Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice. The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases. All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity. Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.

中文翻译：

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初级保健的卒中随访：一项关于多发病率对指南依从性影响的挪威建模研究

专业的急性治疗和高质量的随访旨在降低卒中的死亡率和残疾。虽然中风的急性治疗是在医院进行的，但中风幸存者的随访大部分是在一般实践中进行的。国家准则为后续行动提供了建议。但是，以前的研究表明，指南没有得到足够的遵守。已经提出，这可能是由于一般实践的复杂性。这种复杂性的一部分是由患者的多发病率引起的。同一个人中存在两个或多个慢性病。在这项研究中，我们调查了社区中风幸存者中多发病的程度。目的是评估在一般实践中多发病对中风随访的影响。这项研究是对挪威中部卒中幸存者中多发病率的横断面分析。我们纳入了51位患者，并在18个不同的诊所与全科医生一起列出。该材料包括这些患者的全科医生医疗记录。在搜索中查找了每个患者的病历，以查找与预定义的发病率列表相对应的诊断，从而得出每个参与者的慢性病列表。这51个列表是后续分析的基础。在此分析中，我们对不同的假设患者进行了建模，并评估了遵守影响其疾病的所有临床指南的意义。所有51例患者均符合多发病标准。平均而言，患者为4.7（标准差：1。9）与预定的发病率清单相对应的慢性病。通过对平均合并症患者的指南依从性的影响进行建模，我们发现对慢性病稳定状态的随访需要与全科医生进行10-11次年度咨询。对于具有更多复杂性的多发病的患者，需要更多的咨询。在一般实践中，多发性疾病对卒中患者的随访有明显的影响。即使对于合并症很少的患者，也要遵守每种情况的指导原则。对于患有多种疾病的患者，遵守指南显然是难以控制的。我们发现，对于慢性病稳定状态的随访，需要与全科医生进行10-11次年度咨询。对于具有更多复杂性多发病的患者，需要更多的咨询。在一般实践中，多发性疾病对卒中患者的随访有明显的影响。即使对于合并症很少的患者，也要遵守每种情况的指导原则。对于患有多种疾病的患者，遵守指南显然是难以控制的。我们发现，对于慢性病稳定状态的随访，需要与全科医生进行10-11次年度咨询。对于具有更多复杂性的多发病的患者，需要更多的咨询。在一般实践中，多发性疾病对卒中患者的随访有明显的影响。即使对于合并症很少的患者，也要遵守每种情况的指导原则。对于患有多种疾病的患者，遵守指南显然是难以控制的。即使对于合并症很少的患者，也要遵守每种情况的指导原则。对于患有多种疾病的患者，遵守指南显然是难以控制的。即使对于合并症很少的患者，也要遵守每种情况的指导原则。对于患有多种疾病的患者，遵守指南显然是难以控制的。