COLLEGE OF MEDICINE AND HEALTH
Medicine, Nursing and Allied Health Professions

Threads and Yarns - An International Multimorbidity Research Network

Threads and yarns is a research network which draws together primary care researchers across several European countries with a common interest in research for informing the provision of best health care for people with a complex clinical status. The origin of the network lies in the International Primary Care Research Leadership programme hosted by the University of Oxford, and which originated as part of the Brisbane Initiative, an international collaboration of universities whose aim is to foster and develop future leaders in primary care research. The international programme put in contact researchers with a common interest, stimulated discussions and fostered a collaboration that has resulted in this network.

“Threads and yarns” is the image that Prof. Barbara Starfield proposed for the study of multi-morbidity (Starfield B, Ann Fam Med, 2006):

“As any weaver knows, the elegance of a fabric lies in the yarns, not the threads. The whole is lots more than the sum of its parts. In health services, the threads are the diagnoses on which interventions are based. How these threads are spun into yarn (the underlying biodynamic of the tapestry of health) is poorly understood, to the detriment of efforts to understand the genesis of health problems and the interventions associated with them.”

Central to this metaphor is the fact that while each individual clinical diagnosis is relevant for determining the health care needs of a person, the presence of multi-morbidty requires considering an additional level of complexity.

Objectives

We aim to support each other in the development and conduct of research on multimorbidity that is relevant for primary care. We want to achieve this through collaboration, and peer support.

Research

This network currently includes research from 13 institutions in Germany, Ireland, the Netherlands, Spain and the United Kingdom, and it covers interests in different areas of research in Primary Care with selected population, disease and methods and implementation focus. View the leads for each area, along with current active interests.

Rijken M, Valderas JM, Heins M, Schellevis F, Korevaar J. Identifying high-need patients with multimorbidity from their illness perceptions and personal resources to manage their health and care: a longitudinal study. BMC Fam Pract. 2020 Apr 29;21(1):75. doi: 10.1186/s12875-020-01148-3 PubMed

Violán C, Foguet-Boreu Q, Fernández-Bertolín S, Guisado-Clavero M, Cabrera-Bean M, Formiga F, Valderas JM, Roso-Llorach A. Soft clustering using real-world data for the identification of multimorbidity patterns in an elderly population: cross-sectional study in a Mediterranean population. BMJ Open. 2019 Aug 30;9(8):e029594. doi: 10.1136/bmjopen-2019-029594 PubMed

Calderón-Larrañaga A, Vetrano DL, Ferrucci L, Mercer SW, Marengoni A, Onder G, Eriksdotter M, Fratiglioni L. Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways. Journal of Internal Medicine 2019; 285(3):255-271.  doi: 10.1111/joim.12843 PubMed

Muth C, Blom JW, Smith SM, Johnell K, Gonzalez-Gonzalez AI, Nguyen TS, Brueckle M-S, Cesari M, Timetti ME, Valderas JM. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. Journal of Internal Medicine Review Symposium 2019;285(3): 272-288. doi: 10.1111/joim.12842 PubMed

Valderas JM, Gangannagaripalli J, Nolte E, Boyd CM, Roland M, Sarria-Santamera A, Jones E, Rijken M. Quality of care assessment for people with multimorbidity. Journal of Internal Medicine 2019; 285(3): 289-300. doi: 10.1111/joim.12881 PubMed

Violán C, Roso-Llorach A, Foguet-Boreu Q, Guisado-Clavero M, Pons-Vigués M, Pujol-Ribera E, Valderas JM. Multimorbidity patterns with K-means nonhierarchical cluster analysis. BMC Fam Pract. 2018 Jul 3;19(1):108.  doi: 10.1186/s12875-018-0790-x PubMed

Roso-Llorach A, Violán CFoguet-Boreu Q, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Valderas JM. Comparative analysis of methods for identifying multimorbidity patterns: a study of 'real-world' data. BMJ Open. 2018 Mar 22;8(3):e018986. doi: 10.1136/bmjopen-2017-018986 PubMed

Foguet-Boreu Q, Violán C, Jiménez TL, Pons-Vigués M, Rodríguez-Blanco T,  Valderas JM, Guisado Clavero M, Pujol-Ribera E. Pharmacological control of diabetes and hypertension comorbidity in the elderly: A study of "real world" data. Prim Care Diabetes. 2017 Aug;11(4):348-359. doi: 10.1016/j.pcd.2017.03.007 PubMed

Calderón A, Vetrano DL, Onder G, Gimeno-Feliu LA et al. Assessing and measuring chronic multimorbidity in the older population: a proposal for its operationalization. J Gerontol A Biol Sci Med Sci 2017;72(10):1417-1423. doi: 10.1093/gerona/glw233 PubMed

Violán C, Rodrigues-Blanco T, Roso-Llorach APons-Vigués M, Pujol-Ribera E, Valderas JM. [Patterns of multimorbidity in young adults in Catalonia: a cluster analysis.] Aten Primaria 2016;48(7):479-92 doi:10.1016/j.aprim.2015.10.006 PubMed

Muth C, Harder S, Uhlmann L, Rochon J, Fullerton B, Guthlin C, Erler A, Beyer M, van den Akker M, Perera R, Knotnerus A, Valderas JM, Ferdinand M, Gerlach FM, Haefeli WE. Pilot study to test the feasibility of a trial design and complex intervention on PRioritising MUltimedication in Multimorbidity in general practices (PRIMUMpilot). BMJ Open 2016;6(7):e011613. doi:10.1136/bmjopen-2016-011613 PubMed

Boeckxstaens P, De Sutter A, Vaes B, Degryse JM. Should we  keep on measuring multimorbidity? J Clin Epidemiol. 2016 Mar;71:113-4 doi: 10.1016/j.jclinepi.2015.05.015 PubMed

Boeckxstaens P, Vaes B, De Sutter A, Aujoulat I, van Pottelbergh G, Matheï C, Degryse JM. A high sense of coherence as protection against adverse health outcomes in patients aged 80 years and older. Annals of Family Medicine 2016; 14:337–43 doi: 10.1370/afm.1950 PubMed

Calderón-Larrañaga A, Diaz E, Poblador-Plou B, Gimeno-Feliu LA, Abad-Díez JM, Prados-Torres A. Non-adherence to antihypertensive medication: the role of mental and physical comorbidity. Int J Cardiol 2016;207:310-6. PubMed

Boeckxstaens P, Vaes B, Van Pottelberg G, De Sutter A, Legrand D, Adriaensen W, Matheï C, Dalleur O, Degryse J-M. Multimorbidity measures were poor predictors of adverse events in patients aged ≥80 years: a prospective cohort study. Journal of Clinical Epidemiology 2015; 68(2):220-7. doi: 10.1016/j.jclinepi.2014.08.010. PubMed

Ricci-Cabello I, Stevens S, Kontopantelis E, Dalton ARH, Griffiths RI, Campbell JL, Doran T, Valderas JM. Impact of the prevalence of concordant and discordant conditions on the quality of diabetes care in family practices in England. Ann Fam Med. 2015 13(6):514-22. doi:10.1370/afm./1848 PubMed

Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, Vergara-Mitxeltorena I, Aldaz-Herce P, Poblador-Plou B, Machón-Sobrado M, Egüés-Olazabal N, Abellán-van Kan G, Prados-Torres A. Multimorbidity patterns in hospitalized older patients: associations among chronic diseases and geriatric syndromes. PLoS One 2015;10(7):e0132909.  doi: 10.1371/journal.pone.0132909  PubMed

Calderón-Larrañaga A, Abad-Díez JM, Gimeno-Feliu LA, Marta-Moreno J, González-Rubio F, Clerencia-Sierra M, Poblador-Plou B, Poncel-Falcó A, Prados-Torres A. Global health care use by patients with type 2 diabetes: does the type of comorbidity matter? Eur J Intern Med 2015;26(3):203-10. doi: 10.1016/j.ejim.2015.02.011 PubMed

Calderón-Larrañaga A, Hernández-Olivan P, González-Rubio F, Gimeno-Feliu LA, Poblador-Plou B, Prados-Torres A. Multimorbidity and weight loss in obese primary care patients. Longitudinal study based on electronic healthcare records. BMJ Open 2015;5(3):e006227. doi: 10.1136/bmjopen-2014-006227 PubMed

Foguet-Boreu Q,Violán C, Rodriguez-Blanco T, Roso-Llorach A, Pons-Vigues M, Pujol-Ribera E, Valderas JM. Patterns of multimorbidity in the elderly primary health care patients in a South Mediterranean European region: a cluster analysis. PLoS One 2015;10(11):e0141155. doi:10.1371/journal.pone.0141155 PubMed

Islam MM, McRae I, Yen L, Jowsey T, Valderas JM. Time spent on health-related activities by senior Australians with chronic diseases: what is the role of multimorbidity and comorbidity? Aust N Z J Pub Health. 2015;39(3):277-83. doi:10.111/1753-6405.12355 PubMed

Le Reste JY, Nabbe P, Lingner H, Kasuba Lazic D, Asssenova R, Munoz M, Sowinska A, Lygidakis C, Doerr C, Czachowski S, Argyriadou S, Valderas JM, Le Floch B, Deriennic J, Jan T, Melot E, Barraine P, Odorico M, Lietart C, Van Royen P, Van Marwijk H. What research agenda could be generated from the European General Practice Research Network concept of multimorbidity in family practice? BMC Family Practice 2015;16:125 doi:10.1186/s12875-015-0337-3 PubMed

Ricci-Cabello I, Violán C, Foguet-Boreu Q, Mounce LTA, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy. A scoping review. Eur J Gen Pract 2015;21(3):192-202. doi: 10.3109/13814788.2015.1046046 Pubmed

Blom JW, Azzi ME, Wopereis DM, Glynn L, Muth C, van Driel ML. Reporting of patient-centred outcomes in heart failure trials: are patient preferences being ignored? Heart Fail Rev 2015;20(4):385-92. doi: 10.1007/s10741-015-9476-9. Pubmed

Vos R, van den Akker M, Boesten J, Robertson C, Metsemakers J. Trajectories of multimorbidity: exploring patterns of multimorbidity in patients with more than ten chronic health problems in life course. BMC Fam Pract 2015; Jan 22:16(1):2 doi: 10.1186/s12875-014-0213-6. Pubmed

Bergert FW, Braun M, Ehrenthal K, Fessler J, Gross J, Huttner U, Kluthe B, Liesenfeld A, Seffrin J, Vetter G, Beyer M, Muth C, Popert U, Harder S, Kirchner H, Schubert I. Recommendations for treating adult and geriatric patients on multimedication. Int J Clin Pharmacol Ther 2014; 52 Suppl 1:1-64. doi: 10.5414/cpp52s001 Pubmed

Carretero MT, Calderón-Larrañaga A, Poblador-Plou B, Prados-Torres A. Primary health care use from the perspective of gender and morbidity burden. BMC Womens Health 2014;14(1):145. doi: 10.1186/s12905-014-0145-2 PubMed

Cimarras-Otal C, Calderón-Larrañaga A, Poblador-Plou B, González-Rubio F, Gimeno-Feliu L, Arjol-Serrano J, Prados-Torres A. Association between physical activity, multimorbidity, self-rated health and functional limitation in the Spanish population. BMC Public Health 2014;14:1170. doi: 10.1186/1471-2458-14-1170 PubMed

Poblador-Plou B, van den Akker M, Vos R, Calderón-Larrañaga A, Metsemakers J, Prados-Torres A. Similar multimorbidity patterns in primary care patients from two European regions: results of a factor analysis. PLoS One 2014;9(6):e100375. PubMed

Boeckxstaens P, Vaes B, Legrand D, Dalleur O, De Sutter A, Degryse J. The relationship of multimorbidity with disability and frailty in the oldest patients : a cross-sectional analysis of three measures of multimorbidity in the BELFRAIL cohort. Eur J Gen Pract 2014 21(1):39-44. doi: 10.3109/13814788.2014.914167 PubMed

Boeckxstaens P, Peersman W, Goubin G, Ghali S, De Maeseneer J, Brusselle G, De Sutter A. A practice-based analysis of combinations of diseases in patients aged 65 or older in primary care. BMC Fam Pract. 2014;15:159. doi: 10.1186/1471-2296-15-159. PubMed

Poblador B, Calderón-Larrañaga A, Marta J, Hancco J, Sicras A, Soljak M, Prados A. Comorbidity of dementia: a cross-sectional study of primary care older patients. BMC Psychiatry 2014;14(1):84. Article

Prados-Torres ACalderon-Larrañaga A, Hancco-Saavedra J, Poblador-Plou B, van den Akker M. Multimorbidity patterns: a systematic review. J Clin Epidemiol 2014;67(3):254-66 Pubmed

Cimarras-Otal C, Calderón-Larrañaga A, Poblador-Plou B, González-Rubio F, Gimeno-Feliu L, Arjol-Serrano J, Prados-Torres A. Association between physical activity, multimorbidity, self-rated health and functional limitation in the Spanish population. BMC Public Health 2014;14:1170. IF: 2.32 Pubmed

Poblador-Plou B, van den Akker M, Vos R, Calderón-Larrañaga A, Metsemakers J, Prados-Torres A. Similar multimorbidity patterns in primary care patients from two European regions: results of a factor analysis. PLoS One 2014;9(6):e100375. IF: 3.73 Pubmed

Abad-Díez JM, Calderón-Larrañaga A, Poncel-Falcó A, Poblador-Plou B, Calderón-Meza J, Sicras-Mainar A, Clerencia-Sierra M, Prados-Torres A. Age and gender differences in the prevalence and patterns of multimorbidity in the older population. BMC Geriatr 2014;14:75. doi: 10.1186/1471-2318-14-75 PubMed

Poblador-Plou B, Calderón-Larranaga A, Marta-Moreno J, Hancco-Saavedra J, Sicras-Mainar A, Soljak M, Prados-Torres A. Comorbidity of dementia: a cross-sectional study of primary care older patients. BMC Psychiatry 2014;14(1):84.  doi: 10.1186/1471-244X-14-84 Pubmed

Prados-Torres A, Calderón-Larrañaga A, Hancco-Saavedra J, Poblador-Plou B, van den Akker M. Multimorbidity patterns: a systematic review. J Clin Epidemiol. 2014;67(3):254-66. doi: 10.1016/j.jclinepi.2013.09.021 Pubmed

Muth C, Kirchner H, van den Akker M, Scherer M, Glasziou PP. Current guidelines poorly address multimorbidity: pilot of the interaction matrix method. J Clin Epidemiol. 2014 Nov;67(11):1242-50. doi: 10.1016/j.jclinepi.2014.07.004. PubMed

Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, Becker A, Beyer M, Gensichen J, Kirchner H, Perera R, Prados-Torres A, Scherer M, Thiem U, van den Bussche H, Glasziou PP. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med. 2014 Dec 8;12:223. doi: 10.1186/s12916-014-0223-1. PubMed

Violán C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M, Glynn L, Muth C, Valderas JM. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014 Jul 21;9(7):e102149. doi: 10.1371/journal.pone.0102149. PubMed

Violán C, Foguet-Boreu Q, Roso-Llorach A, Rodriguez-Blanco T, Pons-Vigués M, Pujol-Ribera E, Muñoz-Pérez MÁ, Valderas JM.  Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study. BMC Public Health. 2014 May 29;14:530. doi: 10.1186/1471-2458-14-530.  PubMed

Vos R, Aarts S, van Mulligen E, Metsemakers J, van Boxtel MP, Verhey F, van den Akker M. Finding potentially new multimorbidity patterns of psychiatric and somatic diseases: exploring the use of literature-based discovery in primary care research. J Am Med Inform Assoc 2014;21(1):139-45 doi: 10.1136/amiajnl-2012-001448 Pubmed

Muth C, Beyer M, Fortin M, Rochon J, Oswald F, Valderas JM, Harder S, Glynn LG, Perera R, Freitag M, Kaspar R, Gensichen J, van den Akker M. Multimorbidity's research challenges and priorities from a clinical perspective: the case of 'Mr Curran'. Eur J Gen Pract. 2014 Jun;20(2):139-47. doi: 10.3109/13814788.2013.839651. Epub 2013 Oct 25. PubMed

Violán C, Foguet-Boreu Q, Hermosilla-Pérez E, Valderas JM, Bolíbar B, Fàbregas-Escurriola M, Brugulat-Guiteras P, Muñoz-Pérez MÁ. Comparison of the information provided by electronic health records data and a population health survey to estimate prevalence of selected health conditions and multimorbidity. BMC Public Health. 2013 Mar 21;13:251. doi: 10.1186/1471-2458-13-251. PubMed

Calderón-Larrañaga A, Gimeno-Feliu L, González-Rubio F, Poblador-Plou B, Lairla-San Jose M, Abad-Diez J, Poncel-Falco A, Prados-Torres A. Polypharmacy patterns: unravelling systematic associations between prescribed medications. PLoS One 2013;8(12):e84967. doi: 10.1371/journal.pone.0084967 Pubmed

Calderón-Larrañaga A, Poblador-Plou B, González-Rubio F, Gimeno-Feliu LA, Abad-Diez JM, Prados-Torres A. Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well? Br J Gen Pract 2012;62(605):e821-6  doi:10.3399/bjgp12X659295 Pubmed

Prados-Torres A, Poblador-Plou B, Calderón-Larrañaga A, Gimeno-Feliu LA, González-Rubio F, Poncel-Falco A, Sicras-Mainar A, Alcalá-Nalvaiz JT. Multimorbidity patterns in primary care: interactions among chronic diseases using factor analysis. PloS ONE 2012;7(2):e32190. doi: 10.1371/journal.pone.0032190 Pubmed

Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med. 2012 Mar-Apr;10(2):134-41. doi: 10.1370/afm.1363. PubMed

Boeckxstaens P, Deregt M, Vandesype P, Willems S, Brusselle G, De Sutter A. Chronic obstructive pulmonary disease and comorbidities through the eyes of the patient. Chron Resp Dis. 2012;9(3):183-91. doi: 10.1177/1479972312452436 PubMed

Aarts S, van den Akker M, Bosma H, Tan FES, Verhey FRJ, Metsemakers JFM, van Boxtel MPJ. The effect of multimorbidity on health related functioning: temporary or persistent. Results from a longitudinal cohort study. Journal of Psychosomatic Research 2012;73:211-7. doi: 10.1016/j.jpsychores.2012.05.014 Pubmed 

Glynn LGValderas JM, Healy P, Burke E, Newell J, Gillespie P, Murphy AW. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract. 2011 Oct;28(5):516-23. doi: 10.1093/fampra/cmr013. PubMed

Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011 Jan;61(582):e12-21. doi: 10.3399/bjgp11X548929. PubMed

Glynn LG. Multimorbidity: another key issue for cardiovascular medicine. Comment. Lancet. 2009 Oct 24;374(9699):1421-2. doi: 10.1016/S0140-6736(09)61863-8. PubMed

Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009 Jul-Aug;7(4):357-63. doi: 10.1370/afm.983. PubMed

This network currently includes research from 13 institutions in Germany, Ireland, the Netherlands, Spain and the United Kingdom, and it covers interests in different areas of research in Primary Care with selected population, disease and methods and implementation focus.

The leads for each area are listed, along with current active interests:

Symposium 2019: Patient centred clinical management of frail multimorbid elderly people using Patient Reported Outcome Measures (PROMs)

Friday June 14th 2019, Leeds Beckett University

Following the success of the previous international symposium on Multimorbidity and Frailty co-organized with the Karolinska Institut in 2018, the Health Services Policy Research Group at the University of Exeter in collaboration with the Centre for Health Evaluation & Outcome Sciences (CHEOS) at the University of British Columbia, the School of Nursing at Trinity Western University, Canada and Leeds Beckett University held an international symposium on “Patient centred management of frail multimorbid elderly people using Patient Reported Outcome Measures.”

With the aim of better understanding the rationale, evidence and available tools for delivering patient centred care for this population, the symposium  was organized around presentations by invited speakers followed by open discussion with participants.  There was also an opportunity to attend a workshop at the end of the Symposium focusing on tool selection for this population.

Confirmed speakers at the Symposium included Joakim Öhlen (Director of the University of Gothenburg Centre for Person-centred Care), Rick Sawatzky (Canada Research Chair in Person-Centred Outcomes), Jose M Valderas (President of the International Society for Quality of Life Research) and Alies Maybee (a patient partner with expertise of the electronic administration of PROs).

The Symposium took place on the day following the Annual UK PROMs Conference, which this year was hosted by Leeds Beckett University.

Agenda and speakers

Symposium 2018: International symposium “Multimorbidity research at the cross-roads”, Stockholm 2018

International researchers, physicians and health services and health policy decision makers met at the Alfred Nobel Forum in Stockholm, on 21st May, 2018. Keynote speakers from Europe and the US, such as Mary Tinetti, Martin Roland, Luigi Ferrucci, Stewart Mercer, Cynthia Boyd, Jose M. Valderas and Alessandra Marengoni and discussants set the scene for subsequent constructive panel discussions. Additionally, the programme and the venue provided excellent opportunities for an exchange of ideas and networking among the ca. 120 participants. Key messages of the Symposium (see below) were formulated by participants in a series of subsequent workshops. Three working groups are currently collaborating in the preparation of reviews on clinical management and the public health aspects of multimorbidity, with the aim of publishing them by the end of the year.

The entire meeting was funded by the Journal of Internal Medicine (JIM), with further support from Karolinska Institutet, the University of Exeter, the KI Strategic Research Area in Epidemiology (SfoEpi), the Aging Research Centre (ARC), as well as the European Network on Multimorbidity ‘Threads & Yarns’. For further details, see the Conference programme 2018.

Multimorbidity research at the cross-roads: lessons learned

Conceptual issues:

  • Frailty, multimorbidity and disability overlap substantially at an individual level but are distinct constructs: a high proportion of individuals meeting the criteria for one do not meet those for others. Definitions of each construct may need to be tailored to each specific purpose and context.
  • A life-course approach will help in understanding the complexity behind these three constructs by providing a framework that encompasses the physical and social environment, as well as biological mechanisms.
  • Research on patterns of multimorbidity has the potential to address common disease pathways, contextualize disease accumulation, and develop efficient preventive and curative interventions. Future research needs to establish the internal and external validity of such clusters, their social determinants, longitudinal patterns of association, gender differences, and interactions with other geriatric syndromes.

Clinical care:

  • Models of care are still informed by single-disease approaches, but a model consistent with the challenges of multimorbidity is still lacking; i.e. multiple conditions with multiple etiological factors and multiple management options, and involving a wide range of health professionals.
  • In the clinical management of people with multimorbidity, the presence of conflicting priorities means that trade-offs and personalized management are necessary; i.e. the use of outcomes that are meaningful to patients (e.g. function), the formulation of explicit priorities and goals, and appropriate interventions both in terms of time to and absolute benefit, and burden.
  • Continuity of care offers an instrument to potentially maximising the effectiveness of multidisciplinary care teams while ensuring patient centredness. While care continuity is expected to improve satisfaction and outcomes, reduce costs, and lead to more appropriate decisions, evidence is still scant.

Health policy:

  • Performance assessment frameworks for people with multimorbidity should focus not only on the use of therapies likely to benefit these patients, but also on those unlikely to benefit or even likely to harm them. They also need to capture patients’ voices (both in the form of patient experiences and patient-centred outcomes -PROMs and PREMs-) and to establish whether patient preferences and values inform decision-making.
  • The design of healthcare systems for patients with complex needs will benefit from attention to the following key issues: patient selection and targeting, patient engagement, caregiver involvement, coordination of care, information systems, workforce planning, aligning funding and incentives, enabling innovation, and learning from experience.

Scientific Committee:

Laura Fratiglioni: laura.fratiglioni@ki.se

José M Valderas: J.M.Valderas@exeter.ac.uk

Amaia Calderón: amaia.calderon.larranaga@ki.se

Davide Vetrano: davide.vetrano@ki.se

Christiane Muth: muth@allgemeinmedizin.uni-frankfurt.de

Maria Eriksdotter: maria.eriksdotter@ki.se