Patterns and impact of comorbidity and multimorbidity among community-resident American Indian elders

Multimorbidity patterns: a systematic review

OBJECTIVES

The aim of this review was to identify studies on patterns of associative multimorbidity, defined as the nonrandom association between diseases, focusing on the main methodological features of the studies and the similarities among the detected patterns.

STUDY DESIGN AND SETTING

Studies were identified through MEDLINE and EMBASE electronic database searches from their inception to June 2012 and bibliographies.

RESULTS

The final 14 articles exhibited methodological heterogeneity in terms of the sample size, age and recruitment of study participants, the data source, the number of baseline diseases considered, and the statistical procedure used. A total of 97 patterns composed of two or more diseases were identified. Among these, 63 patterns were composed of three or more diseases. Despite the methodological variability among studies, this review demonstrated relevant similarities for three groups of patterns. The first one comprised a combination of cardiovascular and metabolic diseases, the second one was related with mental health problems, and the third one with musculoskeletal disorders.

CONCLUSION

The existence of associations beyond chance among the different diseases that comprise these patterns should be considered with the aim of directing future lines of research that measure their intensity, clarify their nature, and highlight the possible causal underlying mechanisms.

Examining individual factors according to health risk appraisal data as determinants of absenteeism among US utility employees

OBJECTIVES

To investigate predictors of absenteeism and discuss potential implications for policy/program design.

METHODS

Health Risk Appraisal (HRA) data and self-reported and objective absenteeism (personnel records) were used to develop a structural equation model, controlling for age, sex, and job classification. A Medical Condition Burden Index (MCBI) was created by summing the number of self-reported medical conditions.

RESULTS

Higher MCBI and stress were direct predictors of absenteeism. Physical activity was not associated with absenteeism but mediated both stress and MCBI.

CONCLUSIONS

Because stress impacted both absenteeism and MCBI, organizations may benefit by placing stress management as a priority for wellness program and policy focus. Physical activity was not directly associated with absenteeism but was a mediating variable for stress and MCBI. Measures of stress and physical health may be more meaningful as outcome measures for physical activity programs than absenteeism.

Multimorbidity patterns of and use of health services by Swedish 85-year-olds: an exploratory study

BACKGROUND

As life expectancy continues to rise, more elderly are reaching advanced ages (≥80 years). The increasing prevalence of multimorbidity places additional demands on health-care resources for the elderly. Previous studies noted the impact of multimorbidity on the use of health services, but the effects of multimorbidity patterns on health-service use have not been well studied, especially for very old people. This study determines patterns of multimorbidity associated with emergency-room visits and hospitalization in an 85-year-old population.

METHODS

Health and living conditions were reported via postal questionnaire by 496 Linköping residents aged 85 years (189 men and 307 women). Diagnoses of morbidity were reviewed in patients' case reports, and the local health-care register provided information on the use of health services. Hierarchical cluster analysis was applied to evaluate patterns of multimorbidity with gender stratification. Factors associated with emergency-room visits and hospitalization were analyzed using logistic regression models.

RESULTS

Cluster analyses revealed five clusters: vascular, cardiopulmonary, cardiac (only for men), somatic-mental (only for men), mental disease (only for women), and three other clusters related to aging (one for men and two for women). Heart failure in men (OR = 2.4, 95% CI = 1-5.7) and women (OR = 3, 95% CI = 1.3-6.9) as a single morbidity explained more variance than morbidity clusters in models of emergency-room visits. Men's cardiac cluster (OR = 1.6; 95% CI = 1-2.7) and women's cardiopulmonary cluster (OR = 1.7, 95% CI = 1.2-2.4) were significantly associated with hospitalization. The combination of the cardiopulmonary cluster with the men's cardiac cluster (OR = 1.6, 95% CI = 1-2.4) and one of the women's aging clusters (OR = 0.5, 95% CI = 0.3-0.8) showed interaction effects on hospitalization.

CONCLUSION

In this 85-year-old population, patterns of cardiac and pulmonary conditions were better than a single morbidity in explaining hospitalization. Heart failure was superior to multimorbidity patterns in explaining emergency-room visits. A holistic approach to examining the patterns of multimorbidity and their relationships with the use of health services will contribute to both local health care policy and geriatric practice.

Short and long term determinants of incident multimorbidity in a cohort of 1988 earthquake survivors in Armenia

BACKGROUND

Multimorbidity, presence of two or more health conditions, is a widespread phenomenon affecting populations' health all over the world. It becomes a serious public health concern due to its negative consequences on quality of life, mortality, and cost of healthcare services utilization. Studies exploring determinants of multimorbidity are limited, particularly those looking at vulnerable populations prospectively over time. This study aimed at identifying short and long term socioeconomic, psychosocial, and health behavioral determinants of incident multimorbidity among a cohort of the 1988 Armenian earthquake survivors.

METHODS

The study included a representative subsample of 725 from a larger initial cohort of the earthquake survivors. Data on this subsample were collected via four phases of this cohort study during the period 1990-2012. The final logistic regression analysis eliminated all those cases with baseline multimorbidity to investigate short and long term determinants of incident multimorbidity; this subsample included 600 participants.

RESULTS

More than 75% of the studied sample had multimorbidity. Perceived low affordability of healthcare services, poor living standards during the post-earthquake decade, and lower education were independent predictors of incident multimorbidity developed during the period 1990-2012. Stressful life events and poor social support were among psychosocial determinants of incident multimorbidity. Participants' baseline BMI reported in 1990 was independently associated with incident multimorbidity.

CONCLUSIONS

Most of the identified determinants of incident multimorbidity in our study population were markers of social inequities, indicating that inequities pose a serious threat to both individual and public health-related outcomes. Strategies targeting to decrease such inequities along with promotion of healthy lifestyle and strengthening of social networks may considerably reduce multimorbidity among population groups with similar socioeconomic and cultural profiles.

Examining the relationship between chronic conditions, multi-morbidity and labour market participation in Canada: 2000–2005

Relatively little attention has been paid to understanding and addressing the potential health-related barriers faced by older workers to stay at work. Using three representative samples from the Canadian Community Health Survey, we examined the relationship between seven physical chronic conditions and labour market participation in Canada between 2000 and 2005. We found that all conditions were associated with an increased probability of not being able to work due to health reasons. In our adjusted models, heart disease was associated with the greatest probability of not working due to health reasons. Arthritis was associated with the largest population attributable fraction. Other variables associated with not being able to work due to health reasons included older age, female gender and lower educational attainment. We also found particular combinations of chronic conditions (heart disease and diabetes; and arthritis and back pain) were associated with a greater risk than the separate effects of each condition independently. The results of this study demonstrate that chronic conditions are associated with labour market participation limitations to differing extents. Strategies to keep older workers in the labour market in Canada will need to address barriers to staying at work that result from the presence of chronic conditions, and particular combinations of conditions.

The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature

BACKGROUND

Multimorbidity is a new concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of family medicine and its core competencies. However, the definition of multimorbidity and its subsequent operationalization are still unclear. The European General Practice Research Network wanted to produce a comprehensive definition of multimorbidity.

METHOD

Systematic review of literature involving eight European General Practice Research Network national teams. The databases searched were PubMed, Embase, and Cochrane (1990-2010). Only articles containing descriptions of multimorbidity criteria were selected for inclusion. The multinational team undertook a methodic data extraction, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

RESULTS

The team identified 416 documents, selected 68 abstracts, included 54 articles, and found 132 definitions with 1631 different criteria. These criteria were aggregated into 11 themes that led to the following definition: Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or biopsychosocial factor (associated or not) or somatic risk factor. Any biopsychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption, and the patient's coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty.

CONCLUSION

This study has produced a comprehensive definition of multimorbidity. The resulting improvements in the management of multimorbidity, and its usefulness in long term care and in family medicine, will have to be assessed in future studies.

Patterns of comorbidity and multimorbidity in the oldest old: the Octabaix study

BACKGROUND

Multimorbidity is associated with higher mortality, increased disability, a decline in functional status and a lower quality of life. The objective of the study is to explore patterns of multimorbidity in an elderly population.

METHODS

328 community inhabitants aged 85 years were included. Socio-demographic variables and data from the global geriatric assessment were evaluated. Information on the presence of sixteen common chronic conditions was collected: hypertension, diabetes mellitus, dyslipidemia, ischemic cardiomyopathy, heart failure, stroke, chronic obstructive pulmonary disease, (COPD), atrial fibrillation, peripheral arterial disease, Parkinson's disease, cancer, dementia, anemia, chronic kidney disease (CKD), visual impairment and deafness. Hierarchical cluster analysis was performed.

RESULTS

The rate of multimorbidity (>1 disease) was 95.1%. Men had a higher percentage of COPD and malignancy. Four main clusters were identified. The highest value of the bivariate correlation matrix was that between heart failure and visual impairment. These two diseases were included in a cluster with atrial fibrillation, CKD, heart failure, stroke, high blood pressure and diabetes mellitus.

CONCLUSIONS

The large majority of oldest old subjects had multimorbidity. The results confirm the non-random co-occurrence of certain diseases in this age group.

Identifying comorbidity patterns of health conditions via cluster analysis of pairwise concordance statistics

Identification of comorbidity patterns of health conditions is critical for evidence-based practice to improve the prevention, treatment and health care of relevant diseases. Existing approaches focus mainly on either using descriptive measures of comorbidity in terms of the prevalence of coexisting conditions, or addressing the prevalence of comorbidity based on a particular disease (e.g. psychosis) or a specific population (e.g. hospital patients). As coincidental comorbidity by chance increases with the prevalence rates of the conditions, which in turn depend heavily on the population under study, research findings on comorbidity patterns using those approaches may provide unreliable results. In this paper, we propose an asymmetric version of Somers' D statistic to provide a quantitative measure of comorbidity that accounts for co-occurrence of conditions by chance, and develop a unified clustering algorithm to identify comorbidity patterns with adjustment for multiple testing and control for the false discovery rate. We assess the applicability of the proposed comorbidity measure and investigate the performance of the proposed procedure for the adjustment of multiple testing by conducting a comparative study and a sensitivity analysis, respectively. The proposed method is illustrated using a national survey data set of mental health and wellbeing and a national health survey data set in Australia.

Patterns of multimorbidity in the aged population. Results from the KORA-Age study

Multimorbidity is a common problem in aged populations with a wide range of individual and societal consequences. The objective of the study was to explore patterns of comorbidity and multimorbidity in an elderly population using different analytical approaches. Data were gathered from the population-based KORA-Age project, which included 4,127 persons aged 65–94 years living in the city of Augsburg and its two surrounding counties in Southern Germany. Information on the presence of 13 chronic conditions was collected in a standardized telephone interview and a self-administered questionnaire. Patterns of comorbidity and multimorbidity were analyzed using prevalence figures, logistic regression models and exploratory tetrachoric factor analysis. The prevalence of multimorbidity (≥2 diseases) was 58.6% in the total sample. Hypertension and diabetes (Odds Ratio [OR] 2.95, 99.58% confidence interval [CI] [2.19–3.96]), as well as hypertension and stroke (OR 2.00, 99.58% CI [1.26–3.16]) most often occurred in combination. This association was independent of age, sex and the presence of other conditions. Using factor analysis, we identified four patterns of multimorbidity: the first pattern includes cardiovascular and metabolic diseases, the second includes joint, liver, lung and eye diseases, the third covers mental and neurologic diseases and the fourth pattern includes gastrointestinal diseases and cancer. 44% of the persons were assigned to at least one of the four multimorbidity patterns; 14% could be assigned to both the cardiovascular/metabolic and the joint/liver/lung/eye pattern. Further common pairs were the mental/neurologic pattern combined with the cardiovascular/metabolic pattern (7.2%) or the joint/liver/lung/eye pattern (5.3%), respectively. Our results confirmed the existence of co-occurrence of certain diseases in elderly persons, which is not caused by chance. Some of the identified patterns of multimorbidity and their overlap may indicate common underlying pathological mechanisms.

[Comparison of three methods for measuring multiple morbidity according to the use of health resources in primary healthcare]

OBJECTIVE

To compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC).

DESIGN

Retrospective study using computerized medical records.

SETTING

Thirteen PHC teams in Catalonia (Spain).

PARTICIPANTS

Assigned patients requiring care in 2008.

MAIN MEASUREMENTS

The socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs.

STATISTICAL ANALYSIS

3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R(2)), p< .05.

RESULTS

The study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R(2)=50.4%, the ChI an R(2)=29.2% and BUR an R(2)=39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results.

CONCLUSIONS

The CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix.

Aging with multimorbidity: a systematic review of the literature

A literature search was carried out to summarize the existing scientific evidence concerning occurrence, causes, and consequences of multimorbidity (the coexistence of multiple chronic diseases) in the elderly as well as models and quality of care of persons with multimorbidity. According to pre-established inclusion criteria, and using different search strategies, 41 articles were included (four of these were methodological papers only). Prevalence of multimorbidity in older persons ranges from 55 to 98%. In cross-sectional studies, older age, female gender, and low socioeconomic status are factors associated with multimorbidity, confirmed by longitudinal studies as well. Major consequences of multimorbidity are disability and functional decline, poor quality of life, and high health care costs. Controversial results were found on multimorbidity and mortality risk. Methodological issues in evaluating multimorbidity are discussed as well as future research needs, especially concerning etiological factors, combinations and clustering of chronic diseases, and care models for persons affected by multiple disorders. New insights in this field can lead to the identification of preventive strategies and better treatment of multimorbid patients.

Review: Health Care Utilization and Costs of Elderly Persons With Multiple Chronic Conditions

This systematic literature review identified and summarized 35 studies that investigated the relationship between multiple chronic conditions (MCCs) and health care utilization outcomes (i.e. physician use, hospital use, medication use) and health care cost outcomes (medication costs, out-of-pocket costs, total health care costs) for elderly general populations. Although synthesis of studies was complicated because of ambiguous definitions and measurements of MCCs, and because of the multitude of outcomes investigated, almost all studies observed a positive association of MCCs and use/costs, many of which found that use/costs significantly increased with each additional condition. Several studies indicate a curvilinear, near exponential relationship between MCCs and costs. The rising prevalence, substantial costs, and the fear that current care arrangements may be inappropriate for many patients with MCCs, bring about a multitude of implications for research and policy, of which the most important are presented and discussed.

Longitudinal administrative data can be used to examine multimorbidity, provided false discoveries are controlled for

OBJECTIVE

This article presents methods for using administrative data to study multimorbidity in hospitalized individuals and indicates how the findings can be used to gain a deeper understanding of hospital multimorbidity.

STUDY DESIGN AND SETTING

A Dutch nationwide hospital register (n=4,521,856) was used to calculate age- and sex-standardized observed/expected ratios of disease-pairing prevalences with corresponding confidence intervals.

RESULTS

The strongest association was found for the combination between alcoholic liver and mental disorders due to alcohol abuse (observed/expected=39.2). Septicemia was found to cluster most frequently with other diseases. The consistency of the ratios over time depended on the number of observed cases. Furthermore, the ratios also depend on the length of the time frame considered.

CONCLUSION

Using observed/expected ratios calculated from the administrative data set, we were able to (1) better quantify known morbidity pairings while also revealing hitherto unnoticed associations, (2) find out which pairings cluster most strongly, and (3) gain insight into which diseases cluster frequently with other diseases. Caveats with this method are finding spurious associations on the basis of too few observed cases and the dependency of the ratio magnitude on the length of the time frame observed.

Multimorbidity patterns in the elderly: a new approach of disease clustering identifies complex interrelations between chronic conditions

Objective

Multimorbidity is a common problem in the elderly that is significantly associated with higher mortality, increased disability and functional decline. Information about interactions of chronic diseases can help to facilitate diagnosis, amend prevention and enhance the patients' quality of life. The aim of this study was to increase the knowledge of specific processes of multimorbidity in an unselected elderly population by identifying patterns of statistically significantly associated comorbidity.

Methods

Multimorbidity patterns were identified by exploratory tetrachoric factor analysis based on claims data of 63,104 males and 86,176 females in the age group 65+. Analyses were based on 46 diagnosis groups incorporating all ICD-10 diagnoses of chronic diseases with a prevalence ≥ 1%. Both genders were analyzed separately. Persons were assigned to multimorbidity patterns if they had at least three diagnosis groups with a factor loading of 0.25 on the corresponding pattern.

Results

Three multimorbidity patterns were found: 1) cardiovascular/metabolic disorders [prevalence female: 30%; male: 39%], 2) anxiety/depression/somatoform disorders and pain [34%; 22%], and 3) neuropsychiatric disorders [6%; 0.8%]. The sampling adequacy was meritorious (Kaiser-Meyer-Olkin measure: 0.85 and 0.84, respectively) and the factors explained a large part of the variance (cumulative percent: 78% and 75%, respectively). The patterns were largely age-dependent and overlapped in a sizeable part of the population. Altogether 50% of female and 48% of male persons were assigned to at least one of the three multimorbidity patterns.

Conclusion

This study shows that statistically significant co-occurrence of chronic diseases can be subsumed in three prevalent multimorbidity patterns if accounting for the fact that different multimorbidity patterns share some diagnosis groups, influence each other and overlap in a large part of the population. In recognizing the full complexity of multimorbidity we might improve our ability to predict needs and achieve possible benefits for elderly patients who suffer from multimorbidity.

In-hospital death and adverse clinical events in elderly patients according to disease clustering: the REPOSI study

OBJECTIVE

The aim of the study was to recognize clusters of diseases among hospitalized elderly and to identify groups of patients at risk of in-hospital death and adverse clinical events according to disease clustering.

METHOD

This was a cross-sectional study conducted in 38 internal medicine and geriatric wards in Italy participating in the Registro Politerapie SIMI (REPOSI) study during 2008. The subjects were 1,332 inpatients aged 65 years or older. Clusters of diseases (i.e., two or more co-occurrent diseases) were identified using the odds ratios (OR) for the associations between pairs of conditions, followed by cluster analysis. Logistic regression models were used to evaluate the effect of disease clusters on in-hospital death and adverse clinical events.

RESULTS

A total of 86.7% of the patients were discharged, 8.3% were transferred to another hospital unit, and 5.0% died during hospitalization; 36.4% of the patients had at least one adverse clinical event. Patients affected by the clusters, including heart failure (HF) and either chronic renal failure (CRF) or chronic obstructive pulmonary disease, had a significant association with in-hospital death (OR, 4.3;95% confidence interval [CI], 1.6-11.5; OR, 2.9; 95% CI, 1.1-8.3, respectively), as well as patients affected by CRF and anemia (OR, 6.1; 95% CI, 2.3-16.2). The cluster including HF and CRF was also associated with adverse clinical events (OR, 3.5; 95% CI, 1.5-7.8). The effect of both HF and CRF and anemia and CRF on in-hospital death was additive.

CONCLUSION

Several groups of older patients at risk of in-hospital death and adverse clinical events were identified according to disease clustering. Knowledge of the relationship among co-occurring diseases may help developing strategies to improve clinical practice and preventative interventions.

Comorbidity among older American Indians: the native elder care study

Comorbidity is a growing challenge and the older adult population is most at risk of developing comorbid conditions. Comorbidity is associated with increased risk of mortality, increased hospitalizations, increased doctor visits, increased prescription medications, nursing home placement, poorer mental health, and physical disability. American Indians experience some of the highest rates of chronic conditions, but to date there have been only two published studies on the subject of comorbidity in this population. With a community-based sample of 505 American Indians aged 55 years or older, this study identified the most prevalent chronic conditions, described comorbidity, and identified socio-demographic, functional limitations, and psychosocial correlates of comorbidity. Results indicated that older American Indians experience higher rates of hypertension, diabetes, back pain, and vision loss compared to national statistics of older adults. Two-thirds of the sample experienced some degree of comorbidity according to the scale used. Older age, poorer physical functioning, more depressive symptomatology, and lower personal mastery were all correlates of higher comorbidity scores. Despite medical advances increasing life expectancy, morbidity and mortality statistics suggest that the health of older American Indians lags behind the majority population. These findings highlight the importance of supporting chronic care and management services for the older American Indian population.

Quality of life in American Indian women with arthritis or diabetes

OBJECTIVE

We investigated quality of life (QOL) in American Indian women with different chronic diseases.

METHOD

Sixty American Indian women with diabetes mellitus (DM), rheumatoid arthritis (RA), or both DM and RA (DM + RA), and healthy control women received evaluations of joint motion, hand strength dexterity, pain, activity and participation limitations and QOL.

RESULTS

The DM + RA and RA groups had significantly more pain, less joint motion, decreased hand strength, and more activity limitations. Participation was similar for all groups except the DM + RA group. Past and present QOL were similar; however, the DM + RA group reported significantly decreased future QOL.

CONCLUSION

Results suggest that the presence of more than one chronic disease affects activity and participation. Factors that related to QOL were different for each disease group, with the exception of pain. Identification of factors related to QOL can help occupational therapists identify areas for intervention.

Patterns of chronic multimorbidity in the elderly population

OBJECTIVES

To describe patterns of comorbidity and multimorbidity in elderly people.

DESIGN

A community-based survey.

SETTING

Data were gathered from the Kungsholmen Project, a urban, community-based prospective cohort in Sweden.

PARTICIPANTS

Adults aged 77 and older living in the community and in institutions of the geographically defined Kungsholmen area of Stockholm (N=1,099).

MEASUREMENTS

Diagnoses based on physicians' examinations and supported by hospital records, drug use, and blood samples. Patterns of comorbidity and multimorbidity were evaluated using four analytical approaches: prevalence figures, conditional count, logistic regression models, and cluster analysis.

RESULTS

Visual impairments and heart failure were the diseases with the highest comorbidity (mean 2.9 and 2.6 co-occurring conditions, respectively), whereas dementia had the lowest (mean 1.4 comorbidities). Heart failure occurred rarely without any comorbidity (0.4%). The observed prevalence of comorbid pairs of conditions exceeded the expected prevalence for several circulatory diseases and for dementia and depression. Logistic regression analyses detected similar comorbid pairs. The cluster analysis revealed five clusters. Two clusters included vascular conditions (circulatory and cardiopulmonary clusters), and another included mental diseases along with musculoskeletal disorders. The last two clusters included only one major disease each (diabetes mellitus and malignancy) together with their most common consequences (visual impairment and anemia, respectively).

CONCLUSION

In persons with multimorbidity, there exists co-occurrence of diseases beyond chance, which clinicians need to take into account in their daily practice. Some pathological mechanisms behind the identified clusters are well known; others need further clarification to identify possible preventative strategies.

Mental disorders among persons with arthritis: results from the World Mental Health Surveys

BACKGROUND

Prior studies in the USA have reported higher rates of mental disorders among persons with arthritis but no cross-national studies have been conducted. In this study the prevalence of specific mental disorders among persons with arthritis was estimated and their association with arthritis across diverse countries assessed.

METHOD

The study was a series of cross-sectional population sample surveys. Eighteen population surveys of household-residing adults were carried out in 17 countries in different regions of the world. Most were carried out between 2001 and 2002, but others were completed as late as 2007. Mental disorders were assessed with the World Health Organization (WHO) World Mental Health-Composite International Diagnostic Interview (WMH-CIDI). Arthritis was ascertained by self-report. The association of anxiety disorders, mood disorders and alcohol use disorders with arthritis was assessed, controlling for age and sex. Prevalence rates for specific mental disorders among persons with and without arthritis were calculated and odds ratios (ORs) with 95% confidence intervals were used to estimate the association.

RESULTS

After adjusting for age and sex, specific mood and anxiety disorders occurred among persons with arthritis at higher rates than among persons without arthritis. Alcohol abuse/dependence showed a weaker and less consistent association with arthritis. The pooled estimates of the age- and sex-adjusted ORs were about 1.9 for mood disorders and for anxiety disorders and about 1.5 for alcohol abuse/dependence among persons with versus without arthritis. The pattern of association between specific mood and anxiety disorders and arthritis was similar across countries.

CONCLUSIONS

Mood and anxiety disorders occur with greater frequency among persons with arthritis than those without arthritis across diverse countries. The strength of association of specific mood and anxiety disorders with arthritis was generally consistent across disorders and across countries.

Arthritis prevalence and associations in American Indian and Alaska Native people

OBJECTIVE

To investigate the prevalence of arthritis and associations with arthritis in American Indian and Alaska Native populations.

METHODS

Data on self-reported, doctor-diagnosed arthritis from the baseline visit of 9,968 American Indian and Alaska Native adults from Alaska and the Southwest US were included. The prevalence of arthritis and univariate and multivariate associations between arthritis and demographic characteristics, health-related factors, and treatment are described.

RESULTS

The prevalence of self-reported arthritis increased with age. The age-sex adjusted prevalence was high in Alaska (26.1%) and low in the Southwest US (16.5%) as compared with the US population (21.5%). In both centers, arthritis was associated with age, lack of employment, chronic medical conditions, and poorer self-reported overall health. Arthritis was associated with female sex in Alaska only, whereas education, marital status, and urban residency were associated with arthritis in the Southwest US. In both centers, self-reported physical health measured by the Short Form 12 Health Survey was lower in people with arthritis, and mental health was not associated with arthritis. More frequent use of antiinflammatory medications was reported with arthritis in both centers, but increased use of traditional medicine and healers were associated with arthritis only in Alaska.

CONCLUSION

Compared with US rates, the prevalence of self-reported arthritis was higher among Alaska Native people and lower in a Southwest American Indian population. Some factors associated with arthritis differ between the 2 populations.

Factors That Contribute to Levels of Independent Activity Functioning Among a Group of Navajo Elders

The purpose of this study was to examine factors that contribute to levels of independent activity functioning among a group of elder Navajos. Data were collected from a sample of Navajo elders from Tuba City, Arizona, and a health assessment survey was administered. Multiple regression analysis was used to examine the effects of social support and demographic factors on levels of independent activity functioning, such as bathing, toileting, dressing, eating, walking, and getting in and out of bed. The results indicated that assistive devices, marital status, the frequency of visits to Tuba City, and visits to the elders significantly affected independent activity functioning. Although other factors of social support were not significant, it appeared that visiting Tuba City and visits to the elders in their homes were important factors in maintaining higher levels of independent activity functioning among elder Navajos. Implications for practice, policy, and future research are discussed.

Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs

Persons with multiple chronic conditions are a large and growing segment of the US population. However, little is known about how chronic conditions cluster, and the ramifications of having specific combinations of chronic conditions. Clinical guidelines and disease management programs focus on single conditions, and clinical research often excludes persons with multiple chronic conditions. Understanding how conditions in combination impact the burden of disease and the costs and quality of care received is critical to improving care for the 1 in 5 Americans with multiple chronic conditions. This Medline review of publications examining somatic chronic conditions co-occurring with 1 or more additional specific chronic illness between January 2000 and March 2007 summarizes the state of our understanding of the prevalence and health challenges of multiple chronic conditions and the implications for quality, care management, and costs.

Co-morbidity does not reflect complexity in internal medicine patients

Internal medicine patients are mostly elderly; they have multiple co-morbidities, which are usually chronic, rather than self-limiting or acute diseases. Neither administrative indicators nor co-morbidity indexes, though validated in elderly patients, are able to completely define these "complex" patients or to allow physicians to correctly "cope" with them. For the complex patients found in internal medicine wards, internists need not only to find the best diagnosis and treatment, but also to apply a complex intervention (i.e., a comprehensive assessment and both continuous and multi-disciplinary care) in order to maintain their health and ability to function and to prevent or delay disability, frailty, and displacement from home and community. The aim of this review is to underscore the differences between the concepts of co-morbidity and complexity, to discuss instruments for their measurement, and to highlight related implications, areas of uncertainty, and the responsibilities of internists in the assessment and management of inpatients of their wards. The conclusion we come to is that it is mandatory to shift from a finance/administrative-based management system to a clinical process model (clinical governance) driven by the quality of the medical outcome and the cost of achieving that outcome. From a "complexity theory" standpoint, patient-centered care and collaboration can be seen as simple rules that guide desirable behaviors in a complex system. By exploring the real complexity of our patients, we exercise the holistic, anthropologic medicine of the person that is internal medicine.

The assessment of complexity in internal medicine patients. The FADOI Medicomplex Study

BACKGROUND

Although the number of elderly people is progressively increasing in the world, old and very old patients have been under-represented and understudied in trials evaluating the efficacy of chronic illness management models. The usual hospital indicators and practice guidelines do not consider the effects of complexity - co-morbidity, social support, functional and cognitive status, patient adherence to therapy, risk of adverse drug reactions - in these subjects. The aim of this observational, multi-centric cohort study was to carefully assess factors contributing to the complexity of care for patients admitted to internal medicine wards. This was done by evaluating the severity of disease and degree of stability at admission, co-morbidity, age-related impairments, and the need for discharge planning plus post-discharge support.

METHODS

A total of 386 patients from 11 internal medicine wards in Emilia-Romagna and Marche, Italy, enrolled in a given week were evaluated. At admission, the following variables were recorded: demographic characteristics, medical history, global clinical-social prognostic evaluation, co-morbidity, severity of illness, presence of shock or hemodynamic instability, coma, and frequencies and causes of unscheduled hospital re-admission.

RESULTS

Cancer, congestive heart failure, pneumonia, stroke, and chronic obstructive pulmonary disease were the most frequent primary diagnoses. The complexity of our case study was characterized by several concomitant diseases. Over 50% of the patients were considered severe or more than severe, and over 20% extremely severe, with very high co-morbidity indices and illness severity scores. Some 55% of our patients were in need of partial or total care; 10% had some speech impairment, and 63% needed in-home health care after hospital discharge.

CONCLUSIONS

The increasing numbers of elderly patients admitted to internal medicine departments suggests the need for a chronic illness management model, integrating gerontological and geriatric care to improve outcomes. For effective care, future protocols need to take a multi-dimensional, interdisciplinary approach to these patients and to develop a coordinated, integrated plan for treatment and long-term follow-up.