Defining chronic conditions for primary care with ICPC-2

Association of polydoctoring and mortality among persons over 85 years with multimorbidity: a prospective cohort study in Japan

BACKGROUND

Polydoctoring can increase the risk of care fragmentation among patients with multimorbidity, but its impact on health outcomes remains unclear.

AIM

To determine the effects of polydoctoring, as measured by the regularly visited facilities (RVF) indicator, on patient outcomes among older individuals with multimorbidity.

DESIGN & SETTING

Data from the ongoing prospective cohort study, Kawasaki Aging and Wellbeing Project (KAWP), was utilised in this study. Among the 1026 KAWP participants aged 85-89 years, those with two or more chronic conditions were enrolled in this study.

METHOD

Care fragmentation and polydoctoring was evaluated using the RVF, which is a new indicator that measures the number of medical facilities consistently involved in a patient's care. Based on RVF, mortality was analysed using the Cox proportional hazards model, with adjustments for age, sex, frailty, and number of comorbidities.

RESULTS

A significant reduction in mortality rates was observed in participants with an RVF of ≥3 and 2-4 comorbidities (hazard ratio [HR] 0.43, 95% confidence interval [CI] = 0.18 to 0.99, P value = 0.048). However, no significant difference in mortality based on RVF was observed for those with ≥5 comorbidities. Notably, individuals with ≥5 comorbidities and an RVF of 0 had a significantly higher HR for death (HR 2.68, 95% CI = 1.05 to 6.84, P value = 0.039).

CONCLUSION

In older patients with multimorbidity, polydoctoring may reduce mortality in patients with ≤4 coexisting conditions, but it does not significantly impact mortality in those with ≥5 conditions. These findings provide insights for healthcare decision making in managing older patients with multimorbidity.

Influence of social determinants of health on quality of life in patients with multimorbidity and polypharmacy

BACKGROUND

Multimorbidity is one of the biggest challenges faced by modern medicine, especially when managing older patients who are also often taking multiple medications. Multimorbidity is influenced by social determinants of health, giving rise to health inequalities in the population. Here, we sought to determine the influence of social determinants of health on quality of life in patients with multimorbidity and polypharmacy.

METHODS AND MATERIALS

This cross-sectional observational study included 573 patients aged 65-74 with multimorbidity (≥3 diseases) and polypharmacy (≥5 drugs). Corresponding data was taken drawn from the Spanish MULTIPAP study, and included social and demographic variables, and data on health-related quality of life and overall self-perceived health status, assessed using the 5-level version of the EuroQol 5-dimensional questionnaire (EQ-5D-5L). Descriptive, bivariate and multivariate analyses with logistic regression models were performed.

RESULTS

Mean patient age was 69.7 years, 55.8% of patients were female, 59.7% belonged to low social classes (V, VI), a monthly income of €1051-€1850 predominated, and the median number of diseases in the same patient was 6. Factors associated with higher quality of life were (odds ratio, OR) male gender (OR = 1.599, p = 0.013), a higher educational level (OR = 1.991, p = 0.036), an absence of urban vulnerability (OR = 1.605, p = 0.017), and the presence of medium social support (OR = 1.689, p = 0.017). Having a higher number of diseases was associated with poorer quality of life (OR = 0.912, p = 0.017).

CONCLUSIONS

Our findings describe associations between social determinants of health and quality of life in patients aged 65-74 years with multimorbidity and polypharmacy. More illnesses, female gender, a lower education level, urban vulnerability, and less social support are associated with poorer quality of life, underscoring the need for a biopsychosocial approach in patient care.

Validation of the 40-Item and 24-Item Short Version of the Person-Centred Obesity Care Instrument for Patients Living with Obesity

INTRODUCTION

Person-centred care (PCC) may hold promise for improved healthcare experiences and outcomes among patients living with obesity. A validated instrument to assess the delivery of PCC to patients living with obesity is, however, currently lacking. This study aimed to validate such an instrument. In this article, we describe the development and psychometric testing of the 40-item and 24-item short version of the Person-Centred Obesity Care (PCOC) instrument.

METHODS

A total of 590 individuals living with obesity (BMI 33.4 ± 3.9) from a representative Dutch sample completed the 49-item PCOC instrument measuring the eight dimensions of PCC (patient preferences, physical comfort, coordination of care, emotional support, access to care, continuity and transition, information and education, and family and friends), and two measures of satisfaction with care. We performed confirmatory factor analyses to verify the factor structure of the instrument and examined its reliability and validity.

RESULTS

Fit indicators of the first model with all 49 items showed that the model left room for improvement (comparative fit index [CFI] <0.90). A 40-item version was obtained with satisfactory-to-good fit (standardized root mean square residual [SRMR] = 0.05, root mean square error of approximation [RMSEA] = 0.06, CFI = 0.90). The instrument demonstrated good reliability, and the relationship between the PCOC and two indicators of satisfaction with care supported the validity of the scale. Shortening the instrument only further improved the fit indicators, resulting in the development of a 24-item short version (SRMR = 0.04, RMSEA = 0.05, CFI = 0.96), with similar results in terms of reliability and validity.

CONCLUSION

The 40-item PCOC instrument and the 24-item short version showed to be reliable and valid instruments for the assessment of PCC among patients living with obesity. Based on the results, the 40 and 24-item PCOC are promising tools that can be used by clinicians and researchers to explore PCC delivery for patients living with obesity.

The relationship between person-centred care and well-being and satisfaction with care of patients living with obesity

Person-centred care (PCC) is associated with improved patient well-being and higher levels of satisfaction with care but its impact on individuals living with obesity is not well-established. The main aim of this study was to assess the relationship between PCC and the physical and social well-being of patients living with obesity, as well as their satisfaction with care. This study is based on a cross-sectional, web-based survey administered among a representative panel of Dutch individuals living with obesity. The primary outcomes were physical and social well-being and satisfaction with care. The primary exposure was a rating of overall PCC, encompassing its eight dimensions. In addition, covariates considered in the analyses included sex, age, marital status, education level, body mass index, and chronic illness. The data from a total of 590 participants were analysed using descriptive statistics, correlation analyses, and multiple regression analyses. Among PCC dimensions, participants rated 'access to care' the highest (M 4.1, SD 0.6), while 'coordination of care' (M 3.5, SD 0.8) was rated lower than all other dimensions. Participants' overall PCC ratings were positively correlated with their physical (r = 0.255, P < .001) and social well-being (r = 0.289, P < .001) and their satisfaction with care (r = 0.788, P < .001), as were the separate dimension scores. After controlling for sex, age, marital status, education level, body mass index, and chronic illness in the regression analyses, participants' overall PCC ratings were positively related to their physical (β = 0.24, P < .001) and social well-being (β = 0.26, P < .001), and satisfaction with care (β = 0.79, P < .001). PCC holds promise for improved outcomes among patients living with obesity, both in terms of physical and social well-being, as well as satisfaction with care. This is an important finding, particularly when considering the profound physical, social, and psychological consequences associated with obesity. In addition to highlighting the potential benefits of PCC in the healthcare of individuals living with obesity, the findings offer valuable insights into strategies for further refining the provision of PCC to meet the specific needs of these patients.

School absence legislation governing in Norway, Sweden and Denmark for children with chronic illness in compulsory education-A comparative study

BACKGROUND

Health and education are interrelated and influence social, economic and lifestyle perspectives. Children with chronic illnesses experience barriers in the educational system regarding school attendance and social isolation. Gaining knowledge of compulsory education and how children with chronic illnesses are supported is crucial for the implications of future education policy and legislation in Scandinavia. This study compares Scandinavian legislation frameworks on compulsory education, chronic illness and school absence to form the basis of future research on education for children with chronic illness.

METHODS

The study uses a comparative approach to explore the support of children with chronic illnesses in compulsory education across Norway, Sweden and Denmark. The documents included are 3 education acts and 15 secondary documents, which are notes and guidelines for the education acts. The data were analysed using a manifest content analysis.

FINDINGS

We found four categories and six subcategories: (1) school obligation and rights; (2) chronic illness; (3) school absence: (a) categorisation of absence; (b) registration of absence; and (c) sanction; and (4) education support: (a) Hospital school support; (b) Home instruction support; and (c) technological support.

CONCLUSION

This study's findings demonstrate the similarities and differences in the Scandinavian compulsory education legislation and guidelines regarding chronic illness and school absence. We found similarities across the countries regarding chronic illness and school absence. Still, the findings showed differences in the systematic registration of school absence and requirements for attendance with compulsory education in Norway and Denmark compared with compulsory schooling in Sweden. This knowledge will inform and enlighten future discussions and decisions in education and public health. The results can contribute to awareness of the opportunities for educational support and perspectives about education for children with chronic illnesses. Future research focusing on the experience of children with chronic illness and educational support is needed.

Disease Trajectories from Healthcare Data: Methodologies, Key Results, and Future Perspectives

Disease trajectories, defined as sequential, directional disease associations, have become an intense research field driven by the availability of electronic population-wide healthcare data and sufficient computational power. Here, we provide an overview of disease trajectory studies with a focus on European work, including ontologies used as well as computational methodologies for the construction of disease trajectories. We also discuss different applications of disease trajectories from descriptive risk identification to disease progression, patient stratification, and personalized predictions using machine learning. We describe challenges and opportunities in the area that eventually will benefit from initiatives such as the European Health Data Space, which, with time, will make it possible to analyze data from cohorts comprising hundreds of millions of patients.

Implementation of a virtual community of practice to promote the empowerment of middle-aged people with multimorbidity: study protocol of a randomised controlled trial

INTRODUCTION

Empowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool for fostering patient empowerment and is mostly provided on an individual basis. Virtual communities of practice (VCoP) present a unique opportunity for online education in chronic condition self-management within a social context. This research aims to evaluate the effectiveness/cost-effectiveness of individualised, online self-management education compared with VCoP among middle-aged individuals living with multiple chronic conditions.

METHODS AND ANALYSIS

People aged 30-60, living with ≥2 chronic conditions and receiving care in primary care (PC) centres and outpatient hospital-based clinics in Madrid and Canary Islands will enrol in an 18-month parallel-design, blinded (intervention assessment and data analysts), pragmatic (adhering to the intention-to-treat principle), individually randomised trial. The trial will compare two 12-month web-based educational offers of identical content; one delivered individually (control) and the other with online social interaction (VCoP, intervention). Using repeated measures mixed linear models, with the patient as random effect and allocation groups and time per group as fixed effects, we will estimate between-arm differences in the change in Patient Activation Measure from baseline to 12 months (primary endpoint), including measurements at 6-month and 18-month follow-up. Other outcomes will include measures of depression and anxiety, treatment burden, quality of life. In addition to a process evaluation of the VCoP, we will conduct an economic evaluation estimating the relative cost-effectiveness of the VCoP from the perspectives of both the National Health System and the Community.

ETHICS AND DISSEMINATION

The trial was approved by Clinical Research Ethics Committees of Gregorio Marañón University Hospital in Madrid/Nuestra Señora Candelaria University Hospital in Santa Cruz de Tenerife. The results will be disseminated through workshops, policy briefs, peer-reviewed publications and local/international conferences.

TRIAL REGISTRATION NUMBER

NCT06046326.

Predicting anticipated benefit from an extended consultation to personalise care in multimorbidity: a development and internal validation study of a prioritisation algorithm in general practice

BACKGROUND

Persons with multimorbidity may gain from person-centred care compared with the current protocolised chronic-disease management in Dutch general practice. Given time constraints and limited resources, it is essential to prioritise those most in need of an assessment of person-centred chronic-care needs.

AIM

To develop and validate a prioritisation algorithm based on routine electronic medical record (EMR) data that distinguishes between patients with multimorbidity who would, and those who would not, benefit from an extended person-centred consultation to assess person-centred chronic-care needs, as judged by GPs.

DESIGN AND SETTING

A mixed-methods study was conducted in five general practices in the north-west region of the Netherlands. Four out of the five practices were situated in rural areas.

METHOD

Multivariable logistic regression using EMR data to predict the GPs' judgement on patients' anticipated benefit from an extended consultation, as well as a thematic analysis of a focus group exploring GPs' clinical reasoning for this judgement were conducted. Internal validation was performed using 10-fold cross-validation. Multimorbidity was defined as the presence of ≥3 chronic conditions.

RESULTS

In total, EMRs from 1032 patients were included in the analysis; of these, 352 (34.1%) were judged to have anticipated benefit. The model's cross-validated C-statistic was 0.72 (95% confidence interval = 0.70 to 0.75). Calibration was good. Presence of home visit(s) and history of myocardial infarction were associated with anticipated benefit. Thematic analysis revealed three dimensions feeding anticipated benefit: GPs' cause for concern, patients' mindset regarding their conditions, and balance between received care/expected care needed.

CONCLUSION

This algorithm may facilitate automated prioritisation, potentially avoiding the need for GPs to personally triage the whole practice population that has multimorbidity. However, external validation of the algorithm and evaluation of actual benefit of consultation is recommended before implementation.

Psychological Constructs From the Fear Avoidance Model and Beyond as Predictors for Persisting Symptoms After Concussion: An Integrative Review

OBJECTIVES

To identify the range of evidence for relationships between psychological factors using the Fear Avoidance Model (FAM) as a guiding framework and relevant clinical outcomes in adult patients with persisting symptoms after concussion (PSaC), develop a comprehensive understanding of psychological factors that have been identified as predictors of clinical outcomes for PSaC, and contribute to the theoretical framework of the FAM for PSaC.

DATA SOURCES

Six databases (CINAHL, Embase, PsycINFO, PubMed, SportDiscus, and Web of Science) were searched by a librarian for empirical and theoretical publications and experimental and quasi-experimental study designs. The literature search was not limited by publication date restrictions. Gray literature, with the exception of doctoral dissertations, was excluded.

STUDY SELECTION

We included studies in the English language consisting of human participants aged ≥18 years. Articles must have included both outcomes pertaining to PSaC (≥3mo after injury) and psychological constructs.

DATA EXTRACTION

One reviewer extracted data from the resulting studies using a standardized data extraction form designed for this review. Two reviewers independently assessed risk of bias using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

This review found numerous psychological constructs, some directly linked to the FAM, that have potential prognostic relationships with PSaC. However, research remains limited and some psychological factors central to FAM were only identified in a small number of studies (catastrophizing, cogniphobia, and avoidance), whereas other psychological factors were studied more extensively (anxiety and depression).

CONCLUSIONS

There is the need for additional evidence, and this integrative review provides an adaptation of the FAM for PSaC to be used as a guiding preliminary framework for future research. Future research should aim to include psychological factors proposed in this modified FAM to fully understand PSaC.

A Technological Tool Aimed at Self-Care in Patients With Multimorbidity: Cross-Sectional Usability Study

BACKGROUND

Information and communication technologies (ICTs) have been positioned as useful tools to facilitate self-care. The interaction between a patient and technology, known as usability, is particularly important for achieving positive health outcomes. Specific characteristics of patients with chronic diseases, including multimorbidity, can affect their interaction with different technologies. Thus, studying the usability of ICTs in the field of multimorbidity has become a key element to ensure their relevant role in promoting self-care.

OBJECTIVE

The aim of this study was to analyze the usability of a technological tool dedicated to health and self-care in patients with multimorbidity in primary care.

METHODS

A descriptive observational cross-sectional usability study was performed framed in the clinical trial in the primary care health centers of Madrid Health Service of the TeNDER (Affective Based Integrated Care for Better Quality of Life) project. The TeNDER technological tool integrates sensors for monitoring physical and sleep activity along with a mobile app for consulting the data collected and working with self-management tools. This project included patients over 60 years of age who had one or more chronic diseases, at least one of which was mild-moderate cognitive impairment, Parkinson disease, or cardiovascular disease. From the 250 patients included in the project, 38 agreed to participate in the usability study. The usability variables investigated were effectiveness, which was determined by the degree of completion and the total number of errors per task; efficiency, evaluated as the average time to perform each task; and satisfaction, quantified by the System Usability Scale. Five tasks were evaluated based on real case scenarios. Usability variables were analyzed according to the sociodemographic and clinical characteristics of patients. A logistic regression model was constructed to estimate the factors associated with the type of support provided for task completion.

RESULTS

The median age of the 38 participants was 75 (IQR 72.0-79.0) years. There was a slight majority of women (20/38, 52.6%) and the participants had a median of 8 (IQR 7.0-11.0) chronic diseases. Thirty patients completed the usability study, with a usability effectiveness result of 89.3% (134/150 tasks completed). Among the 30 patients, 66.7% (n=20) completed all tasks and 56.7% (17/30) required personalized help on at least one task. In the multivariate analysis, educational level emerged as a facilitating factor for independent task completion (odds ratio 1.79, 95% CI 0.47-6.83). The median time to complete the total tasks was 296 seconds (IQR 210.0-397.0) and the median satisfaction score was 55 (IQR 45.0-62.5) out of 100.

CONCLUSIONS

Although usability effectiveness was high, the poor efficiency and usability satisfaction scores suggest that there are other factors that may interfere with the results. Multimorbidity was not confirmed to be a key factor affecting the usability of the technological tool.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05681065; https://clinicaltrials.gov/study/NCT05681065.

Perceived weight stigma in healthcare settings among adults living with obesity: A cross-sectional investigation of the relationship with patient characteristics and person-centred care

INTRODUCTION

Patients living with obesity often experience weight stigma in healthcare settings, which has worrying consequences for their healthcare experiences. This cross-sectional study aimed to: (1) provide an overview of stigmatising experiences in healthcare settings reported by adults living with varying classes of obesity, (2) identify associations among patient characteristics and perceived weight stigma and (3) investigate the association between perceived weight stigma and person-centred care (PCC).

METHODS

Dutch adults living with obesity classes I (body mass index [BMI]: 30 to <35 kg/m2; n = 426), II (BMI: 35 to <40 kg/m2; n = 124) and III (BMI: ≥40 kg/m2; n = 40) completed measures of perceived weight stigma in healthcare settings and PCC. Descriptive, correlational and multivariate analyses were conducted.

RESULTS

Of patients living with classes I, II and III obesity, 41%, 59% and 80%, respectively reported experiences of weight stigma in healthcare settings. Younger age, greater obesity severity and the presence of chronic illnesses were associated with greater perceived weight stigma. Greater perceived weight stigma was associated with lower PCC.

CONCLUSION

The results of this study emphasise the significant role of weight stigma in the healthcare experiences of patients living with obesity. Reducing weight stigma is expected to improve PCC and the overall quality of care for these patients. Minimising weight stigma will require efforts across various healthcare domains, including increasing awareness among healthcare professionals about sensitive communication in weight-related discussions.

PATIENT CONTRIBUTION

Our sample consisted of patients living with obesity. Additionally, patients were involved in the pilot testing and refinement of the PCC instrument.

Impact of multimorbidity and complex multimorbidity on healthcare utilisation in older Australian adults aged 45 years or more: a large population-based cross-sectional data linkage study

OBJECTIVES

As life expectancy increases, older people are living longer with multimorbidity (MM, co-occurrence of ≥2 chronic health conditions) and complex multimorbidity (CMM, ≥3 chronic conditions affecting ≥3 different body systems). We assessed the impacts of MM and CMM on healthcare service use in Australia, as little was known about this.

DESIGN

Population-based cross-sectional data linkage study.

SETTING

New South Wales, Australia.

PARTICIPANTS

248 496 people aged ≥45 years who completed the Sax Institute's 45 and Up Study baseline questionnaire.

PRIMARY OUTCOME

High average annual healthcare service use (≥2 hospital admissions, ≥11 general practice visits and ≥2 emergency department (ED) visits) during the 3-year baseline period (year before, year of and year after recruitment).

METHODS

Baseline questionnaire data were linked with hospital, Medicare claims and ED datasets. Poisson regression models were used to estimate adjusted and unadjusted prevalence ratios for high service use with 95% CIs. Using a count of chronic conditions (disease count) as an alternative morbidity metric was requested during peer review.

RESULTS

Prevalence of MM and CMM was 43.8% and 15.5%, respectively, and prevalence increased with age. Across three healthcare settings, MM was associated with a 2.02-fold to 2.26-fold, and CMM was associated with a 1.83-fold to 2.08-fold, increased risk of high service use. The association was higher in the youngest group (45-59 years) versus the oldest group (≥75 years), which was confirmed when disease count was used as the morbidity metric in sensitivity analysis.When comparing impact using three categories with no overlap (no MM/CMM, MM with no CMM, and CMM), CMM had greater impact than MM across all settings.

CONCLUSION

Increased healthcare service use among older adults with MM and CMM impacts on the demand for primary care and hospital services. Which of MM or CMM has greater impact on risk of high healthcare service use depends on the analytic method used. Ageing populations living longer with increasing burdens of MM and CMM will require increased Medicare funding and provision of integrated care across the healthcare system to meet their complex needs.

Ambient temperature and kidney function in primary care patients

INTRODUCTION

Exposure to high ambient temperatures is associated with a risk of acute kidney injury. However, evidence comes from emergency departments or extreme weather exposures. It is unclear whether temperature-related adverse kidney outcomes can also be detected at a community level in a temperate climate zone.

METHODS

In a 9.5-year retrospective cohort study we correlated estimated glomerular filtration rate (eGFR) values of Swiss adult primary care patients from the FIRE cohort (Family medicine Research using Electronic medical records) with same-day maximum local ambient temperature data. We investigated 5 temperature groups (< 15 °C, 15-19 °C, 20-24 °C, 25-29 °C and  ≥ 30 °C) as well as possible interactions for patients with increased kidney vulnerability (chronic heart failure, diabetes, chronic kidney disease, therapy with renin-angiotensin-aldosterone-system (RAAS) inhibitors, diuretics or non-steroidal anti-inflammatory drugs).

RESULTS

We included 18,000 primary care patients who altogether provided 132,176 creatinine measurements. In the unadjusted analysis, higher ambient temperatures were associated with lower eGFR across all age and vulnerability groups. In the adjusted models, we did not find a consistent association.The highest ambient temperature differences (> 25 or > 30 versus < 15 °C) were associated with marginally reduced kidney function only in patients with ≥ 3 risk factors for kidney vulnerability, with a maximum estimated glomerular filtration rate reduction of -2.9 ml/min/1.73m2 (SE 1.0), P 0.003.

DISCUSSION

In a large primary care cohort from a temperate climate zone, we did not find an association between ambient temperatures and kidney function. A marginal inverse association in highly vulnerable patients is of unclear clinical relevance.

Addressing Chronic Conditions and Social Determinants of Health During the COVID-19 Pandemic

Chronic conditions or diseases are defined as persistent conditions lasting ≥ 1 year requiring either ongoing medical attention or limiting daily living or both (Agency for Healthcare Research and Quality (AHRQ) in Programs: SHARE approach workshop, Agency for Healthcare Research and Quality (AHRQ) (2016) Programs: SHARE approach workshop 2016. https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/workshop/index.html . Accessed 20 Jan 2017). Physical chronic conditions, including diabetes, hypertension, heart disease, arthritis, and stroke, are prevalent, especially in the older population. Over 90% of older adults have at least 1 and 77% have ≥ 2 chronic conditions (American Diabetes Association (ADA) in Statistics about diabetes, American Diabetes Association (ADA) (2023) Statistics about diabetes. https://diabetes.org/about-us/statistics/about-diabetes . Accessed 20 Apr 2023). Chronic conditions account for $4.1 trillion of the nation's annual healthcare expenditure (Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion in Health and economic costs of chronic conditions, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Health and Economic Costs of Chronic Conditions (2022). https://www.cdc.gov/chronicdisease/about/costs/index.htm . Accessed 7 Jan 2023). There are marked disparities based on age, color, and income, with older people, people of color, and lower-income people having higher treatment costs or even lost wages in response to having chronic conditions. Chronic conditions are the on-the-top leading causes for death with diabetes being the top 7th in the USA in 2019 (Ferguson in Metabolic Syndrome Related Dis, Ferguson et al., Metab Syndr Relat Disord 21:177-187, 2023).

How do older adults with multimorbidity navigate healthcare?: a qualitative study in Singapore

BACKGROUND

Patients living with multimorbidity may require frequent visits to multiple healthcare institutions and to follow diverse medical regimens and advice. Older adults with multimorbidity could face additional challenges because of declining cognitive capability, frailty, increased complexity of diseases, as well as limited social and economic resources. Research on how this population navigates the healthcare system in Singapore also remains unknown. This study investigates the challenges older adults with multimorbidity face in navigating healthcare in Singapore.

METHODS

Twenty older adults with multimorbidity from a public primary care setting were purposively sampled. Interviews conducted inquired into their experiences of navigating the healthcare system with multiple conditions. Inductive thematic analysis was performed by independent coders who resolved differences through discussion.

RESULTS

Older adults with multimorbidity form a population with specific characteristics and challenges. Their ability to navigate the healthcare system well was influenced by these themes including patient-related factors (autonomy and physical mobility, literacy and technological literacy, social support network), healthcare system-related factors (communication and personal rapport, fragmented system, healthcare staff as advocate) and strategies for navigation (fitting in, asking for help, negotiating to achieve goals, managing the logistics of multimorbidity).

DISCUSSION

Older adults with multimorbidity should not be treated as a homogenous group but can be stratified according to those with less serious or disruptive conditions (less burden of illness and burden of treatment) and those with more severe conditions (more burden of illness and burden of treatment). Among the latter, some became navigational experts while others struggled to obtain the resources needed. The variations of navigational experiences of the healthcare system show the need for further study of the differential needs of older adults with multimorbidity. To be truly patient-centred, healthcare providers should consider factors such as the existence of family support networks, literacy, technological literacy and the age-related challenges older adults face as they interact with the healthcare system, as well as finding ways to improve healthcare systems through personal rapport and strategies for reducing unnecessary burden of treatment for patients with multimorbidity.

Measurement of polydoctoring as a crucial component of fragmentation of care among patients with multimorbidity: Cross-sectional study in Japan

Background

Care fragmentation, characterized by the uncoordinated involvement of multiple healthcare providers, leads to inefficient and ineffective healthcare, posing a significant challenge in managing patients with multimorbidity. In this context, "polydoctoring," where patients see multiple specialists, emerges as a crucial aspect of care fragmentation. This study seeks to develop an indicator to assess polydoctoring, which can subsequently enhance the management of multimorbidity.

Methods

Baseline survey data from the Kawasaki Aging and Wellbeing Project (KAWP) involving independent community-dwelling older adults aged 85-89 were utilized in this cross-sectional study. Polydoctoring measure was defined as the number of regularly visited facilities (RVFs). The association of RVF with the Fragmentation of Care Index (FCI) and the outcome measures of polypharmacy and ambulatory care costs were examined as indicators of care fragmentation.

Results

The analysis comprised 968 participants, with an average of 4.70 comorbid chronic conditions; 65.3% of the participants had two or more RVFs, indicating polydoctoring. A significant correlation between RVF and FCI was observed. Modified Poisson regression analyses revealed associations between higher RVF and increased prevalence ratio of polypharmacy. Likewise, a higher RVF was associated with higher outpatient medical costs.

Conclusions

RVF was significantly correlated with FCI, polypharmacy, and higher outpatient medical costs. Unlike complex indices, RVF is simple and intuitively comprehensible. Further research is needed to evaluate the impact of care fragmentation on patient outcomes, considering factors such as RVF thresholds, patient multimorbidity, and social support. Understanding the influence of polydoctoring can enhance care quality and efficiency for patients with multimorbidity.

Association between Johns Hopkins Adjusted Clinical Groups risk scores and self-reported outcome measures: an observational study among individuals with complex or long-term conditions in Norway

OBJECTIVE

Investigate the association between Johns Hopkins Adjusted Clinical Groups (ACG) risk scores and low scores in self-reported outcome measures (SROMs) among individuals with complex or long-term conditions.

DESIGN

Longitudinal study using five ACG risk scores based on diagnoses from general practitioner (GP) visits in 1 year and responses to a survey including three SROMs 4 months later.

SETTING

Four adjacent municipalities in Central Norway.

PARTICIPANTS

Non-institutionalised individuals ≥18 years with ≥1 diagnosis code indicating a complex or long-term condition, ≥1 visit to a GP, and who participated in the survey (n=2944).

MEASURES

Dependent variables were low scores in the three SROMs (threshold for being defined as a low score in parentheses): Patient Activation Measure (level 1-2), EQ-5D (<0.4) or self-rated health ('Poor'). Independent variables were five ACG variables.

RESULTS

The individuals with the lowest scores in the three SROMs were mostly three separate groups. The lowest Patient Activation Measure scores were associated with high scores in the ACG variables unscaled total cost predicted risk (adjusted odds ratio (adjOR) 1.80) and positive frailty flag (adjOR 1.76). The lowest EQ-5D scores were associated with high scores in the ACG variables unscaled concurrent risk (adjOR 1.60) and probability persistent high user scores (adjOR 2.83). The lowest self-rated health scores were associated with high scores in the ACG variable unscaled concurrent risk scores (adjOR 1.77), unscaled total cost predicted risk scores (adjOR 2.14) and receiving a positive frailty flag (adjOR 1.82).

CONCLUSIONS

There were associations between ACG risk scores and subsequent low SROM scores. This suggests a potential to use diagnosis-based risk stratification systems as a proxy for SROMs to identify individuals with complex or long-term conditions for person-centred healthcare intervention.

Impact of the COVID-19 Outbreak-Delayed Referral of Colorectal and Lung Cancer in Primary Care: A National Retrospective Cohort Study

The Coronavirus disease 2019 (COVID-19) outbreak impacted health care. We investigated its impact on the time to referral and diagnosis for symptomatic cancer patients in The Netherlands. We performed a national retrospective cohort study utilizing primary care records linked to The Netherlands Cancer Registry. For patients with symptomatic colorectal, lung, breast, or melanoma cancer, we manually explored free and coded texts to determine the durations of the primary care (IPC) and secondary care (ISC) diagnostic intervals during the first COVID-19 wave and pre-COVID-19. We found that the median IPC duration increased for colorectal cancer from 5 days (Interquartile Range (IQR) 1-29 days) pre-COVID-19 to 44 days (IQR 6-230, p < 0.01) during the first COVID-19 wave, and for lung cancer, the duration increased from 15 days (IQR) 3-47) to 41 days (IQR 7-102, p < 0.01). For breast cancer and melanoma, the change in IPC duration was negligible. The median ISC duration only increased for breast cancer, from 3 (IQR 2-7) to 6 days (IQR 3-9, p < 0.01). For colorectal cancer, lung cancer, and melanoma, the median ISC durations were 17.5 (IQR (9-52), 18 (IQR 7-40), and 9 (IQR 3-44) days, respectively, similar to pre-COVID-19 results. In conclusion, for colorectal and lung cancer, the time to primary care referral was substantially prolonged during the first COVID-19 wave. In such crises, targeted primary care support is needed to maintain effective cancer diagnosis.

Education support services for improving school engagement and academic performance of children and adolescents with a chronic health condition

BACKGROUND

Chronic health conditions in children and adolescents can have profound impacts on education, well-being and health. They are described as non-communicable illnesses that are prolonged in duration, do not resolve spontaneously, and rarely cured completely. Due to variations in the definition of chronic health conditions and how they are measured prevalence estimates vary considerably and have been reported to be as high as 44% in children and adolescents. Of young people with a chronic health condition, an estimated 5% are affected by severe conditions characterised by limitations to daily activities impacting their ability to attend school. School attendance is important for academic and social skill development as well as well-being. When children and adolescents are absent from school due to a chronic health condition, school engagement can be affected. Disengagement from school is associated with poorer academic achievement, social-emotional functioning and career choices. Education support services for children and adolescents with chronic health conditions aim to prevent disengagement from school, education and learning during periods where their illness caused them to miss school. However, there is limited evidence on the effectiveness of educational support interventions at improving school engagement and educational/learning outcomes for children and adolescents with chronic health conditions.

OBJECTIVES

To describe the nature of educational support interventions for children and adolescents with a chronic health condition, and to examine the effectiveness of these interventions on school engagement and academic achievement.

SEARCH METHODS

We searched eight electronic databases which span the health/medical, social sciences and education disciplines between 18 and 25 January 2021: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid). CINAHL (EBSCO), PsycINFO (EBSCO), ERIC (Education Resources Information Center), Applied Social Sciences Index and Abstracts: ASSIA (ProQuest), and PubMed (from 2019). We also searched five grey literature trials registers and databases between 8 and 12 February 2021 to identify additional published and unpublished studies, theses and conference abstracts, as well as snowballing reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before-and-after studies and interrupted time series studies that met the inclusion criteria were selected. Other inclusion criteria were: participants - must include children or adolescents (aged four to 18 years) with a chronic health condition, intervention - must include educational support, outcomes - must report the primary outcomes (i.e. school engagement or academic achievement) or secondary outcomes (i.e. quality of life, transition to school/school re-entry, mental health or adverse outcomes).

DATA COLLECTION AND ANALYSIS

Two people independently screened titles and abstracts, and full-text articles, to identify included studies. Where disagreements arose between reviewers, the two reviewers discussed the discrepancy. If resolution was unable to be achieved, the issues were discussed with a senior reviewer to resolve the matter. We extracted study characteristic data and risk of bias data from the full texts of included studies using a data extraction form before entering the information into Review Manager 5.4.1. Two people independently extracted data, assessed risk of bias of individual studies and undertook GRADE assessments of the quality of the evidence. Meta-analysis was not possible due to the small number of studies for each outcome. Our synthesis, therefore, used vote-counting based on the direction of the effect/impact of the intervention.

MAIN RESULTS

The database searches identified 14,202 titles and abstracts. Grey literature and reference list searches did not identify any additional studies that met the inclusion criteria. One hundred and twelve full-text studies were assessed for eligibility, of which four studies met the eligibility criteria for inclusion in the review. All studies were randomised controlled studies with a combined total of 359 participants. All included studies were disease-specific; three studies focused on children with cancer, and one study focused on children with Attention Deficit Hyperactivity Disorder (ADHD). There was evidence that education support improved school engagement with three of four studies favouring the intervention. Three studies measured academic achievement but only two studies provided effect estimates. Based on the vote-counting method, we found contradictory results from the studies: one study showed a positive direction of effect and the other study showed a negative direction of effect. One study measured transition back to school and found a positive impact of education support favouring the intervention (SMD 0.18, 95% CI -0.46 to 0.96, no P value reported). The result came from a single study with a small sample size (n = 30), and produced a confidence interval that indicated the possibility of a very small or no effect. The overall certainty of evidence for these three outcomes was judged to be 'very low'. Two of four studies measured mental health (measured as self-esteem). Both studies reported a positive impact of education support interventions on mental health; this was the only outcome for which the overall certainty of evidence was judged to be 'low' rather than 'very low'. No studies measured or reported quality of life or adverse effects. Risk of bias (selection, performance, detection, attrition, reporting and other bias) was assessed using the Cochrane risk of bias tool for randomised trials (version 1). Overall risk of bias for all studies was assessed as 'high risk' because all studies had at least one domain at high risk of bias.

AUTHORS' CONCLUSIONS

This review has demonstrated the infancy of quality research on the effectiveness of education support interventions for children and adolescents with chronic health conditions. At best, we can say that we are uncertain whether education support interventions improve either academic achievement or school engagement. Of the secondary outcomes, we are also uncertain whether education support interventions improve transition back to school, or school re-entry. However, we suggest there is some evidence that education support may slightly improve mental health, measured as self-esteem. Given the current state of the evidence of the effectiveness of education support interventions for children and adolescents with chronic health conditions, we highlight some important implications for future research in this field to strengthen the evidence that can inform effective practice and policy.

Factors influencing the integration of self-management in daily life routines in chronic conditions: a scoping review of qualitative evidence

OBJECTIVE

Self-management of chronic diseases is regarded as dynamic experience which is always evolving and that requires constant adjustment. As unexpected and new shifts in diseases occur, patients tend to abandon acquired behaviours calling into question their sustainability over time. Developing a daily self-management routine as a response to lifestyle changes is considered to facilitate self-management performance. However, fitting self-management recommendations in one's daily life activities is a constant challenge. In this review, we describe the performance of self-management routines within daily settings in people living with chronic conditions with the aim of identifying factors that challenge its integration in daily life.

DESIGN

Scoping review.

DATA SOURCES

We searched PubMed, Web of Science, CINAHL and PsycINFO on February 2022.

ELIGIBILITY CRITERIA

We included qualitative studies on self-management experience, in English, with adult participants, original and peer-reviewed, and depicting the performance of self-management activities in one's own environment.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened titles and abstracts. After agreement, one reviewer screened the full text of relevant articles and extracted the data. The data were synthesised and analysed thematically. PRISMA Extension for Scoping Reviews checklist was used for reporting the steps.

RESULTS

Twenty-two studies were included. The thematic analysis brought up two overreaching themes. The first one is the Environment support with three subthemes: family and cultural norms; health professionals and guiding communication; and society and disease perceptions. The second theme is comprehension gap with two subthemes: reading the body and applying information.

CONCLUSIONS

The integration of self-management requirements in a daily routine is affected by the patients' inability to apply disease knowledge in different context and by the challenge of understanding body symptoms and predicting body reactions in advance.

Analysis of the impact of social determinants and primary care morbidity on population health outcomes by combining big data: A research protocol

Background

In recent years, different tools have been developed to facilitate analysis of social determinants of health (SDH) and apply this to health policy. The possibility of generating predictive models of health outcomes which combine a wide range of socioeconomic indicators with health problems is an approach that is receiving increasing attention. Our objectives are twofold: (1) to predict population health outcomes measured as hospital morbidity, taking primary care (PC) morbidity adjusted for SDH as predictors; and (2) to analyze the geographic variability of the impact of SDH-adjusted PC morbidity on hospital morbidity, by combining data sourced from electronic health records and selected operations of the National Statistics Institute (Instituto Nacional de Estadística/INE).

Methods

The following will be conducted: a qualitative study to select socio-health indicators using RAND methodology in accordance with SDH frameworks, based on indicators published by the INE in selected operations; and a quantitative study combining two large databases drawn from different Spain's Autonomous Regions (ARs) to enable hospital morbidity to be ascertained, i.e., PC electronic health records and the minimum basic data set (MBDS) for hospital discharges. These will be linked to socioeconomic indicators, previously selected by geographic unit. The outcome variable will be hospital morbidity, and the independent variables will be age, sex, PC morbidity, geographic unit, and socioeconomic indicators.

Analysis

To achieve the first objective, predictive models will be used, with a test-and-training technique, fitting multiple logistic regression models. In the analysis of geographic variability, penalized mixed models will be used, with geographic units considered as random effects and independent predictors as fixed effects.

Discussion

This study seeks to show the relationship between SDH and population health, and the geographic differences determined by such determinants. The main limitations are posed by the collection of data for healthcare as opposed to research purposes, and the time lag between collection and publication of data, sampling errors and missing data in registries and surveys. The main strength lies in the project's multidisciplinary nature (family medicine, pediatrics, public health, nursing, psychology, engineering, geography).

Defining and measuring multimorbidity in primary care in Singapore: Results of an online Delphi study

Multimorbidity, common in the primary care setting, has diverse implications for both the patient and the healthcare system. However, there is no consensus on the definition of multimorbidity globally. Thus, we aimed to conduct a Delphi study to gain consensus on the definition of multimorbidity, the list and number of chronic conditions used for defining multimorbidity in the Singapore primary care setting. Our Delphi study comprised three rounds of online voting from purposively sampled family physicians in public and private settings. Delphi round 1 included open-ended questions for idea generation. The subsequent two rounds used questions with pre-selected options. Consensus was achieved based on a pre-defined criteria following an iterative process. The response rates for the three rounds were 61.7% (37/60), 86.5% (32/37) and 93.8% (30/32), respectively. Among 40 panellists who responded, 46.0% were 31-40 years old, 64.9% were male and 73.0% were from the public primary healthcare setting. Based on the findings of rounds 1, 2 and 3, consensus on the definition of a chronic condition, multimorbidity and finalised list of chronic conditions were achieved. For a condition to be chronic, it should last for six months or more, be recurrent or persistent, impact patients across multiple domains and require long-term management. The consensus-derived definition of multimorbidity is the presence of three or more chronic conditions from a finalised list of 23 chronic conditions. We anticipate that our findings will inform multimorbidity conceptualisation at the national level, standardise multimorbidity measurement in primary care and facilitate resource allocation for patients with multimorbidity.

Health behaviours and well-being among older adults with a Surinamese migration background in the Netherlands

Background

This study aims to identify the relationships between health behaviours (healthy diet, physical activity, not smoking and social activity) and well-being among older adults with a Surinamese background.

Methods

Community-dwelling older adults (≥ 70 years) with a Surinamese background living in Rotterdam, the Netherlands, were identified by the municipal register. A survey study was conducted to assess background information, health behaviours (healthy diet, physical activity, not smoking and social activity) and well-being. Multiple regression analyses were performed to assess the relationships of health behaviours with well-being while controlling for background characteristics.

Results

Average age of participants was 76.2 (4.9) years, slightly more than half of them were female (54.2%). Almost half of the participants had a low-income level (49.6%). More than half of the participants met the Dutch guidelines of fruit intake (63.0%) and vegetable intake (62.8%). Less than half of the participants met the guidelines of fish intake (40.9%) and physical activity (39.8%). The majority of the participants were non-smokers (87.9%). Most of the participants had daily contact with family/friends (90.9%) and slightly more than half of the participants visited family/friends often (53.6%). Looking at the health behaviours, a positive relationship was found between eating enough fruit (β = .109; p ≤ 0.05) and vegetables (β = .135; p ≤ 0.01), physical activity (β = .164; p ≤ 0.001) and often visiting family/friends (β = .158; p ≤ 0.001) with well-being.

Conclusion

This study suggests that next to traditional health behaviours also social activity is an essential health behaviour for the well-being of older Surinamese adults. Research about health promotion should expand its focus by including social activity as health behaviour.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14414-z.

Cost-Effectiveness of Care Coordination for Children With Chronic Noncomplex Medical Conditions: Results From a Multicenter Randomized Clinical Trial

OBJECTIVES

To assess the cost-effectiveness of care coordination, compared with standard care, for children with chronic noncomplex medical conditions.

METHODS

A total of 81 children aged between 2 and 15 years newly diagnosed with a noncomplex chronic condition were randomized to either care coordination or standard care as part of a multicenter randomized controlled trial. Families receiving care coordination were provided access to an Allied Health Liaison Officer, who facilitated family-centered healthcare access across hospital, education, primary care, and community sectors. Costs were estimated over a 12-month period from the perspective of the Australian health system. Health outcomes were valued as quality-adjusted life-years (QALYs). Caregiver productivity costs were included in an alternative base-case analysis, and key assumptions were tested in a series of one-way sensitivity analyses. A probabilistic sensitivity analysis was conducted to investigate the overall impact of uncertainty in the data.

RESULTS

Children in the intervention arm incurred an average of $17 in additional health system costs (95% confidence interval -3861 to 1558) and gained an additional 0.031 QALYs (95% confidence interval -0.29 to 0.092) over 12 months, producing an incremental cost-effectiveness ratio of $548 per QALY. When uncertainty was considered, there was a 73% likelihood that care coordination was cost-effective from a health system perspective, assuming a willingness to pay of $50 000 per QALY. This increased to 78% when caregiver productivity costs were included.

CONCLUSIONS

Care coordination is likely to be a cost-effective intervention for children with chronic noncomplex medical conditions in the Australian healthcare setting.

The determinants of healthcare utilisation in regional, rural and remote South Australia: A cross-sectional study

Accessibility of health services outside metropolitan centres in Australia is sub-optimal. Recognising the barriers and enablers of healthcare access in rural, remote and regional settings is necessary to improving health service access in these disadvantaged populations. Accordingly, this study aimed to examine the determinants of healthcare use in rural, remote and regional South Australia. Cross-sectional survey data were collected from adults living outside metropolitan Adelaide in South Australia between April 2017 and March 2018. Using a multi-modal recruitment campaign, eligible adults were invited to complete the 44-item consumer utilisation, expectations and experiences of healthcare instrument. Independent predictors of health service utilisation (dependent variable) were determined using negative binomial regression. The questionnaire was completed by 3926 predominantly female (52.5%) adults aged ≥50 years (56.7%), residing in regional South Australia (84.5%). Fifteen independent variables were significantly associated with health service utilisation using univariate analyses. Using negative binomial regression analysis, two predisposing factors (sex, remoteness), three enabling factors (income, health literacy, employment), two need factors (health rating, multimorbidity) and two personal health practices (alcohol, diet) were independently and significantly associated with healthcare use. Female sex (OR = 1.436, p < 0.001), good/excellent health rating (OR = 0.589, p < 0.001) and high multimorbidity (OR = 1.408, p < 0.001) were the strongest predictors of health service use. These findings will help inform the development of targeted health promotion and service engagement strategies for regional populations, which in addition to addressing workforce shortages, may help address inequity in health outcomes, particularly for groups engaging with regional healthcare services infrequently.

How Do Religiosity and Spirituality Associate with Health-Related Outcomes of Adolescents with Chronic Illnesses? A Scoping Review

The aim of the current scoping review was to explore the associations between religious and spiritual factors and the health-related outcomes of adolescents with chronic illnesses, as well as to investigate possible mechanisms accounting for these relationships. In total, 20 studies meeting the eligibility criteria were reviewed after performing a search of the Scopus, Web of Science, and PubMed databases. The results suggested that religious and spiritual beliefs, thoughts, and practices (e.g., spiritual coping activities) might have both beneficial and deleterious effects on the way adolescents deal with their medical condition, on their psychosocial adjustment, on their mental and physical health, and on their adherence to treatments. Mediating and moderating mechanisms explaining these relations were also evidenced. Suggestions for future research and practical implications for healthcare professionals are provided in the concluding section of this work.

Patterns of multimorbidity in community health centres in Shanghai, China: a retrospective, cross-sectional study based on outpatient data from 2014 to 2018

OBJECTIVE

Caring for patients with multimorbidity is an important part of primary care. It has become increasingly relevant that understanding the spectrum of multimorbidity will help general practitioners (GPs) acquire working knowledge and improve management skills. However, there was little research on characteristics of multimorbidity in primary care in China. This study aimed to identify the spectrum of frequency, proportion and ranking of multimorbidity patterns in adult patients seen at community health centres (CHCs) in Shanghai, China.

DESIGN AND SETTING

This was an observational, retrospective, cross-sectional study analysis of outpatient data of 244 CHCs in Shanghai, China.

PARTICIPANTS

Adult patients with chronic disease who visited Shanghai CHCs during 2014-2018 were selected from Shanghai CHC electronic medical records database using the International Classification of Diseases 10th Revision codes matched to the Second Version of International Classification of Primary Care codes.

PRIMARY AND SECONDARY OUTCOME MEASURES

A number of adult patients with chronic disease were counted. Then frequency, proportion and rank of disease patterns of multimorbidity were analysed.

RESULTS

Analysis of 301 651 158 electronic health records of 5 909 280 adult patients (54.2% females) found the multimorbidity proportion to be 81.2%. The prevalence of multimorbidity increased with age, which climbed from 43.7% among those aged 19-34 to 94.9% among those more than 80 years of age. The proportion of multimorbidity was higher in females (83.2%) than males (79.7%). Vascular and metabolic diseases were the most frequent diseases for patients over 45 years old.

CONCLUSIONS

Multimorbidity has brought huge challenges to primary care practice in Shanghai. The Shanghai government should strengthen its support for the multitargeted prevention of chronic diseases and the improvement of GPs' management capabilities.

What are the barriers and facilitators to self-management of chronic conditions reported by women? A systematic review

INTRODUCTION

Pelvic organ prolapse (POP) can be effectively managed using a pessary. A scoping review found that pessary self-management appears to benefit women with no increased risk. Despite this, many are unwilling to self-manage their pessary. At present, there is a lack of understanding about what affects willingness to self-manage a pessary. However, there may be relevant, transferable findings from other literature about barriers to the self-management of other chronic conditions. Therefore, this systematic review aims to identify, appraise and synthesise the findings of published qualitative research exploring the barriers and facilitators to self-management of chronic conditions reported by women.

METHODS AND ANALYSIS

The systematic review will be conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a guide for the systematic review of qualitative data. A search of MEDLINE, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles that meet the eligibility criteria using the search terms 'Women', 'Woman' 'Female,' 'Chronic', 'Long-term', 'Disease', 'Illness', 'Condition' 'Health,' 'Self-management,' 'Qualitative,' 'Barrier' and 'Facilitator'. A hand search of the reference list of non-original research identified during the search but excluded will be conducted for additional publications, which meet the inclusion and exclusion criteria. Studies published before 2005 and those not available in English will be excluded. Data relevant to the topic will be extracted and critical appraisal of all included publications undertaken.

ETHICS AND DISSEMINATION

No ethical or Health Research Authority approval is required to undertake the systematic review. The systematic review findings will be disseminated by publication. The findings will also inform subsequent exploratory work regarding pessary self-management.

PROSPERO REGISTRATION NUMBER

CRD42022327643.

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial

BACKGROUND

The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care.

METHODS/DESIGN

This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient.

POPULATION

Patients aged 65-74 years with multimorbidity (≥ 3 chronic diseases) and polypharmacy (≥ 5 drugs) during the previous 3 months were included.

SAMPLE SIZE

n = 1148 patients (574 per study arm).

INTERVENTION

Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system.

OUTCOMES

The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables.

STATISTICAL ANALYSIS

The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle.

DISCUSSION

It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04147130 . Registered on 22 October 2019.

Finding good alternatives to hospitalisation: a data register study in five municipal acute wards in Norway

BACKGROUND

In Norway, municipal acute wards (MAWs) have been implemented in primary healthcare since 2012. The MAWs were intended to offer decentralised acute medical care 24/7 for patients who otherwise would be admitted to hospital. The aim of this study was to assess whether the MAW represents the alternative to hospitalisation as intended, through 1) describing the characteristics of patients intended as candidates for MAWs by primary care physicians, 2) exploring the need for extended diagnostics prior to admission in MAWs, and 3) exploring factors associated with patients being transferred from the MAWs to hospital.

METHODS

The study was based on register data from five MAWs in Norway in the period 2014-2020.

RESULTS

In total, 16 786 admissions were included. The median age of the patients was 78 years, 60% were women, and the median length of stay was three days. Receiving oral medication (OR 1.23, 95% CI 1.09-1.40), and the MAW being located nearby the hospital (OR 2.29, 95% CI 1.92-2.72) were factors associated with patients admitted to MAW after extended diagnostics. Patients needing advanced treatment, such as oxygen therapy (OR 2.13, 95% CI 1.81-2.51), intravenous medication (OR 1.60, 95% CI 1.45-1.81), intravenous fluid therapy (OR 1.32, 95% CI 1.19-1.47) and MAWs with long travel distance from the MAW to the hospital (OR 1.46, 95% CI 1.22-1.74) had an increased odds for being transferred to hospital.

CONCLUSIONS

Our findings indicate that MAWs do not represent the alternative to hospitalisation as intended. The results show that patients receiving extended diagnostics before admission to MAW got basic treatment, while patients in need of advanced medical treatment were transferred to hospital from a MAW. This indicates that there is still a potential to develop MAWs in order to fulfil the intended health service level.

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

Multimorbidity is associated with the income, education, employment and health domains of area-level deprivation in adult residents in the UK

Evidence suggests that there are social inequalities in multimorbidity, with a recent review indicating that area levels of deprivation are consistently associated with greater levels of multimorbidity. Definitions of multimorbidity, the most common of which is the co-occurrence of more than one long term condition, can include long term physical conditions, mental health conditions or both. The most commonly used measure of deprivation in England and Wales is the Index of Multiple Deprivation (IMD), an index of seven different deprivation domains. It is unclear which features of IMD may be mediating associations with multimorbidity. Thus, there may be associations because of the individual characteristics of those living in deprived areas, characteristics of the areas themselves or overlap in definitions. Data from over 25,000 participants (aged 16+) of Understanding Society (Wave 10, 1/2018–3/2020) were used to understand the most salient features of multimorbidity associated with IMD and whether physical or mental conditions are differentially associated with the seven domains of IMD. 24% of participants report multimorbidity. There is an increased prevalence of multimorbidity composed of only long-term physical conditions in the most deprived decile of deprivation (22%, 95% CI[19,25]) compared to the least deprived decile (16%, 95% CI[14,18]). Mental health symptoms but not reporting of conditions vary by decile of IMD. Associations with multimorbidity are limited to the health, income, education and employment domains of IMD. We conclude that multimorbidity represents a substantial population burden, particularly in the most deprived areas in England and Wales.

Foot-related diabetes complications: care pathways, patient profiles and costs

BACKGROUND

Foot-related diabetes complications reduce individual well-being, increase mortality and results in increased healthcare costs. Despite their notable stress on health services, studies examining the foot complication care pathways, especially from the viewpoint of health services, are limited. We aimed to identify the most typical care pathways following an initial foot-related diabetes complication, to characterize the patients on each pathway and calculate the related healthcare costs.

METHODS

The identification of pathways was based on population-wide register-based data including all persons diagnosed with diabetes in Finland from 1964 to 2017. For each patient, initial foot-related complication from 2011-2016 was identified using the ICD-10 codes and related healthcare episodes were followed for two years until the end of 2017 or death. A sequence analysis was conducted on care episodes resulting in groups of typical care pathways, as well as their patient profiles. The costs of pathways resulting from the care episodes were calculated based on the data and the reported national unit costs and analyzed using linear models.

RESULTS

We identified six groups of typical pathways each comprising mainly single type of care episodes. Three of the groups comprised over 10 000 patients while the remaining groups ranged from a few hundred to a few thousand. Majority of pathways consisted only single care episode. However, among the rest of the care pathways variability in length of care pathways was observed between and within group of pathways. On average, the patients were over 65 years of age and were diagnosed with diabetes for over a decade. The pathways resulted in an annual cost of EUR 13 million. The mean costs were nearly 20-fold higher in the group with the highest costs (EUR 11 917) compared to the group with the lowest costs (EUR 609).

CONCLUSIONS

We identified groups of typical care pathways for diabetic foot and discovered notable heterogeneity in the resource use within the groups. This information is valuable in guiding the development of diabetes care to meet the growing need. Nevertheless, reasons underlying the observed heterogeneity requires further examination. Since foot complications are largely preventable, substantial savings could be achieved using cost-effective technologies and more efficient organization of care.

Socioeconomic status of practice location and Australian GP registrars' training: a cross-sectional analysis

BACKGROUND

Socioeconomic status (SES) is a major determinant of health. In Australia, areas of socioeconomic disadvantage are characterised by complex health needs and inequity in primary health care provision. General Practice (GP) registrars play an important role in addressing workforce needs, including equitable health care provision in areas of greater socioeconomic disadvantage. We aimed to characterize GP registrars' practice location by level of socioeconomic disadvantage, and establish associations (of registrar, practice, patient characteristics, and registrars' clinical behaviours) with GP registrars training being undertaken in areas of greater socioeconomic disadvantage.

METHODS

A cross-sectional analysis from the Registrars' Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multi-centre, cohort study that documents 60 consecutive consultations by each GP registrar once in each of their three six-monthly training terms. The outcome factor was the practice location's level of socioeconomic disadvantage, defined using the Index of Relative Socio-economic Disadvantage (SEIFA-IRSD). The odds of being in the lowest quintile was compared to the other four quintiles. Independent variables related to the registrar, patient, practice, and consultation.

RESULTS

A total of 1,736 registrars contributed 241,945 consultations. Significant associations of training being in areas of most disadvantage included: the registrar being full-time, being in training term 1, being in the rural training pathway; patients being Aboriginal or Torres Strait Islander, or from a non-English-speaking background; and measures of continuity of care.

CONCLUSIONS

Training in areas of greater social disadvantage, as well as addressing community need, may provide GP registrars with richer learning opportunities.

Effect of Care Coordination Using an Allied Health Liaison Officer for Chronic Noncomplex Medical Conditions in Children: A Multicenter Randomized Clinical Trial

IMPORTANCE

There is a paucity of high-quality evidence on the effect of care coordination on health-related quality of life among children with chronic noncomplex medical conditions (non-CMCs).

OBJECTIVE

To examine whether care coordination delivered by an Allied Health Liaison Officer results in improved quality-of-life (QOL) outcomes for children with chronic non-CMCs and their families.

DESIGN, SETTING AND PARTICIPANTS

This multicenter, open label, randomized clinical trial was conducted in pediatric outpatient clinics at 3 Australian hospitals with tertiary- and secondary-level pediatric care facilities. A total of 81 children with chronic non-CMCs and their families participated in the trial for a period of up to 12 months between October 2017 to October 2020. Primary care reviews were offered at 1 week, 3 months, and 6 months after diagnosis.

INTERVENTIONS

Eligible children were randomized 1:1 to receive care coordination or standard care. Families of children receiving care coordination were provided access to an Allied Health Liaison Officer, who was responsible for facilitation of health care access across hospital, education, primary care, and community sectors.

MAIN OUTCOMES AND MEASURES

The primary outcomes were scores on the Pediatric Quality of Life Inventory (PedsQL), version 4.0, and the PedsQL Family Impact Module, version 2.0, measured at 6 and 12 months. An intent-to-treat approach was used to analyze the data.

RESULTS

Of 81 children (mean [SD] age, 8.2 [3.5] years; 55 [67.9%] male), 42 (51.9%) were randomized to care coordination and 39 (48.1%) to standard care. Compared with standard care, care coordination resulted in greater improvements in overall PedsQL scores (difference in score changes between groups, 7.10; 95% CI, 0.44-13.76; P = .04), overall PedsQL Family Impact Module scores (difference in score changes between groups, 8.62; 95% CI, 1.07-16.16; P = .03), and family functioning QOL (difference in score changes between groups, 15.83; 95% CI, 5.05-26.62; P = .004) at 12 months after diagnosis.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, care coordination improved the quality of life of children with chronic non-CMCs and their families. Further studies should explore specific non-CMCs that may benefit most from care coordination and whether an orientation among health services to provide such a coordination model could lead to longer-term improved clinical outcomes.

TRIAL REGISTRATION

http://anzctr.org.au Identifier: ACTRN12617001188325.

The nebula of chronicity: dealing with metastatic breast cancer in the UK

In this article, I explore how the concept of chronicity is mobilised by different actors in reference to metastatic breast cancer (MBC) and the transformation of the condition as a consequence of medical innovations. I do so by using data collected in the UK between 2017 and 2019 through in-depth interviews with medical professionals involved in the treatment of MBC and with patients living with MBC. I show how chronicity appears as a multidimensional and uncertain concept, which I analyse through the image of the nebula. While the medical literature tends to consider MBC chronic or on route to chronicisation, the medical professionals interviewed were uncertain as to whether MBC can be considered a chronic disease, and attempted to discuss chronicity through survival times, the kind of management possible for the disease, and how it compares to other conditions more commonly considered chronic. In some cases, the patients considered the idea of chronicity a source of hope or a way to link their condition to those of people with other diseases; however, they generally rejected the definition as inappropriate for their experience of the illness. Analysing the fluid uses of the concept of chronicity in the case of MBC contributes to the debate within medical anthropology on how medical categories acquire different values and uses and on the circulation of meanings between the biomedical context and the patient experience.

Age-friendly neighbourhoods and physical activity of older Surinamese individuals in Rotterdam, the Netherlands

BACKGROUND

Age-friendly neighbourhoods seem to promote physical activity among older individuals. Physical activity is especially important for chronically ill individuals. In the Netherlands, older Surinamese individuals are more likely to have chronic diseases than are their native Dutch counterparts. This study examined relationships of neighbourhood characteristics with physical activity among older Surinamese individuals in Rotterdam, the Netherlands.

METHODS

Of 2749 potential participants, 697 (25%) community-dwelling older (age ≥ 70 years) Surinamese individuals living in Rotterdam, the Netherlands, completed a questionnaire on personal and neighbourhood characteristics between March and June 2020. Correlation and multilevel regression analyses were performed to identify associations between missing neighbourhood characteristics for ageing in place and physical activity.

RESULTS

Scores for the neighbourhood domains communication and information (r = -0.099, p ≤ 0.05), community support and health services (r = -0.139, p ≤ 0.001), and respect and social inclusion (r = -0.141, p ≤ 0.001), correlated negatively with participants' PA. In the multilevel analysis, overall missing neighbourhood characteristics to age in place scores were associated negatively with physical activity (p ≤ 0.05).

CONCLUSION

This study showed the importance of age-friendly neighbourhoods for physical activity among older Surinamese individuals in Rotterdam, the Netherlands. Our findings suggest that the neighbourhood plays an important role in supporting older individuals' leading of physically active lifestyles. Further research is needed to support the development of interventions to create age-friendly neighbourhoods.

Chronic conditions and self-perceived health among older employees in relation to indicators of labour participation and retirement over time

BACKGROUND:

A significant proportion of older employees leave the labour market early, amongst others via unemployment or disability benefits, implying that health might affect possibilities to extend working life.

OBJECTIVE:

This study 1) examined associations between chronic conditions (subtypes) and self-perceived health (SPH), independently, and indicators of labour participation and retirement over six-year follow-up among older employees, and 2) explored the impact of differences between prevalent and incident presence of chronic condition(s) in this relation.

METHODS:

Older workers (aged > 45 years) included in the Maastricht Cohort Study were studied (n = 1,763). The Health and Work Performance Questionnaire assessed chronic conditions and one item from the Short Form health survey-36 assessed SPH. Cox regression analyses assessed associations between chronic conditions and SPH, independently, and retirement intentions, employment status, decreasing working hours, and changes in work over time.

RESULTS:

Employees with coexistent physical-mental chronic conditions showed higher risks to lose employment and to receive a disability benefit (HR 1.85, 95% CI 1.23–2.78; HR 8.63, 95% CI 2.47–30.11) over time compared to healthy employees. No statistically significant associations were found between SPH and indicators of labour participation and retirement over time. Having chronic condition(s) was cross-sectionally associated with lower SPH scores and larger proportion of part-timers –compared to healthy employees.

CONCLUSIONS:

Chronic condition(s) among older employees were substantially associated with indicators of labour participation and retirement over time. The role of SPH was mainly instantaneous. Findings provide valuable input for preventive measures aiming to prevent an early labour market exit of older employees.

[Unaccompanied minors' consultation reasons for encounter and health problems managed in a permanence of access to health care]

OBJECTIVE

To describe the unaccompanied minors' reasons for consulting and their health problems managed in a permanence of access to health care (PASS) at the Hospices civils de Lyon.

METHODS

Consultation data of the unaccompanied minors cared for in 2016 and 2017 at the Edouard Herriot Hospital PASS, Lyon, were collected and coded according to the International Classification of Primary Care (CISP-2).

RESULTS

The majority of unaccompanied minors were male adolescents from French-speaking sub-Saharan African countries. Each consultation included an average of 1.6 reason for encounter (95%CI: 1.5-1.8) and 2.0 health problems diagnosed (95%CI: 1.9-2.1). Apart from the discussion of test results, the most frequent reasons for consultation were physical symptoms, particularly generalized abdominal pain (8.7%), headache (6.6%) or pruritus (6.5%). Health problems diagnosed were mainly digestive (11.4%), cutaneous (11.0%) and osteoarticular (7.0%) problems, psychic diagnoses being rare.

CONCLUSIONS

Unaccompanied minors seems to be apparently in good health, which probably results from under-diagnosing infectious diseases and psychic disorders. We recommend the implementation in the PASS of a common protocol for screening infectious conditions and detecting psychic disorders.

Assessing the Impact of Clinical Coordination Interventions on the Continuity of Care for Patients With Chronic Conditions: Participatory Action Research in Five Latin American Countries

Although fragmentation in the provision of services is considered an obstacle to effective health care, there is scant evidence on the impact of interventions to improve care coordination between primary care and secondary care in terms of continuity of care -i.e. from the patient perspective- particularly in Latin America (LA). Within the framework of the Equity-LA II project, interventions to improve coordination across care levels were implemented in five LA countries (Brazil, Chile, Colombia, Mexico and Uruguay) through a participatory action research (PAR) process. This paper analyses the impact of these PAR interventions on the cross-level continuity of care of chronic patients in public healthcare networks. A quasi-experimental study was performed with measurements based on two surveys of a sample of patients with chronic conditions (392 per network; 800 per country). Both the baseline (2015) and evaluation (2017) surveys were conducted using the CCAENA questionnaire. In each country, two comparable public healthcare networks were selected, one intervention and one control. Outcomes were cross-level continuity of information and of clinical management. Descriptive analyses were conducted and Poisson regression models with robust variance fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and of clinical management (care coherence). These results are consistent with those of previous studies on the effectiveness of the interventions implemented in each country in improving care coordination in Brazil, Chile, and Colombia. Differences between countries are probably related to particular contextual factors and events that occurred during the implementation process. This supports the notion that certain context and process factors are needed to improve continuity of care. The results provide evidence that, although the interventions were designed to enhance care coordination and aimed at health professionals, patients report improvements in continuity of care.

Health Profile of Precarious Migrants Attending the Médecins Du Monde's Health and Social Care Centres in France: a Cross-Sectional Study

Objective: The present study aimed to compare the precarious migrants' health problems managed in Médecins du Monde's health and social care centres (CASO) with those of patients attending general practice in France. Methods: We compared the most frequent health problems managed in the 19 CASO in metropolitan France with those of a national sample of usual general practice consultations, after standardisation for age and sex. Results: Precarious migrants had fewer health problems managed per consultation than other patients (mean: 1.31 vs. 2.16), and these corresponded less frequently to chronic conditions (21.3% vs. 46.8%). The overrepresented health problems among CASO consultations were mainly headache (1.11% vs. 0.45%), viral hepatitis (1.05% vs. 0.20%), type 1 diabetes (1.01% vs. 0.50%) and teeth/gum disease (1.01% vs. 0.23%). Their underrepresented health problems were mainly lipid disorder (0.39% vs. 8.20%), depressive disorder (1.36% vs. 5.28%) and hypothyroidism (0.50% vs. 3.08%). Prevention issues were nominal in precarious migrants (0.16%). Conclusion: Both chronic somatic and mental conditions of precarious migrants are presumably underdiagnosed. Their screening should be improved in primary care.

How Compassionate Abilities Influence the Experience of Loneliness and Quality of Life of People with and without Chronic Physical Disease?

The current study aimed to test whether individuals with and without a chronic physical disease differ in levels of compassionate abilities, loneliness and quality of life (QoL); and to examine whether loneliness mediated the impact of self-compassion and of receiving compassion from others in physical, psychological, and social QoL. In this cross-sectional study, individuals with (n = 278) and without (n = 455) physical chronic disease were recruited through an online self-report protocol. The Compassionate Attributes and Engagement Scale, the UCLA Loneliness Scale, and the World Health Organization's QoL-BREF were used. Individuals with a chronic physical disease diagnosis reported lower compassionate abilities and QoL, as well as higher levels of loneliness, when compared to participants without a diagnosis. For both samples, compassionate abilities were negatively linked to loneliness, and positively linked to QoL. Path analysis results indicated that compassionate abilities have a direct effect on loneliness, which explains individuals' perceived QoL. Results highlight the crucial role of self-compassion skills and the ability to perceive others as compassionate, in loneliness and QoL, both in individuals with and without a chronic physical disease. These findings seem to have important research and clinical implications.

Illness perception amongst adults with multimorbidity at primary care clinics in Southwest Nigeria

BACKGROUND

Although shreds of evidence are emerging to show the role of illness perceptions in the health outcomes of patients, most of the previous studies have been on single chronic conditions.

AIM

To assess the illness perceptions and the associated factors amongst adults with multimorbidity.

SETTING

General outpatient clinics of the University College Hospital, Ibadan, Nigeria.

METHODS

A cross-sectional study was conducted amongst a systematic sample of 403 adults with multimorbidity. Data on illness perception and other variables were collected using interviewer-administered questionnaires. Descriptive statistics, chi-square test, t-test and analysis of variance were employed for analyses.

RESULTS

The age of the participants ranged from 18 to 97 years, with a mean of 60.9 years (standard deviation [s.d.] ± 14.3 years). The majority of participants (57.3%) were women. Ninety-four (23.3%) respondents had only two morbid conditions, whilst 31.2% had at least four morbid conditions. Prioritisation sub-domain of illness perception recorded the highest score (mean = 2.0, s.d. ± 0.8), whilst the treatment burden sub-domain was the lowest (mean = 0.8, s.d. ± 0.7). A significant bivariate relationship was observed between emotional representation (p = 0.001), prioritisation (p = 0.013) and causal relationship (p = 0.013) sub-domains and age group of study participants. Emotional burden associated with illnesses declined as educational level increased (p = 0.039).

CONCLUSION

Patient's characteristics such as age, education and the number of morbidities are associated with illness perception. Healthcare providers should pay attention to these factors whilst addressing illness perception as a way to achieve better clinical outcomes.

Predicting hospital admissions from individual patient data (IPD): an applied example to explore key elements driving external validity

OBJECTIVE

To explore factors that potentially impact external validation performance while developing and validating a prognostic model for hospital admissions (HAs) in complex older general practice patients.

STUDY DESIGN AND SETTING

Using individual participant data from four cluster-randomised trials conducted in the Netherlands and Germany, we used logistic regression to develop a prognostic model to predict all-cause HAs within a 6-month follow-up period. A stratified intercept was used to account for heterogeneity in baseline risk between the studies. The model was validated both internally and by using internal-external cross-validation (IECV).

RESULTS

Prior HAs, physical components of the health-related quality of life comorbidity index, and medication-related variables were used in the final model. While achieving moderate discriminatory performance, internal bootstrap validation revealed a pronounced risk of overfitting. The results of the IECV, in which calibration was highly variable even after accounting for between-study heterogeneity, agreed with this finding. Heterogeneity was equally reflected in differing baseline risk, predictor effects and absolute risk predictions.

CONCLUSIONS

Predictor effect heterogeneity and differing baseline risk can explain the limited external performance of HA prediction models. With such drivers known, model adjustments in external validation settings (eg, intercept recalibration, complete updating) can be applied more purposefully.

TRIAL REGISTRATION NUMBER

PROSPERO id: CRD42018088129.

Deprescribing in older patients by early-career general practitioners: Prevalence and associations

RATIONALE AND AIMS

Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs.

METHODS

A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines.

RESULTS

One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration).

CONCLUSION

These findings will have important implications for the education of GPs in deprescribing as a clinical skill.

The prevalence of multimorbidity in primary care: a comparison of two definitions of multimorbidity with two different lists of chronic conditions in Singapore

Background

The prevalence of multimorbidity varies widely due to the lack of consensus in defining multimorbidity. This study aimed to measure the prevalence of multimorbidity in a primary care setting using two definitions of multimorbidity with two different lists of chronic conditions.

Methods

We conducted a cross-sectional study of 787,446 patients, aged 0 to 99 years, who consulted a family physician between July 2015 to June 2016. Multimorbidity was defined as ‘two or more’ (MM2+) or ‘three or more’ (MM3+) chronic conditions using the Fortin list and Chronic Disease Management Program (CDMP) list of chronic conditions. Crude and standardised prevalence rates were reported, and the corresponding age, sex or ethnic-stratified standardised prevalence rates were adjusted to the local population census.

Results

The number of patients with multimorbidity increased with age. Age-sex-ethnicity standardised prevalence rates of multimorbidity using MM2+ and MM3+ for Fortin list (25.9, 17.2%) were higher than those for CDMP list (22.0%; 12.4%). Sex-stratified, age-ethnicity standardised prevalence rates for MM2+ and MM3+ were consistently higher in males compared to females for both lists. Chinese and Indians have the highest standardised prevalence rates among the four ethnicities using MM2+ and MM3+ respectively.

Conclusions

MM3+ was better at identifying a smaller number of patients with multimorbidity requiring higher needs compared to MM2+. Using the Fortin list seemed more appropriate than the CDMP list because the chronic conditions in Fortin’s list were more commonly seen in primary care. A consistent definition of multimorbidity will help researchers and clinicians to understand the epidemiology of multimorbidity better.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11464-7.