{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T15:28:02Z","timestamp":1785252482444,"version":"3.55.0"},"reference-count":35,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2024,1,18]],"date-time":"2024-01-18T00:00:00Z","timestamp":1705536000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["203919"],"award-info":[{"award-number":["203919"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["NIHR201708"],"award-info":[{"award-number":["NIHR201708"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"name":"NIHR Senior Investigator Award","award":["NIHR203745"],"award-info":[{"award-number":["NIHR203745"]}]},{"name":"Research, Evidence and Development Initiative (READ-It), funded by UK aid from the UK government","award":["300342-104"],"award-info":[{"award-number":["300342-104"]}]}],"content-domain":{"domain":["openresearch.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["NIHR Open Res"],"abstract":"<ns3:p>Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub\u2013Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (\u226518 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng\u2019ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.<\/ns3:p>","DOI":"10.3310\/nihropenres.13512.1","type":"journal-article","created":{"date-parts":[[2024,1,18]],"date-time":"2024-01-18T05:25:06Z","timestamp":1705555506000},"page":"2","update-policy":"https:\/\/doi.org\/10.3310\/nihropenres.crossmark-policy","source":"Crossref","is-referenced-by-count":12,"title":["Multimorbidity-associated emergency hospital admissions: a \u201cscreen and link\u201d strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol"],"prefix":"10.3310","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8451-7514","authenticated-orcid":false,"given":"Stephen 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T.","family":"Mmbaga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juma","family":"Mfinanga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rhona","family":"Mijumbi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adamson","family":"Muula","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mulinda","family":"Nyirenda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Rosu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Rubach","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sangwani","family":"Salimu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francis","family":"Sakita","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charity","family":"Salima","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0395-5385","authenticated-orcid":false,"given":"Hendry","family":"Sawe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2130-0673","authenticated-orcid":false,"given":"Ibrahim","family":"Simiyu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5377-2536","authenticated-orcid":false,"given":"Miriam","family":"Taegtmeyer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Urasa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"White","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9659-7926","authenticated-orcid":false,"given":"Nateiya 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status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.3310\/nihropenres.14663.r31181, Rifqah Abeeda Roomaney, South African Medical Research Council, Cape Town, 14 Mar 2024, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/4-2\/v1#referee-response-31181","order":0,"name":"referee-response-31181","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Stephen Spencer<\/b>; \n<i>Posted: 22 Apr 2024<\/i>; \n<i>We would like to take the opportunity to thank the reviewer for their time and thoughtful consideration. We have carefully addressed all comments and updated the manuscript which we believe is now much improved. <\/i>  \n<b>Reviewer\u2019s comment<\/b> Introduction Can the authors elaborate on why there has been an increase in life expectancy in Malawi and Tanzania? Although I can guess why, it would be better for the authors to state.  \n<b>Authors\u2019 reply<\/b> \n<i>Thank you for this suggestion. We have provided explanations (with references) for improvements in life expectancy in Malawi and Tanzania (improvements in prevention and treatment for infectious diseases, particularly HIV\/AIDS, Tuberculosis and Malaria, as well as improvements in maternal and child survival).<\/i>  \n<b>Reviewer\u2019s comment<\/b> Objectives The authors have justified why they are interested in certain pre-selected diseases. They may want to consider the existence of other diseases (even if self-report) to control for confounding in the analysis. The same goes for body mass index. I note that this is addressed by the authors in the limitations.&nbsp;  \n<b>Authors\u2019 reply<\/b> \n<i>We agree. In the objectives section we have highlighted that we are focussing on the four pre-selected diseases using gold-standard diagnostic criteria to inform the design of our planned trial. We have added an additional objective: to measure the prevalence of self-reported \/ clinically-reported chronic diseases.&nbsp; <\/i>  \n<b>Reviewer\u2019s comment<\/b> Can the authors elaborate on why admissions for primary trauma are excluded?  \n<b>&nbsp;Authors\u2019 reply<\/b> \n<i>We acknowledge and agree that trauma is an increasing burden of health systems and an important area to develop context-sensitive policies to improve outcomes. We opted to focus on medical populations as there are existing studies in this context (e.g. <\/i>\n<i>https:\/\/doi.org\/10.1016\/S2214-109X(23)00346-7<\/i>\n<i>; doi: 10.2471\/BLT.23.290755), and health system interventions are for these groups are being addressed. We have made this clearer in the list of exclusions.<\/i>","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/4-2\/v1#referee-comment-3319","order":1,"name":"referee-comment-3319","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.14663.r31103, Claire Rosen, University of Pennsylvania, Philadelphia, PA, 12 Apr 2024, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/4-2\/v1#referee-response-31103","order":2,"name":"referee-response-31103","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Stephen Spencer<\/b>; \n<i>Posted: 22 Apr 2024<\/i>; \n<b>Reviewer\u2019s comment<\/b> I have a few small suggestions that I think would improve this project. To start, the definition of multimorbidity in the literature is not strictly defined as &quot;two or more comorbidities&quot;. In fact, there has been a decent amount of debate in the literature over the ideal definition of multimorbidity. Furthermore, the authors are specifically looking at HIV, hypertension, diabetes, and chronic kidney disease. As such, it would be more honest of an approach to describe the aims and study to be that of understanding the prevalence of specific common comorbid conditions to the populations of interest, and the impact of those comorbidities on outcomes. Either way, a clarification that &quot;multimorbidity&quot; is not universally defined (e.g. &quot;though there are multiple proposed definitions of multimorbidity, we choose to define multimorbidity as X because Y&quot;) and that the study is specifically looking at diseases of importance to the study population (HIV, hypertension, diabetes, and chronic kidney disease) is necessary.  \n<b>Authors\u2019 reply<\/b> \n<i>Thank you very much for your suggestion. We agree and have modified the final paragraph in the introduction section;&nbsp; we have highlighted that there limitations with the definition, particularly to different contexts (and provided an additional reference); and clarified that we will focus on HIV, hypertension, diabetes and chronic kidney disease. <\/i>  \n<b>Reviewer\u2019s comment<\/b> In your methods for this study, you mention that you will include patients with a &quot;physician diagnosis of an acute medical disorder&quot;. How will this be judged? Is it from the clinical records? Claims data? Do you have a proposed list of medical disorders that you plan to include?  \n<b>Authors\u2019 reply<\/b> \n<i>Thank you for highlighting this was not clear. Inclusion was based on capture of acute medical disorder from medical records, using ICD codes. The Inclusion criteria in the manuscript has been updated to reflect this. <\/i>  \n<b>Reviewer\u2019s comment<\/b> Finally, in your plans for Phase 1a analysis, you note that you plan to use logistic regression. It would be helpful to clearly define your planned covariates, or how you intend to select covariates for your regression model. Further, you mention multiple outcomes - as such, would be sure to clarify how you will define statistical or clinical significance, and how this will be adjusted for multiple outcomes (e.g. Bonferroni).  \n<b>Authors\u2019 reply<\/b> \n<i>Thank you for raising this. We will publish a statistical analysis plan (SAP) as a component of our reporting, which is over-seen by the study statistician (Dr Sarah White). We plan to publish this separately on an online repository (see updated \u2018Analysis\u2019 section).<\/i>","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/4-2\/v1#referee-comment-3320","order":3,"name":"referee-comment-3320","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.14663.r31249, Phuong Bich Tran, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, 22 Apr 2024, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/4-2\/v1#referee-response-31249","order":4,"name":"referee-response-31249","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This project is funded by the National Institute for Health and Care Research (NIHR) under its \u2018Research and Innovation for Global Health Transformation\u2019 (Grant Reference Number NIHR201708). This research was funded by the NIHR (NIHR201708) using UK aid from the UK Government to support global health research. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. In addition, this research is supported by a number of individual grants. This research is funded in part by the Wellcome Trust [Wellcome Trust Clinical PhD Fellowship awarded to SAS: Grant number 203919]. PD is also supported by a NIHR Senior Investigator award [NIHR203745]. This publication is associated with the Research, Evidence and Development Initiative (READ-It). READ-It (project number 300342-104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government\u2019s official policies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":5,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}