The questionnaire included socio-demographics (age, sex, native language, occupation, marital status, income), the Disease Burden Morbidity Assessment (DBMA) [38, 39] (comorbidity score), the reference standard IMSA [34, 35], and 12 preliminary questions to develop the case-finding tool, which are available in Additional file 1. Data collection took approximately 40 min per patient (time to explain the study, obtain consent, complete the questionnaire).

We selected 12 questions, already validated, that are associated with complex health needs, based on previous work [4043]. These questions concerned perceived healthcare status (Statistics Canada) [44], insurance healthcare plan [45], social support (Statistics Canada) [46], limitations due to chronic pain (Statistics Canada) [47], psychological distress (K6) [48], alcohol consumption (Statistics Canada) [46], drug use (Statistics Canada) [46], income (Statistics Canada) [49], perception of financial status (Statistics Canada) [50], met or unmet health needs (new question), feeling of having complicated problems (new question), self-efficacy for managing health (new question). Most questions were initially rated on a 4–5 categorical scale (except for alcohol consumption and drug use).

IMSA is a self-administered version of the INTERMED questionnaire that helps to measure the complexity of health needs in an adult patient by evaluating the medical, psychological and social spheres. The first version of INTERMED was developed in the 1990s by an international team that combined their research expertise on complexity in order to empirically develop a measuring instrument [51]. Its psychometric qualities [5254] are well documented. INTERMED presents good validity to predict greater use of services [5557].

IMSA, which was used in this study, has been available since 2016 [34]. It includes 20 questions subdivided into four domains: Biological, Psychological, Social, and Health system. Every domain is divided into three-time segments: History, Current State, and Vulnerability/Prognosis. Three of the questions have one or more sub-questions. All IMSA items are scored on a four-level rating scale. The rating scores range from 0 to 3, representing no evidence of a symptom, disturbance or healthcare need (0) to evidence of complex symptoms or healthcare needs (3). The maximum total score of the IMSA is 60. A score of 19 or higher indicates complex health needs. A French-language version is available as well as a guide explaining how to complete the questionnaire [58]. The correlations between the total score and the subscales of the IMSA, as compared to the initial INTERMED questionnaire, were high (total score: r = 0.79) (95%-CI: [0.70; 0.85]). Cronbach’s α was 0.77, and construct validity was high (SF-36 mental component score: r = − 0.57; HADS Depression: r = 0.59) [34].

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