Living with cancer and multimorbidity: the role of primary care

Digital intervention (Renewed) to support symptom management, wellbeing, and quality of life among cancer survivors in primary care: a randomised controlled trial

BACKGROUND

Many cancer survivors following primary treatment have prolonged poor quality of life.

AIM

To determine the effectiveness of a bespoke digital intervention to support cancer survivors.

DESIGN AND SETTING

This was a pragmatic parallel open randomised trial in UK general practices (ISRCTN:96374224).

METHOD

People having finished primary treatment (≤10 years previously) for colorectal, breast, or prostate cancers, with European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) score ≤85, were randomised by online software to: 1) detailed 'generic' digital NHS support ('LiveWell'; n = 906); 2) a bespoke complex digital intervention ('Renewed'; n = 903) addressing symptom management, physical activity, diet, weight loss, and distress; or 3) 'Renewed with support' (n = 903): 'Renewed' with additional brief email and telephone support.

RESULTS

Mixed linear regression provided estimates of the differences between each intervention group and generic advice. At 6 months all groups improved (primary time point: n for the generic, Renewed groups, and Renewed with support were 806, 749, and 705, respectively), with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both the Renewed groups. By 12 months there were small improvements in EORTC QLQ-C30 for Renewed with support (versus generic advice: 1.42, 95% confidence interval [CI] = 0.33 to 2.51); both Renewed groups improved global health (12 months: Renewed: 3.06, 95% CI = 1.39 to 4.74; Renewed with support: 2.78, 95% CI = 1.08 to 4.48), dyspnoea, constipation and enablement, and lower primary care NHS costs (in comparison with generic advice [£265]: Renewed was -£141 [95% CI = -£153 to-£128] and Renewed with Support was -£77 [95% CI = -£90 to -£65]); and for Renewed with support improvement in several other symptom subscales. No harms were identified.

CONCLUSION

Cancer survivors' quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short-term benefit, but additional longer-term improvement in global health, enablement, and symptom management, with substantially lower NHS costs.

Cancer Survivorship and the Significance of an Integrated Diachronic Life Course Perspective

Standardised health care is primarily focused on remediation and delivered episodically through costly and fragmented health-care systems. Such an approach is untenable, given the diversity and complexity of peoples' health-care needs, increasing prevalence of chronic disease and existing heath inequities. A life course perspective fundamentally challenges our current understanding of health care and has great potential to promote innovation in health-care practice, systems and policy. However, the way that health develops and manifests across the life course is a highly complex process underpinned by a plethora of causal antecedents, consequences and interdependencies that have yet to be adequately captured and articulated in current life course frameworks. The field of cancer survivorship and its recent rise to prominence provides a highly relevant and compelling case example to inform development and refinement of existing life course frameworks. Cancer survivorship exemplifies what can be described as an integrated diachronic life course perspective, which serves as a conceptual framework to enhance our understanding of health development across the life course and guide health-care practice, systems and policy to meet the increasingly complex health-care needs of current and future generations.

"Being ill was the easy part": exploring cancer survivors' reactions to perceived challenges in engaging with primary healthcare

PURPOSE

Cancer survivors experience barriers to primary healthcare (PHC) services. The aim was to explore reactions to and opinions about perceived challenges associated with PHC access and quality among cancer survivors in Sweden, including how they have acted to adapt to challenges.

METHODS

Five semi-structured focus group interviews were conducted with cancer survivors (n = 20) from Skåne, Sweden, diagnosed with breast, prostate, lung, or colorectal cancer or malignant melanoma. Focus groups were mixed in regard to diagnosis. Data were analysed using a descriptive template analysis approach.

RESULTS

In light of perceived challenges associated with access to adequate PHC, participants experienced that they had been forced to work hard to achieve functioning PHC contacts. The demands for self-sufficiency were associated with negative feelings such as loneliness and worry. Participants believed that cancer survivors who lack the ability to express themselves, or sufficient drive, risk missing out on necessary care due to the necessity of being an active patient.

CONCLUSIONS

The findings highlight negative patient experiences. They have implications for the organization of care for cancer survivors as they indicate a need for more efficient post-treatment coordination between cancer specialist care and PHC providers, as well as increased support for patients leaving primary cancer treatment.

Combinations of multiple long term conditions and risk of hospital admission or death during winter 2021-22 in England: population based cohort study

Objective

To describe which combinations of long term conditions were associated with a higher risk of hospital admission or death during winter 2021-22 (the third wave of the covid-19 pandemic) in adults in England.

Design

Population based cohort study.

Setting

Linked primary and secondary care data from the General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) database, Hospital Episode Statistics, and Office for National Statistics death registry, comprising pseudoanonymised routinely collected electronic medical records from the whole population of England registered at a general practice, 1 December 2021 to 31 March 2022.

Participants

48 253 125 individuals, registered in GDPPR in England, aged ≥18 years, and alive on 1 December 2021.

Main outcomes measures

All cause hospital admissions and deaths associated with combinations of multiple long term conditions compared with those with no long term conditions, during the winter season (1 December 2021 to 31 March 2022). Overdispersed Poisson regression models were used to estimate the incidence rate ratios after adjusting for age, sex, ethnic group, and index of multiple deprivation.

Results

Complete data were available for 48 253 125 adults, of whom 15 million (31.2%) had multiple long term conditions. Rates of hospital admissions and deaths among individuals with no long term conditions were 96.3 and 0.8 per 1000 person years, respectively. Compared with those with no long term conditions, the adjusted incidence rate ratio of hospital admissions were 11.0 (95% confidence interval (CI) 9.4 to 12.7) for those with a combination of cancer, chronic kidney disease, cardiovascular disease, and type 2 diabetes mellitus; 9.8 (8.3 to 11.4) for those with cancer, chronic kidney disease, cardiovascular disease, and osteoarthritis; and 9.6 (8.6 to 10.7) for those with cancer, chronic kidney disease, and cardiovascular disease. Compared with those with no long term conditions, the adjusted rate ratio of death was 21.4 (17.5 to 26.0) for those with chronic kidney disease, cardiovascular disease, and dementia; 23.2 (17.5 to 30.3) for those with cancer, chronic kidney disease, cardiovascular disease, and dementia; and 24.3 (19.1 to 30.4) for those with chronic kidney disease, cardiovascular disease, dementia, and osteoarthritis. Cardiovascular disease with dementia appeared in all of the top five combinations of multiple long term conditions for mortality, and this two disease combination was associated with a substantially higher rate of death than many three, four, and five disease combinations.

Conclusions

In this study, rates of hospital admission and death varied by combinations of multiple long term conditions and were substantially higher in those with than in those without any long term conditions. High risk combinations for prioritisation and preventive action by policy makers were highlighted to help manage the challenges imposed by winter pressures on the NHS.

Living With and Beyond Cancer With Comorbid Conditions: Qualitative Insights to Understand Psychosocial Support Needs

INTRODUCTION

There is a pressing need to understand and explore the complex experiences and psychosocial support needs of people LWBC-CM and their informal caregivers, to inform survivorship and supportive care interventions.

METHODS

In-depth qualitative interviews were conducted with people LWBC-CM and their informal caregivers in Scotland, invited via primary care. One-to-one, face-to-face interviews were conducted with informed consent exploring experiences of symptoms, psychosocial support needs and interactions with health services. Interviews were transcribed and analysed using a thematic approach.

RESULTS

Forty-one people LWBC-CM and twenty-three informal caregivers were interviewed. Four themes were identified: the Physical and Psychological Impact of Cancer and Comorbidity, Dominant Storie-Prioritising Conditions and Making Sense of Illness, Navigating Health Services and Treatments and Caring for People with Complex Health Conditions. Type and severity of conditions mediated people's experiences and daily living. Complex fatigue-fatigue arising from a number of health conditions-dominated symptomology. Participants navigated multiple appointments and complex medication regimes. Patients identified the need for acknowledgement of other chronic conditions and for streamlined care provision. Mutual caring and social isolation were also identified as part of the caring relationship.

CONCLUSIONS

There is a mandate to address the psychosocial support needs of people LWBC-CM, and their informal carers, given the burden of treatment for cancer survivors with moderate to severe complex conditions as they navigate health services.

PATIENT OR PUBLIC CONTRIBUTION

A patient representative has been involved in all stages of the study from development of the application through study design, commenting on documentation, analysis of transcripts and writing the manuscript. They are included as an author on the manuscript.

Effect of comorbidity and multimorbidity on adherence to follow-up recommendations among long-term breast cancer survivors

OBJECTIVES

To study the impact of comorbidities, multimorbidity, and multimorbidity clusters on adherence to recommended follow-up guidelines among long-term breast cancer survivors.

STUDY DESIGN

Retrospective cohort study based on 2078 women diagnosed with breast cancer from 2000 to 2006 and followed up from 2012 to 2016.

MAIN OUTCOME MEASURES

Adherence to breast cancer follow-up recommendations (annual medical visit and imaging) was determined. Comorbidities were classified as acute/chronic. Multimorbidity was defined as the presence of two or more chronic comorbidities aside from breast cancer. Five multimorbidity clusters were considered. Multivariate logistic regression models were fitted to determine the relationship between adherence to recommendations and the presence of comorbidities and multimorbidity, considering both sociodemographic and clinical characteristics.

RESULTS

Overall adherence to recommendations was 79.5 %. Adherence was lower among long-term breast cancer survivors with no comorbidities (75.8 %). Among multimorbidity clusters, adherence was highest in the anxiety and fractures cluster (84.3 %) and was lowest in the musculoskeletal and cardiovascular cluster (76.4 %). In adjusted multivariate models, multimorbidity was associated with higher levels of adherence (OR = 1.52 95 %CI 1.16-1.99), and adherence was highest in the metabolic and degenerative cluster (OR = 2.2 95 %CI 1.4-3.5).

CONCLUSION

Adherence to follow-up recommendations was higher among long-term breast cancer survivors with multimorbidity than among those without. Adherence also differed by multimorbidity cluster. These results suggest suboptimal adherence to the current follow-up recommendations in certain groups, suggesting the need to adapt clinical practice guidelines to reflect patients' comorbidities and different characteristics.

Multi-morbidity and its association with common cancer diagnoses: a UK Biobank prospective study

BACKGROUND

Whilst multi-morbidity is known to be a concern in people with cancer, very little is known about the risk of cancer in multi-morbid patients. This study aims to investigate the risk of being diagnosed with lung, colorectal, breast and prostate cancer associated with multi-morbidity.

METHODS

We investigated the association between multi-morbidity and subsequent risk of cancer diagnosis in UK Biobank. Cox models were used to estimate the relative risks of each cancer of interest in multi-morbid participants, using the Cambridge Multimorbidity Score. The extent to which reverse causation, residual confounding and ascertainment bias may have impacted on the findings was robustly investigated.

RESULTS

Of the 436,990 participants included in the study who were cancer-free at baseline, 21.6% (99,965) were multi-morbid (≥ 2 diseases). Over a median follow-up time of 10.9 [IQR 10.0-11.7] years, 9,019 prostate, 7,994 breast, 5,241 colorectal, and 3,591 lung cancers were diagnosed. After exclusion of the first year of follow-up, there was no clear association between multi-morbidity and risk of colorectal, prostate or breast cancer diagnosis. Those with ≥ 4 diseases at recruitment had double the risk of a subsequent lung cancer diagnosis compared to those with no diseases (HR 2.00 [95% CI 1.70-2.35] p for trend < 0.001). These findings were robust to sensitivity analyses aimed at reducing the impact of reverse causation, residual confounding from known cancer risk factors and ascertainment bias.

CONCLUSIONS

Individuals with multi-morbidity are at an increased risk of lung cancer diagnosis. While this association did not appear to be due to common sources of bias in observational studies, further research is needed to understand what underlies this association.

Challenges and perspectives of palliative medicine: A webinar by the Paediatric Virology Study Group

Palliative medicine focuses on the quality of life of patients with incurable conditions, who require the adequate relief of physical symptoms, adequate information to make decisions and spiritual wellbeing. Generalist palliative care is provided by family members, general practitioners, care home workers, community nurses and social care providers, as well as non-specialist hospital doctors and nurses. Patients with more complex, physical or psycho-social problems require the shared work of specialized doctors in palliative medicine, nurses, social workers and allied professionals. It is estimated that ~40 million patients require palliative care annually, worldwide; of these, 8 out of 10 patients reside in low- or middle-income countries, and only ~14% are able to access this type of care. Palliative medicine was recognised as a distinct medical specialty in the UK in 1987, with its own specialist curriculum and training pathway, which was recently revised in 2022. The main obstacles that palliative medicine had to overcome in order to be accepted as a separate specialization were the following: i) Defining a unique body of knowledge; ii) standardisation of training; and iii) proving that it warranted being a specialty in its own right. Over the past decade, it has been accepted as more than end-of-life care, supporting patients with an incurable illness at much earlier stages. Given the current absence of specialized palliative care in low- or middle-income countries, as well as the aging population across most European countries and the USA, it is estimated that there may be an increasing need and demand for specialists in palliative medicine in the ensuing years. This article is based on a webinar on palliative medicine, which was performed on October 20, 2022 in the context of the '8th Workshop of Paediatric Virology' organized by the Institute of Paediatric Virology based on the island of Euboea (Greece).

The role of primary care in the cancer care continuum: a qualitative study of cancer survivors' experiences

OBJECTIVE

To explore how cancer survivors have experienced their contacts with primary care after being diagnosed with cancer, focusing on the integration between cancer specialist and primary care, and participants' views on what could make primary care services better at catering to the needs of cancer survivors.

DESIGN

A qualitative study in which data was collected through semi-structured digital focus group interviews and analyzed using a template analysis approach.

SETTING AND SUBJECTS

Adult residents of Skåne, Sweden, who had been diagnosed with and initiated treatment for either of five common cancer forms, recruited through patient advocacy groups.

MAIN OUTCOME MEASURES

A qualitative description of participants' experiences and perceptions as expressed in focus group interview data.

RESULTS

Most participants felt that primary care services had not played a significant role for them, despite patterns of both increased and unmet health needs. Insufficient coordination and communication with specialist cancer care, low availability, lacking personal continuity, low cancer competence and lacking commitment to cancer-related needs were presented as barriers to satisfactory primary care. A strengthened bond between cancer and primary care services, privileged access, and holistic perspectives were all suggested as measures to make primary care more suitable to cancer survivors' needs.

CONCLUSION

The study suggests that cancer survivors experience a range of issues that hinders primary care services from playing a productive role in the cancer care process. The results speak for a need for interventions to remove barriers to satisfactory primary care contacts in this group of patients.KEY POINTSThe growing number of cancer survivors highlights the role of primary care services in the cancer care continuum.Despite the presence of unmet needs, few cancer survivors felt that primary care services had been significant to their care.Survivors identified a number of barriers to satisfactory primary care, including lacking coordination and communication between cancer and primary care.Strengthened links between healthcare services, privileged access, and holistic perspectives were suggested to improve primary care delivery for cancer survivors.

Sex Differences in Comorbidity Combinations in the Swedish Population

High comorbidity rates, especially mental–physical comorbidity, constitute an increasing health care burden, with women and men being differentially affected. To gain an overview of comorbidity rates stratified by sex across a range of different conditions, this study examines comorbidity patterns within and between cardiovascular, pulmonary, skin, endocrine, digestive, urogenital, musculoskeletal, neurological diseases, and psychiatric conditions. Self-report data from the LifeGene cohort of 31,825 participants from the general Swedish population (62.5% female, 18–84 years) were analyzed. Pairwise comorbidity rates of 54 self-reported conditions in women and men and adjusted odds ratios (ORs) for their comparison were calculated. Overall, the rate of pairwise disease combinations with significant comorbidity was higher in women than men (14.36% vs. 9.40%). Among psychiatric conditions, this rate was considerably high, with 41.76% in women and 39.01% in men. The highest percentages of elevated mental–physical comorbidity in women were found for musculoskeletal diseases (21.43%), digestive diseases (20.71%), and skin diseases (13.39%); in men, for musculoskeletal diseases (14.29%), neurological diseases (11.22%), and digestive diseases (10%). Implications include the need for integrating mental and physical health care services and a shift from a disease-centered to an individualized, patient-centered focus in clinical care.

Multimorbidity in patients living with and beyond cancer: protocol for a scoping review

INTRODUCTION

The number of people living with and beyond cancer is increasing rapidly. Many of them will experience ongoing physical or psychological sequelae as a result of their original cancer diagnosis or comorbidities arising from risk factors common to cancers and other long-term conditions. This poses the complex problem of managing cancer as a 'chronic' illness along with other existing comorbidities. This scoping review aims to map the literature available on multimorbidity in patients living with and beyond cancer, to explore, quantify and understand the impact of comorbid illnesses to inform work around cancer care in UK primary care settings.

METHODS AND ANALYSIS

This review will be guided by Joanna Briggs Institute Reviewer's manual for scoping reviews. A systematic literature search using Medical Subject Heading and text words related to cancer survivors and multimorbidity will be performed in MEDLINE, CINAHL, Embase and Web of Science, from 1990. Results will be described in a narrative style, reported in extraction tables and diagrams, and where appropriate in themes and text.

ETHICS AND DISSEMINATION

The scoping review will undertake secondary analysis of published literature; therefore, ethics committee approval is not required. Results will be disseminated through a peer-reviewed scientific journal and presented in relevant conferences. The scoping review will inform understanding of the burden of multimorbidity for cancer survivors, thus allow families, practitioners, clinicians and researchers to take the steps necessary to improve patient-centred care.

Comorbidities, Rather Than Older Age, Are Strongly Associated With Higher Utilization of Healthcare in Colorectal Cancer Survivors

BACKGROUND

Colorectal cancer (CRC) survivors generally have a higher healthcare utilization (HCU) than the general population due to cancer burden. However, it is unclear which factors are associated with this increased uptake. Our study aimed to (1) compare CRC-related and non-CRC visits to general practitioners (GPs) and medical specialists (MSs) by comorbidities, and (2) assess whether HCU differs by demographic, clinical, and psychological factors.

METHODS

We used data from a German population-based cohort of 1,718 survivors of stage I-III CRC diagnosed in 2003 through 2010 who provided information on HCU at 5-year follow-up. Multivariable linear regression was used to calculate least-square means of CRC-related and non-CRC HCU according to the Charlson comorbidity index and comorbidity cluster, adjusting for relevant demographic, clinical, and psychological characteristics.

RESULTS

A higher comorbidity level was associated with more CRC-related MS visits and non-CRC GP visits. In addition to being strongly associated with non-CRC GP visits, comorbidity clusters were associated with CRC-related GP and MS visits, but their association varied by specific cardiometabolic comorbidities. HCU was less dependent on prognostic factors for CRC, such as age and tumor stage, but was strongly associated with disease recurrence, depression, and emotional functioning.

CONCLUSIONS

Comorbidities, rather than age or tumor stage, were related to HCU, suggesting that CRC survivors use healthcare mainly for reasons other than cancer 5 years postdiagnosis. Improved communication between primary and tertiary healthcare providers could enhance the medical care of cancer survivors with complex health needs and thereby also reduce healthcare costs.

Multimorbid Patient Experiences With Primary Care at Community Health Centers in Shanghai, China

Objective: Primary care in China is facing mounting challenges with multimorbidity as the aging population grows. Knowing how patients experience primary care may highlight the deficiencies of the care system and guide health system reform. The purpose of this study was to compare the quality of primary care experienced by patients with and without multimorbidity at community health centers (CHCs) in Shanghai, China and to examine the factors influencing these experiences.

Methods: A cross-sectional survey was conducted from August to December 2019 using the validated Chinese Primary Care Assessment Tool-Adult Edition (PCAT-AE). ANOVA was performed to compare the overall and domain-specific quality of primary care for patients with and without multimorbidity. Multivariate linear regressions were used to assess the factors associated with primary care quality while controlling for patients' sociodemographic and healthcare characteristics.

Results: From 2,404 completed questionnaires, patients with multimorbidity reported higher PCAT scores in the domains of first contact-utilization (3.54 ± 0.55 vs. 3.48 ± 0.56, P < 0.01), accessibility (2.93 ± 0.49 vs. 2.86 ± 0.47, P < 0.001), and ongoing care (3.20 ± 0.39 vs. 3.14 ± 0.43, P < 0.001), while reporting lower scores in coordination (information system) (2.72 ± 0.41 vs. 2.79 ± 0.35, P < 0.001) and family-centeredness (3.23 ± 0.63 vs. 3.30 ± 0.64, P < 0.01). Multimorbidity (ß = 0.355, P < 0.01), education level (ß = 0.826, P < 0.01), district (suburb: ß = 1.475, P < 0.001), and self-perceived good health status (ß = 0.337, P < 0.05) were associated with better patient experiences in primary care. Patients between the age 61 and 70 (ß = −0.623, P < 0.001; >70 years: ß = −0.573, P < 0.01), with a monthly household income ≥6,000 RMB (ß = −1.385, P < 0.001) and with more than 20 outpatient visits the previous year (ß = −1.883, P < 0.001) reported lower total PCAT scores.

Conclusion: The findings of our study suggest that CHCs in China have contributed to better primary care experiences for patients with multimorbidity in certain quality domains, including first contact-utilization, accessibility, and ongoing care. However, there is still room for improvement in care coordination and family-centeredness.

Associations between multimorbidity and depression among breast cancer survivors within the UK Biobank cohort: a cross-sectional study

BACKGROUND

Advances in the early detection of cancer and its treatment have resulted in an increasing number of people living with and beyond breast cancer. Multimorbidity is also becoming more common in this population as more people live longer with breast cancer and experience late effects of cancer treatment. Breast cancer survivors have heightened risk of depression, but to what extent multimorbidity affects the mental health of this population is less clear. This study aims to investigate the association between multimorbidity and depression among women living with and beyond breast cancer in the UK Biobank cohort.

METHODS

Data from UK Biobank (recruitment during 2006 to 2010, aged 40-70 years) were used to identify 8438 women with a previous diagnosis of breast cancer via linked cancer registries in England, Scotland and Wales. The lifetime number of chronic conditions was self-reported and multimorbidity defined as 0, 1, 2, 3, 4 or 5+. The Patient Health Questionnaire (PHQ-2) was used to define participants that were likely to have depression based on their symptom reporting at baseline. Logistic regression models were used to analyse the associations between multimorbidity and depression, accounting for a number of potential sociodemographic confounding variables (including age, ethnicity, socioeconomic deprivation, education level and marital status) and characteristics related to the cancer (number of years since diagnosis and recurrence/secondary cancer).

RESULTS

Multimorbidity was common among breast cancer survivors, with 32.9% of women experiencing one and 30.1% experiencing two or more chronic health conditions. Hypertension (25.8%), painful conditions (18.3%), and asthma (11.6%) were the three most common co-morbid conditions. 5.3% of participants had current depression. A strong, dose-response relationship was found between multimorbidity and the likelihood of depression (OR = 2.09, 95% CI: 1.56-2.79 for two conditions and OR = 6.06, 95% CI: 3.63-10.14 for five or more conditions).

CONCLUSIONS

Multimorbidity and depression were strongly associated among female UK Biobank participants with a previous breast cancer diagnosis. This association became increasingly pronounced as the number of chronic comorbid conditions increased. As more people survive cancer for longer, increasing recognition and support for multimorbidity and its impact on mental health is needed.

Setting the research agenda for living with and beyond cancer with comorbid illness: reflections on a research prioritisation exercise

BACKGROUND

People living with and beyond cancer are more likely to have comorbid conditions and poorer mental and physical health, but there is a dearth of in-depth research exploring the psychosocial needs of people experiencing cancer and comorbid chronic conditions. A patient partnership approach to research prioritisation and planning can ensure outcomes meaningful to those affected and can inform policy and practice accordingly, but can be challenging.

METHODS

We aimed to inform priorities for qualitative inquiry into the experiences and support needs of people living with and beyond cancer with comorbid illness using a partnership approach. A three-step process including a patient workshop to develop a consultation document, online consultation with patients, and academic expert consultation was carried out. The research prioritisation process was also appraised and reflected upon.

RESULTS

Six people attended the workshop, ten responded online and eight academic experts commented on the consultation document. Five key priorities were identified for exploration in subsequent qualitative studies, including the diagnostic journey, the burden of symptoms, managing medications, addressing the needs of informal carers, and service provision. Limitations of patient involvement and reflections on procedural ethics, and the challenge of making measurable differences to patient outcomes were discussed.

CONCLUSIONS

Findings from this research prioritisation exercise will inform planned qualitative work to explore patients' experiences of living with and beyond cancer with comorbid illness. Including patient partners in the research prioritisation process adds focus and relevance, and feeds into future work and recommendations to improve health and social care for this group of patients. Reflections on the consultation process contribute to a broadening of understanding the field of patient involvement.