of machine learning models designed for patients with multimorbidity.

Methods: The scoping review will be based on the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR). 5 databases (PubMed, EMBASE, IEEE, Web of Science, and Scopus) are chosen to conduct a literature search. Qualified studies will undergo a screening process of title, abstract, and full text.

Results: The findings of the scoping review will be conveyed through a narrative synthesis. Additionally, data extracted from the studies will be formatted in a more comprehensive manner, such as charts or tables. The results will be presented in a forthcoming scoping review, which will be published in a peer-reviewed journal.

Conclusion: This scoping review will offer insight into existing literature on machine learning in multimorbidity patients, outlining approaches and identifying research gaps.

Developing a value-driven approach to the management of multimorbidity in primary care

Desmond Luan Seng Ong¹; Chun Yen Beh¹; Cindy Shiqi Zhu¹; Meena Sundram¹; Yew Seng Kwan¹; Alicia Huiying Ong¹; Hwei Ming Tan¹; Ming Hann Cheah¹; Jose Maria Valderas²

¹National University Polyclinics; ²National University of Singapore

Background: Multimorbidity is associated with poorer primary care processes and outcomes. Reliance on existing condition-specific process and outcome indicators of quality and safety may be suboptimal if not inadequate for evaluating the management of multimorbidity. Appropriate indicator measures are essential to support performance evaluation and quality improvement in the management of multimorbidity in primary care.

Aim: To comprehensively identify available process and outcome indicators for the quality and safety of the management of multimorbidity in primary care.

Methods: We performed a systematic review of scientific publications that used, developed and/or evaluated process and outcomes indicators in the management of multimorbidity in primary care following a detailed protocol (PROSPERO CRD42023388669). With the help of a librarian, we formulated a search strategy organized in three main blocks (multimorbidity, quality and safety, and primary care), which was implemented in electronic databases (MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science). Two reviewers independently screened the titles, abstracts, and full-texts. Data will be extracted from the included full texts using a data extraction form.

Results: A total of 3714 articles were retrieved. After screening, 26 publications were deemed eligible. Publications included papers on development of indicators, evaluation of indicators, as well as interventional studies with indicators as outcome measures. Screening of citations and data extraction are ongoing. Results will include publication characteristics and the identified indicators.

Conclusions: Findings from this review will help inform and develop a set of process and outcome indicators for the management of multimorbidity in primary care in Singapore.