Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

Abstract

Background: Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care.

Methods: We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken.

Results: Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low.

Conclusions: The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.

Fig 1. Flowchart of studies included in the review.

Fig 2. Main analysis of the association between active safety incidents and multimorbidity.

Fig 3. Subgroup analysis of the association between active safety incidents and multimorbidity analysed by different types of active safety incidents.

Fig 4. Subgroup analysis of the association between active safety incidents and multimorbidity analysed by different types of multimorbidity.

Fig 5. Main analysis of the association between poor quality of care and multimorbidity.

Fig 6. Subgroup analysis of the association between poor quality of care and multimorbidity analysed by different types of multimorbidity.

Fig 7. Main analysis of the association between prescription error and multimorbidity.

Fig 8. Subgroup analysis of the association between prescription error and multimorbidity analysed by different types of multimorbidity.

Fig 9. Association between medication non-adherence and multimorbidity analysed by different types of multimorbidity.

Fig 10. Association between diagnostic error and multimorbidity.

Fig 11. Sensitivity analysis examining the effects of multimorbidity on active safety incidents and precursors of safety incidents across studies with superior methodological quality scores.

Fig 12. Funnel plot for studies examining the link between multimorbidity and active safety incidents.

Fig 13. Funnel plot for studies examining the link between multimorbidity and precursors of safety incidents.