“We are currently undertaking this systematic review of the qualitative literature to gain a more comprehensive view of the elements that make up patient capacity and its constraints. This work underpins the current development of a clinical encounter communication tool to make patient capacity visible and useful in the co-creation of treatment plans (the Instrument for Patient Capacity Assessment, ICAN). We often catalog our systematic reviews in PROSPERO, however, due to the qualitative nature of this project we were unable to do so. We are currently screening full texts, and look forward to sharing this with the Minimally Disruptive Medicine Community upon its completion.” – Kasey Boehmer

Patient Capacity and Constraints in the Experience of Chronic Disease: A systematic review of the qualitative literature protocol

Background

Capacity refers to the available abilities and resources the patient can mobilize to address work demands, in healthcare and in life. Limitations to capacity impact the patient’s “ability or readiness to do work.” ¹

For patients, particularly those with chronic conditions, capacity is a finite construct that they must use to access and use healthcare and to enact their self-care, that is, to shoulder the workload of their treatment. This capacity is the same set of available abilities and resources that is used to enact their life roles, such as taking a child to daycare, and relate to their families, friends, and colleagues.

This capacity can be limited by aspects of poor or worsening health, the “burden of illness,” or by limited capabilities resulting from the patient’s life context. Through past research and clinical experience, our research unit has developed a working list of six domains of patient capacity: Personal, Physical, Mental, Social, Financial, and Environmental. Domains of capacity which are limited by the burden of illness are mental and physical capacity. Those that can be limited by scarcity, or difficulties in life context, are personal (busy, burnout, literacy), social (isolation), financial (poverty), and environmental (far distances, poor roads, limited communications).

Within each domain of capacity, the set of resources or abilities can be limited by specific factors that must be overcome. In health care, we can think of these limiters manifesting as barriers to the patient’s ability or resources to access and use health care services or to enact self-care practices. This relationship between a patient’s capacity to shoulder workload and its impact upon patients’ ability to access and use healthcare or enact self-care is described in the Cumulative Complexity Model (CuCoM). While strides have been made to characterize the patient’s workload as manifested in their burden of treatment,² as well as to create a measure to capture burden of treatment,^{3 4} a comprehensive view of patient capacity is lacking from the literature.

Aims

The primary aim of this review will be to identify qualitative descriptions of deficits in capacity or barriers that patients and experience in their lives that affect their ability to access or use healthcare or to enact self-care.

The purpose of this review is to inform the development of a tool for the clinical encounter that creates a conversation that quickly elicits the deficits in capacity that a patient with one or more chronic conditions faces in their daily lives to inform the development and modification of treatment plans. We do not anticipate that this review will create an exhaustive list of every domain and sub-domain of capacity that can be activated or mobilized, but yet that it will illuminate the practical deficits in capacity that must be considered between patients with chronic conditions, their caregivers, and clinicians.

Methods

To answer this question, we will conduct a systematic review of the qualitative literature from four databases (MEDLINE, EMBASE, Psychinfo, and CINAHL) and an environmental scan. The conduct of this review will be built upon much of the methodology described previously by Gallacher et al., for conducting qualitative systematic reviews of a novel construct, treatment burden.⁵

Our approach will be grounded in the Cumulative Complexity Model, and we will organize our findings based upon the six domains of capacity our research team has identified. Any barriers that we identify that fit outside the bounds of any of the six domains will be grouped into an “other” category, and will be analyzed separately to understand their fit with the model and its component domains.

Our first step will be to conduct scoping searches of the qualitative literature in order to pick up key articles that fit our inclusion criteria; this process will identify papers and key terms, with which reviewers should be familiar. As described previously by Gallacher et al., the scoping search includes ‘berry picking,’ in which groups of papers are discovered together, a preliminary search of databases, use of the ‘related articles’ function in PubMed, and consultation with experts in the field.⁵

We will include papers published in or after the year 2000 and use qualitative methodology through direct patient and/or caregiver contact through interactions such as in-depth interviews, focus groups, or ethnographic observations. Papers will be excluded if their primary unit of analysis is not the patient (i.e., patient-provider team, family, caregiver as a surrogate for the patient). We will exclude papers that use strictly quantitative methodology to answer their research question. Papers that are mixed methods will be included if their results presented give priority to the qualitative patient experience and seeks to triangulate the quantitative and qualitative data.⁶ Mixed methods papers that give priority to quantitative design and reporting, particularly following the instrument design model or the data transformation model will be excluded.⁶

We will include articles about patients’ experience with one or more chronic conditions. We will define chronic conditions according to the AHRQ definition:  a condition “that lasts 12 months or more and either limits self-care or independent living or requires ongoing medical intervention.” We will also include studies that focus not specifically on experience with a specific condition but also the experience of living with comorbidities and/or multimorbidity.

While papers will be excluded if the patient is not the primary unit of analysis, will account for in our analysis both patient accounts of barriers related to accessing and using healthcare or enacting self-care and that of their “informal caregivers,” where they appear in the included selection. By informal caregivers, we intend to capture people that interact with the patient regularly to assist with their care or activities of daily living, and are not paid for this role. Most often, the role of an informal caregiver is played by a spouse, family member, or friend.

We will include papers that discuss barriers the patient experience accessing and using health care; access and use includes both the availability of the services as well as the ability to realize the use of available services when it is needed or desired.⁷ We will also be looking to synthesize papers that discuss self-care activities required by the patient for the management of one or more of their chronic conditions or for the management of their overall health and wellness in the context of living with chronic conditions. These include, but are not limited to: activities that promote physical and psychological health, engaging with healthcare providers and adherence, monitoring and decision making.⁸ We will interpret barriers to mean any part of the patient experience that delay, prevent, or minimize their ability to access or use healthcare or enact self-care.

See appendix for full search strategy.

Screening

Papers will be screened in three stages: 1) after the initial search to review titles which will be retained; 2) abstract screening; and 3) full text screening. In each of these stages, each paper will be screened independently by two reviewers; all disagreements will be resolved by a third party. Papers will be excluded only if the two reviewers exclude for the same reason; all others will be sent to the third party for the final decision.

Data extraction

Data will be extracted using Distiller SR. We will extract at what time point in the patients’ disease trajectory the data were collected (i.e., at onset, treatment initiation, after living with the disease for specified period, etc.), the research question, theoretical frameworks used, sampling procedures, data collection method, data analysis method, overall conclusion of the study, limitations, and conflicts of interest.

Quality Appraisal

During the data extraction phase, we will also conduct a quality appraisal. Because qualitative research can be a broad and complex set of literature, and the methods for its evaluation diverse, we have selected a quality appraisal system previously published.⁹ This appraisal is a set of 16 questions that can be answered quickly on a 1 – 7 scale and covers clarity of research question, sampling, and methods; analytical practices such as iteration and grounding; reporting practices such as disclosure of internal processes and investigators’ frameworks; and impact on readers, participants, and theory. The quality appraisal will inform our analysis and discussion, rather than to classify or exclude papers.

Data Analysis

After full text screening and data extraction, PDFs will be imported into Nvivo 10. We will use three analysis techniques for metasynthesis of included studies: event timeline (relation to onset/diagnosis and the specific work trying to be accomplished in that point), Imported Concepts (not coming from the data but related and used to provide synthesis), Taxonomic Analysis (extraction of key findings and coding the relationships between components). If and where appropriate, we will provide a metasummary of the count of the occurrence of domains of capacity.

Results and Discussion sections will then be coded in a first round to import concepts from CuCoM, and those that identify descriptions of capacity deficits and barriers that patients encounter or must overcome when they attempt to access or use health care or enact their self-care. The initial round of coding will also import the capacity domains: Physical, Mental, Personal, Social, Financial, and Environmental. An additional coding category of “other” will be included to ensure that barriers that patients encounter but do not fit as a deficit in a specific domain are not excluded, but instead explored further. Finally, we will import the concept of “lifespace,” i.e., where in the patient’s life are they encountering these barriers (home, office, errands, healthcare, etc). The last concept will be particularly important in bringing forth capacity barriers that occur outside the healthcare lifespace for patients.

While CuCom will guide our underlying analysis, there is a lack of comprehensive understanding of patient capacity in the literature. Furthermore, how capacity operationalizes itself in the lives of patients and within the window of the clinical encounter is unclear. Our taxonomic analysis is intended to provide insight into some of these underlying questions for the development of our communication tool. We will conduct a second round of coding to examine the relationships between the imported concepts (CuCoM and capacity domains) within papers, as well as broader links between findings within all included papers.

Finally, we will attempt to create an event timeline of where in relation to diagnosis of a condition (or conditions) patients experience their barriers. Studies that are not specific in this regard will not be plotted. Our purpose of this part of the analysis is underpinned by our understanding of the Normalization Process Theory, and how patients normalize work that they do for their treatment.¹⁰ However, we do not understand precisely how patient capacity affects their ability to normalize treatment, and a visual appraisal of where this occurs may help further our understanding.

Bibliography

1. Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol 2012;65(10):1041-51.
2. Ridgeway JL, Egginton JS, Tiedje K, Linzer M, Boehm D, Poplau S, et al. Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Prefer Adherence 2014;8:339-51.
3. Eton DT, Elraiyah TA, Yost KJ, Ridgeway JL, Johnson A, Egginton JS, et al. A systematic review of patient-reported measures of burden of treatment in three chronic diseases. Patient Relat Outcome Meas 2013;4:7-20.
4. Eton DT, Ramalho de Oliveira D, Egginton JS, Ridgeway JL, Odell L, May CR, et al. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat Outcome Meas 2012;3:39-49.
5. Gallacher K, Jani B, Morrison D, Macdonald S, Blane D, Erwin P, et al. Qualitative systematic reviews of treatment burden in stroke, heart failure and diabetes – methodological challenges and solutions. BMC Med Res Methodol 2013;13:10.
6. Creswell JW, Fetters MD, Ivankova NV. Designing a mixed methods study in primary care. Ann Fam Med 2004;2(1):7-12.
7. Gulliford M, Figueroa-Munoz J, Morgan M, Hughes D, Gibson B, Beech R, et al. What does ‘access to health care’ mean? J Health Serv Res Policy 2002;7(3):186-8.
8. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med 2003;1(1):15-21.
9. Stiles WB. Evaluating Qualitative Research. Evid Based Mental Health 1999;2:99-101.
10. Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med 2011;9(3):235-43.

Appendix: Search Strategies

MEDLINE

1. *kidney failure, chronic/ or *”end-stage renal disease”/ or *”end-stage kidney disease”/ or *esrd/ or *eskd/ or *hemodialysis/ or (kidney failure, chronic or “end-stage renal disease” or “end-stage kidney disease” or esrd or eskd or hemodialysis).ti.
2. exp *diabetes/ or *diabet*/ or (diabetes or diabet*).ti.
3. exp *Heart Failure/
4. 3 or “cardiac failure”.ti. or “heart failure”.ti.
5. exp *neoplasms/ or cancer*.ti.
6. exp *cognition disorders/ or exp *dementia/ or dement*.ti. or alzheimer*.ti. or (cognitive* adj3 impair*).ti.
7. *hypertension/ or “high blood pressure”.ti. or hyperten*.ti.
8. exp *schizophrenia/ or schizophren*.ti.
9. *autism spectrum disorders/ or autism*.ti. or autistic*.ti.
10. exp *Substance-Related Disorders/
11. 10 or (substance adj abuse*).ti. or alcoholi*.ti.
12. exp *Hyperlipidemias/
13. 12 or hyperlipid*.ti. or hypercholesterol*.ti.
14. exp *arrhythmias, cardiac/ or exp *coronary disease/ or exp *myocardial infarction/
15. 14 or coronary.ti. or lvad*.mp. or *heart assist devices/ or “assist device*”.mp. or arrhythmia*.ti. or fibrillation*.ti. or tachycardia*.ti. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
16. depress*.ti. or exp *depression/ or exp *depressive disorders/
17. exp *osteoporosis/ or osteopor*.ti.
18. exp *arthritis/ or arthrit*.ti. or osteoarthr*.ti.
19. exp *HIV Infections/
20. 19 or aids.ti. or hiv.ti. or “acquired immunodeficien*”.ti.
21. exp *hepatitis/ or hepatitis*.ti.
22. *stroke/ or stroke*.ti. or “cerebrovascular accident*”.ti. or ((cerebral or intracranial) adj3 (thrombo* or infarct* or hemorrhag*)).ti.
23. 1 and (2 or 4 or 5 or 6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
24. 2 and (4 or 5 or 6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
25. 4 and (5 or 6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
26. 5 and (6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
27. 6 and (7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
28. 7 and (8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
29. 8 and (9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
30. 9 and (11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
31. 11 and (13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
32. 13 and (15 or 16 or 17 or 18 or 20 or 21 or 22)
33. 15 and (16 or 17 or 18 or 20 or 21 or 22)
34. 16 and (17 or 18 or 20 or 21 or 22)
35. 17 and (18 or 20 or 21 or 22)
36. 18 and (20 or 21 or 22)
37. 20 and (21 or 22)
38. 21 and 22
39. or/28-38
40. (burden* adj2 (treat* or therap*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
41. Activities of daily living/ or ADL.mp. or health behavior/ or health, knowledge, attitudes, practice/ or lifestyle.mp. or “life style”.mp. or palliat*.mp. or patient education as topic/ or “self care”.mp. or “self manage*”.mp. or barthel*.mp. or disabilit*.mp. or disabled*.mp. or “work capacity”.mp. or “functional disability*”.mp. or “functional limit*”.mp. or fatigue*.mp. or balance*.mp. or falls.mp. or falling.mp. or severity.mp. or falls, accidental/ or “social support”.mp. or supportive.mp. or family.mp. or interpersonal*.mp. or friend*.mp. or companion*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
42. (Mobility or transportation* or driving or walk* or gait or travel*).mp. or automobile driving/ or mobility limitation/ or tasks.mp. or work*.mp. or “job loss”.mp. or “loss of control”.mp. or locus of control/ or adaptation*.mp. or unemploy*.mp. or “self esteem”.mp. or independen*.mp. or dependent.mp. or “life chang*”.mp. or pleasure*.mp. or fear*.mp. or anxious.mp. or anxiety.mp. or leisure*.mp. or medication adherence/ or cope*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
43. coping.mp. or physician-patient relations/ or communicat*.mp. or partnership.mp. or socioeconomic*.mp. or psychosocial*.mp. or attitude*.mp. or acceptance of health care/ or acceptance.mp. or denial.mp. or choice*.mp. or resilien*.mp. or mobiliz*.mp. or mobilis*.mp. or “social conflict*”.mp. or “physical status”.mp. or “physical function*”.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
44. (Depress* or lonely or loneliness or rehabilitat* or “physical therapy” or stress* or disrupt* or recover* or challeng* or negotiat* or goal* or safe or unsafe or neighborhood or “self efficacy” or social* or isolat*).mp. or social isolation/ or costs.mp. or cost of illness/ or “drug costs”.mp. or insurance.mp. or insured.mp. or schedule*.mp. or appointment*.mp. or satisfaction.mp. or satisfy*.mp. or dissatisf*.mp. or suffer*.mp. or delegate*.mp. or qol.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
45. (“quality of life” or “well-being” or dysfunction* or community* or work or intimacy or intimate or emotion* or mood* or unmet or preference* or participat* or “side effect*” or emotion*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
46. Continuity of patient care/ or accessib*.mp. or needs.mp. or autonomy.mp. or (patient adj2 (care or experience* or understand* or expectation* or perspective* or perception* or satisfaction)).mp. or motivat*.mp. or incentiv*.mp. or disincentive*.mp. or compliant.mp. or noncompliant*.mp. or adheren*.mp. or nonadheren*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
47. (barrier* or disparit* or language* or education* or experiences or criminal or crime or (low* adj income*) or burden* or disjoint* or access).mp. or health care accessibility/ or distress.mp. or frustrat*.mp. or knowledge*.mp. or beliefs.mp. or expens*.mp. or “out of pocket”.mp. or spending.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
48. (multimorbid* or comorbid* or morbidities).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
49. (multiple adj3 (chronic or illness* or morbid* or disease* or condition*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
50. ((multi or co) adj morbid*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
51. “more chronic”.mp.
52. or/48-51
53. (“action research” or ethnograph* or ethmolog* or “grounded theory” or (qualitative adj2 (study or studies or data or evidence or synthesis or investigation)) or naturalistic or phenomenolog* or ((semistructured or motivational or structured) adj interview*) or “focus group*” or narrative* or narratolog* or “discourse analysis” or “content analysis” or “constant compar*” or “field stud*” or ((purposive or cluster* or snowball or convenience) adj2 sampl*) or (self adj report*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
54. “data saturation”.mp. or qualitative research/ or naturalistic.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
55. (audiotap* or videotap* or audiorecord* or videorecord*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
56. ((audio or video) adj (record* or tape* or taping)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
57. or/53-56
58. 39 and 57
59. or/40-47
60. 52 and chronic*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
61. 57 and 60
62. (58 or 61) and (59 or burden*.mp. or complex*.mp. or theme*.mp.) [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
63. limit 62 to (english language and yr=”2000 – 2014″)
64. 52 and 63

EMBASE

1. *kidney failure, chronic/ or *”end-stage renal disease”/ or *”end-stage kidney disease”/ or *esrd/ or *eskd/ or *hemodialysis/ or (kidney failure, chronic or “end-stage renal disease” or “end-stage kidney disease” or esrd or eskd or hemodialysis).ti.
2. exp *diabetes/ or *diabet*/ or (diabetes or diabet*).ti.
3. exp *Heart Failure/
4. 3 or “cardiac failure”.ti. or “heart failure”.ti.
5. exp *neoplasms/ or cancer*.ti.
6. exp *cognition disorders/ or exp *dementia/ or dement*.ti. or alzheimer*.ti. or (cognitive* adj3 impair*).ti.
7. *hypertension/ or “high blood pressure”.ti. or hyperten*.ti.
8. exp *schizophrenia/ or schizophren*.ti.
9. *autism spectrum disorders/ or autism*.ti. or autistic*.ti.
10. exp *Substance-Related Disorders/
11. 10 or (substance adj abuse*).ti. or alcoholi*.ti.
12. exp *Hyperlipidemias/
13. 12 or hyperlipid*.ti. or hypercholesterol*.ti.
14. exp *arrhythmias, cardiac/ or exp *coronary disease/ or exp *myocardial infarction/
15. 14 or coronary.ti. or lvad*.mp. or *heart assist devices/ or “assist device*”.mp. or arrhythmia*.ti. or fibrillation*.ti. or tachycardia*.ti. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
16. depress*.ti. or exp *depression/ or exp *depressive disorders/
17. exp *osteoporosis/ or osteopor*.ti.
18. exp *arthritis/ or arthrit*.ti. or osteoarthr*.ti.
19. exp *HIV Infections/
20. 19 or aids.ti. or hiv.ti. or “acquired immunodeficien*”.ti.
21. exp *hepatitis/ or hepatitis*.ti.
22. *stroke/ or stroke*.ti. or “cerebrovascular accident*”.ti. or ((cerebral or intracranial) adj3 (thrombo* or infarct* or hemorrhag*)).ti.
23. 1 and (2 or 4 or 5 or 6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
24. 2 and (4 or 5 or 6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
25. 4 and (5 or 6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
26. 5 and (6 or 7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
27. 6 and (7 or 8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
28. 7 and (8 or 9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
29. 8 and (9 or 11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
30. 9 and (11 or 13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
31. 11 and (13 or 15 or 16 or 17 or 18 or 20 or 21 or 22)
32. 13 and (15 or 16 or 17 or 18 or 20 or 21 or 22)
33. 15 and (16 or 17 or 18 or 20 or 21 or 22)
34. 16 and (17 or 18 or 20 or 21 or 22)
35. 17 and (18 or 20 or 21 or 22)
36. 18 and (20 or 21 or 22)
37. 20 and (21 or 22)
38. 21 and 22
39. or/28-38
40. (burden* adj2 (treat* or therap*)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
41. Activities of daily living/ or ADL.mp. or health behavior/ or health, knowledge, attitudes, practice/ or lifestyle.mp. or “life style”.mp. or palliat*.mp. or patient education as topic/ or “self care”.mp. or “self manage*”.mp. or barthel*.mp. or disabilit*.mp. or disabled*.mp. or “work capacity”.mp. or “functional disability*”.mp. or “functional limit*”.mp. or fatigue*.mp. or balance*.mp. or falls.mp. or falling.mp. or severity.mp. or falls, accidental/ or “social support”.mp. or supportive.mp. or family.mp. or interpersonal*.mp. or friend*.mp. or companion*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
42. (Mobility or transportation* or driving or walk* or gait or travel*).mp. or automobile driving/ or mobility limitation/ or tasks.mp. or work*.mp. or “job loss”.mp. or “loss of control”.mp. or locus of control/ or adaptation*.mp. or unemploy*.mp. or “self esteem”.mp. or independen*.mp. or dependent.mp. or “life chang*”.mp. or pleasure*.mp. or fear*.mp. or anxious.mp. or anxiety.mp. or leisure*.mp. or medication adherence/ or cope*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
43. coping.mp. or physician-patient relations/ or communicat*.mp. or partnership.mp. or socioeconomic*.mp. or psychosocial*.mp. or attitude*.mp. or acceptance of health care/ or acceptance.mp. or denial.mp. or choice*.mp. or resilien*.mp. or mobiliz*.mp. or mobilis*.mp. or “social conflict*”.mp. or “physical status”.mp. or “physical function*”.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
44. (Depress* or lonely or loneliness or rehabilitat* or “physical therapy” or stress* or disrupt* or recover* or challeng* or negotiat* or goal* or safe or unsafe or neighborhood or “self efficacy” or social* or isolat*).mp. or social isolation/ or costs.mp. or cost of illness/ or “drug costs”.mp. or insurance.mp. or insured.mp. or schedule*.mp. or appointment*.mp. or satisfaction.mp. or satisfy*.mp. or dissatisf*.mp. or suffer*.mp. or delegate*.mp. or qol.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
45. (“quality of life” or “well-being” or dysfunction* or community* or work or intimacy or intimate or emotion* or mood* or unmet or preference* or participat* or “side effect*” or emotion*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
46. Continuity of patient care/ or accessib*.mp. or needs.mp. or autonomy.mp. or (patient adj2 (care or experience* or understand* or expectation* or perspective* or perception* or satisfaction)).mp. or motivat*.mp. or incentiv*.mp. or disincentive*.mp. or compliant.mp. or noncompliant*.mp. or adheren*.mp. or nonadheren*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
47. (barrier* or disparit* or language* or education* or experiences or criminal or crime or (low* adj income*) or burden* or disjoint* or access).mp. or health care accessibility/ or distress.mp. or frustrat*.mp. or knowledge*.mp. or beliefs.mp. or expens*.mp. or “out of pocket”.mp. or spending.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
48. (multimorbid* or comorbid* or morbidities).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
49. (multiple adj3 (chronic or illness* or morbid* or disease* or condition*)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
50. ((multi or co) adj morbid*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
51. “more chronic”.mp.
52. or/48-51
53. (“action research” or ethnograph* or ethmolog* or “grounded theory” or (qualitative adj2 (study or studies or data or evidence or synthesis or investigation)) or naturalistic or phenomenolog* or ((semistructured or motivational or structured) adj interview*) or “focus group*” or narrative* or narratolog* or “discourse analysis” or “content analysis” or “constant compar*” or “field stud*” or ((purposive or cluster* or snowball or convenience) adj2 sampl*) or (self adj report*)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
54. “data saturation”.mp. or qualitative research/ or naturalistic.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
55. (audiotap* or videotap* or audiorecord* or videorecord*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
56. ((audio or video) adj (record* or tape* or taping)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
57. or/53-56
58. 39 and 57
59. or/40-47
60. 52 and chronic*.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
61. 57 and 60
62. (58 or 61) and (59 or burden*.mp. or complex*.mp. or theme*.mp.) [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
63. limit 62 to (english language and yr=”2000 – 2014″)
64. 52 and 63
65. 64 and (interview* and (“focus group” or qualitative* or sampl* or theme* or thematic*)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword]
66. information processing/ or content analysis/ or data synthesis/ or discourse analysis/ or thematic analysis/
67. 64 and 66
68. exp interview/
69. 64 and 68
70. 64 and expectation/
71. 64 and (personal experience/ or patient expectation/)
72. 65 or 67 or 69 or 70 or 71

PsycInfo

1. qualitative research/ or grounded theory/ or interviews/
2. exp Life Experiences/ or lived experience.mp.
3. content analysis/ or discourse analysis/
4. exp Chronic Illness/
5. ((multi or multiple) adj3 (chronic* or morbid*)).mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures]
6. exp Comorbidity/ or multimorbid*.mp.
7. or/1-3
8. 7 and (4 or 5 or 6)
9. exp Neoplasms/
10. exp memory disorders/ or exp brain disorders/ or exp cognitive impairment/
11. exp kidney diseases/
12. exp diabetes mellitus/
13. exp heart disorders/
14. exp schizophrenia/
15. exp Autism/
16. exp major depression/
17. exp Osteoporosis/
18. exp Hepatitis/
19. exp Cerebrovascular Accidents/ or exp Cerebral Ischemia/
20. exp hypertension/
21. 9 and (10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20)
22. 10 and (11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20)
23. 11 and (12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20)
24. 12 and (13 or 14 or 15 or 16 or 17 or 18 or 19 or 20)
25. 13 and (14 or 15 or 16 or 17 or 18 or 19 or 20)
26. 14 and (15 or 16 or 17 or 18 or 19 or 20)
27. 15 and (16 or 17 or 18 or 19 or 20)
28. 16 and (17 or 18 or 19 or 20)
29. 17 and (18 or 19 or 20)
30. 18 and (19 or 20)
31. 19 and 20
32. or/21-31
33. 7 and 32
34. 8 or 33
35. limit 34 to (english language and yr=”2000 – 2015″)

CINAHL